Dr. Tseghai Berhe MD
Endocronologist (Pediatric) | Pediatric Endocrinology
1555 BARRINGTON RD HOFFMAN ESTATES IL, 60169Rating
4/5
About
Dr. Tseghai Berhe is a pediatric endocrinologist practicing in HOFFMAN ESTATES, IL. Dr. Berhe specializes in growth, puberty, diabetes or other disorders related to hormones that produce certain conditions in children and growing young adults. Pediatric endocrinologists possess copious knowledge on hormone chemicals and how they can affect other parts of the body and their functions.
Education and Training
Spartan Health Sciences University, School of Medicine,Vieux Fort, Saint Lucia Medicine
Board Certification
DermatologyAmerican Board of DermatologyABD
Provider Details
Dr. Tseghai Berhe MD's Expert Contributions
My child was diagnosed with diabetes?
Diabetes is a common metabolic disease. It results from lack/insuficiency of insulin or inability to utilize its own insulin. Diabetes can be classified in to two major categories (type 1 or type 2). Most caucasian childeren have type 1 diabetes. Most adults have type 2 diabetes. However type 1 diabetes and type 2 diabetes can occur at any age. Your son may have either type 1 or type 2 diabetes. Diabetes is therefore a hormone disorder. Most hormone diorders are managed by specialists called Endocrinologists. In clinical practice Endocrinology is divided in to two major groups (adult and pediatric Endocrinology). Pediatric Endocrinologists mostly managed childhood hormonal disorders, such as, diabetes, Adrenals glands abnormalities, disorders in parathyroid and bone metabolism, pitiutary hormone disorders, thyroid diseases, growth disorders, disorders of pubery, obesity, menstrual disoders and much more. Pediatric Endocrinologists are pediatricians by training and sub-specialize in pediatric Endocrinology. They go through residency training for at leat 3 years to become pediatricians and go through another 3 or more years of fellowship training to become Pediatric Endocrinologists. Most Endocrinologists manage diabetic comfortably, though some are more passionate than others. Your son has diabetes. You need to know exactly what type of diabetes your son has (type 1 or type 2), becuase the initial treatment is different for each type of diabetes. For type 2 diabetes diet and exercise with or without oral medications may be suffice. While type 1 diabetes is managed with insulin promptly and properly. Healthy and balanced diet and structured regular physical activity of 1-2 hours per day, 5-6 days a week is important for any child regardless of diabetes. You should get a referal to see a Pediatric Endocrinologist without any delay. Good luck READ MORE
My son was diagnosed with thyroid issues?
Thyroid disorders: The thyroid gland is a small but a vital gland at the base of the neck, below the adams apple. It is responsible for energy production, metabolism, mood, growth and development. It also supports brain development and cardiovascular health. In children the the thyroid gland is at various sizes becuase children are going through a process of growth and development. In adults the thyroid gland measures about 4-6 cm . It weighs about 20 grams. If it gets larger, the thyroid gland, becomes a goiter. It may also develop a nodule or multiple nodules. The thyroid gland may be normal, under-active or over active. The thyroid gland produces three major hormones namely thyroxine (T4), triiodothyronine (T3), and calcitonine. If your thyroid gland does not make these hormones especially T3 and T4 you may develop a codition called hypothyroidism (low thyroid hormone) and when the thyroid makes excess of these hormones (over active thyroid) a codition called thyrotoxicosis or hyperthyroidism sets in. Calcitonin suppots bone health. In hypothyroidism (under active thyroid) the person may experience the symptoms of sadness, weight gain, poor energy level, dry skin, constipation, hair loss and fatigue. When the thyroid gland is over active, the person may experience, weight loss, fatigue, palpitations, heat intolerance, excessive sweating, irritability, frequent bowel movement and insomnia. The thyroid function test is a necessary blood test in the evaluation of the status of the the thyroid gland, in the production of the thyroid hormones. This test will determine whether the thyroid gland is working well or not. Based on the thyroid function test, further work up may be performed to pin point the cause of thyroid disorder (low or high thyroid hormone). The further work up may include blood work for iodine and various antibodies or imaging studies such as Ultrasound or uptake and scan of the thyroid gland. Thyroid function test is just a blood work to determine the working condition of the thyroid gland. The initial test may include the T3, T3RU, T4, and TSH or TSH, FT4 with or without FT3 depending on the situation. Most endocrinologist use FT4, TSH and or FT3 with or without the various thyroid autoantibodies. Depending on the results more work up may be necessary including Ultrasound and or scan of the thyroid gland. After your blood is drawn and processed or Ultrasound and/or scan of the thyroid gland is performed, the next step is to discuss about the results of the thyroid function test and or imaging studies with your doctor. If your thyroid is functioning properly, only watchful monitoring is advised. However if your thyroid hormone levels are abnormal, the cause of the thyroid abnormality should be evaluated properly. Once the cause is identified, treatment may be offered as indicated. If there is a goiter and the thyroid gland is functioning properly only a watchful waiting is recommended. But is there is a nodule/s then the size of the nodule and the condition of the nodule should be analysed. If the nodule is >1cm or if there are calcifications or other suspicious characteristics a fine needle aspiration biopsy should be performed to determine for malignancy. If there is malignancy the one side or both sides of the gland should be removed depending on the situation. If the nodules are benign watchful monitoring is recommended. Going back to your son; Your son has thyroid disorder. You need to see a pediatric endocrinologist for that. Your son could have underactive thyroid, over-active thyroid, agoiter or nodule/s. depending on his situation the doctor will decide the proper work ups and diagnostic steps. Once the diagnosis is established the doctor will determine the treatment modalities. These could be hormonal replacement or treatment with antithyroid agents or surgical intervation. It depends on his thyroid condition. You need to see your son's doctor and get a referal to see a pediatic endocrinologist. Good luck. READ MORE
Is a thyroid function test painful?
The thyroid function test: The thyroid gland is a small but a vital gland at the base of the neck, below the adams apple. It is responsible for energy production, metabolism, mood, growth and development. It also supports brain development and cardiovascular health. The thyroid gland produces three major hormones namely thyroxine (T4), triiodothyronine (T3), and calcitonine. If your thyroid gland does not make these hormones especially T3 and T4 you may develop a codition called hypothyroidism (low thyroid hormone) and when the thyroid makes excess of these hormones (over active thyroid) a codition called thyrotoxicosis or hyperthyroidism sets in. Calcitonin suppots bone health. In hypothyroidism (under active thyroid) the person may experience the symptoms of sadness, weight gain, poor energy level, dry skin, constipation, hair loss and fatigue. When the thyroid gland is over active, the person may experience, weight loss, fatigue, palpitations, heat intolerance, excessive sweating, irritability, frequent bowel movement and insomnia. The thyroid function test is a necessary blood test in the evaluation of the status of the the thyroid gland, in the production of the thyroid hormones. This test will determine whether the thyroid gland is working well or not. Based on the thyroid function test, further work up may be performed to pin point the cause of thyroid disorder (low or high thyroid hormone). The further work up may include blood work for iodine and various antibodies or imaging studies such as Ultrasound or uptake and scan of the thyroid gland. Thyroid function test is just a blood work to determine the working condition of the thyroid gland. The initial test may include the T3, T3RU, T4, and TSH or TSH, FT4 with or without FT3 depending on the situation. Most endocrinologist use FT4, TSH and or FT3 with or without the various thyroid autoantibodies. Depending on the results more work up may be necessary including Ultrasound and or scan of the thyroid gland. When performing thyroid function test you will go to your doctors office and will be sitted in a comfortable chair. A venipuncture or blood draw will be performed mostly from your upper arm. A rubber band will be tied around your upper arm to make the veins pop up. A needle will be inserted into the vein under your skin. You may feel a prick when the needle withdrawn and the rubber band around your arm is removed. A bandage will be placed on the puncture wound. After your blood is drawn and processed, the next step is to discuss about the results of the thyroid function test with your doctor. If your thyroid is functioning properly, only watchful monitoring is advised. However if your thyroid hormone levels are abnormal, the cause of the thyroid abnormality should be evaluated properly. Once the cause is identified, treatment may be offered as indicated. The thyroid test procedure is minimally invassive and normal routine activity should be resummed immediately after the procedure. The pain is very minimum. But if you have poor pain tolerance you can ask th lab technician to put nubming cream on the area of venopuncture about 30 minutes befor the procedure. If you have needle phobia you may consider 0.5 mg to 1mg alprazolam or lorazepam about 1-2 hour before the procedure in order to lower you level of anxiety. Some people may also have a tendency to faint when they see a blood draw. In those cases the person should lie down on a bench bed (table) before and after the procedure until he/she feels comfortable to get up. In summary, a venopuncture is minimmally invassive and not painful for the average person. Good Luck References; 1. https://medlineplus.gov/ency/article/003423.htm 2. https://phlebotomycoach.com/faqs/what-is-venipuncture 3. https://www.medicinenet.com/script/main/art.asp?articlekey=39466 4. https://www.niddk.nih.gov/health-information/diagnostic-tests/thyroid READ MORE
What can help low blood sugar levels?
Hypoglycemia (low blood sugars) Hypoglycemia is a metabolic state where blood sugars are below normal range. It is usually defined as blood sugar less than 70 mg/dl. In the first 48 hours after birth blood sugars >40 mg/dl may be normal. However after few days the average blood sugars should be maintained greater than 70 mg/dl. The average fasting bolld sugars are 70-100mg/dl. Fasting blood sugars above 100mg/dl is abnormal with people without the history of diabetes. Low blood sugars is defined as hypoglyceia, while high blood sugar is a sign of some form of diabetes. Both forms of blood sugars extremes have short term and long term consequences. The symptoms of low blood sugars are primarily due to the hormones invoved in correcting the low blood sugar. Adrenalin cuases most of the symptoms of the early signs and symptoms of hypoglycemia. Other hormones involved in the correction of the low blood sugars are glucagon, cortisol and growth hormone. Glucagon is involved in the immediate release of sugars from the glucose storages (mainly the liver). The symptoms of low blood sugars are mainly adrenergic (neurogenic) symptom. Nueroglycopenic symptoms may also occur in sever or prolonged hypoglycemia when the brain lack glucose. 1. Adrenergic (neurogenic or sympathoadrenal activation) symptoms result from activation of the adrenergic (sympathetic) nervous system, primarily mediated by adrenalin. Adrenergic symptoms include: -Shakiness -Nervous or anxious -Sweating -Clamminess -Irritability -Impatience -Palpitation -Confusion -Lightheaded -Dizzyiness -Hunger -Nausea -Fatigue -Skin pallor 2. Nueroglycopenic symptomes are secondary to shotage of sugar in the brain due to hypoglycemia. -Abnormal mentation -poor judgement -Irritability/rage -Crying -Emotional lability -Slurred speech -Stuper/loss of consciousness -Siezures -Coma -Death Hypoglycemia or low blood sugars have various causes. Theses causes include: A. In diabetic patients; Both type 1 and type 2 diabetic patients may experience symptoms of low blood sugars. Type 2 diabetetic patients can experience syptoms os low blood sugars is they are on medications primarily oral hypoglycemic agens such as glipizide and glyburide. This may happen when the dose of insulin is too much or they are not eating enough carbohydrates to mactch the amount of insulin taken. In type 1 diabetes low blood sugars are either due to excess insulin, eating less than usual amount of food or skipped meals or exercising more than usual. B. In none diabetic patients 1. Medications. Taking blood sugar lowering medications that are intended for a diabetic patient (sulfonylurease). There are also medications intended for a different condition but who have side effects of hypoglycemia. These medications may include medications for blood pressure, malaria etc. 3. Illnesses. These include; -Adrenal insufficiency -Celiac disease -Liver disease -Kidney disease 4. Ketotic hypoglycemia; This condition ocurs; -In some skinny people who have less glycogen reserve -During prolonged starvation -Eating disorder (anorexia nervosa) -Valley dancers -Gymnasts -People exercising excessively 5. Hormone deficiencies. -Adrenal insuficiency -Pituitary hormone deficiency (growth hormone or cortisol deficiency) 6.Hypoglycemia due to Reactive Hypoglycemia (post prandial hypoglycemia); -This hypoglycemia occurs several hours after eating a meal due more insulin production than the body needed. -In dumping syndrome 7. Hypoglycemia due to metabolic diorders; many metabolic disorderes such as; -Glycogen storage diseases -Fatty acid oxidation disorder -Aminoacid disorders (amino acidopathies) 8. Hypoglycemia due to Insulin overproduction. This could be due to; -Insulin producing tumors known as insulinomas (mostly in adults) -Genetic defects in the pancreatic Beta cell potassium channels, calcium chanels, and others (mostly start in infancy) -Enlarged beta cells of the pancreas known as nesidioblastosis (mostly in babies) Consequencies of hypoglycemia; Hypoglycemia of any cause should never be taken lightly. Blood sugars should be kept >70mg/dl at all times.Our brain depends primarily on normal glucose level. In the absence of normal glucose the brain will suffer more than any tissue in the human body. Early recognition of the signs and symptoms of low blood sugar and prompt treament is vital to preventing life threatening injuries.If hypoglycemia is not recognized and treated early and proptly, it can lead to seizures, falls, injuries, accidents and even death. Causes of hypoglycemia should be investigated properly and be treated promptly. Proper measures should be taken to prevent the ocurrence of hypoglycemia if the cause can not be fixed. Going back to your daughter: Your daughter is experiencing low blood sugars. She is probably experiencing the full range of the signs and symptoms of hypoglycemia. There are many causes of low blood sugars. If your daughter has diabetes and she is on either oral anti-diabetes medications or on some form of insulin regimen, the medications should be adjusted or the amount of food consumed should match the amount of insulin taken at each meal. If she is excerscing excessively, insulin should be lowere appropraitely or apropraite amount of food should be consumed to prevent the occurence of hypoglycemia. If your daughter has no diabetes, the causes of hypoglycemia should be investigated thoroughly. Once the cause/causes are identified treatment plan should be hammered out. The best option in preventing hypoglycemia should be eliminating the cause of the hypoglycemia completely. If eliminating the cause is not possible, reasonable treatment plan should be worked out to keep the blood sugars >70mg/dl at all times to prevent acute and chronic complications of hypoglycemia. If your daughter is experiencing the signs and syptoms of low blood sugar, the first step is to check her blood sugars (using home self monitoring blood glucose machine) to make sure she really have low blood sugars and not other medical or hormonal conditions. If the syptoms are due to low blood sugars you should give her sugar drinks to keep the blood sugars >70mg/dl at all time using fast acting sugars such as juice or milk. You should seek help from your daughter's primary care doctor first. He/She will perform proper evaluation and will determine if you need to see an endocrinologist for further evaluation and treatment of the hypoglycemia. If your daughter is experiencing the signs and syptoms of hypoglycemia, whether she truly have low blood sugars or other medical problems, she needs proper and prompt evaluation by her primary care doctor who will determine the next appropraite steps. Ignoring signs and symptoms of low blood sugars with or without the actual low blood sugar will be a mistake. Good Luck further reading references; 1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2991551/ 2.https://emedicine.medscape.com/article/122122-clinical 3.https://www.lifeextension.com/Protocols/Metabolic-Health/Hypoglycemia/Page-04 4.https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/diabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism/hypoglycemia 5.https://www.healthline.com/health/hypoglycemia READ MORE
Can kids be diagnosed with diabetes?
Diabetes in children: Diabetes is a common metabolic disease in America. Almost 10% (over 33 million) of the American population has diabetes. Over 90% have type 2 diabetes and the rest (10% or 1.30 million) have type 1 diabetes. There are also about 84 million prediabetics in America. Childhood diabetes (children <19 yearsold) make up a small fraction of over all diabetes. Currently, about 300,000 (0.30%) children have diabetes (type 1 and type 2) in the USA. About 220,00 or 85% of childhood diabetes is type 1 diabetes and 15-20% (55,000) have type 2 diabetes. There are about 20,000 new onset type 1 diabetes and about 5,000-6,000 new onset type 2 diabetes children every year in the USA. Childhood type 1 diabetes can occur at any age, though it is more prevalent in the adolescent age group. Type 1 diabetes is more common in the caucasian population than any ethnic group. The diabetes susceptibility genes are more clastered on this ethnic population. Type 1 diabetes is an autoimmune destruction of the insulin producing beta cells of the pancreas. Currently insulin is the only available treatment for type 1 diabetes. Type 2 diabetes is more common in the minority population. Type 2 diabetes can occur in young children as young as 5 years old. Before the 1990s type 2 diabetes in children was unheard. Childhood type 2 diabetes was about 3% of the diabetes in children though in adults it was over 90%. In the last 30 years type 2 diabetes in children has been catching up to about 15%, mainly due to the epidemic and/ or pandemic of obesity and metabolic sydrome. In native American children most of the childhood diabetes is type 2 diabetes. Childhood diabetes in the African American population still 60% is type 2 diabetes and the rest is type 1 diabetes. In the Hispanic population type 2 is catching up to the level of type 1 diabetes. In the Caucasian population (children) type 1 diabetes is the highest, though type 2 diabetes is increasing, but also type 1 is increasing more than type 2. In the Caucasian population type 1 is increasing at a rate of 1.2 % while type 2 is increasing at a rate of less than 1 % (0.6%) annually ( both of them are increasing). In minorities, the African American, Hispanics, Native Americans and Asian Americans type 2 diabetes is increasing at a higher rate (6.3%, 3.1%, 9%, 8.5%, respectively) than type 1 diabetes in children though both of these diabetes are on the rise. It is predicted that both types of diabetes will continue to increase in the future. Childhood type 2 diabetes will continue to increase until obesity rate stabilizes in the future. In some centers type 2 diabetes is the most encountered diabetes in children. Type 2 diabetes is mainly driven by over weight and obesity, though strong family history and genetic susceptibity, gender and ethnicity also play a major role. With the epidemics of childhood overweight and obesity, type 2 diabetes in children is being encountered in children as young as 5years old. Because diabetes is starting much earlier and will have longer duration it will expose them to complications of diabetes at an early age and may cause shortens their life expectancy by as much as 20 years. In average type 2 diabetes takes about 5-10 years to evolve (to have full blown symptoms of diabetes) in most cases. Over 50% of children with type 2 diabetes will have no symptom during diagnosis. Therefore many children with diabetes are not diagnosed at the right time. Initially the person will develop a state of prediabetes before developing type 2 diabetes. Even the prediabetes state will have metabolic insult similar to diabetes. Therefore type 2 diabetes in children has a greater risk for future complications. The first line of treatment in children with type 2 diabetes is healthy diet, regular structured daily exercise and modest weight loss (maintaining close to ideal weight). medications may be added as indicated, mainly metformin. Going back to your son: Yes, diabetes can develope at a youg age. Type 1 diabetes can occur at any age age though it is more common during adolescent age. Type 2 diabetes can develop at a young age, as young as 5 years old. And in some circumstances even at younger age. Obesity (insulin resistance) is the primary driving force in childhood type 2 diabetes.Overweight children from minority ethnic groups who have genetic susceptibility and a strong family history are at a higher risk for type 2 diabetes. If there is a family history and a genetic susceptibility a little weight gain may be sufficient enough for type 2 diabetes. Sometime you can have type 2 diabetes with reasonable weight. So there are many factors in to making type 2 diabetes. However weigh gain plays a bigger role in the development of type 2 diabetes.. You need to make sure your son loses weight through healthy balance diet and regular/structured daily physical activity. He needs to maintain a healthy, safe weight to avoid developing diabetes. You should see a good nutritionist for dietary counseling. You can also follow the my plate method of the USAD recommendation for healthy nutrition. Good luck. READ MORE
Can young people be diagnosed with diabetes?
