Dr. Stuart J. Brink

The answer is yes since each person can have individual response and/or side effects. You should have your daughter speak to her prescribing physician and review these symptoms as well as ask if there are other alternatives (usually possible) that may be considered with different hormone doses that would work better for her. Best of luck. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Type 1 diabetes is an autoimmune track on the pancreas, specifically the beta cells where insulin is produced. This stops automatically controlling the sugar levels when the beta cells can no longer make sufficient insulin and this causes the diabetes symptoms to show up. At the moment, controlling the sugar levels is difficult and involves getting insulin by injection, pens or mini-pumps multiple times each day based on what's eaten, activity, stress, infections and other hormonal factors. It's gotten more and moe semi-automatic with pumps and glucose sensors that communicate with the pumps. This makes type 1 diabetes somewhat different than type 2 diabetes because weight excess and older age are not key issues with type 1 but as younger kids are gaining excess eight around the world, we are also seeing type 2 diabetes increase dramatically in youngsters too. The most important factor is having excellent educational support from a multidisciplinary diabetes team with a diabetes specialist, nurse educator, dietician and sometimes social worker or psychologist as well and to make sure that there is developmentally appropriate education for the person with diabetes (PWD) as well as the parents and others in the family. As the PWD gets older and takes on more self-care responsibility, the education and support needs to continue so that weekend programs with peers an family as well as summer camp programs are extremely helpful. Website support programs like CWD (childenwithdiabetes) also are great for moms meeting other moms, dads meeting other dads, and for kids meeting other kids their own age to support each other. Deciding how best to administer insulin, what typeof meal plan works (and why), what to do with school staff, after-school staff, family members and peers all are very important aspects of diabetes care in type 1 diabetes. Adolescent and young adult issues also are important to be acknowledged and specific support for type 1 PWD needs to address those as well. College diabetes support groups also play an important role too. Best book for education, in my opinion, is Ragnar Hanas' Type 1 Diabetes (in its latest edition revision) which can be ordered at his website and ordered through most bookstores but there are lots of excellent education options that should be a big part of ongoing diabetes care. The new pumps and sensors, the newest insulins and attention to the education and psychosocial challenges for the PWD all come together to help achieve optimized glucose control for the PWD. Best wishes for reaching your goals. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

At the moment juvenile type 1 diabetes cannot be cured. However, modern treatments involve increased self blood glucose monitoring (SBGM) and automatic continuous glucose measurements (CGMS) as well as updated insulin preparations (faster rapid acting insulins to cover immediate meal and snack excursions as well as flatter, basal insulins to better cover between meals and overnight values) and newer, smaller and the beginnings of automatic closed loops pumps that communicate with the CGMS. More details of meal and snack planning also have become available as well as more attention to exercise/activity, stress and psychosocial issues and key importance of family and peer support for the pwd: person with diabetes. The most important issue for children and parents remains working closely with a diabetes care team of specialists, optimizing food, activity, education, support and monitoring/insulin delivery to get the closest A1c values to normal without producing increased hypoglycemia and also avoiding hyperglycemia. Time in range needs to be taught and optimized while minimizing time below range and time above range. Focusing on age-appropriate education for the PWd and also the family is critically important and a training book like Hanas' Type 1 Diabetes Manual is extremely helpful as are summer and weekend camp support programs. There are also some newer medications that may be able to address the root cause of type 1 diabetes which is an autoimmune attack, now better (but not completely understood) against the pancreatic islets where insulin is produced. Early clinical trials have been able to postpone the need for insulin but not yet completely and we do not know how long these effects really last. But medical science is focusing on this with good information becoming more and more available. If you are interested in such an approach then you should review the possibilities with your diabetes specialty team.

Overactive thyroid usually increases metabolism rate so there is usually unexplained weight loss not weight gain. If she takes anti-thyroid medication, the common starting treatment for hyperthyroidism and the dose is too high or for too long a time period, then the thyroid hyperactive changes to underactivity (hypothyroidism) and that can induce weight gain. Key is to have close endocrinology followup with periodic exam and lab testing to track thyroid hormone blood levels to guide treatment decisions.

