Melanie Cole, MS (Host): Welcome to Children's Health Checkup, where we answer parents' most common questions about raising healthy and happy kids. I'm Melanie Cole. And we're asking the question today, can diet and exercise reverse prediabetes in kids? Joining me is Mikie Rangel. She's a clinical dietitian in the nutrition clinic at Children's Health.

Mikie, thank you so much for joining us today. Start by telling us what is prediabetes. We've heard the term diabetes before. What is prediabetes, and how is it different than full-blown type 2 diabetes?

Mikie Rangel, RD: Such an important distinction, especially as parents are maybe hearing these diagnoses for the first time. So, just a little background on the physiology of how our body works. You know, when we eat food, our body breaks it down into glucose or sugar. That raises our blood sugar levels and signals our pancreas to produce insulin. So, insulin acts as the key to unlock the cell so that the sugar can get out of the blood and into the cell to be used for energy. As that happens, our blood sugar levels lower and normalize, and all is right with the world.

Now, in the case of insulin resistance, okay, our cells get less sensitive to that insulin. And the insulin is there, but it's like the key can't quite find the keyhole. So, blood sugar levels stay elevated. Those are the beginning stages. That is pre-diabetes. Now, if that condition continues and blood sugar levels stay chronically elevated, that's when we would diagnose type 2 diabetes, which of course carries a whole host of other health complications.

So when doctors are looking at this, they're generally checking a few different labs, all of which really are measuring blood sugar, either fasting or after eating or maybe some longer term labs. But they're looking for either normal levels, slightly elevated, which would be pre-diabetes, or significantly elevated, and they would make that diagnosis of type 2 diabetes.

Melanie Cole, MS: Thank you for that excellent explanation. That was like a perfect physiology class to help us understand blood sugar and glucose and what this kind of thing really is. So, what factors, Mikie, do you feel and have you heard and the studies show are really driving the rates of kids diagnosed with prediabetes?

Mikie Rangel, RD: Well, certainly the biggest contributor is increasing rates of childhood overweight and obesity. Excessive body weight, excessive body fat, especially in the abdominal area, really increases our risk of insulin resistance because our cells are less sensitive to the insulin. But it's not simply kids are eating too much sugar.

You know, our entire society is set up to make it hard to make healthy choices every day. I mean, when I was growing up, pet stores sold pet supplies and electronic stores sold electronics. But now, you can't run an errand without coming across a cooler of drinks or a checkout line full of, you know, chips and candy and other treats. Fast food on every corner, food delivery services. It's really hard for families to navigate our society and stay healthy every day.

But, you know, we also have to consider less physical activity, more screen time. I mean, this comes up over and over again in conversations about health. But in this case, it's not just that sedentary time can lead to unhealthy weight gain. We have to remember that physical activity means that our muscles are active. They are using our blood sugar, and active muscles are more sensitive to insulin. So, just being an active person helps us use our blood sugar and keep our levels normal.

And finally, when we're considering kids and prediabetes, we have to consider puberty itself. During puberty, there are normal hormonal changes that naturally make the body somewhat less sensitive to insulin. So, in an otherwise healthy kid, the pancreas kind of compensates, maybe makes a little more insulin to help keep levels normal. But in a kid who's also facing maybe some unhealthy weight gain or a sedentary lifestyle, that change during puberty can really push them over the edge and into that prediabetes range.

Melanie Cole, MS: Yeah, those were all really good points. And we always say that exercise has an insulin-like effect. So really, we know that it can help. But the million-dollar question, can diet and exercise reverse pre-diabetes in children? If we're diagnosed, if we know that this is what's happening and it's headed towards type 2 diabetes, can they, with behavioral modifications, change that trajectory?

Mikie Rangel, RD: Absolutely. A child being told they have prediabetes absolutely does not necessarily mean they are destined to develop type 2 diabetes. Yet change is important, and lifestyle changes are going to have to come into play. But then, that diagnosis of prediabetes is often reversible.

