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Original Contribution |

National Surveillance for Type 2 Diabetes Mellitus in Taiwanese Children FREE

Jung-Nan Wei, PhD; Fung-Chang Sung, PhD; Chau-Ching Lin, MD; Ruey-Shiung Lin, MD, DrPH; Chuan-Chi Chiang, PhD; Lee-Ming Chuang, MD, PhD
[+] Author Affiliations

Author Affiliations: Institutes of Environmental Health (Drs Wei and Sung) and Preventive Medicine (Drs R.-S. Lin, Sung, and Chuang), National Taiwan University College of Public Health, Chinese Foundation of Health (Drs C.-C. Lin and Chiang), and Department of Internal Medicine, National Taiwan University Hospital (Dr Chuang), Taipei, Taiwan; and Chia Nan University of Pharmacy & Science, Tainan, Taiwan (Dr Wei).


JAMA. 2003;290(10):1345-1350. doi:10.1001/jama.290.10.1345.
Text Size: A A A
Published online

Context Despite a disturbing trend of increasing prevalence of type 2 diabetes mellitus (DM) in childhood, little is known about the epidemiology of childhood type 2 DM, especially in the Taiwanese population.

Objective To study the rate and risk factors for childhood type 2 DM based on a nationwide screening program in Taiwan.

Design, Setting, and Participants Screening in 1999 for type 2 DM using urine and blood testing and confirmed by follow-up telephone survey among schoolchildren aged 6 to 18 years in Taiwan, followed by a nested case-control study conducted in 2002 comparing 137 children with type 2 DM with 1000 randomly selected children without diabetes chosen to represent the age and sex distribution of the whole student population.

Main Outcome Measures Rate and identification of risk factors associated with childhood type 2 DM.

Results The rate of newly identified diabetes was 9.0 per 100 000 for boys and 15.3 per 100 000 for girls. Follow-up at 3 years revealed that, of 253 children with newly diagnosed diabetes, 24 (9.5%) had type 1 DM, 137 (54.2%) had type 2 DM, and 22 (8.7%) had secondary diabetes. Compared with children aged 6 to 9 years, the odds ratios (ORs) and 95% confidence intervals (CIs) of type 2 DM increased to 6.59 (3.23-13.4) for those aged 13 to 15 years and to 4.59 (2.07-10.2) for those aged 16 to 18 years. The OR (95% CI) of type 2 DM in children with a body mass index in the 95th percentile or higher (obesity) was 18.8 (9.22-38.5) compared with those with a body mass index in less than the 50th percentile. Other factors significantly associated with type 2 DM were hypercholesterolemia (OR, 1.80; 95% CI, 1.04-3.23), blood pressure greater than the 85th percentile (OR, 1.70; 95% CI, 1.07-2.70), and positive family history of diabetes (OR, 3.95; 95% CI, 2.01-7.78).

Conclusions Our mass screening program showed that type 2 DM is the leading cause of childhood DM in Taiwan. Obesity is a major risk factor for the development of type 2 DM in children.

Figures in this Article

Diabetes mellitus (DM) in children and adolescents has long been considered to be primarily type 1 (ie, insulin-dependent) DM. Type 2 (ie, non–insulin-dependent) DM is generally considered to be a disease of adults. However, a disturbing trend of increasing prevalence of type 2 DM in children has been noted worldwide in recent years.16

There is no doubt that better glycemic control in the early stages of diabetes can prevent or delay progression of complications in both type 1 and type 2 DM.7,8 However, it is not clear whether intensive treatment in patients who have their conditions diagnosed in the preclinical stages of diabetes through community screening is cost-effective. A position statement of the American Diabetes Association (ADA) in 2003 discouraged community screening for diabetes, even in high-risk populations.9 Meanwhile, the US Preventive Services Task Force determined that the evidence was insufficient to recommend for or against routine screening for diabetes, impaired glucose tolerance, or impaired fasting glucose in asymptomatic adults.10 Given that there are insufficient data to make a definite recommendation for children, the Consensus Panel of the ADA recommended that a screening test should be considered in high-risk persons, such as those who are overweight or obese, have a family history of type 2 DM, are of high-risk race or ethnic groups, or who have signs of insulin resistance.11

The World Health Organization has estimated that the recent increase in the population with diabetes has come mainly from developing countries, especially in Asia.12 However, there are few data on the epidemiology of type 2 DM in children in Asian developing countries.5,1315 To study the feasibility of a mass screening program to identify children at risk for diabetes and to examine the epidemiology of childhood diabetes in Taiwan, we performed a national screening program for DM and proteinuria in schoolchildren aged 6 to 18 years from 1992 to 1999.16 During subsequent follow-up, we were able to identify new cases of diabetes and to explore the risk factors associated with type 2 DM among these schoolchildren.

