Type I Diabetes – PediaCast 191

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Welcome to another PediaCast!  Today Dr Mike discusses Type I Diabetes with Dr David Repaske, Chief of Endocrinology, Metabolism, and Diabetes at Nationwide Children's Hospital.  Don't forget to submit your comments, questions or concerns to Dr Mike and hear the answer on a future PediaCast.

Topic

• Type I Diabetes

Guest

• Dr David Repaske
  Chief of Endocrinology, Metabolism, and Diabetes
  Nationwide Children's Hospital

Links

• Diabetes Center at Nationwide Children's Hospital

Transcript

Announcer: This is PediaCast.

[Music]

Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcast for moms and dads, it's Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. And welcome, everyone, to the show. So I hope everyone had a happy Thanksgiving.

We are back from the holiday and we have a special guest in the studio today, Dr. David Repaske is with us. And he is the Chief of Endocrinology, Metabolism and Diabetes here at Nationwide Children's. And we are going to talk about Type I diabetes. There's enough information on Type II and gestational diabetes, thought we just limit this one to Type I, but we'll have to have Dr. Repaske back and we'll talk other types of diabetes.

0:01:11

Before we get to our guest, I want to remind you that if you have a topic that you would like us to talk about or you have a question for us, it's easy to get a hold of me at pediacast.org, just click on the Contact link. You can also email pediacast@gmail.com or the call voice line at (347) 404-KIDS. That's (347) 404-KIDS.

I want to also remind you the information presented in every episode of PediaCast is for general educational purpose only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use agreement, which you can find over at pediacast.org.

Alright, Dr. David Repaske is the Chief of the Section of Endocrinology, Metabolism and Diabetes at Nationwide Children's Hospital. And he is a professor of Pediatrics at the Ohio State University College of Medicine.

0:02:10

He holds a PhD in Biochemistry from the University of Wisconsin and earned his medical degree from Vanderbilt. He then traveled to the University of North Carolina at Chapel Hill for his Pediatric Residency and Pediatric Endocrinology Fellowship.

He has since returned to the Big Ten and we are happy to have him here in Nationwide Children's and inside the PediaCast studio, so welcome to the show, Dr. Repaske.

Dr. David Repaske: Hi, Dr. Mike, glad to be here.

Dr. Mike Patrick: Yes, glad to have you. So you spent some time in SEC of Vanderbilt, the ACC at the University of North Carolina and you spent time on the Big Ten at Wisconsin and now, you're back at Ohio State.

So I have to ask you, where exactly do your college sport loyalties lie?

Dr. David Repaske: It's hard not to be a die hard Tar Heel [Laughter] during basketball season at least. But in this town, it is hard not to be a Ohio Buckeye fan during football season.

0:03:07

Dr. Mike Patrick: During thick and thin, right?

Dr. David Repaske: Right.

Dr. Mike Patrick: We won't get into controversies. But you thought we were talking a little bit before we started the show and you know, early follow up kind of sports too much. So you don't get too excited about one particular team?

Dr. David Repaske: But again, it's awfully easy to get caught up in this town.

Dr. Mike Patrick: Oh right, absolutely. I mean, everybody here sort of lives and breeds the Buckeyes. And it's funny we've live in Florida for a while and the Ohio State Alumni Basis is pretty large so you could always find fellow Buckeye fans really, no matter where you go around the country.

Alright, well we aren't here to talk about college football. We're going to talk about diabetes. And Sean in Texas was a listener who recently wrote in. Sean said, “Hello, Dr. Mike. I've been a long-time listener of PediaCast and it's great to see you partnered with Nationwide Children's. I enjoy the new format and especially appreciate the interviews. I was wondering if you could do a show focused on diabetes; identification, prevention, care, medication, nutrition, I'd appreciate anything you can offer on this subject. Thanks, Sean in Texas.”

0:04:10

Well, Sean, ask and you shall receive. In fact, we got the Section Chief of Endocrinology for you. So I guess, why don't we start with just sort of brief definition of what exactly is Type I diabetes mellitus.

Dr. David Repaske: Well may be we should even start a step further and say, what is diabetes?

Dr. Mike Patrick: Absolutely.

Dr. David Repaske: So diabetes is a disease where the blood sugar is elevated. So it can have any of a number of causes and two most likely causes are Type I diabetes and Type II diabetes.

