Supporting Students with Diabetes; Diabetes basics with Marlisa Brown, MS RD CDE CDN

Thank you for joining me for another episode of school nutrition dietitian. November is National Diabetes month. I wanted to take this opportunity to spread more awareness about this condition. There's estimated to be more than 200,000 people under the age of 20 living with this diagnosis, so that means a large number of us are serving students who have been diagnosed with diabetes. Beyond that at least 30 million Americans in general are living with the condition. Most of us are directly affected by this disease. So whether you yourself have the diagnosis, you have a loved one with it or students in your school with this diagnosis. This is a really important episode for you to tune in for.

Thank you so much Marlisa for coming on the show.


Thank you for having me.


I really wanted for the month of November to have someone on who is an expert in diabetes education. There's a lot of confusion around how you manage diabetes, how you prevent it, what the types are, what's going on in the body. And I thought who better to have on than the national spokesperson for the American Association of Diabetes Educators?


That's great. I think that's a good idea, too. I always get mixed information from even patients that are coming into my office that have already been diagnosed. And I think that if we can give your listeners, you know, you know resources and ways to learn more about it, it would make it easier for people to manage their diabetes.


Right. So, to get started, can you tell us a little bit about how you became an expert in diabetes education? There are lots of different kinds of dietitians with different specialties. And the additional credential of being a Certified Diabetes Educator, I know requires a lot of training, but can you tell us what goes into that and how you ended up to be the expert that you are now?


Well, so first, I became a Registered Dietitian. You know, so that requires at least a Bachelor's in nutrition, you have to do an internship, then you have to take an exam every five years, you have to take at least 75 credits, you know, 75 learning hours in the field of nutrition to continue your credential. But when I became a dietitian- registered dietitian, I started to see a lot of patients that were coming in more and more with diabetes. So, I kept going to additional continuing education programs, to a specific program just for diabetes. And I worked on it for a number of years, and I was getting better and better at it. And then I studied to become a Certified Diabetes Educator. So, that required, at least at the time, it was 2000 hours, now it's 1000 hours of direct patient care in diabetes that you had to show and then you had to take another like, you know, four-hour exam and then every five years they were making us retake the exam and so they allowed, in the future credits that you could use instead of taking the exam over again. So, it was, I guess it was about 18 years ago that I became a Certified Diabetes Educator. And you know, it's an evolving field, they learn more and more, there's more medications, there's different treatment methods, there's changes in the protocol on how you treat a patient, what you should do for a patient. And so it's a continuous learning process. And so I encourage anybody that's in the field or anybody that even has the disorder, diabetes themselves, to continually learn, because you know, what you might have learned, you know, three years ago, there might be new things that you can do that will make it even better for you to manage it today.


Can you tell us a little bit about what the differences are between type one and Type 2 Diabetes? Are there any other types?


Good question. Alright, so you know, we used to call Type One Diabetes juvenile diabetes, because we used to see it mostly in young, you know, young children, but we have learned that that is not always the case. Adults can also develop Type One Diabetes, and Type One Diabetes is a very specific thing. Your pancreas for whatever reason, autoimmune attack or different types of issues, other health issues that might cause it to, have stopped functioning to provide your body with insulin. That's how Type One Diabetes is generally diagnosed. You can no longer produce insulin, and therefore, if you don't take insulin, you will not be able to survive because you need insulin to move the sugar from your blood into your cells in your body. And that's how we generally classified Type One; no longer have the ability to produce insulin. That's not to say that somebody with Type 2 Diabetes may also develop the inability to produce insulin later on. But the Type One per se is, that's it. The only thing that caused it was the inability to produce insulin. Where a Type Two Diabetic, a person, and you don't call the person with diabetes a diabetic, anymore, by the way, that's important because we're not trying to classify them as something, somebody with something. They're a person with diabetes, and when it comes to type two, it's a multi-system disorder, like you may- you're still producing insulin but you might not be producing it as quickly or you might not be producing enough of it, or your liver is indiscriminately dumping extra sugar into your body because your liver stores sugar, or your cells in your body had become resistant to your existing insulin, and therefore your body's not moving sugar from your blood into your cells. So, it could be multiple system things that are taking place as gut- there's gut derived hormones that may not be functioning optimally. And so what happens is, is they have this disorder, but it may not necessarily be tied to just one part of their body, unlike the Type One Diabetics works, that pancreas is not functioning. Over time, a type two diabetic- person with diabetes may not be able to produce as much insulin anymore and may ultimately need to take insulin and then may have no ability to produce insulin, you know, because their pancreas got overworked and such over the years, but they don't start off that way. And they don't always end up that way. So, that's the biggest distinction difference.


And do you see Type 2 Diabetes occurring in young people, as well?


