Rates of “adult-onset” diabetes continue to rise among children, with some ethnicities disproportionately affected. Fortunately, providers now have more tools and techniques available to help these patients avoid the serious health risks associated with the condition. This guide from pediatric endocrinologist Kevin Yen, MD, starts by illuminating key factors in how insulin resistance develops in young bodies and how to look at the role of genetics. He then discusses both new and standard medications (touching on how a savvy approach to insulin is essential when treating kids) and offers pointers for helping sedentary teens make sustainable behavioral modifications. Bonus: Hear Yen's first steps for pediatricians who suspect type 2 diabetes.
Great. So, yeah, hi everyone. I'm, I'm Kevin. I'm the uh newest endocrinology, uh endocrinologist that's based in Oakland, the East Bay. Um, I'm not exactly a stranger to the East Bay community. Uh, I did residency at show and also did a fellowship at UCSM. So, uh, my topic today is type 2 diabetes in 2024. I think it's important to, uh, make that distinction that, uh, you know, this is As many of you know, this is one of the fields that's rapidly evolving. So, uh, I thought it would be important to really time stamp ourselves so that this is hopefully an up to-date, uh, uh, review of type 2 diabetes, uh, in, uh, in this time, 2024. So, I'll go ahead and get started. This is, uh, our brief agenda. I think, uh, I thought it would be nice to just Um, have a refresher on the background definition of type 2 diabetes, and then go into these, uh, the, you know, what we call the different pillars of diabetes management. Um, you know, the 3 pillars, 3 major pillars of diabetes management, uh, where it's a pharmacologic activity, and then the diet. If time allows, we'll run through a very, very brief case, and then we will leave some time for questions. Right. So moving on. So definition of type 2 diabetes, as many of us know, uh, diabetes is any disruption of glucose homeostasis and the, and the, uh, in the, you know, specific, uh, instance of type 2 diabetes, much of this, uh, disruption in glucose homeostasis is due to insulin resistance, uh, and its natural history ultimately, ultimately leads to beta cell failure, uh, which is not very unlikely. Type one diabetes. And, uh, of course, we all know that our major, uh, the major, you know, why this even matters is that, uh, the complications that come with diabetes, uh, is that, you know, these are the major, you know, pillars of the American population. So coronary artery disease and then your, uh, microvascular complications, nephropathy, retinopathy, neuropathy. These are all, all things that we know very, very well. Uh, the graph. On the bottom right of the screen, uh, is a, is actually a pretty old flow chart, but it's a, you know, a lot of these different definitions and categories of diabetes. Uh, if you do a list search now, it's much more complicated than what's listed here. But from a, from a practical sense, this flow chart still stands really true in our daily practice, uh, at least, you know, in our clinic when, uh, a child presents with diabetes, a big sort of branching point is whether or not, uh, there are diabetes is autoimmune-driven. Um, that's typically done with, uh, these, uh, autoantibodies that we'll, uh, frequently check for. And then for those who are antibody negative, those who are, you know, insulin resistant, usually with a larger waist or, you know, in our daily practices, those who are obese are often labeled as type 2 diabetes. Um, and, you know, epidemiologically, most of the time we see type 2 diabetes in postpubertal children, and so most kids with type 2 are, they're generally older than 10 years old. So when you get someone who's less than 10, who is, you know, pre-pubertal, they're, you know, they're much, much, much less likely, uh, to have type 2 diabetes. Uh, as we all know, the incidence of type 2 diabetes is on the rise. This is, uh, from, uh, one of these large national, uh, cohorts looking at the incidence of type 2 diabetes. This is the most recent updates from the, uh, search for diabetes study, and you can see there's already a huge rise in incidence, and this was, you know, well before COVID, well before obesity became a, uh, an even bigger issue than what it was before pre-pandemic. Um. And we all know the increase of type 2 diabetes. Type 2 diabetes is largely driven by obesity, not absolutely, uh, but largely driven by obesity, and this is another sort of old graphic, uh, probably many of you have seen this before, but it's a good reminder that, uh, a huge part of type 2 diabetes is driven by obesity in the, in the sense that the, uh, incidence and prevalence of type 2 diabetes, the rise of which largely mirror, uh, that of obesity. We now know, uh, epidemiologically, we now know a lot more about diabetes than before, and, uh, there is, uh, absolutely, uh, ethnic and, uh, racial differences in the incidence of, uh, type 2 diabetes, and, and especially in kids. So, uh, in our clinic, uh, our patient population were much likely, much more likely to see type 2 diabetes, uh, in minority. All right. And this is a, I think a, a, um, you know, I think we can spend some time, uh, going over this graphic. Uh, this kind of illustrates the relationship between, you know, type 2 diabetes and in, in some ways to really visualize and conceptualize, uh, this whole process of type 2 diabetes and insulin resistance. I, I think we, uh, In our trainings, we all learned about insulin resistance and type 2 diabetes. But, uh, and I think in our daily practice, it's really hard to, you know, conceptualize or visualize or describe insulin resistance. So this is uh one of the graphics I've always found pretty helpful to really describe, uh, what it's like, the relationship between, uh, insulin sensitivity and insulin production. And then this really leads to later on how we talk about management because, you know, we have sort of have to understand um how the disease progresses, uh, how it, how it works in order to really tackle it head on and, and, you know, do a good job of management. So in many ways, one can, you know, illustrate diabetes in general, but, you know, in this case, type 2 diabetes, Through this sort of hyperbolic relationship, uh, between, um, how much insulin is being produced and, uh, so insulin release and how responsive our bodies are to insulin or insulin sensitivity. Uh, in terms of, you know, different, uh, aspects of diabetes management, uh, insulin release is largely related to beta cell math or how much outlets, um, uh, we have in our pancreas, uh, whereas insulin sensitivity, uh, uh, uh, very commonly. Use surrogate marker is obesity, uh, or, you know, anthosis, these are your findings. So, um, so that this probably illustrates why not everyone who is insulin resistant and who is, who is obese will have diabetes, uh, because, uh, diabetes or the manifestation of hypoglycemia is really a function of both how much insulin is being made and, uh, how much insulin is needed. Or, or what your insulin resistant or insulin sensitivity is. So you can certainly see, and I think we all see these, uh, kids in our practice where they're, you know, very, very obese, they appear very insulin resistant, they have lots of akanthosis and all their, uh, skin folds, but, you know, their A1Cs are fairly normal. They don't have diabetes. Well, that's probably because they still have a, a good amount of beta cell mass left. So, uh, so they can still really, um, But still really overcome the resistance they have. However, what we know about, uh, these, the natural history of diabetes, type 2 diabetes is that over time, these functions, uh, they are, our insulin, our ability to make insulin, our beta cell mass will decrease over time. So as that happens, if you can follow this arrow, you know, with, you know, very important insulin sensitivity, very High insulin resistance with the, uh, the slow destruction of beta cell mass, we slowly progress into, you know, this glucose impaired glucose tolerance or prediabetes and ultimately, uh, that this could lead to a type 2 diabetes where, uh, where we biochemically can find overt abnormalities, uh, in, uh, in blood sugars. Yeah, and these are some of the really old physiologic studies that really shows, uh, so a few key points that we can take away from this is that, you know, in type 2 diabetes there's both, there is, uh, two components, much like what was illustrated in the last slide of insulin resistance as well as, uh, these decreased insulin release. So, um, um. Uh, graphic A over here shows that there's less insulin sensitivity, meaning that, um, you know, in, in individuals with diabetes, which is the blackest bar here, there's less insulin stimulated glucose, meaning that they're less sensitive to insulin. Uh, and graphic B over here, what this shows is that there's loss of a first phase, uh, uh, insulin release, which, uh, which, you know, practically means that at mealtimes, this is where you will find, uh, most of the, uh, blood sugar abnormalities, uh, in an individual who's, you know, With type 2 diabetes, and of course, a product of which that's shown in graphic C here, a combination of, you know, uh, reduced insulin sensitivity and reduced ability to secrete, uh, insulin leads to, uh, type 2 diabetes. So this is, um, to sort of put that into practice over time. This is sort of what we see. Uh, uh, the first, um, the, uh, first sort of instant secretion response to go, uh, to be lost in type 2 diabetes is really in your sort of mealtime secretion. So, uh, well before we can find abnormalities and fasting glucose, and we will frequently find Abnormalities of blood sugar abnormalities in the postprandial glucose. So this will sort of affect into our diagnostic algorithm and our management and things like that. And the bottom, bottom, um, graphic here really just shows that over time, uh, the ability to secrete insulin, uh, beta cell function really just decreases over time. And I think a lot of times this, you know, uh, this aspect of Type 2 diabetes gets gets overlooked, but it's, you know, absolutely essential and core to our management principles. All right. A little bit on the genetics, uh, I think in we've all sort of, um, anecdotally or, you know, practice know that there's, uh, there's a huge genetic component of type 2 diabetes. Frequently, uh, in kids with type 2 diabetes, they'll have multiple, not just one, but multiple, multiple family members with either type 2 diabetes or gestational diabetes or somewhere on the spectrum of insulin resistance. Uh, from, there are very, very few. studies, uh, um, on type 2 diabetes in kids. Uh, uh, Shai Srinivasan, who's my mentor and, uh, another, uh, faculty in our division. Uh, she's one of the few, uh, few researchers in pediatric type 2 diabetes. And she did one of the first and only studies, uh, uh, GWAS studies of type 2 diabetes. And we found, you know, many similarities with adult studies where this is really a, a very, very complex genetic disease. So with all that said, this, these, you know, the knowing that there's, you know, insulin resistance driven by obesity, as well as loss of beta cell mass through the lifetime of type 2 diabetes, um, we are then able to set our management goals. So the management of type 2 diabetes, the ultimate goal of therapy, we kind of all know we want to reach euglycemia because euglycemia prevents vascular complications, um. From, you know, a practical standpoint, preserving beta cell makes all this a lot easier, meaning that, you know, as the ability to reach euglycemia is, is much more augmented when our patients have their own endogenous insulin secretion. And the best way to preserve beta cell mass from all of our studies we found is actually weight loss and reducing, uh, the amount of insulin resistance. So, Um, This is a very, very old slide, but this stands, uh, very true. In general diabetes management, whether you have type 1 or type 2, there are 3 pillars of diabetes management. Uh, there's, you know, what you're eating, uh, what you're doing in terms of activity. And then the last part of which is taking medicine. Of course, uh, when it comes to type 2 diabetes, there are a few, uh, different things, uh, that are sort of specifically type 2 that may be a little bit different, uh, from, um, uh, individuals with type 1 or other types of diabetes. OK, so I think um we'll start out with medications that are approved for uh pediatric use. Uh, metformin, I think we're all very, very familiar with metformin. It comes from the bigonide family of medications. It's derived from French lilac, and um it's been used for centuries, uh, for type 2 diabetes, but we still don't know exactly what it does in terms of mechanism of action. There are many, many different, uh, sort of hypotheses and the studies looking into this, but there's really no one, sort of, um, one mechanism that everyone can agree upon. Uh, it is, but it is, you know, still remains our first line therapy for, uh, for, uh, type 2 diabetes management in kids. The dosing, I think you'll see that most kids are on 1000 mg twice a day, or at least we try to. Get them to 1000 mg twice a day. But really the, the, um, the max dose is actually 2500. That's true for adults. And, uh, all the dosing data for pediatric metformin actually comes from, uh, adult studies and metformin. Um, what is really different, uh, from adults is that, uh, from, uh, these, from large studies, we know that, uh, about 50% or half of the children with type 2 diabetes will have metformin failure, meaning That their type 2 diabetes cannot be managed by metformin alone and oftentimes it will need to be started on insulin or another modality. And this is, uh, this is in stark contrast to, you know, adult type 2 diabetes where the, uh, the ability to maintain A1C and a healthy blood sugar on metformin alone is much higher in adults compared to kids. And that's why this is really a, uh, it is really an emerging issue, type 2 diabetes in children. Uh, we all know about the side effects. The most common ones we hear about is really GI distress and, uh, and that comes with bloating, abdominal pain, uh, diarrhea, and for this reason, a lot of kids actually self-discontinue metformin, uh, which has been, uh, which can, which is very frustrating because we know metformin works, we know it's helpful, however, uh, a lot of, a lot of children cannot tolerate these side effects. Um, so I don't know, even up until, uh, when I started fellowship, metformin was still the only, uh, non-injectable, non-insulin agent that's approved in kids. However, uh, since I've started fellowship, uh, there's been a lot of progress. We, uh, I think all of us have heard a lot about GLP ones, whether the most popular ones are, uh, Uh, semaglutides or the Ozempic and the Wagovis. Um, but, uh, a little background GLP1, it's an endogenous hormone that's secreted by the L cells in the intestines. So it's one of those