Transcription:
Pediatric Diabetes Program

Melanie Cole: There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. This is kid's Health Cast by Weill Cornell Medicine. I'm Melanie Cole, and I invite you to listen as we discuss the Pediatric Diabetes Program at Weill Cornell Medicine. Joining me is Emily Coppedge. She's a Nurse Practitioner in Pediatric Endocrinology at Weill Cornell Medicine. Emily, it's such a pleasure to have you with us today, and this is such an important topic. First start out by telling us a little bit about what you're seeing in the trends for pediatric diabetes. How common is it and explain for the listeners a little bit briefly of the difference between type one and type two?

Emily Coppedge: Yes. Thank you so much for having me here today. I'm looking forward to talking all about diabetes. So pediatric diabetes, we pretty much have two main types. We have type one diabetes, which is autoimmune, where the body has kind of a self-attack and stops producing insulin type. Two diabetes, which is similar to what we see in adults is where they are still producing insulin, but they have insulin resistance. In general, majority of the diabetes in this country and in the world is type two diabetes. About 90 to 95% of the people have type two diabetes. That's a much lesser population. I think there's about 1.6 million of type one diabetes in the country. But in pediatrics, we're more likely to see type one. Type two is on the rise. As we've seen an increase in obesity in this country, we've definitely started to see more and more type two in the pediatric population. But right now type one does kind of prevail.

Host:

At what age do kids generally present with type one? And as you said, type two is getting more common, but what age do we start to notice some of these things? And while you're answering that, tell parents what symptoms that would alert them, that something's not right, and that they should really contact their pediatrician to get this checked out?

Emily Coppedge: So, type one diabetes, we actually can see across the lifespan. So we can see it from, you know, when they're a little kid age one all the way up, even to when you're a very elderly person. For most of our diagnosis is they tend to be, you see a more common age when they're like that pubertal time, that early adolescents, I think the average age is like 14. And then we also see a decent cohort in that, you know, four to six year old. But like I said, it could be anywhere. We've diagnosed kids as young as eight, nine months. And we definitely had kids as they were entering adulthood, 18 years old. Type two is much more in that adolescent time period in that pubertal time period is more likely when we're going to see someone with type two. The symptoms we've always said in the medical world, we call it the three Ps, which stands for, I mean, use fancy terminology, but polyuria, polydipsia, polyphagia, which is really just increase thirst, increased urination, and increased hunger. Those tends to be the hallmark signs of diabetes. Seeing someone who's definitely drinking a lot more, having to go to the bathroom a lot more. They tend to be more tired as well. And some of our type twos, we'll see a little bit more increased infection, especially yeast infections.

Host: Emily, is there a screening for kids when they go to their pediatric well visits? Are there questions that they answer? Is there health history questions that are important? Tell us a little bit about if there's any screening that kids go through?

Emily Coppedge: So in our general, well visits, we actually tend not to bring it, especially for type, it's one more of it's symptom-based, you know, if someone was, for some reason, a teenager, wasn't getting a period, a teenage girl or someone wasn't growing or gaining weight, and we start to see weight loss and we start to see, you know, we also say, Oh, okay, you know, they're drinking more, they're paying more than they can screen at the pediatrician. They usually get a urine sample and they can get a blood sugar check. For type two, it's actually recommended that if they're over 10 years old or entering puberty, we should be screening if they're obese or overweight and have some risk factors, which includes a family history of type two diabetes. If they have signs of insulin resistance, we can see it with like thickening along the neck or certain ethnic groups that we should be screening more often.

Host: Emily, in your opinion, how do you feel the obesity epidemic plays a role in the uptick of type two among our youth. It used to be an adult condition. I've been in the field a long time, and this was something that we noticed in adults, obese adults, all of these kinds of things. And why are we seeing this in children? And right now in the time of COVID, are you noticing it more that this obesity epidemic is getting worse?

Emily Coppedge: Yes. I mean a hundred percent. We know that as a society, we're all gaining a little bit of weight, let alone during COVID right now and spending more time at home. So we are seeing that this obesity trend that we're seeing across the board is leading to more type two diabetes. And with COVID, you know, you kind of have this perfect storm that if you had any of these risk factors, and now we took you and we pretty much said, sit at home, you know, you didn't go outside as much, you're not getting the same activity. And the daily exercise, you know, even this remote schooling just really has you at home. A lot of time spent in front of your computers and your TVs, that if you have risk factors, you're more likely actually, we're seeing them kind of develop type two diabetes. Our group in general has seen it huge increase in people getting diagnosed with type two diabetes over this past summer. And I think it's just from that whole stagnant activity, eating more food, and gaining more weight.

Host: I couldn't agree with you more. And one of the things that worries medical professionals is the complications that come from diabetes. Tell us a little bit about the complications, why it's so important that we get it under control. And as a child who has type two and they become an adult or even type one, what are some of the things that could happen to them if it's not kept under control?

