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Management of Pediatric Type 2 Diabetes: A Case St ...
Management of Pediatric Type 2 Diabetes: A Case St ...
Management of Pediatric Type 2 Diabetes: A Case Study
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Welcome to today's webinar entitled The Management of Pediatric Type 2 Diabetes. My name is Paige Johnson, and I will be your moderator for today. This is today's agenda. Diabetes is Primary is a continuing education program that actually, this has been an essential resource for primary care professionals committed to improving their patients' outcomes in diabetes care. Just a little history, if you're new to the series, the topics of interest in this webinar, in this bundle of webinars, I should say, are from polling the participants that took this continuing education series and expressed these topics of things that they really wanted to know more about. If you missed the first webinar, just know there is a take two for that webinar. We had so many questions that we felt it was only the right thing to do to address all the questions in a second taping. We appreciate your attendance, and we are grateful to the ADA and foundations like the Helmsley Foundation that make these webinars possible, all in the name of serving our patients with diabetes more efficiently and safely. These are our learning objectives. These are today's presenters. I am very pleased to introduce the esteemed panel of experts who bring a wealth of knowledge and experience in the world of diabetes. I want to thank all of our presenters that are here today, and we are excited to learn from your experiences and your insights. We really appreciate the time that you have devoted to preparing for this. Now I will turn the presentation over to Dr. Elizabeth Walsh. Hello, good afternoon. I'm Elizabeth Walsh. I am a pediatric endocrinologist here at Atrium Health Wake Forest, and I'm in Winston-Salem. I don't have anything to disclose, and I've got a little question to start us off for the afternoon. And so what is the most challenging aspect of diagnosing type 2 diabetes in pediatric patients in your clinical practice? A, distinguishing between type 1 and type 2 diabetes. B, identifying early symptoms. C, screening high-risk populations. D, ordering appropriate diagnostic tests. Or other. All right, so it looks like distinguishing between type 1 and type 2 is probably the thing that is the most difficult for our audience today, and next would be screening high-risk populations, and then next would be identifying early symptoms and ordering the appropriate diagnostic tests, which fall a little bit behind there. All right, thank you. So I think we are going to cover most of those things today. So today, I'm going to get through, in our time together, is defining type 2 diabetes apart from other types of diabetes, as well as prediabetes, and review those guidelines of care for type 2 diabetes. We probably won't get to the treatment options, but we'll try to briefly introduce those. So the definition of diabetes, of course, is a complex metabolic disorder characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. So all types of diabetes results in hyperglycemia, but the pathophysiology of each type is different. And the diagnostic criteria for type 2 is similar to any type of diabetes, and so we quote unquote these classic symptoms of polyuria, polydipsia, and so that's weight loss, nocturia. That's a great one in pediatrics to ask, because most children don't get up at night to go to the bathroom, and so that's a really good criteria to ask for and screen for. And certainly, any blood sugars greater than 200, or if you have fasting glucoses of greater than 125, fasting being greater than 8 hours, an oral glucose tolerance test is used, and we have the way to do that listed at the bottom here, and with a 2-hour glucose being greater than 200, or we do define diabetes in pediatrics as an agency of greater than or equal to 6.5. There are types of diabetes. Type 1 is the one we talk about a lot in pediatrics, and it certainly is most of my patient population. Type 1 is autoimmune, it's treated with insulin. Of course, there's lots of new updates. I said that's another talk about screening for diabetes and potential interventions, automated insulin systems. There is genetic MOGY, and then steroid chronic pancreatitis-induced diabetes, and then type 2 is really classified as everything else. And so, it's been about three decades since the first publication of type 2 diabetes in children as adolescents, so it's a well-established problem at this point. This is this proposed pathophysiology, and so there's eight different areas that can be affected and go wrong here, and I won't spend a lot of time on this, but I just want you to see that this is hard, and it is hard to see. It's a very complex process when we're talking about type 2 diabetes. You have impacts, the neurotransmitter dysfunction. You have impaired liver function, impaired kidney function, and including impaired pancreas function. All of those things are things that can go wrong when we're talking about type 2 diabetes. So, youth-onset type 2 diabetes was initially described in the Pima Indian children, and so that's first, and then they started studying this a little bit. And so, in the mid-90s, there were case reports from various clinics in the U.S. that reported type 2 diabetes from diverse ethnic populations, primarily non-Hispanic African Blacks and Hispanics. The SEARCH study in 2000 also highlighted that there is this different type of diabetes, and 2004, the TODAY study was initiated, also starting to see how many numbers of actual type 2 diabetes patients we have. We've got registries in Germany, Hong Kong, China, India, Israel, and so while the U.S. have the higher numbers, you do see similar trends observed worldwide. So, by the numbers. So, we are starting to see type 2 diabetes accounts in all of the diabetes for 90 to 95 percent of all diabetes. It's less common in adolescents. It is a staggering increase over the past years, from this 2002 to 2018 study, and so the overall incidence has increased greatly, and so we know these numbers are also globally rising. This is not just affecting us, and so we see these increase going by gender and age and across the world. So, typically, right now, we have a higher female to male ratio in the U.S., and we have typically socioeconomic status. We have a higher number of patients that are lower in the U.S. That is different globally. We see in city areas of our countries that have lower socioeconomic levels, actually the patients in the city areas have higher numbers of type 2 diabetes, whereas in areas that are more rural, you see less type 2 diabetes. So, these are our risk factors for type 2 diabetes. Again, it's not just one area. So, the innermost circle here represents the development of type 2 diabetes, and the things that play into that is, you know this in your clinics, that not all obese individuals will go on to develop type 2 diabetes, so that highlights the complexity of these interrelated risk factors. Within the obesity circle is the genetic circle, and so that's influenced by multiple factors such as immigration, sedentary lifestyle, diet, microbiome, medication use, depression, abuse. Not everyone exposed to this environment will have type 2 diabetes, and so within the genetics circle, you have environment, and so that also plays a big part of this as well. This is one, COVID-19, I can't do a talk about type 2 diabetes really without mentioning COVID-19. In my practice, we did not see a lot of type 2 diabetes. Certainly, we saw some increasing numbers, but we did not see a lot of true type 2 diabetes in our adolescent patients until COVID-19, where we were staggered by how many admissions that we saw and how many patients we saw in our clinic, and that is just also representative across the U.S. as well. And so, we know that that was very, for many different factors, but similar, the numbers have been staggering with type 2 diabetes since COVID-19. So the other scary thing with type 2 diabetes in our adolescents that can't go without doing a talk about type 2 without saying is the earlier chronic complications, and so when you have more, when you have earlier type 2, they have earlier chronic complications. A lot of times in my practice, when I'm talking to patients and families about different types of diabetes, a lot of times their families will say, oh, good, it's type 2 diabetes, and in my head, and in my education with them, I say, that's not the good news. I mean, no types of diabetes are good for sure, but certainly type 2 worries me more because of these earlier chronic complications. And so, this is just another slide that represents the blue being type 2 diabetes and the green being type 1 diabetes, what your risk factors are, and you can see it's dramatically, having complications with type 2 diabetes is dramatically higher. So, we have an increasing issue that leads to earlier complications, what can we do? So, early detection and treatment, prevention, certainly, intervention, and so this goes to one of the questions that we talked about, or that was one of the concerns in the poll is who and when to screen for type 2 diabetes, and so this is a screening, this is published by the ADA, they come out with recommendations every year, and they update those every January, so always be on the lookout for those. And so, really what you're going to do is you're going to do patients that after they started puberty, or after the age of 10, whichever occurs early, and we earlier, we know sometimes you can see puberty in females certainly starting as young as nine, even eight at times, and so you want to be watching for that. So, if they're 85th percentile for their weight, or greater than 95th percentile and have one other additional risk factor, then that's who you're going to think about screening for. And so, that's going to be history of diabetes, maternal history of diabetes, or gestational diabetes, your mom's during child's gestation, sorry, family history of type 2 diabetes and first or second degree relatives, you want to look and see what's their background for their race and ethnicity, and then do they have any, on your clinical exam, do they have any signs of insulin resistance, do you see any acanthosis nigragans, are you seeing any high blood pressure, those types of things. And so, these are the screening methods, the most common one probably that I see is an A1C level, it's easy to get in a clinic with a lab, I mean it is a blood draw, so it's easy for me to say that it's easy to get, but certainly it is a method that we use quite a lot, so fasting blood sugar is good to get, you can do that two-hour oral glucose tolerance test, I see that done less often, I typically see an A1C done more. And so, your treatment for type 2 diabetes is going to be determined by your A1C level, this can be measured as frequently as every three months, and the goal there is to have an A1C of less than 7%. You can get it as low as less than 6.5% without signs of hypoglycemia. And so, this again is referencing this American Diabetes Association guideline that comes out again in January 2024, and