Since the American Diabetes Association (ADA) published the Position Statement “Care of Children and Adolescents With Type 1 Diabetes” (1) in 2005, innovations have transformed the landscape and management of type 1 diabetes: novel autoantibodies, sophisticated devices for delivering insulin and measuring glucose, and diabetes registries. However, strategies to prevent or delay type 1 diabetes in youth remain elusive, and meanwhile the number of affected children continues to grow. The SEARCH for Diabetes in Youth (SEARCH) study found a 21.1% rise in the prevalence of type 1 diabetes from 2001 to 2009 in youth aged 0 through 19 years, with increases observed in all sex, age, and race/ethnic subgroups except those with the lowest prevalence (0–4 years old and American Indians) (2). Incidence has also increased; the adjusted risk for developing type 1 diabetes increased 1.4% annually between 2002 and 2012, with significant increases in all age-groups except those 0–4 years old (3).
One theme of this Position Statement is that “children are not little adults”—pediatric-onset diabetes is different from adult diabetes because of its distinct epidemiology, pathophysiology, developmental considerations, and response to therapy (4,5). Diabetes management for children must not be extrapolated from adult diabetes care. In caring for children and adolescents, clinicians need to be mindful of the child’s evolving developmental stages and must adapt care to the child’s needs and circumstances. Timely anticipatory guidance and care coordination will enable a seamless child/adolescent/young adult transition for both the developing patient and his or her family.
Although the ADA stopped developing new position statements in 2018 (6), this Position Statement was developed under the 2017 criteria (7) and provides recommendations for current standards of care for youth (children and adolescents) with type 1 diabetes. It is not intended to be an exhaustive compendium on all aspects of disease management, nor does it discuss type 2 diabetes in youth, which is the subject of an ADA Position Statement currently under review. While adult clinical trials produce robust evidence that has advanced care and improved outcomes (8), pediatric clinical trials remain scarce. Therefore, the majority of pediatric recommendations are not based on large, randomized clinical trials (evidence level A) but rely on supportive evidence from cohort/registry studies (B or C) or expert consensus/clinical experience (E) (Table 1). Please refer to the ADA’s “Standards of Medical Care in Diabetes” for updates to these recommendations (professional.diabetes.org/SOC).
It is well known that cigarette smoking is dangerous to one’s health and to the health of others. For some, using e-cigarettes or “vapes” has allowed them to reduce or quit the use of tobacco. I applaud those who have been able to quit smoking by using these devices. It is a step in the right direction. However, as a practicing emergency room physician, I still have some concerns about the safety of these devices. As a friend who vapes once directly, albeit somewhat inelegantly, put it, “Only a moron would believe that inhaling [stuff] into your lungs is totally harmless.”
For the sake of this article, I will use the general term ENDS (electronic nicotine delivery systems), though I acknowledge that not all e-liquids contain nicotine. This is not an attack on people who use the devices or even sell them, but simply an attempt to educate Americans on the possible risks associated with their use. For the record: I absolutely am not incentivized by any pharmaceutical companies, government agency, political organizations or anyone else.
The Royal College of Physicians published research in the Annals of Internal Medicine and actually encouraged the use of ENDS. That may be misleading, however, because the study didn’t show that vaporizers and e-cigarettes are safe, but rather that their use is safer than smoking tobacco cigarettes. It is encouraging to note, however, that they do not think vaping is a gateway to cigarette smoking. This is especially important because of the popularity of ENDS use among younger people.
All that the doctors who treated Cincinnati, Ohio resident Otto Warmbier knew is what they had seen or maybe read in the news. They knew he had just been released on June 13 from imprisonment in North Korea where he had been held by for more than 17 months. He had been sentenced in March 2016 to 15 years of hard labor for allegedly removing a propaganda poster from a wall at a Pyongyang hotel where he had been staying. The University of Virginia honors student had been visiting the authoritarian state during a five-day trip with a group called Young Pioneer Tours, which is a group out of China – an important note.
Otto Warmbier’s ordeal began on Jan. 2, 2016 when he was removed from a flight that was about to leave Pyongyang, the capital of North Korea, by two North Korean officials who explained that he was very sick and needed to go to a hospital. He was not sick and did not need to go to a hospital. He had just been arrested for allegedly trying to steal that poster.
Most of us have seen the video by now of Otto Warmbier in captivity from March 2016 – just a couple months after he was removed from the flight – he was alert and made a confessional statement in front of media cameras, where he pleaded for leniency and then broke down crying. In another video clip, we see him paraded before cameras being roughly escorted by two North Korean soldiers who had tight grips on each of his arms, his head bowed, his feet shuffling.
Then came the news well over a year later that through various means of diplomacy, he was being released to go back home to Cincinnati, but that he was in a coma and had been for most of his time in captivity. The explanation from the North Koreans? He had contracted botulism and had taken a sleeping pill.
A report on e-cigarettes released at the end of last year by the US Surgeon General’s office shows a number of risks related to the popular product — particularly regarding young people — that should make them a lot less popular, but likely won’t. The act of “vaping” is often thought of as a safer alternative to smoking, but that’s not necessarily the case. Here are the dangers and potential dangers people should be paying attention to related to e-cigarettes:
E-cigs are at the center of one of the most contentious debates in public health. The availability and appeal of using e-cigs as an alternative to smoking cigarettes has been growing quickly over the years for both those who are new to smoking, as an introductory product, and to those who are trying to quit smoking, who see it as a more “healthful” way of trying to kick the smoking habit.
However, e-cigs don’t solve the nicotine problem at all. Yes, e-cigs eliminate tar, and yes, e-cigs eliminate the tobacco — both dangerous elements to one’s health. And that’s definitely good. But what they do not eliminate is the critical element of nicotine. Nicotine is one of the most highly addictive substances on earth. It’s presented in a liquid and then vaporized form in an e-cig; you inhale through the e-cig, and as you inhale, the nicotine and other substances in the liquid are atomized and absorbed into your lungs. The nicotine in an e-cig is a lot more concentrated and potent.
For those who have never smoked and who are interested in the experience, e-cigs are an entry-level product that have been promoted and marketed as being safe. They’re not. They may be “safer” than cigarettes, but that’s only by degree.