Emily Coppedge: Right. So all the complications are a lot of them, especially if you're looking at the type one world and it has to do a lot with those high blood sugars and similar to type two, and what these high blood sugars, this extra glucose that's sitting in their bloodstream, what it can cause. You know, and we see a multitude of complications that can happen along the lifespan, including retinopathy, which we can see damage kind of micro aneurysms on their retinas. We can see nephropathy, which is kidney disease. We can see neuropathy, which is nerve damage. We can see circulation problems, we can see cardiovascular disease. And then on top of that, we have mental health issues. So all of that can result from especially type two world, being obese and these higher blood sugars. What's really important, I think with the weight part, especially in your type two population, is we know that children who are diagnosed with type two, tend to have these worse outcomes, more likely for some of these complications as life goes on. We know that it's really important to get this stuff under control. And in general, I think the mental health side of it is dealing with these chronic illnesses and complications. It does help. And if we're getting this under control, we can kind of alleviate some of that burden.

Host: So then tell us about your program at Weill Cornell Medicine. Tell us about the services that you offer the program highlights and features?

Emily Coppedge: I love our program at Weill Cornell actually. So I'm going to say that. So what I love about our program is that we're all involved. So, in general, there are three main attendings that work including myself as a nurse practitioner. So there's four providers that work with patients and we also have a nutritionist certified diabetes educator who works. We have access to a social worker and we have access to a psychologist. So we kind of hit a lot of the areas we need to with diabetes. And a lot of our focus has not just been on up-to-date therapies and education, but we've really started working on bringing people together. And how are we going to do this? We always traditionally had done the diabetes walk with JDRF and our, all of our members, even our secretaries, everyone would come out and we'd all walk as a group with our patients. We have a diabetes camp that we run a day camp in the summer that I think is not just the kids' favorite week. I would say all of us as providers, it's our favorite week to get out of the office and just have some fun. We run a day camp for kids with type one.

We also do a lot of support groups. We do coffee talks for parents, which right now is coffee, zoom talks, but a chance for parents to talk about the stress and burden of diabetes. We started a teen program this past year, although kind of on hold with COVID right now, where you're getting these pre-teen 11, 12, and 13 year olds together. And just having fun experiences, but kind of building some of their leadership skills because, you know, you need to have a lot of resilience when you're dealing with diabetes and then kind of parallel to our diabetes program. We even have an obesity program that is run by Isabel, who's our nutritionist, and also by another attending. And they work a lot on dealing with kind of that before they get to diabetes time period. So I do think it's been, I think really creative. I'll kind of try to reach our patients in different ways.

Host: Well, that segues very nicely. You've mentioned briefly a few times the mental toll that this can take on the family as a whole and not just the child who has diabetes, certainly the parents as well. So tell us a little bit about how you help kids deal with the regimen for type one. Certainly it is a very regimented way that they have to live their life and for type two, there's a whole lot of changes that need to take place. How do you help them with that psychosocial and emotional, you know, changes in their lives, whether it's self-esteem or sporting activities, any of these factors?

Emily Coppedge: Yeah, I think the first thing I always tell parents, it's like when they have them in the hospital and they've just been diagnosed and some of our type twos actually get hospitalized, we've seen them come in [inaudible 09:50] and they're learning how to manage diabetes. And I always say, when you take your kid home, it's like taking your newborn home again, it's that feeling of fear, you know, excitement to get out of the hospital, but that fear of, you know, this unknown, how am I going to manage this? And so that beginning, it's just a lot of stress on everybody, a lot of hand holding and letting them know that this is nobody's fault and we can do this. And my most important thing to tell kids is they can do this and their life has to pick up. I've had kids who tell me, you know, they get diagnosed and they have a big basketball game two days later. And I'm like, okay, go to it. We're going to make you go to that game. And we're going to figure out diabetes. So a lot of the mental health, the diabetes is teaching kids to go live their lives, but finding a way to do it safely with diabetes. I think the best outlook to have on diabetes is it is kind of a family disease, you know, in type two, we're working on getting a better handle on that side.

It tends not just to be that one patient. It tends to be, there can be changes we all can make. In type one, we got rid of a specific diet and we really said eat healthy. But I know if you told me if I told you I was eating healthy and I went through my diet, I know I could say, well, I can make some changes. You know? So it's really the whole family learning to eat healthy again. For our type ones, it's learning to look at their food and count their carbs. And so it really is working with the families, working with our psychologist, who's been really instrumental in speaking to parents and kids to help deal with that burden. And to give kids an outlet when they need to talk to us and say, it's really hard. I find that these programs that we do with camps and different support groups are helpful because everybody, I think parents need another parent with diabetes and kids need another kid with diabetes just for that normalcy. They don't have to be best friends, but it's nice to hang out with someone and not think twice about checking a blood sugar or giving insulin. So I think all of that kind of factors in to just working on their mental health, but the burden is very real. It's lifelong and it's a lot of work to have these diseases.

Host: Well, it certainly is. And what a wonderful program you've got going there. Tell us a little bit more on the multidisciplinary team to treat these children, because as you said, there's nutritional services, nutritional counseling, I'm sure exercises. There are so many people involved. Tell us about them now.