You know, and it's an excellent question, because years ago, we didn't, and today, yes, we do. And it's hard to say the exact reasoning for it. But the most common reasons that we think it's happening is due to inactivity and obesity, because when you are overweight, it makes you more insulin resistant. And when you are inactive, your blood sugars can also climb. And so today's children are eating a lot of processed foods. They don't have balanced meals as much. Sometimes they're over eating huge amounts of refined carbohydrates at one time. They're not moving, they're moving their fingers. They’re not outside, you don't see them playing as much outside, you don't see them participating unless they're in a sport you don't see them participating in movement as much and they're overeating huge amounts of carbohydrates, sometimes are over eating at one point of the day. And it's just this obesity and lack of movement and poor nutritional intake has been leading more and more children to become not only overweight but insulin resistant and even type two diabetic which was never the case. Type 2 Diabetes in children was never the case before. It's unfortunate. It's an unfortunate change in what we're seeing today.


Now, for the underweight person who develops Type 2 Diabetes, what is- what are some of the factors that seem to cause diabetes in people who are low body weight?


So, when it comes to Type 2 Diabetes and low body weight, it's usually not the children, then. So, in other words, we're talking about the children before I've been finding the children that are coming in that are developing Type 2 Diabetes are usually inactive and under- overweight. It's usually more adults sometimes that we see and there's multiple things that could be taking place in their bodies. I mean, their diet, even though somebody's sin doesn't mean that their diet is good. I mean, they could be consuming huge amounts of and I'm not saying sugar causes Diabetes, but huge amounts of carbohydrates. If you have the, the let's say the propensity to develop Type 2 Diabetes doesn't help you. Like, they might be drinking a lot of juice and eating a lot of candy and eating a lot of, you know, just eating, just eating pasta, but not anything else. They may have some hormone-related issues that are going on in their body, they may be producing insulin, but you know, not as quickly as they need it, which allows their blood sugar to go up. They may have had type- not type, let's not even a type. They may have had a low blood sugar for a period of time, some individuals when you know they're going through the developmental process, they are actually over producing insulin in response to simple carbohydrates. And then what happens is they continually do that they make too much insulin, they make too much insulin, and they get- they're actually getting low blood sugar for a period of years. And this overproduction of insulin sometimes makes their cells insulin resistant, even though they're not overweight, and even though they're not inactive, so they may have had this, you know just additional insulin more than they needed. Every time they something with a lot of carbohydrates. They sent out a little bit more insulin than they needed and these cells eventually become resistant to that insulin. And that resistance can develop into Type 2 Diabetes, even if their weight and everything else is normal.


What are some signs and symptoms of insulin resistance?


Well, so you don't usually get your signs and symptoms until you actually already have the disorder going on for a while. But once you start to get signs and symptoms it's almost the same signs and symptoms that somebody with diabetes would have. So, they might become very tired or lethargic, you know, more often than they were before. And a lot of times when that starts to happen, people will say, "Well, I'm not getting enough sleep or, you know, I'm working too hard or I'm under a lot of stress." But that's one of the symptoms of them, they start to develop this their insulin resistance becomes diabetes, they might start to develop some of the symptoms of diabetes only when the sugars are starting to get high, like so they might be thirsty all the time, they might have to urinate a lot. They might be excessively hungry, they might actually lose weight without dieting because the sugars are so high that their body's not able to move the sugar into their cells. So, the sugars not moving into the cells so they're not getting the calories. It's almost like a state of starvation. They might have some changes in their vision like all the sudden like foggy vision, they're not seeing right. They might go from highs to lows, where sometimes they're getting shaky and sweaty and nervous and irritable. And another time they're like, again, like feeling like they're going to pass out they're very, very, very tired. So, you just don't feel right, you might have an infection that doesn't heal, you might start getting like more urinary tract infections. So, this many different types of symptoms that come up. And most of the time when somebody gets one or two of them, they explain it, "Well, I have to run to the bathroom a lot to pee, but I've been drinking a lot of water," or, again, they'll make up a reason you know, like why they think it's happening. They don't really necessarily always equate it to, "Oh, I'm getting- I have become insulin resistant. Now, I have diabetes."


Right, that makes sense. It's easy to confuse a lot of those symptoms with other things. When it comes to what makes you more likely to develop diabetes, so that you would maybe know when you experienced those symptoms, to ask your healthcare provider to maybe do additional testing, what increases your likelihood of developing diabetes?