Diabetes in children: Diabetes is a common metabolic disease in America. Almost 10% (over 33 million) of the American population has diabetes. Over 90% have type 2 diabetes and the rest (10% or 1.30 million) have type 1 diabetes. There are also about 84 million prediabetics in America. Childhood diabetes (children <19 yearsold) make up a small fraction of over all diabetes. Currently, about 300,000 (0.30%) children have diabetes (type 1 and type 2) in the USA. About 220,00 or 85% of childhood diabetes is type 1 diabetes and 15-20% (55,000) have type 2 diabetes. There are about 20,000 new onset type 1 diabetes and about 5,000-6,000 new onset type 2 diabetes children every year in the USA. Childhood type 1 diabetes can occur at any age, though it is more prevalent in the adolescent age group. Type 1 diabetes is more common in the caucasian population than any ethnic group. The diabetes susceptibility genes are more clastered on this ethnic population. Type 1 diabetes is an autoimmune destruction of the insulin producing beta cells of the pancreas. Currently insulin is the only available treatment for type 1 diabetes. Type 2 diabetes is more common in the minority population. Type 2 diabetes can occur in young children as young as 5 years old. Before the 1990s type 2 diabetes in children was unheard. Childhood type 2 diabetes was about 3% of the diabetes in children though in adults it was over 90%. In the last 30 years type 2 diabetes in children has been catching up to about 15%, mainly due to the epidemic and/ or pandemic of obesity and metabolic sydrome. In native American children most of the childhood diabetes is type 2 diabetes. Childhood diabetes in the African American population still 60% is type 2 diabetes and the rest is type 1 diabetes. In the Hispanic population type 2 is catching up to the level of type 1 diabetes. In the Caucasian population (children) type 1 diabetes is the highest, though type 2 diabetes is increasing, but also type 1 is increasing more than type 2. In the Caucasian population type 1 is increasing at a rate of 1.2 % while type 2 is increasing at a rate of less than 1 % (0.6%) annually ( both of them are increasing). In minorities, the African American, Hispanics, Native Americans and Asian Americans type 2 diabetes is increasing at a higher rate (6.3%, 3.1%, 9%, 8.5%, respectively) than type 1 diabetes in children though both of these diabetes are on the rise. It is predicted that both types of diabetes will continue to increase in the future. Childhood type 2 diabetes will continue to increase until obesity rate stabilizes in the future. In some centers type 2 diabetes is the most encountered diabetes in children. Type 2 diabetes is mainly driven by over weight and obesity, though strong family history and genetic susceptibity, gender and ethnicity also play a major role. With the epidemics of childhood overweight and obesity, type 2 diabetes in children is being encountered in children as young as 5years old. Because diabetes is starting much earlier and will have longer duration it will expose them to complications of diabetes at an early age and may cause shortens their life expectancy by as much as 20 years. In average type 2 diabetes takes about 5-10 years to evolve (to have full blown symptoms of diabetes) in most cases. Over 50% of children with type 2 diabetes will have no symptom during diagnosis. Therefore many children with diabetes are not diagnosed at the right time. Initially the person will develop a state of prediabetes before developing type 2 diabetes. Even the prediabetes state will have metabolic insult similar to diabetes. Therefore type 2 diabetes in children has a greater risk for future complications. The first line of treatment in children with type 2 diabetes is healthy diet, regular structured daily exercise and modest weight loss (maintaining close to ideal weight). medications may be added as indicated, mainly metformin. Going back to your niece: Yes, diabetes can develope at a youg age. Type 1 diabetes can occur at any age age though it is more common during adolescent age. Type 2 diabetes can develop at a young age, as young as 5 years old. And in some circumstances even at younger age. Obesity (insulin resistance) is the primary driving force in childhood type 2 diabetes.Overweight children from minority ethnic groups who have genetic susceptibility and a strong family history are at a higher risk for type 2 diabetes. If there is a family history and a genetic susceptibility a little weight gain may be sufficient enough for type 2 diabetes. Sometime you can have type 2 diabetes with reasonable weight. So there are many factors in to making type 2 diabetes. However weigh gain plays a bigger role in the development of type 2 diabetes.. You need to make sure your niece loses weight through healthy balance diet and regular/structured daily physical activity. she needs to maintain a healthy, safe weight to avoid developing diabetes. She should see a good nutritionist for dietary counseling. You can also follow the my plate method of the USAD recommendation for healthy nutrition. She needs to participate in daily moderate to vigorous physical activity for at least an hour a day for at least 6 days a week. She needs to discuss these issues with her doctor in detail with an open mind. Good luck. READ MORE
How do Type 1 and Type 2 diabetes differ?
The difference between type 1 and type 2 diabetes: Diabetes is a common metabolic disease in America. Almost 10% (over 33 million) of the American population has diabetes. There are various forms of diabetes mellitus. The commonest ones are type 2 (90%), type 1 (5-10%) and Gestational diabetes (2-10%). Gestational diabetes occures during the 2nd or 3rd trimester of pregnancy and generally resolves after delivery. Some gestational diabetes may progress to type 2 diabetes. Over 31 million (90%) have type 2 diabetes and the rest (10% or 1.30 million) have type 1 diabetes. There are also over 84 million prediabetics in America. Most of these prediabetic may continue to develope type 2 diabetes in the future. There are about 1.3 million Americans with type 1 diabetes. Out of these 220,000 are children with type 1 diabetes. Over 50,000 children have type 2 diabetes in the USA. The average incidence of type 2 diabetes in the USA is about 1.5 million adult and 6,000 children persons per year. While the incidence rate of type 1 diabetes is about 40,000 adults and 17,000-20,000 children a years. There are about 5,000-6,000 chidren with new onset type 2 diagnosis. Type 1 and type 2 diabetes affect affect both adults and children. But there is more type 1diabetes than type 2 diabetes in children. While the vast majority of adults have type 2 diabetes mellitus. There are some differences and similarities between type 1 and type 2 diabetes. Type 1 diabetes: 1) Type 1 diabetes is an autoimmune destruction of the insulin producing beta cells of the pancreas. 2) Currently insulin is the only available treatment for type 1 diabetes. 3) Mostly diagnosed in childhood 4) It is not relatred to weight 5) Episods of low blood sugars are more common. 6) Prone to ketoacidosis. 7) Islet or be4ta cell antibodies are present. 8) they produce very little or no insulin. 9) It is less prevalent (0.4%) 10) Identical twin concordance rate is about 20-50%. 11) Usally thin or normal weight. 12) The onset of type type 1 is sudden. it happens in days to weeks. 13) Can not be prevented. Can only be treated with insulin. 14) Glycemic control is mostly brittle with wide flactuations between low and high blood sugars. 15) Risk of diabetes to off springs or siblings is about 4-10%). It is more common in the caucassian population who have more of the susceptibility genes. Type 2 diabetes: 1) Mostly related to weight gain and insulin resistance 2) Can be managed with diet and excercise or oral medications. Insulin will be required if the disease advances. 3) Mostly diagnosed in adults and old age. 4) Episods of low blood sugars are less often. 5) Ketoacidosis is less common. 6) Not an autoimmune process. Auto-Antibodies are mostly negative. 7) They generally produce high or normal insulin (c-peptide). 8) It is more prevalent (10% of the population). 9) Identical twin concordance rate is >90% 10) Generally over weight. 11) Onset is gradual. It may take up to 10 years to evolve. 12) Can be prevented with life stype changed, diet and excercise. 13) There is less brttle blood glucose control. 14) Risk of diabetes to off springs or siblings is about 80%. 15) Type 2 diabetes hits harder the minority population than the caucassian population. Simillarities between type 1 and type 2 diabetes: 1) They share similar symptoms such as polyuria, polydypsia, nocturia, fatigue, high blood sugars,difficulty breathing, fruity smell of breath, nausea and vomiting a dry mouth etc before treatment or if diabetes is poorly controlled. 2). They share simillar Chronic complications of diabetes such as eye, kidney, nerve dieseases, autonomic dysfunction (microvascular complications) and heart disease and stroke (macrovascular complications). 3) they share simillar acute complications such as the symptoms on high blood sugars, the Diabetes ketoacidosis and the symptoms of hypoglycemia. 4) when the disease progresses type 2 diabetic patients may require insulin the same way that the type 1 diabetic patients. Diabetes is a metabolic disorder due to insulin deficiency or insulin resistance or pancreatic beta cell dysfunction. It is classified in to two major categories (type 1 and type 2) based on the characteristics and natural history of the metabolic derangement. There is a huge difference between the two types of diabetes, and, at the same time there are many similarities especially in the symptoms and the final process of the disease. Since obesity is on the rise, some type 1 diabetes patients may be overweight as well. They may not respond to oral medications. In these cases it may be difficult to differentiate between the two types of diabetes. Insulin (c-peptide) and antibodies should be checked. If antibodies are negative and c-peptide is normal or high, they may have type 2 diabetes.If positive pancreatic antibodies and low c-peptide, they should be tried on insulin and oral medications. If the patient is truly type 2 diabetic insulin can be weaned off slowly. If they are over weight with type 1 diabetes withdrawing insulin will make blood sugars worse. Please discuss these issues with your doctor and diabetes educatores if you have diabetes. Good Luck. READ MORE
Is it normal to gain weight while on an insulin pump?
Side effects of insulin: Insulin is a vital peptide hormone that controls blood sugars. When there is lack or absence of insulin a metabolic state known as diabetes takes place. Patients with type 1 diabetes have an absolute need for insulin not only to control blood sugars but also for survival. When insulin is deficient the body can not utilize its own glucose. When blood sugars are elevated >180mg/dl, they spill in to the urine (glycosuria) Currently insulin is the only therapy for type 1 diabetes. All insulin treatment modalities can control blood sugars to a reasonable degree but can not mimic pancreatic insulin, because insulin is mainly given under the skin and is different in time, dose and place than the way the pancreas delivers insulin. Since insulin is given in the wrong place at the wrong time and in the wrong dose (that is under the skin) it is common to see high and low blood sugars in patients with type 1 diabetics on regular basis. There is no perfect blood sugars when some one is using insulin under the skin regardless of the mode of insulin delivery. Before the diagnosis of diabetes or in poorly controlled diabetes the blood sugars are high and some of the blood sugars spill in to the urine. The kidneys are the major site of reabsorption of glucose so we do not lose calories. But when the blood sugars are above the kidney's reabsorption ability the remaining blood sugars is excreted in the urine. The kidneys reabsorb glucose if blood sugars are <180 mg/dl. The 180mg/dl is the maximum threshold of kidneys ability to reabsorb the blood sugars. When a persons blood sugar is 380 mg/dl, the kidneys reabsorb 180mg/dl and the remaining 200 mg/dl is excreted in the urine. Therefore when blood sugars are poorly controlled the kidneys will only reabsorb up to 180mg/dl assuming that person is well hydrated. The extra sugar that spills in the urine is extra calorie the body loses. In the long run poorly controlled diabetes or diabetes before diagnosis, the person can lose significant weight. When sufficient amount of insulin is given or diabetes is well controlled the kidneys stop spilling glucose and weight gain is common in the beginning. Once blood sugars are stable weight gain should not be an issue. This is also true with new onset type 1 diabetics. They lose weight before diagnosis and gain back the weight they lost in 2-3 months there after they will not have an issue with weight gain unless they are experiencing many low blood sugars and are eating more to correct the blood sugars or if they are defensively eating more to to prevent low blood sugars. Patients on insulin pump are generally better controlled than the patients on injection. They may gain more weight until the blood sugars are stable. They may also experience more low blood sugars and they may be eating more to correct the low blood sugars. It is also possible some patients may eat more defensively to prevent low blood sugars. when extra calories are consumed for various reasons weight gain should be expected. There are 4 different ways why some one on insulin therapy may gain extra weight: 1) When blood sugars are well controlled. If a poorly controlled person gets better control or when a new onset diabetes person starts insulin therapy, the kidneys spilling glucose in the urine stops. That may cause initial weight gain since the calories are no longer wasted in the urine. But eventually the weight gain should stop as blood sugars become stable, unless the person is eating more calories for various reasons. 2) Frequent hypoglycemia. When low blood sugars occur more frequnetly, more calories are consumed to correct the low blood sugars. This will cause excess calorie intake than what the body needs for normal growth. Weight gain is therefore common, if there are frequent low blood sugars reguirng frequent consuption of carbohydrates. 3) Defensive eating to prevent hypoglycemia: Many patients with type 1 diabetes fear of low blood sugars. Since they may have bad prior experience with the symptoms of low blood sugars they may defensively eat more snacks to prevent low blood sugars. This excess injestion of carbohydrates eaten defensively to prevent hypoglycemia may lead to extra weight gain. 4) Life style that promote more processed food consumption and sedentary life style: The general population is getting over weight. Children are also gaing more weight due to excess calorie consumption and lack of regular physical activity. Over 30% of children are over weight. Type 1 diabetics are not an exception. They follow the obesity trend of thier none diabetic counter parts in the general population. Regular planned moderate to vigorous physical activity and healthy balanced diet are vital to maintaining an ideal weight. Prevention of Weight Gain: To prevent weight gain the following step can be taken as applicable. 1) Prevent frequent low blood sugars from occuring. Understand your nutritional requirements to only gain appropraite weght. Adjust your insulin and carbohydrate requirents to prevent low blood sugars and to avoid etra weight gain. Discuss your dietary and blood sugars goals with your nutritionist and diasbtetes educators. 2) Do not over correct low blood sugars. When blood sugars are low only it the amount of carbs that will correct the low bloood sugars. Consuming excess calories will lead to extra weight gain. 3) Avoid defensive eating to prevent low blood sugars. If eating excess carbohydrates defensively to avoid low blood sugars is done habitually, it will eventually lead to extra weight gain . 4) Do not skip meals: Skipping meals is not a good practice. Especially skiping breakfast is not a good idea. People that skip a meal tend to eat more in thier next meal. This will eventually lead to extra weight gain. 5) Excercise regularly: Reglar physical activity is recommendaded for all able children. Atleast 1 hour of moderate or vigerous physical activity is recommended for healthy cardiovascular system. Performing the recommended physical activity will also help maintain ideal weight. Diabetic patients should avoid sedentary life style and perform the recommended sports activity routinely. Going back to your daughter: Your daughter is gaining excessive weight after starting insulin pump. Insulin pump can lead to a better glycemic control. When blood sugars are better controlled little glucose spills in the urine. This may lead to some weight gain in the begining. However when blood sugars are well mantained the weight gain should not be an issue. On the other hand gaining 10 pounds in a short time is unusual, especially, if she is not newly diagnosed with type 1 diabetes. You should look in to other possibilities why she is gaining excessive weight in a short time. You may consider the following senarios. 1) She may be experiencing frequent low blood sugars that require frequent eating to correct the low blood sugars. The consuption of extra calories to correct low blood sugars can lead to etra weight gain. 2) The insulin program in the pump may have been set higher than what the body needs. That is she may be getting more insulin than what she needs. If insulin is set higher in the pump, more carbohydrates will be consumed to minimize hypoglycemia. This can lead to extra weight gain. The insulin infusion pump basal, bolus and correction programs should be adjusted to prevent unnecessary hypoglycemia and extra carb consumption. 3) Defensive eating (snaching) to prevent hypoglycemia (low blood sugars): If she may be eating more carbohydrates as a defence against hypoglycemia from happening, she may be consuming more calories that may lead to extra weight gain. Defensive eating should be discouraged if possible. 4) Overcorrecting low blood sugars: Low blood sugars should only be corrected to a safe or desired range with out over-correcting them. Over-correction means eating more carbohydrates. These extra calories will lead to extra weight gain. 5) Skipping meals: Skipping meals especially breakfast is not a good practice. When meals are skipped we tend to eat more in the next meal. This can lead extra weight gain. 6) Consumption of more calories like the rest of the population: Obesity is on the rise. 30- 40% of children are overweight. This is becuase we are eating highly processed fiberless foods and food products. Most of our diet is fortified with high fructose syrups. Try to look in to this issue seriously. Make sure she is eating healthier natural foods high in vegetables, whole gain and fruits with some high quality proteins in moderate portion. You can look in to the Myplate method dietary guide recommended by the USAD. 7) Sedentrary life style: This life style generally leads to excessive weight gain. Children should have a planned daily physical activity. The physical activity should be over an hour a day with moderate to vigorous sports activity in a safe environment under an adult supervision. Performing the recommended physical activity routinely will prevent extra weight gain protect the cardiovascular system. you should carefully consider the above senarios. There may be some other more causes of weight gain. You should discuss these essues with her nutritionis, diabetes educators and physician to figuire the cause of the excessive weight gain and get a solution to fix the problem. Gaining this much weight in a short time is not sustainable. The insulin or theinsulin pump is not a problem or the cause of any of this weight gain. Absolutely not. The problem is in the management of the diabetes. Focus on the management the diabets, dietary recomendations and physical activity. The pump is the best insulin delivery system available todate or until there is a cure for diabetes in the future. If the diabetes management is followed correctly weight gain should not be an issue. Please discuss these issues with your diabetes care team. Good Luck. READ MORE
Can type 1 diabetes affect my child's behavior?
