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Type 2 Diabetes Among Youth

Volume 5, Number 8 - October/November, 2001

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

Inside HealthHints....

• Defining Diabetes
• The Threat of Type 2 Diabetes Among Youth
• Early Detection, Diagnosis and Treatment Issues
• Acanthosis Nigricans: A Common Warning Sign
• Who is Affected? Who is at Risk?
• Reducing the Risk
• Overweight/Obesity: The Latest Trend
• Influencing Factors: Why Type 2 Diabetes is Emerging Among Our Youth
• What We Can Do: Prevention and Management of Type 2 Diabetes Among Youth
• A Healthful Diet
• Physical Activity
• Maintaining a Healthy Weight
• The Role of the Family
• Self Management Education
• Efforts Toward Changing the Trend
• References

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Pediatricians are learning of a disturbing trend. Type 2 diabetes -- formerly called non-insulin dependent diabetes -- is increasingly being found in children and adolescents (Centers for Disease Control, 1999a).

This issue of HealthHints will focus on the increasing trend of obesity and diabetes among youth -- what the trend looks like, how to prevent it, and how to manage it. (For more information about diabetes in general, please refer to the March 1997 issue of HealthHints or go to HealthHints topics on the web at http://fcs.tamu.edu/health/Health_Education_Rural_Outreach/.)

Defining Diabetes

According to a report from the American Diabetes Association, approximately 15.7 million people, or 5.9% of the U.S. population, have diabetes. It is the 7th leading cause of death in the United States (American Academy of Pediatrics, 2000c).

Diabetes is a chronic, life-long disease for which there is not yet a cure. Diabetes impairs the body's ability to use food properly. The hormone insulin, which is produced in the pancreas, helps the body to convert sugar, starches, and other food into energy (American Academy of Pediatrics, 2000c; American Diabetes Association, 2001c.)

In people with diabetes, either the pancreas does not make any insulin, does not make enough insulin, or the insulin does not work properly. Insulin takes glucose (a type of sugar) into cells. If this action doesn't occur, the glucose cannot be used for energy. Without insulin, glucose (the body's main energy source) remains in the blood, and is then removed by the kidneys (American Diabetes Association, 2001c; Lambert, 1999).

When glucose builds up in the blood instead of going to the cells, it can result in two major complications:

• Right away, the body's cells may be starved for energy.
• Over time, high blood sugar can severely hurt the functioning of the eyes, kidneys, nerves, and/or heart (American Diabetes Association, 2001b).

There are several types of diabetes: gestational, type 1, and type 2 diabetes.

• Gestational diabetes occurs during pregnancy and affects about 6% of the U.S. population (Lambert, 1999).
• Type 1 diabetes (also called juvenile diabetes, and formerly called insulin dependent diabetes) occurs when the pancreas stops making insulin. Children with type 1 diabetes require daily injections to enable their bodies to use food properly (American Diabetes Association, 2001c).
• Type 2 diabetes (formerly called non-insulin dependent diabetes) results when either the body doesn't produce enough insulin or the cells ignore the insulin (i.e., the insulin produced by the pancreas cannot connect with the cell to let glucose from the blood into the cell for energy -- also called insulin resistance) (American Diabetes Association, 2001b; Lambert, 1999). Type 2 diabetes accounts for approximately 90% of all cases of diabetes (Lambert, 1999).

The Threat of Type 2 Diabetes Among Youth

Though type 2 diabetes is by far the most common form of diabetes, it was long believed to primarily affect adults (Centers for Disease Control, 1999a). Recent research, however, has shown a surge in youth diagnosed with type 2 diabetes. In 1990, fewer than 4% of cases of childhood diabetes were type 2; that number has risen to approximately 20%, varying from 8% to 45% depending on the age and ethnic mix of the group studied (American Academy of Pediatrics, 2000c).

Cases of type 2 diabetes during adolescence were first reported 20 years ago among the Pima Indians of Arizona, who have the world's highest prevalence of type 2 diabetes during adulthood.... Reports of type 2 diabetes among children and adolescents of other ethnic groups were published more recently, and type 2 diabetes is now being found in all adolescent populations in the United States (Centers for Disease Control, 1999).

