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Design Solutions for Young Diabetic Children

Introduction

Background

Diabetes has become one of the common chronic diseases in children and it affects a considerable number of children across the world. Management of the disease is quite an intricate, unique and inseparable combination of medical services from professionals and self care. Because of that kind of complexity, the presence of the disease among children is even more problematic. Parents, communities and medical service teams have to work in collaboration to offer information and train children so that they can actively participate in their own care and safety, especially at school.

Monitoring the trends of diabetes and its prevalence, symptom and implication among children is a very difficult task yet a very important one. The main issue of concern in schools especially for the collaborative effort to deal with the problem of diabetes is the number of children with the disease and also the type of diabetes that they have whether type 1 or type 2. Unfortunately, many countries are not able to offer such statistics because they do not have proper national reporting systems for diabetes in children1. Type 1 diabetes also referred to as the Insulin Dependent Diabetes Mellitus (IDDM) because of its nature and it also formerly reefed to as juvenile diabetes because of its prevalence in young children2. Type 1 diabetes comes about when the body’s immune system becomes self-destructive.

High blood glucose level that is characteristic of diabetes causes short and long-term implication to health and normal body function. It is however possible to delay possible complications of the disease of prevent them all together by use of proper management techniques3. Later sections of this report will provide a range of information useful in management of diabetes in children. The common short term implications include hypoglycemia and diabetic ketoacidosis while the long-term include retinopathy4, nephropathy, hypertension, dyslipidemia and neuropathy. It is very important that the children and their doctors discuss and understand the possible consequences of not managing diabetes and devise solutions to ensure adherence to insulin management.

Problem Statement

Children suffering from diabetes need to be provided with an ongoing integrated package of care that enhances self care, adherence and medical service. This should be done in order to optimize the efficiency of care and reduce the risk of developing complications; the care strategy should cater for aspects like proper training, education, mental health, diet, lifestyle and foot care5.

The Rationale

Diabetes has a characteristic symptom which is increased blood sugar or glucose. This paper seeks to develop solutions for young children to help them in management of diabetic in the safest way possible. Diabetes is a pure hormone deficiency medical condition especially for the case of type 1 diabetes which is also the most prevalent in children. Nonetheless, because of the hormone therapy and blood glucose monitoring have been suboptimal because of inconveniences of administration; the consequent acute and long-term complications are prevalent despite diet and lifestyle changes6.

Purpose of Study

This document is inspired in the light of an increased campaign to improve diabetes management services for children. Several nations and their national diabetes services frameworks emphasize on the significance of the specialist care required to ensure that diabetic children are always in their best possible health condition and live a quality life.

Research Questions

This report was inspired by the lack of complacency in the existing tools, gadgets and means of measuring and monitoring blood sugar. Many young people fail to comply with the required treatment methods because of inconveniencies. It’s in light of this that the following questions were devised to guide the study in seeking to establish a product that would motivate children to use. This would hence make then to actively take control of their health to get better results and prevent possible complications;

  1. What is the main cause of diabetes, how is it treated, or how is it managed?
  2. Why is it necessary to monitor blood sugar level in diabetics?
  3. What methods are currently used for monitoring blood sugar?
  4. describe is the compliance to this method like
  5. What is its efficiency in the management of diabetes?
  6. What are possible complications of diabetes, describe the quality of life of children suffering from diabetes?
  7. What future prospects in development of diabetes products and their anticipated impact on diabetes management in children?

Hypothesis

The current methods of diabetes treatment and management are not effective in use for preventing the damning implications of the disease because of poor compliance and observance. The demand for advanced solutions in measuring and monitoring blood glucose level has been increasing due to existing methods being ineffective and inconvenient.

Objectives of Study

There is an increasing gap between the available blood sugar tests and what users would actually want. This is the reason why projected emergence of functional and aesthetical designs that are non-invasive will greatly dominate the diabetes test machines or gadgets. The objectives of this paper were to establish a glucose level monitoring device that would be used by children. Dealing with problems of compliance in children is a major challenge in the treatment and management of diabetes7. This leads to the second objective which is to give children more control over their wellbeing, by allowing offering them easier to use and non invasive technologies to encourage compliance with monitoring process8. The new technology will give the children confidence in monitoring their glucose level and as a result there will be less cases of emergency intervention medication hence reducing the health costs.

