Hello, everyone, and welcome to today's Diabetes and Youth Interest Group webinar. Today, our panel is going to be discussing youth onset type 2 diabetes, navigating unique challenges during the pediatric to adult health care transition, and we're so glad that you're all here today. We sure are. I'm Summer Hafida. I will be co-moderating today's webinar along with my colleague, Dr. Srinivasan. Just to share a little bit about myself, I'm an assistant professor here at Boston University. I'm an adult endocrinologist and weight management specialist at Boston Medical Center, and I have a particular interest in management of diabetes and obesity, and I'm privileged to serve as the director of Diabetes and Obesity Adolescent Transition Program here at Boston Medical Center, and I am super excited for today's webinar. Thank you, Summer. Hi, everyone. I will be co-moderating this session along with Summer. My name is Shailaja Srinivasan. I am a pediatric endocrinologist and clinical researcher at UCSF, and both my clinical and research focus is on youth onset type 2 diabetes, so again, really excited for this very important topic. Thank you. Today's agenda will be up on the screen shortly. We'll spend the next hour together by following the agenda right here that you see on the screen. If you have any questions, we have the Zoom Q&A. We can talk about your questions at the end of our presentation today. If you think of any questions during Dr. Finn's presentation, please go ahead and type them in the Q&A rather than the chat, but don't worry, we'll get to your questions as soon as you type them in. Great. We're also going to use an interactive tool called Kahoot to ask you knowledge-based questions and to collect your answers in real time, so we'll tell you how to connect to Kahoot. If you have a mobile phone or a tablet nearby, that is the easiest and best method to do so, but if you want to join using the device that you're connected with right now, you'll just have to open a separate browser, and you can open another window or tab on your browser. Yeah, that's right. We really want you to connect with Kahoot today so we can all be interactive, so go ahead and open that browser and type Kahoot.it, and you'll see the image on the screen right here. It looks like that, and then enter today's game pin that you'll find in the Zoom chat right there, and it'll also be available for you on the screen. Let's give everyone about 15 seconds or so to connect. Okay, hopefully everyone is connecting and successfully connecting to Kahoot. And I am very excited to introduce our speaker for today, Dr. Erin Finn. Dr. Finn completed her undergraduate studies in biochemistry and microbiology at Rice University before receiving her medical degree at the University of Colorado School of Medicine. She completed a combined residency in internal medicine and pediatrics at Baylor College of Medicine in Houston, followed by a dual fellowship in pediatric and adult endocrinology, diabetes, and metabolism at the University of Colorado. Currently, she serves as a faculty member at the University of Colorado, working at both the Children's Hospital of Colorado and at CU Endocrinology at the University of Colorado Health entrance campus. Her primary area of focus includes youth onset type 2 diabetes, young adults with all types of diabetes and transitions of care for young adults with other chronic endocrine conditions, including Prader-Willi syndrome, Turner syndrome, and congenital adrenal hyperplasia. Thank you again, Dr. Finn, and we're so glad to have you here today. Indeed. Thank you, Dr. Finn. At this time, we'll let you introduce yourself and here are your disclosures. I have no disclosures. Thank you so much. I think it's time for me to take over the slides now. Just one moment. Perfect. Okay. There we go. All right. Well, thank you all for joining this December afternoon. I'm really excited to talk about this topic because I often find it is one that gets overshadowed by the many other pressing needs and kind of demands we have in our clinical time. But I really wanted to talk about the youth onset type 2 diabetes and as we navigate from the pediatric to adult health care systems. All right. So the outline of my talk, we're going to talk a little bit about the unique challenges faced both in youth onset type 2 diabetes overall and then as young adults are emerging into adulthood. I don't know kind of the variety of providers we have on this. We might have some pediatrics, some adults, some primary care. And so I want to make sure we start at a good place understanding the unique challenges of youth onset type 2 diabetes. We'll talk about research very specific for transitions of care for this group. And then we'll finish it up with some practical strategies that you can take away from here in your practices to take care of this group. All right. So we'll start with a Kahoot question. What challenges do emerging adults with diabetes face when transitioning from pediatric to adult care? So we'll give it a minute, put some answers in. Any answers are reasonable, so just put some in. Perfect. All right. So understanding insurance coverage, absolutely. Finding a provider. Access, always an issue. Supplies, appointments, scheduling, and finances, and then aspects of adulting with jobs, school, balancing. I completely agree with all of these things. OK. So I'm going to start a little bit, I'm going to start with some definitions. So we're talking about youth onset type 2 diabetes. This is a diagnosis of type 2 diabetes that occurs, and there's a little bit of variation, but we're going to say before 18 to 25 years old. Most clinical trials and groupings of this population are before 18 years old, but there's some evidence that even before 25 has a unique disease. Adolescents and young adults, also known as AYA, is a group that involves the second half of teenagehood, so above 15, considered to 39 in the US, but other countries are 15 to 25. Emerging adults is an 18 to 29 year range. Transitions in our context, we'll be talking about the purposeful and planned movement of adolescents and emerging adults from child-oriented to adult health care systems. And then when I refer to transfer, it's the actual move between the clinics. So we'll start with what makes youth onset type 2 diabetes unique. All right, as many of you are aware, youth onset type 2 diabetes is a unique condition with increasing incidence. In this search study, there was a doubling of prevalence between 2001 and 2017, with about 67 per 100,000 in the US for incidence in 2017. And more recently, global incidence has been rising to up to 183 per 100,000 population. This is not just a US problem, and a lot of their increasing incidence is now driven by increasing rates in China and India, actually. So this is something that across the world, we're going to have to learn to address. When I say youth onset type 2 diabetes is a unique disease, I