Diabetes experts want to raise awareness among physicians and other health care providers, school personnel, and parents so that young people with risk factors are screened for the disease. But most importantly, experts want to prevent obesity, by addressing issues of physical activity and nutrition (Centers for Disease Control, 1999a).

Early Detection, Diagnosis and Treatment Issues

Most practitioners who see children for medical problems, including diabetes, were told throughout their training that type 2 diabetes does not exist in children. As a result, they are hesitant to consider this or make it the initial diagnosis.
- Kenneth Lee Jones, M.D. (American Medical Association, 2001).

Physicians are facing treatment questions, such as, will the same medications and treatment strategies work among youth?

To respond to the emergence of type 2 diabetes among youth, the Centers of Disease Control Division of Diabetes Translation has set out 4 objectives:

1. Raise physicians' awareness about the disease.
2. Develop a standard case definition(s).
3. Determine the magnitude of the problem.
4. Assess and improve the quality of care among children and adolescents diagnosed with type 2 diabetes (Centers for Disease Control, 2001a).

It is difficult to detect type 2 diabetes among children because it can go undiagnosed for a long time. Children may have no symptoms or very mild symptoms (common symptoms are noted in the box below). A blood test is also required for diagnosis. Additionally, it is difficult to differentiate between types of diabetes in children, since children with type 2 can develop acid build-up in the blood (ketoacidosis) -- a common symptom in type 1, and children with type 1 may be overweight -- common among children with type 2 diabetes (Centers for Disease Control, 2001a).

Parents, school nurses (Texas Medical Association, 2000), and others in close contact with children can be helpful in identifying risk factors and early warning signs so that these youth may be screened and identified early.

Acanthosis Nigricans: A Common Warning Sign

A condition known as acanthosis nigricans is a common warning sign associated with type 2 diabetes in youth (American Diabetes Association, 2000). Acanthosis nigricans is a change in the color and texture of the skin. Typically the affected area becomes rough and dark (black). This can occur anywhere on the skin, but the most frequent place is on the back of the neck near the hairline. Acanthosis nigricans can also be seen in the armpits, in the crease on the front of the elbows and behind the knees, over the knuckles of the hands, the skin of the pubic area, and in the folds under the breasts or on the abdomen. It is most commonly found among darker-skinned, obese youth (American Diabetes Association, 2000).

Sometimes parents who observe the change in skin color think that the child is not bathing properly; others have gone to great lengths to remove the "smudge" from their child's neck.

Acanthosis, however, is simply a reaction of the cells of the skin to high levels of insulin being produced inside the body. It is not an infectious condition. One person cannot catch acanthosis from another person; and little can be done to the surface of the skin (scrubbing, bleaching) that will make it go away.

The major implication of acanthosis is the internal levels of insulin are high, suggesting that the body is working very hard to keep the level of blood glucose normal. If the glucose in the body gets too high, this can cause serious problems to many organs and tissues.

In many ways, acanthosis is like black smoke coming out of the tailpipe of an automobile. It is a warning that something may be wrong that is still repairable or that something needs to be done soon to keep the car from breaking down.

There is no need to panic if acanthosis is discovered. It is important, however, to schedule an appointment with the child's doctor to see if the child has elevated blood glucose and fat levels. Dietary and exercise suggestions may be made, and consultations with a registered dietician or other specialists may be recommended.

By identifying and dealing with the problem, the acanthosis can fade and the child can reduce the risk of developing type 2 diabetes and other related problems (Hale, et. al. 2000).

Who is Affected? Who is at Risk?

Among youth, those affected by or at risk for type 2 diabetes:

• commonly have a family history of type 2 diabetes
• are more likely to be African American, Hispanic, or American Indian than of other racial or ethnic groups
• are typically aged 10 to 19 and in middle to late puberty, although children as young as 4 years old have been documented
• are slightly more likely to be girls than boys
• are typically overweight or obese, rather than normal weight
• often have poor eating habits
• are typically sedentary (Fagot-Campagna, 1999; Centers for Disease Control, 1999a; Texas Medical Association, 2000).