During 1992-1999, a nationwide survey for DM and proteinuria was conducted yearly by the Chinese Foundation of Health (CFH) in Taiwan.16 All students from the 1st grade to the 12th grade, aged 6 to 18 years, in the Taiwan Province school system participated in this nationwide survey. Only the children in the 1999 survey were followed up in 2002 for further classification of DM. This mass screening program for diabetes and proteinuria was approved by the Provincial Education Board and supported by the Taiwan Provincial Department of Health, Taiwan, Republic of China. Routinely, a letter was sent to parents to explain the program and to invite the participation of their children in the program. Each student brought instructions and a specimen container home for the collection of the midstream, first morning urine sample (before breakfast). The student then returned the specimen to school, where it was collected by the study team. The provision of a urine specimen was taken as consent to participate. More than 95% of the schoolchildren participated in the survey during these years.

The first morning urine specimen was tested for glucose, protein, and occult blood in CFH laboratories, using a urine strip (Hemscomistix IV urine strip; Ames Division, Miles Lab Ltd, Elkhart, Ind). If the specimen tested positive for glucose, protein, or occult blood, the students were asked to provide a second urine specimen within 2 weeks. The cutoff for positive glycosuria was 1+ or a glucose level of 250 mg/dL (13.9 mmol/L). If results of the second urine screen were positive, arrangements were made for the child to be examined. Body weight, height, and blood pressure were measured and a fasting blood sample was drawn, after obtaining written informed consent from parents. Levels of serum total cholesterol and glucose were measured by an autoanalyzer (Technician RA 2000 Autoanalyzer; Bayer Diagnostic, Michawaka, Ind). For quality control, medical technologists performed 5 quality control procedures for the calibration of the urine analyzer (Bayer CTK-200), life calibration, and KOVA-Trol I, II, and III (Hycor Biomedical Inc, Garden Grove, Calif). The CFH participated in the College of American Pathologists' quality assurance program and won a good performance award. The coefficient of variation for the blood glucose was 2% to 3% during these years.

For this study, children with normal fasting glucose (NFG) levels in 1992-1998 but with a fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher in 1999 were considered to have newly identified DM, based on ADA classification.17 Students newly diagnosed as having diabetes were referred to their family physicians for further evaluation and treatment.

To distinguish type 2 from type 1 DM, we conducted telephone interviews in 2002 with parents of those students newly identified as having diabetes from the 1999 survey. The questionnaire was designed to collect information on the date of diagnosis, diagnosis of type 1 or 2 DM by the referred physicians, modalities of diabetes therapy (diet alone, oral antidiabetic medicines, or insulin injection), and interval between diagnosis (or screening) and initiation of insulin treatment.

Students were considered to have type 2 DM if all of the following criteria were met: (1) FPG level of 126 mg/dL (7.0 mmol/L) or higher at screening and diagnosed as having type 2 DM by physician; (2) current treatment with an oral hypoglycemic drug or on diet control with no insulin injection; and (3) no recurrent diabetic acidosis. Those who had been treated with insulin injections within 3 years of diagnosis were classified as having type 1 or slowly progressive type 1 DM. Drug-induced diabetes was classified based on the presence of another disease and treatment with known drugs or hormones that can impair insulin action.18 Children with an FPG level of 126 mg/dL (7.0 mmol/L) or higher at screening but with no definite diagnosis by their physicians and those not reached by telephone due to an incorrect or missing telephone number were considered to have unclassified diabetes.

To determine risk factors for diabetes, we conducted a nested case-control analysis. A total of 1000 children were randomly selected by stratification from schoolchildren with NFG levels on urine screen in the 1999 survey to reflect the age- and sex-specific proportion of the whole student population and to serve as a comparison population.

