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, I'm Kevin. I'm the newest Endocrinology Endocet Show and also did uh fellowship at U CS M. So, uh my topic today is type two 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 a up to date uh uh review of type two 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 two diabetes. And then go into these uh the, you know what we call the different pillars of diabetes management. Um You know, the three pillars, three 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 two diabetes, as many of us know, uh diabetes is any disruption of glucose homeostasis. And the in the uh in the, you know, specific uh instance of type two 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 unlike type one diabetes. And uh of course, we all know that our ma uh major, you know, why this even matters is that uh the complications that come with diabetes uh is uh 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 things that we know very, very well. Uh the graphic 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 lid 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 a diabetes autoimmune driven um that's typically done with uh these uh an auto antibodies that will, uh, frequently check for and then for those who are antibody negative, those who are, you know, insulin resistant, usually with a larger waste or, you know, in our daily practices, those who are obese are often labeled as type two diabetes. Um, and you know, epidemiologically, most of the time we see type two diabetes in postpubertal Children. And so most kids with type two are, they're generally older than 10 years old. So when you get someone who's less than 10, who is, you know, prepubertal, they're, you know, they are much, much, much less likely to have type two dying. Uh As we all know that the incidence of type two diabetes is on the rise. This is uh from uh one of these large national uh cohorts looking at the incidence of type two diabetes. This is the most recent updates from the search for diabetes study. And you can see there's already a huge rise in incidents and this was, you know, well, before COVID, well, before obesity became a, uh an even bigger issue than what it was before prepay. Um, and we all know the increase of type two diabetes. Type two 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. It is a good reminder that uh a huge part of type two B diabetes is driven by obesity in the, in the sense that the uh incidence and prevalence of type two diabetes, the rise of which, uh, largely mirror 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 racial differences in the incidence of uh type two diabetes and, and especially in kids. So, uh in our clinic, uh our patient population were much likely much more likely to see type two diabetes uh in minor. 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 two diabetes and in, in some ways to really visualize and conceptualize uh this whole process of type two diabetes and insulin resistance. They, I think we uh in our trainings, we all learn about insulin resistance and type two diabetes. But uh and I think in our daily because it's really hard to, you know, conceptualize or visualize or describe insulin resistance. So this is uh one of the graphics. I I 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. As you know, we have sort of have to understand um how a disease progresses, uh how it, how this works in order to really t go ahead on and, and you know, do a good job of management. So I I in many ways, one can, you know, illustrate diabetes in general. But you know, in this case, type two 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, in terms of, you know, different uh aspects of diabetes management. Uh insulin release is largely related to beta math or how much outlet um uh we have in our pancreas. Uh whereas insulin sensitivity, uh uh uh a very commonly used surrogate marker is obesity uh or you know, a and tell these are responding. So, uh 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 and uh how much insulin is needed or, or what your insulin resistant or insulin sensitivity is. So you can certainly see and I, 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 acanthosis and all their uh skin folds. But, you know, their A one CS 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 the these, the natural history of diabetes type two 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 poor insulin sensitivity, very high insulin resistance. With the uh the the slow destruction of beta cell mass, we slowly progress into, you know, just in glucose, impaired glucose tolerance or prediabetes. And ultimately, uh that this could lead to a type two di di 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 sort a few key points that we can take away from. This is that, you know, in type two diabetes, there both, there is uh two components much like what was illustrated in the last slide of insulin resistance as well as uh uh these uh decreased insulin release. So um um uh graphic a over here shows that there's less instant sensitivity, meaning that um you know, in, in individuals with diabetes, which is the blackest part 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 meal times, this is where you will find, uh, most of the, uh, blood sugar abnormalities in an event, individual who's, you know, with type two diabetes. Now, of course, a product of which that's showed in graphic c here, a combination of, you know, uh reduce insulin sensitivity and reduce ability to secrete insulin leads to uh type two 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 two diabetes is really in your sort of mealtime secretion. So, um well, before we can find abnormalities and fasting glucose, so we will frequently find abnormalities of blood sugar abnormalities in the post brand. 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 two 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, well, 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 two diabetes frequently. Uh, in kids with type two diabetes, they'll have multiple, not just one but multiple, multiple family members with either type two diabetes or gestational diabetes or somewhere on the spectrum of insulin resistance. Uh, from there are very, very few studies, uh, um on type two diabetes and kids. Uh uh Shi Srinivasa is my mentor and uh another uh faculty in our division. Uh She's one of the few, a few researchers in pediatric, type two diabetes and she did one of the first and only studies uh uh GW studies and type two diabetes. And we found, you know, many similarities with adult studies where this is really 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 two diabetes. Um we are then able to set our management goals. So the management of type two diabetes, alma goal therapy, we kind of all know we wanna reach elysia because euglycemia prevents the vascular complications uh from a practical standpoint, preserving beta cell, makes all of this a lot easier. Meaning that, you know, as the ability to reach e glycemia 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 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 one or type two, there are three 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 two diabetes, there are a few different things, uh, that are sort of specifically type two, there may be a little bit different, uh, from, um, uh, individuals of type one or other types of diabetes. Ok. So I