mean that in a couple of ways. In studies, we found that youth onset type 2 diabetes, when you have a diagnosis of type 2 diabetes when you're still in the pediatric system, it is often accompanied with significantly more insulin resistance. It's not uncommon if we need to use insulin in our patients that they have one unit per kilogram insulin needs, which is more than we would expect in a lot of our adults in adult onset diabetes. Even with this increased insulin resistance, we then run into an accelerated increase With this increased insulin resistance, we then run into an accelerated and progressive beta cell failure. Even when treated, our patients have less beta cell reserve after a fewer years of diagnosis than those diagnosed later. And then youth onset type 2 diabetes is unique as well because of how much it disproportionately affects families and communities. It is highly genetic. You'll often find multiple people in a family have had diabetes diagnosis, especially when young. It's associated with lower socioeconomic status, racially and ethnically marginalized groups across the world. And it has a strong interplay in the environments as well as kind of future ability to take care of their health care as well as do things to better socioeconomic status like jobs. Are therapies for type 2 diabetes in kids, I just want to throw this out there for those who don't have as much familiarity, some of our adult providers. We actually do use similar medications to adult onset. But it's not completely the same. So not as many medications have been studied or approved for those under 18 years old. So the medications that our kids have been exposed to before they enter adult care vary. We do use all types of insulin, though only Degladec and Tujeo actually have approvals. Metformin is used. Some of the GLP-1 medications are approved in pediatrics, loraglitide, weekly exenatide, olaglitide, and then some of the SGTL-2s. But the effect on A1c and BMI in the trials is not the same as in adult care. So this is a table I got from one of my colleagues, Dr. Megan Kelsey, that shows a good comparison between the pediatric and adult trials for type 2 diabetes in these medications. And as you see, we get a little bit less A1c difference than we'd expect for the same amount of medication. And in some medications, like the 1.5-delaglitide, we actually got neutral weight loss versus a positive weight loss. Now, as you see, there's a lot of question marks on this table as well. Youth onset type 2 diabetes trials are notoriously hard to recruit for and complete. And so a number of trials are actually still ongoing, including our higher-delaglitides, our semaglutide trials, and our terzapatide trials. And so this data may change in the upcoming years, but is currently very much in flux. So how do outcomes differ from other groups? So youth onset type 2 diabetes actually varies compared to type 1 diabetes with worsening outcomes. Now, this may be surprising to some because many youth onset type 2 are treated without insulin medications or multiple daily injections. So you'd assume, oh, it's not as severe of a disease. But our long-term outcomes actually show that they have higher rates of kidney disease, nerve disease, and a number of risk factors for cardiac disease. And this holds when comparing youth onset type 2 compared to later onset type 2 with higher rates of neuropathy and retinopathy, peripheral vascular disease, even when compared to length of time of diagnosis. So of course, you'd assume that someone diagnosed at 15 versus 45 would have more complications at the age of 50. You've had the disease longer. But some of these complications even exist when controlled for length of time of having the disease. And then in a large meta-analysis of 1.3 million individuals from 30 countries, we see that the age of diagnosis is associated with macrovascular, microvascular, and all-cause mortality. So the younger you are when you get your diagnosis, the more we need to be aggressive and manage not only your glucose management, but also your risk for complications. And when we look at, very specifically, a group that is followed from when they were diagnosed until adulthood, this specifically is the TODAY study, which was a study looking at treatment options for youth onset type 2 diabetes, comparing metformin, rosiglitazone, lifestyle, and insulin. When they followed these patients up who were diagnosed when they were pediatric care, they were followed for a mean of 13 years from diagnosis. So they were in their 20s. For most of us, we think of very, they're young still. These are young adults. We found that A1c control deteriorates the farther in you get. So when you are initially diagnosed within the first year, we actually managed to get 75% of participants under an A1c of 6.5. But over time, you see this deterioration in care. And when we think about it, that 6- to 9-year follow-up, if you're getting diagnosed as a young teenager, is exactly when you're transitioning. It's exactly when you're being seen by adult care is when you get this fall-off of management. And when you're getting 9- to 12-years out, 45% had an A1c greater than 10. And this had future health implications, as I said previously, compared to youth onset type 1 and adult onset type 2, where 50% of these youth onset type 2 diabetes have hypertension, nephropathy, neuropathy in their second-decade of life. When they're in their 20s in their peak income-earning years, building families, trying to establish themselves in their lives, this is when they have all the complications that, in some ways, young adults should not have. OK. So how is youth onset type 2 different than adult? This is just seeing if you either know it or questioning if you've been paying attention to this first half. All right, there we go. Show the answers. It's more aggressive. You have deterioration and control. You have the insulin resistance. Pernicious, it's hard to treat. When it gets out of control, it's really challenging to bring it back into control. Growth and maturity impacts consistency. Yes, it's not only a hard disease to take, but man, is it hard to remember medications when you're a teenager and a young adult. Social issues, and then of course, when we're talking about lower socioeconomic status with type two diabetes, we often get those social disadvantages impacting your ability to care for yourself, even when you have the medications. All right, shifting gears, we're gonna just talk about general, what is healthcare transition? So transition occurs at a time of great turbulence. You're moving, you're graduating college, work, new work. You have roommates and new social environments. And then even for our young adults with intellectual and developmental disabilities, they often move from their structured and school-based programs at the end of their teenings to staying at home, maybe not having the structure or the oversight, especially