it just breaks it down so nicely where we go with our patients, and so it looks confusing, but we love a flowchart here, of course in endocrine we always love a good flowchart for hormones and treatment options. So we're going to break this down a little bit. So first one is, if you have somebody, the first thing you're going to work on is lifestyle. Healthy nutrition, work with a registered dietitian, exercise, American Academy of Pediatrics recommends 60 minutes a day of good exercise. It's easy for me to say, but it is hard to implement, so. So these are our patients that fall into this category of 6.5 to less than or equal to 8.5, so they have diabetes at this point, and you've already doing your lifestyle changes, you need to get them in for some comprehensive diabetes education, and then doing a trial with metformin. And so that can start at 500 milligrams per day, going up to 2000 milligrams per day. Common side effects that we see here are typically abdominal discomfort. So typically, what I see in my patients is that we typically, in these patients, it's definitely a case-by-case basis, but we a lot of times do not ask our patients at this point to start checking their blood sugars. That is, from the recommendations, is up to provider and clinic preference. So if you have an A1C of greater than 8.5%, at that point, we're going to start thinking about bringing out our insulin. And so this is not, you know, you're going to do those first steps, of course, lifestyle changes, diabetes education, typically start some metformin, and then we're going to start thinking about monitoring basal, we're going to think about starting a long-acting insulin. And you can do this at 0.5 units per kilo per day. And I say you, but this is just, these are the guidelines, and this is what we do in pediatric endocrine. So we will start monitoring blood sugars pre-meals, and consider a rapid-acting insulin with sliding scale. If we have a patient that presents in diabetes, ketoacidosis, or hyperosmolar hyperglycemic non-keto syndrome, then we are going to start them just like we do any of our patients, whether we know which type or not. They're going to come into the hospital, we're going to start them on a basal bolus regimen. After we talk to the patients, then we're going to see, you know, which type of diabetes, but that's going to be something that we typically diagnose later. We're not going to typically be able to diagnose that initially there. If we're able to, we will titrate oral medications up and insulin down, and that's another point I like to make to my patients that do, sometimes when we start this insulin, it doesn't mean that they won't come off of it. That's a thing a lot of patients ask. I got stuck. Thank you. So how often do we follow up? We follow our patients every three months. Our goal is to keep that A1C below 7%. There are some new medications out here that we are starting in pediatric patients, GLP-1 and the SGL-2 inhibitors, and you can consider these new medications before additional insulin. So blood glucose monitoring, I already mentioned this, this is something that's going to be individualized, and so if they're not on insulin, this is going to be up to the family and the patients. Real-time glucose, continuous glucose monitoring should be offered. I put this in here because I don't know that all of our insurance companies read that, so we sometimes do have a little bit of challenges when we ask our patients or try, patients are eager to start doing a continuous glucose monitor. If they're not on the appropriate medications, then they are denied that, and so that's something that we advocate and we use different patients. All right, so these are the GLP-1s that you hear all about on the news, and so they do, some of these, not all of them, are approved for pediatric patients. As of June, these are the ones that are approved in our patients greater than 10 years of age, and so I am a pediatric endocrinologist. I do not do a weight loss clinic. Different places do different things, certainly, and you want to become familiar in your area, who does what, and so when I am using GLP-1s, I am using those to treat type 2 diabetes. We have weekly and daily ones available, and those are something that I have used as additional treatment for my patients and our teenagers, and they typically, adherence with the weekly medications is very well. I do screen for the risk here and make sure I'm not missing anything there. This is the SGLC-2i ones, and I have not used this. This is approved. It is in the guidelines to be able to be used for patients with type 2 diabetes older than 10 years of age, but it is not something that I see used very commonly in the pediatric world. So, this is just going through why we want to think about managing our type 2 diabetes. It is not easy. There's a lot of things going on here. You see polycystic ovarian syndrome, fatty liver. These are all these risks that we see more often in our patients, and so that's why it is so important to start working on treating these patients early and as aggressively as we can. It goes without saying that metabolic surgery is something we see a lot in our journals when we're reading those. This is something that can be considered and to be on the watch for if you have an area that does this, and so this is an option when you have class 2 obesity and when you have an elevated A1C, and that would certainly want to be in a program that's familiar with doing that and has a multidisciplinary approach. All right. So, this is a question that I feel like that we struggle with a lot in our practice here and probably relates to some of the questions is what do we do with these prediabetes patients, and so that's defined as this fasting glucose between 100 to 125 and the A1C of 5.7 to 6.4, and so the initial thing is you want to consider screening for type 1 diabetes. You don't want to miss an early onset of that, of type 1 diabetes, and then the next step is to do these lifestyle modifications that we talked about and then to monitor our patients every three to six months. Other than that, there's not a lot of good options for what to do at this stage. I put in here, because this is an option that we have, is there are, if you have a weight loss program in your area that's available to you, this is a great patient to get into a weight loss program. So, this is ending here, future options, new medications. Of course, if you have difficult cases, I'm happy to talk about those at the end. And so, this is my take home for my short time here is your therapy is really dependent on A1C. It's very individualized. There are new medications that are designed for weight loss that can actually work well in patients with type 2 diabetes, and we really want to look at the complications of type 2 diabetes because they can be reversed if detected and treated aggressively in their early stages. There's some references here. Thank you, Dr. Walsh. I would be remiss if I did not mention at this point the importance of referring a patient, pediatric patient with type 2 diabetes, to diabetes education. And it's not just because I'm a diabetes educator you're going to get ready to hear from a fabulous diabetes educator here in just a moment. And, you know, oftentimes in our department we talk about, you know, it really takes a village. And if you can imagine being diagnosed with type 2 diabetes if you are 12 or 15 years of age, the relationship that you establish with a diabetes educator is going to be a really good lifeline. I have patients that I have had since they were young, and they know that they can reach out any time above and beyond the five critical times to refer to diabetes education. And that leads me into I'm very excited to talk about Sarah. Sarah is a certified diabetes care and education specialist, and she's a colleague of mine here at Atrium Wake Forest Baptist Health. We are two of a seven-member team of educators, and pediatrics and nutrition is always a challenge. Sarah will be addressing some of the challenges in her presentation. We kind of kid around and in preparation for this we were talking about she has a beautiful daughter that does not like anything in the food line that is green. So it got me to thinking about a couple of questions that as a mom that I would really ask Sarah if I had a 12 year old or a 16 year old that had just received the diabetes type 2 diagnosis and you know some of the things that I it came across my mind was like Sarah you know if they don't like green they're not going to eat anything green you know what are they going to eat beside chicken nuggets what are you going to do with the struggle bus of soda pop you know can they ever drink soda pop again you know when the teenagers get to the stage where they're going out with their friends and they don't want to look like the the crazy kid on the block and they meet after the football game at cookout what are you going to tell them to order so without further ado here is Miss Sarah. Thank you for that wonderful introduction Paige. Yes see I see or I too have a child who is you know challenging to feed so I do have a little bit of skin in the game here. As Paige said my name is Sarah Navalee Rush and I am a registered dietician and certified diabetes care and education specialist. So this afternoon I'm going to kind of touch on the points for you know nutrition strategies for feeding our patients with type 2 diabetes. So to start off with a poll question here how confident are you in providing culturally sensitive nutritional guidance for pediatric patients with type 2 diabetes from diverse backgrounds? A. Do we feel very confident? B. Somewhat confident? C. Not confident at all or D. Do we often refer these patients to dieticians? Okay so there you go actually quite a few of you 62% of you said that you do feel somewhat confident in being able to provide some culturally sensitive nutritional guidance so that's great that you know we feel like maybe we have you know some of that knowledge and background ourselves or or some great resources to send patients to so hopefully those that maybe feel you know somewhat confident in or you know not overly confident for this hopefully I can give you some you know tips and ideas or some resources that can help with that as well today. Okay so what we're gonna start with is talking about just some of the unique challenges that we have to feeding just children and adolescents in general right because they are certainly a different age group in which we're trying to feed and really establish some of those you know healthy early early eating habits. Okay so the first point I wanted to touch on was really just the fact that there is this kind of just total difference between we think about like children's food versus adult food right we think about a lot of the foods that are maybe tailored towards or marketed towards our children or even on kids menus right it's often things that are more like highly processed fried it's also probably like a lot of potatoes right which I'm sure you've seen before or kind of just you know all brown or beige in color and then we think about the foods that as adults that were offered or you know made you know options to us on menus and whatnot