In Type I diabetes, the immune system has attacked the beta cells and the pancreas. The beta cells make insulin and the insulin is sort of the key in your body to moving blood sugar out of the blood and into the cells of the body where it needs to get broken down and turned into energy.

0:05:08

And so in Type I diabetes, there's a deficiency of insulin that's come because the immune system has attacked the beta cells that are making the insulin, and so the blood sugar can't move out of the blood, starts accumulating, blood sugar gets high, and that's type I diabetes.

Dr. Mike Patrick: And you mentioned that the blood glucose rises and I guess the other situation in is since the glucose isn't going inside of the cell, then cells can't use glucose for metabolism?

Dr. David Repaske: Right and so you're sort of starving even though you've got plenty of sugar in the blood, it just can't get to where it needs to be to do what it needs to do which is provide energy source for the body.

Dr: Mike: Now how common is this, I mean everybody's heard of diabetes. And some people may know someone with it, of course, lots of people are affected. But what kind of numbers are we talking about?

0:06:02

Dr. David Repaske: Well, if you look at people who are 20 or 30 years old, it's about 0.3% of the population. So about 1 in 300. Of course, if you're looking at one or two year olds, it's much less common because once you get diabetes it stays with you and so as people are older and older, they accumulated more and more. But about half of diabetes arises in childhood and about half, and I'm talking the Type I diabetes, and about half arises in young adult or even in older adult.

Dr. Mike Patrick: Is there a genetic component to it? Does it tend to run in the families or not so much?

Dr. David Repaske: Well, slightly, slightly. So there seems to be an immune system predispositioned to developing diabetes. So it's not like blue eyes where there's a one in four chance that a child of two people with blue eyes is going to get blue eyes, but some families just have a predisposition for developing their auto-immune disease.

0:07:09

Dr. Mike Patrick: Is there a difference in males versus females or ethnicity, do you see any differences in?

Dr. David Repaske: There's no significant difference males versus females, but there is an ethnicity difference and that's rather interesting. So as you go further north, in general, you have more and more diabetes. So Scandinavia has the highest incidence of diabetes. If you get toward the Mediterranean, Europe the incidence goes down, and as you go to Africa, it was even further down.

Dr. Mike Patrick: And we don't understand why that is?

Dr. David Repaske: Well, I think it is in part the immune system that there's a higher frequency of the susceptibility genes that are in the Northern European population.

Dr. Mike Patrick: But we don't know what those genes are and I guess if we did understand that, that would kind of hold the key to…

0:08:04

Dr. David Repaske: We will, we do know some of the susceptibility, markers and some of the protective markers. There are some immune markers that if you've got that marker, you would essentially not going to get diabetes. But it's not – if you've got the susceptibility markers, it doesn't guarantee you're going to get diabetes. It just increases your odds.

Dr. Mike Patrick: So your risk of it?

Dr. David Repaske: Yes.

Dr: Mike: You talked about the immune system being involved here. So you have these cells and the pancreas that normally make insulin and insulin is a chemical that's needed to help get blood sugar from the blood stream into the cells so that the cell can use it as an energy source. So this is how it can do its job. What exactly happens with the immune system, I mean, does it kill those cells in the pancreas that make the insulin, is that what happens?

Dr: David: It essentially kills the cells, right. The immune system is supposed to be fighting germs, fighting invaders in your body and it starts doing that for the beta cells. It recognizes them as foreign invaders that need to be fought of.

0:09:15

It's kind of misguided, isn't it? But that same attack that would be use against a virus or a bacterial invader is triggered against the beta cells specifically, beta cells.

Dr. Mike Patrick: Sure. There have been some speculation that may be there could be some antigens that kids are exposed to early in life that then the body makes antibodies against them and those sort of cross react and then kill the pancreas cells. Do you think that's the case or we just don't know?

Dr. David Repaske: There are lots and lots of theories that come and…

Dr. Mike Patrick: Lots of scenarios.

Dr. David Repaske: I don't think anything's been proven. There is more and more evidence accumulating although it's still not solid so don't take this home as the truth but some enterovirus just seem to be a trigger. So you have to have the immune system, sort of predisposed or poised to attack the beta cells.

