OVERVIEW OF OVERVIEW OF PEDIATRIC DIABETES PEDIATRIC DIABETES

20102010Alan B. Cortez, M.D.Alan B. Cortez, M.D.

Pediatric EndocrinologyPediatric EndocrinologyChief, Department of PediatricsChief, Department of Pediatrics

Kaiser-Permanente, Orange CountyKaiser-Permanente, Orange CountyJanuary 29, 2010January 29, 2010

OutlineOutline

Types of Pediatric DiabetesTypes of Pediatric Diabetes Role of InsulinRole of Insulin Balancing food and exerciseBalancing food and exercise Insulin StrategiesInsulin Strategies Psychosocial, Goals, and OutcomesPsychosocial, Goals, and Outcomes

TYPES OF PEDIATRIC TYPES OF PEDIATRIC DIABETES MELLITUSDIABETES MELLITUS

Type 1Type 1 Type 2Type 2 MonogenicMonogenic (MODYs and others) (MODYs and others) Atypical DM (seen with African ancestry)Atypical DM (seen with African ancestry) Drug-induced (corticosteroids and others)Drug-induced (corticosteroids and others) Cystic FibrosisCystic Fibrosis Pancreatectomy or Severe PancreatitisPancreatectomy or Severe Pancreatitis Gestational DiabetesGestational Diabetes

PEDIATRIC COMPARISON OF PEDIATRIC COMPARISON OF TYPE 1 VS TYPE 2TYPE 1 VS TYPE 2

Age <40 years oldAge <40 years old Thin vs. overweightThin vs. overweight Wt loss very likelyWt loss very likely Any race/peopleAny race/people No metabolic synNo metabolic syn Weak Family HxWeak Family Hx Ketones very likelyKetones very likely More likely DKAMore likely DKA 2-3 islet antibodies2-3 islet antibodies

Age >10 years oldAge >10 years old Obese vs. very obeseObese vs. very obese Wt loss less likelyWt loss less likely Non-whiteNon-white Met syn/AcanthosisMet syn/Acanthosis Strong Family HxStrong Family Hx Ketones less likelyKetones less likely Less likely DKALess likely DKA 0-1 islet antibodies0-1 islet antibodies

AFTER ~5 YEARS OF AUTOIMMUNE DESTRUCTION

PANCREAS

BETA CELLS INISLETS MAKEINSULIN

The main difference The main difference between the types of between the types of diabetes is whether diabetes is whether insulin deficiency is insulin deficiency is complete or partial.complete or partial.

Which type is more Which type is more severe?severe?

IMPORTANT MESSAGES TO IMPORTANT MESSAGES TO PATIENTS AND PARENTS ON PATIENTS AND PARENTS ON

TYPE 1 DIABETESTYPE 1 DIABETES

Be clear about the diagnosis of diabetesBe clear about the diagnosis of diabetes No one did something or didn’t do something to No one did something or didn’t do something to

cause type 1 diabetescause type 1 diabetes Nothing to be guilty about, though that is what Nothing to be guilty about, though that is what

parents do bestparents do best With the right treatment, the prognosis is for a With the right treatment, the prognosis is for a

long, happy, and healthy lifelong, happy, and healthy life Ignoring diabetes leads to terrible problems in Ignoring diabetes leads to terrible problems in

life.life. Diabetes will be cured in our lifetime.Diabetes will be cured in our lifetime.

MAIN FACTORS AFFECTING MAIN FACTORS AFFECTING BLOOD GLUCOSEBLOOD GLUCOSE

The balancing act can be a three ring circusThe balancing act can be a three ring circus

INSULIN

EXERCISEFOOD

Components of Glucose Components of Glucose metabolismmetabolism

Food (source of glucose)Food (source of glucose) Beta Cells (source of insulin)Beta Cells (source of insulin) Insulinases (destroyers of insulin)Insulinases (destroyers of insulin) Glucose Secretion (primarily liver)Glucose Secretion (primarily liver) Glucose disposal (metabolism, Glucose disposal (metabolism,

muscles)muscles)

ACQUIRING FUEL: ACQUIRING FUEL: AUTOMOBILES VS HUMANSAUTOMOBILES VS HUMANS

Gas PumpGas Pump Gasoline Gasoline Gas TankGas Tank Gas LineGas Line Fuel InjectorFuel Injector EngineEngine

FoodFood GlucoseGlucose Digestive Sys/LiverDigestive Sys/Liver Blood streamBlood stream InsulinInsulin MitochondriaMitochondria

INSULIN PHYSIOLOGYINSULIN PHYSIOLOGY

We ALWAYS need insulinWe ALWAYS need insulin Beta cells increase secretion suddenly in Beta cells increase secretion suddenly in

response to many eating-related signals and response to many eating-related signals and rising BGrising BG

