Transcription:
Preventing Type 2 Diabetes

Introduction: Transforming care through genomic medicine, personalized therapeutics, health services and outcomes research and innovations in healthcare delivery. We're Children's Mercy, Kansas City presenting our audio interview series Transformational Pediatrics with host Dr. Michael Smith.

Dr. Michael Smith: So, obviously prevention is always better than treatment, right? Especially when you're dealing with type two diabetes. This is Transformational Pediatrics, the podcast from Children's Mercy. I'm Dr. Mike. Let's talk with Dr. Kelsee Halpin, a Pediatric Endocrinologist at Children's Mercy and Assistant Professor of Pediatrics at the University of Missouri, Kansas City School of Medicine.

Dr. Halpin: Yeah, yeah. Thanks for having me, Dr. Mike.

Host: So what prompted Children's Mercy, you know, specifically the division of endocrinology and diabetes to create a type two diabetes prevention clinic?

Dr. Halpin: Yeah, that's a great question. So this clinic came about five years ago. The current clinic director, Dr. Union and our division leadership, they put together this clinic just cause we were having a growing number of kids that we were seeing being diagnosed with type two diabetes which is classically thought of as only an adult condition. But we're seeing more and more of it in recent years and just essentially the sheer number of referrals we were getting for children because of abnormal weight gain and concern for type two diabetes risk. And so, you know, right now there's one in five kids in America that are categorized as obese. And so the things that go along with that, like insulin resistance, metabolic syndrome, pre-diabetes those are actually some of the most common referrals that we get to our clinic.

But when we see these kids, you know, a lot of times we're seeing them for counseling and evaluation before they've had any sort of formal nutrition or lifestyle education. And so, we would see them, we'd refer them on for, for a separate visit with a dietician. And those separate visits just require more travel costs, missed work, school burdens and things like that for the family. And so really, this clinic was developed as a multidisciplinary approach with both endocrinology and dietitian services in the same day, and also incorporating social work if needed. And so it's just a way to, to sort of streamline the care for the patients, and just seemed like a good idea for our referring providers as well as our patients at this time.

Host: You know, it's interesting, right, Dr. Halpin that this is relatively a new issue that we're having to deal with. You know, I know, I don't know how old you are, but I grew up in the late seventies, early eighties. And I don't remember ever hearing of a friend of mine with type two diabetes. Yeah. There were a couple with what we called back then, juvenile, right. Type one diabetes. So this is kind of relatively new that we're now seeing type two in younger kids. Right?

Dr. Halpin: Yeah, absolutely. You know, and obviously it's kind of a consequence of higher rates of obesity in children in general. But there's a lot about sort of this juvenile type two that we're seeing in recent years that we don't fully understand why it's happening so much now, that we know it's related to higher obesity risks, but you're exactly right. You know, a couple of decades ago, this just wasn't on anyone's radar. You know, at Children's Mercy, at our center we follow over 2000 kids with diabetes in general. I would say it's about 200 of those are type two diabetes patients. And so it's certainly not the most common form of diabetes in kids, but we're still seeing it in substantial numbers. And unfortunately the recent evidence coming out shows that it's actually tends to be a little bit more rapidly progressive and severe than your older adults that get type two diabetes. So this is kind of a different thing that we're tackling now.

Host: So, you know, back to the prevention clinic, what types of patients are appropriate for community physicians and healthcare practitioners to refer to refer to the clinic?

Dr. Halpin: Yeah. Yeah. So we're really trying to prioritize those Referrals as kids that are already starting to show some lab abnormalities, that suggest they have a diabetes risk. So whether that's their blood sugar's a little high but maybe not in that diabetes range. They've already got high cholesterol or signs of fatty liver disease, you know, the kids that are in those high risk groups to those are kids whose moms and dads have taped two diabetes or our racial minorities that we know are at higher risk. And so we're really trying to get those kids in. We also kind of have a focus on very young children, so children under five that are struggling with severe rapid weight gain. And because in that instance they may be at higher risk for underlying genetic or hormonal condition. And so really kind of an evaluation of that. If I'm being honest, this clinic would be helpful for any of the referrals that we see for abnormal weight gain, just it could discuss diabetes risk. The tricky part is we get probably a thousand plus referrals a year for patients or at least see a thousand patients a year for that. So just based off time and space where we're really trying to prioritize those children at highest risk into this multidisciplinary clinic. And our website has the details as far as specific lab criteria and age and things like that.