0:10:14

And then, these enterovirus infection seem to be associated with moving from the predisposition to actually developing the immune system attack.

Dr. Mike Patrick: Now we're focusing on Type I diabetes, but just sort of take a tangent here very quickly. How does Type I diabetes differ from Type II and then also from gestational diabetes?

Dr. David Repaske: We're getting back to the original question which I never finished.

Dr. Mike Patrick: No, that's OK.

Dr. David Repaske: So diabetes results from a deficiency, a relative deficiency of insulin. You're not making in as much insulin as you need. So in Type I diabetes, the amount that you make goes down because of that auto-immune attack on the factory, so you got a deficiency because you can't make it.

0:11:03

In Type II, the amount of insulin that you need rises. So you can still make insulin, but your body needs more and more and more and more. And at some point, it can't keep up with this increased need for insulin. And so you end up with a relative deficiency but you got a lot. You just don't have enough. And the thing that most frequently triggers that increased need for insulin is extra weight, excess weight gain.

Dr: Mike: Sure. Now so the insulin helps glucose get from the bloodstream to inside of the cells. So if you have a ton of insulin, why isn't it doing its job?

Dr. David Repaske: It's because the body doesn't see the insulin. The body becomes resistant to insulin. Even though there's a ton there, the body only sees an ounce.

Dr. Mike Patrick: Sure. So if the cell, let's say has a door, so to speak, that the glucose has to go through and insulin is the key to that door, that's just the keyhole has changed.

Dr. David Repaske: That's one way of looking at it, yes.

0:12:08

Dr. Mike Patrick: But we don't know why that happens? I mean why would obesity make that happen? Is there some chemical fat cells are making that we don't know?

Dr. David Repaske: Probably. Yes, yes, so the insulin interacts with the receptor on the cell surface and the message gets transmitted inside the cell to end up with all the actions that insulin has.

And it's that, we call it the signal transduction mechanism. It's all the chemical reactions that are triggered as a result of insulin binding the to the receptor. And those are just desensitized. They seem to be not strong as if you're not carrying as much weight.

Dr. Mike Patrick: And that gestational diabetes is something that we see during pregnancy, is that more similar to Type II diabetes.

Dr. David Repaske: Absolutely right.

Dr. Mike Patrick: So it's the cells not being sensitive to the insulin, not deficiency in insulin with gestational diabetes.

Dr. David Repaske: Right.

0:13:05

Dr. Mike Patrick: OK, so getting back to Type I, so let's say you have a kid who the immune system has attacked the cells in the pancreas that make the insulin, they have an insulin deficiency, so they're not getting glucose into the cell. The glucose in the bloodstream is building up. What kind of signs and symptoms then does this result in?

Dr. David Repaske: Well, when the blood sugar gets high, the kidney is filtering the blood all the time isn't ordinarily does. And usually, there's not that much sugar in the blood and the kidney can pull the sugar back from the newly forming urine stream and put it back to the blood where it belong so that it's not going out in the urine.

But as the blood sugar rises and rises, and the magic number seems to be about 180 milligrams per deciliter, above that, the kidney can't pull the sugar back into the blood out of the newly formed urine stream and so the sugar ends up in the urine.

0:14:08

And it draws water. It's like asthmatic force that draws water into the urine and so you pee more and more and more. So you end up what we call polyurea, lots of pee and you're also peeing out lots of sugar which has calories so it's often kids lose weight. They're eating like crazy but they're losing weight because 100 calories in and pee and…

Dr. Mike Patrick: And they just…

Dr. David Repaske: …100 calories out.

Dr. Mike Patrick: Right, right, exactly. So I think that's interesting. So glucose, the blood sugar goes into the urine naturally but then the kidney has to actively take a back end to the body and once you've overwhelmed the capacity of the kidney to do that, then it starts spilling the glucose starts spilling into the urine.

Dr. David Repaske: Yes, literally true.

Dr. Mike Patrick: And then, so we kind of get that classic, it's a kid who's drinking a lot, peeing a lot but yet they're losing weight. Are there any other symptoms that you see?