We need to take this issue seriously. For at least one in five kids, overweightness is not a cute phase that will be outgrown. It's the start of a lifetime of health problems. More Americans are at risk for diabetes and other serious medical conditions -- all at an earlier age (USDA, 1998b).

Reducing the Risk

Though race, age, gender, and an individual's family history are unchangeable risk factors, there are factors that can be changed. By changing practices to include good eating habits and an active lifestyle, some risk factors (e.g., obesity, overweight) can be reduced, and perhaps the cycle of type 2 diabetes in some families can be broken -- thus, changing the family history for the next generation.

Overweight/Obesity: The Latest Trend

The fact is that overweight kids grow up to be overweight adults who suffer drastically higher incidences of high blood pressure, diabetes, heart disease, and cancer. - Agriculture Secretary Dan Glickman (USDA, 1998a)

Obesity in children (as well as adults) is increasing at an alarming rate (Bryant, et. al., 1999).

• Ten million U.S. children are overweight or obese (USDA , 1998b).
• Obesity affects one in five U.S. children (Dietz, 1998).
• In the past 20 years, the number of obese children has doubled (USDA , 1998b).
• Approximately 5% of children and adolescents aged 6 to 17 were overweight in the 1960s and 1970s; approximately 11% of children and adolescents aged 6 to 17 were overweight from 1988 to 1994 (National Institute of Diabetes and Digestive and Kidney Diseases, 1998).
• Of children diagnosed with type 2 diabetes, 85% are obese (American Academy of Pediatrics, 2000c).

The problem of type 2 diabetes is not limited to North America.

• The annual incidence of type 2 diabetes among junior high school children in Tokyo increased from 7.3 per 100,000 in 1976 through 1980 to 12.1 per 100,000 in 1981 through 1985, and to 13.9 per 100,000 in 1991 through 1995.
• Data from Libya, Bangladesh, and aboriginal children in Australia and Canada indicate that childhood type 2 diabetes is occurring in these populations as well.
• Obesity is reaching epidemic proportions in the U.S. and elsewhere (American Diabetes Association, 2000).

Being overweight in childhood and adolescence is associated with being overweight in adulthood. This is of particular significance, since overweight and obese adults are at increased risk for morbidity and mortality associated with diabetes, as well as many other acute and chronic medical conditions (e.g., hypertension, coronary heart disease, gallbladder disease, respiratory disease, and some types of cancer, gout, and arthritis) (Centers for Disease Control, 1997).

Influencing Factors: Why Type 2 Diabetes is Emerging Among Our Youth

One plausible explanation for the emergence of type 2 diabetes is the increase in obesity and decrease in physical activity (American Diabetes Association, 2000). Why then are our youth obese and inactive? Here's a look at some of the habits of our youth.

Multi-media

• The average child and/or adolescent watches an average of nearly 3 hours of television each day (Bar-on, 2000).
• One quarter of all U.S. children spend 4 or more hours in front of the television (or video or computer [Fox, 2000]) screen each day, as do 43% of non-Hispanic blacks (Anderson, et. al., 1998).
• By the time a child finishes high school, almost 3 years will have been spent watching television (Bar-on, 2000).
• The amount of time spent watching television directly correlates with the request, purchase, and consumption of food advertised (Bar-on, 2000).

Television viewing effects both fatness and fitness...(due to) reduced energy expenditure from displacement of physical activity and increased dietary energy intake, either during viewing or as a result of food advertising (Bar-on, 2000).

Eating Habits

• Over 84% of children and adolescents eat too much fat (more than 30% of calories from fat) (Centers for Disease Control, 2000b).
• Over 91% of children and adolescents eat too much saturated fat (more than 10% of calories from saturated fat) (Centers for Disease Control, 2000b).
• On average, children and adolescents get 33 to 34% of calories from total fat and 12 to 13% from saturated fat (Centers for Disease Control, 2000b).
• On average, children and adolescents eat only 3.6 servings of fruits and vegetables a day -- fried potatoes accounting for a large portion of those vegetables eaten (Centers for Disease Control, 2000b).
• 51% of children and adolescents eat less than 1 serving of fruit a day (Centers for Disease Control, 2000b).
• 29% of children and adolescents eat less than 1 serving of vegetables that are not fried (Centers for Disease Control, 2000b).

