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Prevention, Diagnosis & Treatment of Type 2 Diabetes in Children
By Byron Cotton, John Parks and Alice Smith

Once a disease of older adults, Type 2 diabetes is increasingly being diagnosed in children and adolescents due, in part, to increased rates of childhood obesity. Some studies indicate that Type 2 diabetes is becoming more common among children and adolescents, particularly in African-Americans, Hispanic/Latinos and American Indians. In addition, more children are presenting with risk factors associated with Type 2 diabetes, including high blood pressure and high cholesterol.

Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency, resulting in high levels of glucose in the blood. If blood sugar levels are too high, damage can occur to many organs in the body leading to blindness, kidney disease, heart disease, amputations of lower-limbs and premature death.

Physicians at Children's Healthcare of Atlanta are working with parents and children to combat this disease before onset. However, not all cases are prevented in time, requiring accurate diagnosis and effective treatment to prevent further complications.

Prevention
One in four children who are overweight has insulin resistance and is at risk for developing Type 2 diabetes. Research has shown that lifestyle changes, including healthy eating and regular physical activity, decrease insulin resistance and reduce the risk of developing Type 2 diabetes. Awareness of the risk of diabetes, early testing for risk factors, and effective nutrition and exercise intervention programs can prevent or delay the development of Type 2 diabetes in children and teens.

Due to crowded schedules, parents are relying more and more on physicians to coach them about what their children need and how they can accomplish realistic nutrition and physical activity goals.

The Type 2 diabetes prevention program at Children's provides parents of at-risk children with advice to curb many behaviors associated with developing obesity, a primary risk factor. Families should limit time in front of the television, computer or video games to less than 2 hours a day. Families are advised to complete 15 minutes of physical activity together every day. Children should work up to at least one hour of vigorous physical activity every day and an additional hour of a fun activity.

Parents are also advised to reevaluate nutritional practices around the house. For example:
" Cut back gradually on fast food in favor of meals prepared at home.
" Offer healthy snacks like vegetables, fruits and foods low in sugar and salt.
" Plan meals and snacks in advance. It is easier to avoid making unhealthy choices if all of the decisions are already made. Remember that snacks are "mini-meals" and should be healthy and nutritious.
" Drink more water, low-fat milk or low-calorie drinks.
" Drink fewer sodas and sweet drinks, including juice.
" Strive for five servings daily of fruits and vegetables. Try to serve fruits or vegetables with each meal or snack.

Parents are also coached to remember that body size does not indicate fitness and health. Even thin and average weight children should be encouraged to exercise healthy choices. Above all, families should exercise patience when making diet and lifestyle changes. Major changes take time, but will benefit the entire family in the long run.

Diagnosis & Treatment

The American Diabetes Association suggests that overweight children be tested for diabetes every two years if two or more risk factors are present, including: family history of diabetes, patient belongs to certain minority groups (American Indian, African American, Hispanic American, Asian/South Pacific Islander) or have signs of insulin resistance, such as high blood pressure, high blood lipids, polycystic ovary disease in girls, or acanthosis nigricans, or dark, velvety textured skin at base of the neck, armpits and groin area. If the child is overweight it is appropriate to inquire about symptoms of Type 2 diabetes, such as history of fatigue, yeast infection and increased thirst and bathroom use, especially at night.

Symptoms of Type 2 diabetes occur gradually and may be mild, so they often go unnoticed. Blood glucose testing is needed to make a diagnosis, and should be done following an overnight fast. The child is considered to have diabetes if their glucose level is 126 mg/dl or higher. Levels between 100-125 mg/dl are classified as pre-diabetic. The blood test must be processed by a certified laboratory to make an accurate diagnosis. Fingerstick glucose meter tests are not reliable enough to establish a diagnosis.

Children with fasting blood glucose just above 126 mg/dl who are asymptomatic can be treated through a three month trial of family-focused lifestyle changes, including healthy eating and physical activity habits. Prior to the beginning of the lifestyle intervention program it is best to administer a Hemoglobin A1C test, which provides a three-month history of the child's blood sugar patterns. Following the intervention trial another Hemoglobin A1C test should be administered to determine any changes. The child should begin taking oral medications to regulate the disease if there is no improvement after three to six months of lifestyle modifications.

All children with diabetes, especially those recently diagnosed, need to be monitored on a monthly basis by checking weight gain/loss, fasting glucose levels and the status of other symptoms.

Children who are symptomatic upon diagnosis should be immediately placed on medicine and a family-focused lifestyle intervention program.

Byron Cotton, M.D., is a primary practice physician at Children's Healthcare of Atlanta. John Parks, M.D. is a pediatric endocrinologist at Children's Healthcare of Atlanta and Emory University School of Medicine. Alice Smith, MS, MBA, RD, is with the Type 2 diabetes prevention program at Children's Healthcare of Atlanta. For more information about Type 2 Diabetes prevention, diagnosis or treatment, visit www.choa.org or call 404-250-kids.

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