Hypoglycemia Vs Hyperglycemia: Vital Information

Hypoglycemia Vs Hyperglycemia

Diabetes, Type 1

DEFINITION

Type 1 diabetes mellitus, or insulin-dependent diabetes, is a chronic condition in which the pancreas cells do not produce insulin.

Insulin is a hormone necessary for glucose (sugar) in the blood to be absorbed into the body’s cells. If glucose is not absorbed, blood glucose levels can rise dangerously high.

A child diagnosed with type 1 diabetes will have the disease for life and manage it by taking insulin via injections or a pump.

Type 1 diabetes was once known as “juvenile diabetes” because it primarily affects children and adolescents.

In contrast, type 2 diabetes occurs mainly in adults and is caused by a failure of the body’s cells to respond to insulin.

According to the American Diabetes Association, in 2019, 34.2 million Americans, about 10.5 percent of the population, live with diabetes.

DESCRIPTION

Type 1 diabetes disturbs the body’s ability to use the simple sugar glucose from digested food.

Carbohydrate-rich foods such as fruit, pasta, bread, potatoes, rice, cereals, and sweets are broken down into simple sugars, primarily glucose, in the stomach and small intestine.

Similarly, table sugar is broken down into glucose and fructose. Glucose passes through the intestinal wall and into the bloodstream, carried to cells and tissues throughout the body.

Glucose can enter a cell through a protein receptor on the cell’s surface.

The cell “burns” glucose for energy to make ATP, a small molecule that powers all the cell activities.

Usually, the body keeps the amount of glucose in the blood within a very narrow range.

This maintenance is accomplished by the hormone insulin, which tells the cell’s receptors to allow glucose.

Insulin is made by the pancreas, a long gland that sits behind the stomach. Within the pancreas are clusters of cells called the islets of Langerhans.

Each tiny islet (“island”) includes the beta cells that make insulin. In type 1 diabetes, the beta cells cease producing insulin or do not produce enough of it.

With no insulin, glucose stays in the blood, and cells are starved for energy.

When cells are starved, they send a signal to the liver to release even more sugar into the blood. A high level of blood glucose is called hyperglycemia and can be dangerous.

Also, the body may rapidly break down proteins and fats for energy, releasing chemicals called ketones into the blood.

Elevated ketones may lead to ketoacidosis symptoms, which may require a trip to the hospital and sometimes leads to a diagnosis of type 1 diabetes.

DEMOGRAPHICS

In the United States, approximately 1.6 million adults and children have type 1 diabetes, with about 187,000 children affected.

Recent decades have seen a rise in type 1 diabetes cases in the United States, Europe, and even Japan, where this condition is much less common.

Among U.S. ethnic groups, non-Hispanic whites have the highest risk of type 1 diabetes.

Family history, such as having a father or sibling with the condition, increases a child’s risk.

Type 1 diabetes is detected more often in children age 4–7 and 10–14 than in other age groups.

It also occurs in 50% of children with type 1 polyglandular autoimmune syndrome, a disease affecting multiple organs.

CAUSES

While researchers do not know the precise cause of type 1 diabetes, they know that the body’s immune cells, which generally attack and destroy pathogens such as bacteria and viruses, instead of attack the pancreas’ islet cells.

For this reason, type 1 diabetes is considered an autoimmune disorder.

Although genetic factors may make children more likely to develop type 1 diabetes, researchers believe the condition may also require a “triggering event,” such as exposure to a virus or other factors in the environment.

The genes most closely associated with type 1 diabetes are immune system genes called HLAs. Some alleles (variants) of these genes are found more often in type 1 diabetics than in other people.

SYMPTOMS

Hyperglycemia

Symptoms of untreated type 1 diabetes include excessive thirst, frequent urination, and dehydration.

These symptoms occur because hyperglycemia (high blood glucose) causes the kidneys to excrete water as they remove the excess glucose in the blood.

This process may also lead to bedwetting in children. Other symptoms include excessive hunger, weight loss, lethargy (tiredness), irritability, blurred vision, and flu-like symptoms.

Glucose is needed for energy, and when cells do not absorb enough of it, the body lacks the power to function normally.

Ketoacidosis

The breath of a type 1 diabetic may have a sweet or fruity smell. This symptom is due to ketones; compounds formed when the body breaks down fats for energy.

