Artigo Acesso aberto Revisado por pares

Height and diabetes

2020; Wiley; Volume: 37; Issue: 1 Linguagem: Inglês

10.1002/pdi.2252

ISSN

2047-2900

Autores

Rowan Hillson,

Tópico(s)

Diet and metabolism studies

Resumo

Height matters, both practically and psychologically. Many factors influence height including genetics, nutrition, childhood illness, and socioeconomic and geographical issues. The world's tallest man was an American, Robert Pershing Wadlow. Born in 1918, the child grew fast. At eight he was taller than his father. Aged nine, he could carry his father upstairs. His school had to make a special desk for him. By 10 he was 6ft 5in (199cm) tall. He had a pituitary tumour but doctors were too fearful of complications to attempt the only treatment then – surgery. Robert Wadlow had grown to 8ft 11.1in (272cm) when he developed an infection in an ankle blister and died aged 22.1,2 Robert Wadlow's gigantism was caused by a pituitary tumour producing excess growth hormone from childhood causing excessive long bone growth. In adults whose bony epiphyses have fused, growth hormone excess causes acromegaly, without height increase but with overgrowth of other bony and soft tissues. Nowadays, treatment for the growth hormone excess and tumour prevents further growth. Excessive growth is not the only consequence of gigantism or acromegaly. Growth hormone excess increases insulin resistance. A 40-year-old man, not known to have diabetes, was admitted with diabetic ketoacidosis which was treated. He said that his head, hands and feet had grown bigger over the past year. He had obvious facial features of acromegaly which was confirmed on testing. Eight months after surgical removal of his pituitary tumour he had a normal oral glucose tolerance test (OGTT) off glucose-lowering treatment. Ketoacidosis is unusual in acromegaly.3 About 55% of people with acromegaly have glucose intolerance or diabetes.4 A French study including 519 people with acromegaly found a diabetes prevalence of 22.3%. Those with diabetes had a longer duration of acromegaly. As in the general population, age, body mass index and hypertension were risk factors for developing type 2 diabetes.5 Are there people with undiagnosed acromegaly in your diabetic population? Serum insulin-like growth factor (IGF-1) was measured in 2270 patients with diabetes or glucose intolerance aged 20–70 years. Those with raised IGF-1 had growth hormone measurements during an OGTT (which normally suppresses growth hormone). Six people showed failed suppression among whom three were found to have pituitary tumours.6 Suspect acromegaly if a person has thickened facial features, big nose, prominent brow, protruding jaw, big tongue, voice changes, thick skin, skin tags, head, hands or feet enlarging, sweating, or tingling hands. There have long been suggestions that short people are more likely to develop diabetes. Studies have produced variable results, some finding no association between height and diabetes, others a gender difference. A meta-analysis including 25 studies found an inverse relationship between adult height and type 2 diabetes (effect estimate=0.88, 95% CI 0.81–0.95). The inverse relationship applied to both men and women.7 A European study followed 2029 diabetes-free individuals for seven years among whom 820 developed diabetes; 698 with full data were studied in detail. ‘After adjustment for age, potential lifestyle confounders, education and waist circumference, greater height was related to lower diabetes risk (HR per 10cm, men 0.59 [95% CI 0.47, 0.75] and women 0.67 [0.51, 0.88], respectively).’ The association of height with diabetes was reduced, especially in women, by adjusting for liver fat and triacylglycerols, adiponectin and C-reactive protein. This study appears to have used self-reported diabetes.8 ‘Although [shorter] height is seemingly associated with type 2 diabetes, it is likely an indicator of risk that likely reflects both biological and environmental factors.’7 Glucose suppresses growth hormone, so persistently raised glucose during times of growth can impair growth and may reduce adult height. A German study followed 197 children with type 1 diabetes (median age at diagnosis nine years). Relative growth was calculated as the difference between standard deviation scores (SDS) from diagnosis to age 18 years and showed a median loss of 2.9cm in boys and 2.3cm in girls. Poorer growth correlated with higher HbA1c.9 Some children with diabetes develop growth failure, delayed puberty and gross hepatomegaly. This was first described by Mauriac.10 An American group described a 13-year-old boy with diabetes