According to the Centers for Disease Control and Prevention (CDC), an estimated 1.8 million people in the United States have Type 1 diabetes (T1D), with roughly 304,000 of them being children and adolescents under the age of 20. With nine million global sufferers of T1D, that means that the United States has more than 20% of the cases, despite being only 4.2% of the world’s population.
T1D, which differs from Type 2 diabetes (T2D), is an autoimmune condition that causes the pancreas to make little insulin or none at all. This leads to dependence on insulin therapy and the risk of short- and long-term complications, which can include low and high blood sugar; damage to the eyes, heart, nerves and kidneys; and even death. The onset of T1D has nothing to do with diet or lifestyle. While its causes are not yet entirely understood, scientists believe that both genetic factors and environmental triggers are involved.
There is currently no cure for T1D, which has recently been in the news as Mattel releases its diabetic Barbie doll. (See story on Page 1.) For more on diabetes, we’ve turned to Debra Etelson, M.D., a pediatrician at White Plains Hospital Physician Associates in Somers who has a personal as well as professional interest in the condition:
Dr. Etelson, thank you for your time. As you no doubt know, Mattel has a new Barbie with a continuous glucose monitor. How important is such a cultural symbol in raising awareness of Type 1 diabetes, which is a tough diagnosis, especially for kids?
“Role-playing with dolls is an important part of growing up. Therefore, children should be able to play with dolls who can represent or be reflected by themselves. When a child with T1D sees the iconic Barbie wear the accessories which keep her alive (insulin pump and glucose monitor), this feels comfortable and realistic to them. There is also an educational piece, where a child can explain to a friend how and why these devices are important and how the doll may need to take a specific action depending on the blood sugar which is displayed on her monitor.”
How does tTpe 1 diabetes differ from Type 2, and how does diabetes in children differ from the disease in adults?
“Type 1 diabetes is an autoimmune disease where the body attacks and destroys the insulin-producing cells (beta cells) in the pancreas. Insulin is required for glucose metabolism, which is important for every cell and organ system in the body. Patients with T1D are therefore completely dependent on getting insulin from an outside source….”
“In Type 2 diabetes, the patient has their own insulin, but it does not work efficiently and therefore leads to high blood sugars, which can cause damage to bodily organs. Type 2 diabetes is often managed by diet, exercise, oral medications and sometimes insulin.
“Hyperglycemia (high blood sugar) causes acute symptoms of excessive thirst, frequent urination, fatigue, blurred vision and may lead to coma if not treated appropriately. Long- term complications can include stroke, blindness, neuropathy and limb amputation.
“Type 1 diabetes usually occurs in childhood, but later onset is becoming more common. In younger children, diabetes presents additional challenges such as limited communication skills and erratic eating patterns. Children may feel isolated due to food restrictions, adjusting meal or snack times due to blood sugar abnormalities. Younger children don’t understand why they may need to wait until their blood sugar is in a healthy range before eating certain foods. In addition, the child’s own growth hormone causes insulin resistance, so blood sugars are more difficult to control during growth spurts and also during puberty.”
How is T1D treated?
“T1D is treated with insulin… given by injection or pump, which is attached by a device and changed every few days. The correct amount of insulin is different for each person, may differ by every hour of the day, and a certain amount of insulin must be given before any meal or snack.
“A very important and often dangerous part of T1D is low blood sugar, which can occur when insulin is given by an outside source (rather than from the body’s own pancreas). It is impossible to know exactly how the body will react to insulin, and low blood sugars may result in sweating, dizziness, tremors, seizures and even death. Low blood sugars are treated by fast-acting carbohydrates such as juice, glucose gel or tablets and/or a glucagon pen.”
We’ve witnessed cases of diabetes in young children in which the parents were more devastated by the diagnosis than the children. How does T1D envelope the family?
“T1D has a profound impact on parents and siblings, often affecting their emotional, physical, social and financial well-being. A person with T1D (or their caregiver) makes about 100 extra decisions a day, including carbohydrate counting, timing and amount of insulin distribution, blood sugar monitoring and considerations for upcoming meals, constant preparation for the need to correct a high blood sugar with insulin or treat a low blood sugar. While these treatments work, it is never perfect or precise, and a child will often feel the effect of both high or low blood sugar (described above). In addition to hypervigilance on a 24/7 basis, family members also fear disease complications and the possibility they may develop diabetes as well.”
Are there mental health challenges associated with a diabetes diagnosis?
“There is a significantly higher occurrence of depression/ anxiety in people with T1D due to the ongoing demands of diabetes care. This includes blood glucose monitoring, insulin management, meal planning, physical activity management and fear of complications. T1D patients also tend to fear social isolation and their financial well-being in the future due to higher costs of medical care.”
What can we do to prevent diabetes, particularly in the young?
“There is no way to prevent T1D. However, there is a newly approved injection (CD3-directed monoclonal antibody) which helps moderate the immune response and slow down the progression of T1D.
“In order to prevent T2D, it’s important to maintain a healthy lifestyle with respect to diet and physical activity and follow through with advice from health-care professionals.”
Tell us about your background and experience, which we understand has given you a personal stake in T1D care.
“I have been a general pediatrician for 27 years. After completing my pediatric residency at NewYork-Presbyterian/ Weill Cornell Medical Center, I joined the faculty of New York Medical College (in Valhalla), where I worked with medical students and pediatric residents at (neighboring) Maria Fareri Children’s Hospital, in addition to treating my own patients in an affiliated ambulatory pediatric practice.
“Ten years later, I stopped working for several years after the youngest of my three sons was diagnosed with T1D at the age of 13 months. My oldest son (who was 9 years old at the time) was diagnosed with T1D about three years later. There was no family history of T1D, although all three children have celiac disease, which is also an autoimmune disease frequently seen in patients with T1D. They are (respectively) 18 and 24 years old now, and thriving, but T1D presents challenges every day. We have seen firsthand how technology (specifically the continuous glucose monitor) has revolutionized T1D care. The ability to display minute-to-minute blood sugars in a convenient and less invasive way (and shared on a caregiver’s smartphone) has enabled quicker and safer ways to treat abnormal blood sugars.
“I returned to ambulatory pediatric practice once my children’s health was stabilized, and I have remained very involved in the diabetes community. I have enjoyed the opportunity to care for patients and families, from routine growth and development to acute illnesses. I also feel confident in my ability to help patients and their families navigate chronic conditions. While I have always been a compassionate physician, I believe my own experience has enabled me to provide a helpful balance of empathy and structure.”
