What if you could know your risk for type 1 diabetes (T1D) years before symptoms appear — and have the opportunity to delay its progression? As researchers continue to advance early detection of T1D autoantibodies and disease-modifying therapies, a fundamental shift is underway that could change the lives of those most at risk.
At the forefront of this movement is Kimber Simmons, MD, MS, a pediatric endocrinologist, physician-scientist, and lead researcher in type 1 diabetes screening and clinical prevention trials at the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus.
As Director of the Center’s Early-Stage T1D Clinical Care and Disease Modifying Therapy Program, she is dedicated to identifying children with T1D islet autoimmunity, advancing early detection and monitoring strategies, and investigating therapies to delay or prevent its onset.
Her research is helping reframe how we view T1D — not as a diagnosis that arrives without warning, but one with detectable, treatable stages that can be identified years before symptoms appear.
In a recent conversation with T1D Exchange, Dr. Simmons discussed the promise of screening and early detection, the expanding role of Teplizumab (Tzield®) for people in Stages 2 and 3 T1D, and the real-life impact advances are having on families.
One of the clearest benefits of early screening is the dramatic reduction in diabetic ketoacidosis (DKA) at the time of diagnosis, explained Simmons. This is especially important in Colorado, where the Barbara Davis Center serves a large geographic region, and DKA rates at diagnosis are higher than in many other parts of the country.
“Over 50% of our kids are in DKA when they're diagnosed,” Simmons explained. “But with screening and structured follow-up, that number drops to less than 5%.”
Even children who are screened but lost to follow-up had lower rates of life-threatening DKA at diagnosis, underscoring the value of simply knowing a child’s risk.
“DKA rates drop by more than 50% at diagnosis for those without structured follow up,” noted Simmons. “So there’s still a benefit from just knowing — but being followed is even better.”
Screening also provides families with access to clinical trials and therapies like Tzield. Simmons pointed out that having treatment options to offer is key, since avoiding DKA alone may not be a strong enough motivator for some to test.
The FDA has expanded Tzield eligibility, now allowing its use for children as young as 1 year old with Stage 2 T1D and for 8-17-year-olds within 8 weeks of a Stage 3 diagnosis.
Simmons believes this could significantly change the way families approach screening for type 1 diabetes. With newly diagnosed families being exposed to disease-modifying therapy, they may be more likely to consider screening and treatment for other family members.
“If a child screens positive, families now have a treatment option to consider,” she said. This knowledge may encourage more families to participate in autoantibody screening to better understand their child’s risk of developing type 1 diabetes.
Lowering the eligible age is extremely impactful, given that the youngest patients often progress the fastest, she said. Having a proactive option to offer means families no longer have to simply watch and wait.
The availability of Tzield has already transformed these conversations.
“Even with the best technology and the most diligent parents, there’s still so much unpredictability — and disrupted sleep,” she said. Preserving beta cell function, even for a little longer, can make a big difference for families.
For children and adolescents ages 8-17, the expanded use of Tzield after diagnosis may help preserve insulin-producing beta cells, extend the honeymoon period, and support continued endogenous insulin production.
Taken together, these approvals signal a broader shift in T1D care — from earlier detection and intervention to preserving insulin production, and providing families with more options throughout their journey.
Although ASK and TrialNet both focus on screening to identify those at risk for T1D, their foundational goals are different.
TrialNet screens relatives of people living with T1D and offers confirmation testing to anyone aged 2 to 45 years who has screened positive. ASK, on the other hand, screens the general population, reaching those who may not otherwise get tested. Both programs identify individuals who may be eligible for prevention trials.
This matters because about 90% of people diagnosed with T1D have no family history.
ASK screens children ages 1-17 and adults for both T1D autoantibodies and celiac disease. Dual screening is important because people with celiac disease are more likely to develop type 1 autoimmunity, explained Simmons.
TrialNet screens people ages 2-45 with a first-degree relative or ages 2-20 with a second-degree relative who lives with T1D.
While Simmons strongly supports expanding access to T1D screening, she believes the decision should ultimately be left to individuals and families with guidance from their healthcare provider.
“Screening is a personal decision,” she said. “We are still learning how knowing about early type 1 diabetes, sometimes years before symptoms develop, affects individuals and families."
"For some, that knowledge can be empowering and help them prepare; for others, it may create anxiety or uncertainty. People should understand both the potential benefits and burdens of screening and be supported in making the choice that is right for them.”
While the ideal time for childhood screening is still being determined, Simmons offered some practical recommendations.
