May 4, 2006
Weight and Weight Loss
Question from Kansas City, Missouri, USA:
My 15 year old daughter has had type 1 diabetes since she was nine. She has had extremely good control with an A1c of under 7 until puberty. She has had much more difficulty controlling her sugars and her insulin demands have increased tremendously. Her A1cs have been more in the 8s and even one 9.0. As a result, we decided to try a pump in July 2006 with Humalog. She previously was on Lantus and Humalog.
Extremely active in soccer, cheerleading and gymnastics, my daughter eats a very healthy diet. She continues to gain weight, gaining 11 pounds just in the last five months. Gradually, over the last two years, she has cut back on calories but continues to gain. In the last two months, she has cut back to 1200 to 1500 calories per day increasing her exercise every day with no weight loss. She had her thyroid levels checked but they were normal. She is on rather high levels of insulin, four units per 15 grams of carbohydrates using between 70 and 100 units per day total. The last two months, her blood sugars have been better and I would think her A1c is probably better. It has also been a learning curve with the pump, site changes, changing basal rates, etc.
We recently met with a dietitian to reevaluate her diet, but I am wondering if metformin would be a possibility in this case. Do they prescribe this medication to an adolescent in puberty? Her menstrual cycle has been very irregular and only began in August 2005. She has only had one real normal cycle. The other three have been very slight. We have been told she is somewhat insulin resistant due to puberty. I had even wondered about PCOS, but the doctor says he doesn’t see the signs of this.
Will she return to her previous years of response to insulin after puberty or will she always struggle with this as an adult? I am assuming that all this weight gain is due to her high levels of insulin. She is currently 5 feet, 7.5 inches and weighs 162 pounds. The dietitian says she needs to be about 140 pounds. Her cholesterol levels also came back high 200 for total, 109 LDL and 66 HDL. These values also surprised us as she eats very little fat in her diet.
We are very frustrated and I’m not sure our endocrinologist understands how frustrated my daughter is with her weight as a high school freshman. Have there been any studies on the use of metformin in teens? We are getting desperate! Do you have any suggestions?
Answer:
Unfortunately, she sounds like she is getting too many calories based upon her weight. This certainly can be associated with insulin resistance and an exaggerated response during puberty. If the endocrinologist has not already done so, perhaps a pelvic ultrasound or special adrenal and ovarian, as well as pituitary, hormone testing might be reasonable to ask such questions.
The basic law of thermodynamics still comes into play, however… if someone is gaining weight, whatever their individual metabolic rates, they are eating too much or not exercising sufficiently for the amount of food. With weight gain plus elevated blood sugar levels plus an elevated A1c, this is still most likely insulin doses being omitted/forgotten and/or excessive calories in combination. What I see most often in an overweight teenage girl is the intense dislike of the excess calories but the inability to cut back on the excess, so, insulin is omitted consciously or unconsciously, what we call diabulimia. This causes excess calorie loss from the glycosuria and thus less weight gain even with the ongoing overeating and high blood sugar readings, as well as high A1c levels. I would go back and work closer with the diabetes team and see what can be determined to cut back calories. More direct supervision of all insulin boluses, downloading the pump to see how often the doses are not the same as those written in the logbook may also answer such questions rather than confrontation. One cannot be eating as little as you describe and still be gaining so much weight otherwise.
SB