with food, which is a major issue with type two diabetes, or into day programs where they don't have the nursing support to give medications. Healthcare is confusing. It's complicated. We all pull our hair out every day. Can you imagine what it's like for a young adult to navigate this? And then emerging adults think differently, both good and bad. They think differently. They have increased ability to engage in risky and novel behaviors. And it's a time of experimentation in their lives. This of course is challenging because they don't have the structure. They don't have a set of a diet pattern. They have a lot of exposure to things like drugs and alcohol, but don't forget that also makes them more willing to try new things, not be so set in their ways, maybe being open to clinics. So we need to remember to capitalize on the positive aspects of being a young adult. There is decreased structural and family support. And then of course, this is the time in your life when you have the least amount of money. You're working tough jobs, hourly jobs. You don't have any work hierarchy. And then you're without savings. You haven't had that time in your life to build up savings yet. The healthcare systems are different. We all know this. The children's healthcare system, it's family focused, active health follow-up. We track down our patients when they're not showing up. We call their family members because we're allowed to, their children. But there's less variety of care options. You know, in Colorado, there's three pediatric endocrine practices. And the majority of patients actually go to Children's Hospital Colorado. There's better insurance coverage though for pediatrics. We value care of children more in our country. So they have more access to things like Medicaid and places that take care of kids take Medicaid more often. There's a team working, social work, psych, other things. And then the visits are longer for children. But for adults, you know, you're more patient focused. Maybe, which can be an advantage if a parent has always been butting in or really focusing on their care. The adult system does pride of, you know, we're good or bad does focus a little bit more on the only the patient. But it is the patient's responsibility for follow-up. They have to call, they have to make it. There are many care options, but your insurance is often not covered at some. So you have to navigate who can be seen and where. And the visits are shorter. It makes it tough to handle a lot of things, but maybe a little bit easier if your work situation is tough and you only have a 15, 20, 30 minutes break to join a telehealth visit for your care. And so we have to remember not only to complain about the differences, but capitalize on the differences between our care systems. If anyone has been involved in any transition of care kind of talks or work, they may know gottransition.org, gottransition is an organization that provides training and resources for the general transition of young adults in our healthcare system. Both those that will function independently and those with intellectual disability. They have six pillars of kind of how to build and develop a transition program. I am a little simpler and I kind of just group it into three bigger categories, but if you want to get into the details, it's a great resource. I think the key is developing a process, prepare the patients and transfer the patients. And at the end of the day, those are the three things we are able to do and have control over. More talking specifically about diabetes transition, the endocrine world should be proud of themselves. We've been on the forefront of transition of care with our type one transition of care. And that ends up being a huge benefit. We've developed individualized tools like the REDI questionnaire, which anyone who's in the type one transition care, it is a questionnaire and tool to prepare. And I know there's been some talk of development in a number of institutions for REDI specific for type two, but at this point in time, it's focused on type one. Young adult college diabetes support groups are for type one. If you look at the scholarships and things available, a lot of them are actually type one focused while some of them are more generally disability or diabetes focused, it's not necessarily given. Transition clinics, even ones who encourage and include youth onset type two patients, often they're dwarfed by the number of youth onset type one. And then expectations hugely vary. I know in my state, our major HMO system actually, well, we have to do a lot of discussions and arguments if we want them to see endocrine versus PCPs taking care of the patients. And then just endocrine practices in general. Now this can be good and bad that you have two potential options, but we need to realize it's not entirely clear and there's not a unified focus on where these patients should go. And then because of the nature of how different youth onset type two is, because none of the research has really been focused on transition for youth onset type two, I really wanna take a moment and only look at research that's focused on this population so we can take from it what evidence is out there right now. And so with that, we're going to get into the evidence a little bit about what is our current evidence for the youth onset type two diabetes and what should we do with our patients? All right, so one of the first assessments dedicated to youth onset type two transition was a sub-analysis of the Search for Diabetes Youth Study. And so this is of course a big study that followed longitudinally 2000 to 2020, looking at all youth with diabetes, but this was an analysis of just a subgroup of those who had youth onset type two, diagnosed and had their first search visit before 18 years old, comparing to their first visit in the ages of 18 to 25. Important to remember if they had multiple visits, only the first one was included. And so with that, what they found was the average followup between that first visit and second visit was seven years. Now they may have had visits in between, but this was just comparing diagnosis to that first when they were in the adult range, as expected based on just our population for youth onset type two is a very racially and ethnically diverse population. It is from a number of states across the country. About 40% were on government insurance at baseline, about 57 actually with private insurance and a small percent uninsured. And the biggest thing we found was that insurance status on their followup visit was heavily associated with no care. This makes sense, that's very practical. You might say, why do we need a research study to say if you don't have insurance, it's harder to get care. But it's good to remember that if you do not have, you know, those without insurance, we have 73% of the no care group were in that category, about 21% of the government and then 4% or one