Diabetes and Obesity in Children. Janie Berquist, RN, BSN, MPH, CDE Children s Mercy Hospitals and Clinics Kansas City, MO

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1 Diabetes and Obesity in Children Janie Berquist, RN, BSN, MPH, CDE Children s Mercy Hospitals and Clinics Kansas City, MO

2 Diabetes and Obesity in Children What is Diabetes? How are Diabetes and Obesity in Kids related? Who is likely to develop Diabetes?

3 What is DIABETES? Diabetes is a chronic condition that affects the way the body uses food for energy, resulting in elevated blood glucose Insulin (hormone made in the pancreas) helps the body cells utilize the glucose transforming it into energy

4 Dr. Banting and Dr. Best Discovered Insulin

5 Insulin is produced by Beta Cells in the Pancreas

6 How does my body use insulin? Insulin allows blood sugar (glucose) to move from the bloodstream into cells to be used as fuel INSULIN Glucose = CELLS

7 Insulin Role in Glucose Transport

8 Muscle cell metabolism

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10 Insulin Effect Basal-Bolus Insulin Therapy: Insulin Glargine at HS and Mealtime Lispro, Aspart, or Glulisine B L D HS Insulin lispro or aspart Insulin glargine Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc.; 2002:87

11 Types of Diabetes Type 1- Juvenile Diabetes Autoimmune-beta cells are destroyed by immune process (Auto-antibodies present) Sudden onset Must take exogenous insulin

12 Types of Diabetes Type 2 Formerly Adult Diabetes Characterized by insulin resistance Not enough insulin is made, and/or it is not working well Initial treatment includes (in children): healthy eating plan activity plan Metformin (Glucophage)

13 Types of Diabetes Gestational diabetes is diagnosed in some women during pregnancy, OFTEN related to obesity. Other cystic fibrosis related, chemotherapies, toxins, etc.

14 Diagnosing Diabetes (Type 1 or Type 2-ADA) Normal Fasting Plasma Glucose < 100 Pre-diabetes Diabetes or over After two hours (Oral Glucose Tolerance) Pre-diabetes Diabetes - >200

15 A1C--your average blood sugar When your A1C is: Your average blood sugar is: 4% % % % % % % % % %

16 Treatment Protocol for Type 2 at Children s Mercy Hgb A1C 9% or greater admit and begin insulin Hgb A1C 8% - admit and begin diabetes education (start/continue metformin) If A1C is not available, may start insulin if Blood glucose is elevated. If Hgb is <8% (>7%), patient will be seen in clinic asap (within the next week).

17 Type 1 AND Type 2? It is possible to have Auto-Antibodies of Type 1 Diabetes and have Insulin Resistance (typical of Type 2) This confuses the picture! The treatment is probably the same, depending on the A1C and other factors

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20 What is the connection between Obesity and Diabetes? Obesity is accompanied by high circulating insulin and increasing blood glucose Circulating Free Fatty Acids, Triglycerides and inflammatory cytokines from adipose tissue contribute to beta cell death.

21 Cell metabolism of glucose results in Energy or storage as fatty acids

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23 Impaired Glucose Tolerance 3HR GLUCOSE TOL SEE BELOW (3HR GLUCOSE TOL 0 MIN GLUCOSE 68 mg/dl 30 MIN GLUCOSE 142 mg/dl 60 MIN GLUCOSE 175 mg/dl 90 MIN GLUCOSE 174 mg/dl 120 MIN GLUCOSE 158 mg/dl 150 MIN GLUCOSE 131 mg/dl 180 MIN GLUCOSE 113 mg/dl 0 MIN INSULIN 13.0 uiu/ml 30 MIN INSULIN uiu/ml 60 MIN INSULIN uiu/ml 90 MIN INSULIN uiu/ml 120 MIN INSULIN uiu/ml 150 MIN INSULIN uiu/ml 180 MIN INSULIN 95.1

24 Progressing to Impaired Glucose Metabolism Changes in insulin sensitivity, strongly related to weight changes, can have a significant impact on the 2 hour glucose level of obese children and adolescents. Those who reverted from IGT to NGT, on average, decreased their BMI, while those who deteriorated from IGT to overt Type 2 DM continued to gain weight. Weiss R, et al. Predictors of changes in glucose tolerance status in obese youth. Diabetes Care 2005: 28:

25 Progressing to Impaired Glucose Metabolism Children and adolescents with severe degrees of obesity are at very high risk for deterioration of glucose metabolism over relatively short periods of time. At the time of diagnosis, adolescents with T2DM have significant Beta cell dysfunction, compared with newly diagnosed adults.

26 Type 2 Diabetes 3HR GLUCOSE TOL SEE BELOW (3HR GLUCOSE TOL 0 MIN GLUCOSE 106 mg/dl 30 MIN GLUCOSE 181 mg/dl 60 MIN GLUCOSE 211 mg/dl 90 MIN GLUCOSE 224 mg/dl 120 MIN GLUCOSE 202 mg/dl 150 MIN GLUCOSE 179 mg/dl 180 MIN GLUCOSE 136 mg/dl 0 MIN INSULIN 33.7 uiu/ml 30 MIN INSULIN uiu/ml 60 MIN INSULIN uiu/ml 90 MIN INSULIN uiu/ml 120 MIN INSULIN uiu/ml 150 MIN INSULIN uiu/ml 180 MIN INSULIN uiu/ml

27 Premature death of the Beta Cell

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30 Risk factors for developing Type 2 Diabetes in Children Obesity Family History of Diabetes (genetics) Inactivity (Exercise enables entry of glucose into cell metabolism) Race (African Americans, Native Americans, Asian Americans, Pacific Islanders, Hispanics.) Gender (female African Americans, male Hispanics)

31 Fat distribution a Risk Factor

32 Prevalence worldwide 2011

33 Rate (per 100,000/year) Rate of new cases of type 1 and type 2 diabetes among youth aged <20 years, by race/ethnicity, Type 1 Type ALL NHW AA H API AI ALL NHW AA H API AI <10 years years CDC. National Diabetes Fact Sheet, Source: SEARCH for Diabetes in Youth Study NHW=Non-Hispanic whites; AA=African Americans; H=Hispanics; API=Asian/Pacific Islanders; AI=American Indians

34 Percent Estimated lifetime risk of developing diabetes for individuals born in the United States in Total Non-Hispanic Black Non-Hispanic White Hispanic Men Women Narayan et al, JAMA, 2003

35 Environmental Factors Impacting Diabetes The factors leading to obesity complicate treatment of Diabetes Family history and lifestyle Lack of understanding of long term complications Ability to comply with recommendations for multiple reasons (language, culture, financial, etc.)

36 Diabetes affects 8.3 percent of Americans of all ages, and 11.3 percent of adults aged 20 and older, according to the National Diabetes Fact Sheet for About 27 percent of those with diabetes 7 million Americans do not know they have the disease. Prediabetes affects 35 percent of adults aged 20 and older.

37 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Obesity (BMI 30 kg/m 2 ) Diabetes Missing Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% 26.0% Missing data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

38 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults 1994 Obesity (BMI 30 kg/m 2 ) Diabetes Missing Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% 26.0% Missing data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at