Daniel Bintz remembers what it was like to be diagnosed with type 2 diabetes 25 years ago. He was only 19 at the time, and the news hit him like a right hook out of nowhere.

Type 2 diabetes, he thought, was something that older people get. Why did he get it? What did it mean? What changes would he have to make? Would he be able to eat his favorite foods again? Well, you get the picture.
After the diagnosis sunk in, Daniel studied all he could about type 2 diabetes.

Today, Daniel Bintz is an optometrist with a private practice in Elk City, Okla., and is chair of the American Optometric Associations Health Promotion and Disease Prevention Committee (formerly known as the AOA Public Health Committee). He uses his education and AOA involvement, plus his own invaluable personal experience as a diabetic, to help educate both his patients and the public about diabetes and their health care.

Why is that important? Until recently, childhood diabetes was usually assumed to be type 1, or juvenile-onset diabetes. However, in the last two decades, type 2once considered to afflict only middle-aged and elderly individualshas been more frequently reported among children and adolescents in the United States and Europe.

For example, in Dr. Bintz practice, which is located 100 miles outside of Oklahoma City, approximately 10-20% of his patients are under the age of 18. And of those, about 20 have already been diagnosed with diabetes.

Type 2 is now being diagnosed in children and adolescents between the ages of 10 and 19, and most especially in those who are obese. Of all adults and children diagnosed with diabetes, 50% have type 2.

Why is it happening? Most adults are diagnosed after theyve had the disease for three to five years, while children tend to be diagnosed earlier because theyre required to have annual physicals for school, says Dominick Maino, O.D., M.Ed., professor of pediatrics at the Illinois College of Optometry and the Illinois Eye Institute.

With that in mind, are you and your staff thoroughly prepared to adequately help your patients and their families fully understand the potential risk factors of this disease? Do you know what you should and shouldnt do or say?
In this article, youll find tips on what you need to know. First, lets update some recent statistics.

Cause for Concern

Whats causing the rise in type 2 diagnoses? Well, a strong family history is one risk factor. But most studies point the finger at obesity, physical inactivity, sedentary lifestyles and diets overloaded with supersized junk foods.

According to the U.S. Depart-ment of Health and Human Services, as many as 3% of children ages 6 to 11, and 14% of teenagers, are overweight. The Centers for Disease Control and Prevention (CDC) further confirmed that the number of overweight kids has doubled since 1980.

The CDC notes that about 151,000 people below the age of 20 years have diabetes. It further predicts that one in three U.S. children born in 2000 will become diabetic unless theyre encouraged to eat less and exercise more.

If patients can indeed do a lot to prevent or delay type 2, then how do you effectively get the point across of the importance of lifestyle changes to youngsters and their families?

FAST FACTS Approximately 18.2 million children and adults in the United States have diabetes. Of those, 13 million have been diagnosed, and the remaining 5.2 million are estimated to have type 2 but not know it. About 1 million people age 20 or older will be diagnosed with diabetes this year.

What You Can Do

The first and most important thing is to remember what you felt like when you were a kid. The last thing you wanted was to be lectured by anyone about what you could and couldnt do. Naturally, most of your pediatric patients will feel the same way.

After all, theyre dealing with peer pressure, classmates and friends who dont understand diabetes, questions about food options at school and restaurants, how to properly exercise, etc. Thats a lot for anyones plate.

The key is to be understanding and educational. But dont overwhelm everyone with medical terminology. Explain everything in familiar terms.
The following tips should help you and your staff, as well as your patients and their families:

1. Obtain permission from the patient or her/his family to provide follow-up reports to the patients primary health-care provider. Communication with other health professionals will ensure that everyones on the same page regarding your patients care.
   
2. Have your staff obtain a full family history, followed by a full patient history, including date of diagnosis if applicable. The first thing you should ask your diabetic patients is how they and their families are dealing with it, says Dr. Maino. The thing to remember is that children, especially teenagers, dont want to be different from their peers. So, its your role to see how theyre monitoring their blood glucose levels. Ask what theyre eating, and how theyre managing daily activities.
   The patient history should also include any suggestions by the primary health-care provider, such as weight reduction, exercise or diet programs.
   
3. Dilate eyes on every exam. This should be done for all patients with diabetes and is a position that is strongly encouraged by the National Eye Institute.
   
