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To the Editor.—
We read with great interest the Pediatrics article by Reinehr et al.1 The authors provided important information about the changes in insulin sensitivity in obese children and adolescents according to degree of weight loss,1 showing that a decrease of at least 0.5 of SD score BMI (mean: –0.67; 
30% of those who were overweight) is required to observe a significant improvement in insulin sensitivity (65% increase). No data concerning obese subjects with impaired glucose tolerance (IGT) were provided.
Given that type 2 diabetes in children, once considered rare, has become increasingly common in association with obesity2 and IGT represents the frequently missed link between insulin resistance and type 2 diabetes, it might be useful to study the effect of weight loss on glucose metabolism in children with IGT.
Fifteen severely obese children and adolescents with IGT were included in the study (mean age: 12.2 ± 2 years; mean z score BMI at baseline: 4.9 ± 1.3). IGT was defined as a serum glucose level of 
140 mg/dL and <200 mg/dL after a 2-hour oral glucose-tolerance test according to American Diabetes Association guidelines. The subjects were submitted to a nutritionally balanced hypocaloric diet (60% of the recommended dietary energy allowances for age and gender). The oral glucose-tolerance test was repeated after 6 months. Glucose tolerance appeared normalized in 14 children (8 girls), which showed a statistically significant reduction of their z score BMI (mean: –1.6 ± 0.6; range: –2.1 to –1.2) (Table 1). Insulin resistance, calculated by using the homeostasis model assessment, improved and plasma insulin levels decreased (Table 1).
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When insulin resistance increases, insulin secretion must increase for glucose tolerance to remain normal. Deterioration in glucose tolerance occurs when a compensatory increase in insulin secretion is incomplete.3 Adiposity reduction, which restores insulin sensitivity, prevents the impairment of pancreatic islet cell function.
Our observation, which suggests that the reduction of 30% of excess weight is enough to reverse IGT in severely obese children and adolescents, adds data that are consistent with and integrate those reported by Reinehr et al.1 To lose weight when IGT has manifested represents the last opportunity for an obese child to normalize the glucose homeostasis before the appearance of type 2 diabetes with its associated irreversible deterioration in ß-cell function.3,4
REFERENCES
Related articles in Pediatrics:
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