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OVERVIEW OF PEDIATRIC DIABETES 2010

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OVERVIEW OF PEDIATRIC DIABETES 2010 Alan B. Cortez, M.D. Pediatric Endocrinology Chief, Department of Pediatrics Kaiser-Permanente, Orange County – PowerPoint PPT presentation

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Title: OVERVIEW OF PEDIATRIC DIABETES 2010


1
OVERVIEW OF PEDIATRIC DIABETES 2010
  • Alan B. Cortez, M.D.
  • Pediatric Endocrinology
  • Chief, Department of Pediatrics
  • Kaiser-Permanente, Orange County
  • January 29, 2010

2
Outline
  • Types of Pediatric Diabetes
  • Role of Insulin
  • Balancing food and exercise
  • Insulin Strategies
  • Psychosocial, Goals, and Outcomes

3
TYPES OF PEDIATRIC DIABETES MELLITUS
  • Type 1
  • Type 2
  • Monogenic (MODYs and others)
  • Atypical DM (seen with African ancestry)
  • Drug-induced (corticosteroids and others)
  • Cystic Fibrosis
  • Pancreatectomy or Severe Pancreatitis
  • Gestational Diabetes

4
PEDIATRIC COMPARISON OF TYPE 1 VS TYPE 2
  • Age lt40 years old
  • Thin vs. overweight
  • Wt loss very likely
  • Any race/people
  • No metabolic syn
  • Weak Family Hx
  • Ketones very likely
  • More likely DKA
  • 2-3 islet antibodies
  • Age gt10 years old
  • Obese vs. very obese
  • Wt loss less likely
  • Non-white
  • Met syn/Acanthosis
  • Strong Family Hx
  • Ketones less likely
  • Less likely DKA
  • 0-1 islet antibodies

5
PANCREAS
BETA CELLS IN ISLETS MAKE INSULIN
AFTER 5 YEARS OF AUTOIMMUNE DESTRUCTION
6
  • The main difference between the types of
    diabetes is whether insulin deficiency is
    complete or partial.

7
Which type is more severe?
8
IMPORTANT MESSAGES TO PATIENTS AND PARENTS ON
TYPE 1 DIABETES
  • Be clear about the diagnosis of diabetes
  • No one did something or didnt do something to
    cause type 1 diabetes
  • Nothing to be guilty about, though that is what
    parents do best
  • With the right treatment, the prognosis is for a
    long, happy, and healthy life
  • Ignoring diabetes leads to terrible problems in
    life.
  • Diabetes will be cured in our lifetime.

9
MAIN FACTORS AFFECTING BLOOD GLUCOSE
  • The balancing act can be a three ring circus

10
Components of Glucose metabolism
  • Food (source of glucose)
  • Beta Cells (source of insulin)
  • Insulinases (destroyers of insulin)
  • Glucose Secretion (primarily liver)
  • Glucose disposal (metabolism, muscles)

11
ACQUIRING FUEL AUTOMOBILES VS HUMANS
  • Gas Pump
  • Gasoline
  • Gas Tank
  • Gas Line
  • Fuel Injector
  • Engine
  • Food
  • Glucose
  • Digestive Sys/Liver
  • Blood stream
  • Insulin
  • Mitochondria

12
INSULIN PHYSIOLOGY
  • We ALWAYS need insulin
  • Beta cells increase secretion suddenly in
    response to many eating-related signals and
    rising BG
  • Insulin is secreted primarily from pre-formed
    packets in the beta cells into the portal
    circulation
  • The surge of insulin reverts to baseline as the
    signals and BG levels revert to baseline

13
INSULIN PHARMACOLOGY
  • We have no method to deliver insulin yet that is
    even close to how beta cells work, but
  • It is almost natural
  • It is probably the best medicine for any kind of
    diabetes
  • INSULIN ALWAYS WORKS!!!

14
INSULIN- PHYSIOLOGY VS PHARMACOLOGY
  • As a medicine, we inject it into the fat, not the
    portal circulation
  • Injected Insulin is slowly released from fat
  • Our blood, but not fat, destroys insulin
  • We can alter insulin to make it enter the
    bloodstream slower or faster when injected into
    fat

15
INSULIN PHARMACOLOGY
  • Exogenous insulin will never work as well as
    nature does it, but using it properly works well.
  • Technology/Research continues to get us closer
    but since 1921, advances have been modest
  • At any moment, too little insulin causes high BG,
    too much insulin causes low BG- cannot be avoided
    but can be minimized

16
TOP FIVE REASONS TO THINK ABOUT WHEN INSULIN
DOESNT WORK
  • Not taking it
  • Not taking enough
  • Usually taking it too late
  • The injected substance isnt insulin
  • Kinetics that dont match lifestyle