think, um, we start out with medications that are approved for, uh, pediatric use, uh, Metformin. Uh, I think we're all very, very familiar with Metformin. It comes from the big on night family of medications. It's a derived from French Lilac and, um, it's been used for centuries, uh, for type two 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 two diabetes management and 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 from adults is that uh from uh these, from large studies, we know that uh about 50% or half of the Children with type two diabetes will have that form of failure, meaning that their type two diabetes cannot be managed by, um, that form alone. And oftentimes it will need to be uh started on insulin or another modality. And this is, uh, uh this is in stark contrast to, you know, adult, uh type two diabetes where the uh the ability to maintain A one C and healthy blood sugar on the former alone is much higher in those compared to kids. And that's why this is really a, um, it is really an emerging issue. Type two diabetes in Children. Uh We all know about the side effects. The most common ones we hear about is really G I 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 noninjectable noninsulin agent that's proven 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 GOP ones. What are the most popular ones are uh uh semi glu types or the OIC and Rego. Um But uh a little background GOP one, it's 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 type two diabetes. Uh First of all, it is an insult secret to God. 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 two 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 a 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 mo 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 a lot of postmark, uh, noise, I guess that's the technical term for, uh, for, you know, whether or not GOP wants to increase suicidal ideation. Uh and, and uh Children and 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're now what to do yet, but they have not recommended any discontinuation of this drug. But I think uh what like with many other neurotherapy, the post market 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 GOP ones that's FDA approved for uh pediatric diabetes use. So, uh I think we, uh there are 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 the are the ones over here and they're um generally uh used in Children. Their 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 glut was the first one to be approved for use in Children is a daily injection. It's approved uh in Children over 10 years of age, uh semi glutted is the one that always in the news of social media used by all the celebrities. It's a once weekly injection uh and proved in Children over 12 years of age exam aide is also a GOP one. 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 improved in Children over 10 years of age, but it just really just doesn't have much of a buzz or a presence. And um although very recently, uh scot two inhibitors are also approved for using Kiss. Now, uh this is uh and Halo Flos in or the uh uh the market name of Jardiance, it's approved for Children over 10 years of age and is an inhibitor of sodium glucose co transporter two uh which is a major uh transfer for glucose reabsorption. 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 pee 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 the darling drug out there were like and like, I don't know, hundreds of posters dedicated to SGLT two 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 to the pediatric world. Uh and, and there are some, there are side effects there. Uh they can range from sort of annoying to pretty serious. Uh So with its uh sort of genic glycosuria, it uh individuals taking it are at increased risk of var vaginitis and urinary tract infections, as you can all imagine. But one of the more serious side effects is uh e euglycemic 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. Uh our uh patients taking the um SGOT two inhibitors are more likely to go into ketoacidosis. And this is considered uh an emergency where uh they will need to now stop SUD two inhibitor. And depending on 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 SGOT two inhibitors, but it's definitely be uh being used more and more frequently. All right. And of course, insulin, insulin remains a mainstay of, uh, therapy in type two diabetes. Uh, our approach to insulin, if you wanna get down to the think of it is, is, uh, it's used in type two 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 two diabetes. So for that reason, we are, we typically, you know, most kids, we try not to put on the full uh carb count 34 times a day short acting insulin regimen. We try to get by as much, which is 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 two diabetes where uh insulin uh requirement becomes essential. All right. And this field is rapidly changing. There are uh newer drugs um that are already approved in adults. They are awaiting approval on Children. Uh you may hear about Tetty or Majal. This is a combined GOP one G IP Agnes. So two different in, in actions are bunched into one. And there's also the rapid sh T which is three different uh in, in 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 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, I was 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 the podcast rounds and news rounds from uh Doctor Lustick and essentially, um this is his, you know, thoughts on obesity, which largely relates to type two diabetes. And, you know, in order to, I I think in order to really properly take care of him, type two diabetes and, and, or, and obesity, we have to have this, you know, right mindset going into it, meaning that, you know, so this is point number one, 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 type two diabetes, you know, our, our 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, you know, willing to embrace them, give them the tools be on the same pace so we can help them overcome uh 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 a how we like to think about food. But it's really not, there's a huge cultural, emotional behavioral comp component to our relationship with food. And this, you know, makes it really, really hard to do our, you know, counseling and lifestyle modification. Right? Because there's a very, very emotional power that a lot of times my patients that really, really te whenever we talk about, uh, food, uh because 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 as endocrinologist 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, as a personal example, my parents say one thing about how my son is eating my in-laws, say something else. Tik Tok 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 health care providers, it's really easy to look at. So of course, you want to have, you know, some whole grains and proteins, some fruits and vegetables, a balanced diet, like how hard you know, could this be? Uh But, 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. 