March 2019 Issue

CPE Monthly: Special Considerations for Youth With Diabetes
By Kelly Ciovacco, MS, RD, LDN, CNSC
Today’s Dietitian
Vol. 21, No. 3, P. 44

CDR Suggested Learning Codes: 3020, 5070, 5080, 5190
CDR Suggested Performance Indicators: 4.1.2, 8.2.1, 8.3.6
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Diabetes is a rapidly growing chronic disease plaguing America’s health care system. As of 2015, 30.3 million Americans—9.4% of the population—had been diagnosed with diabetes.1 People of all ages can be affected by diabetes, but there are special considerations when diabetes affects children and youth. Whether children are diagnosed with type 1 or type 2 diabetes, nutrition professionals are essential to helping them and their families achieve healthful lifestyles. Individualized guidance provided by dietitians can lead to improved management of blood glucose levels and enhancement of emotional well-being.

This continuing education course examines current research on trends in diabetes among youth, including prevalence, incidence, and risk of comorbid conditions. The course aims to provide dietitians with the tools necessary to assess and monitor youth with diabetes throughout the stages of childhood.

Diabetes Trends in Children and Youth
Of the 30.3 million Americans affected by diabetes, 193,000 of those diagnosed cases are children and youth under the age of 20.1 Throughout the world, it’s estimated that 78,000 youth are diagnosed with type 1 diabetes each year.2 While the greater prevalence of diabetes in youth is primarily type 1, there’s a growing population of youth developing type 2 diabetes. The Centers for Disease Control and Prevention (CDC) report that of the 30.3 million Americans with diabetes as of 2015, 1.25 million youth and adults were diagnosed with type 1 diabetes.1 This statistic means the majority of diabetes cases is type 2, thus highlighting the significance of type 2 diabetes prevalence in the American population. Among youth, the concerning trend may be a result of several factors, including genetic risks, increases in overweight and obesity, increased time spent in a sedentary lifestyle, and consumption of excessive amounts of added sugars.3

Insulin resistance is the hallmark diagnostic feature of type 2 diabetes, which is expressed as children enter puberty.4 Significant increases in secretion of growth hormones during puberty lead to this insulin resistance, or hyperinsulinemia. As a result, the most prevalent age of onset of type 2 diabetes in youth is in the midpuberty stage.4 The effects of obesity on youth further compound the mechanism of insulin resistance seen in puberty. Obese youth are observed to demonstrate a 40% decrease in insulin-mediated glucose metabolism compared with nonobese youth.4 This is postulated to be related to the increased secretion of hormones such as leptin, adiponectin, and tumor-necrosis factor alpha by adipose tissue, all of which promote insulin resistance.4 As a result, several researchers and public health professionals theorize that interventions targeted at children and youth are the future of type 2 diabetes prevention.5

Current Research
The SEARCH for Diabetes in Youth (SEARCH) study is the largest ongoing cohort being investigated by researchers. Beginning in 2000, this study has followed cohort participants in five-year stages. Now entering its fourth phase, SEARCH continues to examine the incidence, prevalence, and outcomes—both acute and chronic—in youth diagnosed with diabetes.6 SEARCH includes both a registry and a cohort and is composed of youth diagnosed with diabetes before the age of 20 enrolled into the registry from multiple recruitment centers across the United States.7 Study design includes the measure of prevalence in 2001 and 2009 and the measure of incidence since 2002.7 According to data published in 2014, approximately 5.5 million youth under the age of 20—an estimated 6% of this population in the United States—are investigated annually as part of the SEARCH registry.7 The cohort portion of the study involves incident cases diagnosed in 2002–2006, 2008, and 2012.7 Those involved in the SEARCH cohort undergo an in-person baseline assessment and must hold a diabetes diagnosis for at least five years at the time of participation.7 The purpose of the cohort is to further examine diabetes-related outcomes, and more specifically, explore the differences in outcomes between type 1 and type 2 diabetes in youth.