So usually, that's more likely to be type two, although there are some genetic defects, that where there are more than one person that develops Type One Diabetes, but in general, it's Type 2 Diabetes that we would have some of the things to watch out for. And so if you have a family history of diabetes that would, you know, increase your risk. If you have had gestational diabetes, diabetes that was diagnosed during a pregnancy, that would increase your risk. If you are from certain ethnic groups. I'm Hispanic and African Americans are generally higher risk of Type 2 Diabetes. If you are overweight, if you don't exercise at all, those, again, are risk factors. Like so if I was pregnant, and I was certain, you know, and I was going to be screened, let's say for gestational diabetes during pregnancy early, they would look at that, they look at my ethnics, they'd look at my weight, they'd look at my previous history, my family history, they'd look to see if I had a baby, a past baby that I had, if it was larger than normal size, because that might have been a sign that my sugar was high. So, there's like different types of things like that. So, overweight, Hispanic, African American, family history. Usually, if the type two we're looking at sometimes over 35 years of age, and inactive, you know, these are the types of things you just would say, "Hey, you know what, let me at least get myself screened. Let me ask the doctor to do a little bit more testing when I go in, just to make sure that I'm not leaning towards pre-diabetes or diabetes or already."


Right. And some of those symptoms that you mentioned that are related to changes in blood sugar, can you have those outside of diabetes? Is that something that can happen to anyone to have moments of low blood sugar that make you feel poorly?


Well, so, you know, your body's blood sugar goes up and down all day long. We regulate things. Your body regulates temperature, it regulates blood sugar, it regulates hydration, and it does all different types of things for us throughout the day. So, everybody's blood sugar goes up and down. The difference between somebody that is pre-diabetic or developing diabetes or has Type 2 Diabetes, is that their body starts to lose the ability to adjust as well. So, yeah, if somebody went out, and they had, let's say, they went on that the Man vs. Food Show and they drank, you know, 25 milkshakes in 10 minutes, or something like that, their body, even if you're not developing diabetes may not adjust as quickly as it normally would because you have done something that is obscene to your body or you went to pie eating contest or something like that. So, you might get a fluctuation in your blood sugar that is not normal for a short period of time. But because our bodies are so equipped to adjust, it will bring it back to normal very quickly. Comparatively, to somebody who has diabetes or has pre-diabetes, who might not do anything like that and just have something in their body doesn't- it doesn't have the ability to adjust and bring it back as quickly.


Okay, that makes it really clear. That's great. So, we mentioned earlier that type one is something that is not related to lifestyle. This may just be a diagnosis that you receive because you were genetically inclined to have that condition or because your body just no longer is able to produce insulin for another reason.


It's almost like an autoimmune attack on the beta cells in your pancreas that kills your pancreas' ability to produce insulin. And they don't know what triggers it, they do know that there sometimes are other such situations that can cause this to happen, which could probably be confusing, so probably not to go into too much. But, but in general, there's usually nothing that you did that made that happen. It's something- something physiologically that happened to you that you really did not have control over. But it often comes on unexpected. So, it's not like it was a gradual feeling of different symptoms, like we spoke about before that built up and built up over time. It's like all of a sudden, you'll see your child or somebody, you know, excessively thirsty, urinating all the time, you know, really, really, really, you know, like not feeling well. And when usually we test them their blood sugars of extremely high, they often need to be hospitalized on first diagnosis, they often need IV fluids in addition to the insulin, because it was like this attack that happened to the pancreas. And when the beta cells stopped producing insulin, it was like, boom, blood sugar went soaring.


Do we see any major differences between how pediatric patients express symptoms and how adult patients do? Or is the bigger difference between the types of diabetes, not age?


It's not- Yes, it's the biggest differences is the type of diabetes when it comes to the symptoms. However, there is- with Type 2 Diabetes, something that happens a lot with the elderly and the elderly seem to be inclined to dehydration. They just don't drink enough. I mean, often I've heard somebody tell me, "Yeah, yeah, I drink," and I'm like, "When do you drink your fluids?" And they're like, "Well, when I have my pills, I take pills," that's when they drink them and same glass of water whole day long. And this, this dehydration-related, extremely high dangerous blood sugar that goes shooting up with the- it's some hyperosmolar hypoglycemia that happens with the elderly. Often that when they are dehydrated and their blood sugar's get high like that, they can go excessively high and be very, very dangerous. So, when I have older patients that come into my office, that are diagnosed with diabetes, I often, one of the main things we first start on in addition to their diet is to make sure that they're well hydrated. I mean, not over hydrated, but that they're drinking fluids. And it's probably because sometimes the pills change this there's mechanism also as you age, the hormones, the anti-diuretic hormones let you know when you're thirsty. They don't always work appropriately. And you're not always- You're not thirsty when you really need to be as quickly as you need to be. But I do work on that a lot with them. Because they can get that shoot up immediate thing, sometimes with the elderly, like you would do with somebody that had Type One Diabetes, but as far as in general, when somebody's blood sugars are high, no matter what the reason is, whether it's the Type One Diabetes or diabetic that has some person with diabetes, type two, the out of control or the elderly person, the symptoms can sometimes be severe, regardless of what type of diabetes that you had, if the diabetes is out of control.


That's interesting.


