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Pediatrics - Diabetes, Type 2 

Introduction

Type 2 Diabetes, also called Adult Onset Diabetes, is the most common form of diabetes.  Diabetes is a disease that affects how the body uses glucose, a sugar that is a source of fuel.  Normally, insulin, a hormone, helps glucose get into the body cells where it is used for energy.  People with Type 2 Diabetes produce insulin, but they either do not produce enough or the insulin is not very effective in allowing glucose to get into the body's cells.  As a result, glucose remains in the bloodstream.  Too much sugar in the blood can make people ill and result in medical complications. 

While many cases of Type 2 Diabetes may be controlled, it remains the leading cause of diabetes related complications such as blindness, lower leg amputations, and chronic kidney failure.  There is no cure for diabetes.  People with diabetes need to diligently manage their disease to remain healthy and reduce the risk of medical complications.

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Anatomy
Your child’s body is composed of millions of cells.  The cells need energy to function.  One way the cells receive energy is from the food that your child eats.  Whenever your child eats or drinks, some of the food is broken down into glucose.  Glucose is a sugar that is released into your child’s blood.  It is a major source of energy for your child’s body cells.  Glucose is transported from your child’s bloodstream and into your child’s cells with the help of insulin.
 
Insulin is a hormone that is produced by the beta cells of the pancreas.  The pancreas is a gland located near the stomach that produces chemicals for food digestion.  Insulin regulates the amount of glucose in your child’s blood continually.  When your child eats, the amount of glucose in your child’s bloodstream rises.  In response to the elevated blood glucose level, your child’s beta cells produce insulin.  The insulin moves the glucose out of the bloodstream and into your child’s cells.  In turn, a lower level of glucose is left in the blood stream.  To prevent your child’s blood glucose level from getting too low, your child’s body signals him or her to eat.  This starts the process again so that your child’s body cells receive the exact energy that they need.

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Causes
Type 2 Diabetes occurs because the pancreas does not produce enough insulin or the body's cells become insulin resistant.  Insulin resistance is a condition in which the body does not recognize or respond to the insulin that is produced.  This results in elevated blood glucose levels because the glucose cannot get into the body cells for energy and remains in the bloodstream.
 
Type 2 Diabetes most frequently develops in people who are over 40 years old and overweight; however, it can occur in people who are not overweight.  Overweight children can also develop Type 2 Diabetes.  People with Type 2 Diabetes must manage their condition with weight control, diet, exercise, and medication.  They may use insulin or a medicine that helps their body make the most of their own insulin.
 
Before most people develop Type 2 Diabetes, they experience “Pre-Diabetes.”  Pre-Diabetes, also known as Impaired Glucose Tolerance or Impaired Fasting Glucose is a condition in which the blood glucose levels are elevated, but are not high enough to meet the criteria for Type 2 Diabetes.  A diagnosis of Pre-Diabetes means that a person is likely to develop diabetes and may already be experiencing adverse health effects.  Research shows that long-term damage to the heart and circulatory system may begin to occur during Pre-Diabetes.  People with Pre-Diabetes can delay or prevent Type 2 Diabetes if blood glucose levels are managed with nutrition and exercise during Pre-Diabetes. 

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Symptoms

Most people with Pre-Diabetes do not have any symptoms.  Symptoms of Pre-Diabetes include increased thirst, frequent urination, blurred vision, or extreme tiredness.  Type 2 Diabetes may or may not produce symptoms.  Many people with Type 2 Diabetes do not know that they have it.  In most cases, the symptoms develop gradually when blood sugar levels become high.
 
A common symptom of Type 2 Diabetes is frequent urination.  This happens as the body tries to remove excess blood sugar by passing it out of the body in urine.  In turn, your child may feel extremely thirsty and your child’s mouth may feel dry.  Because your child’s body is not getting energy from blood sugar, it signals him or her to eat a lot.  Your child may feel hungry even after he or she has just eaten.  However, even though your child is eating and drinking enough, your child may actually lose weight.  This is because your child’s body starts to use fat and muscle for fuel, when it cannot use the blood sugar.  Your child may feel tired and weak because his or her body cells cannot use glucose for energy.
 
Type 2 Diabetes can cause cuts or sores to heal slowly.  The skin in your child’s vaginal or groin area may feel itchy.  Your child may get frequent yeast infections.  The skin in your child’s neck, armpit, and groin may become dark and velvety; a condition called acanthosis nigricans.  Males may experience impotence or erectile dysfunction.  Type 2 Diabetes can cause a sudden weight gain.  Your child’s hands and feet may feel numb or tingle.  Additionally, your child’s vision may decrease.
 
