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
Should my daughter get a diabetic alert dog?
Diabetes mellitus (DM) is the commonest metabolic disorder encountered in clinical practice. It is the major cause of mortality and morbidity in America Today. As of 2019 there are more than 31 million (10%) Americans with diabetes mellitus. There are also over 85 million Americans with prediabetes. Many of these prediabetic patients will progress in to full blown diabetes in the next decade. 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 therefore insulin dependent diabetes. There are about 200,000 (0.24%) of children and adolescents with type 1 diabetes out of 84 million of them. There are one million adults with type 1 diabetes. The incidence rate of type 1 diabetes is about 40,000 new cases per year in America. Out of these about 20,000 are children and adolescent. There are about 1.3 million people with type 1 diabetes in America. Out of these 200,000 are children with type 1 diabetes. Type 2 diabetes is usually due to insulin resistance with some an insulin secretary defect. They can be managed with diet and exercise and weight loss or combinations of different oral medications. Type 2 diabetes are therefore insulin independent, though eventually, they will require insulin to control their diabetes. The incidence rate of both type 2 and type 1 diabetes is increasing at an alarming rate. In the next 30 years over a hundred million Americans will have diabetes. Type 1 diabetes is increasing at an annual rate of 3% in America. By the year 2050 over 600,000 children will have type 1 diabetes. Diabetes is a chronic illness. Both Type 1 and Type 2 diabetes can be managed well but in most cases they cannot be cured. Gestational diabetes is the exception is it resolves after delivery though, some may precede in developing of Type 2 diabetes later on. Since diabetes is a chronic disease it caries grave morbidity and mortality. There are acute and chronic complications of diabetes. Acute complications of diabetes are either due to low blood sugars or due to high blood sugars leading to keto acidosis. The signs and symptoms of hypoglycemia can be very scary. The typical signs of hypoglycemia are as follows: Shakiness, Sweating, palpitations, dizziness, headaches, hunger, irritability or moodiness, anxiety or nervousness. Severe hypoglycemia can lead to stupor, unconsciousness, seizures and death. Chronic exposure to hypoglycemia can lead to long term impairment in executive functioning. Hypoglycemia develops due to either excess insulin injection, skipped meals, mismatch between the amount of food consumed and the amount of insulin delivered or taking excess oral medications. Hypoglycemia and hyperglycemia are common in patients with poorly controlled diabetic patients. In America only 30% of diabetic patients achieve reasonable glycemic control. Acute and chronic complications of diabetes are very common in both poorly controlled type 1 and type 2 diabetic patients. These are also responsible for significant morbidity and mortality. The chronic complications of diabetes are both microvascular (small vessel) and macrovascular (large vessel) diseases. The microvascular complication has the higher prevalence than the macrovascular complications. Microvascular complications include neuropathy (nerve disease), nephropathy (kidney diseases), and retinopathy (eye disease). Macrovascular (atherosclerosis) complications cause, cardiovascular disease, stroke, and peripheral artery disease. Diabetic patients can also develop foot disease that may lead to leg amputation from a combination of nerve disease ( peripheral neuropathy), foot ulcer peripheral artery disease and infection. Therefore combination of microvascular and macrovascular diseases can lead to deadly outcome such as limb amputation. Chronic hyperglycemia or poorly controlled diabetes with blood glucose excursions will lead to the formation of oxidative stress and many glycation end products that are deleterious to the vasculature. These advanced glycation end-products are highly stable and are not easily degraded. The excessive deposition of glycation end products are vital in the development of diabetic complications, by increase oxidative stress, and altering the structure and function of certain molecules causing microvascular and macrovascular diseases. The formation of glycation end products such as HbA1c directly correlates with glycemic control. A reasonable control of diabetes (maintaining HbA1c <7% ) will slow or prevent the formation of these products and the complications of microvascular and macrovascular diseases. Achieving reasonable glycemic control is therefore the corner stone of preventing acute and chronic complication of diabetes. Currently various self monitoring blood glucose systems are used to measure to measure the glucose in blood. Self testing blood glucose levels more often will allow a diabetic patient to determine the precise amount of insulin that must be taken for corrections of the abnormal blood sugar or each meal or snacks consumed. Frequent blood sugar testing will also allow a patient to fine tune his/her daily insulin requirement, especially those patients with history of high or low blood glucose levels ( abnormal blood glucose). This will allow administering the appropriate insulin doses. Self monitoring glucose machines were developed in the 1980. Before the mid 1980's (availability of home-use glucometers), glucose testing was done mostly in the hospitals via clinical-use equipment or the notorious urine testing process. At this time diabetes was poorly controlled and the primary goal of the testing was prevention of hypoglycemia at the cost hyperglycemia. Blood glucose was kept higher to prevent hypoglycemia and chronic complications of diabetes were common. After the advent of home based glucose monitoring devices management of diabetes, the occurrences of hypoglycemia and chronic complications of diabetes has greatly improved the quality of life of diabetics. Myriads of blood sugar testing devices were invented with better ability to detect the precise blood glucose level. These technologies have advanced so much with tremendous functions and memories, that our understanding of diabetes have advanced m much better. These gadgets use a tiny drop of blood to determine the precise blood sugar level and have memories to perform complex mathematical algorithms.. Insulin and oral medications have also improved tremendously especially in the last 25 years. After the advent of genetic engineering human insulin was produced in the lab using the human insulin gene in a bacteria transfected with human insulin gene using a viral vehicle in the 1980's. There after a plethora of advanced fast acting and long acting insulin's were produced. These insulin's were much better and safer than the beef or pork insulin used before. Oral medications for type 2 diabetes have advanced so much in the last 25 years or so. These technological and pharmacological advances have greatly improved not only our understanding of diabetes but also ameliorated the chronic and acute complications of diabetes. However, testing blood glucose with self monitoring systems can not achieve the desired goal of HbA1 <7% for all patients with diabetes. After all only 30% of diabetic patients achieve good glycemic control at this time. Testing blood sugars 4-6 times a day will not tell the who story of what the blood sugars are during. Testing at those specific times will only tell you what the blood sugars are at that time. These blood sugars tested at 4 or 6 intervals can not tell us whether there are low or high blood sugars in between or what happens at night time. Intermittent testing blood sugars, say every hour through out day and night will tell as better story to what the blood sugars are doing. Testing 24 times a day may be better but it is not feasible or humanly possible. The next challenge is therefore introducing continuous blood glucose monitoring system (sensors). In the last 20 years the idea of continuous glucose monitoring systems were advanced. The technology have advanced well that currently there are 4 systems in use in many patients. Medtronic company spearheaded the challenge of the sensor technology followed by Dexcom and Free Style Libre from Abbott and Senseonics Eversense and more. The sensors have gone through many prototypes (generation) and are now able to function much better and more reliable than before. They are good for blood sugar trends. Some are integrated with the pump and some are not. They can give an alarm for high and low blood sugars and work continuously for 3-14 days. They have their advantage and disadvantage. If they are used properly they can be a great asset in thwarting low and high blood sugars. With the use of self monitoring blood sugars (testing at list 4 times daily) and the use of these sensors a reasonable blood glucose control can be achieved with lessening or eliminating of symptomatic hypoglycemia and chronic complications of diabetes. Self monitoring blood systems and sensors are invasive or minimally invasive. They require either pricking the fingers for blood several times a day or inserting the sensing device to the body. This may causes pain and inconvenience and some people with needle phobia or fear they may add more stress and none compliance. It is also important to appreciate that 50 % of the population is none compliant even under the best circumstances. Even with self blood glucose monitoring systems many patients do not test their blood sugars consistently. The next challenge is therefore to develop non invasive continuous glucose monitoring systems. There are two kinds of none invasive continuous blood sugar monitoring systems. 1) Artificial: Noninvasive sensors. This concept was over 30 years ago. Many noninvasive technologies have been tried but non of them have been utilized in the patient care. Some of them are in the early stage. Some of the technologies in development are using: Fluorescence technology, electromagnetic sensing, bioimpedance spectroscopy, near infrared spectroscopy, mid-infrared spectroscopy, ultrasound technology, optical polarimetry, Raman spectroscopy etcetera. We will wait until this technology matures to come to clinical use. 2) Natural sensors: Using pets especially diabetes alert dogs: Dogs have been used for many purposes. including as guide dogs for the blind persons, mobility assistance dogs, psychiatric service dogs hearing dogs and blood sugar alert dogs. Dogs have special smell potential. Dogs have 30 million smell receptors called olfactory receptors. Their brain have a bigger are for processing smell. They can smell 1 part in trillion. They may follow a sent about 40 feet underground. They can detect things from over 10 miles a way. They can smell up to 200,000 times better than humans. Using this special smell ability they can be utilized as diabetes alert dog. Dog will be selected for this service based on their motivation and willingness to serve in this capacity. The first dog to serve in detecting hypoglycemia was in 2003. In 2009 a dog was recruited to assist in a type 2 diabetic patient. There are three kind of dogs suitable for this purpose. They are golden retrievers, poodles, & Labrador dogs. Currently there are several dogs in that capacity specially for type 1 diabetic patients. They are trained for about 6 months with the sample of the patients low and high blood sugars. The training is based on reward system. Every time the correct identification of the desire blood sugar level in obtained the dog gets reward to do more. The dog has also to bond with the patient well for this to happen. Extensive training is very important for a successful out come. Dogs are not machines. They have feelings, attachments and sentiments. They can not work 24 hours a day like a machine. They need enough sleep of about 12 hours a day. They also need to relieve themselves of their urine or feces at least 3 times a day. They also need to be loved and cared continuously. The dog need to bond well with the patient. They need to eat well and they should rest and have a play time. A dog will not be in service while sleeping at tight. Trained dogs can detect the sent of low or high blood sugars. What they smell no body knows. Some say some chemicals called Isoprene?. Once they detect high or low blood sugars they alert the patient by paw tap, licking, nose tap, placing paws on partner’s shoulders, or laying their head on partner’s knee. Diabetes alert dogs are not cheap. They cost between 15-20 thousand dollars. And they require an additional maintains money and time including several veterinary visits several times a year. The accuracy of detecting high or low blood sugars are not exactly know. There is no standardized commercial guide lines in use of diabetes alert dog. Diabetes alert dogs may work well in alerting high and low blood sugars but only during the time they are working (8-10 hours a day). They may also be good company for some patients. In summary frequent blood glucose testing is the most important aspect of monitoring diabetes. Having sensors will greatly improve diabetes control and prevents extremes of blood sugars and may prevent acute and chronic complications of diabetes. The desired HbA1C i of <7% can be achieved in most diabetic patient utilizing frequent blood glucose testing and using sensors. Use of diabetes alert dog will be an addition to a better management of diabetes. It should not be a replace to the frequent blood sugar testing or the use of the various continuous monitoring systems. When dogs are sleeping or not working the parson will be covered the continuous glucose monitoring systems in addition to frequent testing of the blood sugars. Going back to your daughter: Your daughter have type 1 diabetes. She need insulin to control blood sugars. Inappropriate insulin doses or missed or smaller meals may lead to low blood sugar. Fluctuations leading to high or low blood sugars are also worrisome. Maintaining reasonable blood sugars on daily basis and HbA1c <7.5 is advisable. You can achieve this by checking blood sugars several times a day and using one of the continuous glucose monitoring systems. A diabetes alert dog will be an addition to these but not a replacement. If you can afford the dog and you have good amount of time to take care of the dog and if your daughter is fond of a dog having an additional natural sensor will be a good asset to have. You also have to appreciate that the dog may alert for low or high blood sugars but the dog can only do this for certain time of the day. He has to sleep at list 12 hours a day and is not going to alert you at night. He is going to sleep just like you. The sensors, which ever you choose will alert you 24 hrs a day 7 days a week if you use them properly. Of course you have to check blood sugars several times a day as well. So the dog is an addition to these gadgets but not replacement. Some of the sensors such as Dexcom G6 and the Medtronic's G670 have special application and behave like artificial pancreas. They can stop insulin delivery when blood sugar is low and give more insulin when the blood sugars are high. They will also alert you when the blo0od sugars are higher or low. So the answer to your question is if you have the means, the time and devotion, there is no reason why you shouldn't have a diabetes alert dog. It will strengthen the safety of you daughter in managing her diabetes. Good Luck READ MORE
What causes type 1 diabetes?