is there gonna be more maybe of your healthier options right maybe it's more like a grilled chicken salad or chicken wrap or you know it's a nice healthy protein that's gonna have you know two sides you know two sides including some vegetables right so there is such this difference in terms of what we think of like children versus adult food and then really that can kind of also just lead into my next bullet point where we're talking about picky eating right because if we continue to offer our children you know these more like kid-friendly marketed foods then that can certainly lead to you know picky eating that they're not very diverse in the textures that they're eating or whether that's like different spices and seasonings or you know even just different cooking methods so that can certainly lead to some picky eating and just also right children have more of a limited palate they're just learning all these different you know and exploring these new different foods so if they're not exposed to that and they're constantly exposed to this limited you know selection of foods then it is going to become more challenging and just continue to kind of drive that picky eating that we see and then certainly snacking throughout the day well you know I'm gonna address snacks and there are a place there is a place for snacks oftentimes I feel like children and adolescents kind of get grouped into just this group this population that frequently snacks right and especially you know if they come home from school and maybe they come home from school in the afternoon but then mom and dad work late and you know dinner's not really late so maybe they're at home and they're snacking all day long and then by the time that dinner time you know meal is presented to them then that's when they might say hey I'm actually not very hungry because I've been snacking all afternoon right so then they're missing out on this this like good maybe their most balanced meal of the day. Whoops. Next point you know would be then also distractions especially I think this day and age you know with the increase in influx of technology that whether it's like the TV, tablet, video games, social media that absolutely you know that is such a big thing that can be a distraction if the TV's on you know during mealtime or if the child is you know taking their meal in front of social media or you know the iPad or whatever it might be that we kind of get into this concept that we call as dieticians mindless eating right where we're not even paying attention to how does the food taste am I even still hungry am I feeling full because we're so locked in to the other thing that we're watching that we're just not even paying attention to how we are feeding and fueling our body. And this is a huge challenge this next one that I see and often you know parents and guardians of a lot of our patients will tell me this is gosh like our schedule is just so crazy like how am I gonna fit this in how am I gonna be able to come home and you know offer my child these healthy you know healthy food choices that you know you're talking about because we have after-school activities and maybe it's not just that child that you know is in the office with me that that's the one with after school activities if there's no multiple children in the household and they're all involved in after school activities and parents are shuttling from one place or to the other but then also all the working parents right that sometimes it's just like hey we had no time we came from the soccer game we were there really late so we just stopped through the drive-thru or you know we just came home and eat a bowl of cereal or we actually just didn't eat dinner at all right and I'm sure Dr. Walsh can also attest to this but it's like a lot of our patients especially during the summer months come in and their sleep schedule is very off right during the summer so they could say like hey I was up playing video games all late like late last night I was snacking late till about 2-3 in the morning I slept late in the morning skip breakfast and I didn't wake up till you know one in the afternoon so you know that certainly can create another different time frame that that can be a barrier to kind of you know some more healthy eating habits. All right and then certainly lastly peer pressure and social gatherings right obviously that is a huge piece and especially with this age group right that they're eating around you know their friends at school or after-school programs or as you know Paige mentioned like hey after school or after the football game we're all going to cook out or going to McDonald's or whatnot right so just having you know that that that social aspect of it absolutely can also just be another another barrier and unique challenge to feeding this age group right so you know and then you know our main topic today right just type 2 diabetes tack on diabetes management which itself is complex and challenging for many people so it's you know as our job here you know as dieticians or diabetes educators it's how can we make some more patient-centered relevant impactful and you know nutrition recommendations that's going to really work for our patients because honestly if I'm telling somebody hey you need to eat XYZ and they're gonna tell me like well that's not anything that we would ever eat or we have access to right it's not gonna work so we have to meet the patient where it's at so what is a great resource that we can use for that so I'm sure all my registered dietitians that are on here today are very familiar with this right but this is the balance plate and the balance plate is something that we really honestly give to pretty much every patient that comes into my office and into our clinic when we're talking about nutritional recommendations and the reason why this is such a great awesome resource to give to patients is because it's such a simple format right so the concept of the balance plate is that this is visually what we want our plate to look like when we're sitting down for meals that we want to encourage the majority of our meal to be you know non-starchy vegetables half the plate being non-starchy vegetables in a perfect world that's what we're aiming for right so that is the goal right and that can be roasted steam they can be grilled they can be seasoned right here we created this plate for this presentation that is a more you know adolescent child friendly right that we have broccoli with cheese right because how many how many kids will say like I don't want to broccoli but I like it when there's cheese on it so okay we can work with that right then we want to make the other quarter portion of our plate being our protein now here we have chicken nuggets often right a kid friendly food and then lastly we have our carbohydrates on there as well which is then you know our mixed fruit salad here so that is the general layout of this right largest portion on starchy vegetables then carbs and protein the whole approach to this is that we still want carbs right because carbohydrates can be healthy foods they give us vitamins minerals they give us fiber but the point is is that it should not be the star of the show right that it is not going to be the largest portion on the plate you want to encourage more of those non-starchy vegetables great source of vitamins minerals and fiber and you know low impact on blood sugar right and the purpose of this plate now this like I said this is a more you know child friendly image that we have here for today's presentation but the point is is that this is a visual that can help to say that hey this is an all fit foods fit approach right that this then is allowing autonomy for these you know pediatric and adolescent patients that are coming in and saying hey we don't have to take away you know this specific food that you really like we can still make that you know be part of the meal but this is kind of how we want to tweak that portion size and balance that meal out to make sure that you're meeting overall are your nutrition needs and requirements that your body needs to continue to help you to grow and be healthy but also keeping your blood sugar in mind right and then there is no good versus bad food but certainly we are obviously promoting healthier options you know as we're talking to our patients about what we're gonna fill into each one of these categories right another reason why this plate and image is so great for teaching just balance you know nutrition but also you know carbohydrate recommendations in general is that this is a really good for those individuals that maybe aren't carb counting right specifically carb counting they're not dosing insulin based on insulin to carb ratio but they just need to know like visually how do I want to balance my plate and this is this is a great option for them and what I also try to drive home to any of the parents or guardians or siblings that are in my room in my office with the patients is that this is honestly the approach that we would say that everybody should really be following and that's trying to get you know the buy-in from the family members and to get that family support because it's not just the child that's sitting in front of me that needs to follow this but if we took blood sugar that conversation off the table this is really the approach that we all want to try to follow that would keep you know we're all we should all be eating more non-starchy vegetables to be quite honest right but then to the address this in terms oops sorry advanced too quickly here to you know switch the the conversation now to more culturally relevant resources right the ADA is a great resource for this that they have these specific plates so examples here we have the Hispanic plate and we also have the Indian plate they also have some really great options for there's an Asian Pacific Islander and southern plate options too so this also can help for those you know patients of different ethnicities or different backgrounds see that hey we don't have to take away these foods that we really love that are a vital important approach to our diet and to our culture but we can still make all these food foods fit right the rice and the beans and the tortillas that they don't have to go away that they are still there it's just again how are we gonna rethink maybe the portion sizes or the options that we're including with that right something else that is a great organization that's gonna be on your resource list available to you after this presentation is a website called old ways it's an organization and it is like a heritage based organization that really dives a little bit deeper into some of the different like ethnicities and heritages and and really looks at different recipes or food options that are available to patients so if you're looking for some resources to you know give patients maybe some healthier food options or if you yourself are trying to familiarize yourself with some foods that are more culturally relevant to your patients that would be a great resource that I would recommend now certainly like Paige said to and dr. Walsh also mentioned in her you know presentation if you feel like you know your patient struggling with nutrition definitely