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 gonna cut out the juice, we're gonna cut on 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 s satiety or, um, or addressing hunger is one of the hardest things to do in diabetes and obesity management, right? Because that is biochemistry. It's very hard to overcome that with, you know, our, yeah, 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 are, have type two diabetes or diets are just litter with a lot of processed foods. And, uh, a lot of carbs, a lot of simple carbs and usually they, you know, probably 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 kind, just encourage a lot of fiber eating. And I think the easiest way having a toddler at home, uh the easiest way increased 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 uh 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. And I think, uh you know, what, what would you and observe is that it makes a very, very big difference. And it's, I think in sort of in, 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 or satiety signals our 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 and it consists of eating less or you're eating too much. It, 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 a more positive approach. Right. Instead of you're eating too much, it's that, you know, you gotta eat more of something else, right? You gotta eat more of something else. So, starting meals with fiber, I think it's very, very helpful. All 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, it'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 observe this effect over and over and over again at diabetes can, uh this is a very, very profound effect and uh much like uh are 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 it really encouraging sort of more regular daily activity versus sort of less regular intense activity. 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, which is great, uh, which is wonderful. However, uh, lifting weights at school means that their activity is completely reliant on an external structure that they don't have a lot of control in. 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 you two 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 at 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. Yeah. 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, some show over and over time. I think we all experience this as well. Uh, through residency training, uh, whenever you 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 be, eat low quality foods or snacks or chips and cookies, candy, things like that at night, uh, when they are sort of up alone, uh, and trying not to be bothered. So, uh, 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, uh, just some more time to eat junk. All right. And, um, bef yeah. And, uh, lastly, uh, diabetes technology is, of course a part of, uh, a part of management for, uh, our kids with type two diabetes as well. Uh, for most of our kids, we do encourage continuous, uh, continuous glucose monitor 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 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 what, what diabetes looks like throughout the day. So, um we can see that, you know, there are three days of data over here, Monday, Tuesday and Wednesday, it's three 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 the same school doing similar things throughout the day. So, uh you know, blood sugars are very, very dynamic things. And this CGM really give us a lot of information. Uh Sometimes we use it to really give, give feedback because, you know, from looking at the uh blood sugar uh behavior from 6 p.m. M on, I think we can be, you know, so this is on Tuesday, uh after 6 p.m. presumably after dinner time on 6 p.m. this patient's uh blood sugar remain fairly high. Whereas, you know, um and these two other days, uh at around dinner time, 6 p.m. we saw a little spike here, a little spike here and then the bush hair eventually came down. This kind of gives us the 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 really allows us to get down and 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 uh maybe not a not abiding to lifestyle modifications. And sometimes this can be very, very helpful uh 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 our kids. All right. And as a general summary, uh there, there's, you know, we talk about the three pillars of management with uh you know, diet activity as well as uh as uh medicines and all 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 GOP, one sgot two inhibitors and insulin uh remains a mainstay of therapy and then weight loss. So GOP one absolutely helps with weight loss, but also regular activity, good sleep and a balanced diet really goes with weight loss. And these are, you know, always are two big goals of therapy of management, that type two diabetes. All right. And I think we have some time to go over a quick case. Yes. Yes. Are all right. So, uh yeah, briefly speaking, what should I do if I suspect a patient has type two diabetes in my office. So there's probably someone who is uh obese, has some signs of insulin resistance, acanthosis or maybe has some symptoms of poly polydipsia polyphagia. Uh We generally like to start with and, and something immediate we can do in terms of affecting our next step of management is, you know, check your blood sugar and maybe check A U A. Uh for example, if you find a blood sugar, 500 U A has a lot of ketones and uh uh uh glucose area, then that makes your management decision pretty straightforward. That's probably someone who needs insulin, that's probably someone you cause about. Uh but if those don't look, you know, too, too abnormal, uh then, you know, you can always, you know, send an A one C. Uh you know, I know every practice depending on where you are, where the lab is a turnaround time for a one C 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, who, you know, are suspected to have diabetes to discharge from home with the glucometer. Uh using 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 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 two 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, 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 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 just to sort of, you know, a lot of times the question is too well, should they be admitted? What should I do? Uh briefly the uh inpatient criteria from the onset diabetes or DK A very obvious we all know has to be managed 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 in the context of lots of symptoms. That's still an in hospitals. Uh and in hospitals education process for us. And then lastly, for individuals with a one CS, there are well over 10, um we might, we frequently need full uh sort of carb count, uh sort of multiple daily uh doses of uh in insulin. And that's usually, you know, for similar reasons we have made for insulin education as well. Uh This park is constantly changing. I think if you look at the ad a standards of care, you know, starting insulin is still over 8.5. But, uh, there's a lot of movement in the diabetes community to really raise the bar and try to avoid insulin until, um, patients A one C are over 10. Ok. 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 it. There's not a lot going on nationally for pediatric type two diabetes. We are as far as we know the first institution to start a camp for, uh, Children with type two diabetes. Uh, we started that last year with the day long program. We're hoping to continue that. So if you do have patients, uh, who are, uh, you know, who have type two diabetes, uh, please let them know there's a community out there. We are definitely putting up uh this type two 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.
