Diabetes Homeopathic Treatments

Reverse Diabetes Now

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Appropriate Antidiabetic Protocols

The family physician must determine if it is appropriate to continue the outpatient treatment schedule in the hospitalized diabetic patient, depending mainly on the reason for hospitalization. If the patient can eat, the regular outpatient treatment (oral agents and or insulin) should be continued with appropriate adjustments. Supplementing this with basal bolus insulin may be appropriate if significant hyper-glycemia (> 200 mg dL) occurs associated with the stress of illness and hospitalization. The outpatient regimen should not be discontinued in favor of a fixed sliding-scale insulin schedule, which will take days to titrate to the patient's needs and may result in erratic hyper- and hypoglycemic intervals. If the patient cannot be fed and glucose values are drifting above the 150- to 180-mg dL range because of stress-mediated gluconeogenesis, treatment to prevent further hypergly-cemia is appropriate. Basal insulin can be given to fasting patients at starting dosages of 0.25 U...

Subacute Presentation of Type 1 Diabetes

The management of type 1 diabetes will depend on the patient's age and the acuity of the diabetes at presentation. Since there is usually no family history of diabetes, or diