Managing the Transition to Adulthood With Type 1 Diabetes Mellitus; An Interview With Robert Kritzler, MD, Pediatric Endocrinologist, and Deputy Chief Medical Officer, Johns Hopkins Health Care LLC

Published Online: March 13, 2014
An Interview With Robert Kritzler, MD, Pediatric Endocrinologist, and Deputy Chief Medical Officer, Johns Hopkins Health Care LLC; Interview by Stanton R. Mehr
Robert Kritzler, MD, wears 2 hats: He has been a practicing physician for more than 30 years; with a specialty in pediatric endocrinology, he has seen the rise of obesity and diabetes and its effects on the healthcare system. Today, as a leader in a health plan associated with a major academic institution, he is also part of the national conversation on how to control rising costs, as more patients gain access to the system under the Affordable Care Act.

Evidence-Based Diabetes Management: Have you observed progress in the community’s efforts to address diabetes mellitus in children as a public health problem? Robert Kritzler, MD: There has been some progress, but we need to break the progress down into type 1 and type 2 diabetes mellitus. Pediatric endocrinologists see more type 1 disease, and I think there’s been a lot of progress in terms of technology. As a clinician, many more of my young patients are using insulin pumps than in the past. Some of my patients are now using continuous glucose sensors (for continuous glucose monitoring, or CGM). As a managed care medical director, I can say that we’re seeing many more requests for insulin pumps and CGM monitors. That technology is changing how we treat the patient with type 1 disease. Alone, it is, however, not the whole answer. Our bigger concern right now is how we treat the many new young patients with type 2 diabetes, caused by the current epidemic of obesity in the community. We’ve seen a huge rise in the incidence of type 2 diabetes, particularly among teenagers. The obesity epidemic is throughout the United States, but it is hitting harder in the South, and Maryland’s numbers are rising. To an extent, community efforts have resulted in some progress, if not awareness. Clearly, First Lady Michelle Obama’s Let’s Move program has helped to address physical fitness and obesity, as have several other community-based programs. Overall, we’re still moving in the wrong direction with respect to type 2 diabetes.

EBDM: What is the missing element from these efforts? Is it a matter of coordination? Is it a real motivation and commitment to participate in these efforts? Dr Kritzler: You hit the nail on the head. For type 2 diabetes, tied to the obesity epidemic, there have been fits and starts—not one concerted effort. The effort needs to work down to things like school lunches, convenience foods, and fast foods, and work at the main reasons our population as a whole is gaining weight.

It’s seen by folks in the field, but not by the general public, as a public health emergency. I question whether all medical professionals consider it the public health emergency that it really is.

EBDM: What might it take to raise that level of alarm?
Dr Kritzler: It’s hard to say. The data are already there. We see today the increased incidence of type 2 diabetes in teenagers and young adults. The data on the long-term costs of diabetes to the system are also there. Beyond that my crystal ball is as cloudy as everyone else’s.

From my perspective as a managed care medical executive, we’re trying to conquer the cost of medical care by weeding out unnecessary high-tech imaging and focusing on how much we pay for each individual service, but we don’t pay enough attention to the major public health problem that’s right in front of us.

EBDM: You had mentioned the increased use of pumps and sensor devices for type 1 diabetes. What’s your view on our progress toward the artificial pancreas? Dr Kritzler: It’s interesting that you asked me that, because not a day goes by when I’m not asked by one of my patients whether the artificial pancreas is right around the corner. To some extent, the answer is no, although patients and their families desperately want this solution. Today, we have smart pumps that are hooked up to sensors. It even looks achievable with today’s computer technology.

What people don’t fully understand is that glucose regulation involves more than just injecting insulin. We have known for a very long time that glucose regulation involves many hormones beyond insulin. A true artificial pancreas would have to regulate, to some extent, many of those hormones. It’s a more complicated construct than people think. Trials are under way, mostly in Europe, testing multi-channel pumps.

Today’s smart insulin pumps connected with continuous glucose monitoring is a way station towards a more functional artificial pancreas. We’re making progress, but a true artificial pancreas, enabling something approaching more rational glucose control, is further away. I believe this will occur before we see everyday islet cell transplants or that sort of thing. That’s looking into my own crystal ball.

EBDM: And a true synthetic pancreas, constructed through some type of regenerative tissue engineering? How far away are we, realistically, from that? Dr Kritzler: We’re a long way from this. Some pretty good research is ongoing, but we’re not anywhere near clinical utility.

EBDM: Johns Hopkins is a major research institution. How involved is Hopkins in researching these types of new technologies? Dr Kritzler: Researchers from Johns Hopkins University and the University of Maryland are partners in the JHU-UMD Diabetes Research Center. It is headed by Dr Fredric Wondisford, an adult endocrinologist and metabolism physician. The Center is involved in a tremendous number of studies, probably way more than I know.

EBDM: Let me ask you to put on your managed care hat. I’d like to talk about young patients with type 2 diabetes or prediabetes and how they transition from adolescents to teens and young adults.
Dr Kritzler: Coordination is a challenge, not specifically for Hopkins, but in general. Patients with type 1 diabetes primarily receive their care through endocrinologists. Patients with type 2 disease receive their care through a combination of primary care doctors— pediatricians, family physicians, and adult internal medicine—and endocrinology consulting. Coordination can be a real issue. And at some point, teenagers have to transition from a pediatric care system to an adult care system. That’s an issue, even for those with type 1 diabetes, and it’s something the medical community doesn’t do as well as we should.

As with any other hand-off in health care you’re handing off between one provider to another or in some cases between one group of providers, primary care, endocrinologists, to a different group of providers. We all have different styles and different approaches. As a clinician, I tend to continue to see my patients with type 1 diabetes through their college years. These patients are undergoing life transitions at the same time. At some point, we have to transition these patients from pediatric to adult care. As with any other transition in medical care, it can be a challenge.

EBDM: What is the most difficult part? Dr Kritzler: It really has very little to do with the medical care system itself. Part of the real challenge is the transition from being an adolescent to being an adult. They’re undergoing numerous life transitions themselves, including from having a parent overseeing their care (particularly in type 1 disease), to having to oversee it themselves. They go to college, out into the workforce, and they move out of the parent’s home. Suddenly they’re adults, or at least the world calls them adults, and they have to take on more responsibility and accountability. For many of us in pediatric endocrinology, one of the things we try to do, particularly with our type 1 patients, is to be sure the transition to self-care begins well before the transition between pediatric medicine and adult medicine. I have many 11-, 12-, and 13-year olds who pretty much know how to run their own pumps and how to reprogram and how to change their basal levels, without a lot of input from their parents. But I also have 16-year-olds who can’t. That becomes a problem. With young type 2 patients, our first interventions are generally exercise and promotion of weight loss before we start medication therapy, and that’s also a question of taking adult responsibility for themselves.

EBDM: I can imagine this would be extremely challenging for a patient with type 1 disease who goes off to college. They’re exposed to an entirely new environment, new stresses, the same risks that face other teenagers, including excessive drinking, and different eating habits and eating options… Dr Kritzler: Yes, everybody talks about the “freshmen 15”—new freshmen who gain 15 pounds on dormitory food. This is a bigger problem if you’re already overweight and have prediabetes or diabetes: the freshman 15 can easily be the “freshmen 30.”

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