Diabetes Mellitus in Children and Adolescents

1. Diabetes Mellitus in Children and Adolescents Maureen McGrath, PNP-BC, CDE Emory-Children’s Center Division of Endocrinology and Diabetes

2. DIABETES = Defect in Energy Utilization • Glucose is primary energy source of all cells • Insulin is necessary to transport glucose into most cells • Insufficient insulin results in inadequate glucose for energy inside cell, need alternative energy source (fat) • Insufficient insulin results in high extracellular or blood glucose (hyperglycemia)

3. How the Body Uses Food as Fuel Digestion of Macronutrients (CHO, FAT, PRO) I G I G GLUCOSE G G G Pancreas (Insulin) I I Insulin I G I Blood Stream Cell

4. PATHOPHYSIOLOGY HYPERGLYCEMIA Blood glucose increasing above the renal threshold (~180 mg/dL) results in glycosuria • Glucose urinated out = polyuria • Decreased extracellular water stimulates thirst = polydipsia • Lost glucose is lost calories and stimulates hunger =polyphagia

5. Insulin:Before and After

6. TYPE 1 DIABETES • Most common presentation in children and adolescents • Autoimmune pathophysiology • Prevalence: 1 of 350 children • 3-5% risk in siblings; 30% for identical twins • Risk of ketoacidosis • Dependent on insulin for survival

7. Type 1 diabetes: insulin deficiency G Glucose G Pancreas (Insulin) XXXXX G Blood Stream Cell

8. TYPE 2 DIABETES

9. TYPE 2 DIABETES • ~ 30% of children > 10 y.o. present with type 2 diabetes • African-Americans, Latinos, Native Americans, Pacific Islanders • Insulin resistance associated with obesity and acanthosis nigricans • Prevalence: increasing • Very strong family history • May also have ketonuria and ketosis (ketosis-prone type 2 DM) • Treatment: lifestyle, metformin, insulin

10. Type 2 diabetes: insulin resistance I G I GLUCOSE G Pancreas (Insulin) I I Insulin I I I G Cell Blood Stream

11. ACANTHOSIS NIGRICANS

12. PRESENTING SYMPTOMS Symptoms %Type 1 %Type 2 P (n=48) (n=40) value Abdominal Pain 46 33 >.10 Dizziness 15 33 >.10 Headache 33 43 >.10 Nocturia 71 65 >.10 Polydipsia 96 85 >.10 Polyphagia 69 60 >.10 Polyuria 94 88 >.10 Visual Problem 17 20 >.10 Weight loss 71 40 .005

13. PRESENTING SYMPTOMSand SIGNS • Vulvovaginitis, severe candida diaper rash • Vomiting • Dehydration • Difficulty breathing (Kussmaul respirations) • Fruity odor to breath (ketones) • Altered mental status

14. PATHOPHYSIOLOGY ofDIABETIC KETOACIDOSIS (DKA) • Low insulin  hyperglycemia and glycosuria, insufficient suppression of lipolysis and ketogenesis • Glycosuria  osmotic diuresis  polyuria  dehydration  polydipsia • Dehydration  increase in counter-regulatory hormones, which leads to further hyperglycemia and ketosis • Hyperosmolarity  altered mental status

15. DIABETIC KETOACIDOSIS • Hyperglycemia Blood Sugar >300 • Acidosis pH <7.3 or Bicarb <15 • Mortality 2-10%

16. DIAGNOSIS of DIABETES MELLITUS • Symptoms of diabetes and random glucose greater than 200 mg/dl • Fasting lab plasma glucose (not fingerstick) of > 126 mg/dL (2 separate occasions) • OGTT 2 hour plasma glucose > 200 mg/dl - fasting, 1.75 gm/kg, max 75 gm glucose load • HbA1c of 6.5% or greater (lab verified) • 5.7- 6.4% considered sign for increased risk

17. MANAGEMENT of TYPE 1 DIABETES • Insulin • Glucose monitoring • Nutrition • Exercise • Sick Day management • Psychosocial

18. MANAGEMENT of TYPE 2 DIABETES • Eliminate symptoms of hyperglycemia • Weight stabilization • Improve cardiovascular risk factors Hypertension Hyperlipidemia Hyperglycemia • Psychosocial • Oral meds/insulin

19. DIABETES SELF MANAGEMENT EDUCATION • Basic pathophysiology • Short and long term complications • Meal planning • Exercise guidelines • Blood glucose monitoring • Patient-centered goal setting

20. INSULIN

21. Insulin Action Normal insulin delivery This is a 24 hour representation of the insulin profile for someone who does not have diabetes. The pancreas releases insulin for each meal, but there is always a constant background or basal amount present that has nothing to do with food.

22. INSULINSU-100 Human Recombinant DNA or Analog Insulin Onset Peak Duration

23. Basal/Bolus Regimens (physiologic/MDI/BBT) This shows the basal/bolus regimen with the background or basal insulin as the thick black line at the bottom. Meal or bolus doses are delivered in varying amounts and times according to meals.

24. INSULINSMixed • Novolog 70/30 • Humalog 75/25 • Humalog 50/50

25. Two or three injections/day People on this injection regimen would be getting shots at breakfast and supper. • The breakfast shot combines a short-acting insulin which covers just that meal. • The intermediate-acting insulin mixed in the same shot covers lunch and the hours until supper. • The supper shot covers the evening meal and the nighttime hours.

