Diabetes DASH – PediaCast 522

Show Notes


  • Dr Aurelia Wood and Dr Kajal Gandhi visit the studio as we explore Type 1 Diabetes Mellitus. We cover the cause, symptoms, diagnosis and treatment of the disease… and discuss an innovative school-based program that aims to support kids with the diagnosis. We hope you can join us!


  • Type 1 Diabetes Mellitus
  • Diabetes and School Health (DASH)




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.


It's Episode 522 for July 26th, 2022. We're calling this one "Diabetes DASH'. I want to welcome all of you to the program.                            




So, we have a special episode for you this week because we will not only explore Type 1 Diabetes, but we will also learn about an innovative school-based diabetes program called Diabetes and School Health or DASH. And these topics are important for several reasons.


First, Type 1 diabetes is a very common condition. In fact, most of you out there probably know someone who has Type 1 Diabetes or maybe you have it yourself or one of your kids is affected. And even if Type 1 Diabetes does not impact your immediate family, it really should be a concern for all of us as we share the burden of community health and desire to support our friends and neighbors who are impacted by Type 1 Diabetes.


Second, Type 1 Diabetes is a very interesting disease, from the reasons it happens, to the usual signs and symptoms and complications, its diagnosis and treatment, including medications that use some pretty cool high-tech gadgetry. So, if you love science, this is going to be a fantastic episode for you. And if science is not your thing, don't worry, we'll keep it easy to understand and, hopefully, a little fun as we move along.




Third, there are really some really terrific support programs in many local communities across the country whose mission it is to support those with Type 1 Diabetes. Here in Central Ohio, we have a terrific school-based program, as I mentioned, called Diabetes and School Health or DASH. And we're going to learn more about that.


To help us explore Type 1 Diabetes, we have two terrific pediatric endocrinologists from Nationwide Children's Hospital with us today, Dr. Aurelia Wood and Dr. Kajal Gandhi.


Before we get to them, let's cover our usual reminders. Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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So, let's take a quick break. We'll get our expert endocrinologists settled into the studio and then we will be back to talk about Diabetes DASH. It's coming up right after this.






Dr. Mike Patrick: Dr. Aurelia Wood and Dr. Kajal Gandhi are endocrinologists at Nationwide Children's Hospital and assistant professors of Pediatrics at the Ohio State University College of Medicine. Each have a passion for helping patients and families impacted by Type 1 diabetes mellitus. And they're here to help us explore the condition and tell us about an innovative school-based diabetes program called Diabetes and School Health or DASH.


Let's begin with a warm welcome to our guests, Dr. Aurelia Wood and Dr. Kajal Gandhi. Thank you both so much for being here today.


Dr. Kajal Gandhi: Thank you so much. We're thrilled to be here.


Dr. Aurelia Wood: Thank you for having us. We're really excited.




Dr. Mike Patrick: Yeah, I'm really excited, too. I love talking about diabetes because it's a condition that is fairly common. And if your family is not impacted by diabetes, I think you probably know someone whose is. So, it's just kind of smart for all of us to have some general working knowledge about this condition even if it's not in our family. So that we can have empathy and support for our friends and neighbors who are impacted by diabetes.


So, I think a good place to start, Dr. Wood, is what exactly is Type 1 diabetes mellitus?


Dr. Aurelia Wood: Type 1 diabetes is a chronic lifelong autoimmune condition that occurs when the body can't produce insulin which is the hormone that allows to use sugar for energy. Because there's not enough insulin, blood sugars are very high which can be really damaging to the body.


People with diabetes therefore monitor their blood sugar and give themselves insulin throughout their blood sugar in a healthy range which also helps them to feel well. 




Dr. Mike Patrick: Great. So, this is an issue with insulin, and your body is not making insulin. And insulin is needed to get sugar or glucose from the blood into cells and then they get to use this energy. But if the insulin is not there to take glucose into the cell, then the glucose builds up in the blood and that's why you have a high blood sugar, right? 


Dr. Aurelia Wood: Exactly.


Dr. Mike Patrick: And then, we keep saying Type 1 diabetes. There must be a Type 2 if there's a Type 1. What is that and what's the difference between the two?


Dr. Aurelia Wood: So, Type 2 diabetes. Maybe the type that most people are a little bit more familiar with because worldwide, it's the most common type of diabetes and it's more common in adults. So, Type 1, as we mentioned is autoimmune, meaning, the body for some reason attacks that part of the body called our pancreas that makes the insulin.


And so over time, over weeks, maybe months, those insulin cells decrease, and the body just has that response that you talked about, higher blood sugars and then feeling ill, which we'll talk about a little bit later.  




What happens in Type 2 diabetes is that the body actually makes insulin, it just can't respond to it. So as opposed to Type 1 where insulin levels are low and Type 2, insulin levels can be normal or even really high, showing that the body is resistant to insulin.


Dr. Mike Patrick: And Type 1 diabetes where you're not making the insulin, the onset of it is a little bit more common in childhood than it would be in adulthood. And so, kind of an older name for this, but you may still run across where people say "juvenile diabetes" just because it's more common onset-wise in childhood. Whereas Type 2 is more of the old onset. And as you said, you have the insulin, it just isn't helping carry glucose into the cells very well.


Dr. Aurelia Wood: Exactly.


Dr. Mike Patrick: Okay. So then, how common is Type 1 diabetes and who's affected by it?


Dr. Aurelia Wood: Type 1 is actually one of the most common chronic conditions of childhood, interestingly. Right now, there are about 1.6 million people in the United States living with Type 1 and about 200,000 of those are under the age of 20, so in our pediatric population.


Dr. Mike Patrick: So, very common.




Dr. Aurelia Wood: Very common. And we find that the incidents is actually increasing each year, meaning the number of new cases that arise every year. So, there are many many people living with Type 1, and you may know someone that know someone or have a family member that has Type 1 diabetes because it is that common.


Dr. Mike Patrick: Yeah, the fact that it's autoimmune, we're seeing an increase in a lot of immune system kind of issues like with seasonal allergies, and with asthma, with food allergies. It seems like allergic stuff is on the rise. And why that is, it's probably many reasons and beyond the scope of this podcast, but we can lump diabetes in sort of with that group of being something that’s at least at its root an immune system issue. And then, it makes sense that that's kind of increasing like all the other conditions are.


Dr. Aurelia Wood: Right, right. Exactly.




Dr. Mike Patrick: What about differences between males and females? Is it equal across the board or is one sex a little more likely to get it than the other?