0:15:09

Dr. David Repaske: That is…

Dr. Mike Patrick: That's the main…

Dr. David Repaske: That's the main early. I mean, if you go long enough and the amount of insulin that your body is making gets low enough, you start making keytones. So keytones are acidic. And so they're the result of fat breakdown so your body moves on to looking for energy somewhere else and it's starts breaking down fat. Fat produces these acidic keytones and you get into ketoacidosis or DKA diabetic ketoacidosis and you can get really sick.

So if a person isn't diagnosed quickly and you can go from just peeing a lot to being really sick and in a matter of days, you could end up very ill in the intensive care unit.

Dr. Mike Patrick: Are there other disease, processes that can cause similar symptoms? I mean you have to – a doctor who sees someone with who's peeing a lot and drinking a lot can say this sounds like diabetes, but we really need to investigate it further. Are there other things that could do that?

0:16:15

Dr. David Repaske: There probably are, but it's so easy to check the pee for glucose and for keytones that once you've done that, you'd very quickly ruled out the other things.

I mean, you could have a urine track infection, I guess that could make you feel like you're peeing more. You could have another kind of diabetes called diabetes insipidus but those things are very unusual and then they don't have the sugar and the urine either.

Dr. Mike Patrick: And elevated blood sugar, you don't see that with diabetes insipidus?

Dr. David Repaske: And you don't see the elevated blood sugar, right.

Dr. Mike Patrick: And of course, it isn't easier diagnosis when you get a blood sugar back that's multiples of what normal is. But sometimes, can you get where there's a little bit of spilling into the urine and the blood sugar is just a little bit high, sort of a stress response to a disease, making that a more difficult or?

0:17:04

Dr. David Repaske: Well, yes, so I said earlier that the urine starts having sugar when the blood sugar gets above 180. 180 is already way too high. I mean most people are 100 or less. If you get up to a 110 or 115 on your blood sugar, that's kind of abnormal.

And diabetes is actually diagnosed when the blood sugar is 126 or higher. And then we have caveats, like you have to have that twice and you can't be sick at the same time, but basically a blood sugar of above 126 is diabetes, but you're going to have glucose, you're not going to have sugar in the urine at 126.

And so by the time you are peeing a lot and having glucose in the urine, your blood sugar is pretty high.

Dr. Mike Patrick: Now I wanted to address to diagnose that we'd say well, let's see what the blood sugar is. Do you have keytones in the urine. There's also this thing the hemoglobin A1c. What exactly is that?

0:18:10

Dr. David Repaske: OK, so hemoglobin A1c is one of our newest tools for diagnosing diabetes. We've had for a long time, but in the old days, there were many different assays that differed and they weren't fully comparable.

But in the past few years, there's been a lot of effort to make the assay universal so that if you measure it in Europe or in the U.S. or in the South America, you get the same result and has the same meaning.

So a hemoglobin A1c of above 6.5% is considered diagnostic of diabetes now as well. But what is it? So it's a protein – so when you're blood sugar is elevated, sugar starts glamming on the proteins in your body. It glams onto your eyeballs, it glams onto your kidneys, it glams onto your nerves and blood vessels and this is what causes the problems, the side effects, the complications of diabetes.

0:19:14

Dr. Mike Patrick: Sure, it's sticky. The glucose is sticky.

Dr. David Repaske: But when the glucose is elevated, it is also sticking on to the hemoglobin protein in your blood. The red stuff is a protein.

Dr. Mike Patrick: On the red blood cells.

Dr. David Repaske: On the red blood cells. And so we take a drop of blood, we break it open in an instrument and look for what percentage of hemoglobin molecules have a glucose stuck onto it, glammed onto it and that is a reflection of how high the blood sugar is or has been over the past three months.

Dr. Mike Patrick: And the three-month number is just because that's about how long red blood cells lasts in the circulation and once they get like oscillated or glucose stuck to them, they stay that way.

Dr. David Repaske: Right.

Dr. Mike Patrick: So you're just looking at a percentage?

Dr. David Repaske: Right, right.

Dr. Mike Patrick: Very good.

Dr. David Repaske: So the A1c also is a great way to follow how well you're treating your diabetes because if you're not treating it well and getting the glucose down to normal values, then that hemoglobin A1c remains elevated and it's reflecting the damage that the high blood sugar is doing to different parts of the blood.