26. Why only two or three injections per day? • School issues • Injection avoidance • Possibly non-specialty care • Adherence issues • Lack of parental supervision • Developmental issues • Age-inappropriate expectations • Teenagers (away from parental support and supervision)

27. Ways to Give Insulin- Injections Insulin can be injected with a standard vial and syringe or by using a pre-filled insulin pen.

28. Ways to Give Insulin- Insulin Pumps Insulin pumps are computers that deliver insulin continuously instead of taking multiple injections. • Deliver programmed insulin (bolus) • Deliver pre-programmed insulin delivery (basal) • Do not measure glucose levels

29. Pump Sites Catheter- small plastic tube that remains under the skin. • Pump sites generally changed every 3 days • Pumps can be disconnected for activities and/or showers • Sites may have to be changed more frequently as the catheter falls out, becomes untaped

30. Real-time Continuous Glucose Monitoring

31. TREATMENT of TYPE 2 DIABETES - DRUGS INSULIN • Initial Rx if DKA, FBS > 250 mg/dl or if symptomatic • Large dose may be needed because of insulin resistance • Often use 70/30 • Used in combination with oral agent

32. TREATMENT of TYPE 2 DIABETES- DRUGS • Biguanide - metformin • Sulfonylurea - Glipizide, Glyburide, Glimepiride • Meglitinide - Repaglinade (Prandin) • α-Glucosidase inhibitor - Acarbose • Thiazolidinedione - Avandia, Actos

33. METFORMIN (Glucophage) • Inhibits hepatic glucose production, also decreases elevated androgens • No hypoglycemia • Doesn’t cause weight gain • Anorexia, gastrointestinal symptoms • Helpful if taken with food • Risk of Lactic Acidosis

34. USUAL INITIATION OF THERAPY • Education and Monitoring - If ketotic or FBS >300 start insulin • Nutrition and Exercise Guidelines • Evaluation over 3 months, • If on insulin and meeting guidelines, progress to Metformin and decrease insulin • If not on insulin and not meeting guidelines, progress to Metformin

35. GLUCOSE MONITORING • BG should be checked before all meals and bedtime • Additional checks as needed • Physical activity • Driving • Sick days • Snacks

36. GLUCOSE MONITORING Meters • Memory for 30-120 days (3-4xdaily) • Small blood volumes (0.3, 0.6, 1.0, 1.5μl) • Rapid results (5-10 seconds) • Use of sites other than fingers • Serum ketone monitoring • Measurement of serum β hydroxybutyrate

37. American Diabetes Association- BG and HbA1c goals for T1DM by age group Diabetes Care, 2010

38. SPECIFIC TREATMENT GOALS for TYPE 2 DIABETES • FBS < 140 mg/dl, HgbA1C < 7% • LDL cholesterol < 100 mg/dl • BP < 90% for age

39. TIDM Family history of hypercholesterolemia * If LDL < 100 screen every 5 years. Annual microalbumin/creatinine ratio: age 10 and TIDM for 5 years, Annual ophthalmologic exam: age 10 and 3-5 years of TIDM Screen for Thyroid Peroxidase and Thyroglobulin, Transglutaminase or Endomysial Abs at diagnosis TSH q 1-2 yrs * TC >240 and/or Cardiac Event < 55 Screen age >2 otherwise begin screen at > 12. T2DM Lipid Panel yearly Microalbumin/creatinine ratio at diagnosis and yearly Dilated eye exam at diagnosis and yearly Liver function every 6 months if on metformin Annual Screening

40. NUTRITION

41. Why Carbohydrate Counting? • More Precise Meal Planning Method • Greater Flexibility with Food Choices • Only One Main Nutrient Counted • Better Blood Glucose Control

42. NUTRITION PRINCIPLES • 50-55% carbohydrates, 15-20% protein, 30% fat • Sufficient calories for growth • Pattern of food distribution -Exchanges -Carbohydrate counting • Distributed as 3 meals and 2-3 snacks • Individualize plan

43. CARBOHYDRATE COUNTING • Insulin dose is tied to amount of carbohydrate • Read total carbohydrates on food label, not sugar • Most children don’t need to eat a particular number of carbs per meal • Those on basal/bolus regimens or insulin pumps can vary insulin dose with amount of carbohydrate

45. 1 sm. apple, orange or peach 15 grapes ½ large banana ½ cup (4 oz.) juice ½ cup pasta 3 oz. Baked potato 1 slice bread ½ cup cereal 1 cup milk 3 cups popcorn Carbohydrates: These are examples of 15 gram portions

46. The Misconception About Sweets A Carb is a Carb is a Carb - but there are Healthy Carbs: fruits, vegetables, whole grains

47. MANAGEMENT of TYPE 2 DIABETES - NUTRITION • Prevent further weight gain • Decrease energy intake to 65-80% if BMI > 40 or 90% if BMI >30 and <40 • CHO 50-55%,fat 30%, protein 10-15%

48. EXERCISE

49. EXERCISERecommendations • More monitoring, better control • Extra carbohydrates if BG normal-low 15gm per 30 min intense exercise • No exercise if BG >300 or ketonuria • Goal for people with diabetes is 150 minutes per week of moderate-intensity aerobic exercise

50. MANAGEMENT of TYPE 2 DIABETES - EXERCISE • Increase physical activity • Decrease sedentary behavior