After seeing more than 60 patients in the last week in sites around the Washington, DC, area, it seems that one of the hottest concerns for everyone is weight. Too much, too little - and never just right. One of the biggest challenges in children with diabetes is balancing appropriate growth in weight and height along with blood sugar management. Our primary goal in pediatrics is to facilitate weight and height along growth curve norms for children and adolescents. It is no different for children with diabetes. Since food is inextricably linked with insulin and exercise in the overall management of diabetes, weight concerns become a natural consequence and a major topic of discussion.
Indeed, in type 2 diabetes, weight management is a primary goal in blood sugar control. At diagnosis, children with type 2 diabetes generally still have the ability to produce insulin. The problem resides in the body's lack of insulin sensitivity, and the need to produce more and more insulin to lower blood sugars. Eventually, the pancreas reaches a point where the islets can no longer produce enough insulin to keep blood sugars in range. Weight plays a major role in causing insulin insensitivity. As children and teens with type 2 diabetes lose weight, they become more insulin sensitive and blood sugars improve. Thus, diet, along with exercise, is the initial treatment for type 2 diabetes. In this case, weight (loss thereof) is therapeutic in itself. Likewise, weight gain will decrease insulin sensitivity and once again stimulate the pancreas to increase insulin output, thereby stressing the islet cells once again; resulting in the strong likelihood of hyperglycemia.
What about weight and type 1 diabetes? As you all know, obesity does not cause type 1 diabetes. However, obesity in association with type 1 diabetes contributes to insulin resistance as described above. The difference is that insulin is administered by you instead of the pancreas. As weight increases, your insulin requirement may rise as well. Sometimes we need to add additional medications, such as insulin sensitizers (metformin, for example) to help decrease insulin resistance and therefore decrease insulin requirements and units.
Another problem is that insulin is an anabolic hormone: insulin facilitates glucose transport into the cells and allows for further growth in muscle and fat cell development. Therefore, as insulin lowers the glucose levels in the blood it enables the glucose to be utilized for other purposes including weight gain. This is a positive development for children who have lost weight due to lack of insulin at diagnosis but can be more problematic after the diabetes is stabilized. Tighter control of blood sugars has been associated with weight gain, which is not always desirable. Indeed, it is due to this possibility of weight gain secondary to excellent blood sugar control that may lead to eating disorders such as diabulemia, which is not a good outcome. How does one maintain tight blood sugar control and not be confronted with excess weight? To maintain weight, input must equal output. Caloric input must match activity. Therefore, by manipulation of input and activity, one can make a genuine effort to avoid weight issues. The concept is actually the same for people without diabetes. The only difference is that insulin must be given for people with diabetes to allow the carbohydrates to be metabolized. Once metabolism takes place, excess energy is deposited into fat cells and weight is gained.
Basal/bolus insulin regimes (lantus/levemir/rapid acting insulin and insulin pumps) allow total freedom in the amount of carbohydrates consumed. As such, if one consumes more carbohydrates without exercise, there is an increased risk of weight gain. Consult with your dietician to receive information on the recommended daily amount of carbohydrates required to maintain your weight or allow for growth. In this way we can allow for total flexibility in terms of food choices, but limit the amount of carbohydrates if weight becomes an issue. Alternatively, exercising daily either in a gym or walking at least 30 minutes/day would help in terms of increasing activity (and increasing insulin sensitivity). By increasing insulin sensitivity, less insulin would be required and the added benefit would be less risk of weight gain.
Exercise is good.
The most important thing to remember is that weight is only one factor that needs to be juggled in your diabetes management. Take advantage of your diabetes team and ask for help. A dietician can really assist by offering suggestions and solutions that may truly assist with lifestyle choices. In addition, consultation with an exercise physiologist may be helpful. The bottom line is that children or teens with well-controlled diabetes on a flexible insulin regimen can modify weight by input vs. output, which is very similar to your peers without diabetes.
Published On: February 18, 2009