1. Lack of patient follow-up in Concepts Classes for new onset type 2 diabetes (after the initial survival skill class) at Children’s National Medical Center
2. Lack of clinic attendance (we have had to cancel type 2 diabetes clinics due to lack of patients keeping appointments) at Children’s National. 

Behavior change is inordinately difficult. Because the child/adolescent with type 2 diabetes may not need insulin initially, there is a different mind set. The teens that rebel against parents usually do so with impulsive risk-taking behavior including drugs and alcohol as well as eating things they know that they probably should avoid. Unfortunately, fast food is not going to disappear, safer places for play are not imminent (especially in the inner city), and healthy food remains expensive and sometimes unattainable.

In addition, biology is not contributing fast enough to stave off increasing obesity. Evolutionary adaption has not caught up to our present way of living. Thus, in combination with biology, family circumstances, and adolescent lifestyle, I am not optimistic about curbing the type 2 diabetes epidemic until we can improve the rates of obesity in our children. I also believe the current model of type 2 diabetes care is incorrect. Change needs to occur gradually in the home environment and community in terms of life style, etc. Intervention will need to be conducted in places different than the usual healthcare setting: homes/churches/schools, recreation centers. In this way, all family members may be targeted instead of only the child with type 2 diabetes.