Treatment for Type 2 Diabetes can prevent symptoms from happening.  However, even with treatment, some problems associated with Type 2 Diabetes may occur.  These conditions include hyperglycemia, ketoacidosis, hypoglycemia, and hyperosmolar hyperglycemic nonketotic syndrome. 

Hyperglycemia, also called high blood glucose, can lead to medical complications.  Hyperglycemia can occur for many reasons.  People with Type 2 Diabetes may experience it if their body is not using insulin effectively, if they ate more than planned and exercised less than planned, or were sick or stressed.

The warning signs and symptoms of hyperglycemia include high blood glucose levels, high levels of sugar in the urine, frequent urination, and increased thirst.  You should follow your doctor’s instructions for treating hyperglycemia as soon as you detect high blood sugar levels or ketones in your child’s urine—this is very important.  If you fail to do so, ketoacidosis could occur.  If there are ketones in your child’s urine, he or she should not exercise.  Exercising will only make the situation worse.

Ketoacidosis is a serious condition—it can lead to diabetic coma or death.  Ketoacidosis occurs rarely in people with Type 2 Diabetes.  Ketones are acids that accumulate in the blood when the body breaks down fats.  The body releases ketones through urine.  Ketones appear in urine when the body does not have enough insulin.  Ketoacidosis occurs when all of the ketones cannot be released through urine and the amount of ketones remaining in the blood becomes high enough to poison the body.  Ketoacidosis usually develops slowly, but when vomiting occurs, the condition can develop in just a few hours. 

The first symptoms of ketoacidosis include thirst, dry mouth, frequent urination, high blood glucose levels, and high levels of ketones in the urine.  These symptoms are followed by dry or flushed skin; continual tiredness; nausea, abdominal pain, or vomiting; difficulty breathing; impaired attention span or confusion; and fruity smelling breath.  If your child has any of the symptoms contact your doctor immediately; call emergency services, usually 911; or go to the nearest emergency room of a hospital.  Treatment for ketoacidosis usually involves a hospital stay. 

You can help prevent ketoacidosis by monitoring your child for warning signs and checking his or her urine and blood regularly.  Follow your doctor’s instructions if you detect high levels of ketones.  If your child has high levels of ketones, he or she should not exercise.  Exercise increases the levels of ketones. 

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a serious condition that most frequently occurs in older persons with Type 2 Diabetes.  An illness or infection usually brings on HHNS.  HHNS can cause severe dehydration and lead to seizures, coma, and death.

With HHNS, dehydration occurs as the body tries to remove excess blood sugar by passing it out of the body in urine.  Urination may be frequent at first, but then decrease.  Your child may become very thirsty.  Your child’s urine will become very dark.  It is important to drink plenty of liquids to remain hydrated.  Warning signs and symptoms of HHNS include a blood sugar level of over 600 mg/dl; a dry parched mouth; extreme thirst that may gradually disappear; warm dry skin that does not sweat; a high fever, over 101° Fahrenheit; sleepiness or confusion; vision loss; auditory or visual hallucinations, seeing or hearing things that are not there; and weakness on one side of the body.  Call your doctor immediately if your child experiences any of these symptoms. 

You can avoid HHNS by checking your child’s blood glucose levels regularly.  You need to check your child’s blood glucose levels more often when he or she is sick or has an infection.  You should work with your doctor and health care professionals to develop a monitoring plan for when your child is sick.

Hypoglycemia, also called low blood sugar or insulin reaction, is not always preventable.  Hypoglycemia can occur even if your child does everything that he or she can to manage diabetes.  Symptoms of hypoglycemia include shakiness, dizziness, sweating, hunger, headache, pale colored skin, sudden moodiness, clumsiness, seizure, poor attention span, confusion, and tingling sensations around the mouth. 

Check your child’s blood if you suspect that your child’s blood glucose level is low.  You should treat hypoglycemia immediately.  The quickest way to treat hypoglycemia is to raise your child’s blood sugar level with some form of sugar—glucose tablets, fruit juice, or hard candy.  Ask your doctor for a list of appropriate foods.  Once you have tested your child’s blood glucose level and treated your child’s hypoglycemia, repeat the process again until your child’s signs and symptoms have cleared. 

