diabetes is increasing, but thanks to advancements in treatment, the quality of life for these patients has improved.

[MUSIC] Stay with us as we talk with pediatric diabetes specialist Doctor Julia Wood about changes in the management of children with diabetes.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a healthy Kentucky.

[MUSIC] >> Hello and welcome to Kentucky Health.

I'm your host, doctor Wayne Tuckson.

Today we're going to talk about diabetes in children.

The incidence of both type one and type two diabetes are rising.

Explanations for this include childhood and adolescent obesity, insulin resistance, sedentary lifestyles, family history of diabetes, changes in the microbiome, early life nutrition, vitamin D status, and environmental pollutants.

The good news is that thanks to newer medications such as GLP one meds and improvements in delivery methods, pediatric patients with diabetes are living longer with better quality of life.

Though the patient bears the brunt of diabetes, the impact of the disease is not limited to the patients.

Both patients and families experience disease, fatigue, and we are seeing stresses placed upon families, friends, social services and schools to discuss what's new in the diagnosis and management of diabetes in the pediatric population.

We have, as our guest today, Doctor Aurelia Wood, doctor Wood is a graduate of the Wright State University.

Boonshoft School of Medicine in Dayton, Ohio.

She then did her residency in pediatrics at the University of Louisville School of Medicine and followed this with a fellowship in pediatric endocrinology at Washington University.

Barnes-Jewish Hospital in Saint Louis, Missouri.

Doctor Wood is an associate professor in the Department of Pediatrics at the University of Louisville and is an endocrinologist at the WNDI Novak Diabetes Institute at Norton Children's.

She serves as the physician lead of the Diabetes Advanced Resource Team, known as the DART Clinic, and is the visionary physician lead for the WNDI School Health and Equity.

Working with University, institutional and community partners to address the complex, systemic, systemic based needs of patients and families with diabetes.

Doctor Wood WNDI, thanks.

Thanks for being with us.

>> Thank you for having me.

>> Out there.

Right now, there is a young woman who says, I want to do what she's doing.

So what are you going to tell her?

>> Join us.

We welcome you.

>> How?

How's she gonna do it?

What are the steps?

She has to go.

>> Through?

The pathway to becoming a pediatric endocrinologist.

>> Exactly.

>> Includes, of course, first going to medical school to get the basics of your medical education.

You will then, if you like to be a pediatric endocrinologist, apply for a pediatric general specialty.

After your three years of residency, you will then apply for a subspecialty training in pediatric endocrinology and diabetes, which is an additional three year pathway of training.

>> What was the light bulb moment for you that said, I want to be a doctor?

>> That's a great question.

I am one of those kids that loved my pediatrician, and he was wonderful.

And I kind of was like, that's what I want to do when I grow up.

So it was something that I always had in the back of my head.

I was that kid that had the waiting room of toys and gave my dolls and toys exams, but I always was actually surrounded personally and professionally around doctors.

I had friends whose parents were doctors.

Like I said, I loved my pediatrician and so it just worked out that I was able to maintain focus, have some exposure to that, and was able to kind of fulfill my dream.

>> So what is the WNDI Novak Diabetes Institute?

>> The Wendy Novak Diabetes Institute is a part of Norton Children's Hospital, and as an institute, it is a center for comprehensive, interdisciplinary care for persons along the entire lifespan who are living with diabetes.

So our team includes every specialist from nurse practitioners, nurses, educators, dieticians, social workers, psychologists, child life.

Exercise physiologists.

And then we have a huge research aspect as well.

In addition to community and school based programing.

>> So having that sounds like a very comprehensive network within one institute.

How does that help the patient more than if they're going to there?

And this is not to say anything critical about their otherwise pediatric endocrinologist or their pediatrician is managing their diabetes.

What is the extra sauce that you're doing here?

>> Yeah.

So as you kind of alluded to, taking care of diabetes involves multiple different people.

It's not just the patient.