Overall, this research has found increases in the incidence of type 1 and type 2 diabetes from 2002 to 2012 among all youth ages 10 to 19, especially in type 2 diabetes among the Hispanic and Native American ethnic groups.8 Between 2001 and 2009, type 1 diabetes in youth increased by 21.1%, while type 2 diabetes prevalence increased at a higher rate of 30.5%.7 Incidence of newly-diagnosed type 1 and type 2 diabetes also increased during this time.7

The SEARCH cohort has spawned several research publications, all of which examine the various outcomes associated with diabetes. There’s a growing concern among researchers that negative outcomes are associated with the increasing trend of type 2 diabetes in youth. Collectively, research shows that youth who develop type 2 diabetes in childhood or adolescence experience higher risk across all comorbidities, including kidney disease; retinopathy and peripheral neuropathy; as well as cardiovascular autonomic neuropathy, arterial stiffness, and hypertension.9

An observational study, conducted by Dabelea and colleagues between 2002 and 2015, assessed clinical outcomes among 2,018 individuals with type 1 compared with type 2 diabetes diagnosed before the age of 20.9 The most notable results from this study include the increased development of signs of kidney disease (19.9% with type 2 diabetes compared with 5.8% with type 1 diabetes); retinopathy (9.1% with type 1 diabetes compared with 5.6% with type 2 diabetes); peripheral neuropathy (17.7% with type 2 diabetes compared with 8.5% with type 1 diabetes); arterial stiffness, which is a risk factor for heart disease (47.4% with type 2 diabetes compared with 11.6% with type 1 diabetes); and hypertension (21.6% with type 2 diabetes compared with 10.1% with type 1 diabetes).9 After adjusting data to account for risk factor development over time, results showed significantly higher odds of developing diabetic kidney disease, retinopathy, and peripheral neuropathy with type 2 diabetes.9 Odds of prevalence of arterial stiffness and hypertension weren’t found to be significant. The primary objectives of this study were to compare outcomes in youth with type 1 vs type 2 diabetes, but the results show that comorbidity risk is increased among all youth with diabetes, regardless of type.9 These findings also raise concern about the long-term effects of diabetes diagnosed early in life. To decrease risk of developing comorbid conditions, researchers are emphasizing the importance of assessment and clinical monitoring of youth when they’re first diagnosed.

Diabetes Care Throughout the Stages of Childhood
The management of diabetes must be individualized for the age and life stage of the patient, as there are significant differences in estimated energy needs, learning styles, and levels of independence. The American Diabetes Association uses the terms “diabetes self-management education (DSME) and support (DSMS)” to describe how interventions from the multidisciplinary care team responsible for diabetes management must be continuously reassessed and monitored as life stages evolve.2 Clinical assessment for children and adolescents includes evaluation of anthropometrics, laboratory tests, blood glucose levels and insulin requirements, and behavioral monitoring (eg, nutrition knowledge, emotional response to diabetes, self-management ability).2 The goal of DSME and DSMS is to enable and empower youth with diabetes to take ownership of their self-care, which is accomplished by providing support and guidance to adopt healthful lifestyles throughout the life stages.

Considerations for School-Aged Children
It’s likely that parents will have complete control over the care of their children’s diabetes when they’re in the infancy and toddler phases. The first major life stage during which children’s understanding of their diabetes becomes paramount is school age. Children with diabetes are protected under Section 504 of the Rehabilitation Act of 1973, which federally prohibits discrimination due to disability.10 To be compliant with Section 504, school employees must be trained to identify hyper- and hypoglycemia and administer insulin or glucagon as appropriate. They also must be competent in providing additional support or supervision for students with diabetes so those students can fully participate in all school activities.10 This includes physical activity, field trips, and other organized school functions. In addition, students may require academic accommodations to account for sick days and necessary medical appointments.10 School administrators are encouraged to meet with parents before the school year to devise an appropriate plan that addresses all Section 504 regulations for the student.