It is important to treat hypoglycemia immediately or your child could pass out.  If your child passes out, your child needs immediate treatment.  Your child should receive an injection of glucagon.  Glucagon is a medication that raises blood sugar.  You should tell those around your child, how and when to use it.  If glucagon is not available, your child needs emergency medical assistance.  Someone should take your child to the emergency room of a hospital or call emergency medical services, usually 911.  If your child passes out from hypoglycemia, you should not inject insulin or have your child consume food or fluids.

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Diagnosis
It is important to tell your doctor the symptoms that your child experiences.  Your doctor can diagnose Pre-Diabetes or Type 2 Diabetes by testing your child’s urine and blood. 
 
Your doctor will test your child’s urine for glucose and ketones.  Ketones are acids that accumulate in the blood and appear in urine when the body does not have enough insulin.  The tests are simple to conduct.  Test strips are simply placed in your child’s urine sample.  Your doctor will read the results after a short period of time.
 
Your doctor can determine if your child has diabetes or Pre-Diabetes by conducting blood glucose tests.  The Fasting Plasma Glucose Test (FPG) and the Oral Glucose Tolerance Test (OGTT) are commonly used.  The FPG measures blood glucose levels after your child has fasted or not eaten for a period of time.  The OGTT test measures blood glucose levels after fasting and again a few hours after your child drinks a high-glucose beverage.  The FPG and the OGTT test indicate your child’s blood glucose level for one time on a given day. 
 
Because blood glucose levels fluctuate from day to day, your doctor can also test how your child’s blood glucose levels have been over a period of three months.  To do so, your doctor will use an A1C test, also called glycated hemoglobin or HbA1c test.  The A1C test measures how much extra glucose has glycated or attached to your child’s red blood cells over the last 120 days, the lifespan of a red blood cell.

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Treatment
Treatment of Pre-Diabetes can return blood glucose levels back to normal and prevent or delay the onset of Type 2 Diabetes.  Treatment for Pre-Diabetes includes good nutrition, weight loss, and exercise.  Even a small amount of weight loss, 5-10% of the total body weight, can help.  Moderate exercise, such as walking, should be done for 30 minutes each day, five days per week.
 
Because people with Pre-Diabetes have an increased risk for heart disease or stroke, they should be screened and treated for high blood pressure and high cholesterol.  They should also quit smoking.  Not only can smoking raise blood glucose levels, but it can also contribute to heart disease, stroke, high blood pressure, and high cholesterol. 
 
There is no cure for Type 2 Diabetes, but it can be treated and managed.  Treatment can help stop the symptoms from happening.  Treatment may also prevent or delay the development of medical complications associated with diabetes.  Your doctor and health care team will teach you how to keep your child’s blood glucose levels as near to normal as possible with medication, nutrition, and exercise.
 
Purchasing diabetes care supplies can be confusing.  You should select the products that you are most comfortable with and that you will use.  The American Diabetes Association has an extensive list of diabetes care supplies in their Resource Guide.  The Resource Guide provides detailed information that allows you to compare the features of various products.  You should also talk to your health care professionals for product advice, demonstration, and trial.
 
You need to carefully follow your doctor’s instructions for monitoring your child’s blood glucose levels.  You will need to check your child’s blood glucose levels throughout the day.  To test your child’s blood glucose level, you will prick your child’s finger with a sharp needle or lancet.  Your child may test his or her own blood sugar when he or she is at an appropriate age.  Some newer monitoring devices allow a person to prick the forearm or other sites on the body, which may be less painful.  You will place a small amount of blood on a test strip.  A glucose monitor will display your child’s results. 
 
Blood glucose meters have advanced over the past 20 years.  They have become easier to use and there are many types to choose from.  Some meters are easier to use than others.  Most meters provide results in less than a minute.  Some of the newer meters display results in just five seconds.  “Talking” meters are helpful for people with visual impairments.  The talking meters provide verbal instructions and results.  Some of the units are available in Spanish and other languages.
 
You should take your time when deciding on a glucose meter.  You should select the one that you are the most comfortable with because you will be using it regularly.  When purchasing a blood glucose meter, you should check if your insurance company covers the meter and the care supplies, such as the test strips.  You should compare prices for items not covered by insurance. 
 
Your doctor will help you establish a schedule for checking your child’s blood glucose.  Make sure that you write down the time that you tested your child’s blood and the result.  Bring your logbook to each of your child’s doctor appointments.  It is recommended that you keep a written log even if your child’s glucose meter can store the results. 
 