It's sort of like, you know, sort of like- I had patient came in this week that was talking about how she didn't know that she had something wrong with her digestive system, because it's been working like that her whole life. So, she thought it was normal. And so sometimes, if somebody has high blood sugar for a period of years, and they feel a certain way, they may think that that's just the way you feel. When you're that age or whatever, have it and not realize that it's all related to the problems they're having with their diabetes management.


What are some of the consequences of having high blood sugar over a long period of time because the diabetes is not being managed tightly?


And that is also, by the way, an excellent question, because we had mentioned earlier that the type one, the people that have Type One diabetes, often get it when they're young, even though not everybody does. The longer that you have diabetes, and the longer that it's out of control, the more likely that you're going to get some sort of complications from it. So, we can be- there are many different things that can take place, that can be permanent damage, and sometimes it's temporary damage. So, the high blood sugars can affect your nervous system. So, that would mean the nerves that are in your legs, your fingers, your toes, can become damaged to the point where you either lose feeling or you get extreme, horrible feeling, like pain, and if a nerve becomes severely damaged, that horrible pain in ever go away. You can, you can affect your eyes if you, especially if you're not going to an Ophthalmologist regularly and you have high blood sugars, you can get permanent damage to your eyes and some people become you know, have permanent vision loss, but some people actually become blind. And I believe the number one cause for blindness that's not related to an accident or a birth defect is from uncontrolled diabetes. Um, you can damage your kidneys to the point where you might end up on dialysis. You could I mean, there's so many different things that can happen to your body that are, you know, desirable. They say that most of the people that have diabetes will die of heart disease; it increases your risk of heart disease. And so you know, heart disease, kidney failure, blindness, permanent pain or lack of feeling in your hands and feet, you can actually end up with an amputation because there's not enough circulation and you can get prone to infections. People have ulcers that don't heal, I mean, these are all terrible things that we to avoid and can be prevented. See, that's the thing that's scary. A lot of times people think, "Oh, I don't want to go on insulin because of my great grandmother went on insulin. You know, next thing you know, she ended up with an amputation." She didn't end up with an amputation because she went on insulin. She ended up with the amputation because she didn't get her diabetes under control soon enough. So, proper care whether it's proper medication, proper diet, and again, we were talking before doctors, dietitians who should do what, you know, the primary care physician is the first line. But if you have diabetes, and it's not in good control, you want to go to a doctor that's a diabetes specialist, as a specialist, each thing. So, a Registered Dietitian is good is your first line. But if you want to know if you're getting, you know, diabetes for a period of time and you're taking medications, then a Registered Dietitian that's also a Certified Diabetes Educator; that would be the expert for that. For the doctors, you'd want an endocrinologist because sometimes it's not just taking a medication. It's taking the right medication. The timing of the medication, the timing of the medication in conjunction with the timing of the meal sometimes matters. And so, you know, the first line of defense, your primary care physician, a registered dietitian, you know, but then, you know, hey, I need to go to an ophthalmologist and I might need to go to they were higher different types of specialists in ophthalmology. And if I'm showing any kind of blood values that my primary doctor that indicates something with my kidney, maybe I need to go to a nephrologist, the kidney specialist. I don't want to- you know, every level of the medicine everybody is trained, okay, and good for the first line. But then after the first line, if you moving to the second line, you want to get those specialists that are in there because they know more about the different types of medications and the timings and the variables that may not be the primary area that the other specialists are working in.


That makes a lot of sense. Now that sounds like it could be a little overwhelming. If you are the patient. How do you manage all of that care?


Do you want me to tell you what I think is most important? Okay, so you you're a person that either has been told that you have pre-diabetes or you just developed diabetes, you're told by your primary physician. Things that you're supposed to do right away when you get diagnosed; you are supposed to see a registered dietitian and I suggest one that is also a diabetes educator- certified as a diabetes educator. You're supposed to get your eyes checked if you haven't done it recently with an ophthalmologist and you're supposed to get your feet checked to make sure that you can have a damage with the podiatrist. That's what you're supposed to do right away when you get diagnosed. Everybody is supposed to do that right away when they get diagnosed. And then if your- if your primary care doctor is managing your diabetes well and the dietitian the registered dietitian at the certified diabetes educator is helping you with your diet, your numbers are getting better, then your good once a year, go to the podiatrist. Once a year, go to the ophthalmologist, you know, see the dietitian as necessary, you know to get your numbers continuously control and your fine. But if your numbers are climbing, even with those cares, then you might consider then going to see an endocrinologist to make sure that there's something that you miss you if there's something that you're missing that needs to be taken care of.


Okay, that that's, that's perfect, that's concise and that helps people to like exactly what they should do right out the gate. Now, when it comes to how other people in these patient's lives can be supportive, what do we need to be aware of? So, my audience is typically feeding children during the school day. And in most districts, you know, you really request and you push for the parents to give you clear communication from the physician or whoever is helping the child manage the diet who is licensed to write prescriptions in their state is to give us an idea of what we are trying to provide this kid that's best for their condition. But a lot of times with diabetes, we aren't getting any clear information. And some people think if a child has diabetes, don't give them any carbs, which I know isn't true. Could you speak to that before we go on, because that's something I hear all the time. People think people with diabetes should not have any carbs.