would recommend to refer them to diabetes education or to your registered dietitian and that is where that diabetes educator registered dietitian can be really great and in an important role and important you know member of that team to help give more specific individualized recommendations to that to that patient I also then kind of want to piggyback off of this in terms of we talked about like balance meals but now transitioning to balance snacks like I said balance that our snacks in general can certainly have a place you know a healthy place within within eating depending on you know length of time in between meals or depending on you know activity level but again we want to keep in mind that we want to you know balance those snacks yes we can have the carbohydrate the snack but we would do want to try to keep it roughly to about 15 grams and then we also want to include that protein with it right so a balanced snack could be like cheese and crackers or peanut butter and crackers fruit and nuts you know an apple and a cheese stick there's some options listed here on the handout on the screen but really right the the idea here is that the protein is going to help you know us feel more full and satisfied the protein helps with the blood sugar spike but then also because we're feeling more full and satisfied with the protein it can be easier to keep that carbohydrate to the recommended portion all right so then kind of wrapping all this together in terms of how do we try to incorporate some of the things that I mentioned here and establishing you know healthier routines because a huge part of type 2 diabetes is lifestyle components right is really that making sure that we're establishing some mealtime routines right that we want to think about not skipping meals that you know parents or guardians are kind of setting like hey we're gonna have breakfast lunch and dinner you know and if we're not overly hungry at breakfast okay can we at least make sure that we're having some type of like balanced snack in the morning so that we're just not missing that opportunity to eat but also that hey we're getting ready to eat dinner so we're not gonna have you know a snack an hour 30 minutes before eating because we're getting ready to eat this nice balanced meal that was just prepared and then certainly eating together I'm eating together you know not only has there been a ton of positive research about you know family mealtime which it gets really challenging you know obviously with with parent working parents these days but if we can even just try to establish you know maybe it's a couple times a week that the family is eating together that is really important and can be really beneficial here right because there's so much positive research about eating together as a family and that then helps to make sure that we are you know giving that child or that patient that support if we're all you know eating together at the same time it can help to encourage healthy eating patterns and then also that we're eating the same foods right it's not hey I don't have diabetes so I don't have to eat what you're eating I can eat this fast food while you have to eat this you know vegetable and grilled chicken whatnot right it's that we're all gonna be eating these foods together right and and not only are we eating these together but we're also just eating the same exact foods that there is again no difference between what the child is eating versus what the parent is eating even with my picky eater that I have at home we still offer her the same exact foods that we're eating regardless of whether or not she's gonna touch it it's on her plate it's still offered to her because if she continues to see that hey my siblings and mom and dad are eating these foods eventually at some point she's more willing to try it and then maybe hey she might actually realize that she likes that food right so that goes into my next bullet point of right continuing to offer new foods it can take some times between 8 to 10 8 to 15 times I believe it is to try a food until we realize hey actually I kind of like this right even as adults maybe there's food we thought we didn't like when we were younger and we try it again and we realize that we actually do like this and another resource that I have on the page too is Ellen Satter which I'm sure again my registered dietitians are familiar with this the Ellen Satter Institute is a really great organization that has some excellent resources she is a registered dietitian and she's also a family therapist and she basically talks about how the role of the parent or the guardian is to offer the food make sure that we are offering balanced healthy nutritious foods and it is the role of the child whether or not they're going to eat it but her website is a great source also having some positive language around food right it's not that oh those foods are bad and you can never eat those you know there is no good food or bad food so we can all fit them in right yeah certainly these foods are going to be healthier are going to fuel your body more give you more energy where these foods taste really good but maybe these are foods that we're not going to be having all the time but right that we're just not labeling you know a yes and no to some of these foods certainly not having that technology at the table right TV goes off no cell phones at the table you know that helps to again kind of in you know reinforce that that family dinner time but also can you know encourage that more mindful approach to eating like I was talking about and then certainly right remembering the balance plate like I discussed because that is a great visual whether we're going out to eat whether we're preparing meals at home or trying to plan our menu you know for the week that that is such a good visual to kind of really just base all of that off of whether or not we're carb counting and see one other plug I just want to say as well is that just getting the child involved can be really important so you know having them go to the grocery store with mom and dad and say hey let's let's pick out some vegetables or some new like you know whole grains that maybe you'd like to try together but that is also you know a great approach because whenever you can just include the patient adolescent the teen the child more then that helps them feel like they're a part of this as well all right and that takes me to my next segment and I'll let three and Jack take it away Karen Winston and in my section of today's webinar I am going to discuss more in the psychosocial and behavioral health side of diabetes management specifically in pediatric patients and what that might look like for them and I'm gonna give Jack the opportunity real quick to introduce himself as well before I jump into my slides thanks for hey y'all I'm Jack Thomas I was diagnosed with type 1 diabetes in 2014 I'm currently graduated from UNC Wilmington in the spring of 2022 and I currently live down in Baton Rouge Louisiana yeah excited to provide kind of some of my experiences as they relate to type 2 diabetes even though I am a type 1 diabetic I think some of the experiences that I've had growing up relate pretty closely to some of the experiences that type 2 diabetics have as well awesome so I wanted to start just sorry I went through a little too fast there with my question so quick poll in your experience which psychosocial factors pose the greatest challenge to diabetes management when you're working with pediatric patients with type 2 diabetes okay so it looks like it's pretty pretty split here between peer pressure and social stigma and family dynamics which are definitely two big ones followed by self image and body image and then the specific mental health concerns and so I think we'll we'll do a good job about talking about all of these but I wanted to start just generally by describing what we mean when we use the term behavioral health and so it's kind of a hot term that's used a lot and I don't think there's a great understanding of what specifically it refers to and so the best way I like to describe it is this umbrella term that kind of refers to both those diagnosable mental health conditions like the depression and anxiety that was in the poll question but also this like general emotional well-being and so we know that there's data that shows that patients with diabetes have you know experienced mental health diagnoses like depression and anxiety at higher rates and we have these standards of care you know that tell us we should screen for those and so that part of behavioral health is really typically incorporated into care but this section of this general emotional well-being is kind of harder to assess because we don't have standardized measures for that and you know we're seeing our patients in this artificial clinical setting where we're not out in life with them every day and we don't really know everything that's going on and so this brings me to the next section here which is a theory that we work from in the social work world called person and environment. And this theory is just kind of built on the idea that we can't fully understand what our patients are going through and what their behaviors mean if we don't take into consideration all of the environments that they live in and factors that influence their life. And so these were just some like brief examples in the circles here on the screen of things that might impact your patient's engagement in diabetes management behaviors and just their general behavioral and mental health and wellbeing. And so just as a reminder, our patients are coming to see us for diabetes management and for resources for that, but they're also experiencing life in many different aspects outside of our clinic. And we can't really work with them if we don't pull those experiences into our treatment. And so if we think about a teenager or a pediatric patient and what these environments and factors might be that they're experiencing outside of our clinic and outside of diabetes, you know, we can look at this blue box here. And so we think about the fact that many of our patients are getting to the age where they're navigating relationships romantically for the first time in their life, where they have, you know, drama with their friends and families. They are in sports teams or doing extracurriculars that are really demanding. They have a lot of responsibilities across different aspects of their life. They're trying to do well in school currently while also plan for their future and just all of these big life events that are really heavy and really important for them that are going on in their life. And at the same time, when you talk about a teenager or an adolescent, they're also at this really specific developmental point in life and where they aren't really using their brains fully functionally yet. So we know that the prefrontal cortex is still maturing at this age. And so some of those rational decision-making capabilities aren't super strong yet for our patients. And at the same time, they have an amygdala, which is fully developed and is driving their emotions. And so a lot of the characteristics we see in these patients are heightened emotions and emotional or impulsive