Significance of Study

Considering that diabetes has been found to be a major risk factor in developing cardiovascular and other chronic complications like retinopathy leading to blindness9It is pertinent that diabetic children are educated on the importance of monitoring blood sugar levels. Education and training has been done in the past but the prevalence of diabetes in children is increasing very fast and hence the complications of the disease. Much of the problems have been attributed to the current methods being used for the process of testing or measuring blood sugar levels10. The available methods are mostly invasive and one can unequivocally see on the fingers of diabetic children prick marks made whenever their do the testing or inject insulin in the case of type 1 diabetes

Introduction of aesthetical, functional and non-invasive technologies of testing blood sugar will be a great revolution in the treatment and management of diabetes in children. The new design solution will likely encourage use by children because some researchers and designers intend or are already developing instruments that come with games just to attract children to use them. This means that the risk of developing complications will be greatly diminished, therefore such children will be saved from possible risk of amputations, stroke, heart disease and even kidney failure.

Literature Review

Introduction

While there have been improved methods of managing diabetes in children, there are equally increasing challenges in treating the condition in young people. Whereas children still rely on insulin and require a diet that is just the same as that of adults with diabetes, children have differences in terms of social, medical, physiological and emotional aspects. Just like adults suffering from diabetes, children have greater risk of developing complications and possibly life-threatening health situations11.

Research in the United Kingdom and the Scandinavian countries have confirmed that there is higher mortality rates among the children compared to all other age groups and to children without diabetes. The rate is as high as up to nine times more in the school going children age category. Additionally, long-term studies indicate that poor management of diabetes during the early years of life usually has a life-long influence on the future prognosis of the condition12. It is possible that early symptoms of diabetes complication disease comorbidity can be diagnosed among the children suffering from diabetes when better monitoring of the children is carried out. Undeniably, with disregard modern treatment alternatives, following 12 years of diagnosis over 50% of the children with diabetes experience complications related to the condition or are discovered to be having comorbid diseases13.

At the early stages of diagnosis of diabetes in children, there are the initial psychological implications on the family and the children’s lives. Such diagnosis could exacerbate pre-existing crises in the lives of these children. Poor initial adaptation to the condition is greatly influenced by how the family perceives the condition. Depression, anxiousness and low self-esteem develop among these children and they predict the psychological challenges to be encounters14.

The reaction of every family to the condition of their children often varies and so does the type of support to be offered. Some families could take the diagnosis in their hands and handle the new responsibility conscientiously. Nonetheless, there are known psychological risks that cause poor diabetes management, for instance, single-parenthood and major traumatic events in life for parents to bear. Some families could need help in addressing negative emotions like feeling shameful about the condition of their children or feeling guilty for not being able to prevent the disease or effectively manage it. Some families would require extra professional and even financial help. Support is supposed to be an ongoing process and age-appropriate15. It should have to progress and conform to the changing and increasing needs of the growing children.

Type 1 Diabetes

Studies in New York revealed that many children are increasingly suffering from diabetes. There are at least 7,842 diagnosed cases of this condition in children under 18 years. This is quite a large number for the city. Type 1 diabetic children experience the symptoms of the disease within a very short time and the onset can just emerge at any age16. However statistics have shown that most of the diagnoses are made during teenage and young adult age groups. It’s pertinent that families, medical practitioner and communities like schools will continue to work in collaboration about children with diabetes and their needs17.

The symptoms are not usually characteristic but they include frequent urination, blurred vision, increased hunger and thirst, weight loss, nausea, feeling of exhaustion, yeast infections and heavy breathing. When a child presenting symptoms of type 1 diabetes is not properly treated with insulin injections in a well-timed manner, the condition could precipitate into Diabetic Ketoacidosis (DKA) which is a life-threatening condition which can cause diabetic coma to the individual18.