So, that's very, you know, unfortunate that they believe that because people with diabetes need carbohydrates, just like everybody else. And a matter of fact, if you're talking about children, and since we said more likely the children have Type One Diabetes where they're taking insulin. If the insulin happens to be a little bit more than they need and their blood sugar's stop to- start to drop, the number one thing you need to do to give them is carbohydrates, to make sure that the blood sugar doesn't continuously drop because low- a severe low blood sugar is much more damaging and dangerous in an emergency situation than high blood sugar will be. And so, so you don't, you don't- when you take insulin and your child, the insulins there to move the sugar from your blood, your blood into your cells. They carbohydrate just like everybody else and their insulin that they're taking moves the sugar from the blood into their cells. So if they take insulin and they don't have any carbohydrates, they're more likely to get a low blood sugar. So, that's, that's a bad thought process. Don't give carbohydrates. If it's a Type Two Diabetic- Diabetes, like you develop Type 2 Diabetes in your child... Yes, you do need to reduce the amount of carbohydrates and have more balanced meals, but you don't eliminate the carbohydrates. You need to give better sources. So, instead of let's say, you know, two bags full of sugar coated candy as their carbohydrates source. At lunch, maybe we're going to have a I'm on multigrain bread with some vegetables and a fruit and the fruit was the carbohydrate and the bread was the carbohydrate instead of eating a bag of candy for lunch. So, so it's what source of carbohydrates, how much they need which depends on if we're working with a child that was obese with Type 2 Diabetes. Or if we were working with a child that was on insulin, who usually can eat the same as everybody else, as long as the insulin is monitored and appropriate dosage. Like in other words, if somebody didn't write the prescription the right way for that particular child, and the right amount of insulin wasn't coordinated for the amounts of food they're reading, the numbers could go up and down. So, as long as the insulin dosing on a type one diabetic is appropriate. They should be able to eat like everybody else. So-


How does that part typically work? How do you determine the dosage in real time? Are people supposed to check blood sugar and then decide how much insulin to give or the prescription says, try and eat this many carbs at each setting and then have this much insulin or how does that go?


So, it does make a difference on what type of insulin they're taking and what the insulin delivery method is. So, if somebody is on, let's say, injections, and they want injections with a certain amount of insulin they take every day at certain times and it kicks in like there’s insulins that kick in right away and then there's insulins that have a delayed release, so if they have a mixed insulin where there's one that kicks in right away, and then the rest kicks in later, they need to eat it at the times that that insulin kicks in, and a certain amount of carbohydrate based on the dose they took. If somebody is taking an insulin, that's just a quick acting insulin before a meal, they usually have to check the sugar before they have that meal. And they're either adjusting the amount of insulin that's being given based on the blood sugar and or they're also adjusting based on what they're going to eat. So, so some doctors will just say, all right, we want to keep a set amount of food at each meal. And we're just going to adjust the insulin based on what the number is before the meal. Some doctors might have it so that you adjust it based on the number, plus you increase or decrease based on the meal. So, you know what the description is can vary. So, let's say you were at a school, and let's say there's a nurse there, but the nurse isn't a specialist in diabetes. Okay, the nurse might not necessarily be able to adjust things properly for that child. I'll give you an example. I had a child that was a patient. And you know, she was on a very low amount of insulin, she didn't need a lot to lower her sugars. And the doctor wrote an order. So, she was only taking like one or two units before a meal, which is a small amount. And it was an insulin pen. You can carry- it's not like a needle. It's like a little pen with a little needle tip on it. The problem was is the nurse and the mother didn't know you're supposed to prime the pen to make it so that the insulin is up to the tip of the needle before you do the dosing. And so since she was taking such a small amount of insulin, there isn't any insulin being delivered to the child. Okay, and then and the reason I know it was the nurse because I was on the phone with the nurse. That's how we know because she said she didn't know she was supposed to prime it. The other thing that she didn't know was that after 28 days, that pen went in the garbage and since it such a low dose of insulin, that pen would have had had enough insulin for more than 28 days. So, the child was taking expired insulin, and not getting enough out of that needle tip because it wasn't being primed. And there's one more thing that happened to that child, okay, the nurse and the mother didn't know what to do when the blood glucose reading on the machine that you test with says just high. If your blood sugar is excessively high on those machines, sometimes the reading will just say high, which means it's dangerous. The nurse didn't have an order from the doctor on what to do and the mother didn't know either. They were letting that go. So, here we have a child, they didn't prime the pen, because they didn't know and it wasn't because it was the nurse’s fault. She was working in cardiology before. And when she got transferred here, they didn't have like a main nurse that was a diabetes specialist that was helping to make sure that all the nurses understood, because depending on where you work, you may have learned somethings in school, but you may not have learned enough.