Diabetes is the most common metabolic disorder affecting over 30 million (10%) Americans. Type 2 diabetes is over 90% of diabetes. There are also about 80 million Americans with prediabetes. Currently in America the rate of type 2 diabetes by race is as follows. 8% non-Hispanic whites 9%% Asian Americans 12.% of Hispanics 13% blacks 15% of Natives Americans Type 1 diabetes is about 5% of the diabetic population (1.3 million) and 0.4% of the general population. About 16% of the total population with type 1 diabetes are children. There are other forms of diabetes such as gestational diabetes (affects 3% of pregnancies), MODY (maturity onset diabetes of the Young and others. Most adults have type 2 diabetes and most children have type 1 diabetes. However most of the Type 1 diabetics are adults not children. There are about 200,000 (0.24%) of children and adolescents with type 1 diabetes out of 84 million of them. There are one million adults with type 1 diabetes. The incidence of type 1 diabetes may be more in adults than in children though most of childhood diabetes is type 1 diabetes. About 10% of adults are usually misdiagnosed as type 2 though they may have type 1 diabetes. The incidence rate of type 1 diabetes is about 40,000 new cases per year in America. Out of these about 20,000 are children and adolescent. In 90% of cases of new onset type 1 diabetes in children, there is no family history of diabetes at all. Only about 10% have history of affected family members. Type 1 diabetes affected 0.4% of children in the general population and about 6% of children with siblings of childhood onset diabetes which is about 20 fold increase from the general population. Early-onset diabetes affected fathers will transmit 8% risk to their off springs (20 fold increase) while mothers with childhood onset type 1 diabetes will transmitted to their offsprings about 3% risk (10 fold) of developing type 1 diabetes. Dizygotic twins will transmit similar to the rest of the siblings about 7% risk (20 fold) of transmitting to other siblings. Monozygotic twins will have 30-40% risk (100 fold) to the other twin but about 8% to the rest of none twins. About 1.5 million Americans are diagnosed with type 2 diabetes each year. About 6,000 children are diagnosed with type 2 diabetes each. year. There are an estimated 50,000children and adolescents with type 2 diabetes. Childhood diabetes is on the rise. Every year type 1 diabetes is increasing by about 3%. Type 2 diabetes in children is also increase in parallel to the rise of childhood obesity. By the year 2050 childhood diabetes both type 1 and type 2 will triple. Type 1 diabetes in children will be about 600,00 in the next 30 years. A 3 fold increase from the current 200,000 children with type 1 diabetes. During the same period the total type 1 diabetes population (adults + children) will increase by 4-5 fold to about 5 million from 1.3 million. All autoimmune diseases including type 1 diabetes are on the rise especially in the northern hemisphere. The more these societies residing in the northern hemisphere (especially Europeans and European descents) become cleaner and wealthier the incidence of all autoimmune diseases are increasing. In less developed countries the incidence of type 1 diabetes is low. In these countries children are more exposed to microbes and viruses and are less likely to have hypersensitivity reactions or autoimmune diseases. As the body gets exposed to constant stream of microbes it somehow learns to distinguish serious invaders from, from some environmental and dietary factors. When the immune systems does not get that kind of exposure, it gets bored and starts to overreact to its own antigens, causing hypersensitivity reactions and different autoimmune diseases. Genetic factors are important for type 1 diabetes. However the concordance rate of identical twins is about 40%. This demonstrates that environmental factors also influence the immune system. The incidence of type 1 diabetes is more common in Fall and Winter demonstrating the importance of viral infections as a trigger for type 1 diabetes. During these seasons vitamin D level is low. It is possible that, low Vitamin D level may be related to the increased incidence of type 1 diabetes via modulating the immune system. Type 1 diabetes is most common in children during puberty. However there are three peaks were children 0-4 years 7-10 years and 11-15 years. But the highest incidence is during adolescence. 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. 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 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. Environmental factors (triggers) could be viruses, food products and other environmental or cellular agents that interact with the susceptible host. 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 for destruction (islet cells). The immune system is a hosts defense mechanism to defend from invader such as viruses, bacteria, fungus and other organisms. It also have to have a recognition process to identify self (its own cells) so that it does not make a mistake in misidentifying its own cells as invaders. The immune system therefore needs to identify internal tissues and foreign invaders. The immune system is arranged similar to the United states Army with different army missions. The immune system have to recognize itself and foreign invaders using a special molecule called Major histocompatibity molecule/complex (MHC). There are three Major histocopatibity complex ( in humans they are called human leukocyte antigen (HLA)). 1) Class 1 MHC: is found in all nucleated cells except red blood cells. 2) Class 2 MHC: is found only on antigen presenting cells (macrophage, dendritic cells, B cells(plasma cells) 3) Class 3 MHC: found in complement cells. The MHC 1 is made in all nucleated cells and the HLA the human leukocyte antigen which is made inside the cell and is brought up to the surface of the cell and binds to the MHC receptor on the cell surface acts as a recognition antigen (showcase) and tells the immune system (mainly CD8 T lymphocytes) that it should not be attacked. Once the lymphocytes see the self antigen mounted on the cell surface MHC 1 of normal cell, the immune cell do not bother the cell. However if the cell is sick (lets say thyroid or islet cell) it will showcase on her surface receptor MHC1 a different antigen for the T lymphocytes to recognize. When the T lymphocytes identify the bad or non self antigen they will destroy the sick cell or the cell that is showcasing a bad non self antigen. When a cell is invaded by bacteria or virus it will showcase part of the invader on it surface MHC receptor/clip. The showcase antigen will be recognized and will be designated for destruction so that the infection does not spread to other cells. Also when the cell showcases a none recognizable protein or antigen on it surface receptor (MHC 1 ) the T lymphocytes (CD8 killer cells) will designate the cell for destruction. This is also similar to tissue graft or transplant rejection. When the transplant cells present none compatible antigens on their MHC 1 receptor, the immune system will destroy the graft promptly. All nucleated cells have to present an identifiable antigen MHC1 on their cell surface all the time other wise they will be flagged for destruction.. But if they either alter the MHC receptor or the self antigen is not recognized by the immune surveillance unit, the tissue demonstrating those unrecognized antigens will be killed by the surveillance of the immune system promptly. Or if the cell/tissue are infected they will present part of the invading antigen on their surface MHC1 surface receptor and be marked for destruction. MHC 2 on the other hand is present on Antigen presenting cells. These are specialized surveillance cell such as macrophage, dendritic cells and B cells. These cell have MHC 2 surface receptor on their cell surfaces. When they encounter invaders (bacteria or viruses) before they enter cells, they engulf them and process them or tear them into small pieces and present them on their surface receptor MHC 2. Once the antigens are present on their surface MHC receptor/clip the T helper lymphocyte (CD4 cells) come promptly and unleash a deadly assault on the invading organism. They recruited more helper cells and deadly antibody producing plasma cells also participate to completely annihilate the invading organism that has not infected the cells yet. The cells that are already infected have to present/showcase the invaders antigen on their MHC1 surface receptor for CD8 T killer lymphocytes to kill the infected cell to prevent the spread of the invaders into other cells. MHC /HLA is also involved in autoimmune disease besides killing invaders and infected cells. The ( MHC 2 ) Major histocompatibility complex gene is located on the 6p21. It may be responsible up to 50% of type 1 diabetes. The rest of type 1 diabetes is due to other genes problems and there are over 40 of them located on different chromosomes, including on insulin receptor. The MHC 2 genes have great polymorphism. Even though one gene comes from one parent and the other comes from the second parent, these genes have tremendous polymorphism, meaning that it can occur in different alternate forms or alleles. There are about 2000 alternative alleles (forms) for the same gene. These can lead to generating many different kinds of gene products/proteins. The HLA gene have many classes, subclasses and sub sub classes. There are 3 major and 3 minor MHC class I genes in HLA. There are three Major MHC class I, as follows; HLA-A, B and C There are also minor classes (HLA-E, HLA-F and HLA-G .β2-microglobulin binds the MHC 1 receptor to stabilize the receptor. Major MHC class II have three classes HLA-DP, DQ, DR; and many subclasses. there are many possible combinations of these subclasses and sub sub classes. Some of these alleles confer suseptibity to autoimmune diseases. And some of them confer protection from autoimmune disease. Some examples that confer susceptibity are as follows. B27 Ankylosing spondylitis, Reiter's syndrome syndrome, Arthritis HLA-B47 21-hydroxylase deficiency. HLA-DR2; Systemic lupus Erythematosis HLA-DR3 Diabetes mellitus type type 1 HLA-DR4 Rheumatoid arthritis, Diabetes mellitus type 1 ( young age and sudden onset) HLA-DQ2 and HLA-DQ8: Coeliac disease The main T1D susceptibility alleles are located on class II loci HLA-DRB1 and HLA-DQB1. The DR/DQ haplotypes specifically DR3-DQA1*0501-DQB1*0201 (DR3) and DR4-DQA1*0301-DQB1*0302 (DR4), and account for 50% of genetic T1D risk. Over 40% of European Americans have HLA-DR3 or DR4 allele, at least 1 of these alleles is present in 95% of patients with T1D. The estimated risk of developing T1D for the general population in children who have the HLA-DR3/4 genotype is approximately 1 in 20 compared to the risk of 1 in 300 in the population. Existence of DR3/DR4/DQ combinations may lead to a very high risk of type 1 diabetes. There are also protective alleles such as DP*0402 and DRB1*0403. These susceptibly alleles can alter the immune tolerance, cause antigenic mimicry or other means and lead to autoimmune destruction of the target tissue, in this case islet cell that make insulin.. Since Type 1 diabetes is an autoimmune process it takes 2-5 years to evolve into full blown diabetes. Though it is mainly a cell mediated immune destruction of the islet cells, antibodies against various components of islet cell and insulin can be identified years before diagnosis of diabetes. The commonest antibodies are: Islet cell (ICA) antibodies, Glutamic acid decarboxylase antibodies (GAD), (IAA) insulin autoantibodies, IA2 Protein Tyrosine phosphatase autoantibodies and ZnT8 zinc transporter 8 antibodies. ICA is the first one to appear followed by GAD. Some of these antibodies will fade away with time. These antibodies can be used as markers of diabetes in siblings or families with type one diabetes. Going back to your daughter: Your daughter have type 1 diabetes. It is likely that she has Type 1 A diabetes, meaning it is autoimmune mediated diabetes in concert with environmental triggers. There are many trigger factors such as viruses, food products and other auto antigens. She could have genetic susceptibility mostly due to MHC 2 DR3/DR4/DQ conferring suseptiblity that leads to chronic inflammation and destruction of the islet cells. She could also have mutations in the other over 40 genes involved in type 1 diabetes (autoimmune). Over 90% of new onset type 1 diabetes have no family history. Family history only contributes up to 10% in type 1 diabetes with the exception of identical twins (about 40%). Type 1 diabetes will take about 2-5 years to evolve in most cases. In young children it can be drastic. There are about three peaks in the incidence of type 1 diabetes 0-5 years old. 7- 10 years and adolescent 12-15 years. Type 1 diabetes needs insulin therapy for survival and rarely goes a way. Understanding diabetes, monitoring blood sugars adequately and better insulin treatment will bring near normal glycemic control. Good Luck READ MORE
Can certain hormones cause my son to be more introverted?
introversion–extraversion are personality traits not real disorders. Both introvert and extrovert behaviors coexist in the same person. However one trait dominates over the other on individuals. When the introvert trait is dominant the person is called introverted or inward thinking person. When the extrovert trait dominates the person is labeled an extrovert. An introverted person is one who is focus on one's inner psychic activity. And an extrovert is more involved in the outside world. Both are considered as a single continuum than a separate entities of human behavior. Introverts like solitary activities. They prefer to spent time alone, reading, writing, fishing or other indoor or out door activities alone. They are not shy people, but they are not comfortable making many friends. They enjoy the few friends they have. Trust and virtue are at most important for them. Great inventors, scientist, composer, and engineers are very introverted people. These people enjoy spending time thinking and solving problems alone. Though they can get a great pleasure spending time with few trusted friends. Introverted people like quiet environment and do not like group gathering but they are not afraid of social events unlike shy people. They can be also be great speakers or leaders. They are thoughtful, analytical and intelligent people who do not like attention or external stimulation. Shy people have emotional distress, while introverted people have none of it. They are therefore naturally aroused and are prone to over arousal and prefer to withdraw from stimulus. Extroverted people likes external stimulation. They get stimulation and thrive more in group, and social gathering (external stimulation). They under aroused so they seek arousal stimulus and attention. Therefore they are hungry for stimulus from groups and are attention seeking and very approaching people. Information or stimulation that goes into the brain is regulated Ascending Reticular (Reticulocortical) Activating System. This information activates or deactivates the cerebral cortex that matins alertness, concentration and sleep cycles. When more information is passed through the system it causes introverted trait while allowing less information leads to extroverted behavior. Hormones and neurotransmitters are involved in behavior. Dopamine (the hormone of happiness) is involved in behavior. It causes happiness, seeking pleasure, motivation to take risks and explore the environment. Dopamine response is more heightened in extroverts. They respond to dopamine flooding better than introverts. The level of dopamine may be the same in both groups but the response to dopamine is much stronger in extroverts than introverts. Extroverts become more talkative and are eager to explore the environment and socialize with people. Since their brain cortex gets less stimulation from the brain stem they crave more attention from external stimulus (people) Introverts respond better to Acetylcholine than extroverts. Acetyl choline activated the parasympathetic nerves. stimulation of the parasympathetic system is engaged in the person relaxation, digests food, lower blood pressure, becomes much calmer and quieter, which are the things that introverts tend to enjoy. Though both introverts and extroverts use dopamine and acetyl choline, introverts respond and prefer acetyl choline and extroverts prefer dopamine. There are other neurotransmitters involved in aggression and criminal activity such as monoamine oxidase and low level of adrenalin. And others such as neurotransmitter serotonin is involved in obsessive compulsive behavior. Hormones, mainly, high level of testosterone and it androgenic precursors are implicated in aggressive behavior and criminal activity in both men and women. These group of people tend to abuse drugs, have sex with multiple partners and abuse alcohol and have a higher rate of divorce and domestic disturbances. Introverted or extroverted behaviors are not pathological traits but normal variations of human personality. Both have their of qualities. Both can be fine leaders in society. There is no real discernible hormonal deficiencies except different response to certain neurotransmitters. Going back to your son: Your son is introverted, which most likely is perfectly fine. He is probably more reserved and reflective. He is also probably getting more arousable stimulus from the ascending reticular system to his cerebral cortex and is busy processing more information quietly and that may be why he is introverted. Introverted people are great thinkers, scientists and inventors. They are not shy but reserved. They send more time processing more information in their brain. They do not demonstrate abnormal behavior and they can be great speakers or leaders. They are good with the people they trust. They value more trust and virtue. They do not have hormonal imbalances or behavioral disorders. However if your child is shy or have social anxiety or showing odd behaviors, he may have more than introverted behavior. Autistic spectrum and other pervasive developmental disorders need to be ruled out. If your son is a loner, experiencing difficulty in his communication with his peers and school mates or is underperforming at school, he needs to have a proper psychological evaluation by an expert. You should discuss these issues with his doctor. His doctor will perform a complete evaluation and determine if this is a matter of reassurance or needs to get further help. Good Luck READ MORE
Why does my son sweat so much?