17
OTHER FACTORS AFFECTING BLOOD GLUCOSE
  • Ketosis
  • Other Medicines
  • Infections
  • Unauthorized food
  • Internal release of hidden insulin
  • Dawn phenomenon
  • Hormones/menses
  • Stress
  • Absorption of insulin
  • Potency of insulin
  • Measuring insulin
  • Late injections
  • Missed injections
  • Speed of digestion
  • Delayed effects of exercise
  • Hyperglycemia

18
OTHER FACTORS AFFECTING BLOOD GLUCOSE
  • Ketosis
  • Other Medicines
  • Infections
  • Unauthorized food
  • Internal release of hidden insulin
  • Dawn phenomenon
  • Hormones/menses
  • Stress
  • Absorption of insulin
  • Potency of insulin
  • Measuring insulin
  • Late injections
  • Missed injections
  • Speed of digestion
  • Delayed effects of exercise
  • Hyperglycemia

19
MAIN FACTORS AFFECTING BLOOD GLUCOSE
  • INSULIN
  • FOOD
  • EXERCISE

iii hhh h then i
The role of exogenous glucose and insulin to
inhibit hepatic glucose production is critical in
exercise. Giving insulin and glucose during
sports prevents hypoglycemia later
20
CALORIES AND CARBS
  • FAT (30)
  • PROTEIN (15)
  • CARBS (55)
  • About 70 of a healthy diet is pure glucose
  • 10 Glucose
  • 50 Glucose
  • 100 Glucose

21
NUTRITION TIPS FOR BALANCE
  • Goal is healthy diet first and foremost
  • Insulin is slow so food needs to be slow
  • Carb counting is a good technique but only with
    healthy balanced diet, isnt for everyone, and
    isnt a prerequisite for success.
  • Schedule/Routine is a secret of success
  • Vigorous exercise requires fuel

22
INSULIN ACTION
Natural
Breakfast
23
INSULIN ACTION
Natural
Regular
24
INSULIN ACTION
NPH
Regular
25
INSULIN ACTION
26
INSULIN ACTION
27
INSULIN ACTION
28
INSULIN ACTION
29
INSULIN STRATEGIES
  • Insulin pump
  • MDI With Basal
  • Breakfast/Dinner injections
  • Extras- coverage insulin, afternoon snack
    insulin, other extra food insulin, glucose sensor

30
INSULIN NEEDS DUIRNG PHASES OF DIABETES
  • Diagnosis-1st day if no DKA i
  • Diagnosis- 1st day if DKA hhh
  • Insulin resistance (1 week, ) hh
  • Return of normal sensitivity (1-2 weeks), i
  • Increasing insulin secretion (1 week) ii
  • Full-blown honeymoon period (3-6) iii
  • Loss of insulin secretion (3-24 months) h
  • Puberty to early 20s hh
  • Adult i

31
HYPOGLYCEMIA
  • Low BG does not contribute to the opathies
  • Some peoples personal goal for diabetes is to
    avoid low BG.
  • Low BG causes so much anxiety it can interfere
    with good treatment (FEAR OF EUGLYCEMIA)
  • There obviously are some serious concerns here,
    but those who do a good job put them into
    perspective

32
MOTIVATING ADHERENCE IN NORMAL CHILDREN/TEENS
  • Our most important job yet we dont yet know how
    to succeed at it.
  • Fear of Complications, Punishment, and Negative
    Reinforcement havent had too much success in the
    past 89 years.
  • Conditional Positive Reinforcements may have
    time-limited success and unintended consequences.
  • Weekly follow up from health professionals?

33
CHARACTERISTICS OF ADHERENT PEOPLE
  • Enjoy a higher quality of life than those who are
    not
  • Do not view their situation as a punishment
  • Have faith and believe in the future
  • Feel good when they do the right thing
  • Family is strong, close, and eats together
  • Their parents dont keep asking them Did you
    take your blood sugar?

34
MOST IMPORTANT THINGS FOR PEOPLE TO DO
  • Eat healthy at same times each day.
  • NEVER MISS AN INJECTION!!!
  • Give rapid insulin before you eat.
  • Adjust insulin frequently based on blood glucose
    patterns and your goals.
  • Accept hypoglycemia and plan for it.
  • Use KNOWLEDGE!!

35
GOALS FOR TREATMENT
  • A1c lt7 (8 if very young)
  • BG Target 70-150 mg/dL70-200 if lt5 yrs
  • Avoidance of seizures
  • Hypoglycemia approx 3-5 times per week
  • Excellent quality of life
  • Excellent sense of well-being
  • Appropriate monitoring for complications

36
DIABETESISNOTBRITTLE,PEOPLEARE
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