Behavioral changes and type 1 diabetes: Type 1 diabetes is the commonest chronic metabolic disease of childhood. Currently roughly about 220,000 children live with type 1 diabetes in the United States of America. Up to this day there is no cure for type 1 diabetes, though, it is easily treatable with insulin, and when treated properly and aggressively quality of life and life expectancy may be close to that of a non diabetic person. However in poorly controlled diabetes chronic complications are common and quality of life as well as life expectancy is shorter by about 15-20 years. It is therefore important to take a note that poor glycemic control is the risk factor for chronic and acute complications of diabetes. Todate there is no commercially available oral insulin on the market. Insulin is only given either by injection, intraveneous or by inhalation. Insulin is not a dangerous or addictive medication. It will probably continue to stay this way untill other alternatives or cure is found. When diabetes treatment is intensified early enough chronic complications of diabetes can be avoided even when treatment was not optimum in later years due to epigenetic changes that promote protective condition known as a metabolic memory. Conversely, when treatment of diabetes is suboptimum in the early days of diabetes, even intensifying treatment in the later years may not prevent chronic complications of diabetes due to the same process (metabolic memory). The glycemic or metabolic memory therefore plays both roles of protection or predisposition to chronic complications of diabetes (eye, kidney, heart, cardiovascular diseases). Untill the day comes that cure type 1 diabetes, we will continue current insulin therapy. Currently there is a remarkable advancement in the treatment of type 1 diabetes. We have advanced tools to treat diabetes, including, smaller and sharper syringes, more sophisticated insulin brands, advanced blood sugar testers, various insulin infussion pumps and advanced blood glucose sensors. Despite these incredible advances in diabetes management only 20-30% of type 1 diabetes patinets meet the goal of A1C <7% in the United states of American and Europe. The majority of type 1 diabetes patients do not meet this goal and have poor glycemic controll. Any chronic disease including type 1 diabetes have psychological burden on the individual person with chronic disease. This psychological burden imposed by type 1 diabetes especially, when there is functional impairment in the face of poor social support and poor coping skills, is a sett up for mood disorders. Stress frome type 1 diabetes and other stressful events can manifest in two way. 1) internalization; Is when the stressful event is poited to wards the person him/her self. These are such as, depression anxiety, poor energy level, sleep disturbances anorexia, hyperphagia or suicide ideations. 2) Externalization is when the person poits his stress agains others. These are such as bullying, aggration to wards others, disobidience, cheating etc. Type 1 diabetics experience about 3 fold more psychosocial ilness, (mood swings) and mood disorders than their non diabetic counter parts. These are due to psychological and emotional burden imposed by diabetes, and events causing functional impairment such as hyperglycemia and hypoglycemia that are common in type 1 diabetes. 1) Hyperglycemia may cause depressed mood and mood swings. Hyperglycemia is defined when glucose levels rise above 110 mg/dL when fasting and 140 mg/dL 2 hours after meals. Hyperglycemia affects the area of the brain that controls mood and cognition (hippocampus). When blood sugar is high it affects the hippocampus and may lead to neuronal atrophy and apoptosis of the neuronal cells. This leads not only to mood swings but also to impaired cognitive function. Hyperglycemia (lack of insulin) causes hypercotisolism that can disrupt the nueronal generation of the hippocampus leading to depression and other mood disorders. When blood sugars are persistently high about 50% of people may have a depressed mood. Type 1 diabetic adolescents may have about 20% of depressed mood and about 25% may have subclinical depression. Over all transient mood swings or behavioral difficulties may be experienced by over 50% of type 1 diabetic patients. There are some signs that indicate a person may be experiencing high blood sugar levels, such as feeling nervous, fatigue, poor energy level, confusion, difficulty thinking clearly and quickly. When the blood sugars return to normal the symptoms will resolve. In type 1 diabetes cuases chronic stress and hyperglycemia from uncontrolled diabetes leads to excess cortisol production and prolonged sympathetic activation.These can promote insulin resistance, obesity high blood pressure and can lead to metabolic syndrome, also known as double diabetes. Chronic stress can also lead to type 2 diabetes through the same mechanism. These stress hormones that produce the fear (anxiety, anorexia or hyperphagia) and the reward system cause depression and cravings for food, other substances. Hyperglycemia can lead to behavoioural disturbance (mood swings), depression and anxiety. Diabetes is therefore a risk factor for depression and anxiety or other behavioral disturbances. It can also cause chronic microvascular (eye disease, kidney disease and nerve disease) and macrovascular complications complications (stroke, heart disease, peripheral vascular disease) through the recriutment of stress mediators (interlikins, and cytokines, oxidative stress and advanced glycated end products). Diabetes is therefore not only about blood sugars. It can lead to sudden mood changes. Cuases emotional burden affecting personal and social life of the person. It is a risk factor for depression, anxiety and other mood disorders. It can also lead to obesity, visceral adiposity, insulin resistance, metabolic syndrome and chronic complications throgh chronic stress and hyperglycemia. 2) Hypoglycemia (blood sugar levels drop below 70 mg/dl) can affect the mood and mental status of a person. The symptoms of low blood sugars include: Symptoms of hypoglycemia are as follows; Dizziness. Headache. Shakiness. Hunger. Irritability moodiness. sweating. Anxiety or nervousness. trouble speaking fatigue confusion pale skin aggression and irritability personality or behavior changes concentration difficulties co-ordination and decision-making difficulties twitching muscles seizure Low blood glucose can result in rapid mood changes. Depressed mood and irritability are common symptoms of hypoglycemia. during which blood sugar levels drop below 70 milligrams per deciliter (mg/dL). The body compounds this pleasant sensation by releasing adrenaline in an attempt to convert any available glycogen in the liver back into glucose to boost levels in the bloodstream." When blood sugars are low adrenalin surge drives the bodies defense system in to fight-or-flight mode. This stress response is mediated the activation of the pituitary adrenal axis and the sympathetic nervous system to produce adrenalin, catecholamine and cortisol to fight the danger and keep the person conscious and alive, and to correct the low blood sugar. When the blood sugars corrects the system is turned off since hypothalamis pitiutary adrenal axis and the sympathetic out put is strictly controlled. But if there is chronic hypoglycemia there may be persistent heightened response by the sympathetic nervous system and hypothalamic pitiutary system (HPS) leading to persistent mood swings. This contributes to mood swings, such as irritability, aggressiveness, depressed mood or elevated mood. When blood sugars fluctuate it is not uncommon to experience rapid changes in mood in a very short period of time. While symptoms of diabetes related stress may not be severe enough for a diagnose of as a mental illness, these symptoms can affect a person's social interaction and quality of life. On the other hand diabetes is a major risk factor in predicting major mood disorders such as Anxiety and depression. 3) Psychosocial issues. The psychological burden of type 1 diabetes causes persistent stress. The stress of living with diabetes contribute to both changes in mood and concerns about potential complications. The physical effects of diabetes may also lead to nervousness, anxiety, and confusion. The mood swings can be come suddenly and may last a short period of time. These changes may bring strains in personal life and social relationships or interactions. The psychological burden imposed due to type 1 diabetes could be related to concerns about potential complications. Some diabetics feel powerlessness in managing their diabetes. Some may feel can not do enough to take care of their diabetes. Some patients worry about what others think about them and shy away from their friends. Others worry about social embarrassment that they may not recognize when their blood sugars change suddenly. The symptoms of mood or behavioral changes are: depressed mood Low self-esteem Feeling inadequate Hopeless or helpless Excessive guilt Feelings of wanting to die Loss of interest in pleasure Difficulty with relationships lack of sleep or too much sleep. loss of appetite or or over eating weight loss or weight gain poor energy energy Difficulty concentrating poor decision making Suicidal ideation. Frequent physical complaints Running away or threats of running away from home Over sensitivity to failure or rejection Irritability Hostility Aggression Type 1 diabetes take a termendeous amount of energy and time to manage. Focusing on managing type 1 diabetes day in day out reguires a lot of effort. Type 1 diabetes is in the majority of cases is not well controlled. Most patients are not engaged enough with managing thier diabetes. On this planet almost every one is motivated to live healthy and long life. Diabetic patients have also the same wishes and aspirations in life. Howeve the job of diabetes is very tough. It is a tiresome work in progress that has no end in sight or any break in between. The life time job of managing typpe 1 diabetes has to also balance with the rest of the person's busy life. Some of the daily job of a diabetic patient are as follow; 1) Checking blood glucose several times a day. 2) Give appropraite amount of insulin several times a day. 3) Monitor carbohydrate in take closely. 4) Avoid and prevent low blood sugars. 5) Give correction for out of range blood sugars. 6) Perform apropraite ajustment of food and insulin during illness. 7) See your doctor, diabetes educators and dieticians on regular basis. 8) Eat healthy diet (more friuts and vegatables) and limit sweets and fats. 9) Exercise regularly. 10) Have eye exam regularly. 11) Follow a routine in managing your diabetes. 12) Balance your busy life with your diabetes. 13) Develope a coping mechanism againist diabetes fatigue and burn out. And the list goes on and on and the care is life time or untill there is a cure. It is obvious that living with diabetes is about trying to live and balance diabetes care in a very difficult situation. One can be reasonable but should not expect a perfect balance living with type 1 diabetes. Only people who have no diabetes think that diabetes is easy. When you have type 1 diabetes, your main focus that you have to absolutely make sure are: 1) Get a reasonable blood sugar. 2) Avoid life threatening low blood sugars. 3) Balance your busy life with your diabetes. Doing all these are not easy. One will need to have some compromise to do these things. This is a tough job and it can lead to fatigue and of course burn out. You feel lonely as you are limited by what you can and can not do by this disease. It is hard to fit in to the work of diabetes that you did not sign on in the first place. This job is 24 hours per day, seven days a week, and God knows until when?. However it is not all doom and gloom. Well controlled diabetes can lead to a healthy and long life. Mainly poor glycemic control is the risk factor for chronic and acute complication of diabetes. About 30% of type 1 diabetic patients have good glycemic controll. And it is time to learn and take some motivationt from them. Who are these people? 1) They are more engaged but not overwhelmed with thier diabetes. 2) They have good A1C <7%. 3) They have minimum hypoglycemic episods and less erratic blood sugars. The lesson to take from these people is that when motivated enough, one can be engaged to manage his/her diabetes like them. One should find that motivation to balance the diabetes with his/her busy schedule. There are few theories to why some people do well with diabetes and why the majority don't. It may be due to some differences in our biological, personality or psycological endowment. 1) Biological difference may be due to the way our body handles diabetes. They probably have a better form of diabetes. These people may have more islet cells left to add some insulin or they are biologically made to minimize low or high blood sugars. Some of these people may have a very prolonged haneymoon. 2) Personality difference. Some people are psychologically equipped to hand the tough job of type 1 diabetes. They may have good consciousness and have problem focus approach. They have problem focused coping mechanism. They are great problem solvers. 3) Psycholgical discoveries. These are people who were not particularly doing well but started to pay attention to thier diabetes. They become more engaged with their diabetes and are motivated but not overwhelmed. Something click in them and are able to find a a good balance managing their diabetes and thier busy life. They enter in to this self discovery and are doing things right in a reasonable way Diabetes managemenet rotates principaly around three major issues. 1) medical team 2) Diabetes management 3) Psychological factors. 1) The medical world (medical team) is composed of the nurse, diabetes educators, endocrinologist, social worker, and psychologist. The medical team usually measures your physical health (fitnes). Under stress physical health can also lead to physical complaints such as neck pain back pain, headaches etc. It can also associated with psycholgical issues, including anxiety, depression and mood swings. 2) Diabetes Management includes; These measures how you behave in taking your diabetes. This the easiest to measure using the following things. Carbohydrate counting Insulin injections Blood sugar testing Eating healthy diet structured excercise regimen and other routins of diabetes. These measure how often and how much of the above you do or you don't do. This is your behavioral pattern arround your diabetes. Some people test many times a day some test thier blood sugars less often. Some strive for perfection some wanted to get by (adequate). Some would give up and do noting. Perfection is not attainable nor necessary. Even in a good day and you every thing right you may not get a perfect blood sugars. There are external factors that can affect the blood sugars regardless of how much effort you put in.The ideation of perfect blood sugars is not really achievable. 3) Psychological factores; This reflects our fleelings and attitudes about our diabetes. We have internal and external factors. The external factors are those we can not controll. There may be days that we do every thing right and we end up with poor glucose controll. Internal factors are those things that we internaliz, such as stress, anxiety, depression, motivation, confidence, mood swings, fatigue and burn out. These issues are hard to measure. When the medical side, management and psychological realm fail, we may react in many ways. 1) Some may be motivated to change. One may test blood sugars more often, count carbohydrates correctly, give appropraite amount of insulin both for food and correction of high blood sugars, excercise more and eat healthy diet. They may find some courrage to change thier sitiuation for better diabetes control. 2) Others may not change. They will just continue their routine 3) Others will experience burn out. They get so stressed and overwhelmed and get into depression anxiety or mood disterbances. It can be short term or long term. Long term burn out needs proffessional help. Burnout could be due to personal, interpersonal or environmental factors. Barriers to reasonable glycemic control; 1) Personal barriers may be due to bliefes of invincibility (complications will not happen to me. Mostly in young people) or negative attitude about diabetes. Others may fears experiencing high or low blood sugars. These can create barriers to thier diabetes management. 2) Interpersonal Barriers: Stress arrising from family, friends, spouce etc. If a person gets hammed all the time about his/her diabetes management, this can lead to burn out. Social sitiuations may also lead to burn out. Incting blood sugars in the school, restuarants, social area and social events. 3) Environmental Barriers: These includes expenses, availabilty of the various insulins and guadgets. Diabetes is expensive and every available technology is not available for every one. Copping with diabetes burn out: 1) exercise or some activity that you enjoy and makes you happy. 2) Take a little break but do not forget about your diabetes. Do not be negligent. 3) Stay posive. Do not see things as black and white. Blood glucose goals are challenging but possible. 4) Take even a small step. If you do not check your blood sugars try to check at least 1 or 2 times a day. Start somewhere. 5) Get back on track before things are worse; Do not forget about your diabetes. 6) Prepare for high or low blood sugars. 7) Take specific, realistic and achievable measures. Be realistic but not idealistic. There is no perfection in diabetes nor is it necessary. Understand that no insulin regiment will mimic the pancreas so perfection is a myth. 8) Realize that there is always hope that with good glycemic control HA1c <7% you can live a long healthy life with diabetes. 9) Do not do your diabetes alone. Get help and find out how you can access all the necessary resources. Your resources are; family members, friends, Peers,Diabetes comunity, social workers and psychologists; Utilize the ones that have positive impact on you. 10) Get motivation from other succesful diabetic people in various fields of life. One of our supreme court judges has type 1 diabetes since the age of 7 years. There are a lot of athlets engeers, scientists, lawyers, busnessmen and women, professors ETC with diabetes that are very succesful in life. Take a inspiration from them.You can do it too.Think positive. 11) Try to balance your diabetes with your busy life. You need to manage your time with your diabetes and daily life. 12) With positive attitude you should overcome the stigma of type 1 diabetes and mental health issues. Going back to your son: Your son has type 1 diabetes. Behavioral issue are very common with people with chronic medical conditions, especially type 1 diabetes. It is also common to have behavioral issues in adolescents without chronic medical prolems because they are going through hormonal and developmental changes. They are striving to assert thier autonomy. When you add diabetes to it, it gets even worse. Most of the behavioral diffuiculties are transient. But some can persist and may be come progrssively difficult to handle. Many type 1 diabetic patients patients have psychosocial issues. Some internalize it and other externalize it. When they internalize it they will experience depressed mood, anxiety, fatigue, sleep disturances, poor apetite or over eating. When they externalize it, they become aggresive, agitated, disobidient etc. When one is handed a diagnosis of type 1 diabetes he/she is given a tough job that does not have a break, it is hard to accept it. Type 1 diabetes is not an easy job. It reguires a lot of investment in time and energy. It is also metally exhausting. It is a job no one will sign on. It is unfortunate that life is not fare, and some people get it and others don't. When you don't have diabetes it is hard to understand it. For those who do not have it, it may seem so easy becuase they do not experience it. But there is nothing easy about type 1 diabetes. I have been doing this for many years and have seen many, many patients and honestly, it is very hard for me to understand it. Only about 20-30% type 1 diabetic have reasonable glycemic control. Over 70% are not controlled. That tells a lot about type 1 diabetes. It also imposes a huge psychological burden on the individual. This psychological burden leads to psychosocial disturbances as the stress from diabetes becomes overwheming. When there is inadeguate social support with poor copping skills, behavioral disturbances can emerge that can be manifested in many different way. Many of the type 1 diabetes are not only poorly controlled but also experience many of the psychosocial disturbances. At minimum type 1 diabetics need to think about thier glycemic control, prevent or treat low blood sugars and balance thier diabetes with thier normal life. Even doing these mimimum day in day out for a very long time with out a break is a very tough job that can overwhelm any human bieng. Many of the signs and symptoms of hyperglycemia and hypoglycemia can mimic psychosocial illness. One need to check the blood sugars to make sure these symptoms are not from blood sugar flactuations. Low and high blood sugars need to be treated promptly. Mood swings from hypoglycemia and hyperglycemia will go away after treatment. Most of them are transient. However if blood sugar flactuations are more prevalent they can lead not only to psychosocial illnesses, but also cognitive dysfunction. If your son is having serios difficulties in copping with diabetes, you should have him get a proffessional help. Psychosocial coucelling will boost his copping skills. Help your son get engaged with his diabetes, find some motivations and encouragment. Appriciate even when he takes little steps. Find him some positve hope that diabetes is not doom and gloom. That there are many bright futers in well controlled diabetes. Feed him with evidence based hope, that he will do well as others have done it. Regular physical activity will help him cope better with his situation. Focus also on healthy diet. Help him cope will social stigma. Inform his that diabetes is a medical condition but not a crime and there is nothing to be ashamed of having type 1 diabetes. Invove him in positive social group. Avoid over control and let him have some freedom. work as a team. Let him not do diabetes alone. He should not feel lonly. Check blood sugars as often as necessary, with out stressing him. Manage low or high blood sugars. With a posivive attitude he will do very well. Discuss this issues with your doctor and diabetes team. You can also seek help from a psychologist. What ever works for you do not hesitate to do it. Good luck. Further reading references: 1)https://www.cdc.gov/childrensmentalhealth/data.html 2)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863499/ 3)https://www.psychiatrictimes.com/child-adolescent-psychiatry/psychiatric-issues-children-and-adolescents-diabetes 4)https://www.medicalnewstoday.com/articles/317458.php 5)https://www.hindawi.com/journals/jdr/2018/1684175/tab1/ 5)https://care.diabetesjournals.org/content/32/4/575 READ MORE
Are there side effects of insulin therapy in children?
Insulin side effects: Type diabetes or insulin dependent diabetes is the most common encountered chronic metabolic disorder in children. There are about 210,000 out of 80 million children with type 1 diabetes in America (USA). The incidence rate of type 1 diabetes in children is about 17,000-20,000 per year. It is also worse noticing that the incidence rate of type 1 diabetes in children is increasing at about 3% per year. It is more common in the Caucasian population, who carry higher proportions of susceptibility genes. Type 1 diabetes is a chronic autoimmune destruction of the insulin producing cells of the pancreatic islet cells known as beta cells. The autoimmune destruction takes place in a genetically susceptible individual with the help of powerful environmental influencers (causing epigenetic changes). Environmental factor include viruses, toxins, food products and other pathogens. Once the chronic autoimmune process destroys about 85% of beta cells, type 1 diabetes and the symptoms of diabetes emerge. Un-treated type 1 diabetes will have a grave mortality and morbidy. Currently the only treatment for type 1 diabetes is insulin. Diabetic patients can be treated with insulin easily and safely. Insulin is not a dangerous or addictive drug. Insulin is the principal hormone that controls carbohydrate, proteins and fat metabolism of the body. Type 1 diabetic need insulin not only to control the blood sugars but also for survival. Before the discovery of insulin diabetes was treated with carbohydrate restriction or starvation therapy. In type 1 diabetics, starvation therapy was only effective for few weeks to few months as patients succumb to the illness quikly. Pre-insulin diabetes was a death sentence. When insulin was discovered in 1921 and tried in early 1922 on a dying young boy named Leonard Thompson in Canada, what was supposed to be a deadly disease, was transformed in to a disease with grave acute and chronic complications. After the discovery of insulin, tremendous advances took place, that transformed how diabetes is treated. Though there are still significant risk involved in the treatment of diabetes they are much lower than in the first 30 years after insulin discovery. Life expectancy is much longer than in the first 50 years after insulin was introduced. With good diabetes management life expectancy can be close to the normal population. Insulin is produced in the pancreas. It mediates the transport of sugars in to the cells to be consumed for energy. Insulin is also anabolic hormone where it is involved in protein and fat synthesis in the body. Insulin production is strictly controlled by the body so that blood sugars are maintained a narrow specific normal range without much fluctuations. The liver and the kidneys are the primary regulators of insulin. Insulin is produced in small continuous amount (background insulin) and bigger boluses during meal times. After insulin is released from the pancreas, it passes through the liver and 85% of it is destroyed before it does any work. The remaining 15% goes to the systemic circulation and is degraded by the kidneys. The half life of insulin is about 5 minutes and disappears completely in 3 half lives (15 minutes). Insulin released from the pancreas lasts less than an hour from its release to its complete degradation. Insulin is a peptide hormone (protein) it can not be given by mouth. It is mostly given by subcutaneous injections. Though fast acting insulin can be given by inhalation, and, in acute cases it can be given by intravenous access. Since insulin is primarily given by injection it does not act similar to insulin released from the pancreas. It can last more than 4 hours under the skin. Its absorption is also affected by various variables including, hydration status, the bodies condition, the site of injection, the amount and type of insulin, the stress level. Human factors also affect injected insulin such as skipped or small meals, giving smaller or large doses and other human mistakes or negligence. Environmental factors such as illness and physical activity, tempreature and humidity can also affect insulin injected subcutaneously. These are some of the reasons why acute and chronic complication of diabetes need special attention in managing diabetes and specially type 1 diabetes. Todays Insulins are pretty safe if used properly and appropriately. After the advent of genetic engineering in the early 1980's pure human insulin became available. Currently most insulins in the market are human insulins. The porcine and bovine insulins are being abandoned all together. In the early 50 years after the introduction of insulin, animal insulins were the only source of insulin. Animal insulins to have about 80,000 parts per million (8%) impurities. This impurities use to cause Lipoatrophy (local reactions) when injected under the skin. There were also systemic reactions the antigenesity of animal insulin. Todays insulins sold in the industrialized countries contain very little impurities (less than 10 parts per million) and most of it is human insulin. Though, if repeatedly given in the same site, a local reaction called lipohypertrophy can happen as a result of fat accumulation. This can be circumvented by rotating injection site at least 1/2 inch apart every time injection is given under the skin. Type 1 diabetics absolutely need insulin. They can change to different brands and can manage their diabetes with differ regimens from fixed insulin regimen to multiple daily injections with a long acting insulin or insulin infusion pump, but they can not do without insulin. In good trained hands, the side effects of insulin are manageable. Insulin is safe and effective treatment of type 1 diabetes. It is not painful. The needle is very tiny. It becomes only a problem with people that have severe needle phobia. Those people with needle phobia (1% of the population) need to have counseling to ameliorate their irrational fear of a tiny need that is not painful. Insulin may make people gain weight in the beginning but in the long run weight gain due to insulin is a myth. Again insulin is not dangerous or addictive. It is a life saving medication. Since insulin is given under the skin, and its absorption is out of the control of the body hypoglycemia (low blood sugars) and high blood sugars are more common with patients on insulin therapy. Administering too much insulin, skipping or eating smaller portions of food that is not in agreement with the amount of insulin, or administering an injection at the wrong time may cause an excessive drop in blood sugar (hypoglycemia). Symptoms of hypoglycemia are as follows; Dizziness. Headache. Shakiness. Hunger. Irritability moodiness. sweating. Anxiety or nervousness. trouble speaking fatigue confusion pale skin twitching muscles seizure The main advers effects of insulin isLow blood sugar. This can be circumvented with close monitoring of blood sugars. Hypoglycemia should be recognized early and treated properly. With good diabetes and nutritional education most of the adverse events of insulin injections should be managed to a minimum. Blood glucose sensors will provide greater advantage in close monitoring of blood sugars. Going back to your Daughter. Your daughter have type 1 diabetes. Insulin is the only available treatment for your daughter at this time. Currently there is no cure for type 1 diabetes, but there is hope that this will not be for a long time. The best and the brightest are working hard to find a cure very soon. Until that time dawns, insulin is the way to go. In good hands insulin is very safe and is not addictive. The side effects are mainly low blood sugars and lumpy area at the injection site. The lumpy area at the inection site is called liipohypertrophy. It is an accumulation of local fat due to the lipogenic effect of insulin. It Can change the effectiveness and the timing of insulin action. These can be avoided by paying attention to the amount of food and insulin dosses and timing of insulin. Rotating injection sites will circumvent the occurrence of lumpy area known as lipohypertrophy on the skin. Allergic and other antigenic reactions from insulin is very rare since there are very little impurities with todays human insulins. If she ever develops those reactions insulin type and brand can be changed easily. Insulin can not be given orally with good education and understanding of the action of insulin, it is safe and effective medication with very little impurities. Hypoglycemia or low blood sugars can be prevented by by close monitoring of blood sugars (performing frequent blood sugar testing) and paynig attention to insulin doses, amount of carbydrate consumed and physical activity. Use of blood glucose sensors will also be help in close monitoring of blood sugars. At this time you need to pay attention to the diabetes and nutritional education. Learn how insulins work and understand the relationships between food and insulin, both in sedentary life and under physical activity, stress or illnesses. Learn how to prevent and manage low and high blood sugars. With time you will be confident in managing your daughters diabetes. You need to discuss these issues with your diabetes educators and your daughter's diabetes doctor. Try to get more information on medical nutrition from a registered dietician as well. They will be happy to help you. Good Luck. Reference Readings: 1) https://www.medicalnewstoday.com/articles/323387.php 2) http://www.diabetesincontrol.com/history-of-type-1-diabetes-treatments/ READ MORE
Does my son need to be on a special diet for diabetes?
