Type 2 diabetes was commonly associated with the adult population. This diagnosis was even referenced as adult-onset diabetes but in recent years type 2 diabetes in children is on the rise.
Although researchers aren’t clear as to why some children develop type 2 diabetes there are some causes that can increase the risk. When children present with these risks the Children Mercy Diabetes Center can evaluate these patients and create a care plan to possibly alter the path to such a diagnosis.
Hear from Dr. Yan as she explains the types of children that can be seen in clinic and how to proactively get in front of a life altering diagnosis of type 2 diabetes.
Selected Podcast
Getting in Front of Type 2 Diabetes
Featured Speaker:
program in endocrine department at Children’s Mercy Kansas City as
well as an associate professor of pediatrics at University of
Missouri-Kansas School of Medicine. Dr. Yan completed her fellowship
in Pediatric Endocrinology at University of North Carolina, Chapel
Hill and is certified in both pediatrics and pediatric endocrinology.
She received a Physician Scientist Research Award from Children’s
Mercy Kansas City on studying the mechanism of insulin resistance and
diabetes complication.
Yun Yan, MD
Yun Yan, MD is the director of type 2 diabetes preventionprogram in endocrine department at Children’s Mercy Kansas City as
well as an associate professor of pediatrics at University of
Missouri-Kansas School of Medicine. Dr. Yan completed her fellowship
in Pediatric Endocrinology at University of North Carolina, Chapel
Hill and is certified in both pediatrics and pediatric endocrinology.
She received a Physician Scientist Research Award from Children’s
Mercy Kansas City on studying the mechanism of insulin resistance and
diabetes complication.
Transcription:
Getting in Front of Type 2 Diabetes
Michael Smith, MD (Host): Our topic today is Getting in Front of Type Two Diabetes. My guest is Dr. Yun Yan. She’s the Medical Director of the Type Two Diabetes Prevention Program in the Endocrine Department at Children’s Mercy Kansas City. Dr. Yan, welcome to the show.
Yun Yan, MD (Guest): Thank you for having me.
Dr. Smith: So, obviously I think we all know that the type two diabetes originally was called adult onset diabetes and but that’s not the case anymore. Why are we seeing an increase in children with type two diabetes?
Dr. Yan: So, that is a very good question. Because type two diabetes is linked with overweight or obese. So, over the past two decades, we see more and more people become overweight or obese. And when the patient is obese, they would become insulin resistant. So, this is a fundamental mechanism for the patient to develop type two diabetes.
Dr. Smith: Yeah, so basically what we are seeing is some of the same risk factors that we see in the adult population, right, obesity, bad diet, lack of exercise; we are seeing that in kids more today and that’s why we are seeing the rise in type two diabetes. What do you think, at the practitioner level, in the everyday clinics, the community hospitals, what could we be doing better to get a handle on this problem?
Dr. Yan: So, first of all, for the community and also the public health; we would like to make awareness the healthy lifestyle is very important to prevent overweight or obesity. And also, it is important for the parents to know to bring the patient into the primary provider or pediatrician for an annual check and so they – the patient can be found early if they have abnormal weight gain or overweight obese. So, the patient can receive first hand education from the pediatrician regarding the lifestyle modification to prevent further weight gain or like at least maintaining the weight when the patient is still growing.
Dr. Smith: Right, so you are right Dr. Yan. We got to get a handle of this before the diagnosis of type two diabetes. When a community physician or nurse practitioner is trying to make those lifestyle modifications and encouraging the patient and the family to do that, at what point though if they are not making any headway, at what point is it time to come to a clinic that you are running at Children’s Mercy?
