Research by Canadian Health and Care Mall – SYMPTOMS

My partner was very thirsty before she was found to have diabetes. What was the cause of the thirst?

The most common signs of diabetes are thirst and loss of weight. These two symptoms are related and one leads to the other (there is more detail on weight loss in the answer to the next question). The first thing to go wrong is the increased amount of urine. Normally we pass about 1.5 litres (about 2 pints) of urine per day but people with uncontrolled diabetes may produce five times that amount. The continual loss of fluid dries out the body and the sensation of thirst is a warning that, unless they drink enough to replace the extra urine, they will soon become very dehydrated.

Of course people who do not have diabetes may also pass large amounts of urine. Most beer drinkers know the effects of five pints of bitter. In this case it is the volume of beer that causes the extra urine, whereas in diabetes the large volume of urine causes the thirst. In the early stages, the thirst is usually mild and most people fail to realise its significance unless they have had some personal experience of diabetes. Someone with undiagnosed diabetes will often take jugs of water up to bed, wake in the night to quench their thirst and pass urine, and still not realise that something is wrong. It would be helpful if more people knew that troublesome thirst may be due to diabetes.

I had lost quite a lot of weight before I was finally diagnosed with diabetes. Why was this?

The main fuel for the body is glucose, which is obtained from the digestion of sugary or starchy food. People with untreated diabetes cannot use this glucose as fuel in the normal way or store it. The unused glucose builds up in their bloodstream and overflows into the urine. Someone who has uncontrolled diabetes may lose as much as 500 g (just over 1 lb) of glucose (sugar) in their urine in 24 hours. Anyone trying to lose weight knows that sugar equals calories. These calories contained in the urine are lost to the body and are a drain on its resources. The 500 g of glucose lost are equivalent to 10 currant buns (2000 calories per day).

Lack of insulin means that the body cannot use glucose to provide energy or to build stores of starch and fat. As a result body tissues are broken down to form glucose and ketones, and this causes loss of fat and wasting of muscles.

My vagina has been really itchy and sore. My CP says it’s to do with my diabetes. Can this be right?

A woman whose diabetes is out of control may be troubled by itching around the vagina. The technical name for this distressing symptom is pruritus vulvae. The equivalent complaint may be seen in men when the end of the penis becomes sore (balanitis). If the foreskin is also affected, it may become thickened (phimosis), which prevents the foreskin from being pulled back and makes it difficult to keep the penis clean.

Design
This open label study included 60 type 2 diabetes mellitus patients divided into 3 groups; 18 patients received sesame oil, 20 patients took a daily dose of glibenclamide (Glyburide), and 22 took both sesame oil and glibenclamide. The patients in the sesame group were supplied with sesame oil and instructed to use about 35 grams (about 2.4 tablespoons) per day in cooking or salad preparation for 60 days. Blood samples were collected at baseline and after 60 days of the experiment for analysis.

Key Findings
In this group of type 2 diabetics, sesame oil had a synergistic effect with glibenclamide. The combination therapy significantly lowered blood sugar and hemoglobin A1c more than either oil alone or drug alone did.
In those who received only sesame oil, total cholesterol dropped 20%, LDL cholesterol dropped 33.8%, and triglycerides dropped 14%. In those receiving both sesame oil and glibenclamide, these numbers were even better: 22%, 38% and 15% respectively. HDL increased 15.7% in the sesame oil patients and 17% in those receiving the combination of oil and drug.

The combination therapy significantly lowered blood sugar and hemoglobin A1c more than either oil alone or drug alone did.

Practice Implications
This is not the first study to suggest that sesame oil supplementation is beneficial for diabetics. In a 2005 paper on rats with chemically induced diabetes, Ramesh et al reported that, after 42 days of eating a diet supplemented with 6% sesame oil, mean blood glucose dropped from approximately 322.61 mg/dL to 222.02 mg/dL.1 In 2007 Dhar et al, also using rats with chemically induced diabetes, reported that sesame lignans not only improved the lipid profile but significantly reduced the peroxidation of the LDL cholesterol.2

In 2006 Sankar et al reported the results from their pilot study on 40 hypertensive diabetics that found eating sesame oil caused significant effects in hypertensive diabetics medicated with atenolol and glibenclamide. The patients switched to sesame oil for cooking for 45 days at which point they switched to other oils like palm or peanut oils for another 45 days. During the sesame oil portion of the study, “Systolic and diastolic BP decreased remarkably. When oil substitution was withdrawn, BP values rose again.” During the sesame oil phase of the study, body weight, body mass index, girth of waist, girth of hip, and waist:hip ratio decreased. So did plasma glucose, hemoglobin A1c, total cholesterol, and LDL cholesterol and triglycerides.

