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Type-II Diabetes 1

Running head: TYPE-II DIABETES AMONG CHILDREN

Clinical Symptoms Preceding Diagnosis with Type-II Diabetes among Children

Christina M. Leonard

Alverno College

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ABSTRACT

In this exploratory, quantitative study, the purpose will be to identify the clinical signs and symptoms of Type-II Diabetes in children, which preceded their diagnosis. The theoretical framework used in this study is the Theory of Unpleasant Symptoms.

Studying the clinical signs and symptoms related to the diagnosis of this disease in children will help nurses to educate and increase awareness among health care staff, school nurses and administration, and parents to be aware of the signs and symptoms of this disease. The results of the study will aid in early diagnosis and treatment, as well as reducing potential long term complications.

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TABLE OF CONTENTS

ABSTRACT……………………………………………….. Page 2

INTRODUCTON……………………………………………Page 4

Purpose of Study………………………………………. Page 5

Significance to Nursing……………………………….. Page 5

Statement of Research Question………………………. Page 6

Conceptual Framework………………………………... Page 6

Conceptual and Operational Definition of Terms …....... Page 6

Summary………………………………………………. Page 8

REVIEW OF LITERATURE……………………………… Page 7

Review of Key Concepts………………………………. Page 8

Background……………………………………………. Page 9

Measurement Tools……………………………………. Page 14

Hypotheses…………………………………………….. Page 14

Summary………………………………………………. Page 14

METHODS

Design…………………………………………………. Page 15

Sample and Setting……………………………………. Page 15

Protection of Right of Participants……………………. Page 16

Data Collection Procedures ………………………....... Page 16

Plan for Data Analysis……………………………….... Page 16

Data Collection Tools…………………………………. Page 15

Assumptions……………………………………………Page 19

Limitations……………………………………………. Page 19

Summary……………………………………………….Page 19

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Introduction

Type-II Diabetes is now a recognized epidemic among American children, and its incidence continues to increase. Type-II Diabetes used to occur mainly in adults who were overweight and ages 40 and older. However, as more children in the United States are overweight and inactive, Type-II Diabetes is occurring more often in young people. According to the National Diabetes Education Program, currently 10-15% of children and teens are overweight, which is double the number two decades ago – leading to an increasing number of young people with Type-II Diabetes (National Diabetes Education Program, 2007). According to the Centers for Disease Control and Prevention (CDC), overweight is defined as at or above the 95th percentile on the CDC’s Body Mass Index (BMI) for age growth charts (Center for Disease Control, 2007).

According to the National Diabetes Education Program, in Type-II Diabetes, either the body does not produce enough insulin or the cells ignore the insulin being produced. Insulin is necessary for the body to be able to use sugar. This is important to understand because sugar is the basic fuel for the cells in the body, and insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into cells, it can cause two problems: one, it can starve cells of energy, and two, over time high blood glucose levels may damage the eyes, kidneys, nerves and heart (National Diabetes Education Program, 2007).

The risk factors of Type-II Diabetes are being overweight, having family history of the disease, belonging to a member of a high risk ethnic group and being older than 10

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years old. Type-II Diabetes is a gradual onset of clinical manifestations. Common clinical manifestations, if present, include fatigue, increased thirst, nausea, and frequent

urinating, although some children may experience no clinical manifestations at all. If this disease is undiagnosed in children it may place these children at risk for cardiovascular disease and other significant complications.

The new epidemic of American children with Type-II Diabetes is important to study so that nurses are educated on awareness of this disease, diagnosis of the disease and prevention strategies/education. With research on this topic, new knowledge can be shared with not only other health care providers but school nurses and administrators, and parents as well. In the end, with this knowledge nurses will be able to lessen the number of children diagnosed with Type-II Diabetes.

Purpose of Study

In this exploratory, quantitative study, the purpose will be to identify the clinical signs and symptoms of Type-II Diabetes in children, which preceded their diagnosis. The main purpose of studying this research is to be able to recognize the clinical manifestations children experience before their diagnosis of Type-II diabetes. With this knowledge health care professionals, specifically nurses will better be detect and prevent Type-II diabetes, recognize the early onset of this disease, and effectively and promptly diagnosis it. Recognition of prodromal symptoms experienced by children will contribute to recognition at an early stage, thus reducing long term complications from Type-II diabetes.

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Significance to Nursing

Studying the clinical signs and symptoms related to the diagnosis of this disease in children will help us to educate and increase awareness among health care staff, school nurses and administration, and parents to be aware of the signs and symptoms of this disease. The results of the study will aid in early diagnosis, early treatment interventions and reduced risk of complications related to the diagnosis. The nurses’ role in this research is to become knowledgeable about this disease in children, to educate parents and children, and to raise awareness of this new health care epidemic.

Statement of Research Question

The scientific research question examined in this study was, “What are the clinical symptoms that children ages 8 to 14 exhibit six months to a year before they are diagnosed with Type-II Diabetes?”

Conceptual Framework

The conceptual framework for this research proposal is the Theory of Unpleasant Symptoms. According to Lenz, the three main components of the theory are the symptoms the client is experiencing, the influencing factors that give rise to the nature of the symptom, and the consequences of the symptom experience (Lenz, 1997). The three different factors influencing the symptoms according to this theory are the physiological, psychological and situational factors. In this theory, there are four factors that are contained within a symptom; they include distress, duration, intensity, and quality. All of the previous aspects of the theory of unpleasant symptoms, in the end, affect performance of the individual. This theory will be used to evaluate the results of the symptoms survey

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that the participants in this research will be asked to complete. It will shed light on the actual symptoms the child is experiencing, why the symptoms are occurring and what consequences result from their symptoms.

Conceptual and Operational Definition of Terms

The concepts related to the theoretical framework in this research proposal are symptoms, physiological factors, psychological factors, situational factors, duration, distress, intensity, quality, and performance. According to Hegyvary, symptoms are

defined as perceived indicators of change in normal functioning as experienced by patients (Hegyvary, 1993). Physiological factors are defined as normal systems,

pathogenic problems and energy substrate (Lenz, 1997). Psychological factors relate to mental state and reaction to illness (Lenz, 1997). Situational factors of this theory incorporate lifestyle and personal experiences (Lenz, 1997). According to Lenz, the four factors of a symptom are defined as follows: duration is defined as timing and frequency of symptoms; distress is degree of discomfortness or bothersomeness of the symptom; intensity is referred to as the severity, strength or amount of symptom be experienced; and quality is vocabulary used to describe symptom (Lenz, 1997). According to Lenz, performance is defined as physical activity, activities of daily living, social activities and role-related tasks (Lenz, 1997). The operational definition of symptoms are the participants responses about symptoms experienced and reported on the symptom survey data collection tool.

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Summary

The first section of this research proposal gives an introduction, familiarizing readers with the topic, the purpose of the study and its significance to nursing. The statement of the research proposal and the theoretical framework related to this research study were described. The Theory of Unpleasant Symptoms is described and the conceptual and operational definitions are provided. Finally there is a summary of the research proposal. In this quantitative study, prodromal signs and symptoms experienced by children who are eventually diagnosed with Type-II Diabetes are explored. The results of this research

give nurses information to educate health care staff, school nurses and administration, and parents about this disease. The goal of nursing care is diagnosing diabetes early in

these children so that they will have a better prognosis and get the appropriate treatment they need.

REVIEW OF LITERATURE

There are several key concepts to understand when studying Type-II Diabetes in children: According to the American Heart Association, diabetes mellitus is a disease in which the body doesn't produce or properly use insulin; insulin is a hormone produced in the pancreas, an organ near the stomach. Insulin is needed to turn sugar and other food into energy (Zietler, 2007, p. 1823). The Pancreas is a gland organ in the digestive and endocrine systems of vertebrates. Risk factors for this disease are: Acanthosis nigricans, hyperpigmenation and thickening of the skin into velvety irregular folds in the neck and flexural areas reflects chronic hyperinsulinemia (excess insulin in the blood) (Zietler, 2007, p. 172); hypertension, high blood pressure; dyslipidemia, increased fat in the blood

