In the photo: The Pediatric Type 2 Diabetes Clinical and Research Team. Front row, left to right, Kristin Jakubowski, RN; Elizabeth Mann, MD; Betsy Roe, DNP, APNP, CPNP; Kali Ecker, RN; and Jennifer Templeton, MA. Back row, left to right, Whitney Beaton, MSN, RN, ACCNS-P, CDCES, and Jean Reiche, RD. Photo by Kate Feldt/Department of Pediatrics
At UW Health’s E Terrace Dr Medical Center and Deming Way Clinic on the east and west sides of Madison, respectively, Department of Pediatrics endocrinologists and other diabetes specialists serve many pediatric patients with both types 1 and 2 diabetes. Elizabeth Mann, MD, assistant professor in the Division of Endocrinology and Diabetes, is interested in health care for youth and young adults with all types of diabetes, with a special focus on type 2 diabetes. She is the director of the UW Health Kids Pediatric Type 2 Diabetes Program.
“The rates of type 2 diabetes in children and adolescents have at least doubled in the last 20 years,” Mann said. “This increase in rates was predicted 20 to 30 years ago, along with the rising rates of obesity, and this is now what we are seeing.”
Type 1 diabetes is caused by an autoimmune reaction that destroys the cells in the pancreas that produce insulin. People can develop type 1 diabetes at any age; however, it is more frequent in children, teens, and young adults. Having a parent or sibling with type 1 diabetes is a risk factor. It is managed with multiple daily insulin injections or continuous subcutaneous insulin infusion, and no cure exists at this time.
Type 2 diabetes (T2D), conversely, is a condition that develops over time, resulting in the body unable to use insulin effectively (insulin resistance) and potentially decreased insulin production. Risk factors include having a parent or sibling with T2D, maternal obesity or diabetes during gestation, having overweight or obesity, among many other genetic, behavioral and environmental factors. In the past, it was often first diagnosed in people over age 45. In adults, T2D accounts for more than 90% of all diagnosed diabetes cases. However, as Mann noted, more children, teens, and young adults are developing it now.
In 2020, when Mann completed her endocrinology and diabetes fellowship, she recalled that there would be 20 or 30 kids per year with T2D seen in pediatric diabetes clinic. “Now we see more than 150 kids per year, which is similar to what is happening on a national scale,” she said.
Mann also noted that screening guidelines have changed, and there is a rising awareness of type 2 diabetes in pediatrics and in family medicine at large. (The effect of COVID-19 on the development of pediatric diabetes has been documented, but it is not fully understood.) The enormous increase has acutely affected the work of pediatric clinicians like Mann and her colleagues.
Mann noted that the great increase in cases make the public jump to the question of “well, why?” with the subsequent range of answers usually based on myth, bias, and misconceptions. She and her colleagues, including two nurse practitioners and four other clinicians, plus an expert staff, have built this pediatric type 2 diabetes program around the reality that there is a stigma around T2D diagnosis similar to the stigma around obesity.
“When we talk about the rising numbers of kids in clinic affected by the disease, it’s so important that in the same breath we talk about why this is happening and take away personal blame,” Mann explained. She emphasized that it is the most important thing for people to understand about pediatric type 2 diabetes, including for physicians practicing in pediatrics. “It is a very complicated disease, considering the range of causes,” she said. “We don’t fully know what causes it, but it is not a personal choice, not the fault of the individual: it’s not a moral failing or a lack of willpower.”
Mann understands the probability of developing T2D as a complex interplay of environment, genetics, and circumstance. “Environment” includes the in-utero environment, which permanently changes a fetus’s metabolic milieu, and the built environment. Research has shown that the risk factors for pediatric T2D are many, including environmental factors as diverse as the uterus to the residential neighborhood. Genetics is a powerful risk factor. Another is the “obesogenic environment,” which contributes to obesity. It is influenced by such diverse aspects as immigration, sedentary lifestyle, diet, microbiome, depression, and abuse. Exposure to these factors doesn’t guarantee the development of T2D: there are other influencing factors. It is, as Mann described, “a complex interplay,” which must be acknowledged and further understood.