She pointed to an analysis of longitudinal birth cohort data using IBM analytics, which tracked participants over many years.
They asked: If children are screened once or twice, when is best?
Here’s what they found.
If you’re screening once, it’s best to do it at age 4, but it only captures 30% of cases, meaning many children who would go on to develop T1D would be missed.
Screening twice, at ages 2 and 6, improves detection.
Adding a third screening at age 10 raises sensitivity to about 80%.
“From a public health cost perspective, screening at ages 2, 6, and 10 gives a pretty good sensitivity for detection and may be more affordable,” said Simmons.
However, the cost of three screenings in our current healthcare system remains a concern.
To maximize reach while minimizing burdens on families and clinicians, Simmons suggests embedding screening into existing pediatric care, including early childhood visits that families are most likely to attend — when blood is often already being collected for anemia or lead testing — as well as the kindergarten entry visit and the 11- to 12-year vaccination visit.
Researchers still aren’t sure if adults can develop new-onset autoimmunity.
“We assume that people do, but there’s no clear evidence because no one has done a longitudinal study looking at that,” she said.
What we do know is that about 66% of people who screen antibody positive at age 10 develop type 1 by age 18. “That means a good portion of people have antibodies that are simmering for years before diagnosis, and they’re some of the people who get diagnosed as adults.”
“Our general advice without better evidence is: If you haven't been screened as an adult, consider being screened once. If the results are negative, it's unlikely you’ll develop T1D, but if you do, it would probably progress more slowly.”
While abnormal glucose results in adults are often caught on routine lab tests, kids can get really sick, quickly.
One of the hardest conversations after a positive autoantibody screening result is the question every family desperately asks: When will type 1 diabetes develop?
“We don’t know exactly when type 1 diabetes is going to happen,” said Simmons. “It’s this uncertainty — not the testing — that families struggle with most.”
From here, the focus shifts to ongoing support, consistent follow-up, and providing families with the information they need to navigate what’s ahead.
“It's about giving families enough information to be prepared and avoid a crisis while not overwhelming them," she explained.
Even if no autoantibodies were detected, you might wonder: When should I test again?
“There should be some consensus guidance published soon,” explained Simmons. While an initial international publication exists, creating recommendations across healthcare systems is challenging.
“If you want to be sure you catch it in your child, yearly screening probably would allow for this — but it’s too expensive to do that on a larger scale.” That’s why screening recommendations have changed over the years.
“TrialNet first recommended annual screening, then shifted to, ‘If you screen negative, we're not screening again.’ Now, they offer screening every two years until age 17.”
As screening programs expand, Simmons believes the next challenge is ensuring their long-term sustainability.
Much work remains, including developing point-of-care testing options that can be more easily integrated into pediatricians’ offices. Right now, blood draws are difficult, so easier testing could be impactful, she explained. “Home testing is an option, but you’re more likely to get false positives with a finger poke.”
Current efforts aim to make testing both accessible and reliable across methods, but reimbursement also remains a major challenge.
“Some pediatric practices that we’ve partnered with on implementation studies have done antibody testing, and then it's not reimbursed.” Then they're left asking, "What can we do to get this covered?"
“Everyone ends up relying on research and external funding — but those resources won’t always be there to support screening.”
That’s why integrating screening into our healthcare system and ensuring its sustainability are top priorities.
Simmons is optimistic that the future of T1D treatment and prevention won’t rely on a single therapy.
“The best step forward may not be choosing one or the other — combining treatments may be more useful,” she said. “Many medications that are in the pipeline may work together to be more impactful in both early-stage and new-onset populations."
Looking ahead, Simmons hopes advances in personalized medicine will help researchers identify which people are most likely to benefit from a particular therapy, reducing trial and error and improving outcomes.
Simmons took a nontraditional path into diabetes research. After earning a graduate degree in exercise physiology, she spent several years working before returning to complete prerequisites for medical school. She went on to attend medical school, trained as a pediatric endocrinologist, and ultimately built a career as a physician-scientist.
“I was an athlete who enjoyed learning about how the human body works, while also managing type 1 diabetes every day,” said Simmons.
It was at this intersection of personal experience and scientific curiosity that her path shifted: Simmons began working with a researcher on one of the earliest T1D prevention trials.
"From the time I was diagnosed, I hoped scientists would one day transform what it means to live with type 1 diabetes,” she said. “Contributing to that progress feels deeply meaningful and has become the focus of my career."