Given these results it now seems reasonable to suggest a little experiment to your type 2 diabetic patients. Have them switch to eating only sesame oil for 8 weeks and see if their lipid profiles improve.

Given the parameters that are improved by sesame oil, we must wonder whether it might benefit those with metabolic syndrome. Suggesting a similar experiment to those with metabolic syndrome might be worth considering.

As a side note, there has also been recent interest in sesame oil’s capacity to accelerate wound healing.4,5,6,7 Given that a common complication that diabetics suffer is poor wound healing, this action may also prove of useful for this patient population.

Blueberries are a new and attractive option to add to our current assortment of things that improve insulin sensitivity. The best-proven and safest ways to increase insulin sensitivity are still exercise and weight loss. Weight reduction reduces insulin resistance in both children and adults, especially in combination with exercise.

Adding large amounts of cereal fiber to the diet also increases insulin sensitivity. In one experiment, slightly more than 1 ounce a day of oat bran produced significant changes in insulin sensitivity after just 3 days. High-fiber rye breads have a similar beneficial action and have also been shown to lower cholesterol. Any weight gain during these experiments cancels out the benefit.

Low vitamin D levels adversely affect insulin sensitivity. A study published in April 2010 calls into question whether vitamin D will be useful for the general population; low vitamin D levels were only associated with insulin sensitivity in African American women, not Caucasian.9 Obviously there is no reason not to supplement all patients with vitamin D, but it may prove to affect insulin sensitivity in a portion of patients.

Obviously there is no reason not to supplement all patients with vitamin D, but it may prove to affect insulin sensitivity in a portion of patients.

The same might be true of chromium. For years we have given patients with blood sugar problems supplemental chromium. A double-blind, placebo-controlled trial published in July 2009 by Yale University researchers calls this practice into question. After 6 months of supplementation at either 500 or 1,000 mcg/day, insulin sensitivity was no different than in those who had taken placebo. The authors concluded, “Chromium supplementation does not appear to ameliorate insulin resistance or impaired glucose metabolism in patients at risk for type 2 diabetes, and thus is unlikely to attenuate diabetes risk.” However, a paper published 2 months earlier from Louisiana State University reported that some people do respond to chromium. In this study clinical improvement was “more likely in insulin-resistant subjects who have more elevated fasting glucose and A(1c) levels.” The participants in the Yale study were only at high risk for type-2 diabetes. Those in the Louisiana study who responded already had diabetes, and the worse their disease, the better the response.

Until proven otherwise, let us assume that fresh or frozen blueberries will be as effective at improving insulin sensitivity as the powders utilized in the current study. Given that blueberries are thought to provide benefit against a wide range if health disorders, it will be reasonable to suggest daily consumption of blueberries to a large number of patients, especially those with reduced insulin sensitivity.

Seventy-seven percent of participants presented 1 or more magnesium status parameters below the low normal range. Magnesium intake was inadequate in most subjects (82 percent). According to the researchers, “The results presented here show that magnesium intake by the study population was inadequate and that a high percentage of individuals presented alterations in the status of this mineral.”

• Urine magnesium (2.80 ± 1.51 mmol/d): Low end of normal range=3.00 mmol/L
• Plasma magnesium (0.71 ± 0.08 mmol/L): Low end of normal range=0.75 mmol/L
• Erythrocyte magnesium (1.92 ± 0.23 mmol/L): Low end of normal range=1.65 mmol/L

Subjects had evidence of poor blood glucose control with fasting glucose of 8.1 ± 3.7 mmol/L or 145 ± 66 mg/dL (reference range: 3.6–5.8 mmol/L or 64.8–104.4 mg/dL); 2-hour postprandial glucose of 11.1 ± 5.1 mmol/L (200 ± 91 mg/dL) (reference range:
Magnesium intake by the study population was inadequate and a high percentage of individuals presented alterations in the status of this mineral.