Insulin is secreted primarily from pre-formed Insulin is secreted primarily from pre-formed packets in the beta cells into the portal packets in the beta cells into the portal circulationcirculation

The surge of insulin reverts to baseline as the The surge of insulin reverts to baseline as the signals and BG levels revert to baselinesignals and BG levels revert to baseline

INSULIN PHARMACOLOGYINSULIN PHARMACOLOGY

We have no method to deliver insulin yet We have no method to deliver insulin yet that is even close to how beta cells work, that is even close to how beta cells work, but…but…

It is almost naturalIt is almost natural It is probably the best medicine for any It is probably the best medicine for any

kind of diabeteskind of diabetes INSULIN ALWAYS WORKS!!! INSULIN ALWAYS WORKS!!!

INSULIN- PHYSIOLOGY VS INSULIN- PHYSIOLOGY VS PHARMACOLOGYPHARMACOLOGY

As a medicine, we inject it into the fat, not As a medicine, we inject it into the fat, not the portal circulationthe portal circulation

Injected Insulin is slowly released from fatInjected Insulin is slowly released from fat Our blood, but not fat, destroys insulinOur blood, but not fat, destroys insulin We can alter insulin to make it enter the We can alter insulin to make it enter the

bloodstream slower or faster when bloodstream slower or faster when injected into fatinjected into fat

INSULIN PHARMACOLOGYINSULIN PHARMACOLOGY

Exogenous insulin will never work as well as Exogenous insulin will never work as well as nature does it, but using it properly works well. nature does it, but using it properly works well.

Technology/Research continues to get us Technology/Research continues to get us closer but since 1921, advances have been closer but since 1921, advances have been modestmodest

At any moment, too little insulin causes high At any moment, too little insulin causes high BG, too much insulin causes low BG- cannot BG, too much insulin causes low BG- cannot be avoided but can be minimizedbe avoided but can be minimized

TOP FIVE REASONS TO THINK TOP FIVE REASONS TO THINK ABOUT WHEN INSULIN ABOUT WHEN INSULIN

DOESN’T WORKDOESN’T WORK

Not taking itNot taking it Not taking enoughNot taking enough Usually taking it too lateUsually taking it too late The injected substance isn’t insulinThe injected substance isn’t insulin Kinetics that don’t match lifestyleKinetics that don’t match lifestyle

OTHER FACTORS AFFECTING OTHER FACTORS AFFECTING BLOOD GLUCOSEBLOOD GLUCOSE

Absorption of Absorption of insulininsulin

Potency of insulinPotency of insulin Measuring insulinMeasuring insulin Late injectionsLate injections Missed injectionsMissed injections Speed of digestionSpeed of digestion Delayed effects of Delayed effects of

exerciseexercise HyperglycemiaHyperglycemia

KetosisKetosis Other MedicinesOther Medicines InfectionsInfections Unauthorized foodUnauthorized food Internal release of hidden Internal release of hidden

insulininsulin Dawn phenomenonDawn phenomenon Hormones/mensesHormones/menses StressStress

OTHER FACTORS AFFECTING OTHER FACTORS AFFECTING BLOOD GLUCOSEBLOOD GLUCOSE

Absorption of Absorption of insulininsulin

Potency of insulinPotency of insulin Measuring insulinMeasuring insulin Late injectionsLate injections Missed injectionsMissed injections Speed of digestionSpeed of digestion Delayed effects of Delayed effects of

exerciseexercise HyperglycemiaHyperglycemia

KetosisKetosis Other MedicinesOther Medicines InfectionsInfections Unauthorized foodUnauthorized food Internal release of hidden Internal release of hidden

insulininsulin Dawn phenomenonDawn phenomenon Hormones/mensesHormones/menses StressStress

MAIN FACTORS AFFECTING BLOOD GLUCOSE

• INSULIN

• FOOD

• EXERCISE

then

The role of exogenous glucose and insulin to inhibit hepatic glucose production is critical in exercise. Giving insulin and glucose during sports prevents hypoglycemia later

CALORIES AND CARBSCALORIES AND CARBS

FATFAT (30%) (30%)

PROTEINPROTEIN (15%) (15%)

CARBSCARBS (55%) (55%)

About 70% of a About 70% of a healthy diet is healthy diet is pure glucosepure glucose

10 %10 % Glucose Glucose

50%50% Glucose Glucose

100%100% Glucose Glucose

NUTRITION TIPS FOR BALANCENUTRITION TIPS FOR BALANCE

Goal is healthy diet first and foremostGoal is healthy diet first and foremost Insulin is slow so food needs to be slowInsulin is slow so food needs to be slow Carb counting is a good technique but only Carb counting is a good technique but only

with healthy balanced diet, isn’t for with healthy balanced diet, isn’t for everyone, and isn’t a prerequisite for everyone, and isn’t a prerequisite for success.success.