Sweating is the natural thermostat of the body. The body's heat is dissipated through sweating to maintain the body's core temperature is a narrow range from 97°F (36.1°C) to 99°F (37.2°C), for an average of 98.6°F (37°C). It is a normal healthy function of the sweat glands when there is a change in the body's core temperature either due to hot weather, metabolic, hormonal, neuronal or temperament. The sweat glands get activated to dissipate heat by releasing water and salt as coolants to regulate the body's core temperature. The body's core temperature should be maintained at a normal range to allow normal cellular function. If core body temperature exceeds acceptable range, proteins that are vital to the intricate and complex cellular function may get altered or denatured, compromising survival. Hot or warm temperature, and physical activity are potent causes of increased body temperature. Exercise or physically demanding work increases metabolic rate that increases heat production and the demand to cool the body through sweating. Sweating is therefore the preferred mode of water excretion instead of the kidneys because adrenalin surge in exercise and other situations demand a better way of releasing water without wasting time to go to washroom during fight and flight. Sweating may therefore be a natural adaptation to conserve time. The sweat gland are called exocrine because they release their content through a duct system to the surface of the skin for evaporation. There are about 3 million sweat gland throughout the body. The sweat glands are very efficient and effective means of cooling and a person can loose up to 2 litters an hour or 15 litters a day under maximum physical demand. This is about 10% of what the kidneys would filter a day. There are two kinds of sweat gland: 1) Eccrine sweat glands are the majority spread throughout the body in various densities. They are highly mainly concentrated in the palm, sole, head and neck. However the Eccrine glands are spread through out the body. The Eccrine sweat gland are the main (primary) body coolant (thermostat) as they mainly use water and small amount of salt as a cooling medium. These glands release 99% water and 1% salt primarily sodium and to a smaller extent potassium and very little calcium and magnesium. Eccrine glands are supplied mostly by sympathetic nervous system, cholinergic fibers. These cholinergic fibers are primarily sensitive to body temperature changes. Adrenergic fibers are also involved to some extent. Change in body's core temperatures does not affect the sweat glands on palms and soles, but secrete mostly at times of emotional stress. 2) Apocrine sweat glands are only found in the axillar area (armpit) and pubic area have limited role in cooling of human beings. There are also apocrine glands on the eye lid and ear canal (cerumen glands). Apocrine sweat glands are not active until puberty. During puberty the apocrine sweat glands get switched on and can produce copious amount of secretion (armpit and pubic area) as puberty progresses. Apocrine sweat glands do not release the sweat directly to the skin surface but secrete the sweat into the pilary canal of the hair follicle. They produce thick substance that contain fats, protein and androgens. They secrete them in to the hair follicles and the local bacteria in the hair follicles break it down to give the characteristic odor which is typical in puberty. There are many causes of sweating including, exercise, hot weather, spicy food, heavy meal, emotional stress, obesity, pregnancy, illness, tumors, hormonal imbalance, neuronal and temperament. Sweating can be primary hyperhidrosis or secondary hyperhidrosis (due to known medical causes). It can be localized (50%) to specific areas of the body or generalized to the whole area of the body. It can be throughout the day or only at night. It could be physiological response or pathological response or Idiopathic (most cases of hyperhidrosis). Many types of food can cause excessive sweating either during the day or at night. Hot and spicy foods make us sweat though not every one responds the same way. Heavy meals make us sweat as they may lead to more insulin response. Some food may trigger adrenalin response. For some people proteins eaten at dinner make cause night time sweating via stimulating hypoglycemia or adrenalin. Hormonal cause of excessive sweating are rare. Some of the hormonal causes can be hyperthyroidism, premenopausal state, Ovulation, pregnancy, pheocromocytoma, carcinoid syndrome, diabetes, hypoglycemia, adrenalin excess etc. The symptoms of hyperthyroidism are; rapid heartbeat, hand tremors, mood swings, fatigue nervousness, muscle weakness, trouble sleeping, weight loss, frequent hunger, hyper defecation, and abnormal period. It is mainly caused by autoimmune disease called Graves disease but there are also other entities involved in thyrotoxicosis such as over active thyroid nodules and others. Pheochromocytoma is a rare endocrine neoplasia that involves multiple organs that are connected by endocrine dysfunction. episodic surge of catecholamine (adrenal) cause episodic diaphoresis, flushing and elevation in blood pressure. Hypoglycemia is a state of low blood sugar due to many causes that produce excess insulin. In diabetic patients injecting excess insulin or eating less meals can cause hypoglycemia. There are also a different mechanism for sweating in diabetic patients. Gustatory sweating from nerve damage is common in diabetics. This sweating takes place on forehead, neck, face, and scalp after ingesting food. The sweating is mainly in response to adrenalin release not to low blood sugar. Pancreatic tumors (insulinomas) cause hypoglycemia and the correction mechanism of adrenalin surge that causes profuse sweating. Obese/overweight people need to cool more and can easily sweat if they are not in a cool room. Warm room and extra covering blankets and tight cloths may lead to sweating. Many kinds of foods, medications and supplements can cause low blood sugar leading to adrenalin surge in trying to correct the low blood sugar. A person with hypoglycemia is really diaphoretic not because the blood sugar is low but due to the body's correction mechanism which involves surges in adrenalin release. Excessive sweating that have no physiological or pathological explanation without the need to cool the body's core temperature is called hyperhidrosis (primary hyperhidrosis). About 2% of the population have some form of primary hyperhidrosis (Idiopathic hyperhidrosis), 50% of them may sweat under their arm. Excessive sweating of any kind need to be evaluated thoroughly. The person need to see his doctor for proper and complete evaluation. A detailed history, physical exam and laboratory evaluation is necessary. Consider seeing the doctor especially when you have excessive sweating for a long time, when the sweating is interfering with your daily life or interpersonal relations, when it is socially embracing, when you have night sweats, or when you have medical or emotion conditions or when you are taking medications. Treatment should be based on the cause of the hyperhidrosis. known cause of excessive sweating should be directed in treating the cause. If there are no known causes (idiopathic) you may want to try the following: 1) Use cool room. cool your bedroom before going to bed. And change bed sheets daily 2) Take warm bath or shower before bed. 3) Apply antiperspirants if localized sweating and apply them in clean skin 4) Wear loose dress (clothing). Use cotton or natural fibers. Avoid synthetic fibers 5) maintain clean hygiene. If sweating becomes bothersome more medical help can be sought. Aluminum chloride based antiperspirants can be considered initially. Drysol is a good initial deodorant to consider. Anticholinergic medications such as Oxybutynin and benzatropin can be helpful with primary hyperhidrosis. Iontophoresis treatment with low electrical current and Botox injection for localized sweating especially underarm sweating are other alternatives. Surgical removal of some sweat glands and sympathetic nerve supply to certain sweat glands will be reserved for severe cases of hyperhidrosis. Going back to your son: Your son is sweating excessively, mainly at night time. This could be primarily primary hyperhidrosis that is not related to any secondary medical causes or core body temperature. In primary hyperhidrosis the sweat glands are active with out any need to cool the core body temperature or any physiologic or disease causes. Secondary causes medical or hormonal issue are unlikely in the absence of any other symptoms except excess sweating. Excess hormones such as hyperthyroidism, elevated cortisol, hypoglycemia, pheochromocytoma, carcinoid syndrome. diabetes will have other symptoms in addition to sweating. Medical conditions such as infection, fever, tumors etcetera will have other symptoms as well. Night sweat can be a sign of serious medical condition. It should be taken seriously until there is an explanation or every thing is ruled out. Certain foods including high proteins and foods that may lead to excess insulin production may cause night sweat due to hypoglycemia and adrenalin release. This can be avoided by eating lighter dinner or avoiding food that cause night sweating. You can improve the night sweating by having less bed sheets and lighter cotton blankets and cooling the bedroom. Warm bath or warm shower (not cold) before bed time will help cool down the body when going to bed. You should have your son proper medical evaluation. Make sure hormonal and medical issue are ruled out. Anxiety is also a common cause of sweating. mostly it will involve armpit during puberty and adulthood. Before puberty since apocrine glands are not that active it primarily involves the sole and palm (hand). When people are nervous/anxious, they make more adrenal and they are in a fight or flight mode. Anxiety can be treated better with psychological counseling though medications may be needed in some situations. In summary it is important that you discuss this with your doctor. The doctor will perform complete medical, physical and psychological evaluation to distinguish the different causes of the sweating (between primary hyperhidrosis or secondary to various medical or hormonal). Good Luck. READ MORE
My son's voice is very high-pitched and he finds it socially embarrassing. Is there anything we can do?
Voice is created in an area of the throat called the Larynx or voice box. It is situated at the entrance of the wind pipe called trachea. The larynx is located in the throat at the top of the trachea, or windpipe. The larynx contains two structures called vocal cords or vocal folds besides the supporting structures. They are two small muscles folds in the middle of the larynx. The relaxation and tightening of these muscle folds create voice by changing the air that flows through the larynx. And with the help of the mouth and the tongue different sound with different pitch and volumes can be created. High pitch or low pitch voices are therefore the result of alteration on the vocal cord as they tighten or relax. Any change in your larynx can affect the vocal cords and therefore affects your voice. High pitch is as a result of shortening or tightening of the vocal folds while low pitch is the result of lengthening or relaxation of the vocal folds. It is similar to a piano or guitar. When the strings of the piano or guitar are small and tight, they produce high pitch sound and when they are long and loose they produce low pitch sounds. The adjacent and supporting structures in the larynx also play a role in resonance of the voice. During childhood, there is a significant growth changes in the larynx, the vocal folds and the supporting structures. At birth, the length of the vocal folds is around 2 mm. They are the same size for males and females. For the next 18- 22 years of life, the vocal cords grow about 0.7 mm per year in males. However for female the vocal cord only grows about 0.4 mm per year. The maximum adult male length of the vocal cord is about 18 mm, while it is about 12 mm for females. The male vocal folds are over 60% more than the female vocal cord. As we grow during childhood into adolescence our voices get deeper. Infants produce the highest pitch because they have the smallest vocal cord. As the time progress even before puberty male and female pitches start to be different as the vocal cords become bigger and ticker in male than female even though both of them are getting bigger and the pitches are getting deeper for both males and female (more deeper for males than females). Puberty greatly affects the voice change. The vocal cords get longer and thicker as puberty progress from childhood to adolescence. Testosterone affects the muscles and the vocal cords (folds) more than estrogen or progesterone, though both of the later hormones can affect the larynx to some extent. However testosterone has a powerful effect on the growth of the vocal cords and the surrounding structure of the larynx that help with voice and resonance. Boys make much more testosterone than females 10-20 times, therefore the male vocal cord are bigger and thicker and huskier than females. Adolescent girls have husky voices to a lesser extent but they are not much noticeable. In boys and girls the age when puberty starts are variable because some are early bloomers , some are late bloomers, and others are average bloomers. Puberty is divided in 5 stages called tanner stages. Tanner stage 1 is no puberty (prepubertal). Tanner stage 2 is starting early puberty. Boys will have testicular enlargement followed by penile enlargement and pubic hair. At this stage they can produce viable perm cell. Tanner 3 is further enlargement of testicles, the penis and pubic hair, and (cracking of voice may start). Tanner 4 is were growth of more testicular tissue;t up to 20 ml testicles, enlarged penis, growth spurt and deepening of voice. Tanner stage 5 is achieving adult type sexual development. The usual age when puberty will start in boys is about the age of 10 for girls and 12-13 years for boys. But most girls will have by 13 years and most boys by 15 years old. The tempo of Puberty can last from 2-5 years but most adolescent complete it in 2 and half years. The voice change or cracking may start at around 12-13 years for boys. Once boys start cracking the voice, the deepening of the voice takes place within few weeks as cracking tapers. Most voice changes take place during tanner 4 during growth spurt. However most voice changes are complete around 15-18 years. Some may complete the voice change in their late twenties and few may never achieve this, though they may be perfectly normal. Once they complete the voice change the pitch is much lower (deeper). As men maintain a higher concentration of testosterone and since testosterone spikes at times substantial longer and thicker vocal folds are formed leading to deeper voices than women. Babies cry for 5-7 hours a day at a sustained pitch of 400–600 Hz. As we grow old the pitch intensity drops as the vocal folds that vibrate become longer and thicker. The adult person has about 60 percent longer than a female, and that is why men speak at about 110 Hz, and women speak around 150 to 200 Hz. AS the spicks of testosterone fluctuates the pitches of voices will also fluctuate accordingly until a stable stage is reached. The voice of male finally deepens by an octave (about 8 notes or pitches) while girls are few notes or pitches deeper and not badly noticeable. Many women that have abnormal male hormones, testosterone or the weaker androgens (there are many of them), due to adrenal anomalies such congenital adrenal hyperplasia including late onset, adrenal tumors or polycystic ovarian syndrome, or, insulin resistance may suffer from deep or husky voice similar to male or in some case even worse than the average male's voice. Most boys progress in sexual development in a reasonably predictable way. However some may not progress as predicted. Few may be perfectly ok and others may have a physiological or pathological conditions. Late bloomer (delayed growth and sexual development) and children with hypogonadism (low testosterone in males) may not show sexual development or voice changes as they get older. These two entities should be differentiated carefully. The late bloomers are fine except that they have a slower tempo of puberty. They only need watchful waiting if they do not have emotional difficulties. If they develop emotional and psychological problems, with their delayed sexual development, a 6 month course of low testosterone will help them get into puberty. As they enter in to puberty they with show voice changes as puberty progress. Boys who have hypogonadism for various reasons, such as pituitary anomalies ( Kallmenn syndrome or disorders with the pituitary ) or primary or testicular disorders ( Klinefelter's syndrome or testicular anomalies) need proper evolution including imaging studies and karyotype (genetic testing). Once the diagnosis is established treatment with testosterone can be liberally (200 mg every week or every 10 days) considered. If a person have normal sexual development for his age, but, he is not showing voice changes and have a normal male karyotype; he may be perfectly fine. If the person have emotional and psychological issues testosterone treatment can be tried to see if he can crack the voice. Going back to your son: Your son is 16 years old. At this age he should be in puberty. If he is not in puberty he should have a proper evaluation and if every thing is fine, and that he is only a late bloomer, and he has emotional difficulties with his current situation, a course of testosterone therapy can be considered to help him enter into puberty sooner (50-100 mg of testosterone cypionate for 4-6 months) after discussing this with his doctor. Once he goes through puberty his voice change will come in time. But if your son is a not a late bloomer, he needs to be worked up for the various causes of delayed puberty or hypogonadism. And treatment should be sought based on the real cause. On the other hand if your son is in full blown puberty but he has emotional issues with his voice (high pitch voice) either watchful waiting or a trial of testosterone could be considered if indicated after consulting with his doctor. remember some times these things take time to progress. Things are not always simple in life. But if he is experiencing emotional and psychological issues counseling and testosterone trail may help. Please consult with your doctor about these issue in detail he will decide what steps to take to help your son. Good Luck READ MORE
Is it normal for children to drink more water than adults?
