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Question:

From Knoxville, Tennessee:

My daughter's nurse practitioner (NP) said, "Children with type 1 diabetes going into adulthood with as much belly fat as your daughter has, have poor outcomes." Do they die? Do they go blind? Do they lose their limbs? She said this in front of my 10-year-old and then said, "You are an intelligent woman, you can do this." I'm divorced. My daughter goes to her dad's house after school four days a week and every other weekend. They eat man food there. We eat lots of salad, but this kid loves to eat and she always seems to be hungry. She usually has a fabulous A1c, often around 7.1 or 7.2. Last year, we went to the doctor a week after Christmas and she had the best A1c the diabetes team had seen in days. They literally kissed her.

In the fifth grade, my daughter isn't in the obese range, but she is in the high normal. She's also in the 95th percentile for height and weight. She's 4 feet, 11 inches and 119 pounds. She's not been growing a great deal in the last year. I believe her problem is not enough activity. We eat a lot of salads. I've bought her dance videos for Christmas and she plays on the Wii. She has horseback riding lessons once a week but no other sports. I'm 5 feet, 6 inches and grew a great deal in 7th/8th grade and didn't grow an inch more after 8th. I was the tallest person in my 8th grade class and I was a very skinny kid. I am hoping my daughter will have several growth spurts between now and high school. My son was "chunky" before he discovered girls. We threatened to lock the pantry at night. Now, he is very slim, even runs track and plays football. He made a conscious decision to lose the weight and become more athletic. He's also 14 years old and 6 feet tall. He had his growth spurt after 5th grade. Will she not be able to lose weight after adolescence? Why do they say this stuff in front of the child and you're afraid to be "too frank?" I questioned the nurse practitioner and that's when I got the statement, "You're an intelligent woman, you can do this." I've actually lost 40 pounds since my daughter was diagnosed. We have changed our eating habits. But, there is only so much I can do and it scared me. I don't want to make my daughter self-conscious of her weight. She's a beautiful, sweet-natured little girl, not growing up too fast, not worried about boys or wearing make-up. She's a kid and she thinks she looks great. All her excess weight is in her stomach. She has thyroid disease and the DNA for celiac but no antibodies. I've tried to get her off gluten and pack her lunch at school four days (mostly) a week to bring down the carbohydrate count down and control the number of carbohydrates she gets every day.

We spent three hours at the park Saturday, but she didn't do anything active Sunday. If I am busy cleaning, going to church, or whatever, she won't take the initiative to do anything active alone. I work four,10 hour days and it's hard to get her outside when we arrive home and eat late. That's just the way it is. My job has excellent health benefits and her dad has no health insurance so this job is very important for her diabetes care. We drive to Vanderbilt to get the best medical care available in the region. My daughter just doesn't seem to care and I can't go everywhere with her. She's got to care and she doesn't.

Answer:

I am not certain I really understand your question. It would seem to be whether we can confirm the statement made by your NP that "Children with type 1 diabetes going into adulthood with as much belly fat as your daughter has, have poor outcomes" and you would want to know if such "poor outcomes might include whether they die or go blind or lose their limbs?"

Individuals with diabetes mellitus characterized by an HbA1c value that is > 8 to 8.1% for more than five years (probably cumulative) are at higher risk of diabetes complications, such as visual issues, renal issues, and nerve damage, which then can lead to loss of circulatory support for limbs, etc. However, I am not aware that having "increased belly fat," per se, in the patient with type 1 diabetes increases any risk for poorer glycemic control. Having said that, obesity is a risk for cardiovascular disease, pulmonary disease, bone disease, lipid abnormalities and can have an additive risk for the development of insulin resistance.

You describe your daughter as being 59 inches and 119 pounds at age "10 years" and you describe her as at the 95% for height and weight (for age) yet you also describe her as not "in the obese range." I do not believe that both of those statements can be true. By body mass index (BMI) criteria, if the BMI is > 97%, one fulfills some criteria for obesity (unless one is heavily muscled, which I doubt your 10 year old daughter is). The BMI is calculated by taking the weight in KILOGRAMS divided by the square of the height in METERS. Your daughter, at 119 pounds, is 54.1 kilograms and her height at 1.499 meters so that her BMI is 24.1 kg/m2. For a 10 to 10.75-year-old, that is greater than the 97% and, so, your daughter may well be "obese". If not, she is mighty close.

As you know, the three main things to help control glucose levels include insulin, meal planning, and exercise. These things are generally equally important. But while the EASIEST thing we can do clinically and you do at home, is to give more insulin to bring glucose levels down, the most challenging is to "burn" more calories (glucose) with exercise. You commented elsewhere about the challenge you have in having her be active on her own initiative. If there is a family history of obese or overweight individuals, this may be that much more a genetic predisposition, and therefore a challenge, to her.

But, maybe your REAL reason for writing was to vent some frustration and anger following the comments of the NP "in front of your daughter." I am not unsympathetic to that concern and, of course, no one else heard the tone or manner as to how it was relayed. Your 10-year-old daughter is not naive and neither are you. She KNOWS and you know that she is chubby. The NP and your healthcare team know it and want to change it. Statistically, about 80% of obese children grow to be obese adults. Maybe your daughter will be one in the minority and has that "growth spurt" you are counting on to allow her grow into her weight. I hope so, but the odds are not with you.

So, I would suggest you have a non-confrontational, private, quiet, telephone call (or better face-to-face) with the healthcare worker and explain that you thought her comments were perhaps a little too blunt for your daughter's sensibilities and your liking and that you would hope that future discussions on this topic be made with a bit more sensitivity. But, you don't want the healthcare team to lie or mislead you or your daughter; you don't want them to pull punches - you just want them to not be cruel.

If you think that your daughter has been emotionally scarred by this encounter, then I am really concerned as to what may lie ahead for you and her in middle school and the cliques and the body image issues that often come about. You may wish to be so proactive as to work with a counselor now about some self-esteem building and coping strategies, as well as discussions as to ways to overcome the obstacles to more exercise and even more healthy eating.

I hope this helps. If there are follow up questions, please do not hesitate to write more.

DS

DTQ-20111010173523
Original posting 18 Oct 2011
Posted to Weight and Weight Loss

  
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Last Updated: Tuesday October 18, 2011 18:01:20
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