Schedule/Routine is a secret of successSchedule/Routine is a secret of success Vigorous exercise requires fuelVigorous exercise requires fuel

INSULIN ACTION

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INSULIN STRATEGIESINSULIN STRATEGIES

Insulin pumpInsulin pump MDI With Basal MDI With Basal Breakfast/Dinner injectionsBreakfast/Dinner injections

Extras- coverage insulin, afternoon snack Extras- coverage insulin, afternoon snack insulin, other extra food insulin, glucose insulin, other extra food insulin, glucose sensorsensor

INSULIN NEEDS DUIRNG INSULIN NEEDS DUIRNG PHASES OF DIABETESPHASES OF DIABETES

Diagnosis-1Diagnosis-1stst day if no DKA: day if no DKA: Diagnosis- 1Diagnosis- 1stst day if DKA: day if DKA: Insulin resistance (~1 week, ) Insulin resistance (~1 week, ) Return of normal sensitivity (~1-2 weeks), Return of normal sensitivity (~1-2 weeks), Increasing insulin secretion (~1 week) Increasing insulin secretion (~1 week) Full-blown honeymoon period (~3-6) Full-blown honeymoon period (~3-6) Loss of insulin secretion (~3-24 months) Loss of insulin secretion (~3-24 months) Puberty to early 20s Puberty to early 20s Adult Adult

HYPOGLYCEMIAHYPOGLYCEMIA

Low BG does not contribute to the opathiesLow BG does not contribute to the opathies Some people’s personal goal for diabetes is to Some people’s personal goal for diabetes is to

avoid low BG.avoid low BG. Low BG causes so much anxiety it can Low BG causes so much anxiety it can

interfere with good treatment (interfere with good treatment (FEAR OF FEAR OF EUGLYCEMIAEUGLYCEMIA))

There obviously are some serious concerns There obviously are some serious concerns here, but those who do a good job put them here, but those who do a good job put them into perspectiveinto perspective

MOTIVATING ADHERENCE IN MOTIVATING ADHERENCE IN NORMAL CHILDREN/TEENSNORMAL CHILDREN/TEENS

Our most important job yet we don’t yet Our most important job yet we don’t yet know how to succeed at it.know how to succeed at it.

Fear of Complications, Punishment, and Fear of Complications, Punishment, and Negative Reinforcement haven’t had too Negative Reinforcement haven’t had too much success in the past 89 years.much success in the past 89 years.

Conditional Positive Reinforcements may Conditional Positive Reinforcements may have time-limited success and unintended have time-limited success and unintended consequences.consequences.

Weekly follow up from health professionals? Weekly follow up from health professionals?

CHARACTERISTICS OF CHARACTERISTICS OF ADHERENT PEOPLEADHERENT PEOPLE

Enjoy a higher quality of life than those Enjoy a higher quality of life than those who are notwho are not

Do not view their situation as a Do not view their situation as a punishmentpunishment

Have faith and believe in the futureHave faith and believe in the future Feel good when they do the right thingFeel good when they do the right thing Family is strong, close, and eats togetherFamily is strong, close, and eats together Their parents don’t keep asking them “Did Their parents don’t keep asking them “Did

you take your blood sugar?”you take your blood sugar?”

MOST IMPORTANT THINGSMOST IMPORTANT THINGS FOR PEOPLEFOR PEOPLE TO DOTO DO

Eat healthy at same times each day.Eat healthy at same times each day. NEVER MISS AN INJECTION!!!NEVER MISS AN INJECTION!!! Give rapid insulin before you eat. Give rapid insulin before you eat. Adjust insulin frequently based on blood Adjust insulin frequently based on blood

glucose patterns and your goals.glucose patterns and your goals. Accept hypoglycemia and plan for it.Accept hypoglycemia and plan for it. Use KNOWLEDGE!! Use KNOWLEDGE!!

GOALS FOR TREATMENTGOALS FOR TREATMENT

A1c <=7% (8% if very young) A1c <=7% (8% if very young) BG Target ~70-150 mg/dL;70-200 if <5 yrsBG Target ~70-150 mg/dL;70-200 if <5 yrs Avoidance of seizuresAvoidance of seizures Hypoglycemia approx 3-5 times per weekHypoglycemia approx 3-5 times per week Excellent quality of lifeExcellent quality of life Excellent sense of well-beingExcellent sense of well-being Appropriate monitoring for complicationsAppropriate monitoring for complications

DIABETESDIABETESISIS

NOTNOTBRITTLE,BRITTLE,PEOPLEPEOPLE

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