Dr. Aurelia Wood: We don't really see that difference. Type 1 diabetes affects all nationalities, ethnicities, and races. There is a higher prevalence in those with European backgrounds, specifically those with Scandinavian backgrounds. That part of the world is really, really highly affected actually by Type 1 diabetes.


So, in the United States, people of that ancestry are the ones we see the highest rates in. But we do see it again in Hispanic people, in Black and African American people, and the Poly patients, all different backgrounds. But the highest prevalence is in those who identify as White or Caucasian.


Dr. Mike Patrick: And what about a genetic component? Does it run in families?


Dr. Aurelia Wood: That's a great question and something that's really being studied in Type 1 diabetes. So, what really triggers Type 1 to come about, we don't really know. But we know that some people just have some genetic predisposition for their body to start attacking those cells in the pancreas.




And so, there are different very high specialized types of immune cells that we can monitor and check which are often checked more in the research setting than in the clinical setting, that really tell us about risk. But unlike many conditions that have a genetic predisposition, it's not something that if your dad has it, you automatically have it. Your sister has it, you automatically have it. Even among identical twins, 50% chance.


So having a family history of anything autoimmune or certainly similar type one certainly may be the case, but many patients are the first person in their families to be affected by Type 1 diabetes.


Dr. Mike Patrick: So, you don't really inherit diabetes, but you might inherit a tendency toward getting it.


Dr. Aurelia Wood: Absolutely.


Dr. Mike Patrick: Got you. And then, let's really focus down on the pancreas, since we know that that's where insulin is made. And Dr. Gandhi, kind of walk us through, at the organ level, what is happening that makes diabetes occur.




Dr. Kajal Gandhi: So, as Dr. Wood has mentioned, we don't actually know what causes Type 1 diabetes, but we do know it's an autoimmune process. So, what happens is we have this immune reaction that frequently happens over time. And that's a lot of times a misconception with a lot of families that we speak to that it may have occurred suddenly. But in actuality, it happens over a course of time, frequently starting from early childhood.


And over time, what happens is that the immune system attacks the cells in our pancreas called the beta cells. And those beta cells, over time, lose their ability to make insulin properly and react to fluctuating blood sugars in our body.


Dr. Mike Patrick: Okay, so it is where the immune system attacking parts of the pancreas that makes it so that you are not making insulin anymore. And viruses, it would seem, maybe play some role in this process. Tell us about that.




Dr. Kajal Gandhi: Yes, so there's a lot of research and investigation in what different aspects of our environment or genetic predisposition that can cause you to get Type 1 diabetes or accelerate the onset of Type 1 diabetes. And some of those include maternal factors, viruses, vitamin D, among others.


And so, there's a lot of studies that say that there could be a link towards the increased incidence of Type 1 diabetes but there haven't really been shown a strong association with them. So, while we do discuss that with families, it's not something that we routinely recommend in terms of prevention.


Dr. Mike Patrick: Got you. And then, once you do have diabetes, what sort of signs and symptoms are we looking for? So, if you're a parent, when you said it's a slow process, what should we be looking for in our kids to see if they're at risk, that this is what's happening?




Dr. Kajal Gandhi: That's a great question. Because as we mentioned earlier, when our cells have that inability to make enough insulin for our body to function, we can't use the sugar for energy. So over time, our sugar in our blood rises. When that happens, we start having symptoms associated with Type 1 diabetes. And that can include increased urination, increased thirst. You can have increased hunger.


And you can also have fatigue or mental status changes, and of course, mood changes as well because of those fluctuating blood sugars.


I think it's also important for parents to know that some of these symptoms are vague. And it's important understanding that it could be diabetes and to have that awareness. And some of these symptoms are not as apparent in young ages. And so, that understanding is also important as well.


Dr. Mike Patrick: Absolutely. When we think about sort of the science behind diabetes, those symptoms make sense. So, if you have glucose sort of piling up in the blood because it can't get into cells, it also spills into the urine.




And we know that glucose kind of takes water with it. So, if you have a kid who is urinating more frequently than they used to, especially if with each urination, it's a lot. Because a lot of constipated kids also go to the bathroom frequently, but they just pee a little bit each time.


But if you're urinating a lot each time and then you're going to get dehydrated and then that leads to you drinking more to replace the fluid that you lost. So, if you have a kid who's peeing a lot and drinking a lot, especially compared to what is baseline for that child, that would be something to keep an eye on for sure.


Dr. Kajal Gandhi: Absolutely. And it's really just a vicious cycle because until you get that treatment for the high blood sugars are going to continue to urinate and drink a lot.


Dr. Mike Patrick: Now I guess, fortunately, there are other mechanisms by which the body can make energy, because otherwise, this would be deadly pretty quickly. But those other mechanisms lead to acid buildup in the blood, right? And then that leads to something we called ketoacidosis. Eli mentioned it because people who are impacted by diabetes, you probably have heard that word before. And it's just a ketones are a by-product of those alternate energy pathways, right?




Dr. Kajal Gandhi: Yes, absolutely. So as the blood sugar rises in the body, as we mentioned earlier, we cannot use that sugar for energy. So, the body has to use an alternate form of energy and typically, that's fat. And so, when fat breaks down, it produces something called ketones.


And ketones, we make on everyday basis based on various activities, but if you continuously start making ketones, you do develop high levels of acid in our body. And over time, that develops into DKA, called diabetic ketoacidosis which is, with untreated diabetes or underrated diabetes, becomes a life-threatening condition which needs immediate insulin therapy to help reverse that.


Dr. Mike Patrick: And so, one way that you can tell that your diabetes is under pretty good control is checking your urine for ketones, because if you're getting enough insulin and you're getting glucose into yourselves, you're not going to use those alternate pathways.




So, there's not going to be as much ketone production. And so, if your urine is free of ketones, you have some confidence that your glucose system is working right.


Dr. Kajal Gandhi: Yes, and when we diagnose patients, that's a good way for us to know how severe their new onset diabetes is as well. So, our urine starts having glucose present in the urine when we reach a certain level of glucose in our blood. And so, over time, we will have glucose in our urine when we have diabetes. But over time, if that does not get treated, the ketones also develop, and you'll have ketones and glucose in your urine.


Dr. Mike Patrick: At the same time. And then, speaking of diagnoses, that was going to be my next question for Dr. Wood. How do we diagnose this condition? So, it's fairly common, a parent might come in say "Hey, my kids seems like they're urinating more often. They seem to be thirsty." Which maybe it's diabetes and maybe it's not. So how do we diagnose this?