Data management systems are an alternative for storing the results of your child’s glucose monitoring.  Data management systems are a convenience, but not a requirement.  You may keep your own records in a written log.  Some of the newer blood glucose meters have a built in data management system that can store the results of 500 blood glucose checks.  Data management systems vary.  They can record such variables as when you checked your child’s blood glucose, the type and dose of insulin used, and your child’s meals and exercise.
 
There are several things to consider if purchasing a data management system.  You should talk to your doctor to see if your unit is compatible with the doctor’s computer.  You should also ask your doctor what type of records he or she would like the data management system to track.  As always, try the equipment before you purchase it.  Data management systems can be expensive.

Additionally, some people with Type 2 Diabetes need to take medications to stimulate insulin production and to increase their body’s sensitivity to insulin.  There are many oral medications that are available and your doctor will discuss which may be best suited for your child.
 
Depending on the results of your child’s blood glucose test, or your child’s response to oral medications, you may need to inject your child with insulin.  The insulin will help lower your child’s blood glucose level.  Your doctor will let you know how much insulin to use.  It will depend on your child’s weight, what your child eats, and how active your child is.
 
There are different types of insulin that differ in onset, peak time, and duration.  Onset refers to how long it takes the insulin to reach the bloodstream and begin lowering the blood glucose level.  The peak time indicates when the insulin is at its maximum strength.  Insulin duration describes the length of time that the insulin works to lower blood glucose levels.  Some types of insulin may be used alone or with another type of insulin to be as effective as possible.  Additionally, there are new types of medications that enhance the way that insulin works.  Medications may require mixing or they may be purchased in a convenient premixed pen.  Ask your doctor about which medications are right for your child.
 
Before meal rapid-acting insulins should be injected 15 minutes before a meal.  These types of insulins work about 15 minutes after they are injected, peak in an hour, and continue to work for 2 to 4 hours.  Before meal rapid-acting insulins leave the bloodstream quickly and reduce the chance of hypoglycemia after meals.  After meal rapid-acting insulins are well-suited for children because it can be difficult to predict how many calories a child will eat prior to a meal.  After meal rapid-acting insulins are also useful for people with delayed stomach emptying.
 
Short or regular-acting insulins reach the bloodstream within 30 minutes after they are injected, peak in 2 to 3 hours, and continue to work for 3 to 6 hours.  Short acting insulin is often used with another type of insulin, intermediate-acting insulin.  Intermediate-acting insulins reach the bloodstream 2 to 4 hours after they are injected, peak 4 to 12 hours later, and continue to work for about 12 to 18 hours. 
 
Insulin can be administered in a variety of ways that are easy and relatively painless.  Insulin delivery methods include small needles, a pen, or a pump.  Needles are smaller than ever before and have special coatings that make injecting easy and nearly pain-free. 
 
An alternative to a syringe and needle is an insulin pen.  Insulin pens are convenient for active people or those with visual or coordination problems.  The pens contain accurate pre-measured doses of insulin.  The insulin is easy to deliver.  With the push of a button, a spring-loaded device quickly inserts the needle into your child’s skin and delivers the correct does of insulin.
 
An insulin pump is another type of insulin delivery method.  An insulin pump delivers insulin in a continuous steady dose and as a surge dose, at your direction, such as at mealtime.  The insulin is delivered in doses similar to the body’s normal release of insulin.  Some people find that this method helps to control their diabetes better.
 
An infuser may be used to reduce the number of daily injections.  An infuser or a portal is a catheter device that is placed into the skin.  Insulin injections are given into the infuser instead of the skin.  An infuser can remain in place for 48 to 72 hours.
 
Jet injectors deliver insulin without using needles.  Jet injectors force insulin through the skin with pressure.  In some cases, this method may cause bruising. 
 
The insulin pump is a small device that your child can wear on a belt or carry in a pocket.  Insulin travels through soft plastic tubes to a catheter that is placed in the skin.  Some insulin pumps allow the catheter to remain in place while only needles are removed.  The insulin pumps are computerized to deliver steady doses of insulin and surge doses, per your instructions.  You will need to check your child’s blood glucose levels more frequently than with other delivery methods.  However, many people prefer the pump because it allows them to have a more flexible lifestyle.  A new method of insulin delivery has recently been approved that allows people to spray insulin into their nostrils.  Ask your doctor if this is an appropriate treatment option for your child.
 
Every few months, you will need to have your doctor check your child’s blood glucose average with the A1C test.  The A1C test measures your child’s blood glucose level average for the course of about three months.  Your doctor will use this information to alter your child’s course of treatment, if necessary.
 