For this environment. She didn't, she didn't know that the pen had to be primed. She didn't know what high meant on the meter. They didn't know that they needed to throw the pen out after 28 days. So, this child's blood sugar was off the roof. And the reason I ended up talking to them is because I called because I was trying to find out what was going on. These numbers were out of control.



So, so there's more than one place, you know, there's more than one piece. Some of the schools they make the child go to the nursing office to get their shot. But some of those insulins work very quickly, like five or 10 minutes, you know, usually it's about 10 minutes, they really start to kick in. Well, the nursing office is on the other side of the school from the cafeteria and the childhood goes to get this shot, and then they have to walk to the other side of the school to get their lunch and now they have to wait in line to get their lunch. Now they can get low blood sugar, because insulin now was really working because they made them go to the other side of the school and climb to the- to go to the nurse's office.


This perfectly captures my concerns around diabetes management in the school, because that's a perfect example. It isn't that this nurse is incompetent. It's that her area of specialty based on previous work histories, not diabetes. So, it feels like sometimes there's a little bit of- we're at a loss as to how to proceed, because the people sending us the information are making a lot of assumptions about our specialties. And then-


Of course. And it doesn't matter what your specialty is, if you're not in that area, like so I went to school a long time ago, I graduated 25 years ago, right? So, you know, I know a lot of things but I haven't worked in a hospital anymore now for 25 years. So, they've figured out different ways that they put things in the computer, now. There's different ways that they log things, and different ways you look things up. If I went in at first, I would look like incompetent. Somebody that's like, you know, 22 years old needs to show me how to use the computer and how they're looking things up and the new way that they're charting there, because that's not what I've been doing. And so, no matter how good you are at what you do, if you put that person in a different environment, where things have changed, they need somebody to help them. And to be honest, if you're in the field a long period of time, you do feel like you shouldn't be asking, like if you're at a lecture and there's a bunch of let's say, you're 55 years old, you've been in the field for 40 years, 30 years, and there's a bunch of people there that are just graduating. They're all interns and the speaker says does anybody here not know what this is? Is the person that's been in the field when the young people need to raise their hand and say, "I don't know what that means, could you please explain it to me?"


That's a great point. No, you don't want to be that person.


No. And if none of the younger people are doing it, and they're all looking up to you, "Oh, I want to be like you when I grow up," you're definitely not raising your hand. If they didn't raise their hands, you're not raising your hand.


That is so true. So, how do we improve? How do we work around this?


So, in general, like, you know, if I had a child that had Type One Diabetes, I mean, I certainly would have an endocrinologist, a diabetes educator and a regular doctor, you know, all helping educate me and my child, so that I knew what to help and put in to share with the nursing or whoever else is involved in taking care of my child. So, I would want to be informed and trained and knowledgeable and ask questions to the professionals, so I could make sure I bring that information back to whoever's taking care of my child during the day.




It'd be the same thing if I had a child with food allergies, I can't assume that because I tell them that my child has a peanut allergy, that they know what that means, that they know that means that they can even touch peanuts and then touch my child. I don't- can't assume that anybody knows. I have to be informed so that I could make sure I share information and bring in tip sheets and talk to people. So, I can't say to the nurse, listen, do you know enough about diabetes to take care of my son, because that's just like, you know, you know, data, it's like insulting and be more like, "Listen, these are some of the problems that we've found that are important with my child. And I just wanted to make sure you had all the most current information of what my doctors share. And so this pen that I'm giving you it goes expired in 28 days, if the child readings are this, this, or this, this is what we need to do. If there's a problem, you need to call me, here's my emergency number." I need to be part of because I can't assume that the people that are there know enough and I don't want to put them down and the information I'm giving, I just want to provide more information. So this way, if they don't know, they feel comfortable discussing it with me.


That's- that's a good tip for parents and for people who are other- on the other end, like if you're the cafeteria manager, and you've just got in a request for a diabetes diet, sometimes that's all it says. You know that that's really not enough information, because there's no set- I think there's a misconception that there is kind of a standardized treatment for everyone. But as I understand it, everyone is in different stages of their disease development process, and there is no one size fits all diet.


And sometimes the children, they're young, some children that are pretty young, you can have like, let's say you have a 10-year-old that has had diabetes since they were two, and they're on an insulin pump and a continuous glucose monitor, they may have learned how to check their, to check their continuous monitor, look at their sugars and know what to do to fix the problem more than somebody else that's around them. Yes, that-


So, they might be able to walk up to the cafeteria manager and say I need juice. And the cafeteria person says, "Oh, but you have diabetes; you're not supposed to have juice." You know? Because they don't know what they're doing. Just give the kid the juice. The kid knows he needs the juice. But that sometimes happens, because the adults feels the adults should know more. You know, but you know, if you've been living with something, you know, you may know more even if you're still very young.