0:20:17

Dr. Mike Patrick: So as an endocrinologist, especially teenagers that may be difficult to know, they may not be keeping their log, their sugar logs like they're supposed to and their diary so it sometimes can be difficult to figure out if they're in good control, but by looking at hemoglobin A1c, they can't fool you with that number.

Dr. David Repaske: That's true, but it's not always the patient or family's fault either. We generally look at four instance in time, before breakfast, before lunch, before dinner, before bed and there's a lot of time between those four moments during the day when the blood sugar could be up.

Dr. Mike Patrick: And fluctuating.

Dr. David Repaske: And the A1c gives you a good indication that there's something going on that you needed to do a little more detective work to figure out what's going on between those four times of the day.

Dr. Mike Patrick: So let's talk a little bit about treatment. How do you keep the blood sugar then in a normal range?

0:21:12

Dr. David Repaske: Well, so with Type I diabetes, the only way is to provide insulin back, the insulin that's missing. So you're trying to mimic the pancreas essentially in giving insulin. And we normally produce a small amount of insulin 24/7.

So you've got some insulin in your system all the time and then more is produced after a meal. So the small amount of insulin keeps the keytones at bay. It keeps your body from breaking down those fats and making the acidic keytones.

But then after a meal, the carbohydrate in the meal is turned into sugar in the gut and then you need more insulin to move the sugar out of the body, out of the blood into the cells of the body. So we try to mimic the basal insulin and the boluses of insulin after the meals.

0:22:08

Dr. Mike Patrick: Sure. Is there a role for diet to and in the treatment of – and to see if you can control how much sugar is going from the bloodstream into the cell but then can we also control how much sugar goes into the bloodstream to begin with?

Dr. David Repaske: That use to be terribly important. We used to very strictly control the amount of carbohydrate that you would eat and the times that you would be allowed to eat it.

But with modern insulins, that's not necessary. And we've moved from an era where you eat to match the insulin to a near where we give insulin to match what you're eating. And there are – everybody should eat healthy, but there are really no more major restrictions on how a patient with diabetes should eat compared to anyone else.

Dr. Mike Patrick: At least Type 1 diabetes? Would you argue to Type II, you may still…

0:23:03

Dr. David Repaske: OK, right, absolutely right.

Dr. Mike Patrick: Now, let's talk about insulin in a little bit. So insulin is a hormone?

Dr. David Repaske: Insulin's a hormone, yes.

Dr. Mike: And the insulin that we give, talk a little bit about where does that come from. I mean is this, do you get insulin from another person or how do we get insulin?

Dr. David Repaske: Well, we used to get in from pigs and cows. Now it is human insulin that's genetically engineered and produced in a factory, in a vet. I think the popular way of making it is in bacteria.

Dr. Mike Patrick: So we've talked on the show before when you talked about genetics that DNA codes for proteins and so this is an example where we're using genetic material or kind of injecting the code for insulin into a bacteria and then asking, asking the bacteria to produce the insulin and then collecting it?

Dr. David Repaske: Exactly, and the good thing about this is that it is human insulin. It's not a beef or pork insulin which used to cause antibody formation and had other problems at the time.

0:24:13

Dr. Mike Patrick: But at the same time, it's not something that you could get – catch a human disease from – I mean it is a human product but not from another person.

Dr. David Repaske: No, but it does come from a human, right.

Dr. Mike Patrick: Right, so what kind of obviously, there are different type of insulin and I suppose that they differ from each other slightly by their molecular make-up and then how they affect the cell. What are some of the different types of insulin?

Dr. David Repaske: Well, so in the…

Dr. Mike Patrick: Or maybe that's not true. Are they different molecularly?

Dr. David Repaske: Yes, so there is regular insulin that is made by genetic engineering and that is precisely human insulin. But in the past 10 years or may be a little bit more than that, some designer insulins have come along. They've modified the insulin just slightly in order to give it different characteristics.

And so one thing that they've done is modify it to make it time-released. So it comes out over 24 hours so you could give an injection of this long-acting basal insulin, it's called, that comes out slowly after 24 hours.

0:25:22

It's like time-released although it's not like most time-released things like time-released pills. It crystallizes under your skin and then dissolves slowly. So it gives you that basal insulin 24/7 that's in your system.