You will also need to test your child’s urine per the guidelines set by your doctor.  People with Type 2 Diabetes should test their urine for ketones when their blood glucose level is high.  Urine testing involves placing test strips in your urine sample and reading the results after a short period of time. 
 
Managing Type 2 Diabetes also includes a nutritional component.  Your doctor or a registered nutritionist can help you plan what your child should eat to help regulate his or her blood glucose levels, cholesterol, and blood pressure.  A balanced meal plan includes a wide variety of foods, particularly vegetables, whole grains, non-fat dairy products, beans, lean meats, poultry, and fish.  Your health care professional can help you learn to read nutrition labels, measure portion sizes, and plan balanced meals.
 
Exercise is another important element for managing Type 2 Diabetes.  Exercise may help to lower your child’s blood glucose level, blood pressure, and cholesterol.  It also may help your child’s body use insulin better.  Your child should strive for a combination of aerobic activity, strength training, and stretching.  Ideally your child should exercise aerobically for 30 minutes a day, five days per week.  Your child can break the time period into three ten minute segments throughout the day or exercise for the entire 30 minutes.  Aerobic exercise includes physical activities that work your heart, lungs, and vascular system, such as quick walking, riding a stationary bike, or running.
 
In addition to managing his or her blood sugar, eating smart, and exercising, your child should also maintain appropriate cholesterol and blood pressure levels.  It is also important for your child to not smoke.  Smoking increases blood sugar and can contribute to the development of medical complications.  It is important that your child take care of him or herself daily and keep all of his or her doctor appointments.  Type 2 Diabetes is a lifelong condition; however, people with Type 2 diabetes can live healthy, happy, and long lives with good care.

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Prevention
Pre-Diabetes can be treated and prevented.  Your child may even be able to return his or her blood glucose level to the normal range.  If your child is at risk for Pre-Diabetes or you suspect that your child has it, ask your doctor about the screening tests.  Getting diagnosed is the first step. 
 
People with Pre-Diabetes can prevent or delay the development of Type 2 Diabetes with treatment.  Treatment for Pre-Diabetes includes good nutrition, losing weight, and exercising.  Even a small amount of weight loss can help.  Moderate exercise, such as walking, should be done for 30 minutes each day, five days per week.  In some cases, medications may help delay the onset of diabetes.
 
Because people with Pre-Diabetes have an increased risk for heart disease or stroke, they should be screened and treated for high blood pressure and high cholesterol.  They should also quit smoking.  Not only can smoking raise blood glucose levels, but it can also contribute to heart disease, stroke, high blood pressure, and high cholesterol. 
 
Some doctors suggest that people at risk for Type 2 Diabetes should be screened at age 30.  If your child is at risk or experiences the symptoms of Type 2 Diabetes, you should contact your doctor to have your child tested.  Some factors such as heredity, ethnicity, and family history cannot be changed.  However, your child can change his or her lifestyle to help prevent or delay Type 2 Diabetes.
 
Generally, it is helpful for your child to reduce his or her weight, particularly visceral fat.  Visceral fat is located in the abdomen amongst the organs.  It appears to impair the way that insulin works and contributes to insulin resistance.  Ask your doctor to recommend diet changes, nutrition plans, and exercise programs that are right for your child.  Your doctor can also suggest ways to help your child lower his or her blood pressure, quit smoking, lower his or her cholesterol, and stop using alcohol and drugs.  Additionally, some medications can help to reduce the onset of Type 2 Diabetes, but it appears that they may work best when combined with weight loss and exercise. 
 
Your child should wear a MedicAlert bracelet and carry a MedicAlert card in his or her wallet.  In the case of an emergency, the MedicAlert information will be helpful to the healthcare professionals treating your child.  Because the medical complications associated with diabetes can be very serious and life threatening, people that develop Type 2 Diabetes need to diligently manage their disease to remain healthy.  The following are suggestions for preventing complications from diabetes.
 
Monitor your child’s blood glucose levels carefully, and treat your child with insulin daily, as instructed by your doctor.  Make sure that you write down the time that you tested your child’s blood and the result.  Take your child’s logbook to each of your appointments.  Have your child see a physician regularly to prevent and stay on top of any problems that might develop.
 
You should teach your child to eat a balanced diet and consult a nutrition expert if you need help with meal planning.  Your child should exercise regularly and reduce his or her weight if your child is overweight.  Even losing small amounts of weight is helpful for diabetes management.
 