Melanie Cole, MS: So, what are some of the most effective nutrition and physical activity changes that families can realistically start with, Mikie? And I know that we have to be good role models, right? So this is sometimes a family affair, things that we have to do together when it comes to cooking, eating, cooking together, exercising. Tell us what are some of the best strategies

Mikie Rangel, RD: I love all of that. What is practical? Including the family. What's going to make the biggest impact? Those are all things to keep in mind. Starting, of course, with drinks. And I know that we've heard this time and time again, but it's so important to make water the default drink, especially at home. I mean, quite honestly, there's no reason to ever drink anything else, sodas, juices, sports drinks, things like that at home when we're just having our meals and snacks or when we're thirsty throughout the day. All those excess sugars not only can contribute to unhealthy weight gain, but also liquid sugar causes a quick and immediate spike in blood sugar that our body has to work hard to bring down. When it comes to drinks at home, make sure water's the only option. Caveat, milk is also okay. I would say milk is more of a food group, part of our dairy group. But truly just having water at home takes away the negotiations, takes away the battles. This is what we as a family drink day to day, and it's just water.

Now, for families that go out occasionally or if, you know, there's a party or a little event at school, certainly those are times when maybe a child is going to choose something else to drink. That's part of the fun. Hopefully, the majority of their intake is happening at home and, of course, during the school day right now. And if that's all water, those little drinks here and there won't make a big impact.

Now, thinking as a family, thinking very carefully about having a predictable schedule of meals and snacks throughout the day. This certainly doesn't mean a rigid schedule. That's not going to work for most families, especially these days. But generally having three meals a day, breakfast, lunch, and dinner anywhere from four to six hours apart, and then having planned intentional healthy snacks in between when a child is hungry and the next meal is over an hour away. Having regular meals prevents excessive hunger. Kids are skipping breakfast, then oftentimes they're also skipping lunch. They get home from school ravenously hungry, and it's impossible for them to pay attention to those signals of true hunger, satisfaction, fullness, and eat a healthy amount at a meal.

Also, when things are kind of unpredictable, kids will often be snacking all day, right? We might call it grazing all day. That's not only unhealthy because it's often not really related to hunger, usually more boredom or thirst, but it's also a constant stream of sugar going into the blood, our body's constantly having to produce insulin and deal with.

A hungry child should eat. So, the way we put this in place, house rule, all meals and snacks at the table, no screen. We don't eat in our rooms, we don't eat on the sofa, no phone, no TV, no video game. If a child is hungry, they will be willing to come to the table with no screen and sit and eat. And if they're hungry, they should.

But finally, we want to make sure that the entire conversation is not just around meals, snacks, food, drinks. We have to consider sleep, sedentary time, of course activity level, all part of the conversation. Just make sure that when you're talking to kids about being active, this is not in the context of losing weight, right? There are plenty of very healthy, very fit people that exercise every day. Yes, exercise can help maintain a healthy weight, but it's also so good for our heart and our bones, our sleep, our mood. We want to make sure that kids are active, doing exercise they enjoy. There is no one right or wrong way to be active. Find things your kids enjoy doing and look forward to doing every day.

Melanie Cole, MS: What misconceptions have you been hearing in your profession about prediabetes from parents?

Mikie Rangel, RD: Well, certainly, the first, and we've kind of already talked about it, is when they get that diagnosis, they think, "Well, my child obviously has diabetes, or they're going to get diabetes." And as we've covered, that's not necessarily true. Pre-diabetes should certainly be considered a warning sign that there's an increased risk of type 2 diabetes developing, but it's more of a signal to work on some healthy changes.

Parents will often kind of take the blame, like, "My child's been eating too much sugar, right?" Or they ate too many sweets. Pre-diabetes is not caused by one single food or simply by eating sugar. It develops through a combination of factors, diet quality, overall energy balance, activity level, but also genetics and family history.