participant with private. However, looking at A1C, it's actually interesting. So when comparing those who are still in pediatric care versus those who are an adult or no care, well, there was worsening A1C in all groups actually. So baseline A1C compared to followup A1C was worse in all groups as we kind of expected based on our earlier studies that we discussed. But there was comparably worse A1C in both those who transitioned successfully to an adult provider and those with no care. Now, remember, this is their first visit. So would these patients get it back under control once they build a relationship? That is not what the study is looking at. And this is a correlation, not causation. But something for us to remember that those who transition, who have the break and reestablishment of the relationship are more at risk for decompensation. So what I wanna say is first, anticipate worsening glycemic control. Both transfer to adult care and loss of care are associated with worsening control. So our next study we're looking at kind of going further into the insurance was an analysis of the ongoing today study. And this was looking specifically at insurance coverage and if that matters with engagement of care. And specifically, it then looked at the states that had Medicaid expansion and who didn't. Because this is conducted during the time where we have gradual rolling out and changes and states that do and don't have Medicaid expansion. And what we find is states that did have Medicaid expanded, the patients were more likely. So we have basically 2013 through 2016, black bars are government, gray is commercial and dark gray is uninsured. The Medicaid expansions on top, Medicaid non-expanded is on the bottom. And as you see, you get, as you have more engagement in Medicaid, you get more engagement insurance with Medicaid and less uninsured patients and the states would have expansion. But did this make a difference in A1C? Maybe, according to the study, we did not find statistical significance. And so P value 0.7 is not technically statistically significant. Of course, these groups are small. These are not large Ns that are in the study, but we do see worsening whether they have government, commercial or uninsured. But it is something to kind of pay attention to that. Again, across things, we do get worsening. We haven't necessarily shown insurance yet makes a difference. Makes a difference with engaging in care, but not A1C. So young adults are impacted by the state Medicaid policies and insurance coverage alone does not lead to goal A1C unless we do a bigger study and see if we can tease apart the differences. All right, now leaving the United States and actually going north. I like this study just because it gives us an idea of what is it like, you know, youth onset type one versus type two when you live in a country that has a healthcare coverage, a universally and less of a patchwork system. And so this is data from Manitoba, Canada, looking at youth onset type one versus type two. Similar to what we have seen in other ways, there's different social and geographic barriers with higher rates of patients being low socioeconomic status. We have higher rates, it's not in this table, but higher rates of Alaskan native population. And actually higher rates of pregnancy in the youth onset type two versus type one with about 18% of the youth onset type two versus 4% type one having pregnancy during this analysis. Comparing follow-up, about 76% of youth onset type two versus 97% actually had a visit post-transition. So we have more drop-off. We can imagine a couple of reasons. You know, a lot of the time if you have type two, you're asymptomatic, you don't necessarily notice, you can kind of drop off of care and it won't land you in the emergency department within a short amount of time versus what we often find with, you know, our young adults with type one. But they did actually have increased admissions, though this was partly driven by pregnancy rates as well as mental health and not necessarily admissions for endocrine. So even when insurance is not an issue, there is a tendency for youth onset to disappear from care in some ways because the complications are long-term and not immediately on the minds. You do get it where you can drift away from care without the immediate repercussions which often hit closer to home if you're a young adult. And so keeping them engaged ends up being a challenge but more important. And then low socioeconomic status is a trend across countries. All right, so this is a study that is out of Philadelphia, University of Pennsylvania in CHOP. So this is a study about emerging adults with type two diabetes and actually asking them what the experience is like and what they kind of recommend. So I really like this study. It's not large, which all youth onset type two diabetes studies tend to be small, but it looked at 18, it asked qualitative interviews with 18 in pediatric and seven in adult care to get their opinions on what it's like to have youth onset type two and what they recommend for transition of care. And so this is really wordy, but I'm going to on the next few slides just kind of pull out a couple of things. But this paper is a good paper if you want to go through and read, advice to a pediatric providers, advice to adult providers on things about anxieties towards transitioning, the logistics of it and what kind of, what resources the patients themselves would like. And so in pulling it out and kind of summarizing the pediatric provider tips is, when a pediatric provider recommends and ideally knows an adult provider, it does instill confidence in an emerging adult that they know they're going to a good place. If not knowing someone or handing off, we have a very complicated healthcare system, a curated list can help. I know we encourage people to log in and look at your insurance list, but those aren't always up to date. They're sometimes overwhelming. So even if you can give them a place to start, it can be helpful. It's important to start reinforcing skills like self-scheduling and organization prior to leaving pediatric care. And then discuss how to contact your insurance, find a network, make sure you have insurance and things like that. For adults, be welcoming on the first visit. Realize these are often patients who, while have had a lot of contact with healthcare, don't necessarily know how to interact as well. Share your expectations for your clinic, a guide to clinic. This is who you call. This is how you make appointments. Rediscuss self-management. Let them drive the discussion though, so you can actually understand what they do or don't know. And then be aware of comorbid mental health issues and have some resources for that. So the takeaway from this paper, I would say is emerging adults have anxiety and apprehension about leaving their pediatric, partly because they have strong relationships and it's building a new