Monitor your child’s blood pressure.  Ask your doctor what your child’s blood pressure should be, and contact your doctor when it is out of range.  Your child should also keep his or her cholesterol within normal limits, have regular cholesterol checks throughout the year, and follow your doctor’s instructions for lowering cholesterol. 
 
People with diabetes should have an eye exam at least once a year.  The eye examination should include screening for glaucoma, cataracts, and diabetic retinopathy. 
 
Attend all of your child’s scheduled medical appointments.  Your child’s feet should be inspected at every visit.  Discuss any concerns about depression with your doctor as well.

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Am I at Risk

Is My Child at Risk?


Risk factors may increase your child’s likelihood of developing Type 2 Diabetes.  People with all of the risk factors may never develop the disease; however, the chance of developing diabetes increases with the more risk factors your child has.  You should tell your doctor about your child’s risk factors and discuss your concerns.

Type 2 Diabetes was formerly called Adult Onset Diabetes.  However, it is occurring in people of younger ages as obesity rates increase.  Additionally, people of ethnic minority groups, including African Americans, Native Americans, Hispanics, Latinos, Asians, and Pacific Islanders, develop diabetes more frequently than Caucasians. 

Risk factors for Type 2 Diabetes include:

____ A family history of diabetes is associated with an increased chance of developing Type 2  
Diabetes.  If your child’s parents, brothers, or sisters have diabetes, your child’s risk increases. 
_____ Being overweight or obese and particularly carrying weight on the abdomen is a risk factor.  Obesity can promote insulin resistance and reduce the use of insulin.
____   People over the age of 45 have an increased risk because as people age, they are less able to process glucose appropriately.
_____ High blood pressure increases the risk of developing diabetes.  The mechanism is unclear, but it appears that the higher the blood pressure, the worse the insulin resistance.
_____ High cholesterol increases the risk of developing diabetes.  Insulin resistance is associated with low HDL levels or good cholesterol, and high triglyceride levels.
_____   Inactive people, people who do not exercise regularly, are at an increased risk for diabetes.  They may have higher blood sugar levels from lack of exercise.  Exercise helps to move glucose out of the bloodstream. 
____ Women who developed Gestational Diabetes during pregnancy or delivered a baby weighing over nine pounds have an increased risk of developing Type 2 Diabetes later on in life.
____ Women with Polycystic Ovary Syndrome (PCOS) have an increased risk because of irregular hormone production that can cause insulin resistance and Diabetes.

Many doctors believe in testing for Pre-Diabetes at age 30 for people with a family history of
diabetes or who are overweight.  Your child should be tested for Pre-diabetes if he or she has any of the risk factors for diabetes that are listed above or if your child previously had an abnormal glucose tolerance test or impaired fasting glucose level.

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Complications
Many people with diabetes can also have high cholesterol and high blood pressure.  These three factors combined—diabetes, high cholesterol, and high blood pressure, increase the risk of developing a variety of serious medical complications.  Some of the symptoms may be obvious, while others may be subtle and develop over time.  It is important that you monitor your child for signs and symptoms of medical complications and receive regular screening tests.  You should report your concerns to your doctor promptly.  The following paragraphs describe some of the medical complications associated with Type 2 Diabetes. 
 
Type 2 Diabetes is associated with an increased risk of heart disease and stroke.  Heart disease is the leading cause of death in the United States.  Coronary artery disease causes the vessels that carry blood to the heart to narrow.  They become completely or partially blocked by fatty deposits.  A heart attack occurs when the heart does not receive enough oxygen through the blood.  A stroke occurs when the brain does not receive enough oxygen through the blood.  A heart attack or stroke can be fatal.  They can also cause permanent or temporary disability.
 
Kidney Disease, also called Nephropathy, can also be caused by diabetes.  The kidneys remove waste products from the blood.  Diabetes can damage the filtering system of the kidneys resulting in kidney disease or kidney failure.  Persons with severe kidney failure may need dialysis, a process in which a machine filters the blood.  Some people may even need a kidney transplant.
 
People with diabetes have a higher risk of eye problems and blindness than people without diabetes.  A long history of diabetes and older age are factors associated with developing glaucoma.  Glaucoma occurs when pressure builds up in the eye and causes gradual vision loss. People with diabetes tend to develop cataracts at a younger age and at a quicker rate than people without diabetes.  Cataracts cause the clear lens in the eye to become cloudy, diminishing vision. 
 