Dr. Aurelia Wood: So, in kids that we have suspicion based on those symptoms, and those are usually the ones that are bring people in. That and peeing overnight or wetting the bed in the kid that wasn't doing that before. Those are big red flags for a lot of families. For which a pediatrician could easily, in their office, grab a urine sample.


Like Dr. Gandhi said, if there's diabetes present, we'll see glucose in their urine, sugar in their urine, and we may also see ketones. So that's a nice beginning screen. But what we also want to confirm is that the reason that the sugar is in urine is because there's high sugar levels. So doing a finger poke to check the blood sugar is also a great way to screen.


There's also a lab test called a hemoglobin A1C, that people familiar with diabetes may have heard it before. And essentially, that is a lab test that comes out as a percentage and that percentage translates to an average blood sugar level over three months.




So normal blood sugar is 60 to 120. If you're fasting, should be less than 100. Even if you've eaten the biggest meal of your life and I checked it two hours later, you shouldn't be over 200. So, if your blood sugars are in those normal levels, your A1C will be as well.


 So, if we find blood sugars that are over 200 randomly in a kid that's been peeing more, drinking more, urinating more, and we see that sugar and those ketones in the urine, we can make that diagnosis of diabetes. And then we'll send the hemoglobin A1C along with that to correlate what we're seeing clinically with what's been going on based on labs.


Dr. Mike Patrick: I do want to… Because we were going to have a lot of families listening who are impacted by Type 1 diabetes and that's another thing that they hear often, is hemoglobin A1C. So, hemoglobin we know is in red blood cells.


And correct me if I'm wrong about this, but the sugar, we have this increased glucose in the blood. And so, some of it going to stick to those red blood cells. And the percentage of red blood cells that have glucose stuck to them kind of correlate with how good your long-term control has been over the past three months, right?


Dr. Aurelia Wood: That's correct.




Dr. Mike Patrick: So, if we can keep that level lower, then we know that the average daily glucose has not been crazy high. But if it does stay high on a prolonged basis, then you're going to see that hemoglobin A1C be a bigger number.


Dr. Aurelia Wood: That's correct.


Dr. Mike Patrick: Okay. And then how do we go about treating Type 1 diabetes, Dr. Gandhi?


Dr. Kajal Gandhi: Because Type 1 diabetes is an insulin-deficient state where our body is not making enough insulin to function properly, we treat it with insulin. And insulin is an injection that we give underneath the skin. And it can be provided in different ways. It can be given as an injection multiple times a day. Or, with newer technology available, we have insulin pumps as well.


So, if you are in injection therapy, we have a basal long-acting insulin that usually lasts up to 24 hours that's given once a day, in addition to short-acting insulin or bolus insulin that's given for carbohydrate intake and high blood sugar correction as needed.




Dr. Mike Patrick: So, we have two kinds of insulin, a long-acting one and a short-acting one. The long acting is there for the day. But then, as you get kind of loaded with meals that are going to increase your blood sugar, then you're going to have some short-acting insulin in there to kind of help you out,


Dr. Kajal Gandhi: Right. And that basal insulin, that long-acting insulin that you give once a day helps prevent ketones from performing. And it gives you that background insulin to give you some global control of your blood sugars and then help you during the day with the bolus insulin.


Dr. Mike Patrick: And then, why can't this not be done with the pill? I'm sure you get asked that a lot, right?


Dr. Kajal Gandhi: Absolutely. I wish it could be done that way. But right now, there has been a lot of research in different formulations of insulin, including inhaled, oral. They just haven't shown that efficacy that has been shown with the injectables.




And so, the good news about this is we had the advent of diabetes technology that allows patients to be on insulin pumps, which is one type of insulin, that gives them an hourly rate of insulin and boluses that prevent them from having multiple injections and interruption of their daily lifestyle, if they are deemed to be ready for that.


Dr. Mike Patrick: And the digestive system breaks things down. And insulin is a pill, it's a protein, and it's just going to get denatured by stomach acid and it's not going to be very effective.


So, this is where we really have utilized technology in the past 10 to 20 years, really, to the benefit of patients with Type 1 diabetes. Tell us a little bit more about insulin pumps. That seems like a pretty cool thing.


Dr. Kajal Gandhi: I'm so glad you asked that question. It's a very exciting time in our diabetes world because there are so many new developments that have been happening even as often as every six months. We've been seeing lots of exciting new products come up.


So, one of them is an insulin pump which we mentioned earlier, which provides an hourly rate of insulin and it's an injection pump that insulin pumps, that's placed on the body. And it's changed out every two to three days. And it gives an hourly rate of insulin plus bolus insulin.




And with that, we usually have another type of diabetes technology called a CGM, a continuous glucose monitor that has been really popular in the last decade or so, which continuously monitors your blood sugar 24/7. In addition to that, that allows remote caregivers to be alerted to high blood sugars and low blood sugars and gives you detailed information on how your blood sugars are during throughout the day and night to give you more optimal blood sugar control and insulin dose changes.


Dr. Mike Patrick: Does the pump listen to the monitor? And so, like it gives those boluses based on what the actual blood sugar is?


Dr. Kajal Gandhi: Yes, absolutely. That's probably the newest technology that we have out there where the CGM or that continuous glucose monitor speaks to the insulin pump with those blood sugar data and automates that insulin delivery from the pump.




And it's called a hybrid closed loop system. And it gives a lot of children with Type 1 diabetes, and adults as well, that blood sugar control that can help prevent long-term complications.


And when you mentioned blood sugar control, it's not as simple as just, "Oh, your kid weighs this much, this is how much insulin you need." Because our body's using that glucose, so we may be more active sometimes. So then, we're using more glucose. We have more need for insulin.


When we're sick, we have more metabolism going on. Your body's immune system is working to kill the infection. And so, it needs energy to work. And so, there are instances where you may need more and you may need less, correct?


Dr. Kajal Gandhi: Yeah, absolutely. And that's where that diabetes technology comes into play. So, our glucose and insulin needs vary throughout the day depending on our activity, what type of activity we're doing, whether we're sick or ill because that gives you increased insulin needs, as well as even different stages of life.




So, when we are going through puberty, for example, we are in a relative state of insulin resistance where we do have increased insulin needs. And so, all of those kinds of factors play a role to control your blood sugars. And so, having that technology available to automate that system a little bit helps provide better care.


Dr. Mike Patrick: I'm sure another question you get asked often is if you something that's injecting insulin and something that is reading your blood sugar, there must be needles involved. Are these things uncomfortable to wear?