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(of often related to prolonged elevation of lipid (fat) levels). According to the American Diabetes Association, hyperglycemia is the technical term for high blood glucose (sugar). High blood glucose happens when the body has too little, or not enough, insulin or when the body can't use insulin properly (American Diabetic Association, 2007). Ketoacidosis is a type of metabolic acidosis which is caused by high concentrations of ketone bodies, formed by the deamination of amino acids, and the breakdown of fatty acids, it is a serious condition that can lead to diabetic coma (passing out for a long time) or even death (American Diabetic Association, 2007).

Background

“There is a new epidemic upon us,” says White, professor of pediatrics and of medicine at the School of Medicine and a pediatric endocrinologist at

St. Louis Children’s Hospital, affiliated with the School of Medicine; “Over the past decade, it has become apparent that type II diabetes, previously a disorder primarily of adults, is developing at an alarming rate in teenagers and preteens” (Medical Letter on the CDC & FDA, 2007). Diabetes Mellitus is a disease in which blood sugar is elevated. Type-II Diabetes is a disorder associated with the need for more insulin to regulate metabolism, however the pancreas is not able to produce the extra insulin the body needs. There are many long term complications associated with this disorder, if not properly diagnosed or medically managed, which are of concern, such as vision loss, kidney failure, nerve damage and blood vessel damage. These complications can then lead to blindness, kidney failure, heart attack, stroke and even amputation of extremities.

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According to Silvertein et al., “Type 2 diabetes accounts for 8 to 45 percent of new childhood diabetes.” “High-risk youths older than 10 years have a body mass index greater than the 85th percentile for age and sex plus two additional risk factors (i.e., family history, high-risk ethnicity, acanthosis nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia) (2007, p. 658).” According to Peterson, Silvertein, Kaufman, and Warren-Boulton, more than 13,000 youths are diagnosed with diabetes every year, making it one of the most common chronic childhood diseases in the United States (2007). This epidemic is due to the increased amount of youth being overweight and/or obese. “The national prevalence of overweight and obesity in school-

aged children (8-12 years) has nearly quadrupled in the last 25 years (Silvertein et al., 2007). According to Peterson, K, Silvertein, J, Kaufman, F., & Warren-Boulton, E (2007), approximately 30% of children (ages 6 to 11) are overweight/obese.

Obesity that begins in childhood may be more closely associated with severe obesity in adulthood than obesity that begins in adulthood (Chan, et al., 2005). Knowing this information early detection and treatment interventions directed towards young children who are overweight/obese is very important in preventing type II diabetes, as well as the complications of this disorder. Body mass index (BMI, [calculated as weight in kilograms divided by the square of height in meters]) is the most widely accepted method used to screen for obesity in children and adolescents because the measurements needed to calculate BMI are noninvasive (Singhal, et al., 2007). According to Singhal et al. (2007) body mass index is a reliable indicator if body fat content for most children and adolescents, it correlates well to direct measures of body fat (2007). Additionally, BMI

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has been found to correlate well with obesity-related complications (Singhal, et al., 2007).

Singhal et al., state that a fasting glucose greater than 100 mg/dl is considered prediabetic, and a level greater than or equal to 126 mg/dl is consistent with the diagnosis of diabetes (2007). Fasting serum triglyceride levels are often elevated in obesity and are considered an early sign of metabolic syndrome. Children with total triglyceride levels greater than 200 mg/dl should be followed up closely (Singhal, et al, 2007). This is the information that needs to be screened by health care professionals and talked to with the families of these children to initiate early interventional measures. It is also important to

talk to the families about weight loss, dietary management, physical activity and if needed, pharmacological therapy.