A pileup of ketones in the body can lead to diabetic ketoacidosis. Symptoms of this condition include abdominal pain, vomiting, rapid breathing, and extreme tiredness. Ketoacidosis is a severe condition that requires emergency treatment.

Hypoglycemia

Even when diabetes is treated with insulin, hypoglycemia (low blood glucose) can occur if a child is given too much insulin, eats too little, or exercises too much.

Symptoms of hypoglycemia include sweating, shakiness, fatigue, rapid heartbeat, and hunger.

If not treated immediately, symptoms progress to confusion, headache, and loss of consciousness.

Hypoglycemia can occur while a child sleeps, causing night sweats, nightmares, and headaches.

Hypoglycemia requires immediate treatment. Usually, starchy food, juice, or glucose tablets can return blood glucose to normal. In some cases, an injection of the hormone glucagon may be needed.

This hormone causes the liver to release stored glucose into the blood. In emergency cases, glucose may be injected intravenously by medical personnel.

Parents and caregivers of children with type 1 diabetes should understand these symptoms and what they need to do.

DIAGNOSIS

Several tests are used to diagnose diabetes. Usually, the first test looks at a part of the hemoglobin protein called A1C.

(Hemoglobin is a large blood protein that transports oxygen.)

The percentage of A1C with an attached glucose molecule indicates the average blood glucose level over the prior months.

A urine test for ketones can also show that the body breaks down fats and proteins for energy.

Diabetes can also be diagnosed by testing blood glucose measured in milligrams of glucose per deciliter of blood (mg/dL).

Normally, the body tightly controls glucose levels, so they remain within a minimal range (90–110 mg/dL).

(For comparison, this is about an eighth of a teaspoon of glucose in about two and one-third cups of blood.)

After fasting overnight, blood glucose should be less than 100 mg/dL. A result over 126 mg/dL suggests diabetes, while intermediate levels point to “prediabetes.”

If blood is drawn at any other time of day, after the patient has eaten, a result over 200 mg/dL indicates diabetes.

Blood glucose may be tested after the child is given a special milkshake to determine how quickly glucose is removed from the bloodstream.

Doctors may also test for antibodies produced by the immune system to confirm that they have type 1 instead of type 2 diabetes. Only type 1 diabetes is considered an autoimmune disease.

TREATMENT

Abnormal blood glucose levels can lead to symptoms and complications. Therefore, the usual diabetes treatment involves careful daily management of blood glucose.

Part of this process involves frequent monitoring of glucose levels and insulin delivery to ensure that glucose is in a normal range.

Following a good diet, exercising, and maintaining a healthy weight are also important. In particular, a low-carbohydrate diet is beneficial for people with diabetes.

Carbohydrates are nutrients that are converted by the digestive system to simple sugars, entering the bloodstream and raising glucose levels.

Foods with high fiber content are recommended because they are digested more slowly, preventing a sharp rise in blood glucose.

With fewer blood sugar spikes, there is less need for diabetes to inject themselves with insulin.

Healthcare professionals can provide advice about dietary changes that need to be made.

Monitoring blood glucose

Parents and caregivers should understand that often blood glucose is monitored four or more times a day at home.

Recording and tracking blood glucose can reveal whether certain foods or activities trigger highs and lows and whether the insulin dose needs to be adjusted or varied throughout the day.

Technology has evolved over the past few decades, making it easier to take a reading at home with an electronic glucose meter.

Details will depend on the type of meter used, but steps generally include:

• Prick the skin with a fine needle called a lancet. This is usually done on a fingertip to draw a tiny amount of blood.
• Touch the blood drop to a test strip. Test strips are specific to the meter, so care must be taken to use the correct type.
• Slide the test strip into the meter to obtain a reading. Recording each reading on a chart can reveal trends over time.

An alternative monitoring method is continuous glucose monitoring (CGM), which embeds a tiny sensor in the skin.

This transmits a signal to a wireless monitor that is attached to clothing. GGM has some advantages.

There is no requirement to prick the skin or remember to take and record readings, as the device automatically does so.

CGM devices also take readings more frequently, providing a more precise picture of how blood sugar changes throughout the day.

Additionally, CGM devices are beneficial for parents with young diabetic children. The device can be set up to alert the parents of any dangerous changes to their child’s glucose levels.

A disadvantage is that GCM devices cost more than conventional glucose meters.