In the seven years that Betsy Roe, NP, has worked in the UW diabetes clinics, she has seen the understanding of the pathology of type 2 diabetes change enormously. “It’s a much more complex disease than most people appreciate,” Roe explained. She noted that T2D patients used to be treated in the T1D clinic until research showed that it is a very different disease.
“Type 2 is very different in children than it is in type 2 adults, too,” she noted. “In the last four to five years, as the pediatric population has increased, our knowledge has also increased.” Treatment of pediatric T2D has likewise changed, primarily because it is a completely different pathophysiology. “They are both called ‘diabetes,’” Roe explained, “which is hard — and we sometimes see an overlap: you can have type 1 diabetes and type 2 diabetes, two different diseases, just as you can have thyroid disease and diabetes.”
Roe explained that T2D is much more aggressive in children and does not seem to be as preventable in them as in adults. “There’s that point in adolescence when puberty hormones arrive,“ Roe explained. “Every adolescent is more insulin resistant because of those hormones.”
Just as Mann emphasized that it’s a myth that “bad diet” causes T2D, Roe reiterated that is it a misconception: “There’s lots of evidence now that it is not caused by bad diet,” she said. “But there is a lot of stigma associated with the disease: the idea, “I gave myself this disease because of my bad diet and lack of exercise.”
Both Mann and Roe, as well as the rest of their T2D clinic staff, focus time and attention noticing and debunking harmful myths and baseless assumptions among their patients and their parents. There is no place for shame and blame in their treatment protocol. “Dr. Mann has built this program and it has come really far in the last three years,” Roe said. “I’m really proud of our program.” In addition to the physicians and nurse practitioners, the program’s staff includes nurses trained in T2D, a team of registered dieticians, and diabetes educational specialists.
Research into treatments for T2D has produced effective drugs in recent years. More medications were added to the basic two, insulin and metformin. There are GLP-1 RAs (glucagon-like peptide-1 receptor agonists) to stimulate the release of insulin from the pancreas and help manage blood sugar, now FDA approved for children over age 10 years with T2D; and the recent SGLT2is (sodium-glucose cotranspoerter-2 inhibitors) to lower blood sugar, with one approved for children. GLP-1 RAs can also help in the treatment of obesity. Other clinicians working with Mann and Roe also help patients with managing their diets and pursuing activities to increase their fitness.
New faculty member Yashoda (Mita) Naik, MBBS, assistant professor in the Division of Endocrinology and Diabetes, focuses on pediatric obesity and related comorbidities. Her goal is to work in tandem with the T2D clinic to support healthy nutrition and joyful movement for children with obesity and other metabolic diseases. Through the UW Health Kids Fitness Clinic, she is interested in studying psychological barriers and the misconceptions connected to pediatric obesity.
Naik noted that because pediatric obesity is a chronic disease, “it requires long-term care with added focus on social issues, food insecurity, and mental health.”
She explained that in terms of human evolution, starvation was one of the greatest threats to humanity since the beginning. “Our bodies adapted to protect us from the threat of starvation, consequently, sustained weight loss is very difficult to achieve,” she said. Failure to achieve weight loss should not be blamed on lack of willpower. The scientific approach includes a healthy lifestyle combined with FDA-approved anti-obesity medication, if needed.
“While there are many challenges,” Naik said, “it is gratifying to see children thrive when they achieve a positive outcome.”
Mann and the dedicated staff of the pediatric type 2 diabetes program work to make what is often a surprising and concerning diagnosis to patients and their parents a manageable condition. Ongoing research has revealed more complex causes and, subsequently, different approaches that include new, effective drugs and personalized treatment protocols. With the help of the clinics’ many knowledgeable practitioners, pediatric patients and their parents can reconcile their new reality of type 2 diabetes with actually living a normal kid’s life.