Timely testing the blood glucose level is very important among the type 1 diabetic children because delays would cause the child to develop a combination of the abovementioned symptoms. It’s also necessary that diagnostic testing be conducted immediately by professional medical practitioners19. The symptoms can be termed nonspecific because they can be an indication of another disease hence mistaken diagnosis. However, to confirm diabetes, the doctor has to carry out blood glucose tests. They include:

  1. Fasting plasma Glucose test – the blood sugar of the patient is taken after he/she has gone without any food for a period of 8 hours.
  2. Random Plasma Glucose test- this test is also carried out to measure the patient’s blood sugar. However, it is not mandatory for the patient to have gone without food for at least the recommended 8 hours.
  3. Oral Glucose tolerance test – this is a glucose test that is done to measure glucose after an individual has fasted for 8 hours and then 2 hours after that individual has taken drink that contains glucose 20

A combination of blood glucose, taking foods with medium glucose (not very high or very low), insulin jabs, physical exercise and nutrition therapy are required for proper and attainment of best results21. The blood glucose monitoring tests depict the exact amount of glucose that is found in a person’s blood. The child’s physician can hence recommend the frequency that blood glucose tests should be done throughout the day, assist the families and the child to understand that normal levels of blood glucose are healthy and set a target to be achieved.

Children are required to constantly check their blood glucose levels so that there can be fast response to high or low levels. This has several advantages and some include having better control over the personal blood glucose hence reducing the chance of complications developing. Children are safer when blood glucose is monitored and there is very little time lost between checking the symptoms and confirmation of low glucose level and consequent search for treatment22.

Children become more independent in management of their health when the glucose meter is easy to use and available. When glucose monitoring is dealt with as a normal occurrence, the stigma attached to it fades away. Children also spent less time out of school to seek medication as monitoring is a more preventative measure.

Children have Diverse Needs

The needs of children suffering from diabetes change constantly as they grow up emotionally, physically and physiologically, the changes that come as they go through puberty, become mature and gain independence. It is important that blood glucose levels are monitored by measuring a number of times during the day. The child has to take his/her medication and be able to balance the effects of exercising and dieting. These activities have a great impact on the daily lives and the daily routines that these children would have to endure. Sleeping patterns are affected, those children with unpredictable activities during the day are affected and eating behaviors have to be changed as well.

Current Means of Managing Diabetes

Most of the currently used methods for testing glucose levels are invasive23. The general instructions for use are therefore as follows. Clean hands and insert the test strip in the glucose meter as the instruction permits. Once the blood is drawn, it is placed on the test strip and results recorded.

Blood glucose meters are commonly used and most of the time, younger children need assistance with the tests. These tests are simple and can be conducted even in school setting24. Every child has a right to be assisted to monitor glucose and anyone in a position to offer that kind of assistance should do so. The glucometer, otherwise called blood glucose monitor is the instrument of choice for use in monitoring blood glucose because of its availability and simplicity25.

There is also the continuous glucose monitoring system which is used in profiling blood glucose through 24 hours26. This system has a tiny glucose sensitive device that is inserted below the skin and it sends that information to a monitor usually worn around the waist. The reading is delivered after certain intervals (minutes) and the trends of glucose are tracked. Otherwise these readings could have been missed by other types of devices. Intervention strategies including dieting, exercising and insulin injections are done based on this information’s and the results of doing blood glucose test27.

Some systems are designed in a way that the alarm goes off when the glucose levels are lower or higher than normal to warn the patients to take necessary measures. Other systems can even predict the trend of glucose level and the patient is forewarned of taking action before that condition develops to risky limits. If the alarm is activated, the glucose level should be measured by use of the glucose monitor and proactive adjustments in the diabetes treatment regime made like insulin shot or taking food28.

School Environment

Children suffering from diabetes also have the right to education and therefore they should attend school without being discriminated against. They also have the right to take part in school activities and enjoy competent and quality care even when they are in school away from home. It is hence important that teachers and caregivers in schools should be well conversant with the issues around diabetes like myths and prejudices.

Following a phase of successful adaptation, children could develop complications related to diabetes in the long run. Their conditions often change as these individuals grow and this is similar for children’s attitudes and skills concerning diabetes and the management of the disease. The school age children need special consideration so as to help them deal with their condition even in schools29. If the school provides food, then the school menus should have choices that are relevant to the needs of these children. The school environment is very vital for the children’s long-term disease prognosis.