Diet for diabetes: The dietary recommendations for children are based on diet that mainly relies on fruits and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat, to support growth and development and maintain a healthy cardiovascular system. These guidelines advocate the intake of: 1) Low saturated and trans fat. 2) Low cholesterol 3) lower added sugar to <10% of daily calories. Reduce added sugars, including sugar-sweetened drinks and juices 4) Low salt <3 grams per day, including salt from processed foods 5) Low intake of energy drinks 6) Physical activity appropriate for age and gender. 7) Maintenance ideal weight for height.( <85 percentile) 8) Adequate intake of vitamins and minerals. 9) consumption of appropriate amount of fat, protein, carbohydrates and vegetables daily. 10) Perform moderate to vigorous physical activity at least an hour a day with strength and balance activity at least 3 times a week to maintain normal growth. 11) Eat vegetables and fruits daily, while limiting juice intake. 12) Use vegetable oils and soft margarines low in saturated fat and trans fatty acids and avoid butter or most other animal fats in the diet. 13) Eat whole-grain breads and cereals rather than refined-grain products Reduce the intake of sugar-sweetened beverages and foods 14) Use nonfat (skim) or low-fat milk and dairy products daily. Use only lean cuts of meat and reduced-fat meat products. Remove the skin from poultry before eating. 15) Eat more fish, especially oily fish, broiled or baked. 16) Use fresh, frozen, and canned vegetables and fruits and serve at every meal; be careful with added sauces and sugar 17) Use recommended portion sizes on food labels when preparing and serving food. The daily calorie requirement is different for different age groups and gender. Male expend more calorie than women. In general adult males require about 2000-3000 calories a day. Adult females will require a bout 1600-2000 calories a day depending on their activity level. Younger children <8 years old will require about 1000-2000 calories a day. While older children will require 1400-3200 calories a day. Those who a sedentary life style require the list amount of calories. While moderate activity and vigorous physical activity requires additional calories in some cases up to 800 calories more than sedentary people. A 14 years old may require 2400 to 3200 calories for boys when they are physically active. And girls of that age require from 2200-2800 calories depending on their physically active. Sedentary life is considered when activity is only performed to maintain independent living such as doing house chores, cooking etc. Moderate physical activity is when walking a bout 1.5 to 3 miles per day at 3-4 miles an hour in addition to independent living (sedentary) activity. Active life style is when walking more than 3 miles a day at 3-4 miles an hour in addition to sedentary activity to support independent living. Children should be active (moderate or /and vigorous) for at least an hour a day with muscle strengthening as part of the 60 minutes and bone strengthening (running, jumping rope, and lifting weights) and flexibility activity as part of the 60 minutes at least 3 times a week. A typical 14 years old boy should consume about 2200 calories when sedentary and about 3200 calories when he is active. He will require about 325-400 grams carbohydrates a day (50% of the calories) depending his physical activity. Added sugars including from processed food, should be less than 10% of the total carbohydrate intake. Fructose based syrups should be avoided if possible. His protein requirement will be 125 grams of protein (20%) of his daily calories. His fat intake should be bout 90 grams a day (30% of daily calories) daily. Saturated fats and trans fats should be less than 10% of the daily fat intake (<10 grams). A 14 years old or older boy should consume around 1-3 cups of milk, 2 cups of fruits, 3 cups of vegetables and 7 ounces of grains a day. He needs about 30-40 grams of fiber a day. His daily mineral requirement are as follow: Calcium 1200 mg, Sodium <2300 mg, potassium 4700 mg, phosphorus 1250m mg, Magnesium 410 mg, Iron 11 mg. A typical 14 years old require vitamins as follows: Vitamin D 600 units (15 microgram) Vitamin A 900 mg Vitamin C 75 mg Vitamin B-12 2.4 mg. Dietary recommendations are revised by USDA every 5 years. A group of expert panel and dieticians revise the nutritional guidelines sponsored by the United states department of agriculture (USAD). Currently the Choose My Plate method is available since 2010. It was revised in 2015. The next revision will be in 2020. In 1992 the USAD set a nutritional guideline called the food pyramid. In 2005 the food pyramid was replaced by the MyPyramid. Since most people would not be able to quantify foods in ounces and grams the USDA developed choose MyPlate method for children based on the recommendation of scientists and dieticians, based on the current scientific information on nutrition. The Myplate method is divided into five sections of approximately 30 percent grains, 30 percent vegetables, 20 percent fruits and 20 percent protein, and a glass of dairy product such as low fat or skim milk. It is color codded for simplicity so the families with children will understand it. The Choose Myplate method was simpler with out measuring the grams and ounce but visualizing the plate proportions. Half the plate should consist of fruits and vegetables, while the other half is divided between whole grains and lean sources of protein. The dairy is represented by a glass of skim or 1% milk or other nonfat or low fat dairy products. The general guidelines for macronutrients are similar to that of none diabetic population. The choose Myplate method is colored as follows. 1.Vegetables is green 2.Fruits. Like veggies, fruits have vitamins, minerals, and fiber 3.Grains. The orange section of MyPlate is about one quarter of the plate. 4.Protein. High-protein foods help the body build and maintain its tissues. 5.A glass of dairy products such as low fat milk. Fats are not considered here because people use oil to cook and some of the food have enough fat or oil to support the nutritional requirement of a growing child.. A 14 years old with type 1 diabetes may require about 40-60 units of insulin daily in divided doses, depending on his insulin sensitivity. As time goes by his insulin sensitivity may diminish and may require much more insulin. The typical insulin to carbohydrate ratio will be 1 unit for 10 grams in the beginning but may require more insulin later on. As time goes by 1 unit of insulin to 5 grams of carbohydrates is common. This is specially true as the honeymoon period passes. His insulin sensitivity may be about 1 unit for every 30-50 mg/dl of glucose above the target blood sugar. Most target blood sugars are 100-120 mg/dl. The nutritional requirement for diabetic patients are similar to those that healthy individuals with out diabetes as discussed above. However diabetes involves blood sugar testing, insulin adjustment, and carbohydrate counting. Dietary guidelines should be incorporate into diabetic patients lifestyle to maintain good glycemic control, promote growth and development and support cardiovascular health. There are no set of especial nutritional recommendations set for diabetic patient other than to pay special attention to insulin regimen and carbohydrate, insulin and carbohydrate requirements during physical activity and illness. diabetes patients should follow dietary guide. These should be individualized, and accepted by the diabetic patient in order to be effective. This involves a team effort of a dietician, and diabetic team approach not of a single diet sheet or a hand out approach. These include instruction on nutrition therapy and diabetes self-management education. The nutritional goal for diabetic patients is: 1) To promote and support healthful eating patterns, with nutrient dense foods and appropriate portion sizes. 2 Improve glycemic control 3) maintain normal blood pressure, and lipid goals. For children with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. This can be done with either multiple daily insulin injections of a fast acting insulin for meals and corrections and a long acting insulin (bolus/basal principle) or using continuous subcutaneous insulin infusion (insulin pump) therapy. In a non-diabetic patient insulin is made in the pancreatic beta cells and is released continuously (basal or background insulin) and in response to food, mainly carbohydrates. The insulin produced in the pancreas, goes through the liver, and, 85% of it is destroyed by the liver before it goes to the systemic circulation (blood) to mediate glucose transport to the tissues to be consumed for energy. The remaining 15% travels in the systemic circulation and is deactivated in a short period of time. The half life of insulin is about 5 minute in the blood and in 3 half lives (15 minutes) insulin dissipates completely so that we do not experience hypoglycemia afterwards. In patient with insulin dependent diabetes, insulin is not made in the pancreas but given under the skin by injection and stays minimum of 3-4 hours not 15 minutes as in a none diabetic person. It is therefore important to recognize that in diabetic patients insulin is given AT THE WRONG PLACE, AT THE WRONG TIME, AND IN THE WRONG DOSE. This causes a huge problem in managing insulin dependent diabetic patients. Insulin given under the skin leads to greater unpredictability. Unlike non diabetic persons, where insulin is controlled tightly and blood sugars are maintained in a narrow normal range, insulin dependent diabetic patients experience blood sugar variability (excursions). Hypoglycemia and hyperglycemia are very common in insulin dependent patients. During illness in non-diabetic patients the pancreas make more insulin (20-30% more insulin) due to the stress hormones with out causing hypoglycemia or hyperglycemia. In insulin dependent diabetic patients during stress the body makes stress hormones leading to high blood sugars necessitating increase in insulin requirement by 20-30%. Diabetic patients have similar nutritional requirement to the non diabetic patients. However since insulin is given at the wrong site ( not coming from the pancreas to the liver), at the wrong time (30-10 before meals) and in the wrong dose ( bigger dose that lasts at least 3-5 hours instead of 15 minutes) compared to what the body does. Therefore special attention should be taken regarding the following considerations: 1) Insulin management and timing of Insulin and Meals 2) Carbohydrate counting: 3) Prevention of hypoglycemia 4) Sick Day Management 5) Treatment of hypoglycemia guidelines 6) Exercise and diabetes A) insulin dosing and timing of insulin and meals: Insulin doses should be determined for the amount of food to be consumed and for correction for high blood sugars. Insulin to carbohydrate ratio and sensitivity factor should be established and adjusted as needed. The amount of carbohydrate for each meal should be decided if the patient is on fixed insulin therapy. The amount of carbohydrates for each meal and snacks should be kept constantly to avoid high or low blood sugars. The amount and timing of insulin for each meals and snacks should be reasonable to avoid mismatch between the food consumed and the amount of insulin given. In flexible insulin therapy either via the insulin pump or multiple daily injections of fast acting insulin with a long acting insulin the amount of carbohydrates can be varied as needed with out affecting blood sugars as the amount of insulin is matched to the amount of carbohydrate consumed. However the timing of insulin boluses should be constant. Flexible insulin therapy is superior to fixed insulin therapy, though in good hands they will all do reasonably well. B) Carbohydrate counting: The primary goal in the management of diabetes is to achieve a reasonable fasting and postprandial ) blood glucose. This assumes over 50% of blood sugars should be in the desirable range of 70-140 mg/dl with little blood glucose variability. Maintaining an A1c of <7.5% is ideal. It is important to pay attention to the type and amount of carbohydrate in a food because they can influence overall glucose control. This means that the type and the total amount of carbohydrate eaten strongest the glycemic response. Most patients with type 1 diabetes get about 50% of their total energy intake from carbohydrates. The rest of the 50% is derived from proteins and fats (oils). With type 1 diabetics estimating the total grams of carbohydrates by either experience based estimation or actual carbohydrate counting, is useful in achieving reasonable blood glucose control. Most carbohydrate should be consumed from vegetables, fruits, whole grains, legumes, and dairy products with out added sugars, fats or salt. Diabetic should choose low–glycemic load foods for better glycemic control. If substitutions are required with sucrose based products it should be done without compromising nutrient dense food choices. Type 1 diabetic patients should also consume about 30- 40 grams of fiber a day similar recommendation to the general population. Dietary fiber is defined as the carbohydrate and lignin found in plants that is not digested by the stomach or absorbed in the gastrointestinal tract. Some of the high fiber containing carbohydrate that should be consumed daily include whole fruits and vegetables, whole grain breads, legumes, and cereals. At least over 50% of grains should be whole grain and fruits and vegetables should be fresh unprocessed products. Processed foods and high fructose based products should be avoided. Added sugars should be limited to <10% of the total carbohydrate intake. C) Prevention of hypoglycemia: Type 1 diabetic patients must take insulin to control their blood sugars. Since subcutaneous insulin injection does not follow the natural insulin production in the pancreas (wrong site, wrong dose and wrong time) hypoglycemia and hyperglycemia are very common. When blood sugars are low (<70 mg/dl) the person can develop autonomic symptoms of hypoglycemia such as dizziness, weakness hunger, anxiety, irritability, light-headedness, sweating, pale face, tremor, heart palpitations, rapid or irregular heart rate, trembling, or shaking. When hypoglycemia is sever (<30 mg/dl) neuroglycopenia will sett in leading to stupor, unconsciousness seizures and coma. Chronic hypoglycemia will also lead to detrimental health out come. Diabetics on insulin or oral hypoglycemic agents therapy need to prevent hypoglycemia from happening. Some of the following guidelines may be helpful in preventing hypoglycemia. 1) Learn how subcutaneous insulin works. Understanding the what the duration of action of fast acting insulin and long acting insulin are (the time it takes for the injected insulin to dissipate completely). Understanding when insulin starts to work after admitted under the skin or when bolused through the insulin pump (onset of action), and when the maximum of action takes place (peak of action). Understanding how certain insulin behaves will help you to determine whether you need to increase or decrease the insulin dose in the future. 2) Monitor blood sugars before meals and after meals or at least 4 times a day including at bed time. Occasional, testing blood sugars in the middle of the night will be helpful in management your diabetes better. 3) During moderate to vigorous physical activity insulin doses and food intake should be adjusted to correlate with the level of physical activity. Increasing the level or duration of physical activity can lead to significantly low blood sugars. During moderate or vigorous physical activity, insulin dose may need to decrease by about 20-30%, depending on person’s insulin sensitivity. 4) Diabetic patients on insulin therapy or oral hypoglycemic agents should not skip, significantly alter, or delay the amount of meals or snacks without changing the insulin dose. similarly the timing of meals and insulin injections should be maintained appropriately. 5) Document any occurrences of low blood sugars and hypoglycemic symptoms. This can be helpful in determining the cause of hypoglycemia and find ways to prevent them. 6) Every patient with insulin dependent diabetes should carry some form of diabetes identification such necklace or bracelet and wallet card in case of emergency. D)Treatment of Hypoglycemia: Any blood glucose level ≤70 mg/dL is considered hypoglycemia. Symptoms Regardless of the symptoms of hypoglycemia, the low blood sugars must be treated promptly with fast acting sugars such as juice, milk, soda, life savers , etc. Usually the rule of 15/15 rule: That is 15 gms of fast acting carbohydrate increase blood glucose by 30-45 mg/dL within 15 minutes. Blood sugars should be checked in 15-20 minutes. If blood glucose is still < 70 mg/dL, another round of fast acting carbohydrates should be given. This can be repeated every 15-30 minutes until blood glucose increases >70 mg/dl persistently and symptoms of hypoglycemia resolve. About 4 ozs of fruit juice, regular (not diet) soft drink, 4 glucose tablets, 2 table spoon of raisins and a cup of skim milk will raise the blood sugars by a bout 30-40 mg/dl in 15 minutes. if the next meal is at least an hour away, eating a small snack will be helpful. If the patient can not take any thing by mouth or if the patients is not conscious or have a seize do not use fast acting sugars as this will lead to aspiration. Glucagon emergency kit should be used in caser of emergency give 1 mg of glucagon intramuscularly and emergency medical services should be activated by calling 911. If the patient is sick but can not take by mouth due to vomiting or diarrhea glucagon can be used to raise the blood sugar. In this case subcutaneous glucagon of 10-15 units can be given using a diabetes syringe similar to insulin injection every 30 minutes as needed. Glucagon should raise blood glucose level by 30-40 mg/dl in 30 minute. This can be repeated several times as needed or need to go to the emergency room. If the patient is spilling ketones glucagon is not recommended since the glycogen in the liver may be depleted. During hypoglycemic episodes high fat foods should not be given to correct blood sugars, as these will delay blood glucose raise from carbohydrate intake. E) Sick Day Management During illness the body makes stress hormones such as adrenalin and cortisol. These stress hormones cause insulin resistance leading to 20-30% in insulin requirement. Occasionally when patients get sick they develop hypoglycemia especially if they have diarrhea and vomiting. However most of the time diabetic develop high blood sugars due to the stress hormones. Some times diabetic ketoacidosis can develop if enough insulin is not taken or when the patient is not well hydrated. More often many patients omit their insulin doses and develop diabetes ketoacidosis. The most important things to remember during illness are; 1) Self-monitor blood glucose as often as possible. 2)Continue to take insulin 3) increase your insulin doses 20-30% until the illness resolves. 4) give insulin corrections as often as possible every 2-3 hours. 5) keep blood sugars <150 mg/dl by giving multiple injections 6) you should drink enough fluid to keep hydrated. With out hydration insulin can not be absorbed from the skin and does to work no matter how much insulin you give. Hydration, Hydration, Hydration, Hydration, Hydration, 7) Eat the usual amount of carbohydrate, divided into smaller meals and snacks if necessary. Eat foods that are easy-on-the-stomach such as yogurt, soups, non-diet gelatin, crackers, and applesauce. If blood sugars are > 250 mg/dL the usual amount of carbohydrate may not be necessary until the blood sugars come down. It is essential to consume at least about 2/3 or 40-60 grams of carbohydrate every three to four hours. 8) Test urine ketones: If ketones are negative you may correct your blood sugars every 2-3 hrs. with insulin in addition to your usual insulin dose. Push for hydration. If ketones are mild you can increase your usual insulin by 5-10% and give insulin corrections every 2-3 hours. Push for hydration. If ketones are moderate increase your insulin regimen by 10-20%. Correct blood sugars every 2-3 hours. Push for hydration. Consult with you diabetes educators. If ketones are large, increase your insulin regimen by up to 30%. Push for hydration. call your diabetes educators and go to emergency room for intravenous hydration. Patients on insulin pump should consider giving insulin by injection when blood sugars are not coming down or the ketones are moderate or large. Change the pump site and continue to give insulin boluses every 2-3 hours by injection. Also hydration, hydration and hydration. F) Exercise has many benefits to our cardiovascular health. The recommendations for aerobic activity for diabetic patients is similar to persons with out diabetes. Adolescents should spent over an hour a day in moderate to vigorous physical activity. Sports activity brings special challenges in managing the blood sugars of diabetics on medications, especially for those on insulin and oral hypoglycemic agents. Physical activity affects blood glucose response. The duration of activity, the amount and intensity of exercise, timing and type of the previous meal, timing and type of the insulin injection all affect blood glucose repose. In general moderate to vigorous physical activity significantly lowers blood glucose levels. Snacks of about 15 grams should be consumed every 30-60 minutes depending on the individuals blood sugar response to physical activity. Monitoring blood sugars before during and after physical activity and adjusting insulin and carbohydrate snack will be vital in preventing or treating hypoglycemia. Some patients may develop high blood sugars during sports activity. As long as they are not sick or they are not spilling ketones, they can administer at least 1/2 of their boluses if their blood sugars are above 250 mg/dl. If the patient is sick or have ketones with or with out illness participation in sports activity should be avoided. In summary the nutritional requirement of a diabetic person is similar to a non diabetic person. However since insulin is given under the skin and it acts completely different from the normal physiology of insulin in a non diabetic patient, controlling the blood sugars to near normal becomes a great challenge. In insulin dependent diabetes blood sugar excursions are very common. episodes of high and low blood sugars are not easily avoidable. Diet, exercise and illness significantly affect the blood sugars of diabetic patients. It becomes a great task to be able to balance all these variables in order to prevent hypoglycemia, hyperglycemia, diabetes ketoacidosis, and long term complications of diabetes. A balanced diet with adequate macro and micro nutrients will help not only in maintaining good glycemic control but also in maintaining good cardiovascular health. Understanding insulin, and the effect of carbohydrates, physical activity and illness on blood sugars will significantly enhance your ability to manage insulin dependent diabetes better. Going back to your child: You have a newly diagnosed son with type 1 diabetes. In the beginning managing a new onset diabetes is overwhelming, but eventually you will be comfortable in managing it. In the begging, too much information will confuse you. Things need to be taken slowly step by step. The first step it to be able to test blood sugars frequently, administer his insulin for each meals and correct high blood sugars if necessary, and understand low blood sugars and take appropriate action. The second step is to understand how insulin works and how carbohydrates affect the blood sugars. The next step is to learn carbohydrate counting or at least be able to estimate the gram of carbohydrates from a given food. Once you have a reasonable understanding of these issues, you could move on with learning about adjusting insulin and carbohydrate during physical activity, in sick days, understand acute and chronic complications of diabetes and treatment of hypoglycemia so that you can prevent them ahead before they ever happen. You will need a team of diabetes educators and dietician for these to be successful. Start it with simple steps and proceed to complex issues slowly. These take time, but you will be very comfortable as the time goes by. There is no special nutrition for diabetic patients on insulin except that especial considerations should be given to the ones mentioned above. The general nutritional recommendations for children applies to type 1 diabetics as well. I have summarized them in more detail above. You may be overwhelmed now but with time you will have a good handle of it. The most important issue here is paying special attention to insulin requirement for each meals, adjusting insulin as needed and preventing or treating low blood sugars as needed. Talk to your diabetes educator and dietician. You should work as a team and get any help you can, and, use any resource available to you. Good luck Reading references: 1) https://health.gov/dietaryguidelines/2015/guidelines/#subnav-4; 2) Nutritional Recommendations for Individuals with Diabetes Alison Gray, RD, MBA. Author Information Alison Gray, RD, MBA Senior Clinical Research Scientist, Lilly USA LLC; DC 2231 Last Update: May 31, 2015. 3 )Pediatrics; February 2006, VOLUME 117 / ISSUE 2 AMERICAN ACADEMY OF PEDIATRICS 4) https://www.fns.usda.gov/tn/myplate READ MORE
Can type 1 diabetes patients take pills instead of insulin injections?
Type 1 diabetes is the commonest metabolic disorder in children. It affects over 200,000 children in United states of America. About 20,00 children are diagnosed type 1 diabetes annually in America. The incidence of type 1 diabetes is also increasing by about 3% annually in the western hemispher. Type 1 diabetes results from an autoimmune destruction of islet cells called Beta cells, that make insulin. There are about 1.5 million beta cells in the pancreas. Once about 85% of beta cells are destroyed, insulin deficiency prevail and blood sugars become uncontrolled. When left untreated or poorly treated it can lead to acute and chronic complications. These complications can lead to early death or shorter life expectancy. Type 1 diabetics are insulin deficient and can not support the bodies insulin demand to control the blood sugars. Currently insulin is the only treatment for type 1 diabetes. Insulin is mostly given subcutaneously (under the skin) though it can be given by inhalation, and intravenously via IV infusion in the hospital setting for acute complications. Insulin is a peptide (protein) hormone. It is potent mediator of glucose from the blood in to the tissues to be used for energy. The brain depends on glucose almost all the time as it source of energy. Without sufficient insulin glucose will not be transported out of the blood to the tissues for good use. Since insulin is a protein hormone it can not be given by mouth. If it is given through the oral route (mouth) it will not survive the stomach acidity. It will be destroyed by the stomach acid call hydrochloric acid. It will also be destroyed by the digestive juices of the pancreas in the duodenum, if it survives the stomach acidity. Any protein hormone given by oral route will be denatured by the powerful stomach acid or will be destroyed by the pancreatic or intestinal enzymes or digestive juices. Whether it is insulin or growth hormone, any protein hormone, will not survive oral route. So far protein hormone are mainly given by subcutaneous, intravenous or inhalation routes. Up to this time no commercial institution have succeeded in creating a viable oral insulin to be marketed for type 1 diabetic patients. However there are few of them on trial and under FDA review. For insulin or a protein hormone to be delivered oraly three things have to happen: 1) It has to survive the powerful stomach acid without being denatured. 2) It has to survive the powerful digestive juice in the intestines 3) It has to be able to cross the intestinal mucosa to be absorbed to the blood stream. A successful company would be able to design an insulin vehicle to carry it through the stomach acidity, protect it from intestinal juices and aid the insulin to cross the intestinal membrane to the blood steam without diminishing the biological activity of insulin. The School of Engineering and Applied Sciences in Cambridge, MA, is claiming that they have created a vehicle of insulin that is able to do this. The Oramed Pharmaceuticals is also conduction more studies on these aspects of insulin delivery system and are under review by FDA. If oral insulin delivery system materializes in very near future, type 1 diabetic will enjoy a better glycemic control as orally derived insulin will be similar to insulin produced by the pancreas as long as the long term safety of the oral insulin vehicle is not in question. This will be good news to many diabetic patients on insulin injections who have needle phobia (about 10% of them) and though who are tired of giving injections multiple times a day and though who are none complaint. It is also true t5hat multiple daily injections, create inconvenience, disrupt the quality of life and achieving normal blood glucose all the time is difficult. Use of oral insulin which will mimic physiologic insulin in normal patients will be much better. There is also a great optimism in curing diabetes with technologies that promote islet cell regeneration or stem cell technology or genetic engineering. As science and technology advances, cure for type 1 diabetes will not be remote. It will be one of the greatest break through in medical history, the way the discovery of insulin was a glorious moment in medical discovery. These events will happen shortly it is the matter of time. Until oral insulin or cure of diabetes materializes in the near future, we will continue with delivering insulin under the skin (subcutaneously) either by multiple daily injections or using insulin infusion pumps or inhalation insulin with a long acting insulin in some cases. All these insulin delivery systems have their advantages and disadvantages, but in skilled hands they all should work in a similar way. Please discuss these issues with your child's doctor. He/she will be able help more. Good Luck. READ MORE
How often should my kid be exercising with type 1 diabetes?
Regular physical activity have multiple benefits to our health. Physical activity includes all movement that increases energy expenditure, whereas exercise is planned, structured physical activity. Though any form of physical activity will have a positive effect on our health, when exercise is moderate or vigorous in intensity it becomes much more beneficial to our overall health and wellbeing. The benefits of regular exercise include some of the following: -Increase life expectancy by 2-10 years depending on the type of activity performed. -Prevent weight gain or help maintain ideal weight -Prevents obesity and insulin resistance (metabolic syndrome) -Prevents loss of cognitive function. -Increase self esteem -Protect our cardiovascular system - prevent or lower level of depression or anxiety -Help us sleep well -Prevent high blood pressure and stroke -Improve insulin sensitivity and lower our blood sugars with without diabetes. -Help us move around with ease -Prevent or delay arthritis - Help us maintain strong muscles and bones -Prevent certain types of cancers -Boosts our energy -Helps us to socialize with people -It gives us enjoyment and fun Physical activity can be light, moderate or vigorous in intensity, depending on the extent to which they make you breathe harder and your heart beat faster. However any physical activity done for a good duration of time has good health benefit, the moderate and vigorous exercises have more pronounced health beneficial effect and that is what really accounts to our weekly exercise goal of 150 minutes. Exercise can be, Aerobic, resistance or flexibility forms. Aerobic activity can be light, moderate or vigorous. It takes more efforts to do vigorous activity than moderate or light activity. For moderate physical activity, you can talk while you do them, but you can't sing Moderate exercise includes: -Walking briskly (about 3½ miles per hour) -General gardening -Dancing -Bicycling < 10 miles per hour -Playing golf -Canoeing -Playing Tennis Vigorous exercise makes you breathe harder and make your heart beat faster. You can only say a few words without stopping to catch your breath Vigorous exercise includes: •Running/jogging (5 miles per hour) •Walking very fast (4½ miles per hour) •Bicycling (more than 10 miles per hour) •Heavy yard work, such as chopping wood •Swimming (freestyle laps) •Aerobics •Basketball (competitive) •Tennis (singles) Resistance exercise: Resistance exercise is exercise geared towards strengthening the bones and muscles. These include activities like push-ups and lifting weights, jumping, are especially important for children and adolescents by producing force on the bone that promotes bone growth and strength. Flexibility or balancing exercise includes stretching, dancing, yoga, martial arts, seat-ups, and tai taekwondo. This activity enhances physical stability and flexibility and reduces risk of injuries. Moderate and vigorous physical activities can be chosen or can be combined to meet the minimum weekly recommendation of physical activity. Moderate physical activity requires twice the a mount of time to achieve similar out come as vigorous activity. Light physical activity does not contribute towards the recommended weekly exercise requirement. Strength (resistance) activity and balance (flexibility) activity should be performed at least 2-3 times a week in combination to moderate or vigorous physical activity, or separately. Physical activity should not laps more than 2 days in a row. It should last more than 10 minutes at a time. The duration of time for the required weekly physical activities varies with age group. The recommendations only state about the minimum weekly time, type and intensity of the physical activity. Physical activity is recommended from the walking age to the age (2 years to 64 years of age.The United states Agriculture department, states that, the health benefits you gain from being active are far greater than the chances of getting hurt. Physical activity should be performed in a safe environment. There are three levels of recommendations based on the age group. 1) children from walking age, usually 2 years old to 5 years old should be active intermittently several times a day. This will promote growth and development. A child should be active in a safe environment several times a day to enhance growth of the body build strong muscle and bones. Physical activity will also enhance the child's cardiovascular and brain development. 2) School age children and adolescent (6-17years) should have aerobic physical activity at least an hour day of moderate to vigorous intensity. They should also have activities for muscle-strengthening, like climbing, and bone-strengthening activities, like jumping at least 3 days a week, and flexibility activity like, gentle stretching, dancing, yoga, martial arts at least 3 days a week. Sports activity is vital in a growing child to enhance the growth and development properly. It is also important that exercise is performed in a safer environment under supervision in children. Sports activity should be done as a group. This will enhance social life and has the highest benefit in longer life expectancy than when done individually. Certain sports that involve two or more people such as tennis, badminton, golf, and cycling promote longer life according to some European studies. However any sports activity will have a positive health benefit and longevity than sedentary life style. Children and adults should exercise beyond their weekly recommended time of over an hour daily. Usually doubling the weekly recommended time will have a greater effect. 3) Adults, 18 -64 years, are recommended, a minimum of 150 minutes of moderate aerobic physical activity or 75 minutes of vigorous physical activity a week. However increasing aerobic active for 5 or more hours each week can provide even more health benefits. The sports activity should be spread for over at least 3 days a week. Each aerobic activity should be done over 10 at a time. Resistance and balance activities, like push-ups, sit-ups and lifting weights, should be done at least 2-3 days a week. The same recommendations of physical activities are applicable for diabetic patients. Exercise is specially helpful in preventing or delaying type 2 diabetes. Exercise helps control blood sugars, improves cardiovascular system, lowers blood pressure and prevents obesity and helps with weight loss. Regular exercise also has considerable health benefits for people with type 1 diabetes. It improved cardiovascular fitness, muscle strength, insulin sensitivity, lowers blood sugars, lowers insulin requirement, lowers HBA1c, etc..). Type 1 diabetic have more challenges with sports activity. Because these involve insulin regimens, food intake for exercise, and maintaining normal or nearly normal blood glucose levels before, during, and after activities and the prevention of hypoglycemia. These factors can be a barrier to physical activity in type 1 diabetic patients. During exercise diabetic patients react to physical activity differently with great variability. Some will have high blood sugar in response to stress hormones (adrenalin and glucagon), and many others will develop low blood sugars during and after physical activity. Therefore, exercise recommendations, should be tailored to meet the specific needs of each individual. Moderate and vigorous exercise can modify insulin action on the liver and muscle. Vigorous aerobic exercise increases muscle glucose uptake up to fivefold through insulin-independent mechanisms. After exercise, glucose uptake remains elevated by insulin-independent method for up to 2 hours. Also the insulin-dependent mechanisms becomes more sensitive to insulin, up to 48 hour if exercise is prolonged (30-60 minutes). This can replete the glycogen storage in the muscle and liver. Improvements in insulin action may last for 24 h following shorter duration activities (20 min) if the intensity is elevated to near-maximal effort intermittently. Type 1 diabetics should participate in any sports activity like their none diabetic counter part as long as frequent blood glucose monitoring and frequent insulin and carbohydrate adjustment are performed for safer physical activity. Some of the recommendations are: 1) Since the benefit of physical activity is much greater physically active in children and adults with type 1 diabetes should be recommended to all. 2) Blood glucose responses to physical activity in all people with type 1 diabetes are highly variable (higher and low) different adjustments to cars and insulin should be made. 3) Frequent blood glucose checks are required to determine carbohydrate intake and insulin dose adjustments. 4) Insulin users can exercise using either basal-bolus injection regimens or insulin pumps though there are advantages and disadvantages to both insulin delivery methods. 5) Continuous glucose monitoring during physical activity can be used to detect hypoglycemia when used as an adjunct rather than in place of capillary glucose tests. Carbohydrate adjustment during physical activity should be managed as follows: 1) If blood glucose is 90 mg/dL eat 15–30 g carbohydrate or weight and age specific amount, before exercise. If activities is brief in duration (<30 min) or at a very high intensity (weight training, interval training, etc.) may not require any additional carbohydrate intake For prolonged activities at a moderate intensity, consume additional carbohydrate, as needed. 2) 90–150 mg/dL Start consuming carbohydrate at the onset of most exercise (∼0.5–1.0 g/kg body mass per h of exercise), depending on the type of exercise and the amount of active insulin. 3)150–250 mg/dL Initiate exercise and delay consumption of carbohydrate until blood glucose levels are <150 mg/dL 4) 250–350 mg/dL Test for ketones. Do not perform any exercise if moderate-to-large amounts of ketones are present. Initiate mild-to-moderate intensity exercise. Intense exercise should be delayed until glucose levels are <250 mg/dL because intense exercise may exaggerate the hyperglycemia. 5) ≥350 mg/dL Test for ketones. Do not perform any exercise if moderate-to-large amounts of ketones are present. If ketones are negative (or trace), consider conservative insulin correction (e.g., 50% correction) before exercise, depending on active insulin status. Initiate mild-to-moderate exercise and avoid intense exercise until glucose levels decrease. 6) Alternatively, basal insulin regiments can be lowered if exercise is more than 30 minutes. Depending on the blood glucose level, duration and intensity of the exercise, 20-50% reduction of basal insulin could be considered 30-60 minute before exercise to prevent hypoglycemia. For patients with insulin infusion pump lowering the basal insulin or suspending it for a couple of hours be an alternative to consumption of carbohydrates if blood sugars are <150mg/dl before exercise. It is very important to perform frequent blood glucose testing when implementing insulin and carbohydrate adjustments. Glucose sensors should only be used as adjunct but should not replace the capillary blood sugar testing. Exercise is beneficial for people with type 1 diabetes (all ages). It is associated with many health benefits that include improvement in cardiovascular fitness, better bone-health and enhanced physical and psychological well-being and longevity. diabetic patients should exercise at least twice the recommended time of weekly exercise (150 minutes of moderate or 75 minutes of vigorous) for adults and more than an hour a day for children with various strengthening and balance activities, spread at least over 3 days a week. They need to pay special attention to the blood sugars, with more frequent blood sugar testing, and adjusting their insulin and carbohydrates accordingly. When the blood sugars are high >250 mg/dl before start of the exercise and there are little or no ketones, some insulin (half of the usual correction dose) should be administered and blood glucose monitored frequently. When ketones are moderate to large no exercise should be performed until the ketone clear with insulin and hydration. Going Back to your son: Your son has type 1 diabetes. He can participate in any physical activity as his non diabetic peers. He should participate in daily physical activity with at least over an hour of moderate to vigorous exercise at least 5 days a week. light physical activity such as walking or doing home chores do not count towards these recommendations. Regular physical activity will have a great health benefit in type 1 diabetics. It improves cardiovascular health, prevents, high blood pressure, excessive weight gain, mood disorders, certain cancers, prevents chronic complications of diabetes that can shorten life expectancy by about 10 years, brings happiness and enhances socialization and longevity. When he is exercising you should pay special attention to his blood sugars, insulin regimens, and carbohydrate needs. These things need to be balanced all the time. More frequent blood sugar testing is essential regardless of whether you have a blood glucose sensor or whether he is on insulin pump or multiple injections a day or other insulin regimens. Before, during or after exercise you should adjust his insulin regimens and his carbohydrate needs as indicated. His body may respond with low or high blood sugars. There is a lot of variability to the response of glucose to exercise. Every one is a text book for him/her self. Howeve most people will have low blood sugars when performing moderate to vigorous physical activity especially if done over 30 minutes duration. And may experience late hypoglycemia up to 24 hours depending on the duration of time, intensity of physical activity, or situation. With time you will learn how his body responds to exercise and you will be comfortable managing his diabetes. If his blood sugars are low you will treat with appropriate amount of carbohydrates or lower his insulin or do both appropriately. When his blood sugars are high you will treat with about half the correction before and after activity as long as he has little or no ketones. If he has moderate or large ketone treat those first be fore any physical activity with at least 20% more insulin and hydration. When ketones resolve he can participate in sports. As long as he is not sick or have moderate or large ketones he can participate in sports activity while correcting his high or low blood sugars. So the answer to your question is therefore, he can participate in sports more than 5 days a week as needed and more than an hour of moderate to vigorous intensity with at least 3 days of balance and resistance activity under supervision. He can participate in competitive sports activity if he is interested like his none diabetic peers as long as the blood sugars are monitored and appropriate action is taken consistently. Usually twice than the recommended time of physical activity will be more beneficial for good health and longevity. A healthy and balanced is a vital component for good health and longevity. Please discuss these issues with you doctor. He/she will help you in managing your son's diabetes during sports activity. Good Luck References for further reading 1) https://www.choosemyplate.gov/physical-activity-amount 2) Diabetes Care 2016 Nov; 39(11): 2065-2079. 3) Diabetes Care 2016 Nov; 39(11): 2065-2079. READ MORE
Is frequent urination a symptom of type 1 diabetes?
Urination is a complex process that involves neuronal and muscular coordination of the bladder in order to urine from the bladder. Urine is formed in the kidneys and stored in the bladder. The kidneys filter about 150 liters of blood every day. About 20% of the cardiac out put is filtered at any given time. About 99% of the filtered blood is reabsorbed to the blood from the kidneys filtration system. Only about 1% of the total filtrate is excreted as a urine. Urine is acidic about 6 pH. Urine formation is the process of eliminating organic waste products produced from the cellular mechanism of the body. The urination process maintains normal, blood volume, body's pH, blood pressure and electrolytes. The bladder is the storage of urine formed in the kidneys. It usually holds about 500ml though it can go up to 1000ml. When the bladder contains 250-400 ml the bladder walls expand stimulating stretch receptors. These causes stimulation of neuronal reflexes (autonomic) in the lower spine area (sacral area) allowing the contraction of the bladder detrusor muscle to contract and open the internal sphincter of the bladder. Higher centers in the brain get activated from the spinal reflexes and stimulate the pudendal nerve to allow the external sphincter of the bladder to relax and allow urine flow out of the bladder. The internal sphincter is under spinal reflex and is involuntary. when the bladder senses fullness this sphincter opens involuntarily. The external sphincter is under a voluntary control. This does not mature until the toile training age of 3 years. Before the age of three years urination is involuntary and needs to have a diaper. After the age of 3 years when the higher brain centers mature we can control the external sphincter voluntarily and urinate in our convenient time. Patients with spinal cord lesion may have only involuntary micturition since massage to the higher centers can not be relayed through the spinal cord. Generally we urinate about 300-500ml at each micturition. The average person urinates about 1-2 liters a day. This will be about 4-8 trips to the bathroom daily. However there is a big variation from person to person. Some people drink a lot some drink less. The type of drinks and the weather condition and our medical conditions affect how much we drink and how much we urinate. Drinking caffeinated and alcoholic drinks, and cold weather will make us urinate more frequently. Hot weather and low fluid intake will make us micturate less often. Generally over 3000 ml (3 liters) a day and more than 8 trips to the bathroom should be of concern if there is a disturbance in quality of life. If it is not disturbing quality of life it most likely is normal. Children have small bladder and urinate more frequently than adults. Abnormal urination could be due to pathology in the kidneys or the bladder. Since urine is formed and concentrated in the kidneys any abnormalities in the kidney's ability to concentrate urine will reflect in the quantity, frequency and quality of urination. Any problems that affect the bladder can also affect the frequency of urination. Since hormones, neurons and muscle are involved in urination any abnormality in these elements will affect the frequency or urgency of urination. There are several causes of frequent urination that may disrupt quality of life due to frequent visit to the bathroom or frequent waking up at night to urinate. 1) Caffeine or alcohol. Can cause urges to urinate. They act as diuretics. When the bladder if full the urge to go to relieve the void is irresistible. 2) Some people are habitual drinkers. These are people that drink plenty of fluid a day and go to the bathroom more often. 3) Diabetes mellitus: In newly onset diabetes or uncontrolled diabetes high blood sugars spills to the urine. When there is a lot of sugar in the urine water follow the urine by osmotic gradient from the kidneys. Usually blood sugars above 180 mg/dl are excreted in the urine in order to lower the osmotic load of the body. This causes copious urine and frequent urination including nocturnal. 4) Diabetes Insipidus: patients with this disorder produce excess urine and urinate very often. A hormone called antidiuretic hormone is either deficient or the kidneys are resistant to it and it does not function. Under normal condition this hormone helps reabsorb about 10% of the water in the kidneys filtrate. Lack or in effectiveness of this hormone causes the kidney to loss 10% of the water that should have been reabsorbed to maintain the blood volume and blood pressure and electrolytes. These patients can urinate up to 15 liters per day and prefer cold water than any drink. 5) Dipsogenic diabetes insipidus: This patients drink and urinate a lot though they do not have hormone problems. they probably have either damage to their thirsty mechanism in the hypothalamus or have psychiatric issues. 6) Hypercalcemia: Hypercalcemia is mostly due to excess hormone production call parathyroid hormone or multivitamin supplements or vitamin D toxicity. High calcium in the body causes diuresis due to osmotic drugging of water. It also causes kidney stones and blood in the urine, constipation and other nerve problems. 7) Pregnancy: Pregnancy can cause pressure to the bladder to contract and urinate more often. 8) Medications: Diuretics are a good example that may cause frequent urination. 9) Other causes are: bladder infection, bladder injury, structural anomalies of the bladder, bladder cancer, anxiety, kidney stones etc. Other associated symptoms with frequent urination are: difficult urinating in the presence of an urge to urinate, pain while urinating urine, bloody urine, cloudy smelly urine, urinary incontinence, discharge, fever, thirsty, abnormal heart beat etc. Any frequent urination that have other accompanying symptoms that disrupts the quality of life should be evaluated and treated appropriately. Urine and blood sugars need to be tested to rule out diabetes mellitus. A detailed history and physical and the accompanying clinical symptoms will uncover the possible diagnosis is most cases. Early medical evaluation is very essential for those with frequent urination and disturbance in quality of life. Going back to your Daughters: Your daughter urinates about 4-5 times a day which is a normal frequency especially in a child who has a smaller bladder. Children urinate more often than adults. Usually any thing above 7-8 micturition a day would be of a concern especially if this is recent and is disrupting the quality of life. But is there is a family history of diabetes and if you have suspicion it would not hurt to check her out for diabetes. You can see her doctor and discuss your concern with her doctor. The doctor can order simple things such as fasting blood sugar, HbA1c and urine glucose and urinalysis. If she continues to urinate more frequently and there are no other symptoms such as pain, fever or hesitancy when urinating let the doctor check her for diabetes insipidus of any of the causes. But if there is no other disturbances and she is just urinating 4-5 times a day a watchful monitoring would be another option. But make sure she does not have urinary tract infection if there are other clues. See your doctor and discuss these issues in detail. He will relate your concern to the physical exam and perform the necessary steps. Good Luck READ MORE
What medicines should diabetics take for fever?