Water is the most essential element for all living things. The majority of human body is made up of water. Infants have 80% of their body composition as water. In children the body is made of 70% water. In adults men are made of 60% water and females are about 50% water. The human body have different water composition. The brain is 90% water. The bones are 22% made of water. The blood is 85% water, and the muscle is 75% water. Water is not only important as a composition of human body but also maintains cellular structures, keep the fluidity of the blood, regulates body temperature (sweating), dissolves and eliminate metabolic byproducts, moisturizes and lubricates mucus membranes and joints, prevents constipation, and many other important body functions. That is why we require a lot of water. Fluid requirements are usual based on body weight. Roughly a 10 Kg (22pounds) child will have a basic daily fluid requirement of 1 litter (one quart or 33 ounces (4 cups)). A 20 kg (45pounds) child will require at list 1.5 liters (one quart plus one pint or 50 ounces (6 cups)) of fluid a day. A 30 kg (66pound) child will have a minimum fluid requirement of 1.75 liters (one quart plus one and half pints or 60 ounces (7 cups)) per day. A 50 kg (110 pounds) child requires about 2.25 litters (2 quarts and a cup or about 9-10 cups (80 ounces)) a day. A 70 kg (150 pound) adult person will have a minimum fluid requirement of 3 litters ( 3 quarts or 12 cups) a day. Infants and toddlers will have a higher fluid requirement since most of their food comes from milk or formula. Most children formula and whole milk are about 90% water. Therefore infants until 1 year require about 3-4 cups a day. Children until the age of three years require about 4-5 cups a day. At the age of 10 years most children are drinking about 6 cups of fluid. A child between the age of 15-18 years requires about 8-10 cups a day. Adult men have higher fluid requirement than adult women since women have more fat tissue than men and men have more muscle than women. Muscle is 75% water and fat is only 10% water. Since women have a little more fat than men and men have more muscle than women their fluid requirement is slightly different. This is also true for boys and girls. The adult man will require about 10- 12 cups of fluid a days while women generally require 8-10 cups a day. The fluid requirement is greatly affected by temperature, humidity, degree and duration of physical activity, sweating, closing and etcetera. under this conditions fluid requirement will be much higher as fluid loss gets accelerated. Normally fluids are lost through urine (mainly), feces, respiration from the lungs through the mouth and evaporation from the skin without sweating. However under condition that activate the sweat glands such as heat, humidity, intensive exercise or other work environments the fluid loss would be mainly through sweat gland in trying to cool the body. The sweat glans are therefore the air-conditioning of the body. Sometimes sweat loss can be more than 4 litters ( 4 quarts ) a day. Therefore fluid intake should increase during extensive physical activity, hot weather, humidity, diarrhea, vomiting, fever or other conditions that accelerate fluid loss from the body. Fluid requirements are mainly met with water, with the exception of infants and young children who may still need milk and formula as their main source of food. Adults, older children and adolescents meet their fluid requirement from water, various drinks and foods. Most food have water in them. Even solid food contain about 15-25% water though none solid foods contain much higher water in them. Under normal conditions in a temperate climate, most of the fluid loss is by the kidneys through urine. Under this condition the kidney contributed about two third of the total body fluid loss. The kidney is a filtration organ that removes most of the bodies waste products. The average adult kidney filters about 100 ml of blood per minute. At any given time 20% of the blood that gets to the kidneys filtration capsule gets filtered. In an hour the entire blood volume (5 quarts) gets filtered. In 24 hours (a day) the kidneys filter about 150 quarts/litters of blood. About 80% of the filtrate gets reabsorbed back to the body using simple osmotic gradient and another 10% gets absorbed using different pumps in the lumen. About 10% reaches the distal tubule and collecting duct before it becomes a concentrated urine. different hormone activate some of the pumps in the finale stage (distal tubule and collecting duct) to make the tubule and duct to be permeable to water so that the remaining 9% of the water will be reabsorbed. Finally, only about 1% or 1.5 quarts (6 cups) of the 150 quarts (600 cups) filtered in a day, in the kidneys is excreted in the urine. The final stages are important steps because they are controlled by hormones, mainly, antidiuretic hormone. Thirsty is a physiologic mechanism of the body in the quest for water. The thirsty mechanism is housed in the hypothalamus of the brain. It is a mechanism to maintain internal body's homeostasis using hormones, neurons and behavioral factors. The thirsty mechanism in the hypothalamus is tightly controlled in response to change in blood tonicity or osmolality (275-295 mosm/kg). Change in blood osmolality or tonicity is the greatest stimulus of thirsty. Sodium level is the main determinant of plasma osmolality in this case. Changes in sodium level triggers change in osmolality (fluid movement between intracellular and extracellular spaces). Though change in volume (extracellular dehydration) is also a cause of a trigger in the thirsty mechanism, a bigger change in volume (10% volume change is required to stimulate thirsty) is required to achieve the same degree of thirsty compared to 1% change in serum osmolality. Once the thirsty mechanisms are activated either through osmotic dehydration or volume change the hypothalamus responds by releasing hormones vasopressin which acts on the kidney water permiabity to reabsorb more water and excrete less urine. Change in volume or osmolality activates the kidneys special cell (Juxtaglomerular apparatus) also respond by releasing hormones (renin) reabsorb more water from the filtration and increase the vascular tone to increase blood pressure. When renin is activated angiotensin and aldosterone (from the lungs and adrenal respectively) that help absorb more water and electrolyte (sodium) from the kidneys. Angiotensin also stimulates thirsty and increase vascular tone besides reabsorption of sodium and water in the kidneys. Under normal conditions and in a temperate climate, the average person may need 2-3 litters (2-3 quarts) or 8-12 cups a day of fluid, either through various drinks, food or pure water. However when the temperature is hot and humid or when there is more physically demanding work environment or intensive physical activity, the fluid requirement may be more than double or triple. Children besides requiring the basic fluid intake, during intensive activity, hot and humid weather, fever, diarrhea and vomiting, will require double or triple fluid intake for their age and body weight. Besides the basic physiologic cause of thirsty there are pathological conditions that trigger excessive thirsty or drinking. Such pathologic conditions are diabetes mellitus ( high sugar in the blood), hypercalcemia, and diabetes insipidus. These are hormonal conditions that are known to trigger excessive thirsty. Excessive thirsty is considered drinking more than three litters in adults in a temperate climate with out any other environmental factors or intensive physical activity or work environment or illnesses. Excessive drinking in children should be looked carefully. There should be careful consideration when children are suddenly drinking much more frequently (preferably water), or when they are excessive thirsty, bedwetting or waking up at night several times to go to washroom, or they are experiencing weight loss. These issues need to be addressed immediately by visiting their physician. Theses things could be signs of hormonal imbalance, such as diabetes insipidus, diabetes mellitus or hypercalcemia. Diabetes millets is the most common metabolic disorder which affects 30 million Americans. Diabetes is mostly type 2 (90%) of cases. and less than 10% is type 1 diabetes, which is (insulin dependent or juvenile) an autoimmune disease. Though most of type 1 diabetes are adults most of childhood diabetes at list in the Caucasian population is type 1 diabetes. the symptoms of diabetes are frequent urination, increased thirst (dehydration), hunger, blurred vision, fatigue, irritability, weight loss, bed wetting etcetera. Simple urinalysis, blood sugar testing and HA1c would easily confirm the presence of most of diabetes mellitus. Differentiating type 1 diabetes mellitus versus type 2 should be done by performing pancreatic antibodies. Once the presence of diabetes mellitus is confirmed dietary, physical activity and or medications should be initiated as indicated. Hypercalcemia is another cause of frequent drinking. Hypercalcemia can be caused by excess production of parathyroid hormone or other medical conditions. Excess parathyroid hormone can be due to isolated parathyroid adenoma on the neck or may be part of a bigger pathology call multiple endocrine neoplasia called MEN 1 and 2. Hypercalcemia can be diagnosed by checking serum and urine calcium, parathyroid hormone and 25 hydroxyvitamin D and 1,25 dihydroxy vitamin D. If both serum calcium and urine calcium are high a parathyroid scan is done to confirm the adenoma. Once adenoma is identified surgical removal is the next step. Of course there other causes and treatment modalities for hypercalcemia as well. The next important cause of excessive thirsty and water intake is diabetes insipidus (tasteless diabetes as opposed to sweet diabetes due to high blood sugars). Diabetes insipidus is different from diabetes mellitus because it is tasteless and the blood sugars are normal. The hormone at the center of diabetes insipidus is antidiuretic hormone (vasopressin). This hormone is made in the (brain) hypothalamus and stored in the posterior pituitary gland and is released in response to thirsty and dehydration, to maintain normal cellular tonicity (osmolality). It mainly acts in the kidney's final filtration stage at the distal and collecting tubules. It renders the aquaporin in the kidney to become permeable to water so more water can be reabsorbed back to the body ( more concentrated urine) . There are four forms of diabetes insipidus. 1) antidiuretic hormone deficiency or neurogenic diabetes insipidus or Central diabetes insipidus; In this pathology the body does not produce enough vasopressin (antidiuretic hormone) due to various reasons. When antidiuretic hormone is deficient, water reabsorption from the distal and collecting tubule is low. This hormone deficiency could be due to pituitary tumors, surgical removal of the pituitary gland, infections agent, bleedings, genetic defect in the pituitary gland or hypothalamus. These patients can loose many litters of water a day (up to 15 litters). Essentially the distal tubules and the collecting duct are less permeable to water reabsorption and the kidneys excrete large volume of dilute urine. A patient can urinate over 15 litters (quarts) a day. This causes dehydration. Because there is cellular dehydration the person is continuously thirsty and will drink excessive amount of water to compensate for the fluid loss through the urine. As long as the person has free access to water he/she will maintain normal electrolytes and may not get in trouble though it will affect and disrupt his/her life style because he /she will keep on drink frequently and urinates more frequently. This is easily treated with ddavp (desmopressin). It can be given oral or via nasal spray. 2) Nephrogenic diabetes insipidus: This form of diabetes have similar symptoms to neurogenic diabetes insipidus. In this form of diabetes the body make more vasopressin hormone (antidiuretic hormone) but the kidneys do not respond to the hormone due to the defect in the kidney receptors of antidiuretic hormone either due to genetic defect or drug induced (mainly Lithium). The antidiuretic hormone fails to negotiate with the kidney vasopressin receptors to promote water permeability in the distal tubules and collecting duct. So the urine is very dilute and the patient loose a lot of water. Remember that 10% of the filtrates gets absorbed at this area of the nephron and the kidneys filter about 150 litters a day. Therefore 10% of 150 litters could be up to 15 litters a day lost in urine that could have been reabsorbed if the receptors were working fine. This fails to allow water permeability so that the remaining the 9% of the filtrate to be absorb back the from the distal tubule and collecting duct before the concentrate leaves as a urine. Treatment is amiloride and thiazide diuretics. Sometimes lithium therapy and other drugs can cause this type of diabetes insipidus. Removing lithium will solve the problem in some of these cases. 3) Psychogenic diabetes insipidus/ primary polydipsia: This form of diabetes is due to mostly habitual drinking. The patient drinks a lot of water with out hormonal deficiencies. It may be part of a bigger psychological problems such as anxiety obsessive compulsive behavior or schizophrenia. Dipsogenic diabetes insipidus could also be due to damage in the thirsty center of the brain. It can be treated with limiting fluid intake and psychological counseling. 4) Gestational diabetes insipidus: This is mainly in pregnancy and it resolves 4-6 weeks after delivery. The placenta makes a hormone that metabolizes (destroys) the vasopressin (antidiuretic hormone). The pregnant woman develops vasopressin deficient and develops all the symptoms of diabetes incipidus It is similar to central diabetes insipidus. And responds to ddavp. The different hormonal cause of excessive drinking has be summarized above. They can be differentiated with blood glucose, calcium level and vasopressin level. The different forms of diabetes insipidus can be differentiated by taking the blood level of vasopressin, electrolytes, osmolality, and urine test. further evaluation can be done using water deprivation test and if necessary using vasopressin challenge in the case central diabetes insipidus.. These will differentiate 4 of the forms of diabetes insipidus. If central diabetes insipidus is confirmed MRI of the pituitary may be considered to rule out tumors or other anomalies of the pituitary gland or brain. Going back to your son question: your son is drinking more than you and your husband. could this be normal?. It depends how old is he?. How much does he weigh?. How is his activity level?. Does he have any health issues or signs and symptoms?. When did all this start.? Does he prefer cold water or he drinks any thing.? How often does he go to the washroom.? Does he wake up at night to urinate?. Does wet the bed.? Is there any family history of diabetes?. Is there any weight loss?. Is there any recent change in his drinking habits?. Are there any complains such as headaches or visual changes?. When was the last time he saw his doctor?. Was his blood sugar ok.?. In the absence of these information it is hard to answer you question directly. If your son is an adolescent and he is active and is perfectly healthy then it is not an usual that he can drink much more than you or you husband. Most children who are active above the age of 8 years old may drink 6 or more cups a day and adolescents can vary depending on their activity level. They can drink 10 or more cups a day depending on their situation.. However if there is a recent change in drinking behavior and if you have a good reason to be concerned, you should have him see his doctor for complete evaluation. Your gut feeling may be right as some of the above conditions may evolve slowly. Type 2 diabetes may take a long time to evolve. Diabetes insipidus may also take a long time to manifest as a full blown disease. On the other hand psychogenic or habitual drinking is seen in children with emotional issues. It is a good idea to see his doctor and have him get a complete evaluation. Discuss these issues with his doctor and talk to him/her about his dinking habits in detail, current medications and any symptoms. He/she should be able to figure out the next best steps to determine if he has diabetes insipidus, diabetes mellitus or hypercalcemia or other conditions or he may be perfectly fine. Mostly it depends on the history of presentation. He may also refer you to a specialist if necessary and if indicated. Good Luck. READ MORE
My daughter's skin looks very pale and flushed out. What could be wrong?
Flushing or blushing (milder form of flushing) is a sensation of warmth followed by marked reddening of the affected skin of the body. Flushing is a response to increased blood flow, and causes blood vessels just below the skin to widen and fill with more blood. Flushing can take place any where in the body but mostly it happens on the face cheeks, ears neck and upper body (torso). Flushing could be caused by physiological factors or pathological processes. It could be episodic (transient) or persistent in nature. Episodic flushing is usually due to mediators known as vasoactive substances in the vessels or medications that trigger flushing, while persistent flushing is due to fixed facial redness secondary to large superficial skin vessels filled with slow moving blood. Some times flushing is normal physiologic response to hot spicy food, some drinks, heat, exercising, and emotional responses. These conditions and social situations that cause flushing are not harmful in themselves. However there are pathological conditions that can cause either episodic or persistent flushing that need to be considered seriously. Benign conditions that cause flushing are fever (scarlet, slapped cheek disease), rosacea, menopause, hyperthyroidism, cluster headaches, niacin, sun burn etc. While worrisome causes of flushing include, Cushing syndrome, Pheochromocytoma, Mastocytosis, pancreatic tumors, neuroendocrine tumors, medullary thyroid cancer, Carcinoid syndrome, autonomic dysfunction, errors of metabolism, different cancers and certain medications. Of the endocrine and neuroendocrine disorders only carcinoid syndrome has flushing as a serious presentation. The rest manifest flushing rarely, and may present the flushing at the advanced stage of the disease. The first step in the evaluation of flushing is to see your physician. The doctor will take a detailed medical history. The physician will take extensive history of the flushing and any symptoms that may accompany or proceed the flushing. Taking detailed history will allow the physician to narrow the causes of the flushing. He/she will document all the signs and symptoms and any other symptoms that accompany the flushing. When flushing is dry, then it may be due to vasoactive substances in the vessels while flushing accompanied with sweating may be due to autonomic hyperactivation. A detailed physical exam will further narrow the possible causes of the flushing. For example Cushing syndrome or disease may have facial and body characteristics of Cushing ( moon face, buffalo hump, purple striae etc.), while others can be deciphered from the characteristic of flushing, such as carcinoid syndrome. Laboratory studies, imaging and other testing will be the next step in differentiating the causes of the flushing. When a complete medical evaluation is done the different causes of flushing including emotional, stress, extreme psychological state, tumors, hormones allergic reaction, environmental factors, medications and any other pathological process will be determined. Once the possible causes of flushing are identified, the next step is removing or treating the cause. Therapy could be medical, surgical or psychotherapy, depending on the cause. Going back to your daughter: Your daughter look pale which may indicate anemia or other medical conditions. Usually in flushing the skin is mainly reddish though it may assume a slightly different color than reddish color since it may mainly reflect a venous blood (deoxygenated blood) instead of capillary blood. Make sure your daughter does not have anemia. On the other hand your daughter has flushing which seems to be harmless, which is often the case for most flushing. This may be due to social issues, heat, stress, exercise, some anger, embarrassment and other none serious conditions. Flushing may not be avoidable but you can lessen the effect by reassuring your daughter, avoidance of any triggers of the flushing, using relaxation techniques, meditation, by handling stress better, exercising regularly and eating a healthy balanced diet. However flushing can sometimes be a sign of an underlying disease conditions that should not be ignored. If the flushing is associated with other symptoms such as palpitations, abdominal pain, diarrhea, vomiting, extreme emotional states and if the symptoms are persistent or getting worse, she needs to see her doctor for complete evaluation. Your doctor will take a detailed history and thorough physical exam and may proceed with more work up with labs or imaging if deemed necessary to rule out conditions such as Cushing syndrome/disease, carcinoid syndrome, pheochromocytoma, mastocytosis etc. if indicated. He may also refer you to a specialist if indicated. If there is Anemia, it should be treated right away. Anemia is very common in this age group. Please see your doctor and discuss about these issue in detail and explore all avenues if your daughter needs more help. Good Luck READ MORE
My daughter is 14 years old and has PCOD. What should I do?