The rate of newly identified diabetes was calculated by sex and age. Analysis of variance (ANOVA) and χ2 tests were used to determine the significance level of differences in body mass index (BMI), total cholesterol levels, blood pressure, and family history of DM among those with type 2 DM, unclassified diabetes, and NFG levels. The Bonferroni method was used for post hoc comparisons in ANOVA. Overweight and obesity were defined using sex- and age-specific 85th and 95th percentile BMIs based on child anthropometrics in Taiwan.19 The sex- and age-specific 85th percentile values of systolic and diastolic blood pressure based on the entire population in the study were used to define higher blood pressure. A cutoff cholesterol level of 200 mg/dL (5.17 mmol/L) was used to define hypercholesterolemia.20

Univariate and multivariable logistic regression analyses for those with newly identified type 2 DM vs NFG levels were performed, including all factors that were identified as being significantly associated with childhood type 2 DM in the cross-tabulation and ANOVA analysis as covariates. Since we simultaneously included sex, age, BMI, total cholesterol level, blood pressure, and family history of DM in the multivariable regression model, potential problems of collinearity between covariates and goodness of fit for the model could render estimated regression coefficients invalid. We found that collinearity should not be a concern in our data, since the multivariable logistic regression model that included all factors did not have large estimated slope coefficients and estimated SEs21 and the result of the Hosmer-Lemeshow test was not significant (P = .14). Test for linear trend, based on logistic regression with adjustment for sex, total cholesterol level, blood pressure, and family history of DM, was derived for age and BMI. Odds ratios (ORs) and 95% confidence intervals (CIs) were approximated by the method of Woolf.22P<.05 was considered statistically significant. The statistical analyses were performed with SPSS 10.0 (SPSS Inc, Chicago, Ill).

As shown in Figure 1, in 1999, 2 862 083 children aged 6 to 18 years (from a total of 2 926 700) completed the first screen and 15 271 a second screen. A total of 1809 tested positive on both. On examination, we identified 581 cases of diabetes with FPG levels of 126 mg/dL (7.0 mmol/L) or higher. Of the 581 cases, 343 were newly identified and 238 were previously diagnosed. Among the 343 newly identified cases, the parents of 253 students (73.8%) were successfully reached for a telephone interview, and 90 (26.2%) were not reached due to an incorrect or missing telephone number. Of the 253 students, 24 (9.5%) were classified as having type 1 DM, 137 (54.2%) were classified as having type 2 DM, 50 (19.8%) were diagnosed as healthy by their physicians, 22 (8.7%) were diagnosed as having drug-induced diabetes (steroid treatment for specific renal diseases or systemic lupus erythematosus), and 20 (7.8%) had no definite diagnosis from their physicians. After excluding children diagnosed as being healthy, those diagnosed as having type 1 DM, and those diagnosed as having drug-induced diabetes, the data of 1247 children were used in the data analysis, including 137 with type 2 DM, 110 unclassified cases (90 students not reached and 20 students without diagnoses from physicians), and 1000 controls with NFG levels.

Figure. Scheme of Diabetes Identification in Urine Screening Program for Schoolchildren in Taiwan, 1999
Graphic Jump Location
To convert levels of fasting plasma glucose from mg/dL to mmol/L, multiply by 0.0555.

The overall rate of newly identified diabetes was 12.0 per 100 000 students. The rate of newly identified diabetes was greater in girls (15.3 per 100 000) than in boys (9.0 per 100 000) and was lower in the younger group (ages 6-9 years) compared with older age groups, with an estimated mean rate of 1.7 per 100 000 in 6- to 9-year-old boys vs 15.9 per 100 000 in 13- to 15-year-old boys and 6.4 per 100 000 in 6- to 9-year-old girls vs 22.0 per 100 000 in 13- to 15-year-old girls (Table 1). The frequency of diabetes appeared to sharply increase in girls at the ages of 10 to 12 years and in boys at the ages of 13 to 15 years, consistent with an earlier onset of puberty for girls. Assuming the rate is similar between those who could and could not be reached for follow-up, the estimated rates of type 1 and type 2 DM were 1.1 per 100 000 and 6.5 per 100 000, respectively.

Table Graphic Jump LocationTable 1. Rate of Newly Identified Diabetes by Grade and Sex Identified in the Glycosuria Screening for Schoolchildren in Taiwan, 1999*

Compared with the NFG controls, type 2 DM patients were older, had a higher mean BMI and blood pressure, and were more likely to have a family history of diabetes. A total of 54.0% of boys and 44.4% of girls with type 2 DM were obese (Table 2). The unclassified cases were more similar in clinical and biochemical features to children with type 2 DM than to those with NFG levels, except that lower BMI and blood pressure were observed in the boys with unclassified diabetes (Table 2).