Type 1 diabetes is the commonest metabolic disorder in children. It is also called juvenile diabetes or insulin dependent diabetes mellitus. Insulin is required not only to control blood sugars but also for survival. In the abscence of insulin glucose is not transported to the tissues from the blood. The blood glucose stays high, because the body can not utilize glucose. In the abscence of insulin the body startes to convert fats and protiens to glucose raising the blood glucose level even much higher. As fats and protiens are converted into glucose, the remaining by-products form ketones causing acidosis. Once the blood glucose exceeds the renal threshold of 180 mg/dl, glucose starts to spill in the urine. This causes more water loss from the body, leading to even greater acidosis and dehydration. If left untreated, acidosis and dehydration will lead to diabetes ketoacidosis, coma and death. During illness and stress the body makes hormones known as stress hormones` to fight the illnes. This can interfere with the action of insulin as the body becomes resistant to insulin action. Under stressful conditions the insulin requirement due to the stress hormones may be up by 20-30% of the daily insulin requirement. In people without diabetes, the body produces 20-30% more insulin to compensate for this state of insulin resistance, untill the stressful event or illnes is resolved. However in diabetic patients, especially type 1 diabetic patients, when they are sick their blood sugars increase requiring more insulin corrections to be given. During mild illness insulin requirement goes up by about 10%, and during moderate or severe illness that requirement may go up by 20-30% in their daily insulin regiment untill the illness resolves. Animals fight infection using their immune system. The immune system takes some time to fully mature to overcome illnesses.That is why todlers get sick more often than older children and teen age children get less frequent cold infections than younger children. Children get cold infections and other illness about 4-8 times ayear. There is more frequency of cold and other illness in the younger age group up to 12 times a year (average of 6 per year). By the time the children are in their teen age years they may experience 4-5 cold a year. The signs of illness can be, nausea, vomiting coughing, headaches, diarrhrea, fever, fatigue, ear pain chest pain etc. These things can be causes by common cold, flu, stomach flu, bacterial infections, viral infections, parasitic infections, immunological, metabolic, hormonal and other various medical conditions. Fevere is a condition when the body temprature is above the normal range >98.6 degrees Fahrenheit (F), specifically greater than 100.4 F. Mild fever is 100-102F moderate fever is 102-104F High feveris >104-106F Hyperpyrexia (severe) is >106F Most of the time fever is not a disease but a manifestation of a disease. It is a natural body's defense against infection, thogh there are also many non-infectious causes of fever. Fever is usually accompanied by other physical complaints. That is why people feel better when fever is treated. Fever may or may not require medical treatment. This depends on the patient's age, physical condition, and the underlying cause of the fever. Fever is generally not considered dangerous in it self, except when it is associated extreme external temoprature and medications. Fever should be properly and promptly treated when it happens in diabetic patients, in youger children and any person when it is accompanied with symptoms such as weaknes, poor appetite, diarrhea coughing, ear pain vomitting or other serious issue. During febrile illness, the body temprature is higher. It may also be accompanied with sweating. This process causes evaporation of water from the body, exacerbating dehydration. In type 1 diabetic patients fever can cause dehydraion by evaporating water through the skin. Fever raises stress hormones that cause insulin resistance leading to elevated blood sugars. It also increases level of dehydration by water loss from the kidneys and the skin. In paients with diabetes specially type 1 diabetes, treating any level of fever is very important, though, treating the underlying condition is also of greater importance. Diabetic patients should strictly follow the sick day rules to promptly and properly manage their diabetes. Since dehydration is an important element of illness, hydration is the principal step in managing diabetes during fever or illness. For mild fever simple correction of blood sugars to <150 mg/dl every 3 hours and optimum hydration with about 8 ozs of fliud ( a cup) per hour may suffice. For moderate fever with out other symptoms, frequent insulin correction and more frequent hydration will be required. If the fever is high and there are other symptoms such as pain, vommiting, moderate to large ketones, diarrhea etc calling the doctor or going to the emergency room is the best option. During illness insulin regimen should be increased 10-30% depending on the severity of the codition. Fever is a result of a substance called pyrogen, released from pathogens that triggers a release of prostaglandin E2 from inflammatory cells. It acts on the hypothalamus, to increase the body temprature to generate higher temperature in order to fight infection. Treatment of fever is therefore with anti-inflammatory agents and antipyretics..Though some fevers may not need treatment except treating the underlying cause. But becuase the fever may come with discomfort, treatment of the fever may be a good idea in theses cases. In youg children or patients with diabetes, fever should be treated early and properly. In type 1 diabetes, treatment of fever, hydration and adjusting insulin regimen is very important, besides treating the underline illness. In these patinets fever can cause dehydration and elevated blood sugar in a short time. Treament of fevere involves anti-inflammatory agents and antipyretics. For moderate and mild fevers the nonsteroidal anti inflammatory such as Aspirin, Mortrin, advil, Ibuprofen about 10 mg/kg per dose 2-3 times daily depending on the response will be suffice. Tylenol (paracetamol) 10-15 mg/kg per dose every 4 hours a day until fever breaks, will be an option as well. Anti inflammatory agents may be better because they may lower the degree of inflamation. other symptoms of the illness and the cause of the illness should be adressed and treated proptly. Steroidal anti inflammatory such as hydrocortisone and prednisone are preserved for more severe inflammatory illnesses. A diabetic patient can take any pain killer like a non diabetic patient, with some caveats and as long as the patient is not allergic to the medications.The only difference is some medications such as aspirin may lowere blood sugars witch is not a bad idea when some one is sick and the blood sugars are high. Some medications that are on some syrups may contain sugars that may raise the blood sugars. Those can be chased with insulin if the amount of grams of sugar are known in the dose to be taken. Alternatively sugar free medications can be bought if available. Reading medication labels can help figure out if they contain sugars and if they do, how many grams per dose they contain. In a very young child the syrups containing sugar may be important than a teen age or an adult. Those sugar containing syrups need to be covered with insulin if there are no other options. In the older children and adolescent who can not take pills or tablets they may not make a big difference and they can be dosed with insulin while taking them if necessary. These medications are reasonably safe to take on temporary bases as long as blood sugars are controlled and the person has no advers events towards any of these medications. Some medications may also interfer with the function of diabetes related devices. Tylenol is known to interfer with the blood sugar sensor called Dexcom. However if you need to take Tylenol for pain or fever you should relay on the cappilary finger stick to monitor your blood sugars. Going back to your son: Your son is 14 years old. And I am assuming he can swallow a pill. But if he can not swallow a pill, he can still take syrup for the fever. Fever need to be treated aggeressively to prevent dehydration and elevation of blood sugars. You should increase his insulin by 10-20% depending on the degree of his illness. You should also make sure he is well hydrated. Without proper hydration, no matter how much insulin he gets, it will not work. Let him drink at least about 8 ozs of fluid every hour. Correct his insulin every 2-3 hours to less than 150mg/dl. You should treat his fever with what you use to do before and what works for you. Aspirin and may lower blood sugar. But that may not be a bad thing unless he is sick and he is experiencing low blood sugars (some 20% of patients may experince this, though, the majority (80) will have high blood sugars when they are sick). You can use Motrin pill, tablet or syrup which ever works for you. If the syrup contains sugars and you can not find any sugar free Motrin, you can give him the Motrin syrup if he does not swallow a pill and give some insulin for the sugar. If you have it and you need it you can give him and monitor blood sugars and take appropriate action untill the fever breaks. Remember he can take any of the medications he use to take as long as you are on top of his diabetes. If blood sugars are higher correct them and if they are low give him some fast acting sugars to raise the blood sugar. Remember hydration is very important. You can hydrate him with sugar free or sugar containing drinks as long as you controll the blood sugrs. If you have difficulties handling it or things are getting worse or he looks sick or he is vomiting >2 times or he is not drinking enough, you should call your doctor or take him to the emergency room for intravenous hydration. Please work with your doctor or diabetes educators. They should be able to help you when you need them. Good Luck READ MORE
What's the life expectancy of a child with type 1 diabetes?
Type 1 diabetes is the commonest metabolic disorder and the second commonest chronic disease of childhood. About 90% of type 1 diabetes (type A) is an autoimmune disease were as the 10% is idiopathic type 1 diabetes (type B). There are about 200,000 children with type 1 diabetes in America. It is increasing by about 3% annually. It will triple in the next 30 years to 600,000 children in America, with an incidence rate of about 20,000 newly diagnosed type 1 diabetes children in America. Type 1 diabetes is based on genetic susceptibly and strong environmental triggers. Genetic susceptibility is conferred by about 40 genes. About 50% of genetic susceptibility is conferred by a gene that control the a Major histocompatibity ll molecule (MHC ll) also known as human leukocyte antigen (HLA). Changes in MHC ll gene with strong influence from environmental triggers activate a cytotoxic lymphocytes (killer cells) cascading into an autoimmune reaction. Certain gene variants called HLA Class II DR4-DQ8 and DR3-DQ2 are strongly associated with type 1 diabetes. About 90% of children with type 1 diabetes have this susceptibility. People with DR15-DQ6 alleles are protected from type 1 diabetes. The autoimmune reaction destroys insulin producing cells called Islet of Langerhans in honor of the German scientist Paul Langerhans. Generally it takes 2-5 years for clinical diabetes to emerge once the autoimmune process starts. It takes the destruction of more than 80% of the islet cells for clinical diabetes to evolve. There are also antibodies in type 1 diabetes whose purpose in unknown but they are good markers for predicting type 1 diabetes and to determine if the new onset diabetes have type 1 diabetes. These islet cell antibodies are called GAD, ICA, AAI, AI2 and ZnT8. Type 1 diabetes is more common in the Caucasian population than other ethnic groups, because there is more clustering of the susceptibity genes in this ethnic group. However only 4% of the people who have theses susceptibility genes develop type 1 diabetes. Most people (96%) with these genes do not develop type 1 diabetes. This is because there are multiple variables (alleles) of the same gene leading to variable expression of the same gene resulting in greater polymorphism and environmental triggers strongly influence epigenetic changes with out changing the basic DNA sequence, but only changing the expression. Therefore polymorphism of the gene (about 2000 of them) and environmental modifiers (epigenetics) determine who will develop type 1 diabetes among the population with susceptibility genes. Even in identical twins the concordance rate is about 40% risk of developing type 1 diabetes. In siblings with type 1 diabetes or parents with type 1 diabetes only pass a risk of developing type 1 diabetes <10%. This shows environmental exposure is a strong modifier. Once over 80% of the islet cells are destroyed the body can no make enough insulin to control blood sugars and clinical diabetes evolve. Type 1 diabetes is insulin deficiency state and requires insulin not only for metabolic (glucose) control but also survival. If blood glucose is not treated with insulin excessive urination leads to dehydration and acidosis leading to diabetes coma and death. When insulin was discovered in 1921 it was made commercially available globally in a short period of time. Before the discovery of insulin type 1 diabetes was managed by carbohydrate restriction (literally starvation) therapy. The life expectancy was only few weeks to few months and some survived up to 3 years with starvation therapy. But thy literally died slowly as emaciated ghosts. After the introduction of insulin a disease that was a death sentence (terminal illness) became a disease with grave acute and chronic complications. The life expectance however was improved dramatically. In the early years of insulin therapy acute complications from severe hypoglycemia were very common cause of death. Dehydration from hyperglycemia, and diabetes acidosis and diabetes coma were also common cause of death. Chronic complications such as eye disease, kidney disease, nerve disease and cardiovascular disease (heat disease, heart attack, stroke and arterial diseases) start to develop in 10-15 years after diagnosis. These diabetes related comorbidities became the commonest killers of type 1 diabetes in the 1950's. Due to these acute and chronic complications the life expectancy of type 1 diabetics was much shorter. In the 1950's and 1960's (i.e 20-30 years after the introduction of insulin about 35% of patients with type 1 diabetes died of diabetes related complications. There were about 90% eye disease, 25% kidney disease, over 40% cardiovascular disease. Over 12% of blindness in America was from diabetes. In the first 20-30 years after insulin production the insulin was crude as it have so much impurities. It caused more side effects such as skin atrophies and very erratic blood sugars. different short acting, intermediate acting and long acting insulin were advanced, though they have impurities. However as our understanding diabetes, insulin and much more technological advances were made mortality from acute and chronic complications start to slow down. In 1972 blood sugar testing glucometer was commercially available in the hospital setting and in 1982 self blood sugar monitors were commercially available for patients. The 1980's saw one of the greatest technological advancement. Pure Human insulin was synthesized and was made commercially available. Both short acting and long acting insulin became pure and less immunogenic with the human insulin. Diabetics start to monitor their blood sugars at home as often as they need and glycemic control improved much better leading to less complications and longer life expectancy. Insulin pumps, blood sugar sensors and various advanced blood glucose monitors made management of diabetes much better and brought better quality of life and the life expectancy got longer. A large multicenter trail called the DCCT trail conducted between 1983-1993 demonstrated that tight glycemic control lowered all forms of chronic complications by almost 40% (eye disease, kidney disease, and Cardiovascular disease) These was done in over 1400 type 1 diabetic patients over a span of 10 years. This was a great paradigm shift in the management of diabetes that intensification of insulin in type 1 diabetes showed great improvement in all forms of chronic complications of diabetes. Today intensive insulin therapy using fast acting and long acting insulin or insulin pumps with frequent blood sugar monitoring or using sensors has become a standard of care. And as such, chronic and acute complications of diabetes are much lower than the 1970-1990. The quality of life and life expectancy have dramatically improved though there is about 3-4 fold more risk of dying from diabetes related complications compared to the general population. The commonest cause of death for type diabetes are complications of diabetes such as high cholesterol(cardiovascular disease), inflammation, metabolic syndrome, hypertension, endothelial dysfunction oxidative stress, metabolic syndrome and Advanced glycation end products from chronic hyperglycemia leading to cardiovascular disease, kidney disease eye disease and nerve disease. Without this complications life expectance with well controlled diabetes would be close to the normal population. Out of all the comorbidities the commonest cause of death in diabetes is heart disease. Currently the mortality rate of type 1 diabetes is about 7% in 25 years of having diabetes. So the over all life expectancy of a diabetic patient is about 13 years shorter for women and 11 years shorter for men. Patients diagnosed with type 1 diabetes have shorter life expectancy than type 2 diabetes, because type 2 diabetes is mostly diagnosed in later years and their comorbidities (HTN, dyslipidemia, metabolic syndrome, inflammation) are treated earlier, though, it is not fare to compare both of them because both suffer all the complications of diabetes. Some studies show that type 2 diabetes have a bout 10 years shorter life expectance and type 1 about 20 years shorter. The Canadian study puts the average life expectancy about 55 years. In the USA the average life expectancy for a woman with diabetes is 68 years (13 years shorter) Vs. 81 years and for men 66 years (11 years shorter) vs. 77 years. In children the younger the age of diagnoses the shorter the life span is. If a person is diagnosed before the age of 10 years the life expectancy is shorter by 14 for boys and 18 years for girls. If it is greater than the age of 14 years the life expectancy is higher lower than diagnosed in their 20's or 30's because they have more exposure to hyperglycemia that causes glycemic load leading to inflammation, HTN, heart disease , kidney disease, eye disease, nerve disease and metabolic syndrome. Diabetic patients would have life expectancy if they would maintain good glycemic control and prevent the comorbidities or aggressively treat them early. However 50% are non-complaint and only 30% of diabetic patients have good glycemic control. Most type 1 diabetic patients do not get treated for the most of the comorbidities and that is why they develop more chronic complications. Before the age of 40years acute complications are the commonest cause of death in type 1 diabetes. After the age of 40 years chronic complications are more common cause of death. Poorly controlled diabetics have persistent hyperglycemia. Hyperglycemia overtime causes elevation in advanced glycation end products (AGE). Glucose reacts with proteins, fats and nucleic acids to form glycated products. When excess glycated products are produced they can advance to become oxidizing agent that free radicals and reactive oxygen species. These AGE can cause alteration in cell receptors, cause inflammation (through releasing inflammatory cytokines) and denature proteins and disrupt cell function. They cause faster aging and dyslipidemia, atherosclerosis heart disease, HTN, kidney and eye disease, degenerative diseases, through their oxidative stress. These can lead to shortened life expectancy. Children with early onset diabetes especially before the age of 10 years will spend may years with more glycemic load. This glycemic load leads to metabolic or oxidative stress through the formation of AGE. This leads to chronic complications of diabetes intern increasing morbidity and mortality. life expectancy will be expected to shorten by about 10-16 years in those with history of poor glycemic control and genetic susceptibility to develop chronic complications. Therefore good glycemic control can avoid complications of diabetes. This can lead into a healthy long life with normal life expectancy. Longevity could be achieved by: Eating healthy balance diet Obtaining good glycemic control Regular doctor visit Exercise regularly Avoid stress Sleep well Check HbA1C regularly Remember that diabetics die not because they have diabetes but they die from diabetes related complication such as heart disease (cardiovascular disease), kidney disease, HTN, chronic inflammation to leads to atherosclerosis. Preventing or treating these early enough will prolong life expectancy. Going back to your Daughter: Your daughter seems to be doing well with managing her diabetes. She should continue to do so until we have a cure. She should check her blood glucose as often as necessary without additional stress. She needs to get her insulin appropriate to the food eaten and correct blood sugars that are out of range without causing hypoglycemia. Maintain blood sugars between 70-140 about 75% of the time. Maintain HA1c <7.5%. Let her exercise regularly. She need to eat healthy and balanced diet. Maintain ideal weight if possible. She needs to have regular check up for HBA1c, urine microalbumine, Let her get regular eye exam and lipid profile should be monitored on regular basis. Any comorbidities such as high lipids, HTN, nerve disease and urine microalbumine should be treated early and aggressively. If she maintains good glycemic control until there is a cure she should be able to enjoy a happy normal life with normal longevity. But if the glycemic control is poor and the comorbidities are not prevented or not treated early and aggressively the life expectancy with diabetes from the age of 10 years is about 14-18 years shorter than average. However this is a statistical probability (relative risk not an absolute risk) since she does not have any complications at this time and may not develop them in the future. The most important issue right now is to take good care of her diabetes and maintain good glycemic control and not worry about (statistical probability) future complications since we would not know for sure if she will develop complications of diabetes that will cut her life expectancy shorter. She should enjoy normal life with normal life expectancy as long as she is in good glycemic control. Work with your daughter's doctor closely, and utilize any of the available diabetes gadgets we have including insulin pumps and blood glucose sensors, if you are comfortable using them. You should also remain hopeful that a cure may be on horizon. Good Luck READ MORE
Is PCOS serious in kids?