Informing school personnel of special considerations that must be made for children with diabetes is a critical piece of the diabetes management puzzle. Children with diabetes must maintain a structured meal and snack schedule that aligns with the administration of insulin. They may require more snacks than other students; these snacks should be consumed around the same time each day. If the school doesn’t provide snacks, parents are responsible for ensuring that a morning and/or afternoon snack is sent to school with their children each day. If students need a school nurse to administer insulin, this may require an excuse during class time, which can be coordinated with teachers before the start of the school year. Special consideration should be made for periods of increased physical activity, such as gym class or recess, as well as days when the schedule changes (eg, field trips, test days, half days). The Joslin Diabetes Center provides numerous resources for parents and school professionals to engage in effective communication, including a prewritten letter to school personnel that parents can complete.11

Training for school personnel is multifaceted and covers topics such as blood glucose monitoring, insulin administration, and nutrition management.12 Learning the basics of carbohydrate counting can be beneficial for school employees to best serve their students with diabetes.12 The American Diabetes Association provides several training modules based on current nutrition guidelines. As addressed in these training materials, the practice of carbohydrate counting allows for flexibility in what foods students with diabetes can consume.12 Foods that were previously thought to be off limits may now be included as part of a balanced diet if appropriate insulin and carbohydrate count are considered.12 Some students may require direct monitoring when eating meals and snacks to ensure enough carbohydrates are being consumed compared with insulin administration, while other students may be completely independent.12 Understanding these principles may limit potential social isolation of students with diabetes compared with their peers and encourage students to make independent and balanced food choices without judgment.

Physical activity has a beneficial effect on the overall health and well-being of all youth, including those with diabetes. But increases in physical activity can affect the body’s glucose requirements, and, subsequently, the use of insulin to best control blood glucose levels. Studies have shown that exercise can improve physical fitness, insulin sensitivity, glycemic control, and lipid profiles in youth with type 1 diabetes.13 Despite the documented benefits of physical activity, those with type 1 diabetes often are less active and participate in less exercise compared with their counterparts without diabetes.13 There’s potential for fear to develop surrounding exercise-induced hypoglycemia, which can occur during, directly after, or even within hours following exercise when muscles are repleting glycogen levels.2 As a result, children may feel limited in their ability to engage in physical activity. They even may exhibit decreased levels of self-esteem regarding their perceived fitness levels.

The CDC recommends all children achieve 60 minutes of physical activity daily.14 Of those 60 minutes, at least three days per week should be dedicated to vigorous aerobic exercise. Furthermore, the CDC promotes both muscle-strengthening and bone-strengthening exercise at least three days per week.14 Children with diabetes are encouraged to follow these recommendations, but may require modifications to maintain consistent blood glucose levels. These considerations begin with education for the child, family, and third parties involved in the child’s physical activity regarding hypoglycemia prevention.2 Generally, a preexercise blood glucose level of at least 100 mg/dL is recommended; this may require adjustments to insulin administration with the meal or snack consumed before exercise.2 Reducing the insulin dose either with the meal consumed before exercise or even the night before can decrease the risk of hypoglycemia. Families also should be conscious of having an easily digested carbohydrate source available for children to consume during exercise as needed. It’s important for dietitians to assess the meal and snack schedules of children who are involved in physical activity to ensure that adequate carbohydrates are delivered to their bodies before, during, and following exercise.

Considerations for Adolescents and Teenagers
As children grow and mature, they also become increasingly independent, often seeking separation from the protective arms of their parents. During this life stage, it’s important for parents of youths with diabetes to allow exploration of independence while ensuring that they continue to practice healthful behaviors for blood sugar management. According to the American Diabetes Association, it’s recommended that parental involvement continues at a capacity that’s “developmentally appropriate” to prevent assigning sole responsibility of diabetes management to children before they’re ready.2 The adolescent phase of life is one of great emotional and behavioral adaptation, which poses challenges such as peer pressure, maintaining self-esteem, and avoiding disordered eating patterns. While these issues can affect all adolescents to some extent, they can become especially problematic for those with diabetes.

