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July 25, 2003

Daily Care

Question from Bar Harbor, Maine, USA:

My seven year old son who now weighs 102 pounds, has had a steady weight gain of about 10 pounds per year for the past three years. Both his dad and I are overweight and come from overweight families. He had a glucose tolerance test last week, and while blood sugars stayed almost the same (89-93 mg/dl [4.9-5.1 mmol/L]), his fasting insulin level was 17, and after the two hours, it went up to 66. His pediatrician said my son isn't categorized as having diabetes yet, but this could evolve into diabetes if his insulin levels aren't controlled. The doctor diagnosed insulin resistance and dysmetabolic syndrome. The doctor has prescribed a low-carb, high protein diet along with a half-hour of daily exercise as a first level of treatment. If that doesn't appear to be working, he'll move on to possibly treating with medication (Glucophage). I have several questions: How long are we going to have to monitor/work on his insulin levels, on the average? Is this something that "goes away"? If my son is put on medication, how long, on the average, does a person have to stay on this medication? Is it a life-long thing? Is there a point that insulin production usually decreases by itself, or is this something he's going to have to worry about for the rest of his life? My son is an intelligent little guy, but I'm having a hard time answering these kinds of questions for him. Help! Thank you in advance for any guidance you can give. His pediatrician is very busy, and talking to him outside of making an appointment is pretty near to impossible.

Answer:

Your seven year old son is very considerably overweight, but assuming that his insulin levels are in microunits per milliliter, only the second one is modestly elevated. You say nothing about high blood pressure or abnormal lipid levels in his blood so that he is at present in the early stages of the metabolic syndrome (also called the dysmetabolic syndrome).

A low carbohydrate diet and increased exercise are certainly the first steps in management with Glucophage [metformin] as another option. At the same time, with his strong family history of obesity, it is likely that this will be a lifelong problem. There are many plans and some drugs like sibutramine that have been tried in children, but sustained weight loss has been elusive. Gastric plication surgery has been tried in a few teenagers and does result in sustained weight loss, but the procedure would not be considered ethical in a young child. What does afford hope of preventing the long term consequences of this syndrome is the rapidly expanding knowledge about how hormones like leptin, ghrelin, neuropeptide Y, and others affect fat stores. Manipulating the impact of these hormones seems to offer real hope for effective treatment in the not too distant future.

DOB
Additional comments from Dr. Stuart Brink:

Busy pediatricians answer questions so call the office and schedule a consultation time at the end of the day so that you are not feeling rushed. Most people do not monitor insulin levels except under research conditions. The epidemic of obesity in this country and around the world has produced the earliest abnormalities of metabolism called syndrome X or dysmetabolic syndrome. Weight loss through changes in food intake and increase in activity are clearly indicated so you have a wise physician able to make such a diagnosis. Lipid values should also be checked as should blood pressure. Also something called acanthosis nigricans. You’ll have to decide about parental limit setting not only for yourselves but also your child. If your child sees that parents overeat, then why should he or she not also have this option. Changing such lifestyles is clearly the answer but it is difficult. If you succeed, then it is likely that you can postpone or delay the development of diabetes and heart disease/hypertension for years if not decades.

SB