Poly Cystic Ovarian Syndrome (PCOS) is a common disorder in women of child bearing age. About 7% of women in their reproductive age have PCOS (over 5 million American women). In adolescent girls prevalence of PCOS is unknown but it may be about 3% or more. So PCOS is common in adolescent girls. Women with PCOS (irregular menses and hperandrognism (high male hormones)) are at a higher risk for insulin resistance, metabolic syndrome, cardiovascular disease, type II diabetes, obesity, endometrial cancer, infertility, social and psychological disorders. PCOS impacts their quality of life significantly. There are more than three guideline to diagnose PCOS in adults. 1) National institute of health criteria: based on 2 criteria menstrual irregularity and hyperandrogenism 2 )PCOS society: Is based on any 2 of the following: a) hyperandrogenism b) Irregular menses c) poly cystic Ovaries on ultrasound 3) Rotterdam criteria: Based on two out of three: a) hyperandrogenism b) Irregular menses c) poly cystic Ovaries on ultrasound The most commonly used criteria for diagnosing PCOS is the Rotterdam criteria. Hyperandrogenism is defined as the physical manifestation of excess androgens ( mainly high testosterone and androstendione) such as hirsutism, acne androgenic alopecia (male type hair loss), and Acanthosis Nigricans (skin darkening due to insulin resistance). Menstrual Irregularity is defined as Amenorrhea (no period for three or more months in a row) or Oligomenorrhea ( les than 8 periods a year) in the face of high levels of luteinizing hormone (LH). Poly Cystic Ovaries are defined as presence of greater than 12 follicles in each ovaries at least each 2-9 mm in size giving rise to an ovarian volume greater than 10 ml as measured by ultrasound. There are at least 4 phenotypes of PCOS in the Rotterdam criteria; 1) classic PCOS: is composed of chronic anovulation (menstrual irregularity), hyperandrogenism, and polycystic ovaries 2) Classic PCOS with chronic anovulation, hyperandrogenism, but no ovarian cysts. 3) Non-classic PCOS composed of, hyperandrogenism, polycystic ovaries but regular menstrual cycles. 4) Non-classic mild PCOS consists of chronic anovulation, polycystic ovaries), but normal androgens, PCOS has therefore a wide spectrum of manifestation having a combination of two to having all of the conditions. Women who have the classic PCOS have worse metabolic and cardiovascular risk, such as, abnormal lipid levels, insulin resistance, metabolic syndrome, type 2 diabetes, hirsutism and androgenic and alopecia. In adolescent girls with PCOS the criteria is not well defined. In routine practice, the adult criteria's are used for adolescents ( the Rotterdam criteria). However, the adult PCOS criteria have challenges in diagnosing adolescents girls. In many adolescents menstrual irregularity is common in the first 2 years after menarche ( physiologic menstrual irregularity or physiologic Anovulation). Many adolescents also have acne though they typically do not have excess androgens. A significant portion of normal adolescent girls have ovarian cysts similar to women with PCOS. Normal testosterone reference range are not well defined in adolescent girls. Experts recognize that there is a dilemma in distinguishing physiological anovulation’ from true ovulatory dysfunction in adolescents but they noted that most adolescent menstrual cycles are with in certain range and recommend the follow definitions to be used in evaluating adolescent girls for ovulatory dysfunction. I) Amenorrhea more than 3 consecutive months even in the first year after menarche. 2) Menstrual cycle less than 21 days or greater than 45 days, 2 years after menarche. 3) Lack of menses by 15 years of age or 2–3 years after breast development. PCOS in adolescents can therefore be defined as: 1) irregular menses as defined above. 2) Persistently elevated testosterone and/or free testosterone and manifestations of hyperandrogenism such as moderate to severe hirsutism and persistent acne unresponsive to topical therapy. Polycystic Ovaries were deferred for evaluation of adolescent PCOS until high quality data is available. Also the expert panel included that: 1) Treatment of PCOS can be initiated in order to treat the symptoms and minimize the comorbidities of PCOS with out the establishing the diagnosis of PCOS. 2) The diagnosis of PCOS can be deferred, while symptomatic treatment and follow-up of the symptoms is an alternative option; 3) Obesity, hyperinsulinemia, and insulin resistance are common in adolescents with PCOS, but these features should not be used for diagnostic purposes; 4) PCOS is a diagnosis of exclusion. Other causes of abnormal period (menses) and hyperandrogenemia should be ruled out before establishing the diagnosis of PCOS. The hallmark of PCOS both in adults and adolescents is anovulation and hyperandrogenism/hyperandrogenemia. These features stem from progesterone deficiency due to the absence of ovulation. During and after ovulation the corpus luteum produces a lot of progesterone that stabilizes the endometrial lining. When there is no implantation (fertilization) the corpus luteum dies and the progesterone production stops and the progesterone withdrawal causes uterine bleeding. Menstrual cycle is controlled by the hypothalamus pituitary ovarian axis. The hypothalamus is the pulse generator and produces a generator called GnRH (gonadotropin releasing hormone). The GnRH stimulates pituitary hormones called LH/FSH (luteinizing and follicular stimulating hormone). These hormones stimulate some ovarian follicles to mature and produce hormones. The FSH recruits one of the follicular cells to mature into a graafian follicle for ovulation. The LH stimulates the theca cells to make androgens which are converted by the granulose cells into estrogen. Estrogen stimulates the growth of endometrial lining and progesterone stabilizes the endometrial lining. There are two phases in the menstrual cycle. They both take place in the ovaries and the uterus. In the ovaries they are called follicular and luteal phase while in the uterus they are mainly termed proliferative and secretory phase. The first menstrual bleeding is the beginning of the follicular phase. The proliferative (follicular) phase is driven by FSH in the ovaries and estrogen in the uterus. While the luteal phase is driven by LH in the ovaries and Progesterone in the uterus. The follicular (proliferative) phase is the most variable in duration it can last between 7 to 21 days (average 14 days). It is dominated by estrogen production and endometrial proliferation of up to 10 millimeter thickness of the endometrial layer called functionalis layer. While the luteal (secretory) phase is constant and lasts exactly 14 days. women with higher FSH will have shorter follicular phase and women with low FSH will have longer follicular phase. The variation in the length of follicular or proliferative phase in women is determined by the amount of FSH available. This variability is not only among women but also in the same women at different times of her life, she will have fluctuation in the level of FSH. When levels of FSH fluctuate in the same woman she will have shorter or longer duration of her cycle. The luteal phase is driven by the corpus luteum after ovulation and produces a lot of progesterone up to 40 mg per day to support the endometrial lining. During the luteal phase an LH surge takes place that heralds ovulatory event within 2 days of the surge. Once the egg ovulates it is picked up by fimbria and travels to the uterus via the fallopian tube for implantation. The remaining tissue becomes corpus luteum and is the main source of progesterone. A woman is fertile when the egg is ready for implantation. A woman is most fertile bout 6 days after ovulation during days 20-24 days of the menstrual cycle. The uterine environment is conducive for implantation during these days though fertilization is possible any time after ovulation until day 24 of the menstrual cycle. In the absence of implantation the corpus luteum only lives up 10 days and start to die around day 24 of the menstrual cycle. It takes 4 days for the corpus luteum to involute completely. Once the corpus luteum is dead Progesterone production ceases. The withdrawal of progesterone from stabilizing the endometrium causes constrictions of arterial blood supply of the endometrial lining. The endometrial lining ( the functionalis layer becomes necrotic and releases prostaglandins and other inflammatory agents to expedite the sloughing of the >10 millimeter functionalis layer. This also causes contractions of the uterine muscles to expel the sloughed endometrial tissue. This is also the cause of menstrual cramps. The average woman will bleed for 2-6 days ( average 4 days plus or minus 2 days). The average blood flow is a bout 50 ml per menses. About 5 tampon. High adsorbent tampon will hold about 10ml. Less than 20 ml or greater than 80 ml per period is abnormal. In PCOS the GnRH pulse generator is abnormal. The frequency is more rapid the usual. LH release is more dominant than FSH. The LH to FSH ratio is >2 in over 60% of women. Since LH is in excess, the theca cells make a lot of androgens and the granulosa cell convert some of it to estrogen. There are plenty of androgens and estrogen in PCOS women. The excess androgens mainly testosterone and it free form free testosterone and Androstendione cause, acne, hirsutism male type baldness, voice change etcetera. While the estrogen increases endometrial lining. Some of the androgens and estrogens are also converter to estrone that causes endometrial hyperplasia and endometrial cancer. Women with PCOS also have low sex hormone biding globulin (SHBG). SHBG binds to androgens and lower their androgenic effect. When SHBG is low, even if androgens are normal the free hormone will be in excess to cause the skin manifestations oh hyperandrgenemia. In PCOS Ovarian follicles develop but do not mature to ovulate but plenty of the follicles will be recruited and get suspended but do not ovulate. They become cysts and produce a lot of androgens and estrogen but not progesterone. Since these follicles do not ovulate to become corpus luteum there is progesterone deficiency. In the absence of Progesterone withdrawal there will not be a menstrual bleeding. In PCOS Most women will have amenorrhea or Oligomenoria. They are producing excess androgens (also Estrogen). Excess androgens will also lead to excess weight gain and insulin resistance. More weight gain will lead to more insulin resistance. Excess insulin will lead to more stimulation of the ovaries to make more androgens making the condition worse. Obesity also leads to more estrone formation leading to more endometrial hyperplasia or neoplasia. Insulin resistance leads to prediabetes, type 2 diabetes, dyslipidemia, fatty liver, metabolic syndrome and cardiovascular disease. Insulin resistance also leads to Leptin resistance ( a hormone to controls appetite). During leptin resistance there is a persistent hunger that causes more food consumption and more weight gain. In PCOS a hormone called Adiponectin is low. This hormone helps us burn fat and carbohydrates, But when this hormone is low we store more fat and gain more weight. The treatment of PCOS is targeted in lowering the androgen levels and improving of the symptoms. The corner stone of the treatment is the use of low androgenic Combined oral contraceptive. The Progestin component should be low androgenic. It is mainly done in two steps: 1) The endometrial layer should be cleaned with progesterone. Since they are not producing progesterone they do not go through the progesterone withdrawal to slough off the endometrial lining of the functionalis layer ( the basalis layer which is usually 2 mm usually stays). Due to lack of corpus luteum i.e. lack of progesterone the endometrial layer is thicker than usual and, it needs to be cleaned. Progesterone is used initially to cleaned it. A) Provera 10 mg daily for 10 days or 10 mg twice a day for 5 days. B) Micronized Progesterone 200 mg daily for 10 days Once good sloughing takes place then Combined Oral Contraceptives (COC) should be used. 2) Combined Oral Contraceptives: Drespirenone/ethinylEstradiol; yasmin/angeliq Norgestimate/EthinylEstradiol: Orthotricyclen Dosegestrel/EthinylEstradiol: Mircette/Cerazette 3) Cyclic Progestins: If the combined oral contraceptives are not optional cyclic predestines can be used for 10 days of each month. They will protect endometrial hyperplasia but will not suppress the ovarian hyperandrogenism (hirsulism, acne, balding etc.) Hirsutism can be managed with medications if the Combined Oral contraceptives (COC)are not improving the symptoms. The following medications can be added: 1) Eflorenthin hydrochloride 13.9%.(topical) It kills androgenic hair 60-80% 2) Spironolactone 25 mg 100mg twice a day. It is androgen blocked. Should be used with COC since it is erotogenic. 3) Laser therapy Acne can be managed as follows: 1) Topical benzoyl peroxide 5% gel 2) clindamycin 1% or erythromycin gel topical 3) retinoid oral isotretinion. 4) Minocycline 5-100 mg doxycycline oral daily. GnRH agonists such as leuprolide ( Lupron) can be used to suppress GnRH. This can lowered androgens by suppressing ovarian function. Intermittent leuprolide acetate can also be give to initiate ovulation. Insulin resistance can be managed with metformin. Some women can resume regular ovulatory menses by taking metformin. Metformin and pioglitazones (actos) may increase insulin sensitivity that may help the ovaries produce less androgens. If there is dyslipidemia statins and fibrates should be used liberally in PCOS patients. There is an increased risk of cardiovascular disease in PCOS patients. Metabolic syndrome is also common in these patients. There are many comorbidities with PCOS: Nutritional and psychological interventions with life style modification are very important component of the management of PCOS. Weight loss and regular daily structured physical activity should be encouraged consistently. Comorbidities of PCOS should be addressed. 1) Dyslipidemias; About 70% Women with PCOS have abnormal lipid profile. 2) Cardiovascular disease is more common with women with PCOS 3) Endometrial neoplasia 4) Obstructive sleep apnea; Even normal weight women with PCOS have 40% risk of developing sleep apnea. 5) Infertility. This is very common in women with PCOs 6) Early miscourage is 3 times more in PCOS 7) Gestational Hypertension and Gestational diabetes is 3 times common in PCOS 8) Preterm labor is also 3 fold more in PCOS 9) Perinatal mortality is very common. 10) Obesity; 80% of women with PCOS have obesity or are overweight. 11) type 2 diabetes or prediabetes: Over 50% of women with PCOS will develop diabetes or prediabetes by the age of 40 years. 12) Metabolic syndrome. PCOS can lead to metabolic syndrome. 13) Insulin resistance: insulin resistance is common in women with PCOS. 14) Hypertension; HTN is common in women with PCOS. Since PCOS is a diagnoses by exclusion. The following diagnosis should be excluded: 1) hypothyroid or hyperthyroid. 2) Cushing disease and other adrenal anomalies 3) Pituitary abnormalities; pituitary tumors, hyperprolactinemia or hypo gonadotropic hypogonadism. 4) Ovarian failure. 5) Late onset Congenital adrenal hyperplasia. 6) Ovarian or Adrenal androgen producing tumors. Going Back to your Daughter: Your daughter have PCOS. This condition is very common in women of childbearing age (mostly 15-45years). About 3% to as high as 20% adolescent girls may have PCOS. Most of these conditions may have their roots in childhood, but the symptoms and comorbidities start to show up in adult hood. PCOS in adolescents should be managed properly. The symptoms of PCOS should be treated regardless of the diagnosis of PCOS. Weight management should be a priority. Maintaining a reasonable weight will help in the management of PCOS. A healthy balanced diet and daily structured physical activity is very important to lessen the symptoms of PCOS. Untreated PCOS will have various comorbidities. They include: obesity, insulin resistance, dyslipidemias, fatty liver disease, cardiovascular disease, endometrial neoplasia, prediabetes, diabetes, gestational diabetes, hypertension, metabolic syndrome, sleep apnea. infertility, miscourage etc. Theses are serious issues to consider. Therefore PCOS needs to be managed early and should be taken seriously to avoid the above serious complications. You should work with your daughter's doctor closely, and let her get proper treatment. With early intervention the out come will be much better. Good Luck READ MORE
Will my daughter have type 1 diabetes for the rest of her life?
Type 1 diabetes is insulin dependent diabetes or also known as juvenile diabetes. It is classified in to two groups. About 90% of type 1 diabetes (type A) is due to autoimmune disease process while the 10% type 1 diabetes (type B) is not related to autoimmune process. But both require insulin not only to control diabetes but also for survival. Type 1 diabetes is therefore an autoimmune destruction of the insulin producing cells called Islet cell, located mainly at the head of the pancreas. About 90% of type 1 diabetes is therefore due to a destructive inflammatory process of the islet cell called insulitis. This inflammatory process destroys about 85% of islet cells before full blown diabetes will emerge. The remaining 15-20 % of islet cells can not make enough insulin to support the metabolic demand of the body. The purpose of insulin is to transport glucose from the blood to the tissues (cells) to be utilized for energy and for other purposes. In the absence of insulin the blood sugar increase and spills through the kidneys to the urine. Eventually dehydration and acidosis will prevail making survival impossible. Type 1 diabetes is therefore insulin dependent and needs insulin not only to control blood sugars but also for survival. Type 1 diabetes is a destruction of insulin producing cell called islet. Three things are required for type 1 diabetes to happen. 1) Genetic susceptibly 2) Environmental trigger 3) An Autoimmune cascade. For an individual to develop type 1 diabetes, he/she has to have genetic susceptibity (susceptible alleles) interacting with environmental factors leading to chronic autoimmune inflammation of the islet cell leading to the destruction of at list 80% of the cells that make insulin. Genetic susceptibilities are conferred by specific genes or alleles involved in cell surface recognition molecules. Environmental factors (triggers) could be viruses, food products and other environmental or cellular agents that interact with the susceptible host immune system. An autoimmune process is a dysregulation of the immune system that fails to tolerate self antigens. It takes place when auto reactive cell fail to tolerate self antigens and initiate chronic inflammation of specific tissue targeted it for destruction (islet cells). Once the majority of islet cells are destroyed the clinical symptoms of diabetes emerge. Though type 1 diabetes takes 2-5 years to emerge the symptoms of type 1 diabetes are dramatic (come suddenly). These symptoms are; 1) Thirst 2) un usual hunger 3) Fatigue 4) Excessive urination 5) Blurry vision 6) weight loss 7) bed wetting 8) Dehydration and Acidosis. Type 1 diabetes is only treated with insulin. With out insulin survival is difficult. So far there is no cure for type 1 diabetes. It is also true that type 1 diabetes is not reversible because the body can not or does not make enough insulin since the majority of islet cells are destroyed by the chronic autoimmune inflammation. Good diet and exercise would help but does not treat type 1 diabetes. Islet cells (insulin producing cells) have a remarkable ability of regeneration. However the rate of distraction of the islet cells by the immune system is much greater than the ability of the islet cells to regenerate. There are adult centers for islet cell transplant who harvest islet cells from 3-4 human cadavers for a single person transplant into human liver. But the use of immunosuppressant medications in this case is not safe in most adults and will not be considered for children. These islet cell transplants using human cadaver with immune suppressing medication will only last for few years as the transplanted islet cells also get lost with time. Various immune modulating agents were used in the past with little success. There is ongoing research aimed at islet cell regeneration. When stem cell technology, islet cell regeneration technics and islet cell engineering advances, there may be a cure for type 1 diabetes in the future. That time will be one of the greatest accomplishment in medicine as the discovery of insulin in 1921 was one of the most glorious events in medical history. With proper treatment, type 1 diabetic can live a healthy happy normal life, like any person. Their longevity may be closer to that of the average person when diabetes is treated well. The life expectancy was about 10 years shorter than average person, but, with the advent of sophisticated insulin pumps, blood glucose monitors, and sensors an excellent glycemic control is feasible (HbA1c<7.5%). If good glycemic or diabetes control is achieved there is no reason why a diabetic patient would not have a life expectancy much closer to the average person ( currently 78 years for men and 81 years for women). Going back to you daughter: Your daughter has type 1 diabetes for the last three years. You seem to manage her diabetes well. And I hope you continue to do so. At this time there is no cure for type 1 diabetes. And type 1 diabetes typically is not reversible. So far most established autoimmune diseases are not reversible, though some do but typically type 1 diabetes is not one of them. Until there is a cure, which we hope will come in the future, you need to focus on managing her diabetes well, as you seem to be doing now. Use the best available diabetes gadgets we have. Perform frequent blood glucose testing and administer proper amount of insulin and promote healthy diet and weight as to maintain reasonable blood sugars. And limit day to day blood sugar variations. Do not stress your self and don't stress your daughter as well. Only do your best and things will be fine. Get help when you need them and work with your doctor closely. Good luck READ MORE
Why do children get metabolic syndrome?
