Anne L. Peters, MD: Hello. I am Dr Anne Peters, and I am here today with Dr Jessica Lilley, who is a pediatric endocrinologist from Tupelo, Mississippi. Dr Lilley, tell us what it is like where you practice.
Jessica Sparks Lilley, MD: It is wonderful. I really enjoy being in an underserved area. My patient population is quite diverse and very thankful, because many of them remember the days when they had to drive 3 hours to see a pediatric endocrinologist. To be able to offer them these services has been truly rewarding.
Peters: IĘąm glad they have you. I know obesity is an incredibly common problem in your area of Mississippi. Can you tell me a few positive things about the treatment of obesity in your population? What has worked?
Lilley: First, the earlier you start, the better. It is difficult to effect true behavioral change as we get older. Even at my age, I find I am very set in my ways. It isn’t easy to form a new habit.
With a small child, you can introduce new positive changes fairly easily. For a child who has never learned to like the taste of a sugar-sweetened beverage, you can make these changes, which is why I am a pediatrician and not an internist. It is much easier to prevent bad habits from forming than to break them. That is one thing I love about my patient population.
What works best is when we get the entire family involved and realize that it is not just little Johnny’s or little SuzieĘąs problem. It is a whole family unit issue that we have to address.
When the parent says, “I need my regular Coke, I need to be able to hit the McDonaldĘąs drive-thru on the way home from work; we will just prepare special food for the child,” I know that means 100% chance of failure. But when the families truly understand that this is a whole family issue, that they need to change everythingâ€”throw away all the Little Debbies and all the Cheetosâ€”in those who take seriously what is ahead of them, we see positive change.
Peters: When do you begin screening those children for diabetes? What makes you screen?
Lilley: A body mass index (BMI) above the 95th percentile; any kind of acanthosis; a family history of type 2 diabetes, especially at a young ageâ€”those are the factors that suggest screening to me. Many times, the pediatricians have already done that by the time they send the patients to me.
Peters: At what age would you tell someone to screen for diabetes? A 2-year-old, a 4-year-old?
Lilley: We do not typically see type 2 diabetes until after puberty. That is something that has really been vexing to me, because many times I will see a 7-year-old who clearly has type 1 diabetes and someone has started the child on metformin.
One third of children in the state of Mississippi are overweight or obese and thus, one third of children with type 1 diabetes are also overweight or obese. We often have misdiagnoses because of the pervasiveness of type 2 diabetes. I do not start thinking about type 2 diabetesâ€”unless it is an unusual monogenic formâ€”until after puberty, so age 8-10 years.
Peters: When you get one of these kids with new-onset type 2 diabetes, what do you do first in terms of treatment? Let us say you have worked with the family on lifestyle. What would be your first medication?
Lilley: Unfortunately, very few of the diabetes medications are on-label in pediatrics. Not very much has been studied in children. There are a lot of tools available to our adult colleagues that we do not have access to. Our first step is metformin for those with milder cases of type 2 diabetes. With a glycated hemoglobin (A1c) above 8%, I will start the child on insulin.
Peters: What kind of insulin regimen? Are you using basal bolus therapy? Do you treat them as if they have type 1 diabetes?
Lilley: It depends on the severity of the condition. If I have a patient who has a mildly elevated A1c and does not have a lot of postprandial excursions, then I will start with basal insulin alone. For patients who will self-monitor and who I believe have the capacity, we will add a sliding scale at meals and then follow them. Often we will end up adding prandial insulin. We have to follow them very closely at the very beginning.
Peters: What about using glucagon-like peptide-1 (GLP-1) receptor agonists in kids?
Lilley: I have a few patients who use GLP-1 receptor agonists, but this is off-label. I have one young woman whose weight just keeps escalating; she weighs over 400 lb. We know we have effective therapy approved for people like her who just happen to be a couple of years older.
I have spoken at length with the parents. We know that because of her current uncontrolled diabetes, with an A1c of 15%, her poor compliance, and their full family dynamic, we need to use everything that is available to us.
For that patient and others like her, I believe it makes a lot of sense to say, this may be off-label, but I know it could help you. We are fortunate to have had some insurance companies that, after some convincing, will go along with that.
Peters: I have had a lot of success in my underserved patients, either with a once-weekly GLP-1 receptor agonist or, if they are on insulin, the combination of insulin plus a GLP-1 receptor agonist in the same pen. Everything is about adherence. When someone is overweight, it is a good thing to help them with the weight.
Peters: What is your opinion about continuous glucose monitoring and the EversenseÂ® monitor that will last for at least 3 months? Do you like the idea of using that?
Lilley: I would love it. In my patient population, many times when the child has type 2 diabetes at a young age and it is severe enough for the child to see a pediatric endocrinologist, 99% of the time, one of the parents has it as well. Many times, how seriously the parents treat their own diabetes will affect how seriously they will treat their childĘąs diabetes.
When we have a parent who is very cavalier with their diabetes management, then we do not see them very often. But they will get worried about other things. I try to find what it is that I can pick up on that is going to scare them into being more adherent to the medication regimen.
For my parents who say, “Her blood sugar was only 200 mg/dL; mine is 300 mg/dL,” I try to thread that needle. Some of my patients get nervous about hypertension, and some get nervous about nonalcoholic steatohepatitis. So, there are other things we can talk about to try to convey the importance of going after the diabetes.
We know that type 2 diabetes at age 40 is a whole lot different than type 2 diabetes at age 12. The parents had a head start on their children. To begin life behind the 8-ball like that is terrifying.
We know that children diagnosed with type 2 diabetes currently have a shorter lifespan; they are more likely to have complications; and they are more likely to need long-term insulin therapy. We need to get people to understand from the get-go that this is a very serious problem that must be addressed and requires adherence to the treatment regimen.
It is not at all unusual in my practice, that someone with type 2 diabetes will come back for a follow-up visit and will have no blood sugar readings since diagnosis. [I’ll do] anything I can do to get those blood sugars in my hands to know whether what we are doing is even working. How do I adjust the medication? Do I need to add prandial insulin? Do I need to cut back on the basal insulin? How do we know whether this fatigue you are having is from untreated sleep apnea versus low sugars? Any tool at our disposal that will give us more data and more patient engagement is welcome.
Looking at the new continuous glucose monitors, such as the Libre, and their reductions in nocturnal hypoglycemia even without alarms, it shows that you have more patient engagement when you make it simpler for them. I know that is true in my life. If I make it easier to establish good behaviors, they are more likely to become good habits.
The more that we can simplify a complicated life, especially in a patient who may not feel good because of out-of-control blood sugar, the easier it will be to overcome.
Peters: All of these tools in the right patients can make a huge difference. I certainly admire what you are doing. Keep doing it. It is wonderful.
Thank you very much. This has been Dr Anne Peters for Medscape.