relationship, new trust in an office. For pediatric clinics, you know, start practicing scheduling and self-management, provide them with a targeted list, if you're able to, of adult endocrinologists, or if you have a targeted list of primary care docs who like to work with this population, even better. And then adult clinics, guidance to clinic expectations and work on building a relationship first. And then this is a paper that is upcoming. And so Dr. Stephanie Chung's group at the NIH is in the process of writing or completing their, or they're done with writing, they're in the process of completing this kind of scoping review of youth onset type 1 versus type 2 diabetes, the approach. So I'm really excited for this paper to come out. I've been in contact with her and I know she's in the final stages. So if this is an area you're interested in, both youth onset type 1, type 2, and transition, keep an eye out for this. That should be forthcoming in the next year, I hope. So two non-transition related topics, but I really think is important because it's so central to this age group. The first being pregnancy. So in another analysis of the Today Study cohort, of the 452 women or females followed from the Today participants, about 10.2 participants experienced a pregnancy in the years during this study. And of that, there's a 20% rate of congenital anomalies, so a one in five. Now these are patients that were counseled by protocol to in some ways not get pregnant, to be on birth control, to have protection, and you still had a one in five rate, or a 10% rate with a one in five rate of complications. And so practical, these are tips that aren't necessarily research-based, but more practical, my experience-based, is yes, it's important to discuss contraception, especially long-acting reversible contraception, or LARCs, but you also have to review in event of pregnancy recommendations. Because a lot of these patients will be on GLP-1 and SGTL-2 medications that need to be stopped upon first positive pregnancy test, you need to let them know that they have to call the clinic immediately, let them know so we can have them switch over. Metformin can be continued through the end of the first trimester, but eventually should be stopped. But for those planning pregnancy, or even those who you're at high risk, you might wanna consider meeting with a diabetes educator, learning how to use insulin. Some youth onset type 2 diabetes have used long-acting and short-acting insulin, some have not, some have never used insulin, have been managed on these other medications. And so upon positive pregnancy test, you need to get them off the medications onto something else to help control, to really help with those first eight weeks of organogenesis that occurs. And then my other topic I like to touch on is bariatric surgery. Now, the reason I bring this up is that as a adult endocrinology provider, it's sometimes, well, I think it's changing, but we think of bariatric surgery, actually on both sides, as kind of the last resort. We tried everything else, things are really bad. And so when you have someone who's just transitioning into your clinic, who you might wanna follow for a few years, because they're really young and we wouldn't wanna take that big step, you may not realize that bariatric surgery is an option. So I do part of my work in the bariatric surgery clinic at Children's Hospital Colorado. And so we do bariatric surgery on teenagers with onset type two diabetes. And there is fairly good data that while it's a big step, that those who undergo bariatric surgery compared to those, so that's on the left here, the teen labs cohort, versus those who went medical management and were followed from the Today cohort, had more long lasting control of diabetes. So these dark blue is normal, A1C under 5.7, and then the light blue is just under 6.5. And so years out, you have some ability to maintain control, even often off of medications, versus the Today study, which we already saw, you get a gradual decompensation, even when on medications. And then comparing youth onset type two, getting bariatric versus older adult, you actually get a higher sustained rates of remission. So you can get diabetes remission from bariatric surgery. So diabetes control, not on medications. But when comparing the two groups, you actually get better sustained remission if you have bariatric surgery younger than older. Now it is a very big step to get surgery. It needs to be considered, you need a competent surgical team, you need good support. You don't want it to be a rushed situation and you want a surgical team that knows what they're doing, so you don't get complications like post-bariatric hypoglycemia. But at the same time, the difference it can make in these young adults' lives to potentially get remission or have a diabetes that's controlled on one medication or two medications can mean a huge amount. And so I just want you to remember that that is something that if you're just about to hand off or you're about to receive a patient, that we can talk about that in that time period as well. Okay, so hitting the highlights, if you had to take a break and go to the bathroom or were drifted off in my presentation, we'll hit up the highlights of where the evidence is. So youth onset has lower rates of successful transition. Transfer to either no care or adult care are both associated with worsening glycemic control. Insurance creates a disproportionate barrier for our young adults. But even with insurance, follow-up is lower. There's a lot of anxiety and apprehension around transfer of care. And remember, we want to focus on relationship, not A1C. There's high rates of adverse pregnancy outcomes in these emerging adults with type 2 diabetes, so prepare your patients. And bariatric surgery is an option you should consider. Where is research needed? In some ways, everywhere. If you noticed, I didn't talk about what interventions will make a difference. I didn't talk about prospective studies because we don't really have those yet in this group, in this isolated group. So do joint clinics, warm handoffs, improve outcomes? Are emerging adults with youth onset best served by primary care, can manage all of their care, maybe more cost-effectively or closer to home? Or a specialist who is able to really stay on top of data and research, maybe has the CDEs and the access to CGM. Or both. I'm a maximalist, so I always like both. But we have to be aware of the limitations in our healthcare system and meet patients where they're at. What systematic changes are needed to ensure access of care in our system? And then if you notice the timeline of all these studies I put out, it does not see the impact of our GLP-1 agonists that are weakly, are really effective ones, or semaglutide and terzapatide are not reflected in this. And for our long-term outcomes like microvascular kidney disease, we're not necessarily seeing the impact