DIABETES/OBESITY
| TYPE 1 DIABETES UPDATE— Daniel A. Doyle, MD, Assistant Professor of Pediatrics, Thomas Jefferson University,
Division of Endocrinology, Alfred I. DuPont Children’s Hospital, Philadelphia, PA
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| Sample case 1: 2-yr-old diabetic on 2 units insulin lispro (Humalog), 10 units insulin suspension, isophane (NPH
[Lente]; morning), and 2 units insulin lispro plus 1 unit NPH (evening) has seizure at 3 am ; documented blood glucose
(BG) is 23 mg/dL; waking glucose >300 mg/dL for 2 mornings before seizure; BG usually 120 to 150 mg/dL;
child had not been sick before that; parents not taking 2 AM BG readings; no recent changes in child’s diet or exercise
regimen
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 | Factors to look for: things that affect BG (dose and timing of insulin; BG control); when child awakens in middle of
night with hyperglycemia, check for ketones (possible Somogyi effect [glucose plummets during night, then rebounds
due to action of glucagon, growth hormone, cortisol, and epinephrine])
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| Timing of insulin dose: crucial with toddlers; administer 20 to 40 min after child has eaten; tailor dose to carbohydrates
consumed
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| Exercise: some diabetic children may develop hypoglycemia during exercise; include when taking medical history
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| Total insulin dose relative to toddler’s body weight: should be 0.5 to 0.7 units/kg per day 3 to 6 mo after diagnosis
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| Important points to remember: ask about child’s activity, eating habits, and insulin dose; consider Somogyi effect if child
awakens with hyperglycemia; also consider changing insulin regimen, so insulin level does not peak during night
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| Newer insulins: insulin lispro (Humalog and Novolog); both peak 1 to 2 hr after administration (short-acting); clear;
can dilute from U-100 (100 units/mL; normal concentration) to U-10 (10 units/mL) for toddlers to facilitate dosing
by parents (easier to see in syringe); short-acting insulin provides better mealtime coverage of glucose excursions
due to rapid action; short duration permits frequent dosing (helpful for sick-day management); lysine and proline at
positions 29 and 28 permits rapid absorption and action by preventing insulin from forming hexamers under skin
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| Short-acting insulin and meals in toddlers: to use these preparations, parents must demonstrate facility with counting
carbohydrates and calculating carbohydrate/insulin ratios at diagnosis; most toddlers start with ratio of 60 g of carbohydrate
to 1 unit of insulin; older children (teenagers) have ratio of 10:1; if mathemathics proves too difficult, try
sliding scale with base dose calculated according to child’s usual carbohydrate consumption
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| Insulin glargine (Lantus): prevents middle-of-night hypoglycemia; “peakless,” long-acting basal insulin; duration of
action ≈24 hr; dose titrated to fasting morning BG; for older children, initial dose is 0.4 units/kg; for toddlers, who
are more sensitive to all types of insulin, recommended starting dose 0.2 units/kg; cannot be mixed with other insulins;
4 shots/day required (1 with each meal, plus Lantus every morning); Lantus has pH of 4, while other insulins
have pH of 7; short-acting insulin loses its short-acting qualities when mixed with Lantus; giving Lantus at dinnertime
could result in middle-of-night hypoglycemia
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| Ketone strips: allows measurement of blood ketones; can then base insulin dose on that; usually reserved for use in
toddlers
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| Case 2: 17-yr-old high school senior with good BG control; hemoglobin (Hb)A1C of 6.9%; likes to stay up late and does
not want to awaken early on weekends to take insulin and eat breakfast
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| Treatment options: patient good candidate for insulin pump; Lantus (2 shots/day) option for those who do not want to
be “hooked” to pump; meals should be taken 2 to 3 hr apart to give short-acting insulin from previous meal time to
wear off
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| Criteria for pump candidates: willing to test BG 4 times/day (8 times/day in beginning); should be able to select and
activate pump features, count carbohydrates, and use carbohydrate/insulin ratio to calculate insulin dose, change
catheter every 3 days, and perform basal testing; presence of reliable parents and stable psychosocial environment
essential
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| Effect on HbA1C : usually improves by 0.5% to 1% with pump
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| Insulin administration: establish basal rate; bolus dose based on carbohydrate/insulin ratio, plus correction factor depending
on BG level