Diabetic retinopathy can also be caused by diabetes.  The retina is the part of the eye that receives images.  Nonproliferative retinopathy is a condition that affects the capillaries in the retina.  Retinal swelling may result in vision loss.  In some people, retinopathy progresses to a more serious condition called proliferative retinopathy.  The blood vessel damage caused by proliferative retinopathy causes scarring and eventual retina detachment destroys vision.
 
Nerve damage caused by diabetes is called diabetic neuropathy.  Nerves carry messages between the brain and body about pain, temperature, and touch.  They also control muscle movements and organ systems, such as the processes for food digestion and urination.  Sensorimotor neuropathy and autonomic neuropathy are two common types of nerve damage.
 
Sensorimotor neuropathy affects sensation and movement.  It may cause the feet and hands to feel weak, tingly, numb, or painful.  Autonomic neuropathy affects the nerves that regulate involuntary functions or actions that your child cannot directly control, such as his or her heartbeat.  Of great concern, it can cause a loss of the typical warning signs of a heart attack or low blood glucose levels. Autonomic neuropathy can cause dizziness or faintness.  It can also create problems with digesting food; vomiting, diarrhea, or constipation; bladder function; sex; increased or decreased sweating; and changes in the way the eyes function in the dark or light.
 
The feet are very vulnerable to diabetes-related complications.  There are a variety of foot problems that can occur.  Foot problems are the leading reason for diabetes-related hospitalization.  Further, diabetes is the leading cause of lower leg and foot amputation.  Diabetes-related foot conditions are most frequently caused by poor blood circulation, infection, and nerve damage that can result in ulcers or sores, deformities, and trauma.
 
Diabetes can often lead to nerve damage called peripheral neuropathy.  Peripheral neuropathy is a condition in which nerve function deteriorates in the limbs.  This leads to a gradual loss of feeling in the hands, arms, legs, and feet.  This is often problematic because pain is what enables people to know when something is wrong.  Without pain, people may not realize that they have bruises, cuts, blisters or burns and therefore not seek medical treatment.  It is important that people with diabetes receive medical treatment for foot sores because diabetes-related circulation problems can lead to more medical complications.
 
Peripheral vascular disease is a common diabetes-related circulation disorder.  Poor circulation results in reduced blood flow to the limbs.  It can restrict the delivery of oxygen and nutrients that are required for normal wound maintenance and repair.  As a result, foot injuries, infections, and ulcers may heal slowly or poorly.  Minor skin problems on the feet can become worse and lead to infection.
 
Wounds and injuries can be difficult to heal if diabetes is uncontrolled.  This can be especially true of wounds in the feet.  Infections tend to get worse or remain undetected, especially in the presence of diabetic neuropathy or vascular disease.  Neuropathy can cause people to be unaware of wounds.  Additionally, the increased pressure from the feet carrying the body weight aggravates foot wounds.  Further, shoes can cause skin friction, rubbing, and tearing.  The hot moist environment of shoes is favorable to infection and foot ulcers.  Foot ulcers are sores caused by skin breakdown.  They can be exacerbated by infection.  Foot ulcers tend to develop over areas of high pressure, such as bony prominences or foot deformities.
 
Foot deformities are another common problem associated with diabetes.  They occur when the ligaments and muscles that stabilize the foot bones deteriorate.  This can cause the bones to shift out of position or an arch to collapse. 
 
A hammertoe deformity is a common condition that occurs most frequently in the second toe, although it can be present in more than one toe.  Increased pressure on the tips of the toes and the lack of muscle stability causes a joint in the toe to become permanently flexed with a claw-like appearance.  The toe deformity and pressure displacement makes the toe susceptible to skin ulcers.
 
Charcot foot is another common foot deformity associated with diabetic neurogenic arthropathy.  Neurogenic arthropathy is a progressive degenerative arthritis that results from nerve damage.  Charcot foot most frequently affects the metatarsal and tarsal bones located in the midfoot and forefoot.
 
Charcot foot causes the foot muscles, ligaments, and joints to degenerate or break down.  Without support, the foot becomes wider and deformed.  Without joint stability, the foot becomes unstable, making walking difficult.  Inflammation and pressure eventually can cause bone dislocation.  The arches in the foot collapse creating a rocker-bottom appearance. 
 