Physical Education

• 8% of elementary schools (excluding kindergarten), 6.4% of middle/junior high schools, and 5.8% of senior high schools provide daily physical education or its equivalents for the entire school year for all grades in the school, according to the School Health Policies and Programs Study (SHPPS) 2000 (Centers for Disease Control, 2001c).
• 6.7% of elementary schools, 25.3% of middle/junior high schools, and 40% of senior high schools exempt students from required physical education courses for one or more of the following reasons:
  • high physical competency scores
  • participation in other school activities, participation in community sports
  • participation in community service activities
  • At the senior high level, these exemptions also include:
    • enrollment in other school courses
    • participation in school sports
    • participation in vocational training (Centers for Disease Control, 2001c).
• According to a 1996 report of the Surgeon General, only 19% of high school students are physically active for 20 minutes or more, 5 days a week, in physical education classes (Centers for Disease Control, 1999b).

Physical Activity

• Nearly half of American youth aged 12 to 21 are not vigorously active on a regular basis (Centers for Disease Control, 1999b).
• Participation in physical activity decreases markedly as age or grade in school increases (Centers for Disease Control, 1999b).
• Approximately 14% of youth report no recent physical activity (Centers for Disease Control, 1999b).
• Inactivity is reported more often among females than males and among black females than white females (Centers for Disease Control, 1999b).
• Physical inactivity is more common among those residing in rural communities and southern states (Centers for Disease Control,1998).

Nutrition Education

• According to results of the SHPPS 2000 study, among teachers of required health education, hours of nutrition education taught came to a median of:
  • 5 hours per school year at the elementary level
  • 4 hours per school year at the middle/junior high school level
  • 5 hours per school year at the senior high school level.

Food Services

• According to results of the SHPPS 2000 study 65.1% of schools order some 1% or skim milk in a typical week. 62.8% of all milk ordered in a typical week is either 2% or whole milk.
• 68.1% of schools offer two or more fruits or 100% fruit juices; 61.7% offer 2 or more vegetables each day for lunch.
• 43% of elementary, 73.9% of middle/junior high, and 98.2% of senior high schools have either vending machines, school stores, canteens, or snack bars where students can buy food and drinks -- primarily soft drinks, sports drinks, fruit juices that are not 100% juice, salty snacks not low in fat, cookies and other backed goods not low in fat (Centers for Disease Control, 2001b).

What We Can Do: Prevention and Management of Type 2 Diabetes Among Youth

Making healthful lifestyle choices is the most important thing one can do to prevent diabetes. These choices include:

• a healthful diet
• regular physical activity
• maintaining a healthy weight
• family involvement in health
• self management education.

A Healthful Diet

The dietary guidelines are an excellent place for children and adults alike to find solid advice for improving diet and health. - Shirley Watkins, Under Secretary for Food, Nutrition, and Consumer Services (USDA, 1998a)

The dietary guidelines (see Food Guide Pyramid below) stress a healthful diet through:

• a variety of foods;
• a diet high in fruit, vegetable, and grain products; and
• a diet low in sodium, fat, sugar, and cholesterol (USDA, 1998a).

Following these guidelines can help adults and youth alike maintain a healthful diet and body weight.

Food Guide Pyramid

Note: For younger children, please see the USDA Food Guide Pyramid for children ages 2-6.

There are also available Food Guide Pyramids for specific ethnic/cultural groups. These pyramids can be accessed through the USDA Food and Nutrition Information Center at http://www.nal.usda.gov/fnic/etext/000023.html#xtocid2381818.

Physical Activity

Because physical inactivity is related to overweight/obesity (Gordon-Larson, et. al., 1999) and increased risk for diabetes (Fox, 2000) it is an important, modifiable behavior.