for 11 years, who had growth retardation, marked hyperglycaemia (HbA1c 10.2%), neutropenia, and gross hepatomegaly extending to his pelvis and impinging on his diaphragm causing respiratory distress. Ultrasound revealed a massive liver full of glycogen, confirmed on liver biopsy. Treatment improved his glucose control and neutrophil count, and his hepatomegaly shrank somewhat improving his breathing, but his liver was still below his umbilicus. Thirty months later his liver was back down in his pelvis and the neutrophil count was low again. He admitted to giving less insulin than prescribed for fear of hypoglycaemia. The liver stores glucose as glycogen to be released when glucose is needed. These glycogen stores are broken down when glycogen phosphorylase kinase activates glycogen phosphorylase. This patient had a mutation which inhibited glycogen phosphorylase kinase enzyme activity. Glucose inhibits glycogen phosphorylase, so hyperglycaemia combined with the patient's genetic mutation to keep increasing liver glycogen. Furthermore, the patient's inability to break down glycogen could increase his risk of hypoglycaemia. His mother had the mutation but no diabetes. His father had type 1 diabetes but no mutation. Neither parent had a liver problem or growth retardation. So it appears that both the mutation and diabetes were required for development of the syndrome in this family.11 An Ecuadorian group postulated that genetic mutations in the growth hormone receptor blocking growth hormone action and therefore causing short stature (Laron syndrome) may protect against diabetes and cancer. A 22-year study in a population living on the slopes of the Andean mountains found no diabetes in people with this mutation but a 5% rate in control subjects.12 Prader-Willi syndrome occurs in 1/10,000 to 1/30,000 live births. It is associated with short stature, muscular hypotonia, obesity, hypogonadism, mental retardation, behavioural problems, and respiratory and sleep disturbances. Diabetes is common; glycaemia should be monitored regularly, particularly when growth hormone treatment is used to increase height.13 We frequently use body mass index (BMI) which is, of course, weight in kilograms/height in metres2. How accurate are the components of this calculation? NICE says: ‘Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled: They have a BMI of 40kg/m2 or more, or between 35kg/m2 and 40kg/m2 and other significant disease (for example, type 2 diabetes…’14 So a person with diabetes weighing 106.5kg, height 1.75cm, has a BMI of 34.8 and doesn't qualify for surgery. But if their height is 1.74cm the BMI is 35.2. Height falls by about 1% during the day so this person could be excluded from surgery in the morning but accepted in the afternoon. Make accurate ‘stretched’ height measurements on a stadiometer using trained staff. Height falls with age.15 Many busy clinicians ask patients their height without measuring it. An Australian study of young adults compared online self-reported height and weight with an accurate measurement by a trained researcher. Self-reported height was overestimated by a mean of 1.36cm and self-reported weight was underestimated by -0.55kg. ‘The discrepancy in reporting resulted in the misclassification of the BMI category of three participants.’16 Stadiometers must be calibrated regularly. An audit in one hospital stated: ‘With the exception of one stadiometer which underestimated reference length by 2.78cm, the remaining stadiometers (n=27) provided measurements that deviated from the reference 6-foot rod by -0.38cm to +0.72cm and from the 4-foot rod by -0.22cm to +0.58cm.’ They found similar problems with the weighing scales (including 12% that were broken or unusable).17 Adult height is influenced by genetics, nutrition, childhood illness, socioeconomic and geographical factors. Measure height properly on a stadiometer. Patient-reported height may be wrong. Height falls with aging so repeat measurements over the years. Check and maintain weighing scales and stadiometers regularly. Most people with diabetes do not have rare syndromes or uncommon hormone abnormalities. In general, anyone with diabetes whose appearance is unusual may have a genetic and/or hormonal reason for his or her diabetes. That includes people who are very tall or very short. Remember acromegaly – someone reading this will have a patient with undiagnosed acromegaly in his or her diabetes clinic! For normal growth in children and young people, ensure glucose control is as close to normal as is safe for that individual. Investigate poor growth.

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