Education, education, education about insulin treatment options (multiple injections, basal-bolus insulin option, insulin pumps) monitoring of blood glucose levels with blood glucose meters, continuous glucose monitoring, and integrated pumps and CGM to create hybrid closed loop insulin delivery automatically coupled with carbohydrate counting and nutritional education, exercise counseling, optimizing weight and monitoring for complications of the blood pressure, kidneys, eyes, nervous system and cardiovascular system (cholesterol checks) as well as checking for other autoimmune problems like thyroid disease, adrenal disease and celiac disease. Using motivational interviewing and educational approaches maximizes education efforts for the patient with diabetes (PWD) as well as family member and care providers (school nurses, coaches, teachers, scout leaders) etc. Periodic re-education is also needed with education materials such as Insulin Dependent Diabetes Mellitus by Ragnar Hanas, American Diabetes Association, Juvenile Diabetes Research Foundation and many others around the world. Optimizing glucose levels while minimizing hypoglycemia is also a key educational goal. Assistance and support from other parents and other PWD the same age is also very helpful and available on-line as well as in local groups as are weekend as well as summer diabetes camp programs. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Not quite enough information in your question to answer properly. Need to know something about what symptoms or abnormalities on exam were present that prompted the blood work for thyroid functions, exact results of the blood work for total T4, free T4, total T3, TSH levels and also for thyroid colloid and microsomal antibody results. Most common reason for hypothyroidism is a condition that is an autoimmune attack on the thyroid glands called Hashimoto's thyroiditis - so positive antibody results make this diagnosis if present. The thyroid gland can function normally but get enlarged, called a goiter. Sometimes there are cysts and sometimes there has been damage from chemotherapy or radiation therapy or even surgery; other times there are problems with the hypothalamus or pituitary thyroid controlling centers and this too can cause hypothyroidism. And in parts of the world where salt is not supplemented with iodine, iodine deficiency can interfere with thyroid function too. Some newborns are also born with abnormal thyroid glands for a variety of reasons but currently most states in USA do newborn blood screening and thyroid testing is included so this isn't missed as much as when there was no automatic screening done after birth. Once a proper specific diagnosis is made, then answering your question becomes easier and usually once hypothyroidism is diagnosed, thyroid hormone treatment with once-a-day pills is all that is needed. Some people need a little bit of T3 added to their T4 but most just need the thyroxine/levothyroxine once-a-day. The dose you described is actually 25 ugm not mg and this is a very small dose but depends on age and weight. Usually if there is hypothyroidism this is a permanent condition and doses need to be checked 3-4x/year during infancy, childhood and teenage years to adjust individual needs. Goal is to keep the total T4, free T4, total T3 and TSH levels all within normal limits for optimizing outcomes so followup blood work needs to be done 3-4x/year indefinitely to double check that doses are okay and/or any changes identified and treatment adjusted. Hope that gives you some information. The American Thyroid Association has some good information available on line too. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Weight gain without obvious extra calories or decrease in activity could be a sign of several hormone problems. Most common might be an underactive thyroid (hypothyroidism) and the most common cause is an autoimmune attack on the thyroid gland itself so that less main T4 and T3 hormone is produced and TSH, the controller from the pituitary gland is elevated. Often with an enlarged goiter but sometimes only a small enlargement so somewhat subtle. Testing for two thyroid antibodies as well as total and free T4 as well as TSH should be done to check this out. There also can be other sometimes subtle symptoms such as cold intolerance, constipation of less frequent bowel movements, tiredness/lethargy and changes in menstrual function in girls/women. Other hormone problems such as adrenal gland excess (or taking corticosteroids) can cause weight gain as can hypopituitary, hypothalamic problems with growth hormone or other hormones. Important to review with your GP or PCP and then usually would need physical exam and especially some hormone levels (like the 3 thyroid levels previously mentioned above). Other tests for cortisol, ACTH, GH, IGF-1 and perhaps testosterone, LH and FSH or estradiol with LH or FSH if teenagers. A blood count, chemistry profile and lipids might also be needed and maybe also a screening labs such as sedimentation rate or CRP for inflammation markers. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Male teenagers underweight need a full history and physical exam as well as some exploratory lab testing. Possibilities include overactive thyroid, underactive adrenal gland, hypopituitary problems as well as a long list of gastrointestinal problems such as celiac disease, Crohn's, ulcerative colitis and psychological difficulties including eating disorders. If here is something positive on detailed history or examination, that may provide some clues to pursue but first one needs current weight and height plotted

An overactive thyroid is associated with unplanned weight loss not weight gain and usually treated with thyroid blocking medications, radioactive iodine treatment to stop the overactivity of the thyroid system or thyroid surgery. If the hyperthyroidism is corrected and then changes to hypothyroidism because or radioiodine treatment or surgery, then weight gain associated with hypothyroidism can occur if appropriate thyroid hormone replacement is not prescribed or taken. Low carbohydrate (low carb or keto-diets) have shown success with weight excess especially when associated with insulin resistance conditions but not related at all to hyperthyroidism treatment. If there is weight gain and documented hyperthyroidism (not hypothyroidism), then thyroid blood levels should be checked to see if hypothyroidism has occurred and thereafter appropriately treated with replacement thyroid hormones. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Pale skin could indicate some type of anemia, most commonly iron deficiency but needs to be checked by your regular pediatrician or general physician. Redness of the skin is more complicated but a good history and exam by those docs would give some ideas to pursue and also get some lab testing to see if anything is amiss. Questions about sleep pattern, general fatigue, bowel functions etc also may provide some clues to pursue so call your primary physicians to get it checked out. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

Having a sweet tooth has nothing to do with having diabetes; just a common incorrect idea. Diabetes can be a familial pattern but usually this is for older-age, type 2 diabetes associated with excess body weight, high cholesterol, high blood pressure etc. But sometimes type 1 diabetes which is a type of autoimmune attack on the pancreas production of insulin can also be a family pattern along with thyroid problems, celiac disease. Symptoms of diabetes include unexplained weight loss, excess urination or overnight urination, fatigue as well as excess thirst. If you are concerned, then you should call and discuss with your pediatrician or primary care physician to get some lab tests checked out and some advice about food recommendations. Stuart Brink, MD Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC) c/o NEDEC, 196 Pleasant Street, Newton Centre MA 02459-1815, USA phone 1-781-572-4533, e-mail: stuartbrink@gmail.com

You ought to consult with your medical doctor and consider referral to an endocrinologist. There is a condition called Klinefelter Syndrome which may explain the gynecomastia and the lack of muscle development since it includes low testosterone production and can be easily corrected if identified. There are also other conditions that may cause low testosterone and higher estrogen levels such as exposure to certain plastic and other chemicals, soy sensitivity etc. and these and conditions affecting the hypothalamus and pituitary gland should also be considered. Some blood hormone levels, chemistry tests and genetic testing may explain what you are describing.
also should be evaluated.

Juvenile diabetes is the older medical term for what is usually called type 1 diabetes or insulin-dependent diabetes mellitus. Considered an autoimmune disease where the body attacks its own tissues, in this case, the beta cells of the pancreatic islands or islets. It is usually a
disorder that lasts for one's entire life but only if the blood sugar/glucose levels are well controlled. Longstanding out-of-control or high sugar levels cause damage to the blood vessels and especially those of the blood vessels of the eyes, kidneys and nervous system but also the
heart and brain and overall circulation.
Current research has suggested several possible "cures" for type 1 diabetes that would counter-attack the autoimmune attack or, if detected in its earliest stages, perhaps even prevent the autoimmune attack. One of these drugs is recently cleared by the US FDA for such use; long term effectiveness isn't yet known but looks promising. Several other avenues of research also have looked at common viruses associated with type 1 diabetes, protection in breast-fed infants as well as other types of immune protecting/blocking medications but these are still being evaluated.
The best way to better control high and low blood sugar levels in those with type 1 diabetes is with in-depth education of the person with diabetes and their family, frequent self blood glucose or continuous blood glucose monitoring and multidose insulin treatment programs - sometimes with insulin pumps in recent years connected to continuous BG monitoring systems and with automatic dosing possible. Excellent education books exist in multiple languages around the world. Two of my most favorite to recommend are the Pink Panther Diabetes manual by Peter Chase and David Maahs and the Type 1 Diabetes Manual written by Ragnar Hanas. Both are available from your local bookstores or on-line purchase. Your local diabes team may also have copies.
Stuart Brink, MD
Senior Endocrinologist, New England Diabetes & Endocrinology Center (NEDEC)

Not quite enough information provided to answer your specific question. Missing information would include actual height and weight plotted on a standard growth chart, specific height and weight of both parents as well as growth information about siblings, height and weight information about aunts, uncles and grandparents since that would give some "genetic" guidance as to what might be expected. Also, usually after a detailed past medical history, detailed review of systems and detailed physical exam,including Tanner staging now and previously, all these would then allow some possibilities to be considered. Conditions such as Noonan Syndrome, Turner Syndrome and other more rare genetic conditions that are associated with short stature and/or growth deceleration also should be considered with specific genetic testing ordered if there is some suspicion by history or exam or both. If nothing is obvious with that detailed patient and family review review by your primary care provider, then some nonspecific screening blood work and urine testing (urinalysis) is usually the next
step including complete blood count and sedimentation rate, transglutaminase celiac antibody test, thyroid tests (free T4 and TSH) and IGF-1 levels as well as general chemistry screening test (glucose, kidney tests BUN and creatinine, liver tests SGOT, SGPT, calcium, phosphate, albumin and electrolytes sodium, potassium, bicarbonate and chloride), Thyroid and celiac tests often do not have obvious clinical evidence but sometimes only decreased height velocity/short stature and concomitant excess weight for height.
The only other "screening" test would be a simple left hand xray bone age determination; when combined with the other items, this often leads one to more specific testing such as skull xrays of the pituitary region, brain CT or MRI studies etc. Consultation with a pediatric growth specialist, endocrinologiste, usually can help sort out these considerations and help decide if more specialized growth hormone or other hormone testing might be needed.

Difficult to answer succinctly. Complications from diabetes depends on short and long term control of blood sugar levels adjusting insulin doses, food, activity by blood glucose monitoring. Some genetic and familial issues that aren't so easy to assess. If glucose control is continued over many years, then complications can be minimized. Complications occur when years of high glucose levels damage vasctular system and produce retina blood vessel damage that can lead to blindness (retinopathy); kidney blood vessel damage which can lead to hypertension, protein leakage (albuminuria) and kidney malfunction/failure if the blood supply to kidneys is affected; cardiovascular problems like heart attack and stroke as well as circulation difficulties afffecting the feet and legs; and nerve damage that can produce loss of sensation or pain. All these directly correlate with overall glucose control and how well or poorly it is maintained. Many studies such as the DCCT document that improving glucose congrol minimizes or eliminates such severe complications (correlates witih average glucose levels obtained, less day-to-day variability and lower A1c levels. Cholesterol levels can also be impacted by glucose control. The best advice to prevent such problems is to work closely with a board certified pediatric endocrinologist with experience with type 1 diabetes, consider optimizing blood glucose monitoring and analysis with continuous glucose monitoirng systems and consider optimizing insulin delivery with insulin pumps connected to CGMS in what is now called hybrid closed loop systems which optimize and limit hyperglycemia at the same time as minimizing or avoiding hypoglycemia. And getting family/parental/patient support from organizations like childrenwithdiabetes (cwd), American Diabetes Association (ADA), Juvenile Diabetes Research Foundation (JDRF).

Best of luck.

It's a very common question and dilemma but, actually just requires someone to be a parent - and sometimes that means saying no or setting limits. Most importantly is to understand type 1 diabetes in younger kids. Best to be very educated and up-to-date on current management options and engage your child in a developmentally appropriate fashion. I've always used drawing and art to let kids express their ideas and even published some of this in Diabetes Forecast some years ago. Have also lectured on the topic and gotten fantastic audience participation from the doctors and nurses in the audience. If you haven't already seen them, get the Ragnar Hanas Type 1 Diabetes teaching manual and also the Chase/Maahs First Book for Understanding Diabetes pink panther teaching manual since both are
excellent, well written, and up-to-date on psychological and educational aspects of diabetes for parents and for kids as they get more of their own reading skills. You can order them from your local bookstore or online. CWD, children with diabetes, is an excellent online support group for kids and parents too. Life for a Child (LFAC) website has great lists of teaching booklets, some by Lilly and by NovoNordisk, that are written for different age groups with great advice, and pictures and are not only useful for the child with diabetes but also for their peers, teachers, etc. It will give you lots of ideas on how to approach such problems, alternatives to consider, strategies that work, etc. If there is a diabetes camping program operating or a group support system (parents and kids) these are also terrific. And, for sure, talk to your diabetes team to get their ideas about what concerns you, what they have available for support, and what the local situation is in your region. Best of luck and thanks for asking this important question.

You should review his diabetes needs directly with his diabetes team,
either doctor or nurse. There are extra risks when those with type 1
diabetes require general anesthesia and a lot depends on his overall
diabetes care, A1c results as to whether these are high or low risks. More
frequent glucose monitoring, ketone testing all will help since the
surgical risks themselves as well as the anesthesia risks re all able to be
minimized by increased monitoring - much as would be expected during a sick
day. Often there is need for more insulin based on his usual treatment
regimen. Important to know that you can always call your diabetes team for
specific advice depending on such increased monitoring since they will have
the expertise to assist with changing insulin needs according to results
too. If the surgical and anesthesia people involved have questions, they
too can directly contact your diabetologists as well and should be
encouraged to do so if needed.