4. Look for specific ocular problems during the exam. Dr. Maino suggests looking for problems that can affect binocular vision function and accommodation. Ask if the children have complaints of blurred vision, fluctuating vision, the inability to sustain near-point activity such as reading, and/or diplopia, says Dr. Maino. Those are all things you need to evaluate carefully.
   
5. Encourage healthy diet and exercise programs. Says Dr. Bintz: If patients are significantly overweight, then Ill ask them, Does your doctor have you on a weight reduction program? By phrasing it that way, Im politely indicating that weight loss is a vital part of their overall health. If the answer is yes, Dr. Bintz makes a note of their programs. If the answer is no, he asks the patient if hes trying to lose weight on his own. Ill discuss obesity-related complications and risk factors, and further suggest that they talk with their medical doctor. I also make it a point to tell my patients that they cant change their age, sex or heredity, but they can change their weight and health with an exercise program, he says.
   
   One more helpful point is to encourage the patients family to make exercise time a team effort for the patient. And dont forget to ensure that the exercise regimen is appropriate for the patient, and that he/she wears the proper protective eyewear, if necessary.
   
   

   FAST FACTS Of all adults and children diagnosed with diabetes, 90% have type 2. According to the Centers for Disease Control and Prevention (CDC), nearly 50 million U.S. residents could have diabetes by the year 2050. The World Health Organization (WHO) estimates that there are nearly 300 million people with diabetes worldwide.

   
   
6. Offer to set up an appointment with a registered dietitian, preferably one whos a certified diabetes counselor. Explain how the dietitian will teach them the various ways they can still eat the foods they enjoy. I tell my patients how I learned so much more after my dietitian taught me how to prepare my favorite foods differently, how to reduce portion sizes, and how to understand nutrition labels, says Dr. Bintz.
   
7. Share your personal experiences, if applicable. If you or anyone else in the family has a chronic illness, Dr. Maino says you might consider telling your patients and their families what you did that was right and wrong, and what the benefits and consequences were. Dont lecture them by saying, You have to do this, but instead say, This is what I did and this is what worked. Youll get much better results that way, he says.
   Dr. Bintz agrees. I was skinny my whole life, and it was frustrating to think that I couldnt eat certain things anymore, says Dr. Bintz. Thats why I was impressed and relieved when my dietitian asked me, What do you like to eat? That was much better than hearing You cant eat this or that.
   
8. Dont use scare tactics to explain risk factors. Yes, you know that diabetes is a high risk factor for eye disease. But your patients dont. So, point out potential risk factors in terms theyll easily understand. And by all means, avoid showing detailed photographs of disease-related complications. Those will really freak out your younger patients.
   
9. Provide as much additional information as possible. Keep a stock of brochures and lists of reputable medical Web sites to recommend (see Weave A Web of Help, page 94). For example, Dr. Bintz hands out literature from the American Diabetes Association, the AOA and the National Eye Institute. Dr. Maino also distributes printed and online materials, plus he offers to help parents contact local support groups.
   
   

   WEAVE A WEB OF HELP Encourage your patients and their families to either log on to or contact the following organizations for a wide variety of details about diabetes. American Diabetes Association, Attn: National Call Center, 1701 North Beauregard Street, Alexandria, VA 22311, 1-800-DIABETES (1-800-342-2383) (Monday-Friday, 8:30 a.m. to  8:00 p.m. EST), www.diabetes.org. American Optometric Association, 243 North Lindbergh Blvd., St. Louis, MO 63141, Phone: (314) 991-4100, Fax: (314) 991-4101, www.aoanet.org. The Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, GA 30333, Phone: (404) 639-3311, Public Inquiries: (404) 639-3534 or 1-800-311-3435, www.cdc.gov. Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, (617) 732-2400, www.joslin.harvard.edu. Juvenile Diabetes Research Foundation International (JDRF), 120 Wall Street, New York, NY 10005-4001, Phone: 1-800-533-CURE (2873), E-mail: info@jdrf.org, Internet: www.jdrf.org. National Diabetes Education Program, One Diabetes Way, Bethesda, MD 20814-9692, (301) 496-3583, www.ndep.nih.gov. Call 1-800-438-5383 to order diabetes education materials. National Eye Institute, 2020 Vision Place, Bethesda, MD 20892-3655, (301) 496-5248, www.nei.nih.gov. National Institutes of Health (NIH), 9000 Rockville Pike, Bethesda, MD 20892, www.nih.gov.