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| Clinical pearls: presence of blood ketones usually implies failure of pump or catheter and requires change of catheter
site; only short-acting insulin approved for pump use; rapid weight gain with good BG control suggests binge eating
plus accurate bolus calculation; some children (especially younger ones) may object to pump; trial period with saline
pump may help
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| Glucose tracker: personal digital assistant with BG meter; can signal pump when time for another bolus; not recommended
for small children because it may be knocked off
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| Case 3: 14-yr-old boy from single-parent home; failing in school (12 days absence by midyear); checks BG once daily;
mother works, so he manages his diabetes himself, including meal preparation
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| Treatment options: involve school counselor and social worker; school nurse can oversee morning Lantus shot, as well
as short-acting shots at breakfast and lunch, leaving patient responsible only for dinnertime insulin; as last resort, try
simplified regimen with premixed insulin
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| Premixes: insulin lispro 75/25 (25% short-acting and 75% protamine [intermediate-acting] insulin); Novolog 70/30 (30%
short-acting and 70% protamine insulin); available in pens that child can carry
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| Advantages of pens: convenience; less painful injections; higher dose of insulin (1 g/kg per day; two thirds administered
during day, one third at night)
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| Disadvantages: premixed dose rules out fine-tuning; easy to confuse regular insulin lispro with pen; most pens do
not permit dosing in half-unit increments ( often used in younger patients)
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| Continuous glucose monitoring system: most helpful for patients with HbA1C in intermediate range (7%-9%);
usually start wearing it on Tuesday, return for check-up on Friday; patient must correlate readings with finger-stick
glucose measurements; target BG range 80 mg/dL to 180 mg/dL; should be incorporated into child’s normal routine
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| Trialnet: formerly known as Diabetes Prevention Trial; database of diabetics and their first-degree relatives who are
candidates for intervention studies; participants must have risk factors, including antibodies to insulin and islet cells;
offered to parents of diabetic children
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| BARIATRIC SURGERY IN THE TREATMENT OF ADOLESCENT OBESITY —William J. Klish, MD, Professor of
Pediatrics, Baylor College of Medicine, Houston, TX
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| Ideal procedure: safe; produces weight loss and reverses medical comorbidities associated with excess weight;
should itself be reversible; no procedure currently fulfills all of these criteria
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| Types of procedures currently available for adolescents
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| Adjustable gastric band: restricts stomach volume by placing band around it; reversible; band can be inflated with saline
or deflated, thus controlling size of gastric pouch; associated with some morbidity and mortality; greatest drawback
in United States limited weight loss (adult patients lose up to 38% of excess weight; Australian and European
patients fare better, possibly because their health systems pay for more frequent adjustments); not yet approved for
adolescent use in United States due to scarcity of data
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| Roux-en-Y gastric bypass: gold standard; stomach dissected through fundus, creating small pouch disconnected from
rest of stomach; portion of proximal jejunum also bisected, and roux loop anastomosed to pouch, with remaining
jejunum coming from stomach anastomosed to side of intestine downstream; combines restrictive and malabsorptive
techniques; most effective bariatric surgical procedure currently performed in United States, but associated
with significant complications; among adolescents, average hospital stay is 2 to 3 days; patient must stay on liquid
diet for first 6 postoperative weeks (anastomosis edematous, so only liquids pass through until it heals; premature
consumption of solid food leads to vomiting, one of major complications)
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| Postoperative nutrition: patients must consume ≥0.5 g protein/kg body weight per day, due to reduced stomach volume;
postoperative vitamin and mineral supplementation also recommended; girls require iron supplements; calcium
levels hard to maintain, so supplements important; ulcers possible complication, so patients cannot take
nonsteroidal anti-inflammatory drugs; patients take ranitidine and ursodiol for at least 6 mo postoperatively
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| Postoperative rules: eat protein before eating or drinking anything else; drink at least 64 oz of water per day (dehydration
