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Dr. Amanda Flint joins us again to continue our discussion on Endocrine Issues. This time, the focus is on diabetes, obesity, and growth.
Dr. Vellody: Welcome back everyone for the next episode of the Down Syndrome Center of Western Pennsylvania podcast. I can’t believe that this is now our 20th episode with over 4000 downloads in over 20 countries! Thanks to all of you for getting the word out so that parents of children with Down syndrome can find out the most up to date information. Well, today’s podcast is going to be one that covers a few different topics. We are pleased to have Dr. Amanda Flint, a pediatric Endocrinologist here at Children’s Hospital, back with us again today. Thanks for joining us again today.
Dr. Flint: Thanks, it’s great to be back.
Dr. Vellody: It’s great to have you back. Last time, we talked about thyroid issues, but there are a few other issues that you deal with in kids with Down syndrome. What’s another endocrine condition that we should discuss today?
Dr. Flint: Another endocrine disease that we see more commonly in kids with Down syndrome is another one of the autoimmune conditions. We talked last week about how hypothyroidism is often autoimmune caused. Another one of those disease is actually type I diabetes (juvenile onset diabetes).
Dr. Vellody: So, what is type I diabetes? Where does it come from?
Dr. Flint: So type I diabetes is a condition where again, it’s an autoimmune condition, so in this case the immune system attacks the pancreas which is the gland that normally makes insulin. Insulin is the hormone that keeps your body’s blood sugars under control. So patients who can’t make enough insulin will very high blood sugars.
Dr. Vellody: So, this high blood sugar . . . what’s the problem with it? What are the symptoms that might show up in somebody who has type I diabetes?
Dr. Flint: Very often, patients or parents will notice that their kids are drinking a lot more than usual. They’re always thirsty. They don’t seem to ever get enough to drink. Very occasionally, we’ll see them doing odd things like drinking from a toilet or the bathtub even, because they’re so thirsty. They often also pee quite a lot. They’ll go to the bathroom a lot more frequently. Those are the probably the two biggest symptoms, but we also often notice some unexplained weight loss as well. Those are probably the big 3.
Dr. Vellody: Ok, thanks. If a parent notices some of those “Big 3” symptoms in their child, what should they do next?
Dr. Flint: I think as soon as you realize that this is going on, it’s worth seeking medical attention. In the early stages, kids are not often extremely sick. If it progresses, and we don’t know how long that will take, kids can actually get quite sick and end up needing IV medications and can sometimes even have more complications as a result.
Dr. Vellody: Ok, so let’s say the child is brought into a doctor’s office or Emergency Department with these types of symptoms. What happens next?
Dr. Flint: Probably the first thing that happens is we will check the child’s urine to see if there’s any glucose in their urine. We can also check an actual glucose level either via a lab draw or via a finger stick in the office. If there’s sugar in the urine or if that lab glucose or finger stick glucose is high, that’s more concerning and that will probably progress to some more advanced testing.
Dr. Vellody: If the child’s blood sugar is confirmed as abnormally high, how is this managed?
Dr. Flint: At our center, we actually do generally have the patients come into the hospital for a few days. Hopefully, we’ve caught it early enough that they’re not very sick, and it’s not that they’re in the hospital because they’re so ill but because there’s a lot involved in taking care of someone with diabetes. Unfortunately for the juvenile onset type of diabetes, the only treatment is insulin shots. There’s no way to treat this with oral medications. Because of the need to receive insulin shots, there’s a lot of training that’s involved. You have to learn how to give injections, you have to learn how to check blood sugars at home. There’s also a more detailed meal plan that we ask you to follow in order to help control blood sugars and to know how to properly dose the insulin.
Dr. Vellody: Yes, there certainly is a lot that parents have to learn in order to take care of a child with type I diabetes. How common is diabetes in children and, specifically, in children with Down syndrome?
Dr. Flint: Diabetes is another common condition among children. It’s one of the most common endocrine conditions that we follow in any child. Children with Down syndrome actually have a 3-8X more likely chance of developing type I diabetes. So it is even more common among them.
Dr. Vellody: Thanks. One thing we’re going to touch on later in this podcast is obesity because we do see that commonly in kids with Down syndrome as well. Is type I diabetes more common in children who are overweight or obese?
Dr. Flint: No, that’s actually another type. So type I diabetes, as I said, is an autoimmune condition and that affects kids no matter how much they weigh. In fact, we often see kids looking very thin when they develop diabetes because they’ve had weight loss associated with the symptoms. The kind of diabetes typically associated with obesity is what we call type II diabetes, and that’s a little bit different. Where type I diabetes, the pancreas is not working and isn’t making enough insulin. In type II diabetes, the pancreas can make insulin. It’s just that the child or adult with diabetes, their body doesn’t use the insulin appropriately. Often that’s a consequence of obesity. That can cause something called insulin resistance. What that means is that your body needs more insulin in order to keep the blood sugars under control. That’s fine, as long as your pancreas can continue to make that insulin. There’s a threshold or a point at which your pancreas just can’t keep up anymore. When that happens, the blood sugars start to go up, and we see symptoms just like those for type I diabetes.
Dr. Vellody: Thanks, Amanda. We follow several children at the Down Syndrome Center with type I diabetes. Autoimmune conditions, where the body fights its own cells, just are more common in people with Down syndrome for unclear reasons. But, I’ll be honest with you, I just don’t see very much type II diabetes in my patients despite high rates of overweight and obesity. When does it typically happen?