And especially for children who are growing, developing, changing, and going through life, navigating those, those shifts and those transitions is already challenging.

Yeah.

On top of having a chronic disease that requires the intensity of management, that type one does, and the way that it kind of affects your life and the things that you choose to do.

And so having a center where, you know, you can get support for school, for work, for when you're having surgery for, if you're pregnant, for, if you have a family member who might be at risk of diabetes, knowing that you can get all of that in one place, not only ensures that you get the best clinical care, but also ensures that others are able to benefit from that exposure as well.

>> Fantastic.

What is diabetes?

>> Yeah.

So diabetes, diabetes mellitus is a chronic condition that is due to the body's inability to produce insulin or to utilize insulin properly.

Insulin is a hormone produced by our pancreas, a little organ that sits here.

And Insulin's job is to utilize sugar glucose for energy.

So insulin is released through our body throughout the day.

It takes our sugar from the food we eat.

It takes the sugar that our body makes to keep us healthy and energetic.

And it uses that for energy.

And then it keeps the blood sugar levels normal.

So people with any type of diabetes and there are over 20 different types of diabetes, 20 the shared yes, the shared characteristic is high blood sugar due to absence or inefficiency of insulin.

>> Well, I don't know about the other 20, but tell me about these two.

The difference between type one and type two diabetes.

>> Type one and type two.

So definitely the two most commonly known types of diabetes.

So type two diabetes used to be known as kind adult diabetes because it was previously thought to only occur in adults.

But type two diabetes is a condition where your body is making insulin.

It's just resistant to it.

And so that that insulin production is there, but the body's having to increase how it delivers it in order to keep those blood sugars normal.

So it's most common in adults, but can absolutely happen, happen in children.

And we're seeing the incidence of that increasing type one.

Diabetes is an autoimmune condition that someone is born with a genetic susceptibility to.

So the development of both type one and type two is very complex.

But the complexity of the immune system reaction in type one is really what's at the crux of how this disorder emerges.

And so someone's born with a change in the way that their immune system is regulating, that results in the body producing antibodies that attack the pancreas and the part of the pancreas that makes that insulin.

And so once that attack starts over weeks to months, that insulin decreases and that blood sugar increases, and then they present with symptoms of diabetes.

>> So the child that may have type one diabetes, are they manifesting elevated glucose levels from the very beginning?

Or does it take time?

And if so, typically, what age is the diagnosis?

>> Yeah, that's a great question.

So the typical age, the average age of presentation is 12 to 14.

But people as young as 1 to 2 years of age can have type one diabetes and as old as the third, fourth and even fifth decade of life.

>> What is the tip off then for type one diabetes?

If they're not making the insulin as opposed to are you seeing growth retardation or other problems up until before that age of 12, that makes you think that they have something going on.

>> Or not at all, not necessarily.

Most people have no idea they're susceptible unless they were for some reason, part of a study.

But people are living normal, healthy lives otherwise, and we're not yet sure exactly what that immune trigger is that triggers someone from going from what we call stage zero diabetes.

Having that susceptibility to stage one, where those antibodies are being produced to stage two, where they're affecting blood sugar, to stage three, where they have fulminant diabetes.

So lots of research has taken place over decades and decades to try to figure out, is it a. A breast milk versus formula?

Is it an infection?

Is it an environmental exposure?

Lots of supposition, lots of intense research that we don't yet know.

What's that one special trigger?

>> Wow.

>> Tell me about the role of genetics with type one diabetes.

>> Yeah.

So because it's not quite a one gene is different.

It's the inheritance pattern really kind of depends on the person's environment within their immune system.

So all that to say, some conditions are what we call like autosomal dominant, meaning 50% chance if my mom has it, 50% chance I'll get it or autosomal recessive.

If my parent has it, there's a 1 in 4 chance I have it because of the complexity of how the genetics are.

It's not even anywhere near that black and white.

So for example, if identical twins, the incidence is only 50%.

The incidence is a little bit higher than the.