According to Zeitler, the mean age of adolescents with Type-II Diabetes has ranged from 13 to 14 years in various series, and though rare, children as young as 5 years of age have been reported (2007). Zietler goes on to state, in reported series, patients with Type-II Diabetes are almost always in puberty, the age of these children is sometimes surprisingly young because the age of onset of puberty among obese children may be earlier than among their peers (2007). Since puberty is characterized by relative insulin resistance, it is thought that puberty may promote the appearance of overt Type-II Diabetes in obese adolescents (Zietler, 2007). Also, according to Zeitler, girls are more susceptible to Type-II Diabetes than boys, with an overall female-to-male ratio of 1.7:1 regardless of race (Zietler, 2007). However since these ratios are based on studies from diabetes centers and not from population screening, the gender discrepancy nay result

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from a higher proportion of undiagnosed cases among boys caused by the lower frequency of medical visits among adolescent males compared to females (Zietler, 2007).

Adolescents with Type-II Diabetes generally come from families in which the parents are also obese and tend to have insulin resistance or overt Type-II Diabetes themselves (Zietler, 2007). According to Zietler, 60%-80% of patients have a family history of Type-II Diabetes in one first-degree relative (2007). About two-thirds of adolescents with Type-II Diabetes in reported series are African American or Mexican- American, respectively; the rest being white (Zietler, 2007). Published reports indicate, however, that overall, pediatric patients with Type-II Diabetes belong to all ethnic

groups- Hispanics, blacks, whites, Japanese, First Nation children of Canada, and Ashkenazi or Sephardic Jews (Zietler, 2007).

Type-II Diabetes is often asymptomatic early on and is thought to be underdiagnosed (Zietler, 2007). In general, patients with Type-II Diabetes more often present with signs of chronic hyperglycemia, while patients with Type-II Diabetes are more likely to present with acute metabolic decompensation (Zietler, 2007). However, the clinical presentation of Type-II Diabetes in youth can range from mild asymptomatic hyperglycemia to severe ketoacidosis (Zietler, 2007). About 20% of adolescents with Type-II Diabetes have polyuria (increased urination), polydispsia (increased thirst), and weight loss as their presenting complaints, clinical signs common to both Type-I Diabetes and Type-II Diabetes (Zietler, 2007). On the other hand, Type-II Diabetes patients are diagnosed by routine laboratory screening (usually urinalysis) as part of a school physical, rather than as a result of specific complaints (Zietler, 2007).

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According to Zietler, the possible long-term complications of this disease include diabetic ketoacidosis, hypertension, neuropathy, retinopathy, dyslipidaemia, non-alcoholic fatty liver disease, and cardiovascular disease (2007). Diabetic ketoacidosis is described as a diabetic coma, caused by dangerously high levels of ketones. Ketones are acids that build up in the blood. They appear in the urine when the body doesn't have enough insulin. Ketones can poison the body. They are a warning sign that diabetes is out of control or that the individual is getting sick. Treatment for ketoacidosis usually takes place in the hospital and is considered a medical emergency (American Diabetic Association, 2007).

In one study researchers found that 49% and 11% of young people with diabetes had systolic and diastolic blood pressures, respectively, greater than the 95% percentile for age, sex, and height at presentation. Hypertension is eight times as frequent in adolescents with type II diabetes (Zietler, 2007). Hypertension is also a risk factor for heart disease and cardiovascular complications are seen with Type-II Diabetes. According to Zietler, early signs of cardiovascular involvement are investigated by an echocardiogram and blood pressure measurements (2007). Adolescents with type II diabetes who underwent an echocardiogram up to three years after diagnosis showed posterior and septal wall thickness that were above the reference range in 47% of children (Zietler, 2007). Dyslipidaemia is high amount of lipids (fats) in the blood, which can also contribute to cardiovascular disease.

Neuropathy and retinopathy complications have not been reported to date on children with Type-II Diabetes. Non-alcoholic fatty liver disease, is now the most

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frequent case of chronic liver failure disorder in obese individuals (Zietler, 2007). There are also studies that show raised liver enzymes in young people (age 8-18) with type 2 diabetes (Zietler, 2007). With all of these potential long-term complications, the quality of life for the patient if this disease is not managed is poor.

Measurement Tool

Tools to measure for a diagnosis of Type-II Diabetes are a fasting glucose greater than or equal to 126 mg/dl, urinalysis, assessing signs and symptoms consistent with the disease, and/or body mass index evaluation. Much of this information is assumed through a history and physical of the patient.

Hypotheses

The main purpose of studying this research is to be able to recognize the clinical manifestations children experience before their diagnosis of Type-II diabetes. With this knowledge health care professionals, specifically nurses will better be detect and prevent Type-II diabetes, recognize the early onset of this disease, and effectively and promptly diagnosis it. Recognition of prodromal symptoms experienced by children will contribute to recognition at an early stage, thus reducing long term complications from Type-II diabetes.

Summary

Studying the clinical signs and symptoms related to the diagnosis of this disease in children will help to educate and increase awareness among health care staff, school administration, parents, as well as children to be aware of the signs and symptoms of this disease. These results will also enhance the screening process of this disease. Finally

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this study will aid in early diagnosis and treatment, as well as reducing potential long term complications.

METHODS

Design

The design of this research is an exploratory, quantitative study.

Sample and Setting

Children, ages 8 to 14, who have been diagnosed with Type-II Diabetes within the last six months to a year. This sample includes any race, or sex. The participating population will be volunteers from all of the public schools in the Midwest. The recruitment process will be two years. Parents will be asked to sign the following consent form in order to participate in the study.

Research Consent Form

Agreement to Participate in Research

Responsible Investigator- Christina Leonard, Alverno College Nursing Student

Title of Protocol- The purpose of this study will be to identify the clinical signs and symptoms of Type-II Diabetes in children which preceded their diagnosis.

We are recruiting children ages 8-14 years of age who have been diagnosed with Type-II Diabetes within the last six months. The outcomes for this study are to understand the signs and symptoms that occurred before the actual diagnosis of this disease,

If you agree to participate in this study we will simply ask that you fill out a signs and symptoms questionnaire containing eight questions. Your participation is voluntary and you may withdraw at any time and for any reason. The personal benefits for participating in this study are for the future early diagnosis and/or prevention of Type-II Diabetes among children. There are no costs to you or any other party.

All the data collected from the survey will be coded using a unique six-character string and will not be identified with you personally. There is no risk to you.

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If you have any questions or concerns about the study, you can contact Christina Leonard, ACNS, at 414-899-7648.

This signature indicates that you have been fully informed of your rights and voluntarily agree to participate in this study. You will be given a copy of this signed form.

By signing this form, I agree to participate in this study.

______________________________ _____________________

Parent’s Signature Date

Protection of Rights of Human Participants

Participants will volunteer to take part in this study and their parents must give permission for them to participate. There will be one consent form for the parent to give consent to participate in the study. The participants’ identity will remain anonymous and will be able to withdraw from the research at any time. All the data collected from the survey will be coded using a unique six-character string which will allow confidentiality of the participants.

Data Collection Procedures

Consenting participants will complete the signs and symptoms questionnaire. If children are not able to read the questions, an interviewer will read the questions to the participant. Parents will also be able to help the child with the questionnaire and clarifying the signs and symptoms.

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Plan for Data Analysis

After the participants complete the sign and symptoms questionnaire, they will be compared to gather common signs and symptoms experienced by children before their diagnosis of Type-II Diabetes. Signs and symptoms will be analyzed to find similarities and/or common presenting symptoms.

Data Collection Tools

Male _____ Female______ Age______ Race ______ Current Weight_____

1. Compared with other boys/girls, do you think you urinate:

|[pic]More often. |

|[pic]About the same. |

|[pic]Less often. |

|[pic]I don’t know. |

2. How often do you feel thirsty?

|[pic]Most of the time; sometimes it feels as if I can’t get enough to drink. |

|[pic]Often; probably more than most people do. |

|[pic]I rarely feel thirsty. |

|[pic]Occasionally, but probably no more than other people do. |

3. How would you say your appetite has changed at all? Have you started to eat more or less?

|[pic]I eat much more than I used to. |

|[pic]I probably eat about the same as I used to. |

|[pic]Sometimes, but not enough to really be disturbed by it. |

|[pic]Rarely. In fact, I can’t remember the last time I felt tingling. |

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6. Do you ever experience blurred vision?