Emily Coppedge: So, they're not just meeting with the doctor. They're meeting with myself, the nurse practitioner, and I'm an educator. They meet with our nutritionist to not only learn how to carbohydrate count and our type ones actually look at the food, determine how many carbs are in them and then have to determine how much insulin. And then on top of that, they also have to eat healthy. And so we really use a lot from our psychologists. We've been relying heavily on her to speak with both our patients, new onsets. And then as our families kind of go through different times. I mean, technically there's some outside specialists when we have to go to an ophthalmologist every year. Some of our kids develop kidney disease young. So we kind of have to refer and work with our nephrology group, which is our kidney doctor group. So we kind of work with all of them to make sure they have the best treatment. And that we're kind of staying ahead of the game.

Host: Tell us a little bit more about what's unique about the program. You mentioned the camp, tell us some other special things that your team does because you're working with children and their families. What do you do to go above and beyond? We know you love your job. We can hear that passion. Tell us a little bit more.

Emily Coppedge: I think for us is just an understanding of where families are and how can we help them. You know, for a lot of our younger kids, we've had a decent amount of very young kids, our actually under twos that have gotten diagnosed in the last year. And that's a very big burden and stressor. So for them, sometimes it's just listening to the mom, be stressed out and know that they're coming home and that they need extra help. And the minute they get discharged to let them know that our team's going to call them the first night. And that they can get hold of our team, anytime, because we know big life events are happening, that they were nervous about. And we just call and check in afterwards to make sure everything went okay. Or we tell them, you know, we come up with plans for something exciting, even if it's just giving a speech at school and we talk about making sure the blood sugars are in a good spot, so they don't have to worry about them. A lot of what we do is we partner a lot with JDRF. We have good resources from them. That's the Juvenile Diabetes Research Foundation. So they all get a bag, a bag of hope that they get has Rufus the bear and other fun things to help the kids learn. And we've really actually loved using telemedicine really have found it worked great that we can reach families differently, do a lot of trainings over the phone, you know, get them on therapy sooner because we can video in and help them. And it's also helpful, you know, your first night home from the hospital, you can video in with your doctor now and go over stuff. And I think that has been really helpful. Just kind of that personalized approach.

Host: As we wrap up, Emily, tell us about some of the current therapies or anything exciting in the field of endocrinology that you'd like parents to know about as far as what you're doing, besides all of the things that we've been talking about. We haven't really mentioned insulin and medication. Give us a little summary on how those things are used because some people think, Oh, type two, right away, insulin. That's not always the case. So why don't you give us a little summary on some of the treatments and then wrap it up with your best advice?

Emily Coppedge: So, for type two diabetes, the actual hallmark treatment is Metformin. You know, it's the same hallmark treatment that is an adult and it is an oral medication that we use. And we often get really good control of the blood sugars with it. Often if kids had very high blood sugars, if they have type two in a diagnosis, the beginning, we do need insulin at the beginning to get the blood sugars down. And our goal is always to try to wean off that insulin and just keep them on Metformin. It takes a little bit of time to get Metformin on board, but insulin doesn't mean where it's at. I also don't like the thought that insulin is bad, because insulin is not bad. It's what the body naturally produces. We're just giving it from the outside. But those are kind of what we have for type two. We have that. And then we actually have, what's called a GLP one. So it's an injectable that's not insulin that helps with satiety. And it also helps with blood sugar control. So those are kind of three main medications. We don't have all the orals that we use in adults with those have not always been used in pediatrics because they're not approved. And our type ones, it's all insulin, but there's different ways to get your insulin so you can use injections. Or a lot of the new world of technology is really focused on insulin pumps.

And then there's also something called a continuous glucose monitor, which is a sensor that they wear that measures the blood sugar every five minutes. And a lot of the new technology is really looking to get that sensor and that pump to talk and help the pump adjust the insulin based on the sensor readings, which means ideally better control. And it means a little bit less work that you as the person with diabetes has to do. You know, if you read a lot of stuff, that's coming out, it will talk about this artificial pancreas. We don't have an artificial pancreas that would be a pump and a sensor that just do it all for you. But we do have hybrid models that are getting better and better to ease the workload of diabetes. Diabetes is increasing both type one and type two. And so we know it's out there. We know it's in the community. Our program has worked really hard to not just work with you into better your control with diabetes, but also to kind of better your emotional support with diabetes as well. And that has been, I think, one of our strongest points of the program and finding ways for not just kids, but for parents to kind of reach each other and go through this experience together with a little bit of help.

Host: Great information, Emily, I can just hear how much you care for your patients. And thank you so much for joining us today and telling us about the program at Weill Cornell Medicine. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. Thank you so much, Emily for joining us and to our listeners. And that concludes today's episode of Kids' Health Cast. Please remember to subscribe, rate, and review this podcast and all the other Weill Cornell Medicine podcasts. For more health tips and updates, follow us on your social channels. I'm Melanie Cole

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