The law protects these children under disabilities act where schools are required to offer necessary and relevant services for the diabetic children and more importantly proper healthcare. These children need not to be offered substandard care when they attend school30. Every child with special health care needs must be able to access the needed services from school whenever needed.

Prospect Diabetic Products

Following some extensive market research, the investigator realized there was a gap in the blood test devices. As a result, there was great need of designing and developing better blood sugar test machines that could draw emotional attachment31.

The need for non-invasive devices for use especially for children is increasing. New technologies have been advanced to help solve this problem are yet to be launched32. The paper has also identified important ways of designing and diabetic products for administration of insulin and monitoring of blood sugar33.

The Diabetes Jewelry

These are non-invasive devices that could be launched soon because they are deemed to be more efficient and are non-invasive thus very convenient for use in children. Leah Heiss developed a number of jewelry that has nano-technology incorporated in their design to offer healthful benefits in diabetes monitoring and management34.

This is a new generation of non-invasive devices used for monitoring and administering insulin. These jewelleries come in various forms and the necklace and rings have been seen to be more common. These jewelleries transfer insulin into the body of a patient through a nano-patch attached to them35. The neckpiece for instance is designed to have a wearable applicator device instrument used for applying nanotechnology Victoria’s NanoMAPs to the skin of the patient. The NanoMAPs are very tiny, measured at 10x2mm round discs with minute pain-free needles on their surfaces.

This nanotechnology offers an insulin delivery method that is pain free and therefore a very apt replacement for syringes which are greatly feared by children because of pain and the prick marks they leave on the frequently punctured skin36.

The Biosign Technology

Of the new advances in non-invasive diabetes technologies, only Biosign has been approved for use in monitoring glucose levels of the patients of diabetes as well as their blood pressure. This technology works based on computer programs and software. This product is anticipated to get into the market in the near future37. Biosign has also been certified as a modern day glucose meter by medical agencies. The technology measures blood pressure from the wrist and this is used to estimate the blood glucose by use of advance computer program38.

The device is a portable electronic unit that reads the pulse rate from the wrist and the equipment is powered by a computer and controlled by Biosign web servers and assistance from the internet. The product is being commercialized for use basically as a home based instrument for self monitoring of glucose levels39. The hand is wrapped in a wrist cuff which is inflated; the wrist cuff then read the pulse nearly straight away and displays it on the monitor40. The web support and the program algorithms on the supporting servers carry out the relevant calculations and display the results on the monitor of the computer. The gadget is quite impressive as it performs more than glucose level measurement41. The new technology has a lot of potential in the future and the dream of designers and users will be realized when this is implemented and improvements made on it with time.

Research Methodology

Introduction

This thesis employed descriptive study techniques seeking to provide information that would be relevant in the design of new diabetic products. This is because the current invasive products are not convenient and effective for use in children42. The study sought to provide information that supports the need for better diabetic products. It was proposed that when by devising products with aesthetical value or games to the diabetic products of children, it would encourage emotional attachment and therefore better use of the products43.

Method and Design

This was a qualitative study and basically employed interviews, internet search and surveys. The investigator searched online websites for diabetes in youth. In the United States, there has been a program called the “SEARCH for Diabetes in Youth” which is essentially a site that has surveillance information on children with diabetes since the year 2000 up to date44. This site offered important information on diabetes across several centers in the country. These sites provide information that also helped to build literature review and direct the flow of the project.

The investigator visited schools to conduct focused group discussions and interviews with personnel that help student with diabetes learn to use glucose monitoring devises and insulin delivery devices. This helps children to cope well with their condition even in school. The interviews were targeted to the diabetic students and the supporting personnel. The questionnaires were the semi-structured type so as that the children could clearly understand and respond and also collect a lot of insights from them concerning the currently used devices and what they would love to have in future.

The internet search was conducted by use of key words typed in the search engines to find specific cases that address diabetes in children and the use of devices in monitoring and insulin delivery.