of the SGTL2s yet in our research in some of these studies. So what difference will it make with the complications? What difference will it make on glycemic control? It might make it better, but it also might make it that our patients are more dependent on better coverage because our medications that we use are so expensive. And as they go into jobs that may have worse commercial coverage, we may lose access to the GLP-1 agonists because they're so expensive. And so it's both an exciting time, but a time we have to realize the balancing measures in some of the stuff we do. So what are some practical ideas? You know, with all of this stuff we're talking about, and this is kind of, you know, taking away of, you know, there's high rates of complications. We need intensive support. It's good to recognize the things, but then I'll give you just a couple of numbers of things to keep in mind. And so I'm a big fan of not doing gatekeeping appointments for youth onset type 2 diabetes. I completely understand we're really stretched as a system. Many practices in my state have six month out wait lists, but having a higher barrier, like needing to be on MDI for type 2 diabetes to get in with an endocrinologist or needing to have been decompensated prior to getting into an endocrinologist are not a good approach for this group. We may need to lower the barrier if it's a pediatric transfer, then compared to, you know, if you're 60 years old, I think it's very reasonable to, you know, prioritize patients that need it. But please put this in your priority list. There are opportunities of care for both endocrinologists and knowledgeable engaged primary care offices. I have a lot of friends who are primary care, very engaged, very sharp, and I think they do an excellent job, but I want, you know, we need to be very purposeful that the people who take care of these realize the importance. And then of course, preconception counseling. So I am going to give you advice based on one of my more favorite papers in the transition world. So this is Dr. Inger out of University of Michigan. And so she does the adult endocrinology transition clinic up there for diabetes. And so she wrote a great paper on five recommendations for effective receivership. We can't put everything on our pediatric colleagues. We as adult providers need to have a place for these patients. And so I broke it into two things, effective preparation. So one, develop a plan and share with your patients. Two, transition preparation begin years before transfer. You got disease specific education for the patient, not just the providers. Remember they may have gotten lectures at 10 years old, but they need it again at 15, 16, 17. They need to understand what they have. Healthcare system education. And then on the gottransition.org, there are questionnaires and guidance. One of them is the track to guide conversations and engagement with how much do your patients know. Build relationships with adult providers to encourage smooth transition. You know, have people in your back pocket that you can reach out to that will prioritize. This isn't a huge population, but it's important to find a way to get patients in a little bit sooner, a three month visit, not that six month visit. And then track patients and follow up. I know this is a major problem we have. I myself have a major issue figuring out how we're gonna do this without using manpower that doesn't exist. I love research studies because you can use research money to pay for things like this. But at the end of the day, we also need to figure out practical ways who in our clinics can be involved in this for a sustainable thing once those grant money ends. And then effective receivership with a youth onset type two diabetes stem. So I added, I did five plus two additional ones compared to the FHIR receivership guide I gave you. So one, recognize youth onset as a unique population. You need to maintain relationships with your pediatric colleagues. Assess knowledge and skills to identify areas of intervention. I appreciate the long, long lectures we sometimes give our patients, but it's always good to know what they already know and then areas you can intervene so you're kind of meeting where they're at. Focus on relationship, just not A1C. Remember, we're in it for the long run. So if they come to you after having not had care for two years and they've completely decompensated, their A1C is high, and you're just trying to put the pieces back together, your goal is to get them to be in clinic and to come back to clinic so you can start working to get them back under control. Non-judgment, you want them to come back. Be aggressive with the monitoring and management. I've seen a number of times where we've had patients that have gone out who are well-controlled, who looked like they were in remission, got pulled off all their meds, essentially discharged from a clinic, and they decompensated years later. So if you're going to test it out to see if they need less, be cautious, be wary, and you have to follow up because they're high risk for future decompensation. Develop strategies to identify and address psychosocial needs, and a team-based approach. Now, yes, in an academic medical center, you may have a bunch of diabetes. Educators, you may have a lot of options, but even if you don't have that, even if you're a tiny practice, a small practice, have them meet your MA, have your nurse check in with them. Just let them know there's a way to someone to call, a person to, make them feel a part of the home and family, even if it's not a giant clinic like they had in their pediatric side. All right, I covered that, so we're going to skip it. And then you're probably wondering, I'm just going to put this in there, what are we doing at Children's Hospital Colorado? So we have a clinic that's called the Lifestyle Medicine Clinic, and so that is a dedicated type 2 diabetes clinic that we're currently doing a transition QI initiative. We follow patients from diagnosis with youth onset type 2 to when they leave our clinic. Right now, it's kind of a 21 to 25 range, depending on the patients. And we're working on kind of a needs assessment, what our patients think, are seeing kind of like the study, but just seeing what our local patients are wanting from our clinic. We're testing out a combination of warm handoff where I see them both at the pediatric side and the adult side, as well as asynchronous. You know, if they've had a long relationship with their other pediatric endocrinologist and they live far from home, Colorado is a big place, many of our patients, and some of them drive seven hours to get here, handing them off to someone closer to home. And then our focus is to establish both, ideally both a community primary care doc as well as an endocrinologist, but we're gonna try to see, you know, what is feasible and try to meet patients where they're at. You know, if they live far away