Practice Implications
This study set out to assess magnesium intake and magnesium levels in patients with type 2 diabetes. More than 325 magnesium-dependent enzymes allow magnesium to function as a cofactor in a wide range of metabolic reactions. The researchers in this study acknowledge that insulin function is dependent on magnesium, which is responsible for the activation of insulin receptors and for stimulation of proteins and substrates involved in insulin signaling. The researchers cite previous research suggesting that magnesium intake of patients with diabetes is very often below recommended levels. They cite evidence that low levels of magnesium may influence the evolution of the disease by generating further complications.

The incidence of diabetes in the United States is 7.8 percent for diagnosed and undiagnosed cases. The National Academy of Sciences has determined that most American men only obtain about 80 percent of the recommended daily allowance (RDA) of magnesium, and women average only 70 percent.

When the disadvantages of breastfeeding were discussed many myths were mentioned that discouraged women from breastfeeding. For example, all the focus groups mentioned that when the mother is angry she should not breastfeed because the baby will absorb her anger. The women in the focus groups felt that their milk supply would be affected by their nutrition. Tooth decay was a common concern among three of the participant in the first group. All groups felt that pain was one disadvantage of breastfeeding. All groups agreed that when a mother is sick, she should not breastfeed because she will transmit her illness to her infant. Two groups, one English-speaking and the other Spanish-speaking, felt that embarrassment is a disadvantage to breastfeeding.

Even though there were perceived disadvantages, the women said they were asked if they were more likely to breastfeed for a longer period of time if they knew breastfeeding would reduce their risk of diabetes. When they were asked to give reasons why they would be more likely to breastfeed knowing this information all groups commented on the health benefits. One English-speaking woman in the second group is diabetic and she mentioned that breastfeeding has helped her with her diabetes by controlling her glucose levels. She was the only one of the 29 participants that was diabetic. One woman commented that she would breastfeed to prevent diabetes in another pregnancy; this woman was the only woman who had a history of gestational diabetes. All groups mentioned that because diabetes is common among Latinos it is important for them to know of ways to help prevent diabetes.

When women where asked what they needed to breastfeed for six months or more, all groups mentioned that they would need support. The English-speaking group gave more technical answers such as drink milk, calcium, and vitamins. The first Spanish-speaking group emphasized education, and they mentioned that young women were in particular need of receiving education necessary to be successful in breastfeeding. According to this group, women need to know about the benefits and what to expect when they breastfeed so they don’t give up.

WIC participants are constantly bombarded with brochures, handouts, and information on many health topics. The information they receive is simple and applicable. However they receive so much information on similar topics such as nutrition and breastfeeding that they often disregard the content. WIC women and other low-income women need to learn about health topics affecting them. The focus groups revealed that if women knew about the protective effect breastfeeding has against diabetes they would be more likely to breastfeed.

The educational handout developed for this study (PDF) is intended to promote breastfeeding as primary diabetes prevention strategy. The brochure focuses on the prevalence of diabetes among Latinos and how breastfeeding can help reduce the risk of developing diabetes in both mother and infant. The brochure is geared towards Latina women to increase their awareness of diabetes and educate them on how breastfeeding can help prevent diabetes.

Participants were then informed of the discussion topics. They were told what they would be talking about, some of the benefits of breastfeeding, some of the disadvantages of breastfeeding, what is necessary to breastfeed for a longer period of time, why chose to breastfeed or not breastfeed your baby, and the relationship between breastfeeding and some chronic illness like diabetes and cancer. At this point, they were reminded that all their comments would be kept confidential. They were also told that at the end of the study, the video would be destroyed and were encouraged to feel comfortable with providing honest answers.

Once participants were informed of the discussion topics the facilitator began with the first question. When participants did not respond to questions the facilitator would probe questions to encourage more participation. In order to facilitate transcription of the data, facilitator would pause between questions. When answers were vague the facilitator asked participants to elaborate. If participants were soft spoken the facilitator would reiterate what was stated by participant to ensure the conversation was captured by the camera.

Data Transcription
The focus group conversations were captured with a DVD video camera. Video clips were then easily transferred into a computer file. Once all three focus groups were completed data was transcribed by listening to the video clips numerous times. As a backup method a research assistant on the project took notes using a laptop.