Dr. Kajal Gandhi: And that's a great question we get asked by families all the time. And so, the good news is that it's much better than it used to be. And so, the needles and infusion sets have become more automated and user friendly.


And so, because this infusion set for the pump or the injections are given right underneath the skin, they're not quite as invasive as a lot of families think about. And when they start doing it, they realize that this is something that they can definitely do.




Dr. Aurelia Wood: So, the continuous glucose monitors actually don't use a needle which is great. There's just a little filament that goes under the skin, a little piece of soft material that is what sensing the sugar. And for the pumps, though some may use a needle to put it in, that is removed once it's inserted. And all that stays under the skin is a tiny flexible little tube that delivers the insulin.


So, like Dr. Gandhi said, the technology has come quite a long way, both in what the technology is able to do but then also in their user-friendly nature and the attention to comfort. Because most patients find that they're very comfortable, you're always going to have folks that do have more sensitive skin and have maybe rash or irritation.


And we have things that we can help them to make that more manageable and comfortable. But in general, I would say most of our patients do really, really well in either adapt or find fun tips and tricks to help make their devices comfortable and part of their daily care.


Dr. Mike Patrick: Yeah, absolutely.




Dr. Kajal Gandhi: And we've been really surprised with our children, who we knew they could do it. And our parents were really worried about whether their child could do it at diagnosis. And we've been so inspired by a lot of these children, who are now coming back to our clinic after that scary diagnosis in the hospital. They come back to our clinic and they're doing it with supervision on their own. And it's really really amazing to see.


Dr. Mike Patrick: I'm sure the parents are also very happy when they see that everything's working out okay. This sounds expensive. Is there a problem with insurance companies covering the monitors and the pumps, compared to testing the glucose yourself and injecting it yourself?


Dr. Kajal Gandhi: Absolutely. And I think that's been really a challenging part of our diabetes care is the affordability for a lot of our patients, especially some of our race ethnic populations who struggle with that access to care. Especially with diabetes technology, which we know can help every single child with Type 1 diabetes.




And so, there's a lot of advocacy efforts that had been made at the local state, regional and national levels for insulin affordability, technology access and just general access to care.


Dr. Mike Patrick: And I think that you really have to think the long approach with this, because sure, you may be spending more money now, but we're going to talk about the complications of Type 1 diabetes. And if you can keep things under better control, you're going to have less complications down the road. And those complications can be very expensive in terms of hospitalization and taking care of folks. 


And then, when there is a disparity in who gets access to these new technologies that keep things under control, all of us want to have equal access to healthcare and to have long lives and be able to have great times with our families for a long time. And so, this is really something we got to get figured out, right?




Dr. Kajal Gandhi: And what's important is that having those diabetes technology we were alluding to, what Dr. Wood was saying earlier with a hemoglobin A1C, which is a percentage of average blood sugar over three months, with this newer diabetes technology, we are now transitioning to saying that we should have that blood sugar have more time and range. Because now, we're able to see that minute-by-minute blood sugar data. And that has actually been shown to reduce those complications.


Dr. Mike Patrick: Let's talk about what those complications are. So why is it so important to keep our blood glucose within a certain range.


Dr. Aurelia Wood: Yeah, so acutely, meaning, day by day, hour by hour. If your blood sugars are high constantly, you're at risk for those ketones that we talked about earlier. And those ketones, that acid in the blood, really makes kids feel pretty bad. Belly pain, vomiting, not feeling good. And so that can again progress to that diabetic ketoacidosis which requires hospitalization.




So, on everyday basis, we really want to keep blood sugars in as close as we can because it's very hard to do. But as best as we can, keep blood sugars in a healthy range to prevent ketoses and also to prevent frequent low blood sugars. Because we know that having low blood sugar can be very damaging to the brain. So, keeping blood sugar in a range that prevents those complications on a day-to-day basis helps kids have happy healthy daily lives.


And like you mentioned, over time, having healthy blood sugar range for months, years, decades, prevents those complications that we see and those who do have trouble with keeping their diabetes under control.


So, because sugar goes to every different part of our body, those little, tiny blood vessels in the different parts of our body are the first ones to get affected. So those are in our eyes, in our kidneys, in our fingers, in our toes.


So that's why things like having kidney disease due to diabetes, having eye disease due to diabetes, having different neuropathy or different neural pain due to diabetes is a possible complication for those who may have difficulty with decades and decades of control.




So, this is not something that we see for those who are newly diagnosed or in the first few years. But it is something that we mentioned, so people are aware that long term, it's really important, as best as we can with the tools that we have and the support that we have to keep things at healthy range.


Dr. Mike Patrick: And that's start in childhood.


Dr. Aurelia Wood: Absolutely.


Dr. Mike Patrick: With that. And hopefully, once the patient and family understands the importance of keeping it under control, so there's motivation to do so moving forward into adulthood.


Dr. Kajal Gandhi: And we don't want parents to fret because there's also international and national guidelines that help us screen for these things on a regular basis. And so, we have patients who are in good control that lead really healthy fulfilling lives.


And so, the guidelines tell us to screen for these things on a regular basis even throughout childhood, even though it's not common. So that we can take action once we see something that's concerning.




Dr. Mike Patrick: I'm going to head back to treatment very quickly. We're seeing a lot more done with cells and genes. And is there any chance in the future of having like an artificial pancreas or growing new cells in the pancreas that can make insulin again?


Dr. Kajal Gandhi: And I think that's a great question and we do get asked that question a lot. And there's been a lot of research on artificial pancreases. And the key here to remember is that this isn't an autoimmune process. And so just having a new pancreas may not stop the process that's happening that may occur again.


And so, really the key research that's being done is really modulating or changing that immune process that happens which would potentially prevent, delay, or even hopefully in the future cure Type 1 diabetes, which is our hope.


Dr. Mike Patrick: But you'd have to do both of those things. You'd have to figure out a way to grow those cells again and the body not attack them anymore. So, you really have to focus on both of those things.




We talked about the medical complications of Type 1 diabetes, but there's also mental health things that go along with this, right, with any chronic disease? Tell us a little bit about that.   


Dr. Aurelia Wood: Yeah, so having diabetes, as you can probably hear from the discussion, it's complicated. It takes a lot of work. It's definitely a team effort.


But having any chronic condition especially in childhood because you know like we mentioned this is usually diagnosed in childhood, average age of new onset is 12 to 14 years of age. That's already a really exciting, fun, challenging, anxiety-provoking time. So having a chronic condition in childhood, adolescence to teenage years is really really hard.