So, I want to stay within my scope of practice as a dietitian, but a lot of times I feel like I just don't have enough information to make a decision or help the child or the family, at all. What would you say people need to do in that case? You need to just reach out to the family, get in touch with the endocrinologists? Or where do you go from there?


Obviously, it does make a difference on what your position is in the institution that you're working in. So, for example, like a teacher, or a school food service manager is in a different position than let's say the nurse or dietitian that works in that facility. So, depending on what your position is, you might need to work through the people that work there first.

In other words, if I was a teacher might, I might need to go and talk to the nurse first. You know, before I'm able to go. I might, if I'm a teacher, I shouldn't be probably calling the endocrinologist, you know what I'm saying? Because I'm, I might not understand what they give me of information completely. So, there needs to be some sort of flowchart set up for different kinds of issues on where you would go to get your help. You know, that's something that could be set up, like I work a lot with health coaches. And I make a list of red flags, things and so if you any see any of these things, this is what you do. When you see any of these things, this is what you do because it's beyond their scope. But yet, it's something that's the flag that needs to be moved to a different place. And so, I would say that if somebody could at least come in and help develop some sort of the system or flowchart of when we have these issues, our schooling has this limits. Where do we go next?




For the help? So, if I was a nurse, and I didn't know a lot about diabetes, and I called them and they may make me feel uncomfortable and intimidate me if I'm not able to converse appropriately with them.

So in other words, it's like, well, I don't understand enough about diabetes, because I don't know about it. I call the endocrinologist office and they're like, they think that I don't know anything, you know, because I'm not answering them properly. And they sort of like push me. So, at that place, you know, it would be for me to say to my supervisor, you know, that, "Listen, I need to either bring in, you know, for a training or need to go to a training for this, because we're having a lot of children with this and I need to have additional training. I need this training for here, for the facility." Because when I was just first registered dietitian, in the beginning, and I didn't know as much about diabetes, educate medications and insulin and stuff and I would call the endocrinologist, I sometimes got bullied. You know, it was like, because they just thought, you know, I didn't know anything, and they didn't even want to deal with me. But then when I learned a little about insulin and everything else, and I call up, they let me do whatever I want, because they can tell from the conversation that I know what I'm talking about. So, calling the doctor sometimes doesn't always give you the education that you might need to continue with the treatment of that patient. They might give you the dose, this is what I want you to do when it says this, and this is how I want you to do it. But if I don't understand that well enough, they're not going to give me that tutorial. If I don't understand the direction, the doctor is not going to spend time to talk, tutoring me about it, he's just going to give me the direction. I need that extra help.


Where do you recommend that we go to find resources for additional training?


So, there's a lot of information out there. There's a lot of programs. The American Association Diabetes Educator has The American Diabetes Association has a lot of programs. They have regular conferences on a regular level, regular programs on a regular level so they can go to the American Diabetes Educators. They can go to American- They can go to the American Dietetic Association, there's a site called, d and then They have a huge amount of resources there. It's this ongoing information. This is- this is videos, there's webinars, there's books, there's lots of things that you can do to help you. The educational sessions from the conferences are available for purchase to be listened to. So, you know, you would pick the part that you're having a problem with. So, let's say kids are coming in with continuous glucose monitors, and you don't even know what that is. They say CGM, like what's the CGM? Oh, that's a continuous glucose monitor. What's that? You know, that I would listen listening to the webinars and things for what continuous glucose monitors are. You know, I'd find out which one the child had. I might look up the drug rep, the- the company that manufactures that and read about it first and then maybe contact that manufacturer. "Could you tell me a little bit more about this?" They have trainers and information available on the sites and the websites and people that can help you because sometimes people talk in acronyms, they don't talk things out. I don't even know what they talked about, they came in they don't say they're on insulin, they say they were on Aspart, is Aspart insulin? I don't- what is that? They're taking an injection, they say it's not insulin. What is Victoza?




You don't know what it is. So, the first thing it is, is find out what like somebody sit there on Victoza. Look it up. Okay, what it is okay, now I know what it is. What is it supposed to do? Okay, now at least I know what it's supposed to do. Now, I can go and ask some questions about it. Can't ask questions if I don't know what it is.



It can be intimidating because there is so much new medication and were you thinking about fast-acting insulin? And it's- it's a lot. I mean, it can make you feel like you're not ready to make that phone call. What would you say to people who, we've got the child in front of us? They're wanting to eat with our program. We're scared. We're trying to close our educational gaps. How do we navigate day-to-day, because we need to feed them, especially for our children who are lower income and we are their only source of food during the day and they have this diagnosis whether or not we are ready to feel strong about handling it. What should our mental state be like going into that?