Data Organization
Data gathered from the focus group conversation was collected and categorized into trends. For example for the first question “What have you heard about the benefits of breastfeeding?” if at least two women mentioned a response like “breastfeeding helps prevent illness” this was noted as a trend.

Results
A total of 29 women participated in this study. The first focus group consisted of nine participants, the second group 10 participants and the third group 10 participants. The focus groups revealed that all Latina women participating in WIC programs know that breastfeeding is good for their babies. All three focus groups identified breastfeeding as having nutritional, immunological, and developmental benefits. Some other benefits of breastfeeding mentioned were: that it is convenient, it lowers the risk of developing breast cancer, it serves to bond with the infant, and it provides added benefits to mother such as weight loss. When they were asked where they learned about this information all groups mentioned three specific places, the media, doctors, and WIC. WIC was mentioned as one of the number one places where they receive useful information about many health topics. It was mentioned by one Spanish-speaking participant if it wasn’t for WIC she would not have breastfed. Nonetheless breastfeeding rates among WIC participants are still low.

Once participants were screened they were sent an invite by mail reminding them of the time and date of the focus group. If the participant was going to participate in the English focus group, they were sent an English invitation and if they were going to participate in the Spanish group, the invitation was in Spanish. The invitation also served to remind participants to arrange for child care. This would help reduce the amount of noise and distractions during the video taping of the focus groups. Participants were also called one day before the focus group to confirm their attendance and to address any concerns. Coloring books and reading books were provided for women who could not arrange for child care during the focus group.

Coding for Confidentiality
When participants agreed to participate in the focus group their name and phone number was written on a participant list. To protect confidentiality participants were assigned a two letter and two number code to protect confidentiality. Name tags were printed with these codes and given to participants upon arriving to the focus group. Participants wore name tags on their shirts where they can be visible by the note taker. This was done to help the note taker keep track of who was speaking.

Setting
In order to facilitate participation, focus groups were held at the WIC clinic classrooms. Classrooms are typically large enough to accommodate 15-20 participants. Tables were arranged at the center of the classroom. Participants were seated around the table where they were able to face each other. The facilitator of the focus group was seated at the head of the table facing the participants. The video camera was placed on a tripod at the center of the classroom where it was able to capture all participants.

Focus Group Facilitation
When participants arrived at the focus group session they were offered fresh fruit, crackers, and water while they waited for the focus group to begin. On average, focus groups started 20 minutes after the time they were originally schedule to wait for participants. At the beginning of the focus group session, participants were invited to participate in an ice breaker activity. The ice breaker consisted of tossing a beach ball imprinted with pictures of physical activity. They were asked to look at the picture and tell the group if the activity was something they currently engage in or would like to engage in. To facilitate the ice breaker the facilitator started the ice breaker with an example. Once everyone had a turn with the beach ball participants were asked to take a seat to begin the focus group.

Complications attributed to diabetes account for $1 out of every $10 spent on health care in the US (Stuebe et al., 2005). The diabetic epidemic has taken an extraordinary toll on the US population, particularly the Mexican-American population who are at twice the risk of getting diabetes. Low breastfeeding rates are another public health concern among the Mexican-American population, particularly among those participating in the supplemental food program Women Infants and Children (WIC). Less than 25% of WIC participants are breastfeeding exclusively and less than 15% do so after four months of birth (California WIC Association March, 2006).

The purpose of this project is to assess breastfeeding knowledge among Latina women and develop an educational handout to promote breastfeeding as a diabetes prevention strategy.

Methods
Three focus groups were conducted with English and Spanish speaking Latina women participating in the WIC program. A focus group facilitator, videographer and note taker were present during each of the focus group sessions. The following procedures were utilized for all focus groups.

Each focus group was scheduled individually, one focus group was in English and two were in Spanish. Data were collected by video taping participants throughout the duration of the focus group.

Recruitment
Before participants were recruited, an application for use of human subjects in research was submitted and approved by the College’s Institutional Review Board (IRB). Participants were recruited through a flyer posted at the check in counter and the classroom at the WIC clinics. Flyers were posted for each individual focus group, three to four weeks prior to the focus group. Focus group flyers posted were written in English and in Spanish. Additionally, women were invited to participate in the breastfeeding focus groups during their nutrition counseling session at their WIC site. To be able to participate in the focus groups participants had to be between the ages of 18 to 35 and they had to have a child between the ages of zero to five years old. It was not necessary to be breastfeeding at the time of enrollment. Women who were pregnant were excluded from the focus groups. Women who participated in the focus group were compensated for their time with a $25 gift card for any Target store.