decision-making, maybe more increased fears, but at the same time, they have this invincible thinking idea where nothing bad can happen to them. They are really driven by like peer pressure and approval and trying to fit in with their peers. But at the same time, they're also seeking this independence and trying to find their way in the world and who they are. And so when we think about all of this, this is characteristics of an adolescent or teenager outside of diabetes and diabetes management that everyone's experiencing. And so I just wanted to add that reminder in there that like these characteristics or behaviors or trends that you see in your patients are normal. And we expect them to show into our clinics with these things because it's, what we expect from a teenager. And then we just kind of have to consider how diabetes plays into that and what these things we're asking them to do and these lifestyle changes for diabetes management and how that impacts all of these other aspects of their life and what that might mean for them and how we can support them in that. And so I made this chart here with just some different examples of categories that we can fit behaviors into. And so I thought that what I would do is go through each column and then give Jack the opportunity at the end of each column to kind of share his personal experiences from the patient perspective and how this showed up for him and add to the conversation from that patient perspective. And so the first thing, the first category that we can jump into is this idea of seeking independence. And so our teenagers are at a stage in life and where they really wanna be able to do things on their own and they want to be able to manage barriers on their own and problem solve on their own. And when we throw diabetes management into that for them, a lot of times they are having to seek support from their parents or other adults or the school nurse or whoever it may be. And this can kind of make them feel like they've failed in the sense of being able to do things independently. And behaviors that we might see that are characteristic of this are like being really annoyed by parental guidance or adult guidance or any conversation really regarding diabetes management or kind of isolating and pulling away from their support group or their support people because they wanna be able to do it on their own. And a lot of times too, this is just characterized by like a general embarrassment that they have diabetes or that they have to do these things. And so kind of some tips and strategies that I have for this specific barrier, I try to talk to our patients on the sense of like comparing diabetes to a sport, which sounds kind of silly, but when we play a sport, we can go out onto the field or out onto the court and play by ourselves, but we still have a coach. And at the time out or the end of the game or whatever, we still go to our coach and seek feedback and seek support and they help us improve. And so I encourage our patients to like view their parents and view their support people as more of a coach who's helping them improve and helping them like walk through this. And similarly, I tell our parents, and this is a great reminder and tool that you can use as well, is that the way we talk about diabetes management can't look similar to how we talk about things like chores or homework, and that we have to have more compassion in those conversations. And it has to come from a place of support because the more we talk about diabetes management and these things we're asking our patients to do from the perspective of we're just nagging them about something they don't wanna do, the more likely we are to push them towards burnout. And so I think now would be a good time for Jack maybe to pop into the conversation and talk about how this independence category showed up for him. Yeah, I think looking at it like a team is a great point. I know at this point, I think I was just about to start getting my, like get my learner's permit, start driving on my own. I think it was right when I first got my cell phone, starting to gain more independence, going out with my friends by myself, like no parent supervision. And then you're diagnosed with diabetes, very personal thing. It's just kind of flips your world upside down. And like Bree mentioned with the invincibility at this age, as you're gaining that independence, you start gaining more confidence. And when you're diagnosed, you kind of lose some of that. It's hard to get that back too. But I think, and that is one of the reasons why I think you would pull away from some of those support groups is that you want that independence back. You wanna take it on yourself. And it goes beyond just parental guidance and just with your doctors. I know it also shows up in classrooms with teachers, with coaches. I remember having like Kate come in for somebody's birthday and a teacher was like, oh, Jack, like, by the way, this is 28 carbs or make sure, like, are you allowed to eat this? Wasn't the coolest thing to have when you're in eighth grade happen. But I think always having that support group to rely back on. And again, like Bree said, with having a team and a support group and really understanding that it is a very personal thing to have. It is tough sometimes going through when you meet with your endocrinologist and going through day by day, looking at your charts and saying, oh, what happened on June 28th this afternoon? Like you were really high. It can sometimes take some time to get over that and kind of reveal back because it is something that affects your entire life. It's not something that you can turn off and on. It's like Bree said, it's not like chores where it's like, oh, well, did you take care of your diabetes today? It's an ongoing thing every day, every night. No matter what else is going on in life, it's something that is there. Thanks, Jack. And I think just back to that point, like encouraging our patients to find the supports and lean on those support systems is really important. And so in the next column here, I wanted to talk about black and white thinking, which is something that I think we see with our patients a lot too, where there's like these two extremes and they have a really hard time finding anything in the middle. And so a lot of times what that looks like and what I've observed is patients, they either view diabetes management as great or terrible and there's no in-between for them. Or we hear them saying things like, well, if I'm trying and it's not working, what's the point in even trying at all? Or this kind of idea that like, well, I can either do the diabetes management that I don't wanna do and be miserable or I can not do it and be happy. And so therefore I'm just not gonna do it. And so one of the resources that you all will get at the end of the presentation, it's a habit forming worksheet, which is a great thing you can do with your patients in just less than five minutes. And it helps walk them through the things in their life that they're already doing and what habits they already have. And it doesn't have to be diabetes related. So for example, if you have a patient who is really good at brushing their teeth every night and that's something that they always do and they identify that, the goal of the worksheet is to just kind of say, okay, this is the thing you already do. This is the thing we're needing to do. So for example, it could be, take your nightly medication. And so in your habit plan, you identify the thing you already do and say, every night when I brush my teeth, I'm going to start taking my medication. And the reason that can be helpful for our patients is just because it helps them see like there isn't this big black or white, there is in the middle. And like, there are these small things I can add into what I'm already doing and there is compromise. And a lot of times just taking that worksheet, taking the time to do that worksheet and like find the small things can be really helpful because it's not that the patients are being difficult. It's that they like truly feel like there is no compromise. And so if we can take the time to help them find that compromise, that can be really helpful. Anything you wanted to add in there, Jack? Yeah, I think that was really good. There are definitely times where I would be, very focused on finding the A1C or the time and range that I was looking to get. And I would almost kind of on the other side and not having when it's bad, just saying, oh, it's bad, or maybe over-correcting to be, oh, I'm a little bit high. I need to get back to 120. I need to be exactly at 120. And then I would go low and it's like, oh, well then I need to eat. And you go, you bounce way back up. It can almost, it was an over, I guess, exaggeration or I was kind of micromanaging myself with the diabetes. And I know that's, that kind of goes back to the independence thing where you want to prove sometimes that you can't handle this by yourself and you don't need to rely on anybody and gain that independence back once you're diagnosed. But yeah, looking back and kind of finding those times that you already have scheduled out in your day and relying on those to take your medicine or where you can count carbs. I think those are a good thing to implement because those are things that I'll be doing today. It's been 10 years since I was diagnosed and still relying on some of the foundations that I've learned. Yeah, thanks, Jack. I think I'm going to go through my last columns and then turn it back over to you to give some more experiences before I go into my last slide. And some of the last two columns here, we have this category of like being really approval-driven or really focused on self-image, which developmentally and like age-wise is really common for patients this age. They really want to fit in with their peers. They don't want to be different. And so some of the behaviors that you just are normal for that mindset are like, I don't want to wear a CGM. I don't want anyone to see it. I don't want to check my blood sugar or take my medication in front of my peers because that makes me different. Or like even this idea of healthy plate eating if they're with peers in a social situation and their peers aren't doing that, it might be harder for them to do it because their peers might ask them questions. You know, a lot of times we just see too like this hyper-focus on body image and appearance and diabetes is so heavily tied up into body image and appearance. And I could talk about that for a whole nother webinar, but we just, one of the things that I think is really important to remember is that we aren't going to change our patients' minds about this, not in one visit or multiple visits. This is just something that takes time. And so when our patients are coming to us and telling us that they have these concerns, instead of trying to change their minds or, you know, say, well, everyone has something that makes them different. You know, this is just yours. Or the more you do it in front of your peers, the more normal it'll get. That's really invalidating for them. And we're not going to change their minds. Their parents aren't going to change their minds because this is a core belief that they