possible complication); do not snack between meals; take all vitamin and mineral supplements
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| Complications: mortality rate 0.5% to 1%, depending on series; early complications include acute gastric distention
in bypassed portion of stomach (rare, but surgical emergency); pulmonary embolism; anastomotic leaks in up to
2% of cases; wound infections (can be fatal, but laparoscopic procedures reduce risk); late complications more
common and include stricture (occurs in up to 10% of patients); marginal ulcerations (also occur in ≈10% of patients)
may be related to ischemia at gastrojejunal anastomosis or to presence of Helicobacter pylori; small bowel
obstruction (up to 3% of cases) may be due to internal hernia; difficult to diagnose because patients often present
only with periumbilical pain (and negative imaging studies); persistent periumbilical pain should be indication for
reexploration to search for internal hernia, which could lead to bowel obstruction if not repaired
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| Nutritional complications: protein-calorie malnutrition (kwashiorkor); anemia in ≈30% of female patients who do
not take their iron supplements as directed; beriberi (thiamine deficiency; usually “dry” form, characterized by
peripheral neuropathy, rather than “wet” form [congestive heart failure]); deficiencies of folate and calcium also
seen; thiamine deficiency can develop rapidly if patients do not take their supplements, or in patients who vomit
significantly after surgery; symptoms include numbness or pain in extremities, ataxia, nystagmus, and loss of position
sense; if thiamine deficiency suspected, never give glucose before administering thiamine or patient may
develop severe irreversible encephalopathy (Wernicke-Korsakoff syndrome); calcium status concern because
≈50% of calcium deposition in bone occurs during adolescence; long-term effects unknown
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| Candidates for bariatric surgery: adult indications listed by consensus panel convened by National Institutes of
Health in 1991 include body mass index (BMI; weight (kg)/ [height (m2 )]) >40, or BMI >35 with comorbidities;
however, panel noted then that still insufficient evidence to recommend bariatric surgery for children or adolescents;
safety still not proven in pediatric patients; nevertheless, growing number of children undergoing these procedures
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| Outcomes: ≈90% of adult patients who undergo Roux-en-Y procedure lose 50% of their excess weight (20-30 lb in first
month, 5-10 lb/mo thereafter, until it plateaus after first year); compliant patients can lose up to 80% of excess weight
within first year; however, 20% to 30% of patients regain most or all of their weight within 3 to 5 yr; experience with adolescents
similar (weight plateaus within 1 yr; starts creeping back up within 10 yr, and some patients gain most or all of
it back); however, patients often lost to follow-up in years after their surgery, making it hard to generalize
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| Task Force on Bariatric Surgery convened by American Pediatric Surgical Association: charge—to examine ethics
of performing bariatric surgery on teenagers who could not legally consent to it themselves and advisability of
having patient wait until age of consent (18 yr); benefits of surgery include better quality of life related to weight
loss; early intervention may reverse comorbidities before they cause permanent damage; associated behavioral
therapy probably more successful in younger patients; drawbacks include lack of knowledge about complications,
especially in long-term growth and development; adolescents engage in risky behavior, so their assent may not be
informed; adolescents also do not adhere well to protocols; conclusion—risk/benefit balance still unknown
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| Consensus: bariatric surgery should be limited to children with life-altering or life-threatening comorbidities; BMI
>40; history of failed attempts at conventional weight-loss methods (at least 6 mo in organized program); must be
at Tanner stage 4 to 5, committed to medical and psychologic evaluation before and after surgery; be willing and
able to comply with nutritional guidelines; must have supportive family environment; must provide informed
consent; surgery should be done only at centers that can provide multidisciplinary evaluation and as part of prospective
outcomes study
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| Outcomes: so far, overall outcome among adolescents loss of 40% of excess weight at 1 yr
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Educational Objectives
The goal of this program is to review the role of insulin in managing pediatric type 1 diabetes and discuss current thinking
on bariatric surgery for adolescents. After hearing and assimilating this program, the listener will be able to:
| 1. Describe the role of short- and long-acting insulin preparations in controlling the blood sugar of toddlers and adolescents.