Metabolic syndrome is a very serious medical condition that affects almost a third of the American adult population. It has high morbidly and mortality rates. It is associated directly and indirectly in a bout 75% of the health care cost of America. That comes to over 2.5 trillion dollars per year out of the 3.5 trillion annual health expense in America. This is bigger than the GNP of many of the advanced countries of Europe. This could have been enough annual budget for free health care system in America. Preventing metabolic syndrome and it grave comorbidities will ease this financial burden. Metabolic syndrome is a constellation of three or more conditions. It is composed of at least 3 of the following 5 conditions: 1) Central obesity 2) Hypertension 3) Hyperglycemia and/or prediabetes 4) Elevated triglycerides 5) Low serum high-density lipoprotein 6) Microalbuminuria Metabolic syndrome has been defined by at list seven different organizations using any of the above three or more combinations. Definition of Metabolic Syndrome: 1) WHO DEFINITION: Insulin resistance plus any 2 of the above conditions 2) EUROPEAN GROUP FOR STUDY OF INSULIN RESISTANCE DEFINITION: Insulin resistance and any of the above 2 conditions with the exception of microalbuminuria. 3) NCEP ATP III (national cholesterol education pane lll) DEFINITION: Any of the three above conditions except microalbuminuria. 4) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS DEFINITION: No specification of any combination, but considered the following conditions to be included: Elevated triglycerides, reduced HDL-C, high blood pressure, and obesity. The panel also included increase in hypercoagulability, endothelial dysfunction and inflammatory markers. 5) INTERNATIONAL DIABETES FEDERATION GLOBAL CONSENSUS DEFINITION: Increased wait circumference (WC) >94 cm for men and 80cm for women plus 2 of any of the above conditions. 6) AMERICAN DIABETES ASSOCIATION: The panel lowered the criteria for insulin resistance but concur with the definition of NCEP lll definition. 7) AMERICAN HEART ASSOCIATION: Any combination of 3 conditions. Insulin Resistance is closely related with prediabetes HbA1c >5.7% or impaired fasting glucose >100 mg/dl of glucose or impaired 2 hour postprandial blood glucose (140mg/dl of glucose). Since many different criteria were used to define metabolic syndrome in adults, defining the metabolic syndrome in children and adolescents has been difficult. So far, there are no consensus or guidelines for the pediatric population, though there are many definitions with sight differences. Currently, the international diabetes federation defines metabolic syndrome in children and adolescents grater than 10 years old as follows. Central obesity plus at least 2 out of 4 criteria ≥3 criteria: 1) Central Obesity: Waist circumference (WC) ≥90th percentile for age and gender. 2) Hypertension: Systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 mmHg or treatment with anti-hypertensive medication BP ≥90th percentile for age and gender 3) Hypertriglyceridemia Triglyceride ≥150 mg/dL 4) Low HDL (high Density Lipoprotein cholesterol): HDL <40 mg/dL HDL ≤40 mg/dL 5) Impaired glucose Fasting plasma glucose ≥100 mg/dL or known T2DM Others define childhood and adolescent metabolic syndrome using 3 or more criteria in a slightly different way. The clinical features seen in metabolic syndrome are as follows: 1) Obesity: Over the last 30 years, the rate of obesity has been speeding up at an alarming rate. During the same period the prevalence of obesity has increased by 3-4 fold both in adults and children. Obesity in children is increasing more in Hispanic and other minorities both in children and adults though every one is getting bigger. Obesity ( weight greater than 95 percentile for age and gender) has a good correlation with the metabolic syndrome in children and adolescents. About 20% (about 15 million children) of children and adolescents are obese ( there are about 85 million children in America). And a much bigger than that are overweight. Almost 30% of Hispanic children, 22% of blacks and 15% of whites are obese. About 80% of them may continue to be obese adults as well. About 90% of obese children have at list one metabolic risk factor. About 30% of obese children have metabolic syndrome. Non-obese over weight children (weight greater than 85 percentile but less than 95 percentile) have 12% prevalence of metabolic syndrome. About 3.5% of the pediatric population have metabolic syndrome. Normal weight children have very low rate of metabolic syndrome (about 0.5%). The hall mark of metabolic syndrome is therefore insulin resistance for most definitions. Metabolic syndrome is associated none alcoholic fatty liver, elevated liver enzymes, high uric acid level; nonalcoholic fatty liver disease; vascular inflammation, polycystic ovarian syndrome, acanthosis nigricansin, cardiovascular disease sexual dysfunction and others. About 30% of adult Americans may have metabolic syndrome with or without obesity. Metabolic syndrome is more common in obese people though none obese people have metabolic syndrome as well. About 80% of obese people have metabolic syndrome (sick obese) in America. In the adult population, about 20% of obese Americans are healthy ( healthy obese). There are over a 100 million Americans with Metabolic syndrome. Out of these 75 million are obese. About 30% of America adult population (100 million) are obese adults as well. About 25 million people have metabolic syndrome but they have normal weight or are slightly over weight (thin sick). The prevalence of metabolic syndrome increases with age and the degree of obesity in both adults and children. The same is also true for obesity. Obesity may not be a diseases but a metabolic adaption to store excess ingested calories as a body fat. Obesity is an association with metabolic syndrome but not a cause of the disease. During human evolution the thrifty gene that allowed people to undergo insulin resistance in order to store fat during plenty was selected so that survival will be insured during scarcity. However we live in modern society that we have only plenty and no scarcity. In todays affluent society the same thrifty gene may have become a liability rather than security. For what ever reason in the majority of obese adults and over 30% obese children the fat cells get sick. Sick fat tissue leads to metabolic syndrome through exporting insulin resistance or other inflammatory or metabolic means. But when fat tissue remain healthy, obesity will not pose a metabolic problem. When fatty tissue is sick (adiposopathy) it leads to fatty acid leakage which will over load the liver and make fat droplets in the liver leading to fatty liver. This also unleashes inflammatory cytokines that damage the vascular lining leading to inflammation and atherosclerosis. It also exports insulin resistance fueling the metabolic syndrome. Obese people with healthy adipose tissue share non of these metabolic consequence and remain obese healthy. What makes one obese group develop metabolic syndrome but not the other group may be a matter of genetic susceptibility with greater share of environmental factors. Obesity is not only an important part of the metabolic syndrome but also in the development of cardiovascular disease and type 2 diabetes mellitus. It is quite obvious that there is a strong association between the degree of obesity, insulin resistance and the prevalence of metabolic syndrome. Obesity is when the body mass index (BMI), is ≥95th percentile for gender and age. Overweight is when the BMI is ≥85th percentile and <95th percentile for age and gender. Visceral fat has also a strong association with both childhood metabolic syndrome and cardiovascular disease later in life, independent of the degree of obesity. Waist circumference can indicate visceral adiposity. There are no current pediatric reference range for waist circumference, instead waist to hip ratio can be used to determine visceral adiposity. A waist to hip ratio of greater than) 0.6 will be considered a risk for metabolic syndrome. Metabolic syndrome is therefore an interaction between obesity, insulin and inflammation. Obesity increases visceral fat that leads to fatty acid leakage that cause decrease glucose uptake by the muscle and increased glucose and triglyceride production by the liver. This increases over production of triglycerides (lipids) by the liver and increased fat synthesis in the adipose tissue. The sick visceral adipose release inflammatory mediators such as Interleukins (IL) 6, tumor necrotic factor alpha, C-reactive proteins and plasminogen. These mediators cause vascular inflammation and hypercoagulable state. These cause insulin resistance and impaired insulin production. Visceral adiposopathy also causes abnormal Adipokines. It cause low adiponectin, an adipokine, (that is important in protecting the body from oxidative stress) and leptin resistance. Leptin is an important hormone made by fat cells and controls satiety in the hypothalamus. Leptin deficiency or leptin resistance leads to continuous hunger as if there is excess ghrelin (a hormone for hunger). Insulin resistance leads to leptin resistance and over eating behavior. Visceral adiposity causes excess release of angiotensin II type receptors leading to activation Reactive oxygen species and increase stimulation of renin angiotensin aldosterone system in the kidneys that will increase salt retention from the kidneys, increased vascular tone. These causes chronic increase in blood pressure and cause chronic tissue oxidative stress. Visceral adiposity can lead to neurohumoral activation, chronic inflammation and insulin resistance. The interaction of these entities leads to metabolic syndrome. 2) Dyslipidemias; Abnormal lipids mainly triglyceride abnormalities are essential in the metabolic syndrome. Insulin resistance leads to fatty acid leakage (adiposopathy). There is activation of protein kinases that control over production of liver glucose and synthesis of lipids in the liver and adipose tissue (lipogenesis) The liver over produces triglycerides (VLDL) and sugars. The muscle glucose uptake decreases. The excess production of triglycerides in the liver are transported to the muscle and adipose tissue for energy use and storage. Since lipids are not soluble in plasma they are transported in lipoproteins called Apoliporoteins. Apolipoprotein B transports triglycerides from the liver to tissue as VLDL(very low density lipoproteins). The VLDL binds to it receptor in the tissue to deliver the triglyceride for energy and/or storage in adipose tissue. Once it sheds most of it triglycerides it be come smaller but cholesterol richer particle known as IDL (intermediate lipoprotein lipase) This IDL continues to give up more of its Triglycerides to the tissues with the help of an enzyme called lipoprotein lipase with the help of another apolipoprotein call Apo C2. Once it gives up most of it triglycerides it becomes cholesterol enriched species called LDL low density lipoprotein. LDL gives its cholesterol to all the cells for the repair of their extensive cell membrane and those tissues that need to make androgens estrogen vitamin D and others from cholesterol. The rest of the LDL traffics back to the liver to be dismantled by the liver and repackaged with triglycerides in the liver. This cycle goes on and on in life. During its trafficking LDL can give some of it cholesterol or triglycerides to HDL (high density lipoprotein) a lipoprotein called good cholesterol that scavenges any cholesterol in the body so that un used cholesterol does not precipitate to form atherosclerosis in the vasculature when LDL is trafficking. However in the metabolic syndrome or insulin resistance, an enzyme that controllers triglyceride hydrolysis in the tissue called ApoC3 is over produced. This this blocks the hydrolysis of triglycerides by the tissue causing elevated triglyceride level (VLDL) before and after a meals. There is also an overproduction of Triglycerides (elevated VLDL) from the liver since there is fatty acid leakage from sick adipose tissue and the liver is over producing triglycerides from fatty acids and package them as VLDL for trafficking. The triglycerides can only be trafficked from liver as VLDL in the blood since they are not soluble in plasma. So VLDL which is Apo B particle, also called LDL(p) particle increases though the LDL cholesterol LDLc may not increase. In insulin resistance or metabolic syndrome there is over production of triglycerides in the liver and trafficked as VLDL out of the liver in the plasma. The excess triglycerides (VLDL) atherogenic particles called LDLp that are small dense easily oxidized particles that cause atherosclerosis by breaching the vascular endothelium. The overproduced VLDL (triglycerides out side the liver) donate their triglycerides to HDL (the good cholesterol) depleting it cholesterol content and making it small and susceptible to renal elimination. This makes the HDL cholesterol low in metabolic syndrome. Some of the triglycerides overproduced in the liver become oil droplets and sequester in the liver causing non alcoholic fatty liver which can lead to fatty liver disease and cirrhosis. None alcoholic fatty liver also exports insulin resistance independent of visceral obesity. 3) Insulin resistance can lead to glucose impaired fasting glucose or impaired 2 hour post prandial after 75 grams of glucola or heavy carbohydrate meal and may progress to Type 2 diabetes when of β-cell function deteriorates as a result of diminished insulin secretion. Impaired fasting glucose is defined as fasting blood glucose of ≥100mg/dL and impaired glucose tolerance is diagnosed if blood glucose is ≥140 at the 2-h mark of the oral glucose tolerance test. Routine monitoring of the progression from insulin resistance to type 2 diabetes is important since the progression is variable 4) None alcoholic fatty liver disease (NAFLD): This is becoming the most common cause of liver disease in children due to the rise obesity. Obesity strongly correlates with fatty liver disease in children. Diet such as high fructose consumption may also lead to NAFD independent of obesity. Excess ingestion of high fructose, branched chain aminoacides and lactate are converted into triglycerides. Excess triglycerides lead to fat droplets is the liver, and excess VLDL when triglycerides are trafficked out side the liver. This can lead to cirrhosis. Monitoring of liver with US or other non invasive modalities are required. Liver biopsy may be indicated in some cases. 5) Polycystic ovarian syndrome (PCOS): PCOS is another very important risk factor for metabolic syndrome. It is a constellation such as Amenorrhea, high androgen levels or phenotypic manifestations of hyper androgenemia such as hirsutism, severe acne, voice changes etc. with or with out cysts in the ovaries. PCOS is strongly associated with obesity and insulin resistance. It is an independent risk factor for metabolic syndrome regardless of obesity or presence of insulin resistance. Women with PCOS should be screened for metabolic syndrome regularly. Children and adolescents should be screened for overweight and obesity , fatty liver disease dyslipidemias, diabetes, PCOS, metabolic syndrome and hypertension annually and when indicated. Risk factors should be identified on individual bases. Fasting lipid profile should be obtained specially in overweight children. The triglyceride and HDL need to be look at carefully. The triglyceride should not be more than 3 times than HDL (good cholesterol) ratio of TG/HDL <3. If it is >3.0 there is a risk metabolic syndrome should be considered. Prevention should be directed towards maintaining healthy weight though regular structured physical activity and healthy diet. Soft drinks, sports drinks including diet drinks should be avoided if possible. Avoiding salty foods and processed foods will be very important. Children should be encouraged to eat plenty of vegetables and reasonable amount of fresh fruits. Unlike vegetables excess fruits have a lot of sugar though they contain fibers to slow glucose absorption. So, the amount of fruits should be limited to a reasonable portion a day. Metabolic syndrome should be managed initially, with healthy balanced diet and regular structured physical activity. For insulin resistance, insulin sensitizers such as metformin and actos should be considered. For patients with fatty liver actos (pioglitazone) could be tried both in children and adults. Lipids and high blood pressure should be treated aggressively if life style change, diet and exercise are not enough. A good dietician is of at most importance in this case. Behavioral modification and psychological counseling may help in some cases. It is also important to work with your doctor closely for a good outcome. Going back to your son: Metabolic syndrome is getting common with the emergence of overweight/obesity. There are almost 15 million children (20%)with obesity in the USA. About 30% of obese children have metabolic syndrome. There also 12% children with metabolic syndrome who are not obese but they are over weight. About 0.5% of normal weight children have metabolic syndrome. The degree of overweight correlates with metabolic syndrome though it is hard to make a causal relationship. Most overweight kids will end up overweight as adults and will have all the metabolic syndrome and its associates, such as type 2 diabetes, cardiovascular disease, high blood pressure, abnormal lipids, fatty liver, PCOS, and other diseases. Most of metabolic syndrome and diabetes are associated with overweight/obesity. Visceral fat can lead to insulin resistance, release of inflammatory chemicals, fatty liver and abnormal lipids. Genetic interaction may have weak association with obesity and metabolic syndrome. Most of it is environmental exposures such as high sugar intake specially high fructose syrups added to almost 80% our processed foods and drinks. We are consuming more sugar now than 30 years ago. We started consuming high sugars since cheaper highly sweet corn syrup emerged in the late 70's. Metabolic diseases take time to emerge after the time of exposure. And the metabolic consequences have now expressing at a younger age. The average sugar consumption should be 5 teaspoon per day. Currently we consume about 20 teaspoon per day. We are consuming about 170 pounds of sugar per year per person. This adds about 300 extra calories a day. These sugars are cheap and very sweet. Mostly they are high fructose corn syrup added to our processed food and drinks. Fructose does not burn in the body. It is converted at a cost of energy to glucose and fat only in the liver. Excess fat will cause weight gain and insulin resistance leading to metabolic syndrome. It can also lead to metabolic syndrome without causing obesity. There are other causes of metabolic syndrome as discussed above. Children as young as 2 years old are getting type 2 diabetes. Metabolic syndrome is also happening at this early age. The reason is there is something in the environment (such as fructose) that we have created or are exposed that is causing these epidemic of metabolic diseases including metabolic syndrome. Diseases that are supposed to be of adulthood are starting early in childhood now. You should make sure you son is getting good care. With proper diet structured physical activity and reasonable weight loss you should try to reverse the situation. If diet and physical activity are not enough and if indicated use of insulin sensitizer such as metformin and actos will be helpful. Pioglitazones (actos) are options in fatty liver well. You should see a good nutritionist to help you about the direction of over all diet plan. Counseling may be necessary indicated as well. It is very important that you work closely with your son's doctor. Good luck. READ MORE
Are there side effects of Metformin therapy for children?
There are two major classes of diabetes. Most patients have type 2 diabetes (90%) and about 5% have Type 1 diabetes. Besides type 1 and type 2 diabetes, there are other forms of diabetes such as gestational diabetes, cystic fibrosis-related diabetes, congenital diabetes and steroid induced diabetes. Both type 2 diabetes and type 1 diabetes are based on genetic and environmental factors. Type 1 diabetes results from pancreatic islet beta cell destruction by an autoimmune disease. Once more than 80% of islet cells are destroyed by this process the insulin production is insufficient to control blood sugars. Type 1 diabetes is mainly treated with insulin. With out insulin type 1 diabetes patients will not survive. A good insulin regiment, frequent blood glucose testing and a healthy diet will achieve a tie glycemic control of HbA1c of <7.5%. Type 2 diabetes is treated with diet, physical activity and/or oral medications, though as time goes by, many of these type 2 diabetic patients will require insulin to control their blood sugars. Metformin is the first line therapy for type 2 diabetic patients. Metformin (Glucophage) is the commonest drug prescribed to treat type 2 diabetes. Unless there is contraindication metformin is recommended for almost all new onset type 2 diabetes in addition to diet and exercise. Other oral antidiabetes medications may also be indicated depending on their situation. Metformin is the 6th most prescribed medication in America (about 80 million prescriptions per year), Vicodin being the number one prescribed drug in America. It is one of the safest and cheapest medications available. It was isolated from lilac plant in France in the early 1920's by a French scientist. It was not used as antidiabetes medication for 35 years since its use for other purposes.. It was approved as atidiabetes medication in 1957 in France. It took another 35 years (1995) to be approved in the united states. Metformin comes from a class of atidiabets medication called "The Biguanids". There were three biguanides in use. Bufermin, Phenfermin. Bufermin and Phenfermin were abandoned due to their toxicity. Unlike the oral hypoglycemic agents metformin does not involve in increase insulin production. It involves in improving insulin sensitivity by insulin responsive tissues. It increases tissue glucose uptake and utilization. It decreases glucose production (gluconeogenesis) by the liver as diabetics have 3-4 times glucose production in the liver than non diabetic patients. It also decrease glucose absorption in the gastrointestinal tract. Metformin can be combined with different medication to treat type 2 diabetes. There double and triple combinations with metformin in various doses. Such examples from each class are as follows: Janumet, Avandamet, Actoplus Met, Glucovance, Prandimet, Triformin and many other combinations. Side effects of metformin: Metformin has side effects which are mostly tolerated. The most common side effect is gastrointestinal complaints such as diarrhea, flatulence, abdominal pain, nausea, vomiting, distention, heart burn and constipation. Most of these symptoms would be tolerated if metformin can be started in a lower dose and gradual increase it to the desired range. It should be taken consistently with food. If symptoms persist a long acting form of metformin would easy the symptoms on the gastrointestinal tract. Other none Gastrointestinal side effects would include: weakness, muscle pain, chest pain, low levels of vitamin B-12, dizziness and rarely low blood glucose levels. There is also a risk of lactic acidosis. But this is very rare. It occurs probably 1 in 30,000 cases. It is mostly with patients with renal insufficiency, liver disease, contrast medium, or patients with keto-acidosis. The effect of metformin on lactic acidosis is probably similar to the background population. Under normal condition the body needs to get sugar at all times to do its function. The brain solely depends on glucose for energy, though other tissue can utilize non sugar substrates for energy. The body gets glucose from food and glycogen storage in the liver and muscle. If it does not get glucose from theses sources, it makes itself in abundance through a process called gluconeogenesis from the liver. Diabetics make 3-4 times sugar through these process than the general population in their liver. Liver is the biggest machine that makes sugar and lipids from non sugar sources. Lactate is a major source of gluconeogenesis in the liver. Metformin inhibits this gluconeogenesis path way and diminishes glucose production. Therefore metformin increase lactate in the body. In a healthy person this lactate is excreted by a healthy kidney and no significant lactate build up takes place. But in conditions that impair lactate excretion, lactate build up can happen leading to lactic acidosis. These conditions include, impaired kidney function, liver disease or use of contrast media. Overdose of metformin is very rare. The usual dose of metformin is 2,000-2,500 mg per day divided in to two or thee doses. Dose exceeding of 5,000 mg may lead to some form of toxicity. An ingestion of about 60,000 mg may still not kill some one. Metformin is therefore one of the most prescribed, reasonably priced, and safest medications used as a first line therapy for type 2 diabetes. Though its approved use is for type 2 diabetes it is being used off label for many medical conditions. Some of the list of the medical conditions are as follow: 1) in insulin resistance (metabolic syndrome). Metabolic syndrome is a constellation of conditions consisting of central obesity, abnormal blood sugar, dyslipidemia, hypertension, fatty liver etc. The hallmark of metabolic syndrome is insulin resistance. Though most people with metabolic syndrome are obese a significant population is non obese with metabolic syndrome. But both population have insulin resistance or insulin function abnormality. Of note 20% of obese people are healthy Fat (healthy people) and 40% of thin people may have metabolic syndrome (sick thin). These people probably have fatty liver exporting insulin resistance without being obese. Almost 50% of Americans have some form of metabolic abnormality. Metformin is a good option for the management of metabolic syndrome besides diet and exercise. 2) Prediabetes: There are about 85 million Americans with these condition. Many of them will develop diabetes in the near future. Most are obese and some are not. Metformin is a good option to manage these patients besides diet and exercise. 3) PCOS: polycystic Ovarian Syndrome in a condition were there is high male hormones, abnormal period, physical manifestation of excess male hormone such as hirsutism, acne etc with or with out ovarian cysts. These patients are prone to infertility. Many of these women have problems with conceiving children with out the help of fertility drugs. Metformin is in good use in these kind of population. 4) Neuroprotective: metformin have been used to protect the function and integrity of the nervous system in certain risk groups. 5) Antiaging effect; Metformin is being used to slow the aging process. There is ongoing studies on this topic. 6) Cardiovascular protective effect. Metformin is in use to protect the cardiovascular health in certain risk population. 7) Antitumor effect: Metformin is being tested for its anti tumor effects. 8) Acanthuses Nigricans: This is a condition were the skin of the neck, arm pit and other parts of the body becoming dark due to insulin resistance. Insulin stimulates the epidermal growth factor of the skin in those areas and lead to thick velvety or dark skin. Metformin is a good option besides diet and exercise for this population. 9) Obesity; Metformin is believed to suppresses appetite. Metformin has been used in children to treat obesity for many years. Obese children mainly 10 years and above may benefit from metformin therapy as appetite suppressant though younger ones can be tried if there are no other options. 10) Double diabetes: Double diabetes is patients with type 1 diabetes but have additional conditions such as metabolic syndrome. They are mostly obese, showing signs of insulin resistance, Acanthuses Nigricans or are requiring unusually insulin doses. They can also be thin with signs of insulin resistance. These patients with type 1 diabetes who have the above conditions are believed to have double diabetes. For these patients metformin will be a good option besides diet and exercise and their regular insulin regiment. Metformin will lower their liver glucose production, increase insulin sensitivity and glucose uptake and utilization. Going back to your daughter: Your daughter has type 1 diabetes. She needs to be on reasonable dose of insulin and maintain a good glycemic control. A customized insulin regimen, regular frequent blood sugar monitoring, healthy diet and regular physical activity will be suffice to achieve a good glycemic control of HbAc1 of <7.5 %. Double diabetes will develop if she is gaining excessive weight, have abnormal liver fat, dyslipidemias or she is requiring excessive amount of insulin that are not explainable by growth, food intake, activity level or other variables. In this case adding metformin to her insulin regiment may be helpful. metformin will suppress excess production of glucose from the liver and increase sensitivity of the body to insulin. It may also lower the lipid production by the liver which will intern help in the body's insulin sensitivity. Metformin is one of the safest medications to use for type 2 diabetes. Most of the side effects are gastrointestinal which are tolerated in the long run, if they are started at a lower dose and increase it slowly or change it to the extended release form of metformin, which is tolerated much better. I encourage you to talk to her doctor and discuss about these issue in detail. If she has the clinical or physical phenotypes that are listed above, it would not be a bad idea to be on metformin as long as she could tolerate the medication and have close monitoring. Metformin has been used in children as young as 8 years old for many years. It has similar side effects to adults. If a child really needs it, there is no reason why the child (especially teens and adolescent) would not be on it. The most important thing is to focus on her over all health and good glycemic control. Discuss this with her doctor and take what would be the best treatment options for your daughter. Good Luck READ MORE
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Get to know Endocrinologist Dr. Tseghai Berhe, who serves the population of Illinois. Dr. Berhe graduated with his Medical Degree from the Spartan Health Sciences University in Brooklyn, NY, in 2000 giving him nearly two decades of experience in his field. After obtaining his Medical Degree he completed his Pediatrics residency with Howard University Hospital. Wanting to further his training he then completed his Pediatric Endocrinology Fellowship with the National Institute Of Health/Bethesda Graduate Medical Education. Dr. Berhe is dual certified in pediatrics and Pediatric Endocrinology by the American Board of Pediatrics. He currently practices as a Endocrinologist within his private practice Midwest Pediatric Endocrinology, and remains affiliated with AMITA Health Saint Joseph Medical Center Joliet, Advocate Sherman Hospital, and Provena St Joseph Medical Center. Endocrinology is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the integration of developmental events proliferation, growth, and differentiation, and the psychological or behavioral activities of metabolism, growth and development, tissue function, sleep, digestion, respiration, excretion, mood, stress, lactation, movement, reproduction, and sensory perception caused by hormones. Specializations include behavioral endocrinology and comparative endocrinology. The endocrine system consists of several glands, all in different parts of the body, that secrete hormones directly into the blood rather than into a duct system. Hormones have many different functions and modes of action; one hormone may have several effects on different target organs, and, conversely, one target organ may be affected by more than one hormone.
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