And sometimes it takes folks a while to accept that they went from being their normal self yesterday running around and now all of a sudden, they have to do all of these new things. It's disruptive. It can be extremely overwhelming, and it may even feel like, in the beginning, kind of grieving the loss of this life that we had before we knew about Type 1.




So, we do find that we have a lot of kids that understandably experience depression, anxiety, social isolation. You know, lots of questioning and are affected in many different ways by having this diagnosis.


But thankfully, we do have a really great team. So, we work in a team, our doctors, educators, social workers, psychologists, to provide support and to routinely screen, even if someone seems like they're doing okay, to routinely screen for signs and symptoms that may be showing that the patient's experiencing depression, anxiety or having something more significant that might need acute attention urgently.


Dr. Kajal Gandhi: And it's really important to remember that it may not be as severe as depression or anxiety. It can be as simple as just a phase in their life that they have what we call "diabetes distress", and where they have just some struggles that might be temporary that require attention.




Dr. Mike Patrick: And really getting folks in to see counselors is really important for these things, right?


Dr. Aurelia Wood: Absolutely.


Dr. Mike Patrick: Because we can learn to kind of change our thinking around and think more positively and we can all benefit from those skills for sure.


Dr. Aurelia Wood: For a lot of people truly just coping, right? Just you know, going from your normal everyday high school, running from gym class to lunch to cheerleading practice or whatever it may be and not having to stop and check blood sugars. So, a lot of people, everyone has a different relationship with their diabetes and with their diagnosis and how they share it. So, we just try to empower everyone to take that journey, to feel their feelings, but to engage earlier rather than later and getting that support and developing those coping mechanisms.


Dr. Mike Patrick: Yeah, really great advice. So, explain the roles of both the endocrinologist and then the medical home in the treatment of diabetes. How do you guys collaborate with one another?


Dr. Aurelia Wood: Yeah, I think I mentioned that diabetes is a team sport.






Dr. Aurelia Wood: Especially in the very beginning but absolutely on an ongoing basis. So, management of Type 1 diabetes in the United States and most countries is managed by a pediatric endocrinologist. So, someone who's been trained in pediatrics and then has done additional training in endocrinology and diabetes.


We also have our diabetes nurse educators, dietitians, social workers, therapeutic recreation team who help with how to manage sports and activity, and our social workers who help manage just the day-to-day navigation of school and work and all those different supports that families need.


So, every three months, once someone's diagnosed with diabetes, they come to clinic, they see their endocrinologist or an adverse practitioner or PA, who's also trained in diabetes, and talk about all the things that we've talked about today. We review their blood sugar data. We talk about how we're getting insulin. We make any changes that are needed. We do any screenings.


And then, they may meet with, at each visit, one of our other team members, because we want them to see them at least once a year, more if necessary if they have certain questions or concerns.




Dr. Mike Patrick: And then, the primary care provider, what's their role in this?


Dr. Aurelia Wood: So, the primary care is always optimally important. They should absolutely still be following up with that person. Once we find out someone has diabetes, we notify their primary care doctor of that.


And so, while they're not primarily managing the insulin, should still be aware of different things that we've talked about today in terms of illness, low blood sugar, high blood sugar and really making sure they're staying in tune with their diabetes and following up with our clinic as well.


Dr. Kajal Gandhi: And I think it's important, just like Dr. Wood mentioned, to have that collaboration with the primary care provider because these patients may not just have Type 1 diabetes. They may have other medical conditions that require that collaborative care and that could ultimately affect their blood sugars and their Type 1 diabetes outcomes.


Dr. Mike Patrick: Yeah, great point. And certainly, primary care doctors want to be there as a resource. In the middle of the night, you have a quick question, you know, maybe. I don't know you guys take calls in the middle of the night too, don't you?


Dr. Aurelia Wood: We do.






Dr. Mike Patrick: So here in Nationwide Children's Hospital there are not just the clinical program of seeing patients every three months who have diabetes, but there's a lot of other stuff behind the scenes that's going on, with quality improvement, and education, equity considerations. Tell us about some of the things that Nationwide Children's is doing to help these families.


Dr. Kajal Gandhi: Yeah, so we are very lucky to be part of a very robust diabetes program. And one of those things include just not beyond the clinical encounter, but we have regular educational sessions with our diabetes nurse educator, to teach people about diabetes technology and advanced diabetes management.


In addition to that, our staff also provides support through diabetes focus groups, which we actually started in the last couple of years that brings families together on various topics of diabetes. And we do these in the evenings. And we talk about different aspects of care, and they are able to have some camaraderie with other families.




In addition to that, we have families that have participated in the institutional Connecting Families, Mentoring Families Program, where they're able to connect with other patients with chronic diseases.


In addition to that, behind the scenes, we have quality improvement initiatives to increase screenings. We have initiatives to reduce acute care utilization, such as emergency room visits, which we do not want our patients to be in. As well as, what we're currently doing, a quality improvement initiative to reduce healthcare disparities and increase equity and access to diabetes care, namely diabetes technology such as the continuous glucose monitors and insulin pumps.


Dr. Mike Patrick: Yeah, really important work for sure, and multiple progs, really just trying to improve the lives of these families and kids.


We are coming, hopefully, on the tail end of a pandemic. You may have heard of COVID before.




Dr. Kajal Gandhi: Oh yeah, I think I have.




Dr. Mike Patrick: How has the COVID pandemic impacted the incidents of Type 1 diabetes?


Dr. Kajal Gandhi: Yes, and COVID was and is an interesting time, and we continue to have lots of research coming out. And we continue to have that research coming out. What the data has shown that COVID-19 did increase the incidents of Type 1 diabetes.


In addition to that, we have found that the people with Type 1 diabetes were at increased risk for severe complications of COVID, as well as having increased severity, especially among our newly diagnosed diabetes patients, namely, diabetic ketoacidosis or DKA.


And so, COVID-19 also taught us how we can better treat our patients in a more effective way. So, we started the telemedicine world and the telemedicine pathway and allowed us to see our patients on a regular basis and provide that level of care that we knew they needed throughout the pandemic as well.




Dr. Mike Patrick: So important because you still saw them telehealth-wise but every three months, right?


Dr. Kajal Gandhi: Right, exactly. And it was important to not only improve their care and maintain their care but also continue on their diabetes journey to have diabetes technology. Because there is data that showed that the patients who had Type 1 diabetes and had COVID had fewer adverse outcomes if they had diabetes technology or insulin pumps or CGMs.


