From Omaha, Nebraska, USA:
My son was diagnosed about 3 years ago with Type 1 diabetes, on his 7th birthday. We were told right away that he was insulin sensitive. We have been told since then that he developed some antibodies to insulin and resistance. He is just short of 5 feet tall and weighs 125 pounds. He was 69 pounds when diagnosed, down about 10 pounds from normal. Allowing for normal growth, we figure he is about 40 pounds over what he should be at almost 10 years of age. He gained very little the first 18 months after he was diagnosed, so most weight has come on in last 18 months. We are very concerned.
He is on huge doses of insulin, total of 103 units a day, NPH and Humalog, 4 injections, 5-6 blood glucose tests per day. Before we added the lunch injection 6 months ago, he was up to over 140 units a day. His weight continues to climb at every check-up, 2000 calories a day, skim milk and watching fats. He is very active. His last A1C was 6.8. We know that is good but are concerned that the highs (400) and the lows in the 30's are taking a toll. We can't seem to get good control. Highs are not often rebounds. I know growth is a problem, afraid what puberty will do. He is very mature and intelligent for his age.
We are considering putting him on the pump. Doctor is not 100% sure of this move, although he puts adults on pump. Nurse is very hesitant, other nurses that have worked with him think he will do well on pump. Dietitian thinks he would do well, herself a pump user for eight years. His doctor is an endocrinologist, just not a pediatric endocrinologist; there's not a good pediatric endocrinologist for him in this city.
I am hesitant to switch to U since he hangs onto insulin. Takes 2-3 hours for Humalog to peak. Before on R it took 4 hours to peak. Please, any suggestions appreciated. Should we press for the pump? My son thinks the pump would help him. He is very compliant and never cheats. Help us please.
The problem of obesity and high insulin demand in a young person with diabetes is a complex one, and normally it would be important to have more information on the family history, if any, of diabetes and obesity as well as on ethnic background and family attitudes to physical activity. Nonetheless here are some considerations to discuss with your son's endocrinologist.
The antibodies issue is an important one because I think it tells us that he has indeed got autoimmune or Type 1 Diabetes. Normally five antibodies are looked for. Three are specifically for Type 1 Diabetes and the other two are for linked autoimmune conditions. One of the first group is anti-insulin antibody, however its presence does not imply insulin resistance, only that the diagnosis is Type 1 Diabetes. Other syndromes that come to mind are really excluded by this piece of information like the Prader Willi syndrome, the various forms of maturity onset diabetes in the young (MODY), Type 2 diabetes in the young which is different, atypical diabetes and so on.
The first step in trying to deal with this combination of obesity and high insulin demand is to make quite sure that he really is getting this apparently high dose of insulin. Sometimes this sort of situation can be contrived as an appeal for help in some quite different area and it may take an experienced medical social worker to disentangle this.
The next step in any plan to work all this out would be to reduce the insulin abruptly to about 1.0 Units/ kg of body weight/day, that is to about half his present dose, keeping individual doses proportionately the same. This phase must be carefully monitored and of course carried out with the consent of your endocrinologist. Its purpose is to find out if the problem is a fairly common one. In some people insulin is a significant appetite stimulant and in searching for better control it is possible to develop a vicious cycle in which first insulin is increased, this leads to weight gain and then to insulin resistance, a higher dose and so on. Abruptly breaking the cycle can sometimes have a dramatic effect.
The third approach is pharmacological and is to add various drugs to the insulin to try to reduce glucose levels and so permit a lower level of insulin and thus less weight gain. Some of the ones to discuss with the doctor would be troglitazone to increase insulin receptor sensitivity, metformin to reduce liver glucose output, and acarbose to reduce glucose absorption. IGF-1 or insulin like Growth factor 1 would be another one to consider.
Tackling the obesity itself, and your son is well over the 95 percentile for height and weight, especially the latter is often discouraging especially if it is attempted without a simultaneous attempt to reduce insulin. Appetite depressants don't work well in his age group and neither do drugs like Orlistat that interfere with fat absorption: the family's most significant contribution may be to try to reduce TV time and encourage exercise for everyone.
As to going onto a pump, my concern would be that this would be a considerable expense and all that it might achieve would be to produce slightly better control; but without solving the issues of too much weight gain and too high an insulin need. Instead I would suggest having your endocrinologist arrange a visit to a center with a team consisting of a pediatric endocrinologist, a nurse educator, a nutritionist and a medical social worker or child psychologist.
Original posting 6 Jul 97
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