have. And so instead, if we can say, okay, tell me, you know, what about this? It's difficult. What about wearing a CGM for you? It's difficult. And if it truly is that they don't want their friends or their peers to see their CGM, then we as their care team can say, okay, you know, is there a safe way we can wear a CGM somewhere else on our body where our peers aren't going to see it? And then we've taken that concern for them. And instead of minimalizing it, we've agreed with them that it's important and that, you know, we care about that. And we're trying to work with them with it. And so whatever ways you can kind of change the treatment regimen or care plan to work with these concerns that they have is going to be really validating for them. And then lastly, in this column, we have heightened emotions versus rational thinking. And so we've already established this age group is really emotional. They have really emotional thinking. And a lot of times what that looks like is, you know, everything is just as big of a deal to them as diabetes is. And it's really hard for them to take diabetes more seriously than other life experiences because they feel things really big and that's real for them. And even though it might seem like a small, trivial thing to us as their care team, to the patient it's really big and it's really important. And another way that this shows up a lot too, I think with our patients, you know, is they aren't able to rationalize the importance of potential hypothetical complications in the future. And so when we're talking to them about diabetes management and why it's important saying that, you know, bringing up all these future complications aren't really going to mean anything to them because they're really focused in the here and now and what's important to them in the here and now. And so another resource that you all will get with the slides is a values worksheet, which again, it's just a little worksheet. It takes less than five minutes to do with a patient and it walks through different areas of life and asks them to identify what their values are, what things are important to them, the things that they care about. And so then as the care team, you can look at that and identify what they care about and what's important to them. And then you can kind of tie their diabetes management goals and your treatment plan goals to those values. And so they're individualized and they're personalized for that patient, which is going to make it a lot easier for them to do them when they care about them and when they can see why it should matter to them. And so I just wanted to turn it over to Jack before I go to my last slide to share any other patient experiences that he wanted to that might fit in with this. Yeah, so starting with the last one that you had, so kind of the heightened emotions versus rational thinking, I think making this a conversation too also helps. It's tough when you're this age and it can turn into a lecture about what will happen if you don't take care of it in the here and now, this is the number you need to be at, this is the time and range you need to have, this is what your diet should look like. And turning that into a conversation where you're asking questions, it's not just a one way telling somebody what they should do. Like I was saying earlier, diabetes is a very personal thing. I mean, it affects me and it's hard to see how it affects other people in the time being, especially when you're first diagnosed. So having that tailored into stuff that you're already doing, or like you said, matching it up with some of the morals or goals that you have already, I think that's a great way to look at it and how it aligns. Like you said, going off of the self-image stuff, you could do another session about this one. It's definitely tough. There would be times where I would be like firstly, or newly diagnosed in eighth grade where I would try to shag my blood sugar under the table before I had a CGM and this girl sitting next to me is like, oh, what are you doing? And that's not the easiest thing that happens when you're in eighth grade and you're just starting to meet people. It's like, oh, well, I'm type one diabetic. Explaining all that. And like playing sports as well. I grew up playing basketball and baseball. Remember being in a basketball practice right after I got my CGM and somebody was guarding me, hand hit my stomach where the CGM was and felt it. And he goes, ah, like, are you okay, man? Are you okay? And like, kind of stopped playing. And they're like, Jack, are you okay? Like, do you need any help or are you okay? Do you need to go do something? I'm like, no, I'm fine. Like, it's all good. Like, don't worry about it. It definitely does take time to get over. Going on dates, sometimes you order the chicken sandwich and you'll get a side of broccoli instead of the fries. It's like, what's up with this guy? Why is he getting the broccoli instead of fries? It's something that comes up right off the bat, but that definitely is something that takes time to overcome. It definitely gets better with time. And just having those conversations, I think the biggest thing was just making it a two-way conversation and not having it lectured. I think Paige did a great job of that with me when I was first diagnosed and my parents as well. And I think that's something that has helped me throughout 10 years later, still kind of look at it positively and take it day by day. Thanks. Yeah, and I think just what I want to drive home before I go into my last slide is that these things, it's hard to identify every behavioral health concern that a patient might have or every aspect of their life that's going to be impacted by diabetes, but it's just important to remember generally that it's going to flow over into other aspects of life and other aspects of life are going to flow over into diabetes and we can't separate the two. And so on my last slide here, I just had a few resources. So the third bullet point, the behavioral change worksheet, those are the two I discussed. The screen one on the screen here is the values worksheet. And so that can be used to individualize care plans and then you'll get the habit change worksheet as well. The fourth bullet point, the Behavioral Diabetes Institute has these etiquette resources, one's for parents and then one's just for like loved ones or support people who have someone with diabetes in their life. And they're really simple, but they're really important to remember And they're really simple, but they're great resources to read over and to give to patients and families when they come into clinic. They just kind of go over like nine or 10 really simple tips and strategies that can support diabetes from a behavioral health perspective. And then lastly, what I wanted to go over is just this idea of acceptance and this cycle of acceptance that patients go through. And so generally when we think about acceptance, we think about it at initial diagnosis or at the point of life where something bad happens and we go through this cycle. But what I wanted to bring up is that when we're working with pediatric patients, they're going to experience so many different life changes and transitions of life in their time. Being your patient, middle school to high school, high school to college or whatever, that their idea of acceptance of this diagnosis or acceptance of diabetes management might look different during those stages. And even though they've kind of gotten to that acceptance stage before, they might slip back into this denial or anger or depression phase multiple times. And our job is to identify what's changed in their life that's resulted in that and how we can change our approach to diabetes care that supports that lifestyle change for them. And then lastly, this idea of radical acceptance is talked about a lot in the chronic illness community. And some people have this idea of radical acceptance that it's this theory that like, we can't change our circumstances, so why try? And that's not what radical acceptance means. What it means is that there are some things in life that we just can't change. And when we encounter those things, they come along with a variety of negative emotions and experiences. And so, diabetes is talked about a lot from the perspective of management and what we can do to change it. And the things like healthy eating or lifestyle changes that we can do. But at the end of the day, in that moment, you can't change the fact that you have diabetes and you're having to do these things. And if we deny that and we kind of look over that, we deny the patient the opportunity to work through those negative emotions that might be anger or guilt or frustration, whatever it might be. And so, if we take the time to sit down with our patients and just validate that for them and be like, hey, I know this sucks. Diabetes is unfair, this is hard. The validation that we give them in saying that validates those negative emotions that they're having and it really helps them work towards that acceptance phase because they're learning that it's okay to feel that way and that it's okay to have those negative emotions. And that's just part of that acceptance piece. And so, I encourage those conversations with patients and families a lot too, just to sit with them. And the fact that it does stink that they're in this circumstance and it's hard. And I think that's all that I wanted to go over. And I think Jack might close out with just some more personal experiences and stories that he wanted to add. Yeah, so kind of building off the last point that you were making, I think having this conversation also helps you kind of build that team that we were referencing earlier too. The more that you can trust your endocrinologist or your dietician and your parents in the day-to-day, just management of diabetes helps and being able to have somebody in your corner that you can rely on, knowing that if you have a bad day where your blood sugar is gonna be high or maybe you have some lows, that they're not gonna be like, oh, what'd you do? Like, what went wrong? How did that happen? And actually listening and understanding that there are those days that there's a lot of gray area that we were saying, it's not just black and white. And that sometimes those days just happen. Paige sent me a couple of questions to kind of go over too. I know one of the things that was a big change was going to college for me. Went to school, went to UNC Wilmington. Didn't know many classmates that went there. It's a four hour, three and a half hour away from my parents for the first time ever. And that is a big change. And kind of that's another thing where you're starting to meet new people, you're going to classes. And it's it's managing diabetes during that same time. So trying to find I, I believe that Wilmington now has a diabetics more or less a club that you can reach out for support. But when you're first when you first go on, it is tough at the beginning, I remember calling page after like two days and be like, Oh, my gosh, like, I don't know what's going on. That is a big change. And I think also for parents to, I just had a call with both my parents, I was back home in North Carolina over the past