Pubertal or sexual development is a complex hormonal process that transforms a child from childhood into adulthood. Hormones from the brain ( hypothalamic and pituitary) hormones and ovarian hormones in females (testicular hormones in males) mediate the sexual transformation. These brain hormones mainly (LH) Luteinizing hormone and (FSH) follicular stimulating hormone stimulate the ovaries to produce female hormones call Estrogen and progesterone. These Ovarian hormones mediate the growth of the uterus and preparer it to be conducive for fertilization (baby) and or menses. For fertilization or menses to take place one of the millions of eggs in the ovarian milieu should be extruded (ovulation) and able to travel to the uterus. When the egg in the uterus is fertilized pregnancy starts and menses stops for at list 8-9 months. In the absence of fertilization the egg gets destroyed and menses takes place in about 14 days after ovulation. For a menses to take place there must be recruitment of ovarian follicles (foliculogenesis) and ovulation. Once there is ovulation of one of the ovules, the extruded ovule travels to the uterus and waits 14 days (mostly 8-10days) to be fertilized or in the absence of sperm to fertilize its destroyed due to lack of hormonal support and the uterine lining sloughed off as a menstrual bleeding. The ovaries undergo initial recruitment of competing oocytes for a selection of one of oocyte to mature. Most of the time only one of the dominant (selected) oocyte out of the competing ones (10-30 of them) gets extruded (ovulated). The rest of the competing follicles commit suicide, leaving a room for one of them to succeed. The initial recruitment phase is called follicular phase and the 2 phase (ovulatory phase is called luteal phase. Initial or follicular phase of the ovaries is mediated by FSH and the second phase (ovulatory) phase is mediated by LH. The LH surge heralds ovulation were there is a spike in body temperature and mood swings. The luteal phase of the ovaries and uterus are the most stable and predictable phase. It is almost always 14 days of the cycle. The variation in the menstrual cycle is mostly in the follicular or menstrual phase in an ovulating female. There is also parallel changes is the uterine environment. A mature uterus should have a conducive environment for an egg to be fertilized and develop into a baby. Blood vessels need to be prepared for nutrient supply and comforting and supporting home for the baby. In regular (normal) menstrual cycle of a female the uterus will have thee phases. The first phase is recruitment of blood vessels called follicular phase with the second one called secretory phase or luteal phase and the third phase is called menstrual phase. The early phase (follicular) is mediated by estrogen (through mainly FSH). The second phase is through progesterone ( vial LH). The menstrual bleeding ( 3 rd) phase takes place when level of hormones collapses and the vascular and secretory support sloughs off as a menstrual bleeding. Ovulation is very important for a regular menstrual cycle to take place. Though few women can have bleeding without ovulation. Some women with Amenorrhea or PCOS (more 3 months or more without a period) can have bleeding either due to intermittent ovulation (or women with fibroids) the uterus builds up so much and the inner lining of the uterus (endometrium) started to slough off irregularly on its own. It could be spotty or heavy prolonged irregular bleeding. Few women may have regular bleeding with out ovulation for various reasons but they will not able to conceive without ovulation. The majority of Caucasian girls start puberty around the age of 10 years and menarche around the age of 12and half years. The minorities in American start their sexual development and menarche much earlier. Human sexual development is divided into 5 stages also called Tanner stages. Stage 1 is pre pubertal and stage 5 is adult. The three stages 2, 3 and 4 are processes were most of the sexual and physical transformation takes place. Breast development acne body odor pubic hair armpit sweating testicular and penile growth takes place progressively in generally predictable way. Most girls will start their period in the middle of Tanner 4 in their sexual development. But they can start to ovulate as early as late Tanner three though boys can be fertile much earlier though they start wet dreams at Tanner three. Though girls May start ovulation late Tanner 3 and mainly tanner 4, they may start menarche as they ovulate but many of them may not establish a regular menstrual cycle until the 2 rd year of commencing menarche. Some times it may take up to 3 or more years to establish regular menses as the hormonal control (the hypothalamic/pituitary ovarian axis) takes a while to establish rhythmic control of the menstrual cycle. In many females regular ovulation and uterine maturation may take a while to establish. It is also fine to skip a period occasional (2-4 times a year) due to various environmental reasons including stress, diet, weight change, strenuous physical activity, etc. Normal period is considered >8 times a year with average menstrual flow. It is considered abnormal when a women gets her period less than 8 times a year or skips her period three or more months in a row or if she is bleeding more than 10 days a month or have a heavy or spotty period. A regular menstrual bleeding is a bout 3-7 days with bleeding of 30-50 ml ( 6-10 small tampons) per cycle. An average moderately soaked pad or tampon can hold about a teaspoon of blood (5 ml). Heavily soaked tampon may hold about a table spoon (15 ml) of blood. Changing more than 12 small/moderate tampons (80 ml) and less than 2 tampon (10 ml) may be abnormal. Normal menstrual cycle is 21-35 days for an average of 28 days. This may be in response of the moon's electromagnetic forces that may be controlling the hormonal rhythmicity of the female reproductive cycle. Bleeding twice or more a month or bleeding less than 21 days or longer than 35 day after the last cycle is considered abnormal. In female after 2 years of menarche, irregular period is considered 1) skipping menses 3 or more moths in a row (Amenorrhea), 2) < 8 menses a year 3) heavy bleeding >80 ml bleeding. 4) Little bleeding <2 days (<10ml). 5) Bleeding after 35 days of the last menstrual cycle. Primary amenorrhea is considered in a female 15 years old or older who nerve started her period. In all conditions pregnancy need to be ruled out. As the commonest cause of amenorrhea is Pregnancy. There are many causes of irregular period in a female including stress, overweigh/obesity, weight loss/abnormal weight, excessive exercise, illnesses, uterine and ovarian conditions, pituitary abnormalities including pituitary tumors, and genetic conditions such as Turners syndrome or hypogonadism, medications and hormone imbalances. Hormonal imbalances such as uncontrolled/ undiagnosed/ hypothyroidism, excess cortisol, insulin resistance (metabolic syndrome), high prolactin level etcetera can cause irregular bleeding (period) Polycystic ovarian syndrome is a mix of disorders consisting some of the following: 1) Amenorrhea or irregular period as mentioned above, 2) hyperandrogenia, (producing more male hormones called androgens such as testosterone, DHEAS and androstendione ), Hyperandrogenism ( skin manifestations such as acne, excess hair, thinning of hair or hair loss etc., with or with out cysts in the ovary. In PCOS (polycystic ovarian syndrome one does not have to have cysts in the ovaries to be diagnosed with PCOS. Many women with PCOS have no cysts in their ovaries and many normal women have cysts in their ovaries without PCOS. Women with PCOS have skin conditions (acne, facial hair and thinning of hair and hair loss) and metabolic conditions such as prediabetes or diabetes, fatty liver disease high lipids cardiovascular problems and infertility. PCOS could be due to many causes, 1) adrenal causes, abnormal adrenal androgens with or without late onset adrenal hyperplasia. 2) insulin resistance (HAIR AN syndrome (hyperandrogenism insulin resistance ancanthosis nigricans syndrome)). increased insulin causes stimulation of male hormones in the ovaries by stimulating the ovarian theca cell to produce more male hormone. During insulin resistance (obesity) the body is resistant to insulin while the ovaries stay sensitive to insulin. Therefore PCOS is common in insulin resistance. The converse is also true. 3) The Hypothalamic/Pituitary /Ovarian axis abnormality. The pulse generator in the hypothalamus is faster in frequency. The pituitary ovarian axis rhythmicity is altered in PCOS. The rhythmicity is much faster in frequency than normal and ovaries do not have enough time to mature and ovulated. Since there is less ovulation, PCOS is a state of Anovulation. With out ovulation it is less possible to have a normal period. What ever the cause of PCOS, the final effect or out come is similar. PCOS affects the female reproductive, metabolic, hormonal, skin and social conditions. PCOS can cause weight gain and insulin resistance. The other way round is also true (vicious cycle) Untreated or undiagnosed hypothyroidism, hyperprolactinemia and excess cortisol or adrenal androgens (like late onset adrenal hyperplasia) can also suppress pituitary hormone activity (altering the hormonal rhythmicity) leading to irregular period and/or amenorrhea. The initial evaluation into irregular period is to take detailed history and complete physical evaluation. Over 80% of the answers come from taking a detailed history and performing complete physical exam. The next step is to perform complete laboratory and imaging work up. Labs for Amenorrhea profile including pregnancy, adrenal androgens, thyroid profile, CAH profile, metabolic profile, prolactin, ovarian hormone insulin karyotype or genetic testing (if indicated) etc. should be performed (complete bill of health). And once the diagnosis of PCO is established treatment should be initiated including life style change, weight loss, healthy balanced diet and structured regular physical activity. Medical therapy should be initiated as soon as other causes are eliminated (thyroid, adrenal, prolactin etc.). Hormonal causes so as thyroid abnormalities, excess adrenal androgens such as late onset CAH and abnormal prolactin level need to be treated promptly. PCOS need to be treated with low androgenic birth control pills, metformin and if there is skin manifestation spironolactone, fenastride, vaniqua etc. can be considered. Going back to your daughter: Your daughter is 14 years old. When did she start her period?. Does she have dark skin on her neck?. Is there a family history of PCOS in females or men who lost hair early (Balding)?. Lets consider she started her period over 2 years ago and she truly has PCOS. PCOS is a group of disorders. It is not one disease. It is difficult to pinpoint to a single cause, because there is no single cause in PCOS. It is a syndrome (collection of disorders) not a single disorder. It can be due to insulin resistance, adrenal abnormalities, hypothalamic/pituitary/ovarian axis disorder (change in rhythmicity of the pulse generator in the hypothalamus). Any of the above and or combination of the above causes or something else . No one knows for sure. But it has to be evaluated and treated well, because it has long term consequences. Your doctor should also rule out thyroid abnormalities, adrenal anomalies including late onset CAH, prolactin and pregnancy (unlikely) and karyotype or genetic testing if indicated. Let him/her perform a complete evaluation. The history, physical exam and laboratory work up should determine if she has PCOS. PCOS is mostly a diagnosis of exclusion of other hormonal causes. Free and total testosterone are usually high and a protein called SHBG is low in PCOS. Metabolic abnormalities are also common in PCOS. There is no doubt that PCOS cause excessive weight gain. And it is also true that excessive weight gain may cause PCOS. No one knows which one comes first, weight gain or PCOS. But two of them are locked up in a vicious cycle. Once the diagnosis of PCOS is established, treatment should be commenced swiftly. Life style change should be addressed in detail. weight management is very important. Even as small as 5% weight loss will make a big difference. healthy balanced diet with lots of fresh vegetables is essential. Daily structured physical activity is also very necessary. It will be very helpful to see a good nutritionist for good nutritional guidance. Weight loses is very important aspect of the treatment of PCOS. A desired modest weight loss of 5-10% will lead to a major improving in the PCOS. If weight loss is difficult through diet and structured daily exercise, appetite suppressing agents can be tried, if your doctor would be willing to help you. Some of the medications to be considered besides of course metformin, would be Topamax 100-200mg twice a day, contrave (naltrexone/welbuterin), orlestat, Adderall, qysmia, Belvic phentermine, victoza, saxenda etcetera as indicated or on an individual bases. It is also very important to realize that she needs to be on low androgenic birth control pills for the PCOS. Since she is not ovulating regularly, she needs those female hormones replaced and the uterus need to be able to shed regularly to protect the uterus from future uterine problems. Metformin is most of the time added in the treatment of PCOS. It can be used liberally to help her with the metabolic conditions (insulin resistance) of PCOS and help the ovaries function better. Other medications such as spironolactone, vaniqua etc. can be considered if indicated and if she has skin conditions such as hirsutism or thinning of hair (hair loss). You need to work with your daughter, nutritionist and your physician closely. Involve her in structured sports activity and make sure you have a good handle in a healthy balanced diet with lost fresh vegetable. If needed get a referral to see a specialist in PCOS. Good Luck READ MORE
Why is my daughter having irregular periods?
Pubertal or sexual development is a complex hormonal process that transforms a child from childhood into adulthood. Hormones from the brain ( hypothalamic and pituitary) hormones and ovarian hormones in females (testicular hormones in males) mediate the sexual transformation. These brain hormones mainly (LH) Luteinizing hormone and (FSH) follicular stimulating hormone stimulate the ovaries to produce female hormones call Estrogen and progesterone. These Ovarian hormones mediate the growth of the uterus and preparer it to be conducive for fertilization (baby) and or menses. For fertilization or menses to take place one of the millions of eggs in the ovarian milieu should be extruded (ovulation) and able to travel to the uterus. When the egg in the uterus is fertilized pregnancy starts and menses stops for at list 8-9 months. In the absence of fertilization the egg gets destroyed and menses takes place in about 14 days after ovulation. For a menses to take place there must be recruitment of ovarian follicles (foliculogenesis) and ovulation. Once there is ovulation of one of the ovules, the extruded ovule travels to the uterus and waits 14 days (mostly 8-10days) to be fertilized or in the absence of sperm to fertilize its destroyed due to lack of hormonal support and the uterine lining sloughed off as a menstrual bleeding. The ovaries undergo initial recruitment of competing oocytes for a selection of one of oocyte to mature. Most of the time only one of the dominant (selected) oocyte out of the competing ones (10-30 of them) gets extruded (ovulated). The rest of the competing follicles commit suicide, leaving a room for one of them to succeed. The initial recruitment phase is called follicular phase and the 2 phase (ovulatory phase is called luteal phase. Initial or follicular phase of the ovaries is mediated by FSH and the second phase (ovulatory) phase is mediated by LH. The LH surge heralds ovulation were there is a spike in body temperature and mood swings. The luteal phase of the ovaries and uterus are the most stable and predictable phase. It is almost always 14 days of the cycle. The variation in the menstrual cycle is mostly in the follicular or menstrual phase in an ovulating female. There is also parallel changes is the uterine environment. A mature uterus should have a conducive environment for an egg to be fertilized and develop into a baby. Blood vessels need to be prepared for nutrient supply and comforting and supporting home for the baby. In regular (normal) menstrual cycle of a female the uterus will have thee phases. The first phase is recruitment of blood vessels called follicular phase with the second one called secretory phase or luteal phase and the third phase is called menstrual phase. The early phase (follicular) is mediated by estrogen (through mainly FSH). The second phase is through progesterone ( vial LH). The menstrual bleeding ( 3 rd) phase takes place when level of hormones collapses and the vascular and secretory support sloughs off as a menstrual bleeding. Ovulation is very important for a regular menstrual cycle to take place. Though few women can have bleeding without ovulation. Some women with Amenorrhea or PCOS (more 3 months or more without a period) can have bleeding either due to intermittent ovulation (or women with fibroids) the uterus builds up so much and the inner lining of the uterus (endometrium) started to slough off irregularly on its own. It could be spotty or heavy prolonged irregular bleeding. Few women may have regular bleeding with out ovulation for various reasons but they will not able to conceive without ovulation. The majority of Caucasian girls start puberty around the age of 10 years and menarche around the age of 12and half years. The minorities in American start their sexual development and menarche much earlier. Human sexual development is divided into 5 stages also called Tanner stages. Stage 1 is pre pubertal and stage 5 is adult. The three stages 2, 3 and 4 are processes were most of the sexual and physical transformation takes place. Breast development acne body odor pubic hair armpit sweating testicular and penile growth takes place progressively in generally predictable way. Most girls will start their period in the middle of Tanner 4 in their sexual development. But they can start to ovulate as early as late Tanner three though boys can be fertile much earlier though they start wet dreams at Tanner three. Though girls May start ovulation late Tanner 3 and mainly tanner 4, they may start menarche as they ovulate but many of them may not establish a regular menstrual cycle until the 2 rd year of commencing menarche. Some times it may take up to 3 or more years to establish regular menses as the hormonal control (the hypothalamic/pituitary ovarian axis) takes a while to establish rhythmic control of the menstrual cycle. In many females regular ovulation and uterine maturation may take a while to establish. It is also fine to skip a period occasional (2-4 times a year) due to various environmental reasons including stress, diet, weight change, strenuous physical activity, etc. Normal period is considered >8 times a year with average menstrual flow. It is considered abnormal when a women gets her period less than 8 times a year or skips her period three or more months in a row or if she is bleeding more than 10 days a month or have a heavy or spotty period. A regular menstrual bleeding is a bout 3-7 days with bleeding of 30-50 ml ( 6-10 small tampons) per cycle. An average moderately soaked pad or tampon can hold about a teaspoon of blood (5 ml). Heavily soaked tampon may hold about a table spoon (15 ml) of blood. Changing more than 12 small/moderate tampons (80 ml) and less than 2 tampon (10 ml) may be abnormal. Normal menstrual cycle is 21-35 days for an average of 28 days. This may be in response of the moon's electromagnetic forces that may be controlling the hormonal rhythmicity of the female reproductive cycle. Bleeding twice or more a month or bleeding less than 21 days or longer than 35 day after the last cycle is considered abnormal. In female after 2 years of menarche, irregular period is considered 1) skipping menses 3 or more moths in a row (Amenorrhea), 2) < 8 menses a year 3) heavy bleeding >80 ml bleeding. 4) Little bleeding <2 days (<10ml). 5) Bleeding after 35 days of the last menstrual cycle. Primary amenorrhea is considered in a female 15 years old or older who nerve started her period. In all conditions pregnancy need to be ruled out. As the commonest cause of amenorrhea is Pregnancy. There are many causes of irregular period in a female including stress, overweigh/obesity, weight loss/abnormal weight, excessive exercise, illnesses, uterine and ovarian conditions, pituitary abnormalities including pituitary tumors, and genetic conditions such as Turners syndrome or hypogonadism, medications and hormone imbalances. Hormonal imbalances such as uncontrolled/ undiagnosed/ hypothyroidism, excess cortisol, insulin resistance (metabolic syndrome), high prolactin level etcetera can cause irregular bleeding (period) Polycystic ovarian syndrome is a mix of disorders consisting some of the following: 1) Amenorrhea or irregular period as mentioned above, 2) hyperandrogenia, (producing more male hormones called androgens such as testosterone, DHEAS and androstendione ), Hyperandrogenism ( skin manifestations such as acne, excess hair, thinning of hair or hair loss etc., with or with out cysts in the ovary. In PCOS (polycystic ovarian syndrome one does not have to have cysts in the ovaries to be diagnosed with PCOS. Many women with PCOS have no cysts in their ovaries and many normal women have cysts in their ovaries without PCOS. Women with PCOS have skin conditions (acne, facial hair and thinning of hair and hair loss) and metabolic conditions such as prediabetes or diabetes, fatty liver disease high lipids cardiovascular problems and infertility. PCOS could be due to many causes, 1) adrenal causes, abnormal adrenal androgens with or without late onset adrenal hyperplasia. 2) insulin resistance (HAIR AN syndrome (hyperandrogenism insulin resistance ancanthosis nigricans syndrome)). increased insulin causes stimulation of male hormones in the ovaries by stimulating the ovarian theca cell to produce more male hormone. During insulin resistance (obesity) the body is resistant to insulin while the ovaries stay sensitive to insulin. Therefore PCOS is common in insulin resistance. The converse is also true. 3) The Hypothalamic/Pituitary /Ovarian axis abnormality. The pulse generator in the hypothalamus is faster in frequency. The pituitary ovarian axis rhythmicity is altered in PCOS. The rhythmicity is much faster in frequency than normal and ovaries do not have enough time to mature and ovulated. Since there is less ovulation, PCOS is a state of Anovulation. With out ovulation it is less possible to have a normal period. What ever the cause of PCOS, the final effect or out come is similar. PCOS affects the female reproductive, metabolic, hormonal, skin and social conditions. PCOS can cause weight gain and insulin resistance. The other way round is also true (vicious cycle) Untreated or undiagnosed hypothyroidism, hyperprolactinemia and excess cortisol or adrenal androgens (like late onset adrenal hyperplasia) can also suppress pituitary hormone activity (altering the hormonal rhythmicity) leading to irregular period and/or amenorrhea. The initial evaluation into irregular period is to take detailed history and complete physical evaluation. Over 80% of the answers come from taking a detailed history and performing complete physical exam. The next step is to perform complete laboratory and imaging work up. Labs for Amenorrhea profile including pregnancy, adrenal androgens, thyroid profile, CAH profile, metabolic profile, prolactin, ovarian hormone insulin karyotype or genetic testing (if indicated) etc. should be performed (complete bill of health). And once the diagnosis of PCO is established treatment should be initiated including life style change, weight loss, healthy balanced diet and structured regular physical activity. Medical therapy should be initiated as soon as other causes are eliminated (thyroid, adrenal, prolactin etc.). Hormonal causes so as thyroid abnormalities, excess adrenal androgens such as late onset CAH and abnormal prolactin level need to be treated promptly. PCOS need to be treated with low androgenic birth control pills, metformin and if there is skin manifestation spironolactone, fenastride, vaniqua etc. can be considered. Going back to your daughter: Your daughter is 14 years old. When did she start her period? Is she overweight?. Does she have dark skin on her neck?. Is there a family history of PCOS in females or men who lost hair early (Balding)?. Lets consider she started her period over 2 years ago and she truly has PCOS. PCOS is a group of disorders. It is not one disease. It is difficult to pinpoint to a single cause, because there is no single cause in PCOS. It is a syndrome (collection of disorders) not a single disorder. It can be due to insulin resistance, adrenal abnormalities, hypothalamic/pituitary/ovarian axis disorder (change in rhythmicity of the pulse generator in the hypothalamus). Any of the above and or combination of the above causes or something else . No one knows for sure. But it has to be evaluated and treated well, because it has long term consequences. Your doctor should also rule out thyroid abnormalities, adrenal anomalies including late onset CAH, prolactin and pregnancy (unlikely) and karyotype or genetic testing if indicated. Let him/her perform a complete evaluation. The history, physical exam and laboratory work up should determine if she has PCOS. PCOS is mostly a diagnosis of exclusion of other hormonal causes. Free and total testosterone are usually high and a protein called SHBG is low in PCOS. Metabolic abnormalities are also common in PCOS. Once the diagnosis of PCOS is established treatment should be commenced swiftly. Life style change should be addressed in detail. weight management is very important. Even 5% weight loss will make a big difference. healthy balanced diet with lots of fresh vegetables is essential. Daily structured physical activity is also necessary. She needs to be on low androgenic birth control pills. Since she is not ovulating regularly, she needs those female hormones replaced and the uterus need to shed regularly to protect it from future uterine problems. Metformin can be used liberally to help her with the metabolic issues of PCOS and help the ovaries as well. Other medications such as spironolactone, vaniqua etc. can be considered if indicated and if she has skin conditions such as hirsutism or thinning of hair (hair loss). You need to work with your daughter and your physician closely. If needed get a referral to see a specialist in this area ( adolescent specialist or endocrinologist). It will also be helpful to see a good nutritionist. Good Luck READ MORE
My daughter just started her periods and has extreme mood swings. Is it normal in children?
Puberty is a complex genetic program and hormonal process of sexual maturation. A child goes through the hormonal process of sexual maturation to transition from childhood to adulthood. The average female starts puberty about the age of 10 years. The average menarche for a female is around 12 and 1/2 years though there is difference in different ethnic groups. African Americans start puberty much earlier (as early as 6 years) and menarche takes place around the age of 10 years. Changes in the pituitary hormones (LH, FSH) triggers the initiation of puberty. In a female Estrogen and progesterone levels increase to mediate the process of sexual development. During this sexual development, mood swings are common as the child is going through physical and hormonal changes. This is also a more confusing and conflicting time for the child. The sexual development culminates in menarche (menstrual cycle, also known as a period). This usually happens after 2 and h1/2 years after starting puberty. Once starting menstrual cycle the adolescent goes through more mood swings (emotional roller coaster) conflict and confusions. The child goes through a stressful period. They may experience, irritable, sadness, anger, nervousness, fatigue, sleep problems loneliness etc.. Their mood changes from being sad, angry and mean to joyfulness in a short period of time. This is period were there is intense struggle for self image and identity. There is more peer pressure they confide more with their peers and become distant from the parents in search of their own space. This transition time from childhood to adulthood may take a while but it will always come back to normal unless there is psychological issue beyond simple adolescent mood swings. These hormonal changes that are causing body changes are also bringing changes in brain neurotransmitters that can cause mood swings. Changes in Estrogen levels can lead to changes on serotonin and dopamine levels. This neurotransmitters are known to be involved in anxiety and depression. Occasionally undiagnosed hyperthyroidism (toxic thyroid gland may lead to symptoms that are similar to mania and ADHD. checking thyroid hormone and cortisol cortisol levels are important. Going back to your daughter: Your daughter is going through puberty, a process of sexual development to become an independent adult. This is a complex maturation process that involves development of breast tissue, pubic hair, body odor, acne, growth spurt, ovarian and uterine growth and finally menarche ( menstrual cycle). These changes are triggered by hormone changes from the brain (LH, FSH) and ovarian Estrogen, Progesterone) glands. These process of sexual maturation can be overwhelming and confusing to a young adolescent. The hormones of puberty mainly estrogen and to some extent progesterone for females and testosterone in males can trigger changes in brain neurotransmitters, mainly, serotonin and dopamine. Serotonin is known to be involved in mood swings such as anger, frustrations, irritability, sadness anxiety etcetera. During this transition period from childhood to adolescence many children will experience mood swings of sadness, irritability, anger, frustration, loneliness to joyfulness in a short period of time. This can create a lot of challenge and pressure for you and the family. This process is also a very challenging and overwhelming period for your daughter as she goes through these physical and hormonal changes. She is starting to develop her own self image (self-conscious), ideas, and independent thinking. She may be more confused , conflicted and embarrassed about these changes. At time she is torn between being a child and being accepted as an adult. She may do this by pushing you and every one around in trying to have her own autonomy (space). However these changes and mood swings are part of normal transitioning process from childhood to adult hood that most of us would go through. One day these things will pass and your sweet daughter and the family dynamics will be in harmony and life will continue as before. Remember you may have gone through these processes your self. You should reassure her that this is a normal process and that girls have to go through this and that things will be fine eventually. You should work with her closely and openly. You should not be critical and no blaming. You should allow her some freedom (space). You should also allow her to confide with her peers and you should try to know them. You also should address all her concerns and respect her privacy reasonably, as to put more trust on you. Allow her to sleep enough time (at list 8 hours a day). Try to involve her in regular sports activity. Let her eat healthy balanced diet with plenty of fresh fruits and vegetables with adequate micronutrients. Calcium supplement of 1200mg daily and vitamin of 2000units (50 microgram) a day would benefit her. Please be assured that this will pass with time and that your beautiful sweet girl will be a wonderful girl the way you brought her up and the mood swings will slowly fade away and you family dynamics will be restored to your liking. However if the mood swings take a long time to resolve and if they become unmanageable or look extreme that it is interfering with her life you should seek medical help and a counseling. There may be an element of depression, anxiety or other mood disorders that could not be explained by simple adolescent mood swings. At that stage, psychological counseling and medical intervention may be necessary. But I am very hopeful that your daughter has simple pubertal mood swings and that, with time thing will resolve on their own. Thyroid and cortisol abnormalities should be excluded by her doctor. Please talk to her doctor and work with the doctor closely. Let your doctor check her thyroid and cortisol level to rule out thyrotoxicosis and excess cortisol. Good Luck. READ MORE
Can a person get diabetes at any age?
Diabetes is a common metabolic disease in America. Almost 10% (over 30 million) of the American population has diabetes. Over 90% have type 2 diabetes and the rest (10% or 1.25 million) have type 1. Out of this children <19 years make up a small fraction. About 300,000 children have diabetes. Currently, out of the 300,000 children with diabetes, over 85% have type 1 diabetes and closer to 15% (40,000) may have type 2 diabetes. 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. In native American children most of the childhood diabetes is type 2 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 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 also play major role. With the epidemics of childhood overweight and obesity type 2 diabetes in children is being encountered as 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 shortens their life expectancy. In average type 2 diabetes takes about 5-10 years to evolve (to have full blown symptoms of diabetes) in most cases. Over 40% 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. Maintaining HA1c <7.0% is essential to avoid long term and short term complications. Medications such as Oral hypoglycemic agents (glipezide, glyburide), GLP1 receptor agonists (Victoza, Byetta), DPP-4 inhibitors should be utilized if indicated. Victoza may be helpful in weight loss as well. If HA1c does no improve < 7.5 after reasonable trial with medications, insulin should be utilized judiciously. Going back to your son: Yes, Type 2 diabetes can develop at a young age, as young as 5 years old. And in some circumstances even at younger age. At the age of 13 years, most boys are going through puberty and your son is likely in the middle of his puberty. Puberty is a state of insulin resistance and that tips the balance for diabetes for those who have genetic susceptibility and a strong family history, and are also gaining more weight. 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. You need to make sure your son tries to lose weight through healthy balance diet and regular/structured daily physical activity. He needs to be on his anti diabetes medications with or without insulin as indicated. Work closely with your doctor and/or your diabetes educators. Maintain an HA1c of <7%. You will give your son a brighter future to be part of the great American dream. Good luck. READ MORE
How can I help my son gain weight?
Thinness or failure to thrive could be due to inadequate weight gain or inappropriate weight loss. These conditions may be due to poor appetite, poor calorie intake, malabsorption or excessive calorie expenditure. Many children with poor appetite due to various reasons, may have failure to thrive. Failure to thrive may also take place while appetite is normal. In this scenario the child may have either malabsorption or excessive calories expenditure. Malabsorption may be due to gastrointestinal issues such as celiac disease, lactose intolerance, protein allergy etc. And excessive calories expenditure could be due to hyperthyroid, anemia, heart disease, cystic fibrosis, diabetes and other diseases that reguire more calories expenditure. Some children who have good appetite may not gain optimum weight as these children may have constitutional underweight which is a normal variant of growth. Most children gain weight in a predictable fashion. A new born child baby is about 7.5 pounds at birth. Birth weight is doubled at 3 months and tripled at one year. At age 5 years the average child is 40 pounds in weight. Thereafter the child (boys) gains about 5 pounds untill the age of puberty 12 years. After the age of 12 years the average child gains about 9 pounds per year until adulthood. A simple formula could be also used to calculate the weight of a child after the age of 1 year. (age x 4.4 pounds +18 pounds = average weight of a child at that age). Linear height growth also follows a predictable process. The formula for height after the age of 1 year is as follows: age x 5cm + 80 cm = the height in centimeter of the average child for that age. To covert this to inches, simply divide it by 2.54. Children who have poor appetite and or have failure to thrive, those children whose weight is less than 20% of thier hieght or those who fell 2 or more centiles of the wieght growth curve or the ones whose weight is below the 3rd percentile, need proper evaluation by an expert. Medical, hormonal genetic, psychological and environmental factors should be ruled out. Children who have poor appetite and those who are picky and Small eaters and those with failure to thrive need to be provided with high calorie foods. They need to eat more frequently and should always have bedtime snacks. Calories can be fortified with cheese, creams, peanut butter, butter and oil. Seeing a good nutritionist will also be very important. Nutritional consultation will help in understanding of nutritional values of different foods and micronutrients. If indicated some children can benefit from apettite stimulating agents. Cyproheptadine is commonly used for this purpose. 2-4 mg three times a day half hour before meals may help. Oxandrolone 5-10 mg can be considered for some children. Progesterone base medications ( such as megace) are reserved for serious illnesses such as cystic fibrosis and wasting syndromes. These things should be discussed with the physician if they are ever indicated. The most important thing is optimizing calorie intake. Going back to your question: If your son have a normal linear hieght growth but his weight is low or has poor appetite, he may have a constitutional underweight which is a normal variation. But if linear hieght growth is affected, he may have more issues going on. If your son has a good appetite and is not a small or a picky eater and, his height is normal that is likely his genetic program. It is important that you have him see his doctor and have him proper evaluation and get referral if indicated. Basic work up should be performed to rule out hormonal and medical conditions. You should also see a good nutritionist to help you appreciate different foods and nutrients. You should optimize calorie intake as much as you can. Add Cheese, butter, oil etc to his food. Let him eat high calorie foods more frequently at least 6 times (three meals and three snacks) a day and remember to provide him with high calorie bedtime snacks. Ask your doctor if he can benefit from weight promoting agents if indicated. The most important thing is to work with your doctor closely. Good luck. READ MORE
Why is my son not gaining weight?
Thinness or failure to thrive could be due to inadequate weight gain or inappropriate weight loss. These conditions may be due to poor appetite, poor calorie intake, malabsorption or excessive calorie expenditure. Many children with poor appetite due to various reasons, may have failure to thrive. Failure to thrive may also take place while appetite is normal. In this scenario the child may have either malabsorption or excessive calories expenditure. Malabsorption may be due to gastrointestinal issues such as celiac disease, lactose intolerance, protein allergy etc. And excessive calories expenditure could be due to hyperthyroid, anemia, heart disease, cystic fibrosis, diabetes and other diseases that reguire more calories expenditure. Some children who have good appetite may not gain optimum weight as these children may have constitutional underweight which is a normal variant of growth. Most children gain weight in a predictable fashion. A new born child baby is about 7.5 pounds at birth. Birth weight is doubled at 3 months and tripled at one year. At age 5 years the average child is 40 pounds in weight. Thereafter the child (boys) gains about 5 pounds untill the age of puberty 12 years. After the age of 12 years the average child gains about 9 pounds per year until adulthood. A simple formula could be also used to calculate the weight of a child after the age of 1 year. (age x 4.4 pounds +18 pounds = average weight of a child at that age). Linear height growth also follows a predictable process. The formula for height after the age of 1 year is as follows: age x 5cm + 80 cm = the height in centimeter of the average child for that age. To covert this to inches, simply divide it by 2.54. Children who have poor appetite and or have failure to thrive, those children whose weight is less than 20% of thier hieght or those who fell 2 or more centiles of the wieght growth curve or the ones whose weight is below the 3rd percentile, need proper evaluation by an expert. Medical, hormonal genetic, psychological and environmental factors should be ruled out. Children who have poor appetite and those who are picky and Small eaters and those with failure to thrive need to be provided with high calorie foods. They need to eat more frequently and should always have bedtime snacks. Calories can be fortified with cheese, creams, peanut butter, butter and oil. Seeing a good nutritionist will also be very important. Nutritional consultation will help in understanding of nutritional values of different foods and micronutrients. If indicated some children can benefit from apettite stimulating agents. Cyproheptadine is commonly used for this purpose. 2-4 mg three times a day half hour before meals may help. Oxandrolone 5-10 mg can be considered for some children. Progesterone base medications ( such as megace) are reserved for serious illnesses such as cystic fibrosis and wasting syndromes. These things should be discussed with the physician if they are ever indicated. The most important thing is optimizing calorie intake. Going back to your question: If your son have a normal linear hieght growth but his weight is low or has poor appetite, he may have a constitutional underweight which is a normal variation. But if linear hieght growth is affected, he may have more issues going on. If your son has a good appetite and is not a small or a picky eater and, his height is normal that is likely his genetic program. It is important that you have him see his doctor and have him proper evaluation and get referral if indicated. Basic work up should be performed to rule out hormonal and medical conditions. You should also see a good nutritionist to help you appreciate different foods and nutrients. You should optimize calorie intake as much as you can. Add Cheese, butter, oil etc to his food. Let him eat high calorie foods more frequently at least 6 times (three meals and three snacks) a day and remember to provide him with high calorie bedtime snacks. Ask your doctor if he can benefit from weight promoting agents if indicated. The most important thing is to work with your doctor closely. Good luck. READ MORE
My son just doesn’t feel hungry on his own. Should I get some tests done?
Appetite is a desire to eat food. It is mostly driven by hunger. But sometimes appealing foods can trigger appetite while the person may not be hungry. Satiety or fullness lowers hunger. Hunger and satiety are mediated by hormones such as ghrelin, leptin, neuropeptide Y etc. Appetite helps us get sufficient calories to fulfill our growth, repair and metabolic needs. Poor appetite could be due to medical, psychological, gentic or environmental factors. In teens and adolescent Anaroxia Nervosa is a common cause of poor appetite. Children with Anorexia may restrict food, purge or excercise excessively because they have intense fear of weight gain or they may think they are fat though they are not. Many children with poor appetite due to various reasons, may have failure to thrive. Failure to thrive may happen in the setting of good appetite. In this scenario the child may have either malabsorption or excessive calories expenditure. Malabsorption may be due to gastrointestinal issues such as celiac. And excessive calories expenditure could be due to hyperthyroid, anemia, heart disease, cystic fibrosis and other diseases that reguire more calories intake. Most children gain weight in a predictable fashion. A new born child is about 7.5 pounds. Birth weight is doubled at 3 months and tripled at one year. At age 5 years the average child is 40 pounds in weight. Thereafter the child (boys) gains about 5 pounds untill the age of puberty 12 years. After the age of 12 years the average child gains about 9 pounds per year until adulthood. Many children with poor appetite but who have reasonable linear hieght growth may have a constitutional under weight, which is a variation of normal growth. Children who have poor appetite and or have failure to thrive, those children whose weight is less than 20% of thier hieght or those who fell 2 or more centiles of the wieght growth curve or the ones whose weight is below the 3rd percentile need proper evaluation by an expert. Medical, hormonal genetic, psychological and environmental factors should be ruled out. Children who have poor appetite and those who are picky and Small eaters and those with failure to thrive need to be provided with high calorie foods. They need to eat more frequently and should always have bedtime snacks. Calories can be fortified with cheese, creams, peanut butter, butter and oil. Seeing a good nutritionist will also be very important. If indicated some children can benefit from apettite stimulating agents. Cyproheptadine is commonly used for this purpose. 2-4 mg three times a day half hour before meals may help. Oxandrolone 5-10 mg can be considered for some children. Progesterone base medications ( such as megace) are reserved for serious illnesses such as cystic fibrosis and wasting syndromes. These things should be discussed with the physician if they are ever indicated. The most important thing is optimizing calorie intake. Going back to your question: If your son have a linear hieght growth but his weight is low or has poor appetite, he may have a constitutional underweight which is a normal variation. But if linear hieght growth is affected, he may have more issues going on. It is important that you have him see his doctor and have him proper evaluation and get referral if indicated. You should also see a good nutritionist. You should optimize calorie intake. Add Cheese, butter, oil etc to his food. Let him eat high calorie foods more frequently at least 6 times a day and provide him high calorie bedtime snacks. Discuss with your doctor if appetite stimulating agents are indicated. Good luck. READ MORE
Are there really growth supplements my son can take to be taller?
Height is an important parameter of growth. Height is not only a measure of good health and nutrition, but also important symbol of social status in our modern society. Today the average adult man is a little above 5 feet 9 inches tall, while the average women is 5 feet 4 inches tall. How ever the average president in America is above 5 feet 11 inches. In the last 90 years all American presidents were 6 feet or more except Eisenhower and Carter who both were 5 feet and 10 inches tall (still taller than the average man in the USA). It is also true in all forms of politics and leadership positions and important jobs in governments and institutions, the taller person has a better chance than the smaller competitor to have the job. If a shorter man wins he must have a better attributes than the taller man. Relationships also go the same way. The taller person is more successful than the shorter one in relationships (such as dating). This may not be true for tall woman in terms of relationships. Most men marry shorter women than themselves, and most women marry taller men than them. In sports most successful sports men in America are above 6 feet (exception may be soccer players). Stature is deeply ingrained in our perception that tallness is considered a sign of smartness, power, authority as special attribute of ones genetic endowment. It is important to consider growth as an important measure of good health and nutrition. Normal linear height growth is determined by the population's height dispersion called standard deviation. Normal height is therefore a height within two standard deviation above and below the mean of height values for age and gender for that population. It includes about 95% of the population in consideration. It ranks the individual's height in that population. The two standard deviation falls between the 3rd percentile and 97% percentile of the heights of that population.. If some one is at the 10%, he/she is normal but at the shorter side for the population, and if one is at the 95 percentile he/she is normal but taller side. Those above 97 percentile are mostly healthy people but are very tall ( >6feet 3 inches). Few of them may have medical problems that may need attention but in most cases they are healthy tall people. People in the <3rd percentile of the population height are those less than 5 feet 4 inches for adult men and less that 5 feet for adult women. In children who do not yet attain final adult height we only talk in terms of percentile ranking (comparisons), because, height without specific reference for age and gender does not have any meaning. However there are few caveats to consider when we talk about normal distribution of height in children of any population under consideration. WE also have to look at the genetic or family background to make sense of the child's height. If he/she is from tall parents and he or she is growing at the 25 or 50 percentile of the population for age and gender, that may not be normal though the child is in the normal growth distribution for age and gender. Therefore the genetic background should be looked at while child's height is accessed. Most children growing below the 3rd percentile for age and gender or those who are not growing according to their genetic background need proper evaluation and workup to rule out hormonal, medical and genetic problems. Girls who are growing below the 3rd % need to be ruled out for turners syndrome. One of the commonest causes of short stature are constitutional delay of growth and sexual development (late bloomers), familial short stature, idiopathic short statue (children who are small but parents are of good height and all medical workups are normal). Some of the hormonal causes of short stature or growth failure are Growth hormone deficiency, hypothyroid, cortisol excess and etc. Other medical causes are such as celiac, inflammatory bowel disease, renal insufficiency, renal tubular acidosis, anemia, heart diseases, musculoskeletal disorders, etc. Genetic disorder such as turners syndrome, Noonan syndrome, Prader Willi syndrome, Russell silver syndrome, downs syndrome, achondroplasia, hypochondroplasia or skeletal dysplasias etc, are few worth mentioning. Going back to your question about growth supplements: The first step is have him evaluated properly. If he is the shortest in his class or among his peers, he needs to have proper work up to figure out if he has constitutional short stature (a late bloomer), familial short stature , idiopathic, medical, hormonal or genetic conditions. It is very important that he has proper evaluation. If he is deemed to have medical or hormonal deficiencies, he needs to be on some form of therapy. If every thing is normal but he is not growing and that he still has more growth potential, you need to find a good endocrinologist to help him grow to his genetic potential. In terms of supplement, besides healthy balanced nutrition there are no real growth supplements that are worth spending money. You can give him multivitamins daily. Health diet, regular physical activity and good sleep will be suffice for growth in a healthy child with no medical problems. You need to stay away from using supplements that are not scientifically proven or are not recommended for children. Please work with your doctor closely. Have your son get evaluated properly and get help so he can grow to his genetic potential if/as indicated. Good luck. READ MORE
Insulin injections vs. insulin pump?
One of the greatest discoveries in the history of medicine was the discovery of insulin in 1922 by an orthopedic surgeon named Frederick Banting and a medical student named Charles Best in the Physiology laboratory of a Scottish professor named J Macleod at the University of Toronto Canada. It was purified by a biochemist named James Collip. It was so wonderful that the fastest Nobel prize was awarded to Banting and Macleod in Nobel prize history. It was also sad that Charles best and J Collip did not share the Nobel prize for the discovery of insulin, though they share the money among four of them. One of the greatest ironies of modern medicine is that, Banting who was not successful as an Orthopedic surgeon and with out publishing a single scientific paper was able to claim one of the greatest glories of modern medical discoveries. J Collip purified insulin was tried on a 14 years od dying patient named Leonard Thompson in 1922 at the Toronto Hospital Canada who was in diabetic coma. After the discovery of insulin Thompson lived another 13 years and died of complications of Pneumonia. After the discovery of insulin many dying diabetic patients flocked to Toronto to get the wonderful medication called insulin from Banting before it become available world wide in industrial scale shortly . Before the discovery of insulin diabetes was a sentence of a slow death especially for type 1 diabetes. The primary treatment then was starvation (low carbohydrates). Starvation therapy was so cruel that it made patients live few week ?months but, changed the patients to a ghost as they slowly die. After the discovery of insulin, Ely Lilly of Indianapolis and Novo Nordisc of Denmark made insulin available globally in a very short period of time. Diabetes treatment was then transformed from starvation therapy to insulin therapy world wide. A disease which was a death sentence was transformed to a disease with chronic complication. Different insulin types were developed. They were from pork or beef with lots of impurities. Short acting insulin and long acting, intermediate a acting insulin were advanced. Most diabetic patients were not well controlled. Acute and chronic complications of diabetes were rampant. Our understanding of diabetes started to broaden and the concept of insulin pump therapy was introduced in the 1960s. A prototype of insulin pump was developed similar to a backpack however a wearable insulin pump prototype was not developed until 1973. In 1976 manufacturing of was started. The 1980s human insulin was manufactured using Coli bacteria and animal insulin were abandoned slowly. Most of the complications of these insulins were also avoided. The 1980 also saw the advancement in genetic engineering, proliferation of diabetes gadgets and diabetes management. Home self monitoring blood sugar devices, ketone strips and insulin pump therapy became available. Acute and chronic complications start to decline as the management of diabetes continue to advance and advanced diabetes gadgets started to become widely available. The 1990 saw discoveries better designer insulins called long acting and fast acting insulins. Insulin pump therapy started to become better and reliable. Diabetes education, nutritional education, flexible insulin therapy and insulin pump therapy almost replaced the old insulins. From the mid nineties use of insulin infusion pump started to explode not only in adults but also in children and adolescents. At this time about (400,000 25% of type 1 diabetic patients (there are 1.3 million of them in the USA) and about (35,000 pumps) 0.1% type 2 diabetics patients are on insulin pump therapy. Most of the pumps are Medtronic insulin pumps. Animas, T slim and Omnipad are other examples in the USA. In the last 15 years continuous blood glucose monitoring systems (glucose sensors) have become widely available. AS the technology and our understanding of diabetes advances, these gadgets may be reliable replacement for capillary blood glucose (finger stick) testing in the future until we have a cure for diabetes. Diabetes management has advanced so much from the days of starvation therapy and intramuscular injections of less purified animal insulin to todays advanced different types of pure human insulin , insulin pumps, inhaled insulin (Afraza) and continuous blood glucose (monitoring systems) sensors. This is a tremendous progress in modern medicine short of finding a cure. With todays advanced understanding of diabetes, better insulins and sophisticated gadgets, we can postpone or eliminated complications of diabetes that were rampant before the 1980s. Today we can administer insulin in many different ways using many different insulin regimens and would get similar glycemic out come. The most important issue is to have fairly good understanding of diabetes, nutrition and how different insulins behave for the different foods we eat. Whether we use subcutaneous insulin injections using different insulin injection regimens, insulin inhalation or insulin pump therapy the glycemic out come would be comparable as long as we have a good understanding of the diabetes and its therapy. Todays insulins work similarly regardless of how the insulin is delivered. In the hand of knowledgeable patient or caretaker. Though current insulin regimens may work similarly, they may not give us flexibility or may not be convenient for ever body or for our different circumstances. Therefore, since we have different advanced insulin regimens, sophisticated gadgets and delivery systems and means of insulin delivery, we can choose the one that fits our individual needs and circumstances. It is also important to note that every insulin regimen has advantage and disadvantage regardless of how good we use them. some of the examples of insulin regimen would be fixed insulin therapy, flexible insulin therapy, insulin pump therapy and insulin inhalation therapy. (1) fixed insulin therapy would be taking fixed amount of insulin for meals with or with out sliding scale for high blood sugar correction above target range. This can be accomplished using intermediate acting insulin NPH or long acting insulin (lantus, levemir etc.) with short acting (regular insulin) or fast acting insulin (Humalog, Novolog Apidra etc.), with or with out sliding scale for high blood sugar correction. These insulin regimens can be mixed or given separate (big) snacks are usually given. There is little flexibility in life style but good for some people and people with some circumstances. hypoglycemia and hyperglycemia are common if food portions are changed during meal time. (2) Flexible insulin regimen; This is based on a basal bolus principle were insulin is given as a long acting insulin once or twice a day with peak less long acting insulins such as lantus, Levemire, Tresiba etc., and fast acting insulin based the amount of carbohydrate consumed and using correction for blood sugars above target. This regimen gives great flexibility with life style and controls diabetes much easier. Here multiple injections may be needed depending on the meals and snacks consumed. It is also very important to note that one may only use fast acting insulin with out long acting insulin as long as insulin is given more often (every three ours for food and for correction of blood sugars our of target >100mg/dl). (3) insulin pump therapy; This is based on the basal bolus insulin therapy principle, the same as flexible insulin therapy. Here the basal insulin is a continues infusion of fast acting insulin and boluses of fast acting insulin delivered at each meal or snack time with correction for high blood sugars out of target at each meal, snacks and as needed. There is no long acting insulin is given here. The pump gives minute amount of insulin if necessary that are not possible by injection. The pump will give the greatest flexibility in those who have hectic life style and though who want to control their diabetes better. It may also be excellent for little children who graze through out the day and whose eating habits are variable. It would give small amount of insulin for the small food they eat to also correct blood glucose out of target. Pump site is changed every 2-3 days. unlike 4-5 injections a day in flexible insulin therapy. This will also be ideal for younger children and people with needle fear and phobia. Note also that 10% of the population have fear of needles and 1% have severe needle phobia. (4) inhaled insulin therapy Afraza) will be beyond our discussion at this time especially in children. Going back to your question: Is insulin pump more beneficial?. If you use it properly with good understanding, the pump is more advantageous than any insulin regimen available for children with type 1 diabetes at this time. If it is not used properly, it would not do better that any treatment regimen available. There may be more going on with your daughter. Such as anger, denial, sadness, fear of needle/needle phobia and more, which are common with people with chronic illness or right after diagnosis with diabetes. She may need support and counseling at this time. As long as you control the diabetes, she needs to be told that she is perfectly healthy, and she can realize the American dream through hard work, and, that she could be one of the best and brightest in our society. Nothing will stop her. Not diabetes if you manage it well which is not hard to do. At this time you need to help her and walk her though this difficult time. Support and counseling would be important. The pump will be a good asset to have. Todays pumps are more advanced and more reliable. You can also include blood glucose sensors. Some of them are integrated to the pump it self. Therefore with the use of the pump you minimize injections. better quality of life, give insulin many times a day, give precise amount of insulin, document amount of insulin given etc., There are also some disadvantages such as pump failure, discomfort with wearing pump, scar tissue etc. These not a big barrier, but, inconvenience. If you add blood glucose sensors, it will help manage diabetes much better, though you don't have to. Remember that any insulin regimen will have advantages and disadvantages. Just think what will make your life and your child's life better. Finally with good diabetes education and understanding insulin using any regimen will work with reasonably similar outcome. But flexible therapy is better than fixed insulin regimen and insulin pump therapy is superior than flexible insulin therapy for many type diabetic patients at least in my opinion. Please discuss this with your doctor and diabetes educators and work as a team. Good luck. READ MORE
What is the emergency treatment for hyperglycemia?