Participants

The sample studies were composed of 190 students suffering from diabetes but those who completed the study were only 140. These are the only ones who fully completed the interview questionnaires. The children were aged from 7 years to 12 years and were all using the current glucose monitoring meter and insulin delivery means. The younger participants required a lot of assistance and supervision from adults.

Data Collection

The investigator interviewed the participants and recorded their responses for further diabetes analyses. The researcher helped the younger participant fill the semi-structured questionnaires while the older children were able to complete them on their own. Only the fully completed questionnaires were collected for analysis. Some students failed to answer some questions for their own reasons. The investigator assured the participants that their information was safe as it was to be treated as confidential. Confidentiality was a factor for participation therefore to uphold this, only the investigator was to access personal information in the questionnaires.

Limitation

The possible limitations that could have affected the research were the choice of design and time of the research. There was likely to be a problem with the generalization of the study results. This is in view of the fact that the research covered a very large area of the country yet selected very few people to investigate.

Another possible limitation was the technical limitations leading to biased results. This type of limitation comes when the participants, especially children in this context, want to be seen as being more knowledgeable about their medical condition and also compliant with the standards of care. As a result, they anticipate what the investigator wants to hear and give their answers based on those grounds. They may also want to portray the current methods as being extremely inefficient because of their exaggerated fear of needles hence giving a false impression of the real situation.

Ethical Issues

The participation was voluntary and only those willing were allowed to take part. The doctrine of informed consent was respected to the latter with participants given full information about the benefits and risks of participation. For the younger participants, their parents were actively involved in this decision. The confidentiality principle was also assured, as the researcher assured the children that their information was to be only accessed by the investigator and that it would not be revealed to anyone else except for medical reasons to enhance the right to access medication. The anonymity concept was also upheld by not asking the names of the children and home addresses.

Results

Introduction

The research then settled on emotional design so that the users would eventually get attached to the device. Consequently, users would be able to check their health more often. The results show there is a market gap and people are yearning for advanced solutions to improve service delivery and involvement in personal health45.

Notable Interview Responses

Most of the children were very inconsistent in their blood glucose tests. Some disregarded it completely while others performed it irregularly as times they felt the symptoms having a toll on them46. However, doctors recommend that the blood glucose levels needed to be conducted as often as one could afford47. However, despite the types of problems one could face by not adhering to the recommendations, children failed to do their tests and injections. The main reason for failing to adhere to that was the pain of pricking or injection48. Some children showed their fingers which had lots of lancing holes and some of the injuries were bruising. Students reported that bruises came up even when they set the lowest level of the pen to poke their fingers.

Some children were greatly inconvenienced by having to check their blood glucose levels several times as they considered it time wasting and a nuisance49. Doing the pricks for over six times a day was quite problematic and the children wished that it would be better if there was a way to wear the monitor with strips. They also suggested that if the monitor was something like a necklace or a watch, if would be user friendly to use frequently.

Those with no alarm devices said they always forgot to do their test and were still terrified of the needles. Certainly non-invasive devices would lessen the fear, in fact, there will be no fear at all and these new technologies would save health and lives of many people who find invasive methods very excruciating and stressful5051.

Survey

Target Participants.
Chart 1: Target Participants.
Frequency of Using Blood Test.
Chart 2: Frequency of Using Blood Test.
Glucose Meter Is Efficient.
Chart 3: Glucose Meter Is Efficient.
Current vs New Technology.
Chart 4: Current vs New Technology.

Discussion

Introduction

The non-invasive glucose system has been the main inspiration into attainment of bloodless or no pricks method of assessing glucose level52. Over the past, the transdermal and optical approaches have been the commonest methods used53. However, lately, the GlucoWatch biographer has also found use in testing glucose levels. However, it suffered a serious blow on the market as it was not accepted widely because of some shortcomings like false alarm, sweaty, inaccuracy and irritant to the skin54. It was consequently withdrawn in 2008 for these adverse characteristics. Since then, efforts to have better non-invasive glucose testing devices and insulin administration have been aggressively sought. Unfortunately there has not been successful development of reliable non-invasive devices for use in children’s management of diabetes55.

