An Obese Teen: More Than Meets the Eye

Shannon Patrick, ARNP, MSN; Janet Silverstein, MD


June 18, 2013

Long-term Management of Children With T2DM

The AAP guideline states that all youth who do not meet the above criteria for initiation of insulin therapy should be placed on a regimen of lifestyle modification with metformin.[2] Lifestyle modification alone is rarely successful in maintaining long-term glycemic control.

Ashley was initiated on a program of lifestyle modification and metformin, with instructions to monitor her blood glucose before meals and at bedtime. Lifestyle modification strategies emphasize elimination of sweetened beverages; limiting television viewing to 2 hours or less daily; consuming 5 servings of fruits and vegetables daily; decreasing meals eaten at fast-food restaurants; eating breakfast and lunch; and increasing physical activity, with a goal of 60 minutes of moderate to vigorous exercise daily.[2,5] Because Ashley's blood pressure was elevated, she was also encouraged to limit sodium to foods served at the table and that in processed foods.[6]

Ashley's mother expressed willingness to implement a healthier lifestyle, although she was concerned that healthier foods would be more expensive. In addition, as the sole care provider, she was not sure how they would eliminate fast foods on the nights they ate out, owing to the family's tight schedule. She did agree to walk with Ashley around the soccer field while her son was at soccer practice twice weekly and 1 day each weekend for half an hour.

Metformin therapy was initiated at 500 mg daily. The extended-release preparation was chosen for Ashley for the convenience of once-daily dosing. Ashley was cautioned to take it with a meal to decrease adverse gastrointestinal effects. Ashley and her mother were instructed to increase the dosage by 500 mg every 2 weeks until reaching 2000 mg daily. Doses greater than 2000 mg daily are generally not associated with additional benefit.

Metformin therapy is first-line therapy for children and adolescents who do not have significant hyperglycemia or ketosis. It is quite safe, with no reports in the literature of lactic acidosis or vitamin B12 deficiency in children or adolescents. In addition to improving insulin sensitivity, metformin may help with weight control and the lipid profile and, by increasing insulin sensitivity, improve nonalcoholic fatty liver disease and menstrual irregularity in girls with polycystic ovary syndrome.[2,7] Ashley was cautioned to use contraception if she becomes sexually active.

Ashley and her mother were taught self-monitoring of blood glucose, and she was asked to check her blood glucose levels before breakfast and 2 hours after a meal each day. Ashley was asked to report blood glucose values weekly for the first month. Target blood glucose ranges for Ashley were set at 70-130 mg/dL fasting and < 150 mg/dL 2 hours after meals. A goal was set to reduce the A1c value to 7%, which correlates with an average blood glucose level of 154 mg/dL.[1]


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