As of 2020, CGM devices are not considered as accurate as meters and must first be programmed using readings taken with a meter.

However, there is one device, the Dexcom G5 Mobile, approved for treatment decisions and does not require finger-stick blood glucose.

Administering insulin

The standard treatment for type 1 diabetes is the administration of insulin several times each day.

Several insulin types are available; these differ in how quickly they reach the bloodstream, when they “peak,” and the amount of time that must pass before more insulin can be administered.

Usually, shorter-acting insulin, given before meals, is combined with longer-acting insulin administered once or twice a day.

Forms of insulin include:

• Rapid-acting insulin, such as Apidra, Humalog, and Novolog, reaches the bloodstream quickly, peaks after an hour, and lasts 2–4 hours.
• Short-acting (regular) insulin, such as Humulin R and Novolin R, reaches the bloodstream in 30 minutes, peaks in 2–3 hours, and lasts 3–6 hours.
• Intermediate-acting insulin, such as Humulin N and Novolin N, reaches the bloodstream in 2–4 hours, peaks in 4–12 hours, and lasts 12–18 hours.
• Long-lasting insulin, such as insulin glargine or insulin detemir, works to regulate blood glucose 24 hours.
• Ultra-long-lasting insulin, such as insulin degludec, begins to work within 30 to 90 minutes and is active for as long as 40 hours.
• Pre-mixed insulin, such as Humulin 70/30, contains both shorter-and longer-acting forms.

INJECTING INSULIN

Because insulin is digested in the stomach, it cannot be taken by mouth. It must be injected or delivered by the pump.

Young diabetic patients need an adult to help with injections, but older children may begin to inject themselves under supervision.

All regular caregivers and grandparents or others who care for a diabetic child should be trained to inject insulin in an emergency.

Because many children (and adults) are fearful of needles, this aspect of diabetes treatment may be the most challenging.

However, most patients become comfortable with injections over time.

INSULIN PUMPS

An insulin pump, worn on the body, delivers insulin through a small tube inserted into the skin.

The pump must be programmed to deliver the appropriate amount. It continuously pumps a basal (base) rate of insulin to keep blood glucose levels steady.

Before meals or when blood glucose is too high, a button can be pressed to deliver a larger bolus (dose) of insulin.

While insulin delivery with a pump is more accurate and convenient than injections, the tube may sometimes be pulled out of the skin, resulting in missed doses.

New and experimental treatments

VACCINES

In 2013, researchers at Stanford University published results of a “reverse” vaccine designed to teach the immune system to turn off a portion of its response, resulting in diabetes by ignoring the pancreas’ beta cells producing insulin.

(In contrast, most vaccines teach the immune system to attack specific targets.)

In initial trials among volunteers with type 1 diabetes, none could stop using additional insulin, but some insulin was made naturally by the pancreas. Research using this approach is ongoing.

In 2015, clinical trials began to test a vaccine for treating existing cases of diabetes. The vaccine, called Bacillus Calmette-Guerin (BCG), actually dates to 1921 when used to treat tuberculosis.

If the vaccine proves successful, it would cure rather than prevent type 1 diabetes.

IMMUNOTHERAPY

 The initial immunotherapy drug for type 1 diabetes showed success in initial trials by delaying the onset of diabetes in high-risk participants by more than two years.

Further trials are ongoing, and the drug teplizumab received FDA breakthrough drug status in 2019 for use as a preventative agent for people at elevated risk of developing type 1 diabetes.

ISLET TRANSPLANTATION

 Islet transplantation involves removing the insulin-producing islets of Langerhans from a donor pancreas and injecting them into the recipient’s liver (the individual with type 1 diabetes).

This transplant is often done when the pancreas must be removed (for example, cancer).

In clinical trials, people with diabetes receiving transplants were often able to reduce or stop taking insulin. However, this procedure is generally performed in adult patients.

AUTOMATIC INSULIN

 Research is being done into devices that would act as an artificial pancreas. These devices would be able to monitor and regulate blood glucose levels automatically.

Like with a continuous glucose monitor, a sensor regularly checks blood glucose levels, and when it detects that insulin is needed, a pump releases the hormone.

This would eliminate the need for diabetes to constantly check their glucose levels and inject the insulin themselves, allowing them to lead a more normal life.

This would be especially beneficial for young children with diabetes who cannot monitor and inject independently.

As of 2019, the device and its trial results had been submitted to the FDA and were awaiting approval.

PROGNOSIS

By maintaining blood glucose at normal levels, children and adults with type 1 diabetes can live normal, active lives and avoid the most serious complications.

The high blood glucose seen in poorly controlled diabetes can damage the blood vessels and nerves and increase skin infections.

While these symptoms may not occur until much later in life, they can be prevented by establishing healthy childhood habits.

Long-term complications

Diabetes increases the risk of cardiovascular problems, stroke, and high blood pressure.

Excess blood glucose can damage the eye’s capillaries (tiny blood vessels), leading to diabetic retinopathy, glaucoma, and cataracts.

Damage to the capillaries of the kidney can lead to kidney disease or kidney failure.

Excess blood glucose can damage the capillaries leading to nerves, causing neuropathy.

This disorder may cause pain or other uncomfortable sensations, commonly in the legs or feet.

Neuropathy from chronically high blood glucose can eventually lead to numbness.

Combined with reduced blood flow, this can lead to infections that, if left untreated, may require amputation of affected body parts.

PARENTAL CONCERNS

Parents may be concerned about a diabetic child missing out on the fun of childhood—such as birthday parties that feature cakes and cookies or Halloween trick-or-treating for candy.

Diabetic children can enjoy these foods but in moderation. Families should develop a meal plan with the help of a nutritionist, dietitian, or medical professional.

Parents should work closely with their healthcare team to understand their child’s condition and treatment plan.

Support groups in the local area can help them to understand how to manage this condition.

Diabetes, Type 2

DEFINITION

Type 2 diabetes mellitus is considered a chronic condition in which the pancreas stops producing the required quantity of insulin or cells in the body stop responding to the produced insulin.

Insulin is a hormone necessary for glucose (sugar) in the blood to be absorbed into energy. (“Mellitus” means “honey-sweet,” referring to the presence of this sugar in the urine.)

Type 2 diabetes is a permanent condition that must be managed through diet, exercise, blood glucose monitoring, and medication, possibly including insulin injection.

While type 2 diabetes most commonly affects adults, an increasing number of children and adolescents have been diagnosed with this condition.

DEMOGRAPHICS

In 2020, an estimated 210,000 Americans under the age of 20 were diagnosed with diabetes. Type 2 diabetes rarely occurs in children under 10.

As a child becomes older, the risk of type 2 diabetes increases.

The American Diabetes Association (ADA) estimates that of about 24,000 new diabetes cases diagnosed in U.S. youth under 20 in 2015, 5,800 were type 2 diabetes.

While type 1 diabetes is far more common in this age group, type 2 diabetes is rising.

The worldwide increase in type 2 diabetes follows similar increases in obesity, and the two conditions are related.

While the rate among very young children did not increase greatly, for youths between ages 10–19, diagnosed type 2 diabetes cases increased 35% in the first decade of the 2000s.

The largest increase was among children of Hispanic descent, followed by African American youth.

For most ethnic groups, type 2 diabetes is still far less common among youth than type 1 diabetes (Native Americans aged 10–19 are the exception).

Native American, African American, and Hispanic youth have the greatest risk of type 2 diabetes—in that order.

CAUSES AND SYMPTOMS

causes

type 2 diabetes, the pancreas may not produce enough insulin, or the body’s cells may not respond as well to the insulin present in the bloodstream.

This decreased response is known as insulin resistance. Over time, insulin resistance may diminish the pancreas’s ability to produce insulin.

The causes of insulin resistance are unclear. However, both hereditary factors and environmental factors seem to be involved.

Age, being overweight, and family history of diabetes play a role in type 2 diabetes.

Experts believe the rise in childhood obesity and the more sedentary lifestyles of many children have contributed to the rise in type 2 diabetes among youth.

Symptoms

Symptoms of type 2 diabetes can develop suddenly, over days or weeks, in previously healthy children or adolescents.

They can also develop more gradually, over months or even a year or more. Early signs that parents should be alert to include fatigue/lethargy, acute thirst, and frequent urge to urinate.

Other symptoms can include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or blurred vision.

Patches of darkened skin around the neck, underarms, or groin, called acanthosis nigricans, may also point to type 2 diabetes.

It is not unusual for type 2 diabetes to be detected while a child or teen visits a doctor about another health concern. About 40% of children with this condition are asymptomatic.

