A Pathway Forward for Children with Diabetes

Bandy: This is a special episode to celebrate Diabetes Awareness Month but also talk about endocrinology. Today, we're going to dig into that. Can you tell me what drew you to endocrinology? 

Oden: When I was around nine years old, my dream was to become a Navy fighter pilot. I have always loved airplanes. But, at 10 years of age [in 1981], I was diagnosed with Type 1 diabetes. 

Bandy: How has your experience as a child influenced how you treat your patients? 

Oden: It [gives] me more insight into the daily grind of having a complex and chronic disease. I have more footing to understand what they're going through. I know some things they're explaining can be overcome, and I can give them insight into how to do that. I have a lot of colleagues that have Type 1 diabetes. It does lend at least comfort and understanding.   

Bandy: I've always said there's magic in shared experiences, and I can't imagine, as a parent, how amazing that would be to have a doctor who knows almost exactly what we are going through as a family with our child. 

Oden: There is a pathway forward. I'm not going to say ‘a light at the end of the tunnel’ because there is no cure, but a pathway forward, meaning that [children with diabetes] can become very successful in their lives. They can go to college. They can go to trade school. They can be a teacher. They can be a lawyer. They can be a doctor. They can be a pilot. They can be all these things that people just put out of their minds when they're first diagnosed with diabetes. 

Bandy: What are the differences between the types of diabetes?   

Oden: There are several forms of diabetes. The most common form in the pediatric age range is Type 1. Type 1 is an autoimmune disease, which means our bodies create an antibody, which usually protects us against infection or foreign things invading us. [However], individuals with Type 1 develop an antibody that destroys a cell called the beta cell. The beta cell is the only cell in our body that creates the only hormone that lowers blood sugar. When we start losing beta cell mass, our ability to make that hormone drops. Because we can’t make enough of it anymore, blood sugar starts to go up, and [that leads to Type 1] diabetes.  

Type 2 diabetes is different. Type 2 diabetes doesn't come from the destruction or loss of the cells or the inability to make insulin. It comes from a process called insulin resistance, which means you can't use [insulin] anymore. So, Type 1 is where you can't make [insulin]; Type 2 is where you can't use [insulin].  

There are ways of telling the difference, just visually seeing a child. Sometimes, those can be very subtle, so we measure things like antibody levels when we first detect diabetes in kids.

Bandy: One of the ways that [Arkansas Children’s] helps children who are diagnosed is the diabetes management plan. Tell me about that. 

Oden: The diabetes management form is individualized for each family. [This plan is also] for people like camp staff if the child is going to diabetes camp, Boy Scout camp, or Girl Scout camp. If they go to school, we give this to the school nurse. It tells them what to do with high blood sugars, what to do with low blood sugars, what dose of insulin to give and what to do with ketones, which are acids that can build up in somebody with Type 1 diabetes when their blood sugars are out of control. 

Bandy: You’ve had a long career helping children with diabetes. Have you noticed any patterns or anything in this [diabetes management] plan that is more difficult for them to process or to accept? 

Oden: Sick day management, which is when a child has symptoms of an illness like throwing up or belly pain, not eating as well, coughing, fever, runny nose – those kinds of things. These children can develop ketones in their system, which are those acids that develop when blood sugars are out of control. But, they also develop higher blood sugars or even lower blood sugars. We give them guidelines and a step-by-step approach to treat sick days. But it is very challenging, and we understand that. When you have a child who is sick, it's hard to process everything, every step that you're supposed to do.  

Bandy: Any tips for that? 

Oden: Just to be patient with yourself. Take everything slowly and take everything step-by-step. If you need us, we are always here for a patient to call. We have a physician on call 24 hours a day, and we have diabetes educators [available] during the workday. 

Bandy: You mentioned the management plan is also for school nurses. Schools have a wide variety of activities. [Children are] sitting still in the library and then going to the gym or the playground. Does activity level affect children with diabetes?  

Oden: Not only activity level but stress. Stress can affect different lunch options, which is very challenging for our [patients] with diabetes because they don't always have a menu in front of them. And when they have a menu, and they know what they’re going to eat, they don’t know how much of it they will eat. They don't know how many carbohydrates – which is what we focus on with insulin treatment – how many carbohydrates were in that meal. I remember my school lunches were a challenge. 

Bandy: We love these foods, but we know they're not great for us, diabetes or otherwise, right? 

Oden: Yeah, that's absolutely right. You have to be careful.

Bandy: How has diabetes care changed [since you were diagnosed]? 

Oden: I was diagnosed in ‘81. The technical advances of checking blood sugar – finger pricking for blood sugars was a new thing back then. Over the last 42 years, we have gone from animal-substrate insulin to human, genetically-derived insulin. It's much better, much cleaner, much easier to be made. [Diabetes treatments included] ultra-fast-acting insulin, then [insulin] pumps, then pumps that interact with a continuous glucose monitoring system that can communicate with your pump and alter the amount of insulin. It's a vast array of different things that have made things much better and much easier for families. But, diabetes is still a chronic and very difficult-to-manage disease. 

Bandy: I've heard [Arkansas Children’s Hospital] has a new retinal eye exam machine that is helpful. Tell me all about it. 

