Recovery of a Vietnamese Child from Impaired Fasting Glucose and Hyperinsulinemia After one Year of Implementation of an Appropriate Diet Plan: A Case Report

Background: Increasing type 2 diabetes mellitus (T2D) in children and adolescents has bypassed the living standard barrier among countries to become a global epidemics. The diagnosis of T2D often focuses on overweight or obese individuals which leaves behind the normal Body Mass Index (BMI) ones whose late diagnosis causes grave complications and consequences. Changing diet and lifestyle are affective means for the management of the disease. Method: A 9-year-old normal weight Vietnamese male with a BMI of 23.3 kg/m2 was diagnosed with impaired fasting glucose (IFG) and hyperinsulinemia a in December 2019 after intensive treatments for severe hair loss progression (Alopecia areata). The patient was under both topical and oral cortisol (4mg of Methylprednisolone and 0.1% Mometasone furoate, daily), fasting blood glucose was 6.6 mmol/L, HbA1C was 5.1%, fasting insulin was 123.048 μU/mL, C-peptide was 4.7 nmol/L and a complete hair loss. His white blood count showed an increase in % Lymphocytes associated with a decrease in: % Neutrophils, number of Eosinophils and number of Basophils. He was born 4.1 kg and his mother did not have gestational diabetes. He adopted an anti-inflammatory diet protocol for the first 6 months which was then extended to high fat low carb diet. Result: After about one year of changing his diet, from May 2020 to April 2021, the patient was off all his medications, his blood test was back to normal (glucose, HbA1C, insulin and C-peptide are 4.22 mmol/L, 4.94%, 3.9 μU/mL, 0.72 nmol/L respectively) and his complete blood count has completely recovered. However, there have been no signs of recovery for his hair loss. Conclusion: The adoption of an appropriate diet is an effective tool for the prevention of T2D progression as well as the management of the disease. Thanks to changes in his diet, the patient has recovered from not only IFG and hyperinsulinemia but also the severe inflammation which, if left advanced, could have led to other complications including the development of polygranular autoimmune disease. Routine screening and early diagnosis of T2D, impaired fasting glucose and hyperinsulinemia are recommended to help patients to avoid serious consequences from the disease complications. Children and adults with normal BMI should be paid as much attention as to those whose BMI is high.


Introduction
Global increase in T2D in children and aldolesents has raised a serious concern on the health condition of the future generation.
Combination of multiple risk factors such as genetics, the mother's gestational diabetes, poor diet and lifestyle are considered as the cause of this rise (Castorani, et al. [1]). While there are no possible actions can be done to change the genetics of the person, adopting an appropriate personalized diet and lifestyle represents the sole option for the prevention of the disease pathogenesis and management. High fat low carb diet has demonstrated health benefits in restoring metabolic syndroms and other diseases (Walton, et al. [2]) (Dowis, et al. [3]). Recent data shows a significant increase in T2D mellitus as well as in prevalence of non-diagnosed T2D in children worldwide (Spurr,et al. [4]). In Vietnam, it was reported in a recently published study that the prevalence of T2D in children from 11-14 years old is lower than in most countries and the impaired fasting glucose prevalence is up to 6.5% (Phan,et al. [5]). T2D mellitus in children is often diagnosed only when grave complications have already occurred because of the poor risk management and the lack of surveillance programs and tools.
Consequently, pediatric patients risk being put on medicaments including insulin injection at a very young age. We report here a case of a 9-year-old Vietnamese male diagnosed with IFG and hyperinsulinemia in December 2019 following cortisol treatment (from August 2018) for severe hair loss (Alopecia areata). One year after changing his diet, the patient has restored his IFG, insulin, complete blood count and re-started to grow taller after more than one year staying at the same height.  B) photo taken in May 2020.

Results
His mother was seeking help outside of the conventional medical approach, reaching to her research scientist friends in Vietnam and oversea. As provided by the mother, the patient was born lightly overweight (4.1 kg) and has itchy skin at birth. He

Discussion
The rise of T2D mellitus in children in developing countries like Vietnam is regarded to be caused by the westernization of their conventional diet or the combination of both. Impact of the introduction of a number of snacks and high sugar beverages to the routine consumption upon three conventional meals filled with rice and starchy vegetables must be taken into account for T2D epidemics in Vietnam and Asia, especially in children of young age.
Prior to the arrival of alopecia areata, the patient did not show any symptoms of T2D or autoimmune disorders. He was not overweight and didn't endured any intensive treatment of antibiotic or/and anti-inflammation prior to the severe and rapid hair loss. As there were no blood tests for fasting glucose and insulin before starting the cortisol treatment, we cannot know if the treatment had contributed to graver his IFG and hyperinsulinemia condition. As alopecia areata is often associated with insulin-dependent diabetes (Wang,et al. [8]) and taking into account his previous diet, it is likely that he possessed a pre-existing hyperinsulinemia condition long before the appearance of the severe hair loss.
Routine screening for IFG and hyperinsulinemia in children Despite all these difficulties and social inconveniences, the patient and his family have made a huge step forward, helping the child to recover from his diseases and to continue his growing curve right before entering puberty. His recovery encourages many others to take actions as showing that adopting an appropriate diet may not be an easy option but is the one that works.

Conclusion
Implementation of an anti-inflammatory diet followed by an extension to low carb high fat diet has rescued the 9-year-old child, now is 10 years old, not only from the development of T2D mellitus but also the severe inflammation. Routine screening for IFG and hyperinsulinemia in children is highly recommended for the prevention of the T2D and therefore reduction of serious complications and consequences.