Benefits

Exercise is important for many reasons:

• It improves the flow of blood through the small blood vessels and increases the heart's pumping power.
• It prevents or reduces the development of high blood pressure.
• It helps lower blood sugar levels by helping the body use its food supply better.
• It may help insulin work better.
• It helps control weight, build lean muscle, strengthen and maintain healthy bones, muscles, and joints, and reduce fat.
• It burns calories that your body would otherwise store as extra weight.
• Combined with an appropriate diet, it can help take off extra pounds.
• It may make you look and feel better; reduces feelings of depression, anxiety, and stress (American Academy of Pediatrics, 2000a; American Diabetes Association, 2001a; Centers for Disease Control, 2000c).

We have known for some time that children's freedom for activity has been endangered. ...Between 1971 and 1990 there had been reductions in walking to school, low levels of cycling to school, and generally less license offered to children by their parents to play out of the home on their own and be independent (Fox, 2000).

Barriers

Unfortunately, there have been a number of barriers on the rise, decreasing opportunities for physical activity.

• Children are becoming increasingly restricted by parental fears of traffic and child abduction.
• There is increasing reliance by the family on cars for transport, rather than walking, cycling, etc.
• There has been a reduction in curriculum time for physical education in schools.
• An increasing array of "wall-to-wall screen entertainment" is available in the home to take time away from physical pursuits (Fox, 2000).

Children and adolescents in the United States cannot become more physically active and fit if they don't have a wide range of accessible, safe, and affordable opportunities to be active. However,...our young people... will not increase their levels of physical activity and fitness unless they are sufficiently motivated to do so. Their motivation to be active will depend on the degree to which they find their physical activity experiences to be enjoyable (Centers for Disease Control, 2000c).

Strategies to Promote Physical Activity

To obtain the opportunities and motivation needed to increase physical activity levels among youth, they need:

• Families who model and support participation in enjoyable physical activity.
• School programs -- including quality, daily physical education; health education; recess; and extracurricular activities -- that help students develop the knowledge, attitudes, skills, behaviors, and confidence to adopt and maintain physically active lifestyles, while providing opportunities for enjoyable physical activity.
• After-school care programs that provide regular opportunities for active, physical play.
• Youth sports and recreation programs that offer a range of developmentally appropriate activities that are attractive to all young people.
• A community structural environment that makes it easy and safe for young people to walk, ride bicycles, and use close-to-home physical activity facilities.
• Media campaigns that increase the motivation of young people to be physically active (Adapted from Centers for Disease Control, 2000c).

Walk Across Texas

One example of a safe and enjoyable way that youth, families, schools, and communities can get involved in physical activity, and promote fitness through the media is the Walk Across Texas (W.A.T.) Program.

The Walk Across Texas Program is an 8-week walking program for teams of 8 people. The teams have a friendly competition to see who can log the most miles walking, jogging, or biking. Each individual walks, jogs, or bikes and reports his/her miles to their selected team captain at the end of each week. Miles are totaled each week for each team. Those miles are recorded on a Texas map posted in the Extension office and other places around the community, so everyone can see the progress. The team who walks the farthest "across Texas" wins, but everyone who participates receives recognition and takes home a healthy habit.

The Walk Across Texas Program can also include components of nutrition education, and diabetes prevention and management education. In Cameron County, Ileana Hinojosa, Health Education and Rural Outreach Specialist, organized such a program with the Brownsville Community Health Center school-based clinic, Texas AgriLife Extension Service, and Expanded Nutrition Program. The coalition implemented joint nutrition and physical activity programming for children and their parents at the Del Castillio Elementary School in Brownsville. The partnership addressed:

• Children with type 2 diabetes and children with acanthosis nigricans, identified as high risk for developing type 2 diabetes by the school-based clinic
• Parents of the children
• Nutrition Education by teaching parents and children proper nutrition and healthy food preparation
• Implementation of regular physical activity for parents and children using the Walk Across Texas Program.