Risk factors adolescents who are at higher risk of developing type 2 diabetes include the following:

• those who are overweight or obese (above the 85th percentile in BMI for the age group)
• those with a relative with diabetes mellitus
• those belonging to a high-risk population (Hispanic, African American, Native American, Native Hawaiian)
• those who were born with a high or low birth weight

DIAGNOSIS

Diabetes is diagnosed by testing blood glucose, measured in milligrams of glucose per deciliter of blood (mg/dL).

(Alternately, the unit mmol/L [millimoles per liter] may also be used.) Normally, the body tightly controls glucose levels, so they remain within a minimal range (90–110 mg/dL).

For comparison, this is the equivalent of about one-eighth of a teaspoon of glucose in about two and one-third cups of blood. Blood glucose can be measured directly or indirectly.

Blood glucose tests

A1C TEST AND EAG. A1C is one component of hemoglobin, the large protein that transports oxygen in the blood.

The percentage of A1C with an attached glucose molecule indicates the average blood glucose level for the previous 60–90 days.

For this test, blood is drawn after fasting for at least eight hours. Diabetes is indicated by an A1C level equaling or exceeding 6.5% or greater on two separate test dates.

In 2009, the International Diabetes Federation proposed the A1C test as the preferable procedure for diagnosing diabetes and monitoring the quality of treatment.

The result of an A1C test may be converted to eAG (average glucose number), which reports blood glucose in the same units as home glucose meters.

For example, an A1C result of 6.5% corresponds to an eAG of 140 mg/dL.

FASTING GLUCOSE TEST

For a fasting glucose test, blood is drawn at least eight hours after the individual has eaten, usually ahead of breakfast. 

Red blood cells are extracted from the sample, and the amount of glucose is measured in the remaining plasma.

A plasma glucose degree of 126 mg/dL (7 mmol/L) or higher can suggest diabetes. The fasting glucose testing is usually repeated on another day to confirm the results.

RANDOM GLUCOSE TEST

For the random glucose test, blood is drawn at any time of day. A plasma glucose niveau of 200 mg/dL (11.1 mmol/L) or greater can indicate diabetes.

ORAL GLUCOSE TOLERANCE TEST

 For the oral glucose tolerance test, blood samples are taken before and after the individual drinks a thick, sweet syrup containing glucose.

In a healthy person, the glucose level in the blood goes up immediately after the drink and then decreases gradually as the cells and tissues absorb the sugar.

In a person with diabetes, blood glucose increases and remains high. A plasma glucose level with a value of 200 mg/dL (11.1 mmol/L) or higher, two hours after drinking the syrup, indicates diabetes.

TREATMENT

Diabetes is often handled with medication and style of living adjustments so that patients can live a relatively normal life.

Treatment of diabetes focuses on two goals: keeping blood glucose within normal range and preventing long-term complications.

Careful monitoring of diet, exercise, and blood glucose levels is as important as insulin or oral medications in preventing complications of diabetes.

When a child’s diagnosis is clearly typed 2 diabetes, the American Academy of Pediatrics strongly recommends diet and lifestyle changes involving the whole family, including nutritional support to develop a healthy diet for the whole family;

increased levels of physical activity, such as 60 minutes or more of moderate or vigorous activity daily; a two-hour daily limit on sedentary activities such as television and computer time (not counting the school day or homework); and ongoing monitoring of blood sugar levels through home glucose monitors and laboratory blood tests.

Sometimes, dedicated adherence to these changes is adequate to reduce blood sugar to normal levels, though the child will need to continue this lifestyle throughout the lifespan. Lifetime glucose monitoring is also critical.

The diabetes treatment plan is likely to change as a child grows into adulthood, but parents can help established good habits early.

Weight loss may be an important goal in helping children and adolescents to control type 2 diabetes.

Often, weight management is recommended, allowing children to “grow into” their current weight. Changes in diet and exercise can help children achieve these goals.

Implementing dietary changes

A well-balanced, nutritious diet for children ages 4–18 provides approximately 45–65% of calories from carbohydrates, 10–30% of calories from protein, and 25–35% of calories from fat.

The total number of calories required daily depends on age, gender, weight, and activity level.

The calorie intake should be distributed over the course of the entire day, so surges of glucose entering the blood system are kept to a minimum.

Some foods cause blood glucose to rise more rapidly than others. One measure of how likely a food is to raise blood sugar is the glycemic index (GI).