General population.

If you have a father with diabetes and just a little bit higher than if you have a mother with diabetes.

>> Even with identical twins.

>> Even with identical twins, which just speaks to that complexity within the genes of two people that presumably have the exact same genetic makeup.

>> So how does this differ from what's going on in type two diabetes in terms of that presentation?

Yeah.

And are you.

Yeah.

And obviously we're seeing it.

That used to be something we wouldn't see to adulthood.

But now you're seeing it in kids.

What does it look like?

>> Yeah.

So type two diabetes seems to have a more familial association.

So again, we don't yet have one specific gene.

There's a lot of research in that area, but we do know that there's a more familial association.

So you might see multiple generations of persons having type two diabetes where that's not quite the case in type one.

So knowing that you have that risk is important to be able to be screened appropriately over time, because the way because of the insulin resistance rather than deficiency, that happens more quickly, it can be an insidious process that kind of develops over weeks, months, years.

And sometimes people are living with.

Diabetes and don't even know it until they get a screening.

>> So since it's a problem of insulin resistance, what are the risk factors that give rise to type two diabetes?

>> Yeah.

So a big one is family history.

And there's probably a genetic component that will uncover over time.

And there are exogenous factors that can make one more resistant to insulin.

So if you have a BMI that is on the higher scale.

>> BMI being.

>> Body mass index.

Okay, so kind of that ratio of weight to height, which isn't a perfect marker because everyone's body is made up of muscle and fat and bones in a different way.

But if someone has a little bit more adiposity, meaning fatty tissue, that can make them a little bit more resistant to insulin, having a more sedentary lifestyle where your body's not utilizing your insulin in the same way can make you a little bit more resistant to insulin.

And then certain medications and drugs can also make you more insulin resistant.

>> So what's the big deal?

So my glucose is a little bit elevated.

My blood sugar is high.

Is that the only problem with diabetes or are there other organ systems that are involved?

>> Yeah, absolutely.

So the body is a very complex machine and really tries to protect itself.

And so particularly for kids that are developing type one, when the body is unable to use that glucose, that sugar for energy, it goes to other sources in the body, such as fat and protein.

So kids start to lose weight.

So you're breaking down muscle, you're breaking down fat.

That affects your body's ability to efficiently use energy.

And so you're not energetic, you're not feeling well.

You're losing weight.

Your body's peeing out all that extra sugar.

It can't use.

You're drinking more.

So in the initial presenting stages, it really can affect the whole person.

And once someone's diagnosed and gets treated and they're doing well, those things kind of return to normal.

They gain their weight back, they get their energy back, they're feeling better long term.

We of course, want to maintain what we call good glycemic control.

So having blood sugars in a healthy range, because we know that high blood sugars over time affect organs, fingers, kidneys, and then macrovascular our big blood vessels on our heart.

And those types of areas.

So that that cardiovascular health.

So we know that long term, having very high blood sugars can cause both microvascular and macrovascular damage.

>> Is it the sugar itself that's causing the problem, or is it something surrounding an inflammatory response or something like that?

>> Because definitely it's a it's a bit of both.

So that hyperglycemia, that energy inefficiency does trigger multiple different inflammatory type of processes.

Because again, the body's trying to protect itself.

But those become damaging over time.

>> Same thing.

What's going on as far as the nerves and all that.

>> That's right.

Yeah.

>> Do you see these kinds of problems developing in the pediatric population with type two diabetes, or is that something that we don't see to way down the road?

>> Yeah.

Timing of onset of complications is a great question.

So with someone with type one diabetes, we're going to find out and diagnose them relatively early in their diagnosis in that process, because the symptoms are so severe.

And so once someone is under relatively healthy control, they're really not at risk of those complications unless they're having challenges maintaining that healthy control for years and decades.

So we have a routine screening protocol that we have based on clinical research to inform when to start screening for those complications for people with type two, because it can be insidious.

They may have complications at the time they're diagnosed and not know it.