In the Coastal Bend Region of south Texas, Maria Gutierrez, Health Education and Rural Outreach Specialist, approached middle school principals and asked them to implement the Walk Across Texas Program to provide daily physical activity for their students. Key components of the Coastal Bend Walk Across Texas Program included:

• Staff training with school principles, coaches, and nurses
• Health education for students, including information on nutrition, skin cancer, and tobacco prevention
• Increased activity with classes competing against each other for the most miles
• Students involved their families by taking the Walk Across Texas Program home to their loved ones
• Students learned Texas geography by plotting their "route" on a Texas map
• Recognition with individual certificates, fruit, toothpaste, and sun screen.

(This section adapted from fact sheets written by Courtney J. Schoessow, Extension Associate-Health, 2001).

Age Appropriate Activity

As children develop, so do their physical skills. It is important that youth enjoy the activities they are involved in and stay safe while participating. It is also important not to thrust children into activities for which they are not developmentally ready. The following are some age appropriate ideas:

2 to 3 Years Old

Two- and 3-year olds thrive on unstructured play. Parents and child-care providers can help develop skills by encouraging:

• running
• swinging
• climbing
• playing in a sandbox
• carefully supervised water play.

4 to 5 Years Old

At ages 4 and 5, children begin to increase their coordination and are able to participate in some organized games. Parents can encourage physical activity through guiding children to:

• roll large balls
• play catch
• ride a bike with training wheels
• swim
• dance
• ski
• skate
• play an organized sport, but only without pressure -- remember, activity should be fun; unstructured time is important; children should not be over-scheduled in this type of activity.

6 to 12 Years Old

As children develop, particularly between ages 10 to 12, so do their abilities to participate in a variety of sporting activities, such as:

• softball
• baseball
• soccer
• volleyball
• basketball.

Keep in mind, however, not all children enjoy team sports at this age. There are also a variety of noncompetitive, individual and team sports to be enjoyed, and encouraged, such as:

• swimming
• ice-skating
• gymnastics
• dance
• non-violent martial arts.

At age 11, children who are interested may begin to lift weights (under supervision) to build muscle and prevent sports injuries.

13-18 Years Old

Developmentally, teenagers can pick up on any activity they enjoy, from competitive to non-competitive sports. In addition to focused competitive sports, teenagers may enjoy:

• skateboarding
• in-line skating
• snowboarding
• rock climbing
• weightlifting (under supervision).

Teenagers, like adults, should aim to exercise every day, at least 3 to 4 times a week; participating in some type of aerobic (continuous motion) activity for at least 20 to 30 minutes each time -- being sure not to overdo (i.e., not exercising to the point of pain) (American Academy of Pediatrics, 2000b; American Medical Association, 1999a; American Medical Association, 1999b; American Medical Association, 1999c; American Medical Association, 1999d).

The issue of childhood obesity starts with prevention -- empowering children to be in control of their bodies and helping parents make the right decisions with regard to nutrition and exercise (Mayo Clinic, 2000b).

Maintaining a Healthy Weight

It is important to address weight concerns early, before complications develop. Since children are still growing, they have the opportunity to grow into their weight allowing for weight stabilization rather than weight reduction as an appropriate treatment. With growth, the weight shifts from stored calories to lean tissues such as muscle and bone. The best approach will include a meal plan and consultation by a registered dietitian to achieve weight stabilization. The dietitian can also provide recommendations for healthy snacks, food preparation, and lifestyle changes. The long-term goal is to change the eating behavior of the obese children and their families (Bryant, 1999).

If a parent suspects a child is overweight, it is crucial that they consult a doctor. A doctor can determine if a child is overweight by measuring height and weight and considering age and growth patterns (National Institute of Diabetes and Digestive and Kidney Diseases, 1998). Diagnosis by a doctor should not be dismissed as unimportant:

• A child may have a genetic or metabolic condition, or a disease which is causing weight gain.
• A child may already have consequences of weight that require treatment.
• Sometimes well-intended parents make inappropriate choices in terms of weight loss (e.g., overly restricting the child's diet; using adult medications, alternative medications, or herbals that are unendorsed and may cause harm). (Contributed by Dr. Sharon Robinson, Assistant Professor and Nutrition Specialist, Texas AgriLife Extension Service).