And then the other new insulin, relatively new insulin, is a rapid acting insulin. You give an injection and it comes out peaks within an hour or two and then it's out of your system within another hour or two. And so it very much mimics the time course for absorption of carbohydrate out of your food.

So when you give a bowls of insulin before the meal and then eat the meal and the carb from the meal and the insulin sort of hit at the same time and then are cleared out of the system about simultaneously.

0:26:15

Dr. Mike Patrick: So really, you can give design a regimen of insulin that's really targeted toward the person and their own metabolism and their own diet and exercise portfolio and by using a combination of these different insulins try to keep the blood sugar at a relatively stable level.

Dr. David Repaske: Right, absolutely, absolutely.

Dr. Mike Patrick: But that makes your job more difficult than it used to be then. I mean trying to tailor a regimen for each person.

Dr. David Repaske: Yes, but it's not about me, it's all about the family.

Dr. Mike Patrick: Absolutely, absolutely. Now let's talk a little bit about insulin delivery mechanisms. Why can't insulin just be given as a pill?

Dr. David Repaske: It's a protein and so just like a hamburger, it gets dissolved in your stomach and digest it. So it doesn't get into your system, into the blood where it needs to be. That way, it has to be injected.

0:27:08

Having said that, there are lots of companies work on a lots of alternative ways of delivering insulin and there was inhaled insulin for a while, it's now out the market. There's another one that is going to be sprayed into your cheek and somehow absorbed through the lining of the cheek.

There's another one that's being designed, it's sort of encapsulated, it's a pill that you take and slips through the stomach. It's got a coating over it that protects the insulin from the digestive enzymes and the acid in the stomach and so it should deliver the insulin to the gut.

But these things are in development. They're not available right now.

Dr. Mike Patrick: What happened with the inter-nasal insulin? Did it just not work very well or were there problems with it?

Dr. David Repaske: The inhaled insulin?

Dr. Mike Patrick: Yes. It seemed promising.

0:28:07

Dr. David Repaske: Sure, it seem promising. There were some – I think the biggest problem was that there were some changes in the lung that it seem like all that insulin getting on the thin layer inside the lung was starting to cause the lung to thicken, the tiny absorbed surface for that, it was showing that the oxygen getting across the lung quite the same after prolonged inhaled insulin. And so…

Dr. Mike Patrick: They took it off the market.

Dr. David Repaske: They took it off the market.

Dr. Mike Patrick: Got you. Now we give it as individual injections. What about insulin pumps?

Dr. David Repaske: Well, I think insulin pump is a fantastic way of getting insulin. It is something you got to wear, it's got to be on your body. You can disconnect it for brief periods of time, but that's wonderful for some people. But other don't want to have that. It's easier to inject something and then be relatively free for at least a few hours.

0:29:18

So the different therapies, it was wonderful for one person, it's not just right for the next. The insulin pump just has rapid acting insulin.

Dr. Mike Patrick: It is just that needle then under the skin, it get sort of gets taped there. So how do that mechanism works?

Dr. David Repaske: Right, right, right. And in fact, it's inserted under the skin with a needle but then the needle's pulled out. It just leaves a little spaghetti tube behind that insulin drips or is pumped out of the – that pump through this little spaghetti tube and under the skin.

And it's got some nice advantages in that you can change the basal rate. If you give a long-acting basal insulin, it's there and you can't decrease the amount, you can't take it out of the system and you can't decrease the amount that's present say, during exercise.

0:30:13

With the pump you can, if you're blood's sugar is getting a little bit low, you can cut down the basal rate and you can do a lot more fine tuning or the bowl is that you can get half immediately and half over the next couple of hours. Where's with the injection, it's all in immediately.

Dr. Mike Patrick: Can't take it out.

Dr. David Repaske: And yes, you can't take it out and it's also delivered all at once. So the pump has advantages but it has disadvantages and everybody has…

Dr. Mike Patrick: Yes, once again it's about tailoring it to the individual patient, what's going to work best for their lifestyle and – we talked a little bit about diabetic ketoacidosis as a complication of diabetes. So when the cells can't use glucose as an energy source, then they start to break down fat and you get keytones as a byproduct of that and then that makes you acidotic and of course, this can be a dangerous kind of situation because…

0:31:06

Dr. David Repaske: It can be life threatening because your body is not designed to have acid flowing through the blood. Your brain doesn't work well and your organs don't work well.