Host: You mentioned earlier in our conversation about you know, a patient can actually see a lot of professionals, health professionals at, at one visit. How about if you walk us through what that first visit to the clinic actually looks like and what the patient experiences?

Dr. Halpin: Yeah. The first visit can be a little bit lengthy just cause that's kind of what's expected with some of these multidisciplinary clinics where you're seeing multiple providers. But we try and streamline it as much as possible. And so normally when they come, they check in just as they would for a typical, you know, provider visit. But that we do have the capability, you know, when we're doing vital signs and things like that. We also have a very specific scale in the clinic that helps determine muscle mass, fat mass, which is not, and then we do routinely as part of our standard of care and provide some more data collection. But then, you know, depending on the flow, they'll either meet with an endocrinologist or a dietician first. And usually they're meeting with, with each of us for 30 to 40 minutes. So a pretty lengthy amount of time that they're seeing us. And our dieticians are really uniquely qualified just because they're all certified diabetes educators as well. So they've already got experience with children who have type two diabetes. So they're really able to sort of uniquely hone in on some modifications that the families can make to hopefully prevent that from happening.

So, they'll meet with them and chat with them. And then our role is endocrinologist is we're really trying to explain to families the hormonal and genetic causes of weight gain and the health consequences that can result, if you don't intervene appropriately. And so we're really doing our best with our specific expertise to help the families understand insulin, this sort of spectrum of insulin resistance, prediabetes, on to type two diabetes. It's very complicated. It's not just lifestyle though. That's the cornerstone of all our interventions. And so we try to help them see that there's a lot, ah, plays into it outside of that. And also, you know, the families usually can expect, if they haven't had recent lab work done, we will probably recommend some fasting lab work be done at that visit or when, when they can next be fasting. And we also, we are pretty proactive about genetic testing. So in those young kids I was talking about the kids under five or if we're seeing children at high risk for diabetes that have some other like neurocognitive or developmental delays, we are pretty proactive about sending genetic testing off for some syndromes that can cause that risk as well as those features.

And so this kind of the first full visit that they'll go through if we encounter any sort of social or environmental barriers that we feel like are impairing their ability to maintain a healthy lifestyle, we also have the option of bringing in our social workers to meet with families as well. And after that first visit, the follow-up kind of depends on how that goes, but almost all of our patients come in for at least a three to six months follow-up where we can sort of see their progress just with counseling alone. And then at that point is when we may start talking interventions with medications and things like that as we're seeing progression in their lab abnormalities.

Host: So what's the, you know, when you look at the type of patient, a child you're bringing in, these are kids, if I got it right, that are already showing some, some changes, some abnormalities, whether it be blood, work, waking, whatever. What ultimately then is your goal moving forward for this clinic?

Dr. Halpin: Well, I mean, our, our hope is obviously with all of our care is providing the best absolute healthcare we can for patients while providing convenience, by allowing them to see us and a dietician expert in a single visit. We want to prevent the development of type two diabetes. That's why it's called type two diabetes prevention whenever possible. So they'll honestly, that's a big undertaking. Just cause like we've talked about the type two diabetes in youth can be more aggressive, and we are limited by the fact that there's no FDA approved drugs in children for prediabetes. So before you go on to develop type two diabetes. So, this clinic, in addition to providing care and counseling and intervention for patients, it's really letting us standardize our approach and our data collection. And we thought we can really start digging into research, a risk factors for these kids who are progressing in an effective intervention. So as part of this clinic, we're already collecting outcome data or collaborating with, with other areas at Children's Mercy including our genome center and precision therapeutics and trying to really understand some of these genetics contributions to diabetes risk and also just strategies for enhancing the efficacy of our interventions.

Host: That's Dr. Kelsee Halpin. She is a pediatric endocrinologist at Children's Mercy. I want to thank you for checking out this episode of Transformational Pediatrics. Please visit childrensmercy.org to get connected with Dr. Halpin or another provider. Hey, by the way, if you found this podcast helpful, share it on your social channels and be sure to check the entire podcast library for topics of interest to you, and be sure to check back soon for the next podcast. I'm Dr. Mike. Thanks for listening.