|[pic]No, not that I can recall. |

|[pic]Sometimes, but it always seems explainable. |

|[pic]Yes, quite often, and I don’t know why. |

| |

|7. When you get a cut or scrape, how quickly does it heal? |

|[pic]It heals quickly. |

| |

|[pic]Fairly quickly, but it seems as if my cuts and scrapes take longer to heal than other people’s do. |

| |

|[pic]It tends to heal very slowly. |

| |

|8. How often do you experience urinary tract infections (UTIs)? |

|[pic]Frequently; it seems as though they keep coming back. |

| |

|[pic]Sometimes; probably about the same as most women. |

| |

|[pic]Rarely; I don’t get many, if any, UTIs. |

| |

|Patient specific signs and symptoms please list signs and symptoms you experienced which lead to your diagnosis. |

| |

| |

| |

| |

| |

| |

This survey was created by the Everyday Health website as a tool to diagnosis Type-II Diabetes or pre-diabetes.

Assumptions

The assumptions of this research will be that many of the children that have been diagnosed with this disease will have a lot of the same characteristics and presenting signs and symptoms.

Limitations

Limitations of this experiment could be lack of knowledge, lack of health care, and lack of participation in this research. Another limitation might be that children will

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not be able to describe or identify their signs and symptoms. The developmental age that the child is in could affect how they report their signs and symptoms as well.

Summary

In this exploratory, quantitative study, the purpose will be to identify the clinical signs and symptoms of Type-II Diabetes in children, which preceded their diagnosis.

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References

American Heart Association. Retrieved November 18, 2007, from

.

American Diabetic Association. Retrieved November 16, 2007, from

.

Chan, S.C., Lam, T.H., Salli, F., Leung, G.M., Wong, D.C., Botehlho, R.L., et al. (2005).

A Randomized Controlled Trial of an Individualized Motivational Intervention on

Smoking Cessation for Parents of Sick Children. A Pilot Study, Applied Nursing, 18, 178-181.

Everyday Health. Retrieved November 1, 2007, from .

Lenz, E., Pugh, L., Milligan, R., Gift, A., & Suppe, F. (1997). The Middle Range Theory

of Unpleasant Symptoms: An Update. [Electronic Version]. Advances in

Nursing Science, 19(3), 14-27. Retrieved October 31, 2007, from .

LoBiondo-Wood, G., & Haber, J. (2006). Nursing research: Methods and critical

appraisal for evidence-based practice (6th ed.). St. Louis: Mosby.

Medical Letter on the CDC & FDA. (2007). Obesity and Diabetes; Overweight Children,

An Emerging Epidemic. ProQuest Nursing & Allied Health Source, p. 12.

National Diabetes Education Program. Retrieved October 13, 2007, from

ndep..

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Peterson, K., Silverstein, F., Kaufman, F., and Warren-Boulton, E. (2007, September 1).

Management of Type 2 Diabetes in Youth: An Update [Electronic version].

American Family Physician, 76, 658, from ProQuest Nursing and Allied

Health.

Singhal, V. (2007, October). Evaluation and Management of Childhood and Adolescent

Obesity. Mayo Foundation for Medical Education and Research, 82(10), 1258-1264.

Zeitler, Phil, M.D., Ph.D. (2007, August). Type 2 Diabetes in Children and Adolescents:

Clinical Features. Pediatric Obesity Management, 10, 170-173.

Zeitler, Phil, (2007, June). Type 2 Diabetes in Children and Adolescents:

Diagnosis and Typology. Pediatric Obesity Management, 10, 125-127.

Zietler, Phil, (2007, May 26). Acute and Chronic Complications of Type 2 Diabetes

Mellitus in Children and Adolescents [Electronic version]. The Lancet, 369, 1823

1830, from ProQuest Nursing and Allied Health.

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