weekend. And just talking to them about when I was first diagnosed, and them talking about how kind of the same thing where they're like, you're starting to gain your own independence, you're becoming your own person starting to make your friends about to start driving. And then we're thrown with this where, first of all, we need to make sure you're going to be okay. Like, I know, in my family, we don't have a history of type one diabetes, they didn't have really any friends that were diabetics. So they didn't know what was going on, why this happened? Was it their fault? And for me, I remember the first question I asked when I was diagnosed, I was like, Can I play my basketball game tomorrow? Like, am I going to be out of here? Am I going to be good to go? And their main concern was, is he like, will he be okay? Can he just in general, is he going to be okay? And I was worried about 16 hours in advance. So I think just talking to the parents and helping them, I guess, understands that it's a strange time, because the, the kids are like Brie was talking about. So it's much more of a short term goals that you're looking at, then the long term that parents may be looking at. All right, so we're going to move into the Q&A. And we are actually going to start with Dr. Walsh. There were a couple questions in the Q&A. And the first was, C-peptide is also important measure to indicate patients at any stage from type two are transitioning to type one. Kind of, I'm assuming they're asking, you know, what are you looking at? Are there any telltale signs for a patient that might be transitioning to type one? Okay, I'm not sure if it's a comment or a question. But for C-peptide is part of the insulin, like pro insulin, it's attached when you're have the extra long hormone and C-peptide is part of that initial hormone. And, and so it's a representative of endogenous insulin, how much you have. And so it can be helpful. It's something that is used a lot of times to see is your insulin level high, it's a little bit more stable. And so if the level is high, then that would be more indicative of a type two patient that has insulin resistance. Unfortunately, if the level is low, it's not as helpful because it can be low in both type one and type two diabetes. And so it is a level that can be used at times I don't use it for screening basis. I don't use it to differentiate between type one and type two just because it's only reliable in certain cases. But definitely another tool in the toolbox to help guide you. Excellent. Do you utilize many CGMs with the pediatric population? Do you find they have positive impacts on behavior management? We do use a lot of CGMs in our pediatric population, both type one, type two, and everything in between. And so we, we love it. We love our CGMs in our pediatric population. I think that's a great question. A positive impact on behavior management depends on the patient, sometimes definitely, but sometimes not as much. Um, what is your take on LADA in pediatric diabetes patients? Um, I'm not sure exactly what you mean by what's my take on it. It's another type of diabetes we see, we probably we don't call it LADA in pediatric, we call it antibody negative, type one diabetes or antibody negative diabetes. Actually, when you're billing it, you're supposed to bill for it as type two diabetes, because it's the classifications are type two and everything else not differentiated. And so if I remember to do it, I do that. But we have a fair number of patients that are antibody negative, and, but require insulin and do not have the features of our type two patients. And so we definitely see it. I don't know if that answers your question or not. I can't see the question exactly. So this is a question for Sarah. Do you encourage bedtime snacks? I think that would really kind of depend maybe. I mean, there's a few factors, right? I mean, what is blood sugar at bedtime? What is blood sugar when waking up if we have that information, right with a CGM or if they're monitoring blood sugars? Or if right, I mean, maybe the patient's just like parents are saying like, oh, I'm not sure I'm going to be able to do that. Or if right, I mean, maybe the patient's just like parents are saying, like, they're just so hungry, right? So I mean, certainly a bedtime snack could be appropriate, depending on the patient. If they have a snack, I'm going to default to kind of my general recommendation of like, if we're going to have carbs, keeping it to 15 grams or less, and then put a protein with it to balance the snack out. Now, certainly, if blood sugar is high on the higher end, whether it's at bedtime or in the morning, and, you know, they're again, they're still saying like, we're just really hungry. That's where I would kind of encourage or recommend more of just those higher protein, low carb snacks, right? If it was just like a cheese stick or some beef jerky or like some trail mix or nuts, something like that. Dr. Walsh, if all pancreatic antibodies are negative, can it still be type 1 diabetes? When are you 100% sure it's type 2? With the antibodies and oh, thanks. Sorry, I didn't mean myself. Okay, so type 1 diabetes is typically classified as using the auto antibodies. And so when you fall into that other category, like the LADA or the antibody negative different types, then, again, it's a gray zone, you can say, a lot of times I'll put in presumed type 2 diabetes for patients. So as a myriad of their presentation, their body habitus, their response to insulin, all of those things help us. I don't know if there's a 100% sure it's type 1. I think it's a clinical diagnosis at that point. Brianna, can you give an example of how you would use the value sheet? This particular person is interested in using it with her patients. Um, so if you, if you look at it, it has different categories in it. And so it's, you know, self, family, friends, society. And if there's other categories that the patient comes up with, that's fine, too. But, you know, if family relationships and having a good relationship with their family is something that's important to them, and they're able to identify, you know, with higher blood sugars, they're really irritable, and they feel like they're not getting along with their family. That could be that could be a way to identify a motivating factor, you know, family relationships might improve if they identify that, you know, sports is something that's really, really important to them, and they feel like they're not performing at their best level, then we can talk about how, you know, improved diabetes management might improve sports performance. If they have, I had a patient recently who had a goal of getting a motorcycle and getting his motorcycle license, and he wasn't able to do so because his A1C was too high. And so we talked a lot about how that specific goal that he had that you generally wouldn't, you know, you wouldn't generally tie riding motorcycle to diabetes, but we, you know, talked about how that was a direct correlation for him. And that was a really motivating factor for him. And so it's just about finding things in their life that are important to them. And sometimes it can take a little bit of pulling it out of them if they're not very specific. But once you identify those things that they care about, and that are important to them, a lot of times it's easier to find ways to tie diabetes-related goals to that too. Excellent. Okay, Miss Sarah, how do you deal with cases where kids have little control of what they eat and parents are unreceptive to nutritional guidance? This is a good one. And a challenging one, obviously. Right. I mean, certainly, we definitely come across that, you know, in with some of our patients. And that's where I think maybe trying to explore what the patient's parents, like what the parents or guardians, like, why, and obviously not saying, like, why are you unwilling to do this? You know, framing it in a nice, nicer, softer, more professional way, but kind of maybe just digging in and saying, like, you know, is it maybe like limitation? Like, do they not have, you know, great access to food? Is that the reason? Sometimes I also just find like, dad's a picky eater, and mom is not willing to make two different dinners. And that's what it is. And dad at the end of the day, right? He he's the final answer. Meat and potatoes kind of guy. Right. So I think just kind of exploring as to maybe why they why there are these barriers in places, you know, as to why, you know, parents are maybe not as receptive. And then another thing too, is also just meeting them where they're at, right? I mean, it's not that that balance plate that we were talking about earlier, that is that is the goal. That is the goal that we're aiming for the majority of the time that is not saying that that is the goal, or that's where we're going to get to every single meal every single day. Right? We are not expecting perfection, but how can we maybe make it better? Right? If you know, child is snacking on potato chips all day long. Okay, well, can we maybe talk about the portion size of the chips? Or we can we talk about maybe balancing it right that keeping it to more appropriate portion, but then can we put you know, a protein with it and trying to find maybe some some little tweaks. And I always like to tell my patients to small changes can add up to have big results, right? So I'm not saying that we need to do this 100% overhaul. But if we can just maybe identify one small change and tweak one little thing that we're doing, that at the end of the day, can make some impacts in blood sugar, but then also maybe empower them to say like, hey, when we change that, we actually ended up having these positive results, which then can kind of trickle down and make some additional changes down the road. So how do you answer this question? Healthy food is so expensive. Um, yes, obviously, when you're comparing it to maybe some of the fast food meals, you know, trying to encourage some of those food options that are more of those like pantry staple items, which can be less expensive. So you know, in terms of vegetables, like your frozen vegetables, you can get those, you know, store brands, frozen vegetables, they keep well in the freezer, or even if it's canned goods, right, like canned beans, canned vegetables, those are certainly options we can use. And, you know, again, talking with the registered dietitian as to how we can, you know, what would maybe be the better option, you know, with some of those options, just coming, getting back to basics. And even if it is that we're stopping at the fast food, because we're going for the dollar menu, that's just what the deal is, you know, can we maybe just make some more mindful choices there where, you know, instead of getting the medium fry, we get the small fry. Again, small changes. Small changes. So next up is Jack. So, Jack, I have a question. I already know the answer in your particular case, but I just want your perspective on this. Calm parents. The question is, is keeping the parents calm, you know, it's going to take some work from us as providers. But this person answering the question says it's very key in helping the child. And non-calm parent will increase more stress at home and