and don't have an endocrinologist, which is really common in a lot of our state, having a good primary care close to home is often sometimes a better option. And so we're kind of working on that. So Laura, stay tuned. All right, so just the takeaway points, youth onset is a unique population, deserves special recognitions and hopefully a fast track into your adult practice if you have one. Create space for these patients, provide resources, understanding, and encouragement. And remember, this is an exciting time for you, you know, type two diabetes overall, you know, now versus 15 years ago. We are, you know, remember as a diabetes community, we are the front page of like New England Journal of Medicine articles almost every other week with all the GLP-1s, the SGTL-2s. And so bring that enthusiasm into a population that actually is not as well studied. Our youth onset type two that are still pediatric, but also those who graduate into young adults. We need more evidence in this, we need a special interest in the providers who care for these patients. And these are just some transition specific resources. Healthcare.gov is a governmental website that actually has a specific area on young adults and navigating insurance, transition.org. And the Endocrine Society does also has an improved, I did look for the ADA if they had a specific one, but they have a lot of stuff with type one. And so maybe we'll need to build resources for type two site. All right. So in your practice, everyone has a different practice, but what things can you implement or do you take away from this that you might bring back to your home practice to help smooth the transition to adult care for emerging adults? You know, either our pediatric colleagues, what are you gonna do to get them ready? Our adult colleagues, what are you gonna do to make them feel welcome, make space for them? Let us know if you have any thoughts or anything else that you guys have found works for your practices. We'd love to hear it. It's a lot to type in in a short amount of time, I think. All right. I'm sure there's probably, okay, we got a couple. I was going to say it would take me a minute, so. Nice. Thank you. Yes. So partner with adult practices. I love it. As a researcher, please add these in your research protocols. Figure out a way to recruit enough that you can actually use it. They don't need the same resources. You know, you're not necessarily coaching them about hypoglycemia when drinking alcohol. Now that's true for some, but it's different. You know, and you've got to remember and meet them where it's at that there's needs and concerns. They're just different. And then I love, so I just was sending emails to get some of my adult fellows into my pediatric clinics. And so I think adult endocrine trainees being aware that it's just a different population, I think it's a huge thing. The end answer is education and awareness, I think, always. Okay. Here's my references on the slides, but also here, and I'm going to hand it back over to our moderators. All right. Thank you so much, Dr. Finn, for a wonderful presentation. This was really awesome. We thank you so much for sharing your expertise with us, and we want to thank all of our participants today for joining us. I'm giving up remote control, okay? There we go. Thank you. Yeah. For those of you in the audience, if you have any questions, please enter them into the Q&A box on Zoom. Some positive feedback for Kahoot and for your talk already. So that's great to hear. I'll maybe start off with the first question, if that's okay. I think you shared a lot about what the gaps are and some potential strategies. One aspect that I personally always struggle with in my own clinics is that the recommendation is to start these transition discussions, like starting at age 12. And so sometimes that's only when the patient enters our clinic or even later, and I always feel like, oh, I don't want to talk about you leaving the clinic when you just got here, because it just seems like... So I feel like were those numbers sort of based on type 1 diabetes transition? So that's always, I'm always like, oh, so that's why sometimes I put it off, because I don't want it to seem like I'm just handing them off to the next person, even though the transition process is several years long. So that's one area that I always struggle with, and I would love to hear your thoughts. And the second question is, I wonder if you have any advice for us as we take in referrals for 17, 18-year-olds, are they best served in our clinics versus the adult clinic? This is a debate that we often have in our practice. We tend to keep them on the P side just because we like to keep everybody for longer, but I'm just curious about your own thoughts and practices for that age group. Oh, you're hitting on like some of my favorite things. So the, you know, so the age group, so like the gottransitions.org, I think they're, if you look at it, they technically say 14. And in our children's hospital also, I'm a part of a couple of like the transitions of care, group meetings and stuff like that. And we talk about like from my clinic and what we bring, I often talk with them about how, you know, a lot of our patients are diagnosed between 14 and 18 years old, or 14 and 20 if you have a clinic that actually goes adolescent and young adult and a little bit older. I completely agree. I don't think it's kind of like a sport analogy. You don't like catch and throw at the same time. So it's sometimes you have to like have a person established and be a part of them. We're currently taking the approach of the transition preparation early, if you actually look at it as more like adult skills, understanding the disease, that type of stuff. Just things that, you know, are good to do and know, and not necessarily being like, you need to go look for your clinic. If your hospital or clinic has the capacity, if you find that you are able to meet young adults where they are, our clinic personally, I'm not, because I'm the one trying to set up and get all of our other providers on board with when they let go of their patients. I'm currently working on a kind of lenient that there's some we have to get ready at 18, you know, TRICARE doesn't like, you know, a lot of, they want them to go back to their PCP. So we need to start thinking about that, have them start to be ready there. You know, 17 and 18, I think no one disagrees. You have to be aware of insurance and stuff. You get onto adult Medicaid, you'll lose it. Sometimes if you're working. So in the younger teenage years, I think it's just skills, understanding and stuff. Now, remember, if you have a 15 year old and they're uncontrolled, you don't necessarily want to be like, no mom, they're in charge of their medication. It is still 100% reasonable to have a parent involved to engage the family and all that stuff. So it's not that you're telling them to hand off control. You want