Dr. Mike Patrick: And that can leave the confusion and coma sometimes, like you said, it can be life threatening. What are some of the other complications that we see with diabetes? And you were saying before that the glucose sticking to things, like red blood cells and then also the inside of arteries is what leads to some of these. What are some of the complications that we see?

Dr. David Repaske: Well, fortunately, we don't see many of complications during the pediatric years.

Dr. Mike Patrick: The adult endocrinologist have the…

Dr. David Repaske: It is more the adult endocrinologist but I think the damage is probably starting in the pediatric years, if you're not careful to keep the blood sugar under control.

0:32:00

So I think the first thing that's really important to say is that diabetes itself doesn't lead to the complications. It's diabetes out of control. It's having too high blood sugar for too long a time and then the sugar starts sticking to different things in your body and that leads to the problems.

The problems are really serious. I mean, the problems can be kidney failure from too much glucose glamming on to that nice little filter that's supposed to filter the blood.

It can lead to blindness, it can lead to nerve disfunctions so that you can't feel like the tip of your toes and then you have an injury but you don't know it. And then it gets infected but you don't know it.

And then another problem is the circulation from the glucose glamming on to the inside of the blood vessels and so you can't fight infection well. It's kind of a ice skating problem and so you can – you hear about people who have amputations, who go blind, who end up on dialysis from kidney failure.

0:33:06

And the heart disease, the arteries that feed the heart itself get blocked up and…

Dr. Mike Patrick: And if it's in the brain strokes or possible as well.

Dr. David Repaske: Possible as well.

Dr. Mike Patrick: So definitely something that you keep under good control to try to avoid these kind of things from happening. Now there's also complications that can arise with the treatment of diabetes. Too much insulin is – more of a good thing is not always better.

Dr. David Repaske: Absolutely, right, right. So the insulin moves the sugar out of the blood and into the cells of the body, but if there's not enough sugar in the blood for the amount of insulin that you've given or that's there, you can get hypoglycemia, which is low blood sugar, and your brain sort of needs sugar to operate well. So too much insulin can cause low blood sugar.

0:34:01

It's really a problem if you say, you're driving a car and suddenly, your blood sugar drops down low.

Dr. Mike Patrick: And you passed out.

Dr. David Repaske: And you passed out, that's not so good.

Dr. Mike Patrick: Yes, what is the long-term outlook of folks with Type I diabetes? I mean as long as they keep it under pretty good control, I mean, are they able then to live a pretty normal life or ultimately, are these problems and complications going to arise?

Dr. David Repaske: No, absolutely it's controllable. So the magic number seems to be around 7%, A1c of around 7%. If you can keep your blood glucose at or below that level, you should be able to live 150 years without any of the complications of diabetes accumulating.

Dr. Mike Patrick: Do you see much Type II diabetes than folks with Type I? I guess this is more of an adult question, isn't it?

Dr. David Repaske: Well, there certainly are people who have both features. So they have a deficiency of insulin like Type I, but also are maybe overweight and have insulin resistance until they need a larger dose of insulin. But still, they need insulin.

0:35:12

Dr. Mike Patrick: Is there any way to prevent Type I diabetes?

Dr. David Repaske: Oh, I wish there were. There's a lot of research going on in that area. If you can just quiet down the immune system so that it stops picking on those beta cells that would theoretically prevent it from coming.

There's some new evidence that the beta cells are constantly being born. New ones are being born in the pancreas. And so even somebody who has diabetes, theoretically, you should be able to calm the immune system if you could do a immunization that's sort of like a on flu shot. Get the immune system to stop picking on the beta cells rather than focus on the flu virus. And just wait, may be the beta cells would come back and repopulate the pancreas.

0:36:09

There's some new projects going on now. You should try immunizing against these enteroviruses that I mentioned earlier. That's very sort of theoretical but there's enough evidence to be worth a try.

Dr. Mike Patrick: Yes, but there's smart folks working on this kind of thing?

Dr. David Repaske: Oh, there are lots of smart folks working on lots of different aspects.