Women who were interested were given an informed consent, the informed consent outlined the purpose of the focus group, procedures, contact information, benefits for participating, confidentiality, and it stated that they would be video taped. Participants either signed the informed consent at the clinic or signed it prior to the start of the focus group. Participants were screened over the phone with a demographic questionnaire. They were asked questions pertaining to their age, ethnicity, how long they lived in the US, preferred language, highest grade completed, if they were currently working, number of children, and their breastfeeding history. At least 15 women were recruited to ensure attendance for the focus groups.

Stuebe et al. (2005) analyzed data from two sets of nurses’ health studies to evaluate the association between lactation history and incidence of Type 2 diabetes. The nurses’ health studies consisted of large cohorts enrolled in prospective longitudinal studies of women’s health. Participants in both cohorts were asked to report total lifetime duration of lactation for all pregnancies as a categorical variable. Women completed health questionnaires every two years, when women reported the diagnosis of diabetes, diagnosis was confirmed by supplemental questionnaire. Lifetime duration of breastfeeding history among women was stratified into six groups, more than zero to three months, more than three months to six months, more than six months to 11 months, more than 11 months to 23 months, and more than 23 months. Researchers utilized a cox proportional hazards model, to compare Type 2 diabetes to lactation history. This study found that women who breastfed for longer periods of time were less likely to have diabetes. For each additional year of lactation, women had a 15% decreased risk of developing diabetes (Stuebe et al., 2005).

Research conducted by Malcova et al. (2005) also suggests breastfeeding can be protective against Type 1 diabetes. Their case control study indicates that the absence of breastfeeding can be associated with the risk of Type 1 diabetes. A case control dataset was analyzed consisting of 868 diabetic children and 1466 non diabetic children. After a univariate analysis, the associations were analyzed using a multiple logistic regression adjusted for confounders such as year of birth. The data revealed that the risk of Type 1 diabetes decreased with increasing duration of breast-feeding while no breastfeeding was associated with an increased risk of Type 1 diabetes; breastfeeding for more than 12 months was associated with a protective effect against diabetes (Malcova et al., 2005).

There is no cure for diabetes, however diabetes can be prevented or delayed through proper diet and exercise (Fisher et al., 2002). Recent studies suggest that a longer duration of breastfeeding is associated with reduced incidence of Type 2 diabetes among women who breastfeed. (Stuebe et al., 2005). Breastfeeding provides many benefits to mother and baby. One of the benefits of breastfeeding is that it helps women lose weight between pregnancies. Breastfeeding also aids in controlling glucose levels; hypothetically this regulatory effect is what helps reduce the risk of diabetes (Stuebe et al., 2005).

Despite the numerous benefits of breastfeeding, rates are declining particularly among low income Latina women (Wood, Sasnoff, & Beal, 1998). The decline of breastfeeding is due in part to; restricted freedom, embarrassment, lack of time, social constraints, and perceived lack of social support (Knox-Stewart, Gardiner, & Wright, 2003; Mira, Hoary, Caruthers, & Fritch, 2003;). Numerous studies have been conducted on ways to increase breastfeeding rates among low-income women. One study found that women who know about the advantages of breastfeeding are more likely to breastfeed (USDA Food and Nutrition Service and Hoyer & Horvat, 2000). A study conducted by Kaufman et al. (2001) suggests that in order to have successful breastfeeding outcomes, it is imperative to offer simple breastfeeding educational materials. It is important to educate women on the relationship between breastfeeding and diabetes as it can potentially increase both the incidence and duration of breastfeeding.

Type 2 diabetes is a serious illness affecting more than 20 million Americans; if left untreated it can lead to life threatening complications such as heart disease, stroke, and kidney disease. Efforts to prevent the onset or delay the complications of diabetes are urgently needed particularly among Mexican Americans who are 1.7 times more likely to develop diabetes. Medical professionals agree that diabetes may be prevented through proper diet and exercise. A growing body of evidence suggest that the risk of diabetes may also be reduced among women who breastfeed. New research shows that women who breastfeed exclusively are less likely to develop diabetes. However, despite the many known benefits of breastfeeding, rates are declining particularly among low- income Latina women. Focus groups were conducted with low-income women participating in the Women Infants and Children Program (WIC) to assess their knowledge and perceptions of breastfeeding. It was found that all focus group participants would be more likely to breastfeed if they knew it reduced their risk of diabetes. As a result of this study, an educational handout was then developed to promote breastfeeding as a diabetes prevention strategy among low-income Latina women.