incretins, uh, that we'll hear about. Uh, it has two major physiologic functions that really helps, uh, managing, uh, management of type 2 diabetes. Uh, first of all, it is an insulin. Secreta go. So it does increase insulin secretion and that will, will, uh, help with, uh, blood sugar management. But, uh, some, but it's really most powerful and, and kind of a novel effect in terms of the management of type 2 diabetes is that it increases satiety and thereby reduces hunger. And this is very helpful, uh, in weight loss and preventing overeating, uh, which is, which is really a game changer, uh, in the landscape of diabetes management. It has an absolute contraindication uh for um for a personal or family history of medullary thyroid cancer. Uh, this is a very rare form of thyroid cancer and most, uh, most. Uh, patients with diabetes do not have this in their family. There is a sort of a new statement from the FDA recently. Uh, there's been a lot of, there's, uh, a lot of post-market, uh, noise, it's the technical term for, uh, for, you know, whether or not GLP ones will increase suicidal ideation, uh, and, and, uh, from an adult. Uh, using these agents. Uh, they, uh, so they put out a statement, uh, just this month saying that they are looking into it. They don't know what to do yet, but they have not recommended any discontinuation of this drug. But I think, uh, like with many other newer therapies, the postmarket surveillance, it's very important and we'll find out more about it, uh, as we go on. All right, and these are the uh GLP ones that's FDA approved for uh pediatric diabetes use. So uh I think we, uh, they're all three of these listed have a weight loss counterpart. I specifically did not choose to talk about obesity and weight loss, uh, today. I thought it would be more in many ways a little bit more straightforward to talk about diabetes, uh. So, uh, these are the ones over here, and they're, um, generally, uh, used in children. The ages of approval are a little bit different. I think it really depends on what their, uh, trials were designed to do, but, uh, lyric glutide was the first one to be approved for use in children. This is a daily injection, it's approved in children over 10 years of age, uh. Semaglutide is the one that's always in the news on social media, used by all the celebrities. It's a once weekly injection, uh, and approved in children over 12 years of age. Examinide is also GLP-1. This is the one that, that, yeah, I guess no one really talks about, no one really hears about, but it's also a once weekly injection. It's also approved in children over 10 years of age, but it just really just doesn't have, uh, much of a buzz or a presence. And, um, as a very recently, uh, SGRT2 inhibitors are also approved for use in kids now. Uh, this is, uh, and haliflozin or the uh uh the market name is Jardiance. It's approved for children over 10 years of age, and it's an inhibitor of sodium glucose co-transporter 2. Uh, which is a major, uh, transfer for glucose reabsorption in the nephron. Uh, so essentially when, uh, children are, when, when people are taking these drugs, they're having this sort of, uh, they have a lot of, uh, glycosuria and they're peeing out all the glucoses and thereby reduces, uh, serum glucose. Uh, this is a, uh, at this past year's American Diabetes Association, this is really, Uh, the darling drug out there were like, like, I don't know, hundreds of posters dedicated to SGLT2 in terms of diabetes, uh, cardio, uh, cardiovascular risk. This is definitely a very, very popular drug in the adult world and it's finally being introduced, uh, to the pediatric world. Uh, and, and there are some, uh, side effects that Uh, they can range from the sort of annoying to pretty serious. Uh, so with it's, uh, sort of iatrogenic glycosuria, it, uh, individuals taking it are at increased risk of vulva vaginitis and urinary tract infections, as you can all imagine, but one of the more serious side effects is, uh, euglycemic, uh, ketoacidosis, um. Uh, this essentially occurs when a patient is taking these drugs, but, uh, during, uh, during the context of acute illness, uh, especially when, uh, there's an inability to eat or drink, our patients taking the, um, SGOT2 inhibitors are more likely to go into ketoacidosis and this is considered an emergency where they will need to You know, stop SGOD2 inhibitor and depending on uh the level of their ketosis, they may need insulin therapy on top, uh, to really bring them out of ketosis. So, um, and so I think for this reason, a lot of the pediatric providers have, you know, have, you know, yet to really, uh, go all in on SGOT2 inhibitors, but it's definitely, uh, being used more and more frequently. All right, and of course insulin, insulin remains a mainstay of therapy in type 2 diabetes. Uh, our approach to insulin, if you want to get down to the thick of it, is, is, uh, it's used in type 2 diabetes is a little bit different. Uh, from how we dose and how we think about in type one diabetes, uh, generally speaking, because of the, uh, anabolic effects of insulin, uh, and where, you know, insulin could lead to weight gain and weight gain leads to worsening of insulin resistance. We really try to minimize the amount of insulin that's, that's used in children with type 2 diabetes. So for that reason, we are, we typically, you know, most kids, we try not to put on the full, uh, carbon. Count 34 times a day short-acting insulin regimen. We try to get by as much as possible with a sort of a once a day long-acting insulin. And we really try to add on different modalities, different drugs, different interventions to try to reduce the overall amount of insulin. And this is all, uh, so that we can really preserve beta cell function and, and sort of prevent this end stage of uh type 2 diabetes where uh insulin uh requirement becomes essential. All right, and the field is rapidly changing. There are newer drugs, um, that are already approved in adults that are awaiting approval on children. Uh, you may hear about trazepatide or Mojaro. This is a combined GLP-1 GIP agonist. So two different incretin actions, uh, bunched into one, and there's also the rapid. True tide, which is 3 different incretin actions, you know, packed into one as a small molecule. So these are coming and our field is rapidly changing and this is really exciting, uh, because now we have more options for our patients and, uh, instead of just, you know, metformin and insulin, which is what we were stuck with, you know, just, just 34 years ago. All right. So moving on. So, uh, uh, we'll move on to healthy eating next. So if you recall the three pillars of diabetes management, we just knocked out medicine and, you know, the pharmacologic options and the next two, what's left is healthy eating and physical activity that we frequently like to refer to as lifestyle modifications. And this is, uh, perhaps the hardest part and perhaps the most essential part and the hardest part to do. And, um, and I think really, it's really important for us to, you know, we have a united front and send the same message, uh, to our patients so that we can really, uh, you know, achieve these lifestyle modifications. Uh, so I think before we get started, let's try to do something lighthearted. This is a message, uh, this is an email that we got from one of our Senior faculty members, some of you may have seen him making your podcast rounds and the news rounds from, uh, Doctor Lustick and essentially, um, this is his, you know, thoughts on obesity, which largely relates to type 2 diabetes. And, you know, in order to, I, I think in order to really properly take care of our patients with type 2 diabetes and, and, and obesity, we, we have to have this, you know, right mindset going into it, meaning that, you know, so his point number 1, obesity is biochemistry. So, um, and yeah, there's a behavioral component of it, but the behavior is a result of biochemistry and, uh, sort of, and prevention is the only solution, meaning that, you know, lifestyle things are really, really hard to change. And I think the biggest take home message is that obesity or type 2 diabetes, you know, Our patients are not, you know, fat and lazy as in the past, uh, they are often referred to. They are really just bigger kids with blood sugar problems and blood sugar issues. And we really need to embrace them, give them the tools, be on the same page so we can help them overcome diabetes, which is a very terrifying illness. So All right. So healthy eating and diet. Well, we all know food, uh, our relationship with food is very, very complicated. Uh, our society has evolved to a point where, you know, eating food is not just, you know, just for nutrition and survival, which is how we like to think about food, but it's really not. There's a huge cultural, emotional, behavioral component to our relationship with food and this, you know, You know, makes it really, really hard to do our, you know, counseling and lifestyle modification, right? Cause there's a very, very emotional part of it. A lot of times my patients get really, really teary whenever we talk about, uh, food, uh, cause there are a lot of, you know, psychosocial challenges that's much beyond blood sugar control. And I think, you know, you know, in our partnership with endocrinologists and pediatricians, this is probably the most Key component, uh, because there's so much out there on food, right? There's, you know, my, you know, a personal example, my parents say one thing about how my son is eating, my in-laws say something else, TikTok says one thing. And so if our patients are getting all these different information about food from all these different sources, it becomes very hard and very difficult, uh, to make changes. So, um, This is uh the plate model from our uh watch clinic, and I think it's, it's not novel. I think we've all seen some, uh, some version of it, but the, the, uh, the hardest part is trying to really decipher this information down to something concrete that our families and our patients can use. So, um, you know, in, in many ways, I think for, uh, for, for healthcare providers, it's really easy to look at. So, of course, you want to. You know, some whole grains, some proteins, some fruits and vegetables, uh, a balanced diet, right? How hard, you know, could this be? Uh, you know, in practice, we all found that doing, you know, counseling on food and eating is, is extremely hard and extremely difficult. So I have a, I, you know, I have a couple of ways to try to sort of hack this plate model for you to simplify it down even more. I think the first point we all know, right? We just want to get rid of processed food. So we, our first, um, point in dietary counseling is always, hey, And you know, we're going to cut out the juice, we're going to cut out snacks and the packaged foods. But then it becomes very, very hard to talk about what people's actual meals look like. And I think, uh, some of the approach that we've taken is that we know that satiety or, um, or addressing hunger is one of the hardest. Things to do in diabetes and obesity management, right? Cause that is biochemistry. It's very hard to overcome that with, you know, our, our free will or personal will, if you believe that. So, uh, we really need to sort of game in a little bit. And one of the, one of the ways to do it is to eat more fiber. Uh, Almost invariably for kids who have type 2 diabetes, their diets are just littered with a lot of processed foods and uh a lot of carbs, a lot of simple carbs, and usually they're, you know, problem isn't necessarily they're eating too much protein, it's really they're eating too much carbs. And one of the ways to do that is to really just encourage a lot of fiber eating. And I think the easiest way, having a toddler at home, uh, the easiest way increase fiber. It's probably not vegetables, but fruits. Uh, fruits are, you know, I think one of the easiest tools that we have in our, in our armament to really try to increase fiber intake. Uh, most kids like fruits. Um, you know, kids are very ambivalent. Uh, most kids don't. Let's be honest, most kids don't like to eat broccoli or celery or these, you know, kale, arugula, what have you. But kids are generally very Very receptive to different types of fruits and fruits are great, great for the diet, a great, uh, you know, a great carbohydrate to have and very, very high in fiber. And, and I think oftentimes if we can encourage the increase, you know, encourage the intake of fruits instead of like fruits and vegetables or just vegetables, we can achieve a lot of what we want to do, which is, uh, you know, with the fiber, we can increase satiety and, uh, one of the ways to You know, practically do that. I found this to ask kids to eat fruit first. I think in a lot of, in a lot of our cultural backgrounds, fruits are really treated as not part of the, the main plate and the main meal. But you know, in our plate model, we, we really do encourage that any source of fiber you can get, any source of fiber that you can push into kids, I think, uh, you know, where we And observed is that it makes a very, very big difference. And it's, I think in sort of in your short, you know, in your short visits, these are sort of, these are, this is a very practical way of bringing more uh fiber into your diet is to eat food at every meal, start out each meal with a fruit, and I, and that automatically sort of increases your fiber intake. And that's kind of uh one approach to this. And that really brings home the point of Um, portion control is very, very hard. It's about our hunger, our satiety. Signals are biochemical response, it's not a reflection of personal accountability. It's not because they're bad kids, it's really just that's what their brains are telling them to do. So, um, and the sort of the traditional approaches to weight loss that consists of eating less or you're eating too much. It really hasn't been shown to work. Uh, we know that from numerous trials of weight loss and that, you know, the, this just doesn't work. It's not a sustainable thing. Uh, so we often take a more sort of more positive approach, right? Instead of you're eating too much, it's that, you know, you got to eat more of something else, right? You got to eat more of something else. So starting meals with fiber, I think it's very, very helpful. Right. The next part is activity. And, you know, we all know the, the very obvious part of activity is exercise. Uh, and, um, and we sort of generally know that, you know, American teenagers are very sedentary, whether it's watching TV, social media, cell phone use, all that, there's a lot of that's a whole body of research out there. Uh, but we also know very well that exercise activity can not only lead to weight loss, but activity alone, exercise alone can lead to increased insulin sensitivity. We observe, we observed this effect over and over and over again at diabetes camp. Uh, this is a very, very profound effect. And, uh, much like, Uh, our sort of, uh, changes in