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The best remedy for type 2 diabetes is theoretically simple: medication, education, counseling and weight loss.
It starts when a teenager — let's call him Max — is overweight or obese, and has a diet high in excess calories and lives a sedentary lifestyle. Excess fat tissue causes a loss of response to insulin and, to compensate, the body responds by making more insulin. Eventually, the cells producing insulin become tired and can't produce enough to keep the blood sugar normal.
An endocrinologist diagnoses Max with type 2 diabetes, a condition that, even when treated with excellent care, puts him at risk for a host of health challenges, including: hypertension, fatty liver disease, sleep apnea and a decreased life span.
Many hospitals group patients with type 1 and type 2 diabetes in the same clinic. The immediate treatment for both conditions is blood sugar management, but the underlying cause of type 2 diabetes isn't an autoimmune disease as in type 1: It's behavior.
This should be good news, because it means people can potentially treat type 2 diabetes with lifestyle changes. Kids like Max can improve their life expectancy and overcome their comorbidities.
"There's no fancy treatment for weight loss; it requires decreasing energy in and increasing energy out," says Megan Kelsey, MD, Director of Lifestyle Medicine. But the success of behavior change — i.e., long-term weight loss — is low in everyone. For teenagers with type 2 diabetes, it's even lower.
"Type 2 diabetes is extremely burdensome," says pediatric psychologist Natalie Walders Abramson, PhD. "It requires vigilance, diligence and determination. Those characteristics are not inherent to the teenage psyche. They're having to make an investment in their future. Developmentally, the future is the next ten minutes. For some of these kids, they don't know where to start. They're not even sure why to start."
Add to that the results of the landmark TODAY study, led by Children's Hospital Colorado Chief of Pediatric Endocrinology, Philip Zeitler, MD, PhD, published in The New England Journal of Medicine in 2012.* The study compared kids with type 2 diabetes on metformin to those who also received a second medication or who had support from an intensive lifestyle intervention; it found that the lifestyle group did not do significantly better at weight control than kids in the metformin-only group. Though kids lost weight initially, they did no better in the long run than kids who did not receive the lifestyle intervention.
"There are few successful treatments for severe obesity in pediatrics and very little evidence base for our current practice," says Dr. Kelsey.
"You don't always walk out of the patient's room high-fiving yourself," Dr. Abramson adds. "But you still feel very compelled to help. These teenagers deserve cutting-edge care because they've often been left behind in other areas of their life."
"We plan to be at the forefront of new treatments for obesity, especially severe obesity, but we also want to be sure that we are doing the right thing for our patients," Dr. Kelsey says.
Bariatric surgery for adolescents with type 2 diabetes
Max is on three medications for diabetes, plus a cholesterol medication and a blood pressure medication. His condition is not improving.
"When traditional weight loss methods fail, metabolic or bariatric surgery offers significant and sustainable weight loss in adolescents with severe obesity," says pediatric bariatric surgeon Thomas Inge, MD, PhD, Surgical Director of the Bariatric Surgery Center.
"The major mechanisms by which the operations improve health likely go far beyond the anatomic changes in the gut," says Dr. Inge. "Changes in hormonal cross-talk between the gut, fat tissue and the brain appear to be important for long-term maintenance of weight loss and effective long-term treatment of obesity-related health conditions."
In 2017, Children's Colorado recruited Dr. Inge to offer bariatric surgery to patients. A leading expert in pediatric bariatric surgery and obesity, he's been awarded more than $20 million in research funding from the National Institutes of Health over the past decade. He and his team have published more than 100 peer-reviewed manuscripts.
Bariatric surgery shows promising results for weight loss maintenance and remission of type 2 diabetes. In a multi-institutional study published in The New England Journal of Medicine, Dr. Inge found that kids' chances of diabetes remission were about 95%, three years out from surgery. The rates seemed much better than those for identical operations performed in adults with diabetes.
"The use of bariatric surgery in adolescents is gaining more visibility," says Dr. Inge. "As more primary care providers and families learn of the positive outcomes these operations bring for teens, greater numbers of teens will likely choose surgery to take control of their weight and reverse health complications."
For some, bariatric surgery is most certainly the best solution; for others, it's not ideal.
To even qualify, many insurance companies require adolescent candidates undergo six months of medical supervision. The team uses this time to prepare patients and their families for the lifelong commitment to lifestyle changes.
It takes three to six months after surgery to see significant weight loss. Kids still must commit to lifestyle changes afterward. And there are so few pediatric surgeons specializing in bariatric surgery that many kids don't even have access.