Ongoing monitoring of youth with diabetes includes psychological well-being, which is recommended to be assessed at least annually, with referrals to mental health professionals as needed.2 In recent years, there’s been an increased focus on addressing the psychological component of the diabetes diagnosis.15 Youth with diabetes not only have to come to terms with the medical diagnosis, but also must accept the lifestyle changes required. Researchers have questioned whether interventions focused on improving psychological well-being also can improve glycemic control. A meta-analysis of several studies examined the difference between standard therapy and the addition of a behavioral intervention on psychological well-being and effect on hemoglobin A1c (HbA1c) control.15 Behavioral interventions involved both peer and family support sessions aimed at improving coping behaviors among patients with diabetes. Overall, these trials resulted in general improvements to psychological well-being, including improved family interaction and relationships and less diabetes-related conflict. However, the majority of these studies didn’t see significant improvement in HbA1c or improvement couldn’t be sustained over time.15 Three studies included in the meta-analysis demonstrated marginal improvement in glycemic control when measured at six months to one year following the intervention.15 Despite the limited effect on HbA1c control, behavioral interventions that focus on family and peer support appear to have a positive effect on diabetes treatment.15

The investigation into risk of psychological difficulties in youth with diabetes stems from the understanding that youth with diabetes may feel that they’re different from their peers. While the exact level of increased risk of development of depression in diabetes is unclear, research is finding a significant link between diabetes and depression.16 Various studies have suggested that those with diabetes may have four times the risk of depression compared with those without diabetes.16 This is often a result of frustration or lack of control over management of blood glucose levels, which can lead to a stage of diabetes referred to as “diabetes burnout.”17 Many diabetes professionals accept this as a common stage in the course of diabetes and encourage open communication between families and community resources, such as social workers or school psychologists.17

Disordered eating also may arise at this life stage as adolescents are navigating through puberty and often becoming critical of their changing bodies. Women with type 1 diabetes are said to be at more than two times the risk of developing eating disorders compared with women of the same age without diabetes.18 An emerging disordered eating pattern specific to type 1 diabetes is called “diabulimia,” which involves manipulation of insulin administration to lose weight. By self-restricting insulin, glucose from food can’t be effectively delivered to the body’s cells; thus leading to persistently elevated blood glucose levels and weight loss due to severe limiting of caloric delivery. It’s important for families and health professionals to understand the warning signs of eating disorders in diabetes—elevated HbA1c levels, increased frequency of diabetic ketoacidosis (DKA), constant criticism of one’s body or appearance, changes in meal patterns, intense or constant exercise, and amenorrhea.18 While all eating disorders can have harmful and lasting effects on health, diabulimia must be taken into special consideration for the danger it poses to both short- and long-term well-being. Increased hospitalizations for DKA can place an emotional and financial burden on families, and the onset of diabetes comorbidities often is earlier and higher in the disordered eating population.18 Effective treatment of diabulimia in youth requires the addition of a mental health professional to the treatment team, and strategies for treatment are complex and ongoing.

Considerations for College-Aged Young Adults
For young adults moving away from home to attend college, it’s often the first time they’re faced with the responsibility of completely independent self-care. Both medical and emotional preparation for this transition is critical for successful outcomes. The first priority is establishing an accessible medical team; this depends on the distance students travel to attend college. Many students are most comfortable with continuing care via their home-based medical team, to which they have become accustomed over the course of their diabetes treatment. If distance is a barrier, it’s important to investigate the quality and accessibility of the campus health services department as well as local health and emergency services in the town or city where the college is located. Students need to know where their diabetes medication and supplies will be procured, as well as how they can quickly obtain them in the event of a shortage.19

While it’s the students’ prerogative to disclose their diabetes diagnoses, it at least must be shared with student health services, the students’ roommates, and their resident advisors.20 In the event of a hyper- or hypoglycemic episode, these parties should be informed regarding location of diabetes supplies and necessary steps to administer temporary treatment. The students and their family members are encouraged to educate campus personnel on the administration of antihypoglycemic agents, how to check blood glucose, and whom to contact in the case of emergency. All of this education can be effective in preventing a potentially dangerous situation.

Alcohol use also must be considered in the college-aged population. Students should understand the effects of alcohol on glucose levels to continue proper management of meals and insulin. Alcohol can lower blood sugar, causing an increased risk of hypoglycemia if alcohol isn’t consumed alongside food. Therefore, it’s recommended to consume a meal or snack containing carbohydrates in conjunction with alcohol.21 Students who require insulin and practice carbohydrate counting to determine their insulin doses should be advised to omit carbohydrates from alcohol in that count due to alcohol’s effect on lowering blood sugar.21 The exception is beverages that contain high amounts of sugar, such as mixed drinks. Recommendations for moderate consumption of alcohol are two drinks per day for men; and one drink per day for women. Counseling for college-aged youth involves setting realistic expectations regarding alcohol consumption, with emphasis on ensuring safety.