Dr. Mike Patrick: And so, in terms of the increased incidents, it comes back to maybe viral infections, somehow sparked that immune reaction that causes the pancreas damage. Again, we don't know the all the details of that, but it certainly makes that explanation of the viral involvement more plausible when we see an increase with COVID.




And then, another one of those complications of diabetes is your immune system doesn't function quite as well as it does if your blood sugar's under good control. And so, if your immune system's not functioning well and you get COVID, then that's why you're at a higher risk for severe disease and all that, right?


Dr. Kajal Gandhi: Right. And there's a lot of research showing that the patients with Type 1 diabetes who had COVID infection have increased inflammatory markers, increased immune mediation. And so, there are some studies out there that are thinking that the immune mediation accelerated their Type 1 diabetes diagnosis. But I think there's a lot more work and research to be done to understand that better.


Dr. Mike Patrick: So, it's one of those things, like the Space Program, like all of these new technologies came out of the Space Program. I feel like there's a lot of stuff going to come out of the pandemic, just in all sorts of ways that we're learning, you know about the new things in medicine, right?


Dr. Kajal Gandhi: Absolutely. And just with everyone in a COVID pandemic, just adaptability to our care, learning how to take care of our diabetes patients better has really improved our care and made it more efficient, actually.




Dr. Mike Patrick: Yeah, absolutely. So, I want to transition to the role of schools in the care of kids with Type 1 diabetes because kids spend a lot of their time in school. And so, if you have this chronic illness and your blood sugar is fluctuating throughout the day, seems like the school's really out to play some kind of a role in the management. So, Dr. Wood, tell us, what is the role of the schools with Type 1 diabetes?


Dr. Aurelia Wood: Yeah, like you mentioned, kids do, they spend the majority of their time at schools, during the school year. They're with their teachers, their bus drivers, their peers more than they are with their family. So, the school staff and school nurses really do play a vital role in helping kids take care of their diabetes.


Almost every kid eats at least one meal at school. And like we mentioned, at mealtimes, we've got to check blood sugar, count our carbs, and give insulin. So that's one of the primary roles.




But of course, kids get sick, kids may be active in gym class and have a low. Kids might not be feeling well and need to check ketones. So that school nurse who's patching up booboos and attending to other kids that are sick in the middle of their day still has to do that.


So, the schools really do play a really vital role in helping to keep our kids with diabetes safe while they're in their school environment. That said, not every school has a school nurse. Some schools may share a school nurse across districts. Some school may not have a nurse at all and may have a staff member that needs to be trained.


So, the type of care that kids get across settings is not the same. And so, that in itself can provide challenges, not only for the school but for the students and their families.


Dr. Mike Patrick: I'm going to go a little out of order of our original plan, but I think this is really good time to bring up the Diabetes and School Health Program or DASH. Because as you mentioned, there is this need for expertise on diabetes care in the school. And if you don't have a school nurse, or you have a school nurse that's one nurse for many buildings, can be a real big problem.




So, Dr. Wood, what is the DASH Program?


Dr. Aurelia Wood: So, the DASH Program is Diabetes and School Health. It is, at its core, a health equity initiative to really help support school staff and nurses in taking care of diabetes, but to also help empower our students in managing and understanding their own diabetes. We really also are utilizing this program to remove any barriers and address any inequities that exist in the school or healthcare system that prevent people from being able to achieve that optimal care.


And so, this is a new program that was developed within the Department of Community Wellness here at Nationwide Children's that actually houses all of our school health programs. And so, Dr. Gandhi and I, as people who are very interested in helping our families with Type 1, approached them about starting a new program specifically for kids with Type 1 diabetes. And they were overly enthusiastic, and it really helps support us in developing this program for our kids.




Dr. Mike Patrick: I'm going to put a link in the show notes for this episode over pediacast.org to the Diabetes and School Health Program. Do you guys share space in the schools with other programs? So, I know we have an Asthma Program that's very active in the schools. Is this something that you guys all collaborate, like there's a room for the clinics, the school clinic?


Dr. Aurelia Wood: Yeah. So, it definitely varies by school. So, Nationwide does have I think over 13 different actual clinical spaces in Central Ohio. And they're in the different schools.


So, the way our program works is that once we identify that a child is eligible for our program, then they meet with our diabetes nurse educator and APN once a month one on one, to go over their diabetes, how's it going, what are we doing?


If there is a school clinic in that space, they will meet there. If not, they'll work with the school nurse to find a safe, hygienic place to meet and have that interaction. And again, that varies by space, but they make it work and they're flexible and we do what needs to be done.


Dr. Mike Patrick: Yeah, absolutely. Do we have any data on the impact that the program is having for students and families?




Dr. Aurelia Wood: Yeah. So, as I've mentioned, this was our pilot program year. So, we really wanted to start with those families that we knew kind of needed us the most. And the way we identified those is using a novel tool, actually developed by our Diabetes QR Team called the Diabetes Composite Score.


So, this is a tool that composes many different aspects of someone's diabetes care over the past couple months to identify how vulnerable they are to complications, both acute and chronic. So, the scale goes from 0 to 18, with less than 10 being those at highest risk.


So, we took that tool and we identified students in Central Ohio who've met that criteria and enrolled them in the program. And so, for our pilot year, our goal was 50 to 75 kids depending on feasibility. So, our team went to 10 different districts and 35 schools, and we enrolled 55 students this first year.


The age range was 5 to 18 years. Sixty percent identified as an ethnic minority and 16% have a primary language other than English. Three percent of our patients are gender diverse. So, our composite score for this first year actually went from an average of high risk to intermediate risk, which was awesome.




One of the biggest impacts of the program, that I didn't mention yet, is that we actually coordinate medication and supply delivery directly to the student's home and school. Because sometimes that's a challenge to get those things there, make sure they're up to date and not expired.


On top of that, a big aspect and a big push was to get kids on to that technology to bridge those gaps and inequity that Dr. Gandhi mentioned. So, at the beginning of the program, we had about half of the kids had never used the CGM before and now about 40% are.


Dr. Mike Patrick: Oh, that is awesome.


Dr. Aurelia Wood: So that's been a really positive impact. And then subjectively, just the interaction, the engagement, the feedback we get from the nurses, from the families, about what they've seen and how their kids relate to their diabetes, has just been amazing. And it's just a huge tribute to our clinical team which is Amy Moffett, our APN, Dr. Kline and Kathy Simms, our diabetes educators, and Adrean Jones, our pharmacist.




Dr. Mike Patrick: I can imagine if you're a kid with diabetes that you would otherwise feel sort of alone in dealing with this in the school setting, and you feel different. And you've got to talk to the school nurse and other kids are asking "What's going on? What are you doing?" And I would think that having a program like this really also empowers kids to feel better about themselves and the disease that they're managing.


Dr. Aurelia Wood: Yeah, for sure. I think that it's really great when we get together for our routine meetings to just hear the feedback from the kids. And from the psychosocial aspect, which for a lot of them, maybe A1C won't move, maybe we'll still have ketones here and there, but man, if you are a little bit more empowered, if you understand your diabetes a little bit better, if you are willing to share with your best friend who you've been hiding this from for ten years, that you actually have diabetes, those are the things that we think really move the needle and really impact their care.




Because that psychosocial lens, if you really are struggling in that way, it's really difficult to do anything else especially care for something as complicated as Type 1 diabetes.


Dr. Mike Patrick: Yeah, it really spills into your academic work, your relationships, your friends, your family life, all those things. Really important to feel supported and empowered. Are there plans to expand to more buildings and more schools?


Dr. Kajal Gandhi: Yes, absolutely. We are very excited. We weren't sure how this for sure was going to go and we are just so excited about the success and the impact it has made. We are actively recruiting for our second year. And we have already met our current goal for our staffing. And so, because we have so much interest, and I think that's a really exciting thing for us.


We have plans to, of course, increase our staff. So, we have plans to increase our advanced practitioners, our diabetes nurse educators, as well as eventually expand to maybe Type 2 diabetes.




We also have ongoing conversations with our fabulous colleagues here at Nationwide Children's, with Sports Medicine and our Healthy Weight and Nutrition clinics to provide some comprehensive care for obesity and maybe associated Type 2 diabetes, to make a better impact with these kids spending so much time at school.


Dr. Mike Patrick: Absolutely. That also brings up some of the functions of school that can be complicated by diabetes, things like bus rides, field trips, summer school. Tell me how do those things impact kids with Type 1 diabetes?


Dr. Kajal Gandhi: It impacts them quite a bit. And so, what's actually interesting and what Dr. Wood was alluding to earlier, not only do we have these data statistics on the rate of diabetes technology and the A1Cs and how many racial ethnic minorities are involved. But anecdotally, we're seeing stories that we never heard before. Because we see them as diabetes providers every three months for maybe 30 minutes at a time, and we don't really hear the stories about what happens in the school.




And so, now going out into the school, we're learning about those struggles. So, getting on a bus, having a bus driver maybe not trained diabetes care, having a school nurse that's overwhelmed with many patients that have other medical conditions. Or, just maybe struggling with basic diabetes care and understanding what they need to do, especially with so much diabetes technology at hand.


Dr. Mike Patrick: There may be a field trip and the school nurse is not going on the bus to be with them. And so, you want to make sure that there's at least someone with the group if there is a child with diabetes who knows what to do if they go low. And that's something that I guess you have to be an advocate for in your district, right?


Dr. Kajal Gandhi: Right. We used to hear those stories in our clinic all the time. That, "Oh, my child wanted to go on a diabetes field trip, but I couldn't go." The parent couldn't go, or the caregiver couldn't go, because they have to work. And the school nurse wasn't there and there was no one else trained in diabetes.




But now that we're going out to the schools on a regular basis, our staff is identifying these issues and potentially helping these children participate in the activities that maybe they couldn't have participated in, because of that increased education and training.


Dr. Mike Patrick: When I was at pediatric resident, I did diabetes camp. I was like the camp doctor. And I still have such great memories…




Dr. Mike Patrick: From my summers doing that. Something else that families have to think about is overnight visits, spending the night with friends, going on vacation. There's just so many parts of life that those of us who are not impacted by chronic illness just sort of take for granted.


But Dr. Wood, is that something that the diabetes educators also really look at? Like they help families think through what problems you might encounter? It's always better to know what the barriers are before you hit them, right?


Dr. Aurelia Wood: Absolutely, yep. So, the name of the game is preparation and planning. So, during appointments, which is also the reason we see kids so often, right? You know, six months to a nine-year-old, that's a huge amount of time and things can change in terms of sports, or their friend group, or when they're finally ready to do that overnight.




So, it is important that we see them so we can provide that direct to education, and then figure out what parts of their life are upcoming and exciting. So, we can prepare for diabetes to not be the thing that makes it not a good experience.


So, we always want to have all of our supplies on our person, especially if we're going out of town or to a new place, "Let's bring extra". Planning ahead to say, "Hmm, we're going to be more active. Let's prepare and let's have a plan before that activity."  Maybe we'll target a higher blood sugar. Maybe we'll have extra snacks on hand, so we can give those.


So really just thinking through the potential things that can happen and preparing as best as you can. Mistakes happen, the unexpected is unexpected because we didn't expect it. So, there are going to be times where things don't go well. But as best as we can, we try to empower our patient to at least know what to expect in situations that we encountered and that our other patients have encountered, so that they can enjoy their life and not have diabetes be that big of a burden at the moment, especially when it's a moment of fun.




Dr. Mike Patrick: Absolutely. We've really been focusing on kids with diabetes. But there's really a role for all of us, in terms of supporting folks who are impacted by this disease. What advice do you have for families and kids in schools? How can they best support their friends who have Type 1 diabetes?


Dr. Kajal Gandhi: Yes, that's a great question. And I'm so glad that more and more people are becoming more aware of Type 1 diabetes. So, they're asking that question more.


And so, like Dr. Wood mentioned earlier, diabetes is a personal journey. And every child and family goes through their own pace and rate at which they accept and empower themselves with their Type 1 diabetes diagnosis. And so, we do encourage, as they feel more comfortable with their diabetes diagnosis, to share it with their friends, their family members, or any other support communities that they have Type 1 diabetes, because that serves many functions.




One is that they get the support that they need. We, as a diabetes team, speak about all the time saying that the success of a child or an adult with Type 1 diabetes comes down to support.


And no matter how much care, medical care that I provide to that patient, the support makes all the difference. And so, not only giving that support from the community. But then, once they feel comfortable sharing that information to their community, they in turn can say, "Well, let me learn more about it. I understand that you have Type 1 diabetes. Let me learn about what that is. Tell me more."  


And once they learn more about it, they feel comfortable with that support that they're having. And then in turn, that child or adult with Type 1 diabetes go out, and then they can help the greater community.


And so, we have a lot of patients who initially share that with their closer circle, then go out to local, regional, and national organizations and they become Juvenile Diabetes Research Foundation Youth Ambassadors. And they help educate their schools with symptoms of diabetes and then may save a life or may help another child.




