Ask the Expert: Risa Wolf, MD
Living with diabetes can sometimes be overwhelming. This section focuses on practical information about diabetes. Experts in various fields related to diabetes will give advice about day-to-day living. These topics will change regularly, so check back often to meet our new experts!
Questions & Answers with Risa Wolf, MD, Associate Professor of Pediatric ENDOCRINOLOGY
1. What is the epidemiology of diabetes among children in the US?
Type 1 diabetes is one of the most common chronic childhood diseases, and affects 1 in 500 youths. Type 2 diabetes is less common in children and adolescents, but has been increasing over the last two decades and affects 1 in 2000 youths. Based on surveillance data from the SEARCH for Diabetes in Youth study, there are approximately 18,000 new cases of Type 1 diabetes per year, and 6,000 new cases of Type 2 diabetes in youth every year in the U.S. The incidence of Type 2 diabetes has been increasing, particularly among non-Hispanic black and Hispanic youth.
2. What are unique factors that affect blood glucose in children with type 1 diabetes?
Children with Type 1 diabetes take insulin to help control their blood sugars, but less than 25% of all youth achieve optimal glycemic control. There are many factors that can affect blood glucose levels in children, including food, exercise, stress, growth, puberty, among others, and specific periods in the course of the disease when blood glucose levels are affected differently. For instance, shortly after a child is diagnosed with diabetes, he/she can experience the “honeymoon phase” which is a time when some of the remaining beta cells of the pancreas are still functioning and producing insulin on their own, such that the child needs to take less insulin. During puberty, the body is less sensitive to insulin, thus requiring higher doses of insulin to achieve the same blood glucose control. For young women, they may experience higher blood glucose levels during their menstrual cycles, requiring higher doses of insulin during this time as well.
3. What are some considerations for children when transitioning to self-management as adolescents or young adults?
The transition of diabetes management from parent or caregiver to child should occur over time, with appropriate instruction and supervision. For instance, young children with diabetes can help check their blood sugars. A child in middle school may be able to read food labels, perform carbohydrate counting, and calculate insulin doses, while an adolescent in high school may be able to self-manage diabetes with supervision. There are stressors and new experiences at every transition in childhood, from elementary to middle school, middle school to high school, and high school to college. This includes meeting new friends, teachers, and coaches, and sharing that you have diabetes with new people; parents and diabetes providers can help children develop “talking points” about diabetes to make these conversations easier to initiate.
4. How is diabetes managed in school settings?
Children with diabetes spend most of their day at school and in school-related activities, so it is important for caregivers to communicate with school nursing or administrators who will be overseeing the child’s diabetes care in the school setting. Your child’s diabetes team will provide a diabetes management plan, also known as diabetes school forms, with instructions for the school nurse on managing the diabetes. Caregivers may consider setting up a 504 plan which provides specific instructions for the school on accommodations for the student, related to checking blood glucose levels, using the restroom, managing hypoglycemia (low blood glucose levels) or hyperglycemia (high blood glucose levels) during exams, carrying a phone for continuous glucose monitor readings, extracurricular activities and more.
For people with diabetes in college, the Americans with Disabilities Act ensures that accommodations can be provided to the student, which for instance, may include extending the time of an exam due to treating a high or low blood glucose level. Accommodations in college are not automatic, and the student has to register for this in advance or at the start of the academic school year.
5. What are some crucial factors in best managing or enhancing blood glucose control for children and adolescents with Type 1 diabetes and Type 2 diabetes?
Children and adolescents with diabetes are most successful when they have caregiver support to manage their diabetes. People with type 1 diabetes need to take their insulin as recommended and following their diabetes management plan. Diabetes technologies, such as continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery systems have been shown to improve glycemic control and can often help make diabetes management easier. In addition to family support, peer support can also help optimize diabetes control. With type 2 diabetes, it is important for the family to support the adolescent with diabetes, and make dietary and lifestyle changes for the entire household to positively impact the child with diabetes.
6. What are the nutritional recommendations for Type 1 and Type 2 diabetes in children?
Nutrition is a core component of diabetes management. In general, a healthy, balanced diet is recommended for all children, including those with diabetes. In type 1 diabetes, insulin doses should be matched to carbohydrate intake. Carbohydrates typically make up 40-50% of the daily energy intake. With diabetes, it is recommended to avoid drinks high in sugar unless treating a low blood sugar.
7. How do hypoglycemia prevention and management work during the day and night time?
Hypoglycemia, or low blood glucose levels, can be dangerous and should be treated with simple carbohydrates to increase the blood glucose level quickly. If an individual becomes unconscious from hypoglycemia, then glucagon should be given. Glucagon is a hormone medication that is administered as an injection or intranasal spray that rapidly increases the blood glucose levels in an emergency situation. People with diabetes should always carry a snack for hypoglycemia and ideally a form of glucagon with them at all times. A continuous glucose monitor, or CGM, is a technological tool used to monitor blood glucose levels in real time that can alert the individual to impending low blood sugars before they occur, or low blood sugars at the moment. Blood glucose data from the CGM can be shared to other family members or followers who can also see the blood glucose levels in real time.
8. What are the unique challenges for mental health and stigma that children with diabetes face?
Children and adolescents with diabetes can have diabetes distress, or feelings of frustration or being overwhelmed by the daily management of diabetes. Youth with diabetes are also at increased risk for depression, anxiety and other mental health disorders, so it is important for caregivers to discuss these concerns with the diabetes team who can provide the resources necessary to support the child. Children and adolescents with diabetes can also gain a lot of support from their peers with diabetes – so considering diabetes camp attendance, JDRF meet-ups, and other functions hosted by the American Diabetes Association and Children with Diabetes can be helpful. Children often find it challenging to share that they have diabetes with new friends or peers, and working with the child to have focused conversations on various diabetes topics which can make the disclosure process feel less stressful.
9. What are some travel tips and recommendations that you have before, during, and after travel?
Traveling with diabetes is possible, but it is important to think ahead and bring extra supplies and insulin with you. Your diabetes team can provide a travel letter for the Transportation Security Administration (TSA) so that insulin, syringes, and low-snacks or drinks can be carried on board. Look ahead and find nearby pharmacies and medical centers near your destination so that you are prepared in case medical assistance is needed.
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Risa Wolf, MD
Associate Professor of Pediatrics
Meet Risa Wolf, our pediatric ENDOCRINOLOGIST and expert of the month!
Dr. Risa Wolf is an Associate Professor of Pediatric Endocrinology in the Division of Pediatric Endocrinology at the Johns Hopkins University School of Medicine. She is an NIH funded investigator with research focused on using innovative technologies to improve outcomes in pediatric diabetes. She is the founder and medical director of Camp Charm City diabetes camp, a collaboration with the American Diabetes Association to improve access to diabetes camping for underserved youth. She has served as a member of the American Diabetes Association committees on Eye Health, Diabetes Youth and Diabetes Camp, and is on the Board of Directors for the JDRF Mid-Atlantic Chapter.