diet, healthy eating. The biggest challenge is making this a sustainable thing. Uh, so we, we really take an approach of, um, a really encouraging sort of more regular daily activity versus sort of less regular, you know, intense activities. So a lot of times when we talk to our kids, uh, their activities are, uh, you know, are, you know, like I, I lift weights at school. Well, but it, it, which is great, uh, which is wonderful. However, uh, lifting weights at school means that their activity is completely, uh, reliant on an external structure that they don't have a lot of controlling. So, uh, this means that, you know, once winter break hits, once summer break hits, their activity is gone. So our approach is to really encourage activity, uh, that they can do aside from school, a, aside from something, you know, being reliant on something else and someone else. So something easy like walking around at home, uh, you know, watching. YouTube, doing some exercises. We, our, our approach is to, uh, really find something that's more sustainable than relying on these large outside structures. And, and, uh, hopefully, you know, our hope is that these can become sort of lifelong practices that can, that they can, our kids can take with them once they exit the home, once they go off to college, once they go off to work, and once they become more independent because diabetes is a lifelong thing. And a part of activity that's not frequently thought about is, uh, sleep, um, Uh, yeah, no, sadly, we also know very well that most kids right now are getting pretty low quality sleep. Uh, poor sleep, uh, leads to, you know, increased hunger. So over and over time, I think we all experience this as well, uh, through residency training, uh, whenever you're post call, you get really, really hungry. And then, um, you know, and also experience when you're up at night, you often eat and for teens, for kids in particular, um, they're more likely to Eat low quality foods, your snacks, your chips and cookies, candy, things like that at night, uh, when they're sort of up alone and trying not to be bothered. So sleep is absolutely a huge component of it from a biochemistry standpoint, there's a lot of studies looking at into different adipose tissue growth and activity, but I think, uh, that could affect obesity, but from a practical standpoint, uh, there's this increased hunger, you know, less the motivation to exercise and also just more time to eat junk. All right. And, um, yeah, and, uh, lastly, uh, diabetes technology is of course a part of, uh, a part of management for our kids with type 2 diabetes as well. Uh, for most of our kids we do encourage continuous, uh, continuous glucose monitoring use. Uh, you know, as much as we can, as, as long as they're accepting of it, uh, whether or not they're on insulin therapy, I think traditionally this is thought of as a tool that's, you know, only helpful for, um, individuals with diabetes who are on chronic insulin, but we really do use it. Uh, regardless of whether or not they're on, uh, they're on insulin. And, uh, I actually pulled this from one of my patients, and this kind of illustrates, uh, how, uh, in many ways how helpful this tool can be and also illustrates, uh, really, uh, Uh, what, what diabetes looks like throughout the day. So, um, we can see that, you know, there are 3 days of data over here. It's a Monday, Tuesday and Wednesday. It's 3 days of school, however, uh, the, the glucose patterns are very, very different. Uh, even though, you know, presumably this child has been going to school at the same school doing similar things throughout the day. So, uh, you know, blood sugars are very, very dynamic things and this CGM really gives us a lot of information. Uh, sometimes we use it to really give feedback cause, you know, from looking at the, uh, blood sugar behavior from 6 p.m. and on, I think we can be, you know, so this is on Tuesday, uh, after 6 p.m. presumably after dinner time. 6 p.m. this patient's blood sugar remained fairly high, whereas, you know, um, on these two other days at around dinner time, 6 p.m. we saw a little spike here, a little spike here, and then the blood sugar eventually came down. This kind of gives us a sense of, you know, something different happened at dinner on Tuesday, whether it's forgetting their medication, eating larger portions, larger carbs than they normally do. Uh, so these are, uh, a lot of times having this data. It really allows us to get down, get into details with our patients on what happened and it really shows a, a pretty direct cause and effect and the consequences of, of, um, of maybe not, not abiding to lifestyle modifications. And sometimes this can be very, very helpful of providing, you know, positive, positive and or, or, you know, a little bit of a negative feedback, uh, for our patients with diabetes. So these are very, very helpful tools that we try to bring to all our kids. All right. And as a general summary, uh, there's, there's, you know, we talked about the three pillars