Oden: It is called Topcon. The nurses affectionally call it ‘Goose.’ What we've run into over the past several years is that families have a hard time getting to an ophthalmologist to do their yearly eye exams. Those eye exams entail looking in the back of our retinas, looking at vascular permeability and vascular health. An ophthalmologist can tell if there's been any diabetes-related damage to our retina, which would cause what's called diabetic retinopathy – poor vision. This Topcon machine takes a picture of the back of our eyes, the retinal part of our eyes, and that image is sent to an ophthalmologist in a different institution who reads it and sends us the report back. We can see if everything is okay, and we can compare. If there is something abnormal, then we know to send those kids immediately to an ophthalmologist to have it checked out. It's a very cool machine. 

Bandy: When a parent thinks their kid may have diabetes and is coming [to Arkansas Children’s], what are the common symptoms?  

Oden: The most common things we see are what doctors will term ‘polyuria’ and ‘polydipsia,’ which means the kids are urinating more and they're drinking more. It is constant. Kids will wake up in the middle of the night. They will drink. They will wake up in the middle of the night to go to the bathroom. We have had kids who have been potty trained or are in their teenage years who all of a sudden started to wet the bed. 

Fatigue is another [common] one. They're not able to get up and move because their body is no longer able to utilize our main fuel, which is sugar, and has to revert to things like fats and proteins. If you have ever been on a diet like the Atkins diet, and you go through the Keto flu, it is very similar. The Keto flu is where you are transitioning from sugar in your diet to the ketones that your body is burning off, but [diabetes is] 10 times worse, and it doesn't ever go away. Weight loss is also a huge sign.   

Bandy: How do you test for [diabetes]? Is it a blood test? 

Oden: For diabetes, it's a blood test looking at blood sugar, and it's also something called the hemoglobin A1C, which looks at an average blood sugar over the past three months. There are defined values that we're looking for. 

Bandy: What is prediabetes? 

Oden: I'm glad you asked. Prediabetes used to be solely focused on Type 2 diabetes because there was a slower progression from a normal glucose state to a prediabetes state to actual diabetes over several years. If we had a [child] at risk of developing Type 2 diabetes, which means their weight was a little bit high, or they had a skin finding that was dark, coarse skin around their neck called acanthosis, or they had a family history of Type 2 diabetes. These [children] could be screened for diabetes. They would check the hemoglobin A1C. The American Diabetes Association has defined prediabetes as hemoglobin A1C between 5.7 and 6.4. Below 5.7 is normal, and 6.5 and above is diabetes. 

Bandy: That seems like not a very wide window. It's just a hairline between being fine and diabetes? 

Oden: It's open to interpretation. We get a lot of referrals for [children] with hemoglobin A1Cs of of 5.7, 5.8, and 5.9., but many kids live [in that range] and their blood sugars are normal – they just have a little bit of a higher number at that particular time. We focus more on kids with 6.0, 6.3, 6.4. In that range, there is more impetus to delay Type 2 diabetes. Lifestyle management and sometimes medications can be used to slow down the progress of diabetes. If done well, and the [child] really wants to, they can be very successful in staving off the development of Type 2 diabetes. Whereas if they don't, they can develop Type 2 diabetes within two years of [a prediabetes] diagnosis. 

Bandy: Can you avoid [Type 2] diabetes? 

Oden: You can. The thing that has recently come to light is a prediabetes form of Type 1 diabetes; it's called Stage 2. There are stages to Type 1 diabetes. The first stage is where you develop antibodies. And that can happen as early as nine months, but blood sugars are fine. Stage 2 [of Type 1 diabetes] is where you have these antibodies, but your blood sugars are starting to go up. Stage 3 [of Type 1 diabetes] is full-blown Type 1 diabetes with polyuria, polydipsia, weight loss and really high blood sugars.  

Bandy: With Type 1 diabetes, if you have pre-Type 1 diabetes, will it come no matter what you do because it’s an autoimmune disease? Is that right? 

Oden: I’m glad you asked that, too. We have developed treatments for autoimmune diseases – rheumatoid arthritis, Crohn's disease [for example.] We have all these injections that help. Recently, a medication called teplizumab or Tzield has been approved for kids eight and above who have Stage 2 [pre-Type 1 diabetes]. If you have Stage 2 and you are eight and above, we can give [children] this medication and that reduces the risk of developing full-blown Type 1 diabetes by about 50%.  

Bandy: Wow!  

Oden: That effect. can last up to two to three years, which is very exciting. It is FDA-approved, and we can give it to [children], but we must be able to screen them, identify them and then get them on that list. We have the [treatment] ready. Arkansas Children's has allowed us to do this. They have put forward all the support we need. We have a plan; we just need to get those kids in the clinic. We need to find them and start the treatment. 

Bandy: How incredible is it to watch this type of technology progress from what you experienced as a kid? 

Oden: It's fabulous. It's fabulous, not just for me but for all of us. Jennifer Sellers, RN III, CDE, is one of our diabetes educators who has been [at Arkansas Children’s] for over 20 years. She has led the charge in the screening clinic and getting kids in to screen them.  

Bandy: What is your favorite part about your job? 

Oden: The best thing about my job is seeing these kiddos. It’s not always a happy day to have a kiddo come in with new-onset diabetes. But, it is a happy day when you see that they respond very well and families absorb the information very well. I try to emphasize when I’m in that hospital room with that family that their kiddo is going to be fine. There are no restrictions in school. They can be on the debate team, they can be on the football team, they can be on the basketball team, they can be a cheerleader. They can go to sleepovers. That’s something people think about – sending a [child] who is on insulin to another house. It’s hard for parents not to worry. 

Watch the Better Today, Healthier Tomorrow vodcast with Dr. Oden