understanding, you want engagement. As they get older, you need to start talking about some of the other stuff because we have patients we're planning to transition at 20 and they can't make it back after 18. So I kind of have a like big picture and then preparing for those who make it all the way through then we start talking and handing off and that stuff. For the new diagnoses, I generally am going to recommend that we have them for at least a year so that they have a couple visits. There are some advantages to starting in an adult endocrine. None of my pediatric colleagues like to hear that because we have a lot of resources, but I have had some like 20, 21, 22, 19, 20, 21 year olds that actually do okay. They engage in the adult system. They're able to come back. We've got them involved and then we don't have to switch clinics. So you never like the answer, it depends, but it does depend a little bit. Sometimes my adults with intellectual disabilities, still get all their care at children's. I'll try to get them at children's. For my patients who are young parents, they already have two kids at 20, doesn't make sense for them to be seen at children's. I see them in adult endocrine because when they get pregnant, people aren't scared of them. So that's that weird thing where you kind of have to be aware and open, but it's also okay if we have overlaps and it's not this like hard cutoff. Thank you. We also, we have a question in the chat from Mary Jane Roche, in emerging adults with type one diabetes, typically parents or caregivers are deeply involved in care and navigating the transition. Is that also the case for emerging adults with type two? And if not, what should support look like for this group, medically, emotionally, et cetera? Honestly, it widely depends. I have some young adult guys who are 22 years old and their moms still call for all their visits. They still live at home. You know, some of it's familial, you know, it's a multi-generational household. And so some of it's like good and their moms are never gonna let go. They'll be 45 years old and their moms are probably still gonna be calling to make their appointment. So I do have some like that. I have others that when they hit 18, it's so good because their parents were there, not engaged. Some of the reasons they had the, you know, kind of a chaotic childhood with medical problems and stuff like that was their parents really had a hard time navigating adulting. You know, so sometimes our young adults are more adult than their parents. And I see that maybe a little bit more in my youth onset type two clinic because, you know, chaotic home environments do lend to risks of obesity and things like that. So it kind of depends. Yeah, it's wild how different it can be. And then, as I said, I have some of my, you know, 18, 19 year olds who they have their parents themselves. I have one who she's been the parent, she actually parented her sister. So when she had a kid, it was like the parent moved out of the house. And so there's, you know, a lot of stuff there. I now see her at my adult clinic though. So yeah, it is more interesting actually, the variety I think I see in my adult youth onset type two than my youth onset type one. I don't know, Chai and Samara, if you've seen that as well. Oh yeah, very wildly different, like you said. But it's an experience that I think adult people need to see, adult clinicians need to see. I call it the prelog of what's happening. I think we have about two minutes left. And in your community and Chai, how often is our pediatric endocrinologists having the discussion of diabetes remission? Why are we managing? Why are we aiming for remission right away? And how often is that the focus? Chai, do you want to take it first? Yeah, sure. I honestly, I think my, my conversations necessarily don't spell out diabetes remission, but more talk about maybe different phases of glycemic, of change in sort of glycemic control. So I will often say that in the initial periods, you might need different medications or that will lower your A1C. And that may change over time and that's not your fault. And that's just sort of the natural disease progression. But honestly, I feel like outside of bariatric surgery, I often don't, you know, I don't, remission is not something that comes up. It's usually like, you may be on different medications. You may need minimal medications, but you're always at risk for diabetes progressing. Bariatric surgery, I think is a little bit different because you maybe truly have a little bit of, of some opportunity for remission in that case. But that's generally how I tend to approach it. And that makes sense. Cause in my pediatric clinic, when I'm on children's, I never talk about remission, actually. I have some that are, you know, really well controlled on metformin. I have some families that are, you know, well, can we come off of it? And we do like a really long runoff coaching. I tend to not ever push, actually coming off of the medications. I do have some families that vehemently try to pursue it, but I just, I think it's that teenager hormones, I get, you know, just seen it enough where it comes, you know, it goes out of control. In my adult clinic, I'll talk about it, especially, you know, five to 10% weight loss early on, things like that. And I think it has to do with the likelihood you'll go into it, the rapidity of if you go, you know, if it comes back. And we don't, I don't know if we really have much evidence that diabetes remission in youth actually exists outside the bariatric. In my adult clinic, honestly, I feel like I hear about diabetes remission more on social media than I sometimes do in my endocrine office, you know, where they need to talk about keto diet and various things and kind of, and I think it's a wonderful thing for us to really pursue aggressive lifestyle measurements and stuff like that. But in our pediatric studies that we have lifestyle measurement as one of our arms, we haven't seen it be as effective. And so I wanna, and of course, like with our new medication, sometimes my patients come in and they're like, I'm in remission. I'm like, no, you're on trazepatide 15 milligrams a week. You know, so, but, so remission is an interesting thing, but it is different. It's almost like non-existent in youth onset type two. Maybe we'll find out five to 10% have durable remission with me, but like it hasn't in my experience and you could correct me been a thing and it is more so an adult. Yeah. Well, thank you everyone again. I think we're one minute over time. We really appreciate this talk today and I hope everyone enjoyed it. Thank you. Yes, thank you all so much and join us for the next ADA webinar.

youth onset type 2 diabetes

transition to adult healthcare

insulin resistance

beta-cell deterioration

healthcare navigation

glycemic control

bariatric surgery

pediatric endocrinologist

adverse pregnancy outcomes

transition strategies