   
   
10. Send a detailed follow-up report to the patients primary health-care provider. Some families think that the family doctor, not the eye doctor, should be the only one giving weight loss and general health-care advice, says Dr. Bintz. Unfortunately, many parents still regard weight problems as cosmetic rather than medical, so to them, obesity isnt a big deal, especially if the child loses weight by high school. But O.D.s shouldnt be intimidated by that attitude at all. The more health professionals who get involved in an existing or potential diabetic situation, the more likely that the patients family will accept it as a serious matter and do whats necessary.
    
11. Encourage the patients family to educate teachers and classmates. Dr. Maino recommends asking the parents if theyve discussed their childs diabetes with the teachers and principals. Everyone at the childs school should know ahead of time whos supposed to give insulin and who should check the childs diet, says Dr. Maino. Encourage a review of signs of hypoglycemia and hyperglycemia. This gives your young patient a chance to educate his/her peers, and ensures that everyone knows what to do in the event of an emergency.
    Most importantly, says Dr. Maino, Treat these kids just like everyone else, but be there for them and their families to ensure that theyre following up with everything they should be doing.
    
    

    FAST FACTS Diabetes causes more blindness in people under age 65 than any other disease. Type 2 diabetescan linger for 10 to 15 years before serious effects manifest themselves. While type 1 diabetes is a result of genetics, type 2 can be delayed or prevented with weight reduction, exercise programs and dietary changes.

Strength in Numbers

Dr. Maino points out that it takes time for parents to fully accept the idea that their child has type 2 diabetes, or may be at risk of developing it. The initial reactions I see from parents of children who have been diagnosed with type 2 diabetes are usually denial, and then they slowly progress to a final acceptance of it, says Dr. Maino. The optometrists role is to help them get to that point of acceptance by providing as much information, education, concern and follow-up as possible.

You can also show the families that theyre not alone by pointing out whats being done across the country regarding type 2 diabetes.

For example, the CDC and the National Institutes of Health (NIH) are funding a five-year, multi-center study called SEARCH for Diabetes in Youth. This study will examine the current status of diabetes among U.S. children and adolescents.

In The Big Apple, Mayor Michael Bloomberg has successfully pushed for the removal of vending machines from some New York City schools. In August, the school district of Everett, Washington, voted to replace all unhealthy beverages and foods in all its schools vending machines and cafeterias with completely healthy options.

FAST FACTS Walking 30 minutes daily and shedding excess pounds can cut the risk of diabetes by 58%, according to the U.S. Department of Health and Human Services Small Steps, Big Rewards campaign. The CDC notes that the number of overweight children has doubled since 1980. More than 30 percent of Hispanic children are overweight. The number of Hispanic children who have type 2 diabetes has tripled in the past decade. About 151,000 people below the age of 20 have diabetes, according to the CDC. The CDC predicts that one in three children born in the year 2000 will develop diabetes during his or her lifetime.

And earlier this year, the Joslin Diabetes Center in Boston and the Joslin Diabetes Center at SUNY Medical University in Syracuse, N.Y., and Massachusetts General Hospital in Boston, announced they are participating in an NIH-funded clinical study to compare treatments options for children and teenagers.

In addition, the AOAs Health Promotion and Disease Prevention Committee is currently developing plans to enhance the publics understanding of health care and how it relates to the eyes. Its primary focus currently is two-fold: Diabetes and its associated obesity-related complications; and tobacco prevention/cessation programs.

The goal is to help practitioners cover more general heath issues within eye exams, and to help people understand that many diseases, such as diabetes, have complications involving the eyes, says Dr. Bintz. Type 2 diabetes, especially among adults, will be seen in the eye first.

The bottom line in all of this is that people don"t know what they dont know, so they end up not understanding diabetes very well, he adds. Diabetes is a very patient-intensive disease, so you must encourage the patients to take an active role in their health. We as doctors are merely their coaches.

FAST FACTS Those affected with type 2 diabetes belong to all ethnic groups, but it is more prevalent among Native Americans, African-Americans, Hispanic-Americans and Asian-Americans/Pacific Islanders.