So the screening protocol is a little bit different just because of the nature of the physiology.

>> If you.

>> Catch it and you control the patient, can you prevent worsening of those other symptoms associated with diabetes?

>> Absolutely, absolutely.

And that is our goal acutely.

Our goal is to get the person feeling well, their blood sugars in a healthy range.

And our long term goal is to help maintain that healthy control, to prevent those complications.

So absolutely able to prevent and mitigate, even if someone has had challenges for years and years, getting back in a healthy place decreases the risk of progression and also the development of other complications.

>> Well, I have to tell you, doctor, Wood, I have a family history of diabetes and the one reason why I try my best to keep control of my sugar is I don't want to get finger stuck.

So we know that finger sticking is one of the primary ways for people to measure, you know, measure glucose, what goes on with finger stick and why do I get.

>> Yeah, yeah.

So stuck.

So the blood sugar checking is important because it directs how we treat the diabetes.

So people with type one diabetes because they're not making insulin, the treatment is giving them insulin through the subcutaneous tissue.

So either through an injection or through an insulin pump.

And so in order to know that that insulin is being delivered safely, being used effectively, we have to check blood sugars routinely.

>> Yeah.

But you have some other ways.

Tell me about what continuous glucose monitor.

What is that?

How is.

>> That working?

So CGM, continuous glucose monitors are devices that are worn on the skin, that have a little tiny filament that goes underneath the skin.

You can wear them for 10 to 15 days, and they're constantly monitoring what our sugar that's dissolved from the blood into the interstitial space.

So underneath the skin.

Really is delivering.

>> And it's accurate.

I mean.

>> They have made great advances over, I'd say, the last ten years to where it used to be.

You could use the CGM for peripheral monitoring, but you still needed that accurate blood stick to now where we can utilize the CGM readings for in the moment.

>> And what are we using to you just use your cell phone or do you have to use a special thing?

>> Yep.

That's right.

So the sensor within the device transmits that blood glucose data either to a phone app or a little device called a reader.

So every five minutes you can see exactly what the updated value is, as well as the trends of your blood sugar, which is really important if you're thinking about everyday life, being prepared and being safe.

>> I know this doesn't happen to your patients, but you know, I'm sure there is somebody out there who is really gorging in on the sugary substances and all that sort of thing.

And 30 days before they come to see you, they stop doing all that so that their blood glucose level will be normal.

But you have a way of finding out if we've been honest about our sugar intake, right?

It was this hemoglobin A one C or something like that.

Yeah.

>> I presume all my patients are telling me the truth.

I try to open up an environment of non-judgment non-judgment.

But yes, a tool that we can use in addition to the reports generated by the CGM, is a lab called a onesie.

So hemoglobin a onesie is a lab that comes out as a percentage, and that percentage translates to an average blood sugar over a three month period.

And so because you have that average information, it really tells you how high or low or above or below target your blood sugar has been.

And so by definition, a normal, a onesie for someone that's having normal blood sugars is less than 5.7.

The diagnosis of diabetes is.

If your a1c's 6.5 or higher.

>> Gotcha.

Is there anything else besides hemoglobin A one C that's out there?

Or are there some new diagnostic lab tests?

>> Yeah.

So I think that the advent of CGM has really opened up space for us to more closely individualize how we think about what's healthy glycemic control, because the A one C again, it doesn't tell me how yesterday went.

It doesn't tell me how the last month for you has been going.

It just gives me an average value.

And so what we really are utilizing is that CGM data to see how much of the time are you in that range, and what does it look like for you to get there?

Are you working really, really hard and giving yourself lots of insulin?

Are you having lots of low blood sugars?

So we really look at those reports to help our patients live a healthy, happy life.

And the A one C is absolutely important because it's a reflection of that.

But really having the ability to have CGM data has allowed us to really individualize care and make sure that the A one C is not in range because of some flukes with with variability.

>> Tell me about insulin pumps and how these things work.