Dr. Yan: So, we receive the referral from the local pediatrician when the pediatrician was screening the risk factors. So, if the patient is overweight and also if they have a first or second degree relative who has type two diabetes or they are some minority group like American Indian, black, Latino; so they have a higher risk to develop diabetes if they are overweight and also if the patient has clinical signs of insulin resistance such as high blood pressure, dyslipidemia, and also acanthosis nigricans which is a darker color around the neck region or the patient has polycystic ovarian syndrome or when the patient is born with a very low birth weight. So, the pediatrician will run some labs. So, they check – in general they will check a hemoglobin A1C which is a marker that reflects the average blood sugar over the past two to three months and if the hemoglobin A1C is elevated; I would say normal range is 5.7%. So, in that case, they are - they send the patient to us. And also, if the patient has elevated triglycerides which is a marker of the insulin resistance or the patient has abnormal liver enzymes which is the sign of the fatty liver syndrome. So, and also, we see the patient if they are very young, younger than five years old, so because they will have some other conditions that might cause the overweight like genetic condition.
Dr. Smith: Dr. Yan, I want to talk about two of the blood tests that you just mentioned. And of course, physicians are very familiar with these two blood tests. They check them all the time and that’s hemoglobin A1C and the triglycerides. If you read some of the literature that’s out there, let’s talk about hemoglobin A1C first. Some of the studies show normal hemoglobin A1C might be in the six, seven range but I think more and more clinicians are finding that to be too high. So, you are targeting a much lower hemoglobin A1C. Is that correct?
Dr. Yan: Yes. So, the normal hemoglobin A1C we would like to see is 5.7% or lower.
Dr. Smith: Yeah and so – in the context of a child who is overweight, who is not eating well, who is inactive, what kind of hemoglobin A1Cs do you commonly see? What level does it get up to?
Dr. Yan: Yeah, so in general, it is from the 5.8% to like 6.3%, that population are the patients we see the most before they develop real true type two diabetes which is hemoglobin A1C will be 6.5 and above.
Dr. Smith: Right and so that 5.5 to 6.5 range, that’s that opportunity, right, to act now and proactively start doing the things we need to do to improve insulin sensitivity. What about the triglycerides? What’s your – what level do you look for there?
Dr. Yan: Triglyceride is actually based on the new Pediatric Endocrine Society. So the new criteria based on the age, in general, we don’t want to see higher than 130 for the younger patient, but for the older patients we would like to see actually lower than 100, which is a little bit different with the regular reference range because based on the lab sometimes, they will labelled it is normal if the triglyceride is less than 200, which is high for the patient if they are overweight or obese.
Dr. Smith: Right, so we need to rethink those triglyceride numbers a little bit as well. So, before we get into the clinic that you manage the Type Two Diabetes Prevention Program at Children’s Mercy, I want to talk a little bit about and get your take on this. How powerful, how much of an effect can those lifestyle modifications really make? If a child loses weight and starts eating fresh, healthy food, what kind of outcome do we see from that?
Dr. Yan: It is great outcome. So, we see a lot of good results after the patient made lifestyle modifications including reduced sugary containing beverages, and increased vegetable intake and reduced and control their carbohydrate portion size and increase physical activity level. So, we do see very good results. When I see the patient back in three or four months, when we recheck the lab and then, so all the markers actually have improved. So, we do see a very good result if the patient can make changes.
Dr. Smith: Let’s talk a little bit Dr. Yan about the clinic that you run at Children’s Mercy. Walk us through a typical patient visit with the family when they come see you.
Dr. Yan: So, when the patient comes here, and I work with one nutrition specialist working in our clinic. So, the patient will be evaluated by nutrition specialist regarding the lifestyle. So, the nutrition specialist will find the area the patient can make change such as reducing the sugary drinks or actually avoid and also increase the vegetable intake and evaluate the patient’s screen time like stay on the computer or phone and games and also talking about physical activity. That is a very important role for the nutrition specialist to give the education to the family and the patient.
So, after the nutrition specialist sees the patient, we will talk through and so then I will learn something like key things, so the nutrition specialist would like to make change first. I will go to see the patient and emphasize the key points and as a pediatric endocrinologist, there are two things I’m actually focused on, in addition to the lifestyle modifications which is screening for any potential reason actually causing this abnormal weight gain, such as some rare condition like Cushing’s syndrome, and significant hypothyroidism or some genetic condition like Prader-Willi syndrome or other rare conditions. That’s number one. Number two is that I would like – as a medical provider, screening for the comorbidity or like complications like sleep apnea or if it is a female, screening for the polycystic ovarian syndrome which is PCOS and also if the patient has any orthopedic complications like joint injury or knee injury or we are screening for the mental health like if the patient has depression or anxiety. So, we combine this effort together so the number one is that we can give the patient instructions and also give them too how to make changes but, in the meantime, we would like the patient and the parents to understand why we need to make changes. Right, so number one is that we would like to prevent or delay the onset of type two diabetes and also, we would like the patient to have a good life quality in the future.