And so, I think reaching out to their closest circle and reaching out for that support once they feel comfortable is key.


Dr. Mike Patrick: Absolutely. What are some misconceptions about Type 1 diabetes? And in particular folks who may not have it directly in their family, maybe you don't have access to an endocrinologist to ask your questions. And just what are some of the general things that we need to know and that can be confusing for some people?


Dr. Kajal Gandhi: Yeah, absolutely. And I think the important things to remember is what we talked about earlier, is the difference between Type1 and Type 2 diabetes. That Type 1 diabetes is different from Type 2 diabetes, and it's treated differently.


In addition to that, when we see patients and families their diagnosis, we see a lot of parents or caregiver guilt about, "I wish I could have prevented this." No matter how severe they came into the hospital, "I wish I could have done something."




And we try to reassure the parents, like we talked about earlier, there's probably not much that they could have done to prevent this process, which has been going on for quite some time prior to their diagnosis, because although there might be a genetic risk that's not as common, it is sporadic, and it does sometimes the only person in their family that has it.


So, we always hope to help families understand that point. Is that there's nothing that they did, that they did a great job recognizing the symptoms that they weren't feeling well, and they brought them in to receive medical attention. And that's why they're here and that's why they're going to lead fulfilling lives.


Dr. Mike Patrick: So, you do not get diabetes from eating too much sugar.


Dr. Kajal Gandhi: Right. Exactly. And that's just common misconception because Type 2 diabetes is the more common diabetes, which is sometimes associated with a suboptimal lifestyle, where you're unhealthy foods and not exercising as much. Where Type 1 diabetes, no matter what you're doing, it's an autoimmune process that could not be stopped.




Dr. Mike Patrick: Since it is autoimmune, and it takes a while for the… You don't have symptoms for a while, but that process is happening. Is there any way to identify who that might be happening to before it gets to the point of symptoms?


Dr. Kajal Gandhi: Yeah. And so, there's actually a lot of studies out there. And so, one of the biggest national studies that's out there is called TrialNet. 


And so, that encourages patients who have Type 1 diabetes. Their siblings or their extended family members who might want to learn more about their risk, they get testing done. And there's just a big national database that they're learning from to see what type of antibody status that they have or what type of clinical status that they have that allows them to progress either more slowly or they don't progress, or they may progress faster.




Dr. Mike Patrick: Very interesting. So, all of these, there's so much research. This is a great area of medicine to get into. If you're looking to get into the medical field, because there's really going to be some interesting and fascinating things moving forward, right?


Dr. Aurelia Wood: Absolutely.


Dr. Mike Patrick: What are some useful resources for families and schools both impacted by diabetes but also anyone in the general public that would like to learn more about this disorder?


Dr. Kajal Gandhi: Yes, thankfully with the introduction of the Internet, we have lots of resources and media channels to learn more about diabetes.


Dr. Mike Patrick: And podcasts.


Dr. Aurelia Wood: There you go.


Dr. Kajal Gandhi: Exactly, that's why we're here. And so, I think any family who's maybe wanting to know about diabetes, or they're concerned about their child who might have diabetes, they should first start with their primary care provider. And that's a really great go-to person to get the most accurate information to get that access to care.




Moving from there, just getting general information, there's a lot of organizations, such as the American Diabetes Association, the Juvenile Diabetes Research Foundation, JDRF.


And then, there's also smaller organizations which now have become bigger called Type 1 Diabetes and the College Diabetes Network, which helped allow networking for college students with diabetes as well.


The Diabetes Camp Association, Diabetes Education and Camp Association also have resources for diabetes camps, not only for youth with Type 1 diabetes but also siblings as well to include them in the fun.


And last but not the least, we do know that there are health disparities with Type 1 diabetes and the access to care. So, there's more and more organizations that are addressing those issues and inequities. One of them is called is Do Diabetes and one of them is Diversity in Diabetes which are really exciting.




Dr. Mike Patrick: And we'll put a link to some of those resources in the show notes so folks can find them easily, again, over at pediacast.org. This is Episode 522.


Now, Endocrinology at Nationwide Children's Hospital is not just about diabetes, right? What are some of the other things that your division does?


Dr. Aurelia Wood: So, Endocrinology for those who may not know is the study of hormones. That's why we take care of kids with diabetes who aren't making that hormone, insulin. So, in addition to our patient with Type 1 diabetes which we have about 3,000 patients, we take care of kids with Type 2 diabetes.


There's actually some rare genetic types of diabetes that we also take care of. But we take care of kids with endocrine disorders across the whole spectrum.  So that's any gland that can be affected that's over-producing or under-producing a hormone and that causes a condition.


So that could be growth hormone deficiency, any pituitary hormone problem, any thyroid problem, concerns about growth that aren't related to growth hormone deficiency, certain genetic conditions that have multiple endocrine manifestations.




We see kids with concerns about puberty. We see kids with concerns about metabolic bone disease and adrenal problems and cortisol problems.


So really, the endocrine system, though it's a system, it’s really across the whole body. So, we take care of lots of different kids, both in the inpatient and outpatient setting.


We also have some subspecialty clinics that are multidisciplinary. So many of these conditions, endocrine conditions are like Type 1 and that they really require a team approach. So, some of those include our Polycystic Ovarian Syndrome Clinic, the PCOS Clinic, our Type 2 Diabetes Clinic, our cystic fibrosis-related diabetes clinic, and then some clinics related to genetic disorders.


And we'll put a link to Endocrinology at Nationwide Children's Hospital in the show notes as well. So, lots of links there for resources to get more information if you're interested.


So, I do want to thank both of you once again for stopping by today, Dr. Aurelia Wood and Dr. Kajal Gandhi, both pediatric endocrinologists at Nationwide Children's Hospital. Thanks again for being with us.




Dr. Kajal Gandhi: Thank you so much. We love being here.


Dr. Aurelia Wood: Yes, thank you for having us. It's a great time.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.


Also, thanks to our guests this week, Dr. Aurelia Wood and Dr. Kajal Gandhi, both pediatric endocrinologists at Nationwide Children's Hospital.


Don't forget, you can find us wherever podcasts are found. There may be an easier for you to listen. We are in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.




Our landing site is pediacast.org. You'll find our entire archive of past programs there, along with show notes for each of the episodes, our Terms of Use Agreement, and that handy Contact page if you would like to suggest a future topic for the program.


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And since Nationwide Children's is jointly accredited by all of those professional organizations, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the content of the episode matches your scope of practice.




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




Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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