Is that something that you all you love?

>> Absolutely, absolutely.

So the standard of care before we had insulin pumps.

Okay.

Just to kind of explain the scope of how they utilize, we try to mimic what the body does in terms of insulin delivery.

So as I mentioned, our body's always kind of making sugar to use for energy.

So we mimic what the body does in that regard by giving a basal insulin.

So meaning a once a day injection of insulin that lasts for 24 hours to kind of be in the background to address that normal glycemic variability, when we eat something with carbs, our that gets converted to sugar to glucose.

And so our blood sugar goes up.

So we give a short acting insulin to bring that back down.

And so we have to teach our patients different calculations and different ways to address how to do those treatments.

And those change over time with an insulin pump, we're able to individualize further.

And what we do is instead of giving that once a day shot, we program the insulin pump, which is full of insulin, to give you an hourly amount to replace that rate.

Wow.

And then when you go to eat a meal, or let's say you want to correct a high blood sugar, you just tell the pump what's going on and it calculates a delivery for you.

>> Wow.

Are we to the point where using combining a continuous glucose monitor and the pump that the monitor can tell the pump, I need more?

>> Yes, yes.

So we call those hybrid closed loop pumps.

The first.

>> Closed.

>> Loop hybrid closed loop pumps.

So the first hybrid closed loop pump in the United States was approved for adults in 2017.

And so what they do is the pump sees the CGM data.

It sees the predictive technology the CGM uses to say, what do I think your blood sugar is going to do?

And it adjusts your insulin delivery based on that.

So if it notices you're going low, it can back off your insulin.

If it notices you're going high, it can give you extra insulin.

Knowing how much insulin is giving you to do it in a safe way.

>> That is incredible.

You said adults, though not ready for kids yet.

>> It's approved for kids.

The first one was approved for adults, as most things are, but shortly was approved for kids.

And now we have five six different types of devices that we can offer for our families.

>> So what age child are you putting this in?

Because it seemed to me that the younger the child, the less I want to do fingerstick.

So I want continuous glucose monitoring and then I want to do this.

>> Yes, yes.

So we really want everyone to be able to utilize the CGM.

Excuse me, the continuous glucose monitor, because it gives that in the moment information, especially if you can think of for kids, they're running around, they're probably going to go low.

You want to be able to know.

So we kind of recommend that everyone, as soon as they're comfortable or able to get on a CGM.

Sure.

And once people are ready and comfortable to explore an insulin pump, we're ready and comfortable to teach them about how to utilize it.

So they, of course, have ages of FDA approval down to two and four years of age.

So even our youngest patients can benefit from, from these technologies.

>> Wow.

That is impressive.

Tell me.

So we've talked about trying to control people's weight, control people's diet.

That's been a big thing out there.

But with plus or minus successes when doing that.

But right now, one of the newer drugs that's coming out is this class of drug called the GLP one, right?

AM I not right?

>> GLP one agonist?

>> Yes.

That's right.

And so what is it that they're doing?

And is that something that is used in the managing of children.

>> Yes.

So GLP one is a molecule our body makes within our digestive system.

Its job is to help slow down our gastric emptying, help our liver to control how much sugar it's making, and then also help our body use insulin more effectively.

So these drugs are very helpful for both pediatric and adult patients that have type two diabetes.

>> What are you seeing down the road that you guys at the WNDI Novak Diabetes Institute are working on to advance the treatment for these patients with diabetes?

>> Yeah.

So as I mentioned, we have a really comprehensive set of programing, both clinical and research, because one of the main goals of WNDI Novak is to make sure that people living with diabetes, both have the access to clinical and research efforts that can make their current life better for people that are at risk of diabetes, to be able to be taken care of.

And then for people that are living with diabetes, to have actually, you know, hope for a cure.

Sure.

And so, and the research and we're doing basic translational and clinical research in all of those areas, but we have multiple different programs and clinics and different ways that we help support our families.