Supporting Youth With Diabetes
The management of diabetes throughout the lifespan is most effective with a multidisciplinary care team approach, and dietitians are an integral part of that team. Just as diabetes management must evolve through all life stages, so must the counseling style of the dietitian. Motivational interviewing, a technique that focuses on fostering the patients’ motivation for behavior change in a nonconfrontational and supportive way, can be very effective.22 Patients are empowered to make lifestyle changes without feeling condescended to or judged.22 Motivational interviewing encourages patients to develop their own goals, which, in the case of diabetes, can build confidence for self-reliant treatment.

It’s important to understand the treatment goals when counseling children and youth with diabetes, as these parameters may differ from those of the adult population. For example, the American Diabetes Association sets the HbA1c goal level for adults as less than 7%; however, that laboratory value across all pediatric groups is now recommended to be less than 7.5%.2 Target blood glucose levels should be individualized to each patient’s care plan with the purpose of achieving consistency and avoiding frequent episodes of hypoglycemia or hyperglycemia. Medications used to manage diabetes include insulin and several oral agents, but only insulin and Metformin are approved for use in youth under the age of 18.4 Metformin is considered to be the most appropriate form of treatment for youth with type 2 diabetes, and its effectiveness has been validated through clinical studies.4

Once a treatment plan has been established, including appropriate medication and goal blood glucose levels, frequent monitoring and clinical evaluation should be implemented to ensure success. Loss to follow-up is unfortunately a prevalent occurrence in the health care field and is especially observed as patients grow from children to young adults.2 As counselors, dietitians who can establish a positive rapport with patients and their families may be able to minimize this loss to follow-up and retain their patients. Establishing a positive rapport includes building trust, introducing open communication, and establishing a nonjudgmental environment.

Dietitians involved in the care of school-aged children can help to ensure their success at school by assisting with the development of meal and snack ideas that promote glycemic control. Pairing carbohydrates with protein, as well as choosing healthful carbohydrates that contain fiber, can delay digestion and absorption of glucose. This not only promotes longer-lasting energy for students, but also improves insulin response. At this life stage, the exploration and trial of new foods often is a challenge. Dietitians can help children embrace consumption of healthful carbohydrates and lean protein sources for overall health and diabetes management. Techniques such as food chaining can be effective in guiding picky eaters to broaden the variety of foods consumed.23 Food chaining involves the slow introduction of new foods in a nonthreatening way, utilizing creativity and foods that the child already enjoys.23 For example, a child who already eats applesauce can be introduced to whole apples in a stepwise fashion that eliminates the “neophobia” associated with the new food. Touching an apple slice, then kissing or licking it, then trying applesauce with small chopped pieces of apple allows the child to explore the new food with decreased anxiety. By introducing nutrient-dense foods to a child’s diet, there’s likely to be less reliance on processed foods, which often are made with refined carbohydrates and added sugars.

Especially in the early childhood stage, family involvement is paramount to modeling healthful behavior.24 If the child is encouraged to follow a specific meal schedule to control diabetes, all family members would benefit from a similar eating pattern to ensure the child doesn’t feel excluded. Limiting foods containing high amounts of added sugars is recommended for all children, and the entire family can adopt this behavior. In addition, it’s beneficial to provide education to siblings and extended family members regarding the diabetes diagnosis and how it affects the body. Allow family members to attend counseling appointments and provide opportunities for role-playing or visual learning, which can be effective tools for educating family members of all ages.

As children enter the adolescent stage, dietitians should take notice to shift the direction of their recommendations from the parent to the child directly. An effective dietitian can help patients build confidence in their ability to manage diabetes independently, with the knowledge that there are support systems in place to offer guidance. Adolescents and teenagers may be more comfortable attending counseling appointments without their parents present, as topics such as dating, sexual activity, and alcohol may arise.2 Dietitians can guide their recommendations with emphasis on topics relevant to teenagers at their current life stage; for example, how diabetes can be managed for peak sports performance. Elaborating on topics such as long-term side effects of uncontrolled diabetes wouldn’t be relevant to the teenager. Instead, discuss diabetes management in terms of academic and sports performance as well as how diabetes can affect the body. Internet resources, such as blogs or social media accounts, can be most effective for this population. Dietitians can provide an e-mail or text contact if teenagers are more comfortable reaching out with questions in this manner. Overall, dietitians help ensure that patients retain their diabetes management goals at a time in the lifespan when there’s frequent loss to follow-up.

Once patients have transitioned to young adulthood, dietitians remain integral to the treatment team, but their involvement continues to change and progress. College-aged patients may seldom attend appointments at a clinic, in which case e-mail, text, or phone contact may be the primary form of communication between them and the dietitian. Even periodic communication can be beneficial, as new challenges to blood glucose management can be addressed as they arise. Maintaining adequate glycemic control in young adulthood can decrease risk of long-term complications; therefore, ongoing nutrition education remains important at this life stage.2

Nutrition professionals are crucial elements of the treatment team charged with ensuring adequate management of diabetes throughout the lifespan. Special considerations and adaptations must be made for children, especially as they grow and advance through each life stage. Treatment goals and counseling techniques should be continuously reevaluated and adjusted as appropriate to ensure a continuum of care.

— Kelly Ciovacco, MS, RD, LDN, CNSC, is an outpatient and consulting dietitian based in Hingham, Massachusetts, specializing in pediatric and sports nutrition.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Evaluate the growing trends of diabetes among youth.
2. Discuss federal laws to support the education of children with diabetes in schools.
3. Identify potential dangerous behaviors that result from mismanagement of diabetes in teens and adolescents.
4. Assess goals for diabetes management as they evolve throughout the stages of childhood.
5. Develop counseling skills targeted to youth with diabetes and their families.

CPE Monthly Examination
1. What is the recommended hemoglobin A1c goal across all pediatric groups?
a. Less than 6%
b. Less than 7%
c. Less than 7.5%
d. Less than 9%

2. What’s required of school employees to be compliant with Section 504 of the Rehabilitation Act of 1973 with regard to children with diabetes?
a. Be able to provide psychological counseling
b. Be able to identify symptoms of hypo- and hyperglycemia
c. Be able to excuse children with diabetes from physical activity
d. Be able to send children home from school if they need insulin

3. Which is the only oral hypoglycemic agent approved for use in children younger than 18?
a. Glipizide
b. Januvia
c. Metformin
d. Glyburide

4. What are the acronyms associated with ongoing diabetes management education and treatment that’s continuously reassessed throughout the life stages?
a. DSME and DSMS
b. DES and DYEM
c. DCAE and DMEC
d. DSEM and DSCY

5. What’s considered the safe preexercise blood glucose level for children?
a. At least 95 mg/dL
b. At least 100 mg/dL
c. At least 120 mg/dL
d. At least 130 mg/dL

6. What’s one hormone secreted by adipose tissue that increases insulin resistance in obese adolescents?
a. Ghrelin
b. Cortisol
c. Leptin
d. Gastrin

7. What’s an eating disorder involving manipulation of insulin as a method to lose weight?
a. Anorexia of diabetes
b. Diabulimia
c. Diabetic disordered eating
d. Restrictive diabetes

8. An effective way for dietitians to counsel adolescents with diabetes is to do which of the following?
a. Communicate their expert opinions regarding blood glucose control.
b. Shift all communication to online platforms such as blogs, e-mail, and social media.
c. Teach them about long-term side effects of uncontrolled diabetes, such as kidney disease and retinopathy.
d. Encourage them to set their own goals to achieve independent management of their diabetes.

9. What’s the term to describe frustration and depression with diabetes?
a. Diabetes burnout
b. Diabetes exhaustion
c. Postdiabetic depression
d. Diabetes dejection

10. Which person at a college should be aware of a student’s diabetes diagnosis?
a. Dean of admissions
b. Professor
c. Resident advisor
d. Dining services director

References
1. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Published July 19, 2017. Accessed August 12, 2017.

2. Chiang JL, Kirkman MS, Laffel LM, Peters AL; Type 1 Diabetes Sourcebook Authors. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care. 2014;37(7):2034-2054.

3. Wilmot E, Idris I. Early onset type 2 diabetes: risk factors, clinical impact and management. Ther Adv Chron Dis. 2014;5(6):234-244.

4. Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J Diabetes. 2013;4(6):270-281.

5. Gregg EW. Are children the future of type 2 diabetes prevention? N Engl J Med. 2010;362(6):548-550.

6. SEARCH 4 protocol: summary of changes. https://www.searchfordiabetes.org/docs/SEARCH_Phase_4_Protocol.pdf. Updated February 11, 2016. Accessed February 18, 2018.

7. Hamman RF, Bell RA, Dabelea D, et al. The SEARCH for diabetes in youth study: rationale, findings, and future directions. Diabetes Care. 2014;37(12):3336-3344.

8. Gregg EW. The changing tides of the type 2 diabetes epidemic — smooth sailing or troubled waters ahead? Kelly West Award lecture 2016. Diabetes Care. 2017;40(10):1289-1297.

9. Dabelea D, Stafford JM, Mayer-Davis EJ. Association of type 1 diabetes vs type 2 diabetes diagnosed during childhood and adolescence with complications during teenage years and young adulthood. JAMA. 2017;317(8):825-835.

10. Section 504 of the Rehabilitation Act of 1973. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/legal-protections/section-504.html. Published August 17, 2016. Accessed September 23, 2017.

11. Diabetes information for school personnel. Joslin Diabetes Center website. http://www.joslin.org/docs/Diabetes_Information_for_School_Personnel.pdf. Published 2007. Accessed September 23, 2017.

12. Diabetes care tasks at school: what key personnel need to know. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/school-staff-trainings/diabetes-care-tasks.html. Updated May 15, 2018. Accessed July 23, 2018.

13. Leclair E, de Kerdanet M, Riddell M, Heyman E. Type 1 diabetes and physical activity in children and adolescents. J Diabetes Metab. 2013;S10:004.

14. Youth physical activity guidelines toolkit. Centers for Disease Control and Prevention website. https://www.cdc.gov/healthyschools/physicalactivity/guidelines.htm. Published June 28, 2017. Accessed September 30, 2017.

15. Harvey JN. Psychosocial interventions for the diabetic patient. Diabetes Metab Syndr Obes. 2015;8:29-43.

16. Are depression and diabetes linked? Joslin Diabetes Center website. https://www.joslin.org/info/are_depression_and_diabetes_linked.html. Published 2017. Accessed September 23, 2017.

17. Understanding your child’s feelings about diabetes. Joslin Diabetes Center website. http://www.joslin.org/info/understanding_your_childs_feelings_about_diabetes.html. Published 2017. Accessed September 16, 2017.

18. Eating disorders/“diabulimia” in type 1 diabetes. Joslin Diabetes Center website. http://www.joslin.org/info/Eating_Disorders_Diabulimia_in_Type_1_Diabetes.html. Published 2017. Accessed September 23, 2017.

19. College-bound: preparing to take your diabetes away from home. Joslin Diabetes Center website. http://www.joslin.org/info/college_bound_preparing_to_take_your_diabetes_away_from_home.html. Published 2017. Accessed August 12, 2017.

20. College-bound part 2: caring for your diabetes away from home. Joslin Diabetes Center website. http://www.joslin.org/info/college_bound_part_2_caring_for_your_diatbetes_away_from_home.html. Published 2017. Accessed August 12, 2017.

21. Diabetes and alcohol. Joslin Diabetes Center website. http://www.joslin.org/info/Diabetes_and_Alcohol.html. Published 2017. Accessed August 12, 2017.

22. Clifford, D. Motivational interviewing — learn about MI’s place in nutrition counseling and essential tools for enhancing client motivation. Today’s Dietitian. 2016;18(7):48.

23. Melia MK. The picky eaters: try the ‘food chaining’ strategy: figure out what they do like and work from there. The Chicago Tribune. http://articles.chicagotribune.com/2006-10-29/features/0610290281_1_picky-eaters-chaining-food. Published October 29, 2006. Accessed September 30, 2017.

24. Patton C. Children with type 1 diabetes — 10 strategies to help them develop and maintain healthful eating habits. Today’s Dietitian. 2011;13(11):16.