Embedding type 2 diabetes in lifestyle medicine
Until the last few decades, type 2 diabetes was almost unheard of in anyone under age 18. With childhood obesity rates increasing at alarming rates nationwide, so is the prevalence of type 2 diabetes, starting at age 12 or 13. Children's Colorado sees approximately 50 new kids a year with the disease, and there is no sign of these numbers decreasing. If they continue to rise, healthcare professionals will inevitably need to shift to prevention.
If Max were at another hospital, upon his immediate diagnosis he might go to an endocrinology clinic that groups kids with type 1 and type 2 diabetes. This is how Children's Colorado used to do it, but the team found that was a reactive approach.
"In type 1, there's a lot of focus on getting the right ratio of insulin to carbs," Dr. Kelsey says. "But what about when you're trying to limit carbs?"
Now, at Children's Colorado, Max goes to his first appointment with the Lifestyle Medicine Program, originally set up to treat kids with obesity and metabolic syndrome. Our Program, it turns out, is perfectly suited to address the complex medical and weight loss needs of kids with type 2 diabetes.
Max immediately goes to tier 2 of Lifestyle Medicine, the Weight Management Specialty Clinic. There he is assigned an endocrinologist and other specialists to treat his comorbidities, plus a dietitian, exercise physiologist, psychologist and diabetes nurse to help him address behavior change.
"In their first meeting with us, teens are very appreciative of the opportunity to have someone focus on their feelings, the different roles and responsibilities of family members in helping with type 2 diabetes management, and emotional and logistical adjustment to the diagnosis," Dr. Abramson says.
Plugging in communities
"It's not just getting families to show up for a doctor visit, have a blood test and take a pill," says Heidi Baskfield, JD, Vice President of Population Health and the Children's Health Advocacy Institute. "It requires layers of behavior change, forever, in an environment that's conducive to behavior change. The time and energy someone previously had to dedicate to their healthy lifestyle might not be present because they're having to use it to survive the challenges of their daily life."
For example, Max might not have access to nutritious food or safe, outdoor play areas. Maybe the people around him aren't physically active. These "barriers to health" might explain why kids with type 2 diabetes can't lose weight. Ignoring the barriers, the overly simplistic "eat less, move more" solution fails to offer support for healthy lifestyles when and where kids need it. In the traditional model, which treats the symptoms without addressing the underlying cause, there may be no hope for remission or prevention besides surgery.
The multidisciplinary structure of Children's Colorado's Department of Endocrinology is set up to start breaking those barriers from various touch points.
"It's not just the endocrinologist individually saying, 'It's really important that you make changes,'" says Dr. Abramson. "It's the exercise physiologist meeting them that day, taking them to the gym, getting them on the treadmill, getting a plan that day. It's the psychologist coming in and assessing family dynamics. And it's the dietitian, walking in with food models and showing them exactly what is the right portion size, being right there, in that moment. Our clinic does a really wonderful job of understanding why someone might be deteriorating in their management."
Bringing the population health approach to lifestyle medicine
"Electricity is a finite resource that we don't think about," Baskfield says. "But every time we need it, it's there. Healthcare should operate the same way. When you 'flip the switch,' the thing you need to be healthy should be there."
If you can go into communities, assess their lifestyles, beliefs, challenges and strengths, Baskfield says, you can arm them with tools tailored to meet their needs. For Max, that means the places he spends the most time would offer him more outside physical activities and access to healthier food. It means influencing the people around him to support a healthy lifestyle. If this idea of wellness surrounds Max, he might have a greater chance at weight loss maintenance.
This is the essence of Population Health, an approach to healthcare gaining popularity around the world. For Children's Colorado's part, Baskfield and her team are currently building relationships with organizations in three major categories — primary care, K12 school settings and community-based organizations — to build the "grid" of wellness in Colorado. They have initiated programs like Bikes for Life, which gives new bikes to kids through the Boys & Girls Club; and Cooking Matters, which teaches families how to cook healthy meals and grocery shop on limited budgets.
Dozens of hospitals around the country are producing similar efforts; they predict that this approach will — and must — lead healthcare in the future.
"At first, it's going to feel so foreign," says Baskfield. "Ten years from now, we're going to wonder how we could have done it differently and how it took us so long to get here."
* "A Clinical Trial to Maintain Glycemic Control in Youth with Type 2 Diabetes," by the TODAY Study Group, The New England Journal of Medicine, June 14, 2012.
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