Invasive Devices Inconvenience

Everyone that has used the invasive devices has an experience of these instruments and most of them are very nasty and unpleasant as sharp objects and blood are involved56. Before the home blood glucose test became common to most patients, a sharp piece of steel was the only tool available for lancing and it was very painful to use causing deep punctures on the fingertip57.

Through the years, there have emerged devices that are less invasive that are disposable and others reusable. Better improvement came with the introduction of laser-based devices though they were quite bulky and noisy hence did not gain wide acceptance58. Modern lancing devices have made further improvements and many are designed to allow adjustment of the needle to limit the penetration. The needles are also very small and shaper. Besides, practitioner have sites they recommend for less pain called the “alternate site testing” and they include drawing blood from the forearm, upper arm, on the thigh, and at the back of the hand59. However, even those who have tried these sites say that they sometimes hurt and cause bruises.

There is the natural dislike of sharp objects like needles even without pain and the growing social unacceptability of blood drops and blood stained strips and risk of blood-borne disease. This makes their use unacceptable.

Better Design

In the development of new solutions or the diabetic children, the glucose monitoring industry has developed the concept of attaining test at better cost, comfort and convenient use60. This is now referred to as the 3C’s, and the comfort or no pain advantage of the non-invasive technologies is understandable. Besides, the proposed new non-invasive methods do not make use of a test strip which is used each time a test is carried out and as a result, the cost advantage is enjoyed by the patient and the health insurance firms61. The cost of meters is seen to increase with better development of non-invasive approaches. The convenience benefit comes by looking at the time taken to perform a test, the visibility or obtrusiveness of the apparatus of the devices and whether they require visible blood droplets or not62. This factor is more subjective and depends on individual’s assessment or perception of testing in public, concerns about seeing blood or allowing people know their condition63.

Since the age group being considered in this paper is predominantly school going and therefore faces problems of inaccurate information handling. The non-medical staff in school may fail daily in making proper interpretation of symptoms and offering treatment. The outcomes would be unplanned for and dangerous consequences. This is a major safety concern for the children who need education and medical care service at all times. Evaluating the condition of these children cannot be taught in passing in short sessions.

Conclusion

Goal of the Study

The major objectives of the study were to devise devices that would be convenient to use in children with diabetes. To do this, the new devices were supposed to build the emotional and personal attachment with the user so that they can be able to make good use of these instruments64. Besides, the new devices would eliminate the frustration and need for isolation so as to be able to use the tools. Other feelings to be eliminated were the self conscious feeling like injecting in public or disinclination or dread of injection and blood65.

Sophisticated Devices

Currently, most of the tests require lancing or pricking to get blood droplet for use with the meter66. A number of non-invasive devices are being studied so that the designers and researchers can develop completely non-invasive devices. The idea behind these advances is that the new devices should be able to use other aspects technology like laser technology or infrared to provide measurement of blood glucose without necessarily having to puncture the skin67.

Blood glucose monitoring has been proven to be a very helpful means of managing blood sugar in diabetic children68. There has been notable improvement of the glucose biosensors over the past 50 years but there are still some crucial challenges that have hindered development of accurate and reliable glucose monitoring systems. This is what inspired further development needed in this report. There needs to be a standard to allow reliability and validity of the glucose tests so that even lay people or children can be able to use these devices without a problem69.

It is anticipated that the new technologies like biosign will be acceptable in the market among patients. These methods will be effective because of less time used in measuring glucose, convenience and comfort. Consequently, they would encourage faster correction of the blood glucose levels based on the regular measurements by the new devices.

Specific Treatment Needs

The main objective of diabetes management among children is to prevent or delay permanent complications by offering optimal management of glucose. This requires insulin therapy and this has to be compounded by flexibility and well-versed self-management strategies as crucial for the healthy development of children. As children approach puberty, the hormonal changes are affected by sickness and lifestyle and in turn they affect insulin levels. Children are forced to seek more restrictive regimes because there are no specialist practitioners at home or at school. Besides discrimination remains a crucial factor while some families face disproportionately high costs of medication.

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American Diabetes Association. ‘Care of Children and Adolescents with Type 1 Diabetes,’ Diabetes Care. 2005; 28:186-212

American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2007; 30:S42-S47.