Dr. Mike Patrick: Any way to cure it once – well, of course, this kind of goes with the same thing. I mean if the pancreas can regenerate the cells, then maybe someday there is the…

Dr. David Repaske: But again, if you look back over the past 10, 20 or 30 years, we've come so far. I think that, of course, this is my opinion, but I think that somebody who's come down with diabetes today, a child is not going to have diabetes their whole life that we're going to have a cure in the next 10, 15, 20 years. That's the difficult thing to predict.

0:37:09

I think we're also going to have better treatments. And so, that's not quite a cure, but we have some pretty amazing technology now. We've got the insulin pump that continuously delivers small amounts of insulin. We've got continuous blood glucose sensors that essentially check your blood glucose every couple of minutes.

And if we could get those two talking to one another, you could – anytime the blood sugar is rising a little bit, it could signal to the pump to deliver some more insulin to bring the blood sugar down. If the blood sugar were starting to get too low, it would signal to the pump to back off, not so much insulin, let the blood sugar come back up.

Dr. Mike Patrick: It's an artificial pancreas.

Dr. David Repaske: It's an artificial pancreas, right. And I think we've got the technology to do it. We just have to put it together and make it absolutely 100.00% reliable. And I think it's going to be here and certainly, in the next decade.

0:38:08

Dr. Mike Patrick: Sure. Now tell us a little bit about the Diabetes Center here at Nationwide Children's. I supposed you guys see folks from all over the place and anyone out there with kids with diabetes that would want to see you guys can get in to see you?

Dr. David Repaske: Absolutely. We have diabetes clinics at three locations: Downtown, the Dublin and Westerville. We have a multi-discipline area approach. We have physicians and nurse practitioners and physician assistant. We have social workers, recreation therapists, diabetes educator, dieticians, all part of the Diabetes Center.

And everybody who comes under the typical once every three months and we rotate the different people that you see. We try to be very proactive to identify developing problems before they become a problem to just help people healthy and happy too.

0:39:14

I mean, I think quality of life is a big deal in diabetes. It's with you 24/7. You can't take an evening off, you can't take the weekend off. You can't take a week vacation and so helping people maintain as normal a life as possible is really, really important to us.

Dr. Mike Patrick: Seeing folks every three months, you really get to know your patients quite well, don't you?

Dr. David Repaske: Yes, oh, yes.

Dr. Mike Patrick: I can tell that you enjoy that. So we'll have a link in the Show Notes over at pediacast.org to the Diabetes Center here in Nationwide Children's Hospital. So if you want to know more about it, or you'd like your child to be seen there, you can go to again pediacast.org and there'll be link in the Show Notes to the Diabetes Center at Nationwide Children's Hospital.

Well, before you take off, Dr. Repaske, one of the questions that we ask all of our studio guests, we really try to encourage families to do stuff together that doesn't always involved computer screens and television.

0:40:08

And so we've been talking about board games, and I'm just curious what your favorite game is?

Dr. David Repaske: Whoa, you're reaching back, you're reaching…[Laughter]

Dr. Mike Patrick: Or was?

Dr. David Repaske: Yes, well you know what I play recently is sequence. Ever played that?

Dr. Mike Patrick: Yes, yes. My daughter doesn't like it, but my son and my wife do. So sometimes we say, OK, we got to do our own thing for a little while and we'll play or have a sequence. But yes, it's a fun one. Kind of a card game and kind of connect for sort of thing at the same time.

Dr. David Repaske: Right, right.

Dr. Mike Patrick: Cool. Alright, well once again, we appreciate you stopping by.

Dr. David Repaske: Oh, it's my pleasure.

Dr. Mike Patrick: So thanks goes out to Dr. David Repaske for stopping by, Chief of Endocrinology here at Nationwide Children's Hospital. And of course, we want to thank all of you for taking the time out of your day to listen to PediaCast. We know there's lots of sources of the information for pediatric stuff and we appreciate you using us as part of your education.

0:41:09

I want to also remind you, iTunes reviews are helpful, as your mentions on your blogs and Facebook and tweets and make sure you tell your doctor about PediaCast so they can spread the word to other families.

I want to also remind you if there's a particular topic you'd like us to talk about or you have a question for us. Just head over to pediacast.org and use the Contact Link. You can also email pediacast@gmail.com or call the voice line at (347) 404-KIDS and that's (347) 404-KIDS.

And until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long, everybody.