Quickly digested cereals, white bread, white rice, soft drinks, and sweets are high GI foods, causing blood sugar to rise quickly after being eaten.

Carbohydrates such as whole grains, vegetables, legumes, and fruits are lower GI foods. They take longer to digest and are recommended for diabetic patients.

Keeping track of calories and carbohydrates provided by different foods can become complicated, so parents usually are advised to consult a nutritionist, dietitian, or certified diabetes educator (CDE).

An individualized, easy-to-manage diet plan can be set up for diabetic children, adolescents, and their families.

Monitoring blood glucose at home

A child’s blood glucose may need to be monitored at home one or more times per day.

If insulin is prescribed, monitoring can reveal whether the dose needs to be adjusted.

Technology has made it easier to take a reading at home with an electronic glucose meter.

Details will depend on the type of meter used, but steps generally include the following:

• Pricking the skin with a fine needle, called a lancet. This is usually done on the fingertips and draws a tiny amount of blood.
• Touching the blood to a test strip. Test strips are specific to the meter, so care must be taken to use the correct type.
• Inserting the test strip into the meter to obtain a reading. Recording each reading on a chart can reveal trends over time.

Medications

Often for initial treatment and when lifestyle changes do not bring about the desired blood sugar levels, medication is required.

While there are several oral medications on the market, most were originally developed and tested for adults.

As of 2020, metformin is the only oral drug approved by the FDA for patients under age 18. Available in pill and liquid form, metformin is taken daily to reduce the amount of stored glucose released by the liver.

During initial treatment, some children might experience upset stomachs, diarrhea, and nausea, but these side effects usually go away after a few weeks.

Liraglutide, a daily injectable drug, was also approved in 2019 for use in children with type 2 diabetes aged 10 and over.

Other types of oral and injectable drugs are approved for adult type 2 diabetes, and research is underway to determine if they might be appropriate for children.

The child’s medical professionals are the best source of information for newly approved treatments for children under 18.

RISKS

Hypoglycemia, or low blood sugar, can be caused by too much insulin, too little food (or eating too late to coincide with the action of the insulin), or too much exercise.

Children or adolescents with hypoglycemia may be hungry, cranky, confused, and tired.

They may become sweaty and shaky. Left untreated, a child or teen can lose consciousness or have a seizure.

This condition is sometimes called an insulin reaction and should be treated by giving the patient 15–20 grams of sugars in glucose tablets, sugar cubes, fruit juice, or another high-sugar snack.

In some cases, parents of children with type 2 diabetes may need to work with the child’s teachers and school administrators to ensure that the child can take medications as needed and have access to healthy foods.

If the child takes insulin, someone at school should be trained in administering a glucagon injection, an emergency treatment for a hypoglycemic episode when a child loses consciousness.

PROGNOSIS

Type 2 diabetes is a chronic condition that will be a concern for the rest of a child’s life.

However, with proper medical management, the complications of diabetes can be minimized.

Lifestyle changes to increase exercise and healthy eating, losing weight when appropriate, and careful monitoring will help keep diabetes under control.

However, many long-term complications of type 2 diabetes do not occur until adulthood.

Unmanaged diabetes is a leading cause of blindness, kidney disease, and limb amputations in adults.

It also duplicates the risks of heart illness and grows the chance of stroke.

Eye issues, including cataracts, glaucoma, and diabetic retinopathy, are also common in people with diabetes.

Other problems often experienced by those with diabetes include problems with the nerves in the legs and feet that can lead to pain, delayed wound healing, and infection. Heart disease and kidney disease are common complications of diabetes.

PREVENTION

Leading a healthy lifestyle is crucial to preventing the onset of type 2 diabetes and avoiding further disease complications.

Weight is one of the primary risk factors for type 2 diabetes in children, as obese or overweight children are more likely to develop the condition.

Maintaining a healthy weight or losing weight when necessary is the best way to prevent diabetes.

Some ways to do this include

• avoid sweetened drinks; drink water instead
• increase the consumption of fruits and vegetables
• limit the consumption of fast food, prepared foods, and sweets
• reduce portion sizes—especially of high-fat, high-sugar foods
• increase physical activity by encouraging active play and walking and biking in place of car travel, when possible
• impose a two-hour daily limit on sedentary “screen time” in front of the television, computer, or video games

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