unrealistic goals. And I think you had the ultimate calm parents. And it was so funny. They would be blushing right now if they were here. Yeah, they were. And the reason I say this as a diabetes, your educator is because, you know, there were times when they would just drop Jack off and we would have our visit. So, you know, I thought that was very empowering for for Jack. And it allowed him to communicate with me what was going on and how he felt about certain goals that he had and things like that. So I want to let you address that. Yeah, that definitely helps. And I mean, I feel like I've harped on it, but back to the independence thing is them trusting me enough to, like you said, just drop me off and say, OK, I'll pick you up in 45 minutes. That that just instilled a lot of trust in me and that this is on me. You kind of got to look yourself in the mirror and be like, OK, this is like I am responsible for myself at the end of the day. And I think they did a wonderful job. I'm sure there's more parenting advice that they could give on that. But I think at the end of the day, that's kind of something that I've always had. And that from kind of when I was first diagnosed, they helped me at first give myself shots. But soon after I moved on to giving myself shots. Yeah, taking putting me in charge of whenever maybe a sensor would mess up or I needed more supplies, I would I would be responsible for calling the companies to reorder supplies or explain what happened. Yeah, just giving that trusted it helps me. I think it's probably helps me in a lot of different areas of life is that trust that they've given me that. So I will reminisce a bit. I remember it was probably within a year, maybe a year and a half after you went to college. I'm not quite sure if who was more nervous about this. You actually were at the beach. That's Wilmington, North Carolina is at a beach. And you experienced a hurricane. Because I remember calling you and say, Okay, now, Jack, where are you going to be getting your insulin? And do you know if you go pick it up at the pharmacy, it's been properly stored? And was it kept cool and all these things. And, you know, you I remember you haven't you had a plan? You you were prepared? Yeah, and I've Yeah, it's always trying to have some sort of plan. Yeah, just kind of knowing that it's on you at the end of the day. No, no one else that I mean, like I was saying, it's a very personal disease. It's, it's just about me with my diabetes. Yeah, kind of looking out for yourself in that sense. You were always ready to educate people that were kind of in your circle. And it kind of solicit people that were going to help in case you needed them. You you kind of sought out specific people, if I remember correctly. Most definitely. Yeah. And I mean, throughout college, I even, I guess I was a quote, unquote, nanny for a child who was six years old, who's a type one diabetic, too. And that was really cool being able to kind of talk to him about some of the different experiences that he's had. And I kind of saw a lot of myself in him when he when I was younger, even though he was diagnosed much younger age than I was, but kind of talking through some of the same experiences, even though he was like six years young, or 10 years at that point younger than me. Yeah, that kind of seeking out. And yeah, I think applying that to other areas of life to stuff that I've learned from diabetes. Sarah, they wanted to ask you about glycemic index and glycemic load. How does that help the type two diabetes patient? Well, honestly, we don't really, you know, teach glycemic index. There's a lot of gray area around that. And that's kind of because too, it just depends on like the resource that you're pulling the glycemic index from. I mean, you look at one glycemic index, it could say something as low or moderate where you look at another glycemic index, it could say it's high. So we really don't address glycemic index, more talking about foods in terms of these food, these carbohydrate foods have more fiber, when your carbohydrates have more fiber, you know, that can help, you know, with your blood sugar stability, you know, affects the spike in, you know, in the blood sugar, but then also what are we pairing our carbohydrates with, that goes back to kind of what I was talking about with, you know, making sure that we're pairing our carbohydrates, you know, with protein, that that is kind of something else that, you know, we encourage. So more about kind of what you're putting the carbs with, and then making sure that they're more majority of the time, more of your, you know, higher fiber, more whole grain, complex types carbs. If, if you have a population of patient that cannot afford to see a registered dietitian, do you have a recommendation for carb counting, carb intake in pediatrics? Like what do like, the question is, are we asking, like, what's the recommended carb amount for our pediatric patients? If I'm assuming that's probably one of the questions. Community Health Center, and at times her patients cannot afford to see a registered dietitian in terms of carb counting, what would be the best recommendation for a carb intake in pediatrics? I know this varies on age, or would you just recommend the plate example? Plate examples, I think it kind of depends on blood sugars and medications, what the patient's on. Certainly the plate example is a great general tool that we can apply across again, different age groups, different backgrounds, cultures, whatnot. And especially if they're not carb counting, if you have a patient that's carb counting, what we typically recommend is keeping those carbohydrates to less than 60 grams per meal, and then 15 grams per snacks. Gotcha. Did you have a resource, Jack? I'm sorry, what, me? Jack, did he have a resource? I'm sorry. A resource? Resource for carb counting that you liked? Um, I believe it was MyFitnessPal is what I used. Okay. Calorie King is another great, sorry, Calorie King is another great option too. It's a free app that you can download on your phone. And it's just a big food database, right? So and what's so great about that too, is you can look up, you know, Chick-fil-A or certain brand name foods, but you can also look up something very generic, like an apple. So it is just a huge wealth of information. And right, a lot of your adolescent children and patients have cell phones, smartphones. Dr. Walsh, do you use between visit calls with families to check on goals? If so, how are they received by the family? We typically, can you hear me? We typically bring our patients back, we can, our center is a comprehensive center. And so what we'll do is we'll have patients see us. And sometimes if they're traveling from a distance, we'll do a combined visit with one of our dieticians. If not, we'll intersperse the visit. So if I'm seeing a patient every three months, then I'll have them see one of our diabetes educators in six weeks. And so that way we're alternating and seeing them every six weeks. Certainly we make it available for them to call in, we can also use electronic messaging, they can contact us, we encourage patients to let us review blood triggers as often as they would like. And it just varies for the patients who take us up on that. So real quick, cereals. How do you talk to a child about with type two about making best choices for cereals? Cereal is a tough one. Not gonna lie there. Right? I think, again, Dr. Walsh kind of tested this, you can look at a you can look at a CGM download and say you had cereal for breakfast this morning, didn't you? It's a very obvious, you know, blood sugar spike versus, you know, eggs and toast. Um, you know, that's where, again, if we can try to encourage maybe if cereal is the option, and that's what it's going to be, right? And is that going to be the perfect option? Probably not. But that's what we have. That's what we're going to go with, right? That's what the patient wants. They're picky eater, they're only gonna eat cereal, can we at least try to find a cereal that has, you know, less added sugar, maybe it's made with a whole grain, so it's going to incorporate some fiber. And then there's certainly always that option. If anyone's familiar with Fairlife milk, I'm recommending I'm putting this out there. But obviously, it's also a, it can be more expensive than your regular cow's milk. But an ultra filtered milk is certainly an option that I have some patients that use because it's lower in carbohydrate and higher in protein. So it can be a way to incorporate, you know, some protein. And hey, maybe if we can throw in like a cheese stick on the side that can at least give a little bit more that can help minimize that, you know, really high blood sugar spike that we see with cereal. There you go. Well, this has been a great presentation. I share all the sentiments that are in the chat that it's just an excellent presentation, and everybody has enjoyed it. And thank you all very much.
Video Summary
The webinar on managing pediatric Type 2 diabetes, moderated by Paige Johnson, provides essential insights for primary care professionals. Dr. Elizabeth Walsh, a pediatric endocrinologist, highlights the complexities of diagnosing pediatric Type 2 diabetes, noting challenges such as distinguishing between Type 1 and Type 2, and screening high-risk populations. Dr. Walsh emphasizes that Type 2 diabetes in children, initially identified in Pima Indian children, has seen a staggering increase, particularly post-COVID-19, due to several risk factors including genetics and lifestyle. Early detection and treatment are vital, and the American Diabetes Association provides guidelines for screening, especially for children over ten who have other risk factors.<br /><br />Treatment strategies vary according to A1C levels, often starting with lifestyle interventions and metformin, and possibly insulin for higher A1C levels. New medications, like GLP-1 receptor agonists, are being considered for pediatric use, underlining the importance of prompt and aggressive management to prevent early complications.<br /><br />Concurrently, Sarah Navalee Rush, a registered dietitian, discusses strategies for nutritional management, highlighting the balance plate model as a resource to promote healthier eating habits. This model balances non-starchy vegetables, protein, and carbohydrates, fitting within cultural dietary preferences and supporting the physiological needs of young patients.<br /><br />Behavioral health aspects, presented by Brianna Winston, address the psychosocial challenges faced by adolescents managing diabetes. Factors like peer pressure, independence, and self-image significantly impact their management rates, echoed by patient Jack Thomas. Strategies to assist these patients include promoting open communication, validating emotions, and encouraging a support network to foster acceptance and long-term management of diabetes.
Keywords
pediatric Type 2 diabetes
primary care
Dr. Elizabeth Walsh
diagnosing diabetes
high-risk populations
American Diabetes Association
screening guidelines
treatment strategies
GLP-1 receptor agonists
nutritional management
balance plate model
behavioral health
psychosocial challenges
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