In Reply .—While it may be far out to think that there may be greater efficiency in conserving energy in some who gain weight with fewer calories and that this represents Darwinian improvement, I do believe that we should not be satisfied with an obvious explanation, thereby limiting thought processes. I am delighted to read that Dr Kashani agrees that consumption of more calories and less activity results in obesity. This takes us to about 1890. I certainly do not argue that all practitioners should advocating proper diet and moderate exercise. Perhaps I erred in mentioning too many etiologic possibilities when I should have objected more clearly to the use of what I consider pejorative terms, especially when seeing and treating children, and I thank Dr Kashani for highlighting this. I did try unsuccessfully to think of better terminology. Even with the help of Stanley Garn, MD, who is a stellar
On reading your letter, the first question that comes to mind is, how come your wife is so smart. Apparently she is the one who makes up the new words and develops the hypotheses about physicians and their lab tests. Secondly, it is my firm belief that treatment of obese-writing is about as effective as treatment of any other kind of obesity. If the patient isn't very interested in reducing, no type of behavior modification or any other treatment is likely to be effective.
Flourescein angiography (FA) was performed on 80 children with diabetes one year after an initial evaluation with FA. The grading system: Stage 0 no microaneurysms (MA), Stage 1<10 MA, Stage 2>10 MA, Stage 3>10 MA plus neovascularization. 2-3 DPG was measured as an indicator of vascular compromise and compared with FA. The levels in non-diabetics is 14.4 ± 1.0mM/gmHb, Stage 0 is 15.6 ± .2 and Stage 1-3 is 16.7 ± .5. The difference between controls and Stages 1-3 is significant at p<.02 and suggests that the abnormalities noted on FA indicate functional vascular abnormalities. The Stage was unchanged in 71/80, 9/71 remained Stage 0, 3 improved and 6 increased in severity. The percent of hemoglobin A1, (HbA1) and the concentration of sorbitol (S) in packed red blood cells (PRBC), indicators of glycemic control, were not significantly different in children with Stage 0 when compared to those with Stage 1,2 and 3. Three of 4 children with chemical diabetes (CD) had MA. A 12 yr. old child with diabetes of 3 mos. duration had Stage 3 retinopathy. The demonstration of MA early in the clinical course of diabetes (CD) plus the lack of apparent difference in the degree of glycemic control between those with progressive vascular abnormalities and those with none or stable retinopathy suggest that factors other than glycemic control are important in the prevention of the vascular complications of childhood diabetes.
