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A Holistic Prediabetes Clinical Approach

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Through their holistic approach, endocrinologist Sheela Magge, right, and diabetes nurse practitioner Julia Tracey are catching young patients with signs of diabetes earlier and earlier.

Endocrine specialists, nutritionists and a behavioral psychologist focus on young patients with early signs of diabetes.

Staff in the pediatric diabetes clinic were thrilled when Sheela Magge, the new director of the Division of Pediatric Endocrinology at Johns Hopkins Children’s Center, made seeing young patients with early signs and symptoms of diabetes a priority after her arrival in 2018. With rising rates of diabetes in children — and youth with prediabetes at increased risk for progressing to type 2 diabetes faster than adults — this was what staff in the pediatric diabetes clinic wanted for some time but did not have the staffing to pursue.

“Historically, in our division we did not treat prediabetes prior to patients being diagnosed with type 2 diabetes in the hospital and being started on insulin therapy,” says pediatric nurse practitioner Julia Tracey. “Dr. Magge has been a big proponent of using the knowledge base of our endocrine clinic and our skills and resources to see patients with prediabetes with the objective of preventing diabetes.”

Consequently, pediatric patients with prediabetes are now seen in the pediatric diabetes clinic in the Rubenstein Child Health Building, connected by a bridge to Johns Hopkins Children’s Center. There, patients and parents find a holistic clinic staffed by diabetes physicians and nurses, nutritionists and a behavioral psychologist, as well as family support services through the neighboring primary care Harriet Lane Clinic, a medical home model.

Academic medical centers have struggled to provide such services, says pediatric endocrinologist Risa Wolf, citing limited multidisciplinary provider availability, leaving much of the identification and management of patients with prediabetes to community pediatricians. While general pediatricians offer anticipatory guidance for patients with obesity and risk factors for diabetes, Wolf explains, most do not have additional resources like a nutritionist on-site.

“That means parents need to set aside more time to meet with a nutritionist separately, which rarely happens,” says Wolf. “The fact that nutrition and other point-of-care services are built in together here makes it a lot simpler for the family.”

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Pediatric nutritionists like Meredith Thivierge take a less-demanding and balanced approach in helping patients set achievable healthy eating and lifestyle goals.

In the clinic’s early-intervention approach to avoid worsening outcomes of diabetes, the nutritionists focus their counseling on the patient’s diet — specifically blood sugars — and lifestyle to reduce the risk of cardiovascular disease and hyperlipidemia. The criteria for pediatric prediabetes is a hemoglobin of 5.7–-6.4%. Hemoglobin of 6.5 or greater is considered diabetes. Without lifestyle changes, studies show, 15% to 30% of people with prediabetes will progress to type 2 diabetes within five years (CDC, 2015).

“Lifestyle interventions like exercise benefit multiple areas of a patient’s health,” says Tracey. “We’re not just saying take this medication because it’s going to help your blood sugar. Our prescriptions, by and large, are designed to improve nutrition and increase physical activity.”

The nutritionists counsel nutrition across the different systems that might be affected. For patients with elevated cholesterol or high blood pressure, for example, they would recommend a sodium restricted diet. The nutritionist’s assessment of the patient’s overall nutritional habits also guides the patient in setting specific goals, which can be very challenging for young patients. To help patients achieve success, nutritionists take a less-demanding, balanced approach.

“We talk about healthy eating and lifestyle, what they’re eating and how it might impact their blood sugar, and where they eat, in front of a TV or with their family,” says pediatric nutritionist Meredith Thivierge. “We ask if they’re interested in changing their diet habits and, if not, what they’re willing to do. We help them by making our recommendations more manageable and realistic.”

Supporting that effort, especially for patients struggling with adherence to diet and lifestyle changes, is behavioral psychologist Meg Snyder of the pediatric psychology consultation service at neighboring Kennedy Krieger Institute. Through her initial assessment and follow-up motivational interview sessions every three months, she drills deeper regarding the patient’s and the family’s barriers to healthy choices, as well as mental health issues like anxiety and depression.

“Motivation can be a part of it, as well as the environment, having access to a gym, feeling safe going for a walk to the park, and family finances — it does cost more for healthy foods,” says Snyder. “Our goal might be exercise 30 minutes, five days a week, but if you’re not doing any exercise right now, we can set a goal of 10 minutes, two days a week to start building up momentum. We are giving patients recommendations that are helpful in fine-tuning what they’ve started to do with the nutritionist.”

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“Having the behavioral health specialist, who can help motivate and check goals not only for the patient but for the whole family, is huge,” adds Tracey. “In addition to counseling patients based on their comorbidities, our nutritionists and psychologist can steer families to access to fresh vegetables and other resources through the Harriet Lane Clinic just down the hall.”

As the clinic is still in its infancy, it’s too early to assess the full impact of such resources. Nonetheless, Tracey and others working in the clinic are seeing positive results in real time.

“I’ve had a good number of patients who have come back after one or two visits and their hemoglobin A1C level is normal,” says Tracey. “It’s a nice conversation to tell them I don’t need to see you anymore. That’s one of the things we emphasize with patients — it is possible to reverse prediabetes.”

In concert with the establishment of the clinic, endocrinologists like Magge and Wolf are expanding their research into factors that may make children more vulnerable to prediabetes, with the goal of reaching them earlier. With a special interest in pediatric obesity and type 2 diabetes, Magge — through an NIH R01 study — is using MRI to study body composition, and oral glucose tolerance testing to investigate metabolic mechanisms and determine what puts children at higher cardiovascular risk and how to prevent it.

“Not all BMI is the same,” says Magge. “Diabetes risk is influenced by where the fat is deposited in the body, with more central visceral fat between organs posing a higher risk than subcutaneous fat. These children seem to have more insulin resistance, and are more likely to progress to type 2 diabetes. They also are at increased risk for metabolic syndrome and cardiovascular disease.”

In another study, Wolf has been parlaying her telemedicine experience in using continuing glucose monitoring to inform patients with type 2 diabetes of their blood glucose levels over a 10-day period (IMPaCT2). That allows patients to see how their food choices and exercise affect blood sugars in a short-term range. Now, as part of the division’s early intervention approach, she’s exploring a similar study for pediatric patients with prediabetes. Clinical care of patients with prediabetes, which has been needed, is now the priority, says Wolf, and similar studies will be starting up soon to assess outcomes.

“There will be a lot of opportunities in how we apply technologies and innovations in clinical care to improve outcomes for kids with type 2 diabetes, and have their glycemic control not deteriorate,” says Wolf. “The focus for now is on how we care for our patients, but we’re always assessing data and how we’re doing, and we look retrospectively at data all the time. We’ll be assessing the outcomes regarding BMI and glycemic control, which will tell us how effective this approach is.”

Tracey adds that by its existence alone, the prediabetes/type 2 diabetes clinic is already a significant success.

“We needed to start offering those services — if we didn’t, we would just be putting off the inevitable and end up seeing more kids with type 2 diabetes,” says Tracey. “If we don’t intervene now with these patients, they will almost certainly be at high risk of prediabetes converting to fulminant diabetes presenting more acutely in one, two or five years.”


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