of management with, uh, you know, diet, activity, as well as, uh, as, uh, medicines and all of that is really in an effort to achieve, uh, these two major goals, which is we want to lower blood glucose and we can do that with Um, medications listed here, metformin, GLP-1, SGLT-2 inhibitors, and insulin remains the mainstay of therapy, and then weight loss. So GLP-1 absolutely helps with weight loss, but also regular activity, good sleep, and a balanced diet really goes into weight loss, and these are, you know, always our two big goals of therapy of management in type 2 diabetes. All right, and I think we have some. Time To go over a quick case. Yes. Yes, all right. All right, so, uh, Yeah, briefly speaking, what should I do if I suspect a patient has type 2 diabetes in my office? So there's probably someone who is, uh, obese, has some signs of insulin resistance, akanthosis, or maybe has some symptoms of polyuria, polydipsia, polyphagia. Uh, we generally like to start with and something immediate we can do in terms of affecting our next step of management is, you know, check your blood sugar and maybe checking UA, uh, for example, if you find a blood sugar of 500 and a UA has a lot of ketones. And, uh, uh, glucose uria, then that makes your management decision pretty straightforward. That's probably someone who needs insulin. That's probably someone you call us about. Uh, but if those don't look, you know, too, too abnormal, uh, then, you know, we can always, you know, send the A1C, uh, you know, I know every practice depending on where you are, where the lab is, a turnaround time for A1C, uh, could be very different. So that's something good to think about, uh, as you're going on with it. And I think this is probably the biggest thing uh that can help with patients who are who, you know, are suspected to have diabetes to discharge from home with a glucometer using a glucometer, having data, having blood sugar data, whether it's fasting postprandial, uh, that is, that is very, very helpful in, in determining, you know, how their blood sugar is behaving and then that you will give, give us or a better sense of what they need in terms of intervention, what they need in terms of. Therapy. And if you do really suspect someone has um Type 2 diabetes before, you know, you know, going through all the long wait times to see us, you know, it's very safe to start metformin, even if they end up, even if it ends up they have some autoimmune component to it, you know, individuals with insulin signs of insulin sensitivity to obesity can generally benefit from metformin use. And of course limiting concentrated sweets. So, um, anytime there is diabetes, there's some, uh, there's, uh, sort of abnormal glucose homeostasis limiting the amount of Soda, juice, concentrated sweets they can get, uh, really helps prevent a lot of complications right away. And as we've discussed, that's really our 1st, 1st step in lifestyle modification. And these are sort of, um, very concrete, uh, uh, changes that we can ask our patients to make. Of course, if you have questions, you can call us. And then lastly, uh, this is sort of, you know, a lot of times the question. to, well, should I be admitted? What should I do? Um, briefly, the inpatient criteria for the onset diabetes or DKA very obvious, we all know it has to be managed, uh, in a new patient in the hospital, uh, very, very high blood, blood sugars with ketones and lots of symptoms that usually means that they will require insulin therapy and, uh, for, for the most part, our insulin initiation, our insulin teaching, uh, essentially, Especially in the context of lots of symptoms, that's still an in-hospital, uh, an in-hospital education process for us. And then lastly, for individuals with A1Cs that are well over 10, um, you might, will frequently need full, uh, sort of carb count, uh, sort of multiple daily, uh, doses of, uh, insulin, and that's usually, you know, for similar reasons, we admit for insulin education as well. Uh, this target is constantly changing. I think if you look at the ADA standards of care, the starting insulin is still over 8.5, but there's a lot of movement in the diabetes community to really raise that bar and try to avoid insulin until, um, patients A1Cs are over 10. So that's a brief overview. I'm gonna give lastly, uh, uh, a sort of a shameless plug for some of our programs. Uh, we are, I think I sort of mentioned that there's not a lot going on nationally for pediatric type 2 diabetes. We are, as far as we know, the first institution to start a camp for Uh, children with type 2 diabetes, uh, we started out last year with a day-long program. We're hoping to continue that. So if you do have patients, uh, who are, uh, you know, who have type 2 diabetes, uh, please let them know there's a community out there. We are definitely putting up, uh, this type 2 day again. And then, uh, if you want to help out, we're always welcoming of it. And that is all I have for materials. I think we can open up for questions.