Table Graphic Jump LocationTable 2. Demographic and Biochemical Characteristics Among Schoolchildren With Type 2 DM, Unclassified Diabetes, and Normal Fasting Glucose (Comparison Group) in Taiwan*

The multivariable logistic regression analysis confirmed that girls had a higher risk of type 2 DM than boys (OR, 1.62; 95% CI, 1.03-2.55) (Table 3). The risk of type 2 DM was the highest for children at ages 13 to 15 years (OR, 6.59; 95% CI, 3.23-13.4). There was a strong dose-response relationship for BMI and risk of type 2 DM in children, with an OR of 18.8 (95% CI, 9.22-38.5) for children with a BMI higher than the 95th percentile compared with those with a BMI in the 50th percentile or lower. Hypercholesterolemia and higher blood pressure were also significantly associated with type 2 DM (OR, 1.80; 95% CI, 1.04-3.23; and OR, 1.70; 95% CI, 1.07-2.70, respectively). A positive family history of diabetes was a strong risk factor for children with type 2 DM (OR, 3.95; 95% CI, 2.01-7.78).

Table Graphic Jump LocationTable 3. Univariate and Multivariable Logistic Regression Analyses for Factors Associated With Type 2 Diabetes Mellitus in Schoolchildren in Taiwan

In the present study, the rate of newly identified diabetes was estimated to be 12.0 per 100 000. Of these cases, 24 (9.5%) had type 1 DM, 137 (54.2%) had type 2 DM, and 22 (8.7%) had drug-induced diabetes. The estimated rate of type 2 diabetes was 6.5 per 100 000. Previous studies have demonstrated an increased prevalence of type 2 DM in Pima Indians (22.3 and 50.9 per 1000 for children ages 10 to 14 and 15 to 19 years, respectively, in 1992-1994)11 and Canadians (1.0 and 2.3 per 1000 for children ages 5 to 14 years and 15 to 19 years in 1998)11 and an increased incidence in Japanese children (2.0 per 100 000 and 13.9 per 100 000 for primary and junior high school children in 1995).5

In our analysis of newly diagnosed diabetes, we found that girls had a higher risk of type 2 DM compared with boys. A similar observation has been made in other Asian populations,5 First Nations children in Canada,23 Pima Indians,2 and Mexican Americans.24

Similar to the risk factors for type 2 DM identified in a previous prospective study in Taiwanese adults older than 40 years,25 we also found that obesity, age, higher blood pressure, and a family history of diabetes were risk factors for type 2 DM in our young cohort. Obesity is a common finding in children with type 2 DM.2330 Obese children usually have hyperinsulinemia and have a 40% decrease in insulin-stimulated glucose metabolism when compared with nonobese children.31 We found that the risk for type 2 DM was increased stepwise with increasing BMI, reaching an OR of 9.93 for overweight children and 18.8 for obese children compared with the children with a BMI in the 50th percentile or lower. Type 2 DM was also significantly associated with hypercholesterolemia, although we did not measure levels of triglyceride or high-density lipoprotein cholesterol. Our data indicate an aggregation of a variety of cardiovascular risk factors.

In addition to the nested case-control analysis using the 1000 children with NFG levels as a comparison group, we also compared our study cohort with the whole population with NFG levels in a secondary analysis. Similar patterns were found except for the sex difference (complete results available from the authors on request). The whole NFG group was biased to have more girls due to a higher rate of abnormal findings on the urinalysis, such as more red blood cells and leukocytes. Therefore, we believe the nested case-control study, with a total of 1000 children randomly selected by stratification according to the age- and sex-specific proportion of the whole student population, is more accurate.