And most importantly, that reaction of, "My child needs to be on a diabetes diet," or, "We have to cut sugar. We have to cut carbohydrates, low carb, keto." This is certainly one of the most problematic reactions. Children need carbohydrates. There is no need to eliminate grains or fruit or potatoes or any other carbohydrate-containing food just because you're hearing this diagnosis of pre-diabetes. Restrictive diets can make it very hard for kids to get adequate nutrition, but they can also contribute to an unhealthy relationship with food. So more importantly, choose healthier carbohydrates. Higher fiber sources might be things like choosing whole grains or whole wheat for staples like bread or pasta, looking for higher fiber or whole grain cereals or granola bars. Look for at least three grams of fiber on the food label. Choose whole fruits instead of juices. Serve vegetables regularly. Gently encourage without forcing their intake. The most important thing is that we're not singling the child out, okay? We want to be very careful with the conversations and the comments that we're making.

Even the most well-intentioned parents thinking they're helping, comments like, "Well, you can't have that cake, you have pre-diabetes," or, "We all need to eat more vegetables and be active because your sister has pre-diabetes," that's not helpful. This can make kids fearful of food. It can make them feel singled out or ashamed, and no parent wants that for their child.

Melanie Cole, MS: Well, I'm so glad that you brought up the point about carbohydrates, because I've heard that in my many years in the field so many times, "Oh, now we can't eat carbohydrates," but that's what your brain and spinal cord really need. And kids won't be able to think straight. And like you said, there's all kinds of things that can happen from cutting those out of our diet.

In kids that are diagnosed with pre-diabetes, Mikie, when should parents seek help from a pediatric endocrinologist or a registered dietician? When is it that you really feel it's important that they seek out that professional help?

Mikie Rangel, RD: Definitely want to emphasize to parents don't wait until your child develops type 2 diabetes to ask for help. This is your opportunity to seek out those professionals that can help you the most. So, seeing a pediatric endocrinologist can be helpful when maybe the testing from the pediatrician has been inconsistent or unclear.

Maybe one level is normal and one's a little elevated, and we're not really sure which to believe. Seeing an endocrinologist can also be very helpful when the child has significant risk factors, like a strong family history of diabetes, or if there are other endocrine or metabolic conditions going on, or certainly if they're on any kind of medication that might be affecting their blood sugar.

Definitely if you are seeing chronic labs, you know, repeat labs that have been elevated for a couple of visits, and if there are any symptoms at all, like increased thirst or urination, some unusual fatigue, definitely something like blurry vision, you want to seek out that endocrinologist. Now, seeing a pediatric dietician can be really helpful, especially if you've just been receiving this diagnosis and you're not really sure where to start, or maybe you have made some changes and aren't really seeing progress.

Dieticians can help you set those priorities. Where does my family need to prioritize our changes to see the best results in our health? Dieticians can also be very helpful to help your child understand, how is this food working in my body? What does this diagnosis mean? Dieticians are great with working with kids and explaining food on terms that they understand.

And then, of course, for those kids that are maybe a little more selective, we might in the past have called them picky, it can be really hard to make changes at home when your child is unwilling to eat a lot of different foods. Pediatric dieticians are especially good at helping prioritize which foods do we need to be more mindful of, and which can I maybe say, "Okay, my selective eater, I'm going to let this one go."

Melanie Cole, MS: You have given us such great information, usable information that parents listening can use right now and such great advice. What's your final message to families who may feel overwhelmed by a new diagnosis of prediabetes in their children?

Mikie Rangel, RD: Yeah. Of course, first, take a breath. This diagnosis is a reason to pay attention, but not really a reason to panic. We don't want to be overhauling everything at once. That's not sustainable. Look at how life is going right now. Where are those little wins you can have? Like changing over to water, increasing activity even by a little bit every day. So, think about making the change, make a habit, and then maybe move on to the next thing.

I'd want to be very careful how parents talk to their kids. You know, we talked about those comments that can be well-intentioned, but maybe received the wrong way. Think more of, you know, "Your body's having a little trouble handling blood sugar right now, so as a family, we're all going to make some healthy changes because healthy eating really is good for all of us."

Melanie Cole, MS: Great information. Mikie, thank you so much for joining us today and really sharing your incredible expertise and knowledge for parents today. Thank you again. And for more information on how to support your child with prediabetes, you can always visit childrens.com/diabetes. Thank you so much for listening to Children's Health Checkup. If you found this podcast helpful, please rate or review and share the episode, and please follow Children's Health on your social channels.