Dr. Flint: Sure. As you mentioned, we aren’t seeing a whole lot of type II diabetes in kids with Down syndrome. Of course, it gets more an more prevalent or common among adults as they get older. The longer you’ve had insulin resistance and obesity, probably the higher chance of developing diabetes. I can’t speak to the prevalence or the rate at which adults with Down syndrome end up with diabetes, but I certainly have seen patients in clinic who have already had some of the earlier signs. From that standpoint, obesity is important to address. Unfortunately, children with Down syndrome struggle with excess weight gain. We think, in part, it’s because they do burn fewer calories when they’re resting. So it is a struggle, despite eating similarly to kids without Down syndrome, they will gain weight whereas other kids won’t.
Dr. Vellody: So that’s a good transition to our next topic. Obesity is a real problem in America today and not just in kids with Down syndrome. We’ve become a society that eats far more calories than we burn off in a day. As we all know, its very easy to gain weight but much harder to lose weight. How do you counsel families regarding obesity prevention?
Dr. Flint: The prevention of obesity is important for any child. It’s tricky in Down syndrome because babies with Down syndrome sometimes struggle to gain weight. So there’s a tipping point where you have to go around encouraging calories to trying to back off and limit that a little bit. So that’s a very hard transition for a lot of families. As I said, prevention of obesity is important for anybody, and really that starts at home. It starts with a healthy diet and limiting excess sugars, sugary beverages in particular, and encouraging activity as much as possible.
Dr. Vellody: Thanks, Amanda. I couldn’t agree more. I counsel families that older kids can be transitioned from whole milk to skim milk or that sugary beverages including soda but also juices really can be avoided. Juice is not a required part of the diet for any child so it should be avoided especially in children who struggle with weight gain. Also, food being used as rewards should be minimized. As a family member of someone with Down syndrome myself, I know how tempting it can be to reward a child with Down syndrome with candies and other sweets or even unhealthy fast foods. However, in the long run, this is going to be potentially harmful for the child. Finally, with regards to exercise, I always try to tell families that it does not have to be vigorous, triathalon-type of training! Just a 20-30 minute walk around the neighborhood or on a treadmill will help. Sometimes, just linking up TV or movie time with walking on the treadmill can help. Amanda, can you tell our listeners whether childhood obesity has any long term consequences?
Dr. Flint: Yes, absolutely, we worry about long term consequences. We know that there are people who are heavier and who are still relatively healthy. That is what we hope for, of course. Really, again, the key is preventing, and we don’t know who is going to go on to have problems. Even in childhood, we’re seeing kids, with obesity either with or without Down syndrome, who have complications including elevated cholesterol levels. We talked about type II diabetes but the sort of precursor to that is called insulin resistance. We see that quite a bit. We can see something called fatty liver disease where some of that excess fat is actually stored in the liver. That can cause liver dysfunction. All of that really increases the risk of heart disease in the future and probably, ultimately, that’s what we’re trying to prevent.
Dr. Vellody: Thanks for that overview. Thankfully, cholesterol related complications like atherosclerosis (fatty plaques) in the blood vessels of the heart are almost unheard of in people with Down syndrome. It’s thought to be one of the several benefits of an extra 21st chromosome along with a lower incidence of high blood pressure, a lower frequence of solid organ tumors, and others. But returning back to our discussion on obesity . . . can you tell us if there are other complications that our families should be aware of?
Dr. Flint: Yes. A common complication that we see even in adolescent girls with obesity, again with and without Down syndrome, is something called PCOS (polycystic ovary syndrome). It’s kind of a bad name because it doesn’t need to involve cysts on the ovaries. What it shows up as is girls who area heavier, who have irregular periods typically, and they may also have signs of higher testosterone levels. That’s where the ovary part comes in. The ovaries make more testosterone probably as a consequence of insulin resistance, and we don’t fully understand why that happens. These girls, as I mentioned, have irregular periods, but they may also have things like bad acne and hair growing in places that would be more typical of a male (like on the face or on the abdomen).
Dr. Vellody: Is there anything that can be done with some of these obesity complications? Are there medication options?
Dr. Flint: Probably the first thing that we try to do is modify the lifestyle. If we can identify some problems where maybe kids are consuming too many calories, we try to work with families in helping them to adjust their child’s diet and encourage healthy habits. Again, increasing exercise is also extremely important . But, depending on what’s going on, if we find something like PCOS or what we call prediabetes where blood sugars are a little bit high but not fully diagnostic of diabetes, there are some medication options. One of them is metformin which is actually a pill usually used to treat type II diabetes, but we know that it helps with insulin resistance. That can often help things like PCOS or prediabetes as well.
Dr. Vellody: Thanks. Now, before we close this podcast, I think it’s important to touch on other growth concerns. Kids with Down syndrome are most often shorter than their peers. Do we know why that is the case? I know some people have wondered about whether this could be a growth hormone deficiency. Maybe you could you touch on that too?
Dr. Flint: Absolutely. We know that kids with Down syndrome do tend to be shorter when they are done growing. Some of that comes early in life; we already see some discrepancy. A lot of that comes from the fact that for whatever reasons they just don’t have as good of a growth spurt when they are going through puberty. Kids often become more obviously shorter as that time hits. We don’t really understand why it happens. We don’t think it’s because of an increased rate of deficiency in growth hormone, but we don’t fully understand that yet.
Dr. Vellody: Okay, like so many other things in Down syndrome, we still need to find out more about the causes of short stature. Well Amanda, thank you for sharing your expertise in endocrinology with us in these 2 podcasts.
Dr. Flint: You’re very welcome. I’m pleased to do it.
Dr. Vellody: Okay, our faithful listeners, this concludes our podcast today. Please be sure to stay tuned for future podcasts that are on the way! If there are topics we have not yet covered that you would like more information on, please drop us an e-mail at email@example.com. Until next time, bye bye!
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