The differentiation of type 1 and type 2 DM in childhood is difficult, unless extensive immunologic and B-cell function tests are performed. In the present study, the differentiation of type 1 from type 2 DM may not be totally accurate, since the ascertainment of type 2 DM was based on a retrospective questionnaire interview and reports from family physicians. However, a similar questionnaire approach for the diagnosis of diabetes was used in the Nurses' Health Study, in which 98% of the self-reported cases could be confirmed by medical record review.32 In fact, the occurrence of type 2 DM might have been underestimated if some of the children with type 2 DM were misclassified as having type 1 DM and treated with insulin. In addition, the unclassified type showed a clinical picture more similar to type 2 DM. Type 1 DM also may have been underestimated if, given its more precipitous presentation, children's conditions were diagnosed outside the surveillance program and therefore the children did not participate in screening or their conditions were not detected on screening if they were taking insulin. Although misclassification might have occurred, it is unlikely that it would have changed the overall conclusion that type 2 DM is the leading cause of childhood diabetes in our study.

To our knowledge, the high rate of type 2 DM in this young population has never been noted before in Taiwan. Therefore, the results of this study will have significant public health ramifications. The high rate of drug-induced diabetes was also unexpected. However, there remains the possibility that we screened more children with systemic lupus erythematosus who have a lower renal threshold for glycosuria due to tubular dysfunction.33 Nearly 20% (n = 50) of the cases with diabetes were diagnosed as healthy by physicians. To our knowledge, there have been no reports showing regression of diabetes in young children. However, it is possible that the hormonal effect of puberty on insulin resistance might fade after reaching puberty,34,35 similar to the insulin resistance that occurs during gestational diabetes.36 Other explanations include laboratory error and misdiagnosis by physicians. The long-term outcome and the natural history of early-onset diabetes in schoolchildren in Taiwan warrant further investigation.

The screening method may represent a limitation in the present study. The sensitivity of glycosuria for diabetes screening has been generally regarded as low, ranging from less than 20% to more than 80% in different settings.3740 However, a diagnostic test with a high sensitivity may not necessarily be useful or cost-effective for screening purposes, especially when applied in a population in which the prevalence of the disease is low. In this study, the positive predictive value for abnormal glycemia (FPG level ≥110 mg/dL [6.1 mmol/L]) was only 11.8% (1809/15 271) if the first urine screen result was positive. However, this value increased to 78.6% (1421/1809) if both urine screen results were positive. Although urine screening is not recommended for clinical use, some epidemiologic studies have shown that glycosuria may be a useful screening tool for a large population.38 The cost of screening is a main concern. The cost of yearly screening, including the personnel and laboratory tests, was approximately $2.00 for each student in the present study. Therefore, the cost for identifying a patient with abnormal glycemia was $4028. We had to screen approximately 2000 children to find 1 case of abnormal glucose tolerance or approximately 5000 children to find 1 case of diabetes. However, this program also screened for proteinuria to achieve better cost-effectiveness.

In summary, among schoolchildren aged 6 to 18 years with newly diagnosed diabetes, the ratio of type 2 to type 1 DM was approximately 6:1. Those with type 2 DM were more obese and had a higher rate of hypercholesterolemia, higher blood pressure, and a positive family history of diabetes.

Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ. Increasing prevalence of type 2 diabetes in American Indian children.  Diabetologia.1998;41:904-910.
Rosenbloom AL, Young RS, Joe JR, Winter WE. Emerging epidemic of type 2 diabetes in youth.  Diabetes Care.1999;22:345-354.
Dean H. NIDDM-Y in first nation children in Canada.  Clin Pediatr.1998;37:89-96.
Orit PH, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents.  J Pediatr.1996;128:608-615.
Kitagawa T, Owada M, Urakami T, Tajima N. Epidemiology of type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus in Japanese children.  Diabetes Res Clin Pract.1994;24(suppl):S7-S13.
Pihoker C, Scott CR, Lensing SY, Cradock MM, Smith J. Non-insulin-dependent diabetes mellitus in African-American youth of Arkansas.  Clin Pediatr.1998;37:97-102.
The Diabetes Control and Complications Trial Research Group.  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med.1993;329:977-986.
UK Prospective Diabetes Study Group.  Tight blood pressure and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  BMJ.1998;317:703-713.
American Diabetes Association.  Screening for type 2 diabetes.  Diabetes Care.2003;26(suppl 1):S21-24.
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American Diabetes Association.  Type 2 diabetes in children and adolescents.  Diabetes Care.2000;23:381-389.
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections.  Diabetes Care.1998;21:1414-1431.
Kitagawa T, Owada M, Urakami T, Yamauchi K. Increased incidence of non-insulin dependent diabetes mellitus among Japanese schoolchildren correlates with an increased intake of animal protein and fat.  Clin Pediatr.1998;37:111-116.
Kawamura T, Kadotani S, Kimura K, Nishihara S, Inada H, Ishiki G. The epidemiological study on the prevalence rate of childhood type 2 diabetes in Osaka City of Japan using capture and recapture method.  Diabetes.1999;48(suppl 1):A168.
Kida K, Owada M, Kikuchi N. Type 2 diabetes in children and adolescents in Asia. In: Silink M, Kida K, Rosenbloom A, eds. Type 2 Diabetes in Children and Adolescents. London, England: Martin Duniz; 2003.
Wei JN, Chuang LM, Lin CC, Chiang CC, Lin RS, Sung FC. Childhood diabetes identified in mass urine screening program in Taiwan, 1993-1999.  Diabetes Res Clin Pract.2003;59:201-206.
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Figures