Hyperglycemia is a state of high blood glucose. Normal blood sugars are considered <100mg/dl fasting (no food for 8 hours), or blood glucose <200mg/dl 2 hour after heavy carbohydrate meal or 75 mg of glucose drink (glucola), or if a person has blood glucose over 200mg/dl with the symptoms of diabetes such as, excessive thirsty, frequent urination, weight loss, blurred vision, bed wetting chronic yeast infection, fatigue and headaches. Hyperglycemia could be due to diabetes or none diabetes. Hyperglycemia may be symptomatic or asymptomatic. In hyperglycemia due to diabetes, HA1c (>6.5% diabetes and between 5.7-6.4% prediabetes) is elevated most of the time. Symptoms of diabetes can be drastic or may evolve insidiously. In type 1 diabetes the symptoms of diabetes are drastic. They typically evolves within few week to few months. Type 2 diabetes may take many years to evolve. In fact some type 2 diabetic patients may present with chronic complications of diabetes during the diagnosis. There are many other forms of diabetes besides type 1 and type 2 diabetes. Maturity onset Diabetes of the young, gestational diabetes and diabetes due to other genetic abnormalities are examples. When diabetes are treated properly the person should be able to control the blood sugars reasonably. Reasonable blood sugars are 70-140 mg/dl over 50% of the time. In most cases of diabetes expecting perfectly normal blood sugars is not realistic. check blood sugars at least 4 times a day (before each meal bed time and at night). Take medication properly. give correction for high blood sugars and adjust medications regularly. Work with your doctor and diabetes educators as a team. Manage low and high blood sugars appropriately. As you practice in daily management of diabetes you will be comfortable in handling extreme issue in diabetes such handling low and high blood sugars with little help from out side of your house. The only time you can think of going to ER is the child is sick and you can not hydrate her/him at home. Some of the causes of none diabetic hyperglycemia could be stress, fever, illnesses, and medications. Chronic use of hyperglycemic medications can cause elevation in HA1c and therefore lead to diabetes. Once Offending medications are removed blood glucose she normalize. Going back to your question, we need to know what your daughter has. How old is your daughter?. Does she have hyperglycemia due to diabetes?. Is she on medications?. Does she have other medical conditions?. Is she taking insulin?. When was she diagnosed?. Does she have type 1 diabetes or type 2 or other forms of diabetes?. Is she on insulin?. What kind of insulin regimen is she on?. Do you do carbohydrate counting?. do you correct high blood glucose with insulin?. How often do you check blood sugars?. Or does she only have intermittent hyperglycemia without any diagnosis?. Is there family history of diabetes?. Do you mean HYPOGLYCEMIA????. Or she has uncontrolled diabetes with episodic of hyperglycemic excursions?. Lets assume the most likely scenario. Lets say your daughter has type 1 diabetes on insulin and she is having blood sugar excursions more often. In this scenario; you should focus on the basics of diabetes management. You need to check her blood sugars at least 4 times daily without stressing her. With properly attention to blood sugars you should be able to control diabetes reasonably. You should focus on getting blood sugars between 70-140 mg/dl over 50% of the time. Do not expect perfectly normal blood sugars. that will not realistic. Do not check blood sugars every half hour unnecessarily. If she is eating and you gave her medication do not check blood sugar after 1/2 hr, it will be high. Unless you have a real concern or she is sick or she is experiencing low blood sugars it would be reasonable to check blood sugars after 2 hrs of her food. She need the appropriate amount of medication at the right time. Give correction insulin for high blood sugars and adjust medications on regular basis. I Work with your doctor and diabetes educators and nutritionist as a team. Manage low and high blood sugars appropriately. As you practice in daily management of diabetes you will be comfortable in handling extreme issue in diabetes such low and high blood sugars on your own at home. The only time you can think of going to ER is if the child is sick and you can not hydrate her/him at home. But is the child has low blood sugar and she can not take any thing by mouth due to vomiting, unconsciousness, stupor or seizures, do not go to ER call 911. If her hyperglycemic episodes are not due to diabetes please call your doctor and have her proper evaluation and work up. It is therefore important to discuss this with your doctor for more diabetes and nutritional education proper evaluation and workup. Good Luck READ MORE
My 7 year old son is diagnosed with type 2 diabetes. Will it affect his growth?
Obesity is a medical condition were excess fat is stored in the body (in adipose tissue). Obesity is becoming a major health problem not only in the USA but also globally. In the United States over 50% of adults and over 25% of children are obese/overweight. Obesity increases risk factors such as type 2 diabetes, hypertension, fatty liver disease, sleep apnea, cardiovascular and colorectal diseases, irregular menstrual cycle and more other medical problems. Type 2 diabetes is mostly common in obese people with insulin resistance. It is mainly characterized by high blood sugars, insulin resistance, and, eventually, inadequate insulin secretion. Type 2 diabetes is therefore mostly driven by obesity, lack of regular daily physical activity, and unhealthy diet (high carbohydrate and high intake of saturated fat). As we get more obese, Type 2 diabetes also increases proportionally to the degree of obesity. It is the commonest form of diabetes in the adults population. Currently, as children become more obese, type 2 diabetes is becoming more prevalent. Though type 1 diabetes is more common in children, type 2 diabetes is also catching up very fast. In some areas of America, type 2 diabetes in children is becoming more prevalent than type 1 diabetes due to more prevalence in obesity. In native Indians, children with type 2 diabetes is more common than type 1 diabetes. Type 2 is surpassing type 1 diabetes in Hispanic and black children in some areas of the united States. As the epidemic of obesity explodes (the tsunami of obesity), type 2 diabetes will be the most encountered metabolic disease very soon in both adults and children. To prevent type 2 diabetes, we need to prevent obesity, have regular physical activity, healthy diet, and maintain ideal weight. Once the prevalence of obesity is controlled, type 2 diabetes would be prevented better. Your son needs regular daily physical activity, weight loss, and a healthy diet. He needs to participate in regular sports activity and needs to see a nutritionist. He needs to lose weight, at least 10% of his body weight. It is important that he works closely with his diabetes educators and dietitians. The goal is weight loss, regular daily structured physical activity, and a healthy diet. Early stage type 2 diabetes may be managed with diet and regular daily physical activity. Metformin can be used liberally (as it lowers insulin resistance) and oral hypoglycemic agents (such as glyburide and Glipizide) can be added. GLP1 agonists (such as victoza) and Dpp-4 inhibitors such as Januvia) could be considered if indicated. Again going back to your question about your son's growth; his growth and development will progress normally like any normal child as long as you control the diabetes through healthy diet, regular daily physical activity, maintaining healthy weight and taking his medications if/as indicated. You should work with your doctor, nutritionist and diabetes educators. You should work as a team; you as the team leader in your child's care. Good luck. READ MORE
My daughter is losing her appetite. Is this connected to a thyroid imbalance?
Appetite is a desired to eat. All higher animals have appetite. It exists to control the energy balance adequate enough to meet our metabolic needs. Appetite is more important not only to regulate energy balance but also for growth and development. A healthy appetite helps us ingest enough amount of food to sustain our metabolic needs, repair, growth and development. Hunger, nice food, good smell etc stimulates appetite. When we are full satiety kicks in and we stop eating. Some medical, emotional, psychiatric and hormonal conditions can cause loss of appetite (anaroxia) or may stimulate of appetite. Anorexia Nervosa is an emotional state that can lead to food avoidance or eating smaller portions. It stems from a distorted body image (that the person believe he/she is fat though it is not true). There is therefore an intense fear of weight gain. This requires early recognition and counselling intervention for a good out come. It is common especially in teenage girls who are just starting to realize thier body image. Anxiety, depression, stress and other psychological illnesses can suppress appetite. Various Medical problems such gastrointestinal issues can suppress appetite. Hormonal conditions such as under-active thyroid may suppress apettite as well. It is therefore to appreciate that there are many causes of anaroxia (loss of appetite). The first step is to provide her with food that she likes and see if there is any improvement in her apettite. If the anorexia is situational it will improve in a short period of time. If there is no improvement you need to take her to her doctor for proper evaluation. The doctor will do complete medical evaluation and perform basic laboratory studies to rule out medical and hormonal conditions. Once medical and hormonal conditions are ruled out and the condition persists, she will need more help with counselling if indicated. If her appetite is situational, you can provide her with high calorie food with high protein intake and encourage her to eat more frequently with at least three meals and three snack a day. It is therefore very important that you discuss this issue with your doctor in a timely manner. Good luck READ MORE
How should we help our son lose weight?
Obesity is a medical condition were excess fat is stored in the body (in adipose tissue). Obesity is becoming a major health problem not only in the USA but also globally. In the United States over 50% of adults and over 25% of children are obese/overweight. Obesity increases risk factors such as type 2 diabetes, hypertension, fatty liver disease, sleep apnea, cardiovascular and colorectal diseases, irregular menstrual cycle and many other medical problems. excess fat is stored in the body deep in side the body (viscera) or superficial (subcutaneous). It may be distributed in two forms. Central or Android (apple shape) or Gynoid (pear shape) obesity. Central obesity (apple shape) is when fat is deposited on the abdomen, trunk and neck. This form of obesity is common in men. Abdominal girth is much bigger in central or Android obesity. It is also true that abdominal (central) obesity is worse than the gynoid (pear shape) obesity because it exports insulin resistance, leading to metabolic syndrome, type 2 diabetes, high blood pressure, fatty liver disease, hyperlipidemia, sleep apnea and others. The Gynoid (pear shape) obesity is when fat is distributed in the hip and thigh area. This type of obesity (Gynoid) is more common in women though some men will have it as well. The gynoid obesity is not as strong as the Android obesity in causing obesity related morbidities such as insulin resistance (metabolic syndrome) as the abdominal girth is not increased to the degree of the Android obesity. The majority of obesity whether it is Android or Gynoid are caused by lack of regular physical activity, wrong diet and excess calorie ingestion. Few cases of obesity are as a result of hormonal imbalances and genetic abnormalities. Some of the hormone causes of over weight can be thyroid hormone deficiency, excess cortisol, insulin resistance, leptin abnormalities etcetera. Obesity (overweight) due to hormonal imbalances will follow the Android or central obesity form of body fat distribution. In cortisol excess for example, the fat distribution is more prominent on the trunk and neck. There are also rare genetic abnormalities that can cause obesity such as Prader Will syndrome, Bordet Biedl syndrome, downs syndrome, leptin deficiency, MC4 defect, psuedohypoparathyroidism and much more. These genetic disorders are beyond the scope of our discussion at this time. The human history has been so successful that we have evolved into a complex and affluent modern society. From the days of scarcity ( hunter and Gatherer) we have evolved into a wealthy society with plenty of food and endless festivities. during the days of food scarcity in the era of hunter and gatherer society a thrifty gene evolved for our survival. The thrifty gene helped as gain more weight during plenty (hunting season) and we used the body fat to survive during scarcity when there was little prey to hunt. The thrifty gene was able to store more fat by creating insulin resistance during the seasons of plenty. Those calories were used during the time of scarcity. The thrifty gene was therefore a survival gene in that era. The people who had the thrifty gene faired better than the people with out the thrifty gene. AS we became affluent the thrifty gene was no longer needed, and instead it be became a liability. It continued to unleash the epidemics of obesity leading to the metabolic syndrome mostly through insulin resistance. Suppose we all go to the Kalahari desert to become hunter and gatherers or we go to some poor countries where there is food scarcity, regardless of the thrifty gene our body fat will melt in a matter of time. It is therefore important to appreciate that wrong diet (high carbohydrate and high saturated fat), excess calorie intake and lack of daily regular exercise are driving most of our obesity and its co-morbidities. It is therefore important to remember that nutrition is the hallmark of the maximum expression of the gene. The more food we have the more maladaptive genes will express, leading to more medical problems which were not common before. In some cases medications for appetite suppression may be indicated on individual basis. Specially in adolescent and adults persons with obesity appetite suppressing medications can be tried if diet and exercise fail. Such medications are stimulants (such as Adderall), phentermine, belviq, qsymia, contrive, Topamax, metformin, (Naltrexone+welbuterine), HCG (150-250 units daily injection for 40days), Saxenda 3.0 mg, Victoza and more others can be tried as indicated. If every thing fails and if obesity either severe or morbid and are signs of comorbidity, bariatric surgical intervention should be entertained seriously. Psychological and emotional counseling is very important for life style modification. Good counseling would facilitate life style modification. Change is not always easy. For a change to be successful the mind needs to be receptive of the change. That is, the mind need to accept the change to make the process easier. With out emotional psychological readiness weight loss program will not be effective. In young children weight loss may not be the preferred step. Since young children are growing halting weight gain will be sufficient. If they do not gain any weight as they grow they will slim out nicely compared to adolescents and adults who have no more future potential left for growth. Going back to your question, your son most likely gaining excess due to wrong diet (high carbohydrate, high saturated fat) excess calorie ingestion and lack of daily regular physical activity like the majority of over weight and obese people in the USA, though there could be a slim possibility of hormonal imbalance. It is therefore very important that you see your son's doctor for proper evaluation. You should ask him to run some tests to rule out hormonal imbalances and check for any genetic conditions. If his weight gain is due to hormone problems, things will improve with correcting the hormone imbalance. The most important issue is to recognize that wrong diet, excess calorie intake and lack of regular (daily) physical activity are the overwhelming causes of the overweight/obesity epidemics in the USA. So I encourage you to look in to this issue. Healthy balanced diet with bigger portions of vegetables and regular daily structured physical activity should be intensified to maintain an ideal body weight. You should see a good nutritionist to give you a nutritional guide. Provide your son with healthy diet, limit calorie intake with out restricting growth and daily structured physical activity. Create partnership with a good nutritionist and your doctor and you as the leader of the team. If he still continues to gain more weight despite all endeavors, ask your doctor for appetite suppressing medications if indicated. Discuss these issues with you doctor and listen to his expert advice and work as a team. 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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