The simplest changes to prevent and treat children who are overweight include:

• Reducing dietary fat -- highly restrictive diets that forbid favorite foods are likely to fail. Highly restrictive diets should be limited to rare patients who must lose weight quickly and under strict supervision by a doctor.
• Becoming more physically active; creating an environment that encourages and supports physical activity.
• Parents modeling healthful eating and activity habits.

The Role of the Family

Parents play a crucial role in helping obese children feel normal, control weight and develop healthy habits to stay fit for life (Mayo Clinic, 2000b). Involving the entire family is also important so that an overweight child does not feel singled out.

Pediatricians, Philip Fischer, M.D., and Robert Jacobson, M.D., from the Mayo Clinic recommend the following six tips for parents of obese kids:

1. Be a role model. Pay attention to your own and your child's eating habits that may contribute to overeating; then, be the role model by setting a good example (e.g., don't order french fries, eat cookies, or spend hours in front of the television if you don't want your kids doing the same).
2. Make eating an activity in itself. Don't allow your kids to eat in the car, walking through the kitchen, or in front of the television or computer. Eating should be a significant and enjoyable activity where everyone sits down just to eat. Remember, the parent can help by setting the example.
3. Try not to 'love' with food. Try not to reward your kids with food. Try other ways of celebrating (e.g., spending time with them at the bowling alley, playing a game, or riding bicycles).
4. Limit television, video, and computer time. Don't allow your child to have a television in his/her bedroom. Limit time spent in front of the television, video games, or computer to no more than 1 to 2 hours a day.
5. Focus on positive goals. Try not to focus on "losing weight." Focus on positive goals, such as being able to ride a bike for 20 minutes or beating their best time walking a particular distance from the week before.
6. Take small steps as a family. Take it slow, making small subtle changes, such as fruit for dessert or parking further from the store and walking. Make sure you do this as a family, so that no one feels singled out or individually deprived. (Adapted from Mayo Clinic, 2000b.)

Self Management Education

All youth with type 2 diabetes should receive comprehensive self management education (American Diabetes Association, 2000). This education should include:

• how to test and record blood glucose
• referral to a dietitian to learn what to eat and when
• information on the importance of balancing caloric intake and physical activity
• how to recognize and treat low and high blood sugar levels
• how to take medications and store diabetic supplies, if indicated (American Diabetes Association, 2000; Lambert, 1999).

Helping youth to treat and manage type 2 diabetes, however, requires a different approach than that used for adults (Centers for Disease Control, 1999a). To help youth with type 2 diabetes, the following issues need addressing:

• Unstable glucose levels -- Teens tend to have unstable glucose levels and are challenged to comply with strict diabetic regimens.
• Rebellion -- Rebellion and denial are common among 12 and 13-year olds. It is normal for them to want to test the limits.
• Peer issues -- Youth want to "fit in" with their peers. They don't want to have to be singled out as having a disease that makes them different; they don't want to have to turn down foods in front of their friends, etc.
• Family and school involvement -- Both families and schools need to be involved in addressing problems among children with diabetes. Young people may not understand the consequences of type 2 diabetes, since neglect may not lead to immediate consequences. Families and schools can help to educate their children.
• Access to care -- Many of the most susceptible groups may be under-insured or uninsured. Additionally, issues of transportation and time spent at clinics and missed from school and work may be barriers to seeking care.
• Medication efficacy -- Many medications found to be safe among adults have not been tested for use in children. Thus standard dosages, safety, and efficacy of medications for children have not been confirmed in many cases (adapted from Centers for Disease Control, 1999a). One recent study, however, has shown that a drug known as metformin may complement diet and exercise to reduce risk of type 2 diabetes among selected patients (Freekmark, et. al., 2000).

Efforts Toward Changing the Trend

To change the trend of type 2 diabetes among our youth, it is essential that we educate them and help them to start and maintain healthy habits throughout their lives. These habits require that parents, families, schools, and communities work together to promote healthy eating habits and regular physical activity.

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References

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Acknowledgement
A note of thanks to Mickey Bielamowicz, Professor and Extension Nutrition Specialist, for her guidance on resources for this issue of the HealthHints Newsletter.

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Last updated: 7 January, 2008

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