Figure. Scheme of Diabetes Identification in Urine Screening Program for Schoolchildren in Taiwan, 1999
Graphic Jump Location
To convert levels of fasting plasma glucose from mg/dL to mmol/L, multiply by 0.0555.

Tables

Table Graphic Jump LocationTable 1. Rate of Newly Identified Diabetes by Grade and Sex Identified in the Glycosuria Screening for Schoolchildren in Taiwan, 1999*
Table Graphic Jump LocationTable 2. Demographic and Biochemical Characteristics Among Schoolchildren With Type 2 DM, Unclassified Diabetes, and Normal Fasting Glucose (Comparison Group) in Taiwan*
Table Graphic Jump LocationTable 3. Univariate and Multivariable Logistic Regression Analyses for Factors Associated With Type 2 Diabetes Mellitus in Schoolchildren in Taiwan

References

Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ. Increasing prevalence of type 2 diabetes in American Indian children.  Diabetologia.1998;41:904-910.
Rosenbloom AL, Young RS, Joe JR, Winter WE. Emerging epidemic of type 2 diabetes in youth.  Diabetes Care.1999;22:345-354.
Dean H. NIDDM-Y in first nation children in Canada.  Clin Pediatr.1998;37:89-96.
Orit PH, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents.  J Pediatr.1996;128:608-615.
Kitagawa T, Owada M, Urakami T, Tajima N. Epidemiology of type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus in Japanese children.  Diabetes Res Clin Pract.1994;24(suppl):S7-S13.
Pihoker C, Scott CR, Lensing SY, Cradock MM, Smith J. Non-insulin-dependent diabetes mellitus in African-American youth of Arkansas.  Clin Pediatr.1998;37:97-102.
The Diabetes Control and Complications Trial Research Group.  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med.1993;329:977-986.
UK Prospective Diabetes Study Group.  Tight blood pressure and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  BMJ.1998;317:703-713.
American Diabetes Association.  Screening for type 2 diabetes.  Diabetes Care.2003;26(suppl 1):S21-24.
US Preventive Services Task Force.  Screening for type 2 diabetes mellitus in adults: recommendations and rationale.  Ann Intern Med.2003;138:212-214.
American Diabetes Association.  Type 2 diabetes in children and adolescents.  Diabetes Care.2000;23:381-389.
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections.  Diabetes Care.1998;21:1414-1431.
Kitagawa T, Owada M, Urakami T, Yamauchi K. Increased incidence of non-insulin dependent diabetes mellitus among Japanese schoolchildren correlates with an increased intake of animal protein and fat.  Clin Pediatr.1998;37:111-116.
Kawamura T, Kadotani S, Kimura K, Nishihara S, Inada H, Ishiki G. The epidemiological study on the prevalence rate of childhood type 2 diabetes in Osaka City of Japan using capture and recapture method.  Diabetes.1999;48(suppl 1):A168.
Kida K, Owada M, Kikuchi N. Type 2 diabetes in children and adolescents in Asia. In: Silink M, Kida K, Rosenbloom A, eds. Type 2 Diabetes in Children and Adolescents. London, England: Martin Duniz; 2003.
Wei JN, Chuang LM, Lin CC, Chiang CC, Lin RS, Sung FC. Childhood diabetes identified in mass urine screening program in Taiwan, 1993-1999.  Diabetes Res Clin Pract.2003;59:201-206.
Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.  Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.  Diabetes Care.1997;20:1183-1197.
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