Dr. Smith: Right, well very comprehensive right and I like that approach where you are really looking at the child holistically, what’s going on, why is there that weight gain, so it’s a very comprehensive and rigorous workup of the child. So, Dr. Yan, I want to thank you for the work that you are doing at Children’s Mercy and I want to thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information you can go to www.childrensmercy.org that’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.
Getting in Front of Type 2 Diabetes
Michael Smith, MD (Host): Our topic today is Getting in Front of Type Two Diabetes. My guest is Dr. Yun Yan. She’s the Medical Director of the Type Two Diabetes Prevention Program in the Endocrine Department at Children’s Mercy Kansas City. Dr. Yan, welcome to the show.
Yun Yan, MD (Guest): Thank you for having me.
Dr. Smith: So, obviously I think we all know that the type two diabetes originally was called adult onset diabetes and but that’s not the case anymore. Why are we seeing an increase in children with type two diabetes?
Dr. Yan: So, that is a very good question. Because type two diabetes is linked with overweight or obese. So, over the past two decades, we see more and more people become overweight or obese. And when the patient is obese, they would become insulin resistant. So, this is a fundamental mechanism for the patient to develop type two diabetes.
Dr. Smith: Yeah, so basically what we are seeing is some of the same risk factors that we see in the adult population, right, obesity, bad diet, lack of exercise; we are seeing that in kids more today and that’s why we are seeing the rise in type two diabetes. What do you think, at the practitioner level, in the everyday clinics, the community hospitals, what could we be doing better to get a handle on this problem?
Dr. Yan: So, first of all, for the community and also the public health; we would like to make awareness the healthy lifestyle is very important to prevent overweight or obesity. And also, it is important for the parents to know to bring the patient into the primary provider or pediatrician for an annual check and so they – the patient can be found early if they have abnormal weight gain or overweight obese. So, the patient can receive first hand education from the pediatrician regarding the lifestyle modification to prevent further weight gain or like at least maintaining the weight when the patient is still growing.
Dr. Smith: Right, so you are right Dr. Yan. We got to get a handle of this before the diagnosis of type two diabetes. When a community physician or nurse practitioner is trying to make those lifestyle modifications and encouraging the patient and the family to do that, at what point though if they are not making any headway, at what point is it time to come to a clinic that you are running at Children’s Mercy?
Dr. Yan: So, we receive the referral from the local pediatrician when the pediatrician was screening the risk factors. So, if the patient is overweight and also if they have a first or second degree relative who has type two diabetes or they are some minority group like American Indian, black, Latino; so they have a higher risk to develop diabetes if they are overweight and also if the patient has clinical signs of insulin resistance such as high blood pressure, dyslipidemia, and also acanthosis nigricans which is a darker color around the neck region or the patient has polycystic ovarian syndrome or when the patient is born with a very low birth weight. So, the pediatrician will run some labs. So, they check – in general they will check a hemoglobin A1C which is a marker that reflects the average blood sugar over the past two to three months and if the hemoglobin A1C is elevated; I would say normal range is 5.7%. So, in that case, they are - they send the patient to us. And also, if the patient has elevated triglycerides which is a marker of the insulin resistance or the patient has abnormal liver enzymes which is the sign of the fatty liver syndrome. So, and also, we see the patient if they are very young, younger than five years old, so because they will have some other conditions that might cause the overweight like genetic condition.
Dr. Smith: Dr. Yan, I want to talk about two of the blood tests that you just mentioned. And of course, physicians are very familiar with these two blood tests. They check them all the time and that’s hemoglobin A1C and the triglycerides. If you read some of the literature that’s out there, let’s talk about hemoglobin A1C first. Some of the studies show normal hemoglobin A1C might be in the six, seven range but I think more and more clinicians are finding that to be too high. So, you are targeting a much lower hemoglobin A1C. Is that correct?