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| 2. List the characteristics that make a patient a good candidate for the insulin pump.
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| 3. Discuss the risks and benefits of bariatric surgery in adolescents.
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| 4. Name the types of malnutrition that may occur after bariatric surgery.
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| 5. Summarize the consensus of the American Pediatric Surgical Association Task Force on Bariatric Surgery.
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Discussed on this Program
Insulin aspart (rDNA origin) [NovoLog, Novolog Mix 70/30]
Insulin detemir (rDNA origin) [Levemir]
Insulin glargine [Lantus]
Insulin injection, concentrated [Humulin R Regular U-500 (concentrated)]
Insulin lispro, human (rDNA) [Insulin lispro, Insulin lispro Mix 75/25]
Insulin suspension, isophane (NPH) [Humulin N, Novolin N, Novolin N PenFill, Novolin N Prefilled, NPH Iletin II]
Insulin suspension, isophane (NPH) and insulin injection, regular [Humulin 50/50, Humulin 70/30, Novolin 70/30,
Novolin 70/30 PenFill, Novolin 70/30 Prefilled]
Ranitidine HCl [Zantac, Zantac 75, Zantac EFFERdose]
Ursodiol (ursodeoxycholic acid) [Actigall. URSO Forte, URSO 250]
Suggested Reading
Apovian CM et al: Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res 13:274, 2005;
Barrio Castellanos R: Long-acting insulin analogues (insulin glargine or detemir) and continuous subcutaneous insulin
infusion in the treatment of type I diabetes mellitus in the paediatric population. J Pediatr Endocrinol Metab 18
Suppl 1:1173, 2005; Battelino T: Risk and benefits of continuous subcutaneous insulin infusion (CSII) treatment in
school children and adolescents. Pediatr Diabetes 7 Suppl 4:20, 2006; Hassan K et al: The role of socioeconomic status,
depression, quality of life, and glycemic control in type I diabetes mellitus. J Pediatr 149:526, 2006; Helmrath
MA et al: Adolescent obesity and bariatric surgery. Surg Clin North Am 86:441, 2006; Inge TH et al: Bariatric surgery
for severely overweight adolescents: concerns and recommendations. Pediatrics 114:217, 2004; Jeha GS, Heptulla
MA: Newer therapeutic options for children with diabetes mellitus: theoretical and practical considerations.
Pediatr Diabetes 7:122, 2006; Maggard MA et al: Meta-analysis: surgical treatment of obesity. Ann Intern Med
142:547, 2005; Nabhan ZM et al: Predictors of glycemic control on insulin pump therapy in children and adolescents
with type I diabetes. Diabetes Res Clin Pract May 14, 2006 [Epub ahead of print; Sugerman HJ et al: Bariatric surgery
for severely obese adolescents. J Gastrointest Surg 7:102, 2003; Wilde ML: Bioethical and legal implications of
pediatric gastric bypass. Willamette Law Rev 40:575, 2004; Xanthakos SA et al: Bariatric surgery in adolescents: an
update. Adolesc Med Clin 17:589, 2006; Xanthakos SA, Inge TH: Nutritional consequences of bariatric surgery.
Curr Opin Clin Nutr Metab Care 9:489, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has
been disclosed: Dr. Klish is a scientific advisor for Nestle USA.
Dr. Doyle spoke at the Cape Cod Conference on Pediatrics 2006, held August 4-6, 2006, in Hyannis, MA, and sponsored
by the Nemours Children’s Clinic, Jacksonville, FL. Dr. Klish spoke at Advances & Controversies in Clinical Pediatrics
, held June 1-3, 2006, in San Francisco, CA, and sponsored by the University of California, San Francisco,
School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
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