People with Charcot foot have impaired or absent abilities to feel pain, temperature, and trauma.  They may not be able to sense the position that their foot is in.  This makes them vulnerable to injury, such as fractures, sprains, joint dislocation, bone erosion, cartilage damage, and foot deformity.  They may even continue to walk on a broken bone without knowing it, because they cannot feel it.
 
People with diabetes are generally more prone to skin infections and skin disorders than people without diabetes.  People with diabetes have a greater tendency to get bacterial infections, fungal infections, and itchy skin.  Some skin problems happen mostly to or only to people with diabetes.  Such conditions include diabetic dermopathy, necrobiosis lipoidica diabeticorum, and atherosclerosis. 
 
Bacterial infections tend to manifest as styes on the eyelid, boils, infected hair follicles, deep infections under the skin, and nail infections.  Bacterial infections cause the skin to become hot, swollen, red, and painful.  Fungus infections are caused by yeast-like organisms.  They create itchy rashes in moist areas of the skin.  Common fungal infections include jock itch, athlete’s foot, ringworm, and vaginal infections.  Both bacterial infections and fungal infections can be treated with prescription medication.
 
Diabetic dermopathy and necrobiosis lipoidica diabeticorum (NLD) are similar skin disorders caused by changes in the blood vessels.  Both conditions cause brown spots to appear on the skin.  Diabetic dermopathy is harmless, but NLD can cause the skin to crack and bleed.  NLD is a rare condition affecting mostly adult women.  Open sores need to be treated by a doctor.
 
People with diabetes tend to get atherosclerosis at a younger age than people without diabetes.  Atherosclerosis causes the arteries to thicken, narrowing the route for blood flow.  It results in skin changes.  The skin becomes hairless, thin, cool, and shiny.  The toes become cold, and the toenails thicken and discolor.  Atherosclerosis can also cause wounds to heal slower or become infected because of lack of blood flow.
 
Another complication of Type 2 Diabetes can be gastroparesis, a stomach disorder in which the movement of food is slowed or stopped.  Gastroparesis occurs when high blood glucose levels damage the vagus nerve and the nerves that regulate stomach functioning over a period of time.  The muscles in the stomach and intestines stop working properly. Signs and symptoms of gastroparesis include heartburn, nausea, vomiting, feeling full early when eating, weight loss, bloating, erratic blood glucose levels, lack of appetite, reflux, and stomach spasms. 
 
If food stays in the stomach too long it can be dangerous.  Delayed stomach emptying can lead to bacterial overgrowth and stomach or intestinal obstructions.  Medications and nutritional changes can treat gastroparesis.  In severe cases, a feeding tube may need to be inserted to deliver nutrients to the small intestine. 
 
Finally, people with diabetes have a greater risk of depression than people without diabetes.  Depression is a real medical condition that can be treated.  Depression is not a “normal part” of every day life.  You should monitor your child for signs of depression.  Symptoms of depression include continually feel sad, irritable, tired, and uninterested in activities that your child used to find enjoyable.  Other common symptoms of depression include changes in appetite, having difficulty getting a good night’s sleep, moving the body at a much slower pace, and not being able to remember things or concentrate as easily as before.
 
Doctors are not exactly sure why people with diabetes are at risk for developing depression.  They suspect that people cope with diabetes management differently.  Additionally, some of the symptoms of low or high blood sugar can cause symptoms that look like depression.  You should discuss your concerns with your doctor so your child can receive appropriate diagnosis and treatment.

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Advancements
Prevention, technology, and research have greatly improved the management of diabetes.  Sugar-free foods, new types of insulin, and easy-to-use insulin delivery methods have made diabetes management more convenient.  The American Diabetes Association’s Resource Guide is a great resource for new products.  

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This information is intended for educational and informational purposes only. It should not be used in place of an individual consultation or examination or replace the advice of your health care professional and should not be relied upon to determine diagnosis or course of treatment.

The iHealthSpot patient education library was written collaboratively by the iHealthSpot editorial team which includes Senior Medical Authors Dr. Mary Car-Blanchard, OTD/OTR/L and Valerie K. Clark, and the following editorial advisors: Steve Meadows, MD, Ernie F. Soto, DDS, Ronald J. Glatzer, MD, Jonathan Rosenberg, MD, Christopher M. Nolte, MD, David Applebaum, MD, Jonathan M. Tarrash, MD, and Paula Soto, RN/BSN. This content complies with the HONcode standard for trustworthy health information. The library commenced development on September 1, 2005 with the latest update/addition on April 13th, 2016. For information on iHealthSpot’s other services including medical website design, visit www.iHealthSpot.com.