Dr. Yan: Yes. So, the normal hemoglobin A1C we would like to see is 5.7% or lower.
Dr. Smith: Yeah and so – in the context of a child who is overweight, who is not eating well, who is inactive, what kind of hemoglobin A1Cs do you commonly see? What level does it get up to?
Dr. Yan: Yeah, so in general, it is from the 5.8% to like 6.3%, that population are the patients we see the most before they develop real true type two diabetes which is hemoglobin A1C will be 6.5 and above.
Dr. Smith: Right and so that 5.5 to 6.5 range, that’s that opportunity, right, to act now and proactively start doing the things we need to do to improve insulin sensitivity. What about the triglycerides? What’s your – what level do you look for there?
Dr. Yan: Triglyceride is actually based on the new Pediatric Endocrine Society. So the new criteria based on the age, in general, we don’t want to see higher than 130 for the younger patient, but for the older patients we would like to see actually lower than 100, which is a little bit different with the regular reference range because based on the lab sometimes, they will labelled it is normal if the triglyceride is less than 200, which is high for the patient if they are overweight or obese.
Dr. Smith: Right, so we need to rethink those triglyceride numbers a little bit as well. So, before we get into the clinic that you manage the Type Two Diabetes Prevention Program at Children’s Mercy, I want to talk a little bit about and get your take on this. How powerful, how much of an effect can those lifestyle modifications really make? If a child loses weight and starts eating fresh, healthy food, what kind of outcome do we see from that?
Dr. Yan: It is great outcome. So, we see a lot of good results after the patient made lifestyle modifications including reduced sugary containing beverages, and increased vegetable intake and reduced and control their carbohydrate portion size and increase physical activity level. So, we do see very good results. When I see the patient back in three or four months, when we recheck the lab and then, so all the markers actually have improved. So, we do see a very good result if the patient can make changes.
Dr. Smith: Let’s talk a little bit Dr. Yan about the clinic that you run at Children’s Mercy. Walk us through a typical patient visit with the family when they come see you.
Dr. Yan: So, when the patient comes here, and I work with one nutrition specialist working in our clinic. So, the patient will be evaluated by nutrition specialist regarding the lifestyle. So, the nutrition specialist will find the area the patient can make change such as reducing the sugary drinks or actually avoid and also increase the vegetable intake and evaluate the patient’s screen time like stay on the computer or phone and games and also talking about physical activity. That is a very important role for the nutrition specialist to give the education to the family and the patient.
So, after the nutrition specialist sees the patient, we will talk through and so then I will learn something like key things, so the nutrition specialist would like to make change first. I will go to see the patient and emphasize the key points and as a pediatric endocrinologist, there are two things I’m actually focused on, in addition to the lifestyle modifications which is screening for any potential reason actually causing this abnormal weight gain, such as some rare condition like Cushing’s syndrome, and significant hypothyroidism or some genetic condition like Prader-Willi syndrome or other rare conditions. That’s number one. Number two is that I would like – as a medical provider, screening for the comorbidity or like complications like sleep apnea or if it is a female, screening for the polycystic ovarian syndrome which is PCOS and also if the patient has any orthopedic complications like joint injury or knee injury or we are screening for the mental health like if the patient has depression or anxiety. So, we combine this effort together so the number one is that we can give the patient instructions and also give them too how to make changes but, in the meantime, we would like the patient and the parents to understand why we need to make changes. Right, so number one is that we would like to prevent or delay the onset of type two diabetes and also, we would like the patient to have a good life quality in the future.
Dr. Smith: Right, well very comprehensive right and I like that approach where you are really looking at the child holistically, what’s going on, why is there that weight gain, so it’s a very comprehensive and rigorous workup of the child. So, Dr. Yan, I want to thank you for the work that you are doing at Children’s Mercy and I want to thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information you can go to www.childrensmercy.org that’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.