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Biosign Technologies Inc. New Study Finds Blood Glucose Measurement by Biosign’s Non-Invasive Monitor Just like Lab Analysis, 2007. Web.

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Center for Disease Control and Prevention. CDC. (2000). National Diabetes Fact Sheet: Sheet: National and General Information On Diabetes In The United States. Atlanta, GA, CDC

Chiasson, J., et al ‘Diagnosis and Treatment of Diabetic Ketoacidosis and the Hyperglycaemic Hyperosmolar’. Can Med Ass J, 2003, 168 (7) 859-66

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Footnotes

  1. Centers for Disease Control and Prevention. CDC. (2000). National Diabetes Fact Sheet: Sheet: National and General Information On Diabetes In The United States. Atlanta, GA, CDC.
  2. National Diabetes Education Program. Overview of Diabetes in Children and Adolescents, 2007, Web.
  3. F. Cardella, ‘Insulin Therapy during Diabetic Ketoacidosis in Children’. ACTA Biomed, 76; Suppl. 3: 49-54.
  4. J. Chiasson, et al ‘Diagnosis and Treatment of Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar’. Can Med Ass J, 2003, 168 (7) 859-66.
  5. S.M. Virtanen et al. Changes in Food Habits in Families with a Newly Diagnosed Child with Type 1 Diabetes Mellitus. J Pediatric Endocrinol Metab 2001; 14: 627-36.
  6. SEARCH For Diabetes In Youth Study Group: Incidence Of Diabetes In Youth In The United States. JAMA 2007; 297 (24): 2716-2724.
  7. SEARCH For Diabetes In Youth Study Group: Incidence Of Diabetes In Youth In The United States. JAMA 2007; 297 (24): 2716-2724.
  8. SEARCH Study Group, op. cit., p. 1514.
  9. Cardella, op. cit., p. 52.
  10. SEARCH For Diabetes In Youth Study Group: Incidence Of Diabetes In Youth In The United States. JAMA 2007; 297 (24): 2716-2724.
  11. American Diabetes Association. ‘Care of Children and Adolescents with Type 1 Diabetes,’ Diabetes Care. 2005; 28:186-212.
  12. American Diabetes Association. ‘ibid. p. 86-212.
  13. American Diabetes Association. ‘ibid. p. 86-212.
  14. R. Hanas, Type 1 Diabetes in Children, Adolescents and Young Adults, 2nd Ed, Class Publishing; London, 2004.
  15. Hanas, ibid., p. 45.
  16. American Diabetes Association. ‘Care of Children and Adolescents with Type 1 Diabetes,’ Diabetes Care. 2005; 28:186-212.
  17. SEARCH Study Group, op. cit., p. 1516.
  18. Chiasson, et al, op. cit. p. 862.
  19. American Diabetes Association, op. cit., p. 193.
  20. Ibid., p. 19.
  21. American Diabetes Association, op. cit., p. 193.
  22. Ibid., p. 19.
  23. American Diabetes Association, op. cit., p. 194.
  24. F.R. Kaufman, op. cit., p. 739.
  25. ibid, p. 741.
  26. R. Hanas, op. cit., p.45.
  27. Ibid, p. 67.
  28. Virtanen, et al. Op. cit., p. 632.
  29. Ibid., p. 34.
  30. Ibid., p. 46.
  31. R. Hanas, Type 1 Diabetes in Children, Adolescents and Young Adults, 2nd Ed, Class Publishing; London, 2004.
  32. Centers for Disease Control and Prevention. CDC. (2000). National Diabetes Fact Sheet: Sheet: National and General Information On Diabetes In The United States. Atlanta, GA, CDC.
  33. Ibid., p. 78.
  34. L. Heiss, Diabetes and Arsenic Jewelry. Web.
  35. Ibid., para 2.
  36. Ibid., para 2.
  37. R. Leca. Biosign Certified for Non-Invasive Blood Glucose Monitoring, 2010, Biosign Technologies Inc. Web.
  38. Ibid, para. 3.
  39. Ibid., para. 3.
  40. Biosign Technologies Inc. New Study Finds Blood Glucose Measurement By Biosign’s Non-Invasive Monitor Just Like Lab Analysis, Web.
  41. Ibid. para. 3.
  42. Soltész, G., Patterson, C., & Dahlquist, G. ‘Global Trends in Childhood Type 1 Diabetes. In: International Diabetes Federation,’ Diabetes Atlas Third Edition.IDF. Brussels, 2006. pp 154-90.
  43. McElroy. Op. cit., p. 121.
  44. SEARCH Study Group. The Burden of Diabetes Mellitus among U.S. Youth: Prevalence Estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510-1518.
  45. G. Soltész. Diabetes in the Young: A Pediatric and Epidemiological Perspective. Diabetologia 2003; 46: 447-54.
  46. M.C. Eppens, et al. Prevalence Of Diabetes Complications In Adolescents With Type 2 Diabetes Compared With Type 1 Diabetes. Diabetes Care 2006; 29: 1300-6.
  47. Soltész, G. ibid., p. 449.
  48. J. Silverstein et al., ‘Care of Children and Adolescents with Type 1 Diabetes: A Statement of the American Diabetes Association,’ Diabetes Care, 2005; 28 (1):186–212.
  49. Ibid, p. 189.
  50. F. Snoek, & T. Skinner, (Eds). Psychology in Diabetes Care, John Wiley & Sons: New York. 2000.
  51. R. Hanas., K. Donaghue., G. Klingensmith., & P.G. Swift. ‘International Society for Pediatric and Adolescent Diabetes. ISPAD Clinical Practice Consensus Guidelines 2006-2007,’ Pediatric Diabetes 2006; 7: 341-2.
  52. M. Silink. Childhood Diabetes: A Global Perspective, Horm Res, 2002, 57 Suppl; 1-5.
  53. R. Singh., J. Shaw., & P. Zimmet. ‘Type 2 Diabetes in the Young. In: International Diabetes Federation,’ Diabetes Atlas Third Edition. IDF. Brussels, 2006, pp 193-207.
  54. M.S. Faulkner, ‘Quality Of Life for Adolescents with Type 1 Diabetes: Parental and Youth Perspectives’ Pediatr Nurs 2003; 29: 362-8.
  55. Ibid, p. 367.
  56. Silink. Op. cit., p. 3.
  57. Diabetes Prevention Program Research Group. Costs Associated With The Primary Prevention Of Type 2 Diabetes Mellitus In The Diabetes Prevention Program. Diabetes Care, 2003, Vol. 26 (1), 36-47.
  58. R. Singh., J. Shaw., & P. Zimmet. ‘op. cit., pp 193-207.
  59. Silink. Op. cit., p. 3.
  60. M. Lievre., et al., ‘On Behalf Of The Diabetes, Therapeutic Strategies And Complications (DISCO) Investigators. Cross-Sectional Study Of Care, Socio-Economic Status And Complications In Young French Patients With Type 1 Diabetes Mellitus,’ Diabetes Metab 2005; 312: 41-6.
  61. Lievre, et al., ibid. p. 44.
  62. Diabetes Prevention Program Research Group. Op. cit., p. 38.
  63. Lievre, et al., op. cit., p. 45.
  64. G. Alberti., et al. ‘The International Diabetes Federation Consensus Workshop. Type 2 Diabetes In The Young: The Evolving Epidemic,’ Diabetes Care 2004; 27: 1798-811.
  65. W.A Fisher., & H. Schachner, ‘Selfmonitoring of blood glucose in diabetic children and adolescentsbarriers, behaviors, and the search for solutions’ US Endocrinology. 2009; 4:2-5.
  66. Ibid., p. 4.
  67. S. Ehtisham et al. First UK Survey Of Pediatric Type 2 Diabetes And MODY. Arch Dis Child 2004; 89: 526-9.
  68. Ibid., p. 528.
  69. J. Hamilton., & D. Daneman. Deteriorating Diabetes Control During Adolescence: Physiological Or Psychological? J Pediatr Endocrinol Metab 2002; 15: 115-26.
  70. Diabetes Control and Complications Trial (DCTCP)/Epidemiology Of Diabetes Interventions And Complications (EDIC) Research Group, J Pediatr, 2001; 139(6):804–12.

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