Okay, so the first thing you want to consider is that if a child with Type One Diabetes says that they need food, no matter what time of day it is lunchtime, break time, snack time or anything. They say I need something to eat or I need some- you need to give it to them. That's the first thing to always consider, even if you don't allow food in school or whatever have you. If they say they need food, there's a good chance their sugars are dropping when they say that to you. So, it's- you should always have something if you have a child in your classes or anything like that that has diabetes, have the little juice packs, you know, even if you're not feeding kids in general and some crackers in the drawer, okay, just in case a child says I need food or anything okay available that should be there for you. You need to be able to have kids come in school really early in the morning. If you find that you know your children are coming in and they're not going to get breakfast there, you don't know if they had breakfast at home, you need to like find a way of encouraging the children to that, did you guys have something to eat? You know, you should have something to eat before first period, you know, try to get them to have something. Sometimes, the break times at the schools aren't like really that early, like in other words, kid might come in, let's say it's seven o'clock in the morning and their lunch period isn't until 130. Did that child have something to eat, you know, is there a way to talk to them and say "Hey, you guys have your breakfast today? Everybody had breakfast?" Like it, put it as part of a class or something to make sure everybody is getting encouraged and make it- make it easier for a child to have something in between classes and things. I know we don't like them eating and classes and putting food on the- try to find a way of making it possible to make sure that the kids get a chance to have something if they come in early in the morning and they don't have break for a period of time. Encourage hydration in the school, too. Dehydration can increase blood sugar's if a child is dehydrated it can contribute. So, encourage hydration. Have hydration stations. If you don't want the child carrying fluids, they have schools that have different types of you know, fluid stations that you can go to get something to drink, and then you know and then continue on. If there's a way of setting that up in the school somehow. Make sure that the people that are working in the food services areas understand that even sometimes waiting in line for a long period of time can be a problem for a child that has diabetes, they might need that food quicker. And you can't separate the children from other children and offer them more but like pay attention. If you see a kid that has, that you know has diabetes is starting to act strange, unlike their usual character that might be that they need something right away. You can hand them something, you know, without making you know, hey, you want this this juice pop that I have over here, you could see it, like this kids acting up. This is a good, quiet kid. They're- they're acting really weird right now. They're acting crazy. You know, they may need something faster, but you don't want to differentiate them from the other kids. So, but you could- you can hand something over to them. Hey, I got a pretzel for you, Steve, you know, and just- just hand them something. You know, make sure that that the parents have the opportunity to easily talk to the people that are in the classroom and that are in the food service area. You know, some schools make it easy. Some schools make it difficult. I've had a parent and a child that had Type One Diabetes and celiac disease. Almost 15% of the people with Type One Diabetes have celiac disease.


Oh, I didn't know that.


It's a very- it's, they're both autoimmune diseases. And, you know, they- she's having a huge difficulty. I mean, it was they were having special parties and things like that and they weren't having any- they weren't giving her a heads up, you know that they were going to have this. They were letting parents bring in like cupcakes or whatever have you. There was nothing there for her child because, you know, nobody knew what to do when nobody knows she tried to call ahead, nobody could give her information ahead of time. Her child was being left out of all different kinds of activities. You know, all different types of food-related events when they went on field trips, they didn't have the right kind of snacks but I mean it was like a big, big thing, you know, and they weren't making it easy for her. And the parent was trying. Sometimes, you get a parent that's not even trying. You know, what happens to that poor kid?


Right. Those are excellent tips. Yeah, I appreciate you coming on. Where can people find you online because obviously all we can do is kind of introduce the topic and give everyone ideas about how to get more information because this is going to be an ongoing educational project for all of us.

\Well, if they just wanted to reach out to me, they go to there's a contact button there. If you just Google me, I'm Google-able. I'm also on Instagram; marlisabrown8, Facebook under Dieting Dietitian.


You're everywhere. Perfect.


Well, not everywhere yet, but, somewhere.


Thank you so much for coming on. I really appreciate it.


Thank you for having me.


That was a fascinating episode. There is a lot of information there. I'm going to list all of the resources that were mentioned in the podcast in the show notes so you can visit or , to see those notes you just want to visit the podcast section. And it's all right there for you to make this simple. This is really a subject that requires effort to understand the understanding that we have the condition is always growing, which is certainly good thing. But in order to keep up we have to exert some effort. I personally find the condition fascinating and it is so common I find reading about it extremely useful because I'm constantly coming into contact with people who are newly diagnosed or just need support. Not always in the school setting. But this is really good information to have. If you got anything out of the episode, please be sure to share this with your friends and your coworkers, anyone that you think might benefit. The episodes are really easy to share. If you visit the website, you'll see the link there that connected to other places on social media and please give me some feedback if there are other topics that you would like to hear more about already.