So from the time they're diagnosed, we're usually meeting them in the hospital.

We have a great inpatient team consisting of our diabetes educators, our dieticians, our social workers to help give the families all the support they need and keeping communication with them once they're ready for discharge, after they've completed that intensive education, it's very overwhelming.

It's a very emotional time.

It's a huge life change, but our team does a great job of equipping people with the skills to take on this big new chronic disease.

Once patients are discharged within 2 to 3 weeks, they enter our new diabetes program.

So our patients, for what we call new onset diabetes, those who have recently been diagnosed, and this is a comprehensive program that again, is interdisciplinary, multidisciplinary, so that the family can touch base to say, how have we been doing?

What questions do we have to adjust our insulin doses to talk about sports and school and daycare to integrate?

Maybe teaching parents or grandparents who weren't able to be there for the initial diagnosis to also explore technology like our CGM and our pumps, but then also to learn about research.

Then they enter in our typical diabetes program, where we see our kids every three months.

So every three months after they've been diagnosed, we see them in clinic.

There are multiple other clinical things that we do have available for them as well.

So many kids are in sports.

Many adolescents and young adults are in sports as well.

So we have the Christiansen Family Sports program, which is a.

>> Very I mean, we're talking baseball, football, basketball.

>> Volleyball, any sport.

Six any sport because we want to help them optimize their diabetes regimen and routine for when they're active and playing and also learn and understand how their sport affects their diabetes.

>> And how does it how does sports affect your diet?

>> It depends on the sport and it depends on the activity.

So so some activities where you're burning lots of calories and burning lots of carbs, you can tend to have a low blood sugar, adrenaline is a counter-regulatory hormone, meaning opposite of glucose.

So it actually can raise your sugar.

So some people find they go high when they're active and then they drop low afterwards.

So every activity, every day may be a little bit different depending on what kids are doing.

And so this intensive program really helps them understand those dynamics and then prepare for when they have a game so they can be at their optimal activity.

>> Doctor Wood, I want you to give me the one take home point that you want all of us to remember.

When we think about pediatric diabetes, what is your number one thing?

>> My number one thing I'd want people to know is that it's common.

It's nobody's fault, no matter the etiology.

It's treatable.

And people with diabetes deserve dignity and grace and support in every environment they should be in.

>> See, that's the difference between a surgeon and a pediatrician and interns.

You gave me seven things when I asked for one, and they all fit in and matched up very nicely.

That was cool.

Just just one last thing though.

Real quick.

In real brief, this must be a shock to a patient family when you.

>> Absolutely, absolutely.

Yes.

Because again, most people, because it's not that strong, super strong genetic connection would have never thought that they'd be dealing with a diagnosis.

>> Because it is the whole family, as you said, all the people.

I like the fact that you're bringing in everybody in.

That's that's really fantastic.

Well, Doctor Wood, thank you very much for being with us.

I gave a lot of good information out there.

Thank you.

>> You're welcome.

>> And thank you for being with us today.

As you have seen, there are many reasons for us to be optimistic for the long term outlook for children with diabetes.

[MUSIC] We also heard how we may alter the risk for developing diabetes and ways to improve support for children and their families.

[MUSIC] If you wish to watch this show again or watch an archived version of past shows, please go to w w w dot ket.org forward slash Health.

If you have a question or comment about this or other shows, we can be reached at KY.

Health at ket.org.

I look forward to seeing you on the next Kentucky Health.

But in the meantime, if you have any questions about diabetes for you or for your family members, please talk to your health care providers.

Or if you really want to reach out, you can talk to the folks at Wendy Novak Diabetes Institute.

They'll be more than happy to provide your information or talk to your local public health facility.

But please do not ignore this.

[MUSIC] Diabetes is a serious problem, but it can be controlled.

And as we heard, we can have normal lifestyles.

Look forward to seeing you again next week.

>> Kentucky health is funded in part by a grant from the Foundation for a healthy Kentucky.

[MUSIC]