Diabetes is a growing public health concern with many serious health consequences. If left untreated, diabetes can lead to other health problems such as heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, and amputations (Engelgau et al., 2004). Diabetes is a metabolic disorder characterized by hyperglycemia or high blood sugar resulting from the body’s inability to use blood glucose for energy. (Engelgau et al., 2004). There are three major types of diabetes, Type 1, Type 2, and Gestational Diabetes Mellitus (GDM). Type 1 diabetes usually accounts for 5-10% of all diagnosed cases whereas Type 2 diabetes accounts for 90-95% of all diagnosed cases (American Diabetes Association, 2006). Gestational diabetes is the most common medical complication during pregnancy; it usually disappears post partum but it can develop into Type 2 diabetes over time (Rosenberg, Garbers, Lipkind, & Chaisson, 2005).

Recurrence of GDM in subsequent pregnancies range from 35% in white populations and 50% in non-white populations. Women who experience GDM and do not breastfeed their baby from that pregnancy are twice as likely to develop Type 2 diabetes (Engelgau et al., 2004). Breastfeeding helps lose weight between pregnancies and aids in controlling glucose levels (Stuebe, Rich-Edwards, Willet, Mason, & Michels, 2005). The ongoing metabolism of glucose into galactose and lactose during milk synthesis reduces the amount of insulin needed by lactating mothers by 27-50%. Both human studies and animals studies have demonstrated improved insulin sensitivity and glucose tolerance during lactation compared to non-lactating mothers (Stuebe et al., 2005).

The data clearly indicate a strong interest in youth/family summer camps geared towards diabetes education. Eight out of 14 youth expressed an interest in meeting other youth with type 2 diabetes and attending youth/family camps. Currently, summer camps and prevention programs specifically targeting Latino and African-American youth do not exist within many states and counties in the United States including Santa Clara County, despite these being the populations that comprise most of the newly diagnosed cases of type 2 diabetes mellitus among youth.

The characteristics described in the present study are consistent with previous studies that have examined the demographics, physical characteristics, and family history of type 2 diabetes in North American children and adolescents. While some of the environmental factors that contribute to type 2 diabetes are both recognized and preventable, the rates of type 2 diabetes among youth, specifically in certain ethnic groups, are on the rise. Additionally, a family history of diabetes does not necessarily equate to increased knowledge of the associated diabetes risk factors that may minimize early-onset of this disease.

As the characteristics and diabetes risk factors of type 2 diabetes among youth continue to be identified, prevention programs will need to be designed and implemented. Summer camps and school-based education programs are available for children with type 2 diabetes in certain parts of the United States and Canada. These camps and school-based education and prevention programs have been established because type 2 diabetes has been recognized in Native American youth for over 15 years (Rosenbloom, Joe, Young & Winter, 1999). It has been shown that a child who attends a summer camp for two consecutive years is more likely to adopt lifestyle changes that lead to improved diabetes management (Cook, & Hurley, 1998). Diabetes education programs for this population will need to be culturally appropriate and focus on family involvement to increase the quality of life and decrease some of the preventable health risks associated with this disease.

The youth diagnosed with type 2 diabetes are reported to be a challenging population to work with due to poor blood sugar control, missed appointments with physicians and diabetes educators, and the pressure to conform to the lifestyle behaviors of their peers. As more youth are diagnosed with type 2 diabetes at increasingly younger ages, they will be living with the disease for much longer periods of time than their adult counterparts, potentially facing higher medical costs and more diabetes complications including cardiovascular disease and hypertension at younger ages. Due to the recent increase of cases of type 2 diabetes among youth, support programs and services have yet to be developed and implemented to address the needs of this unique population.

It is also clear that family involvement and positive role models will be integral in the success of the self-care required of youth who are diagnosed with type 2 diabetes. Finally, the community programs developed for this population will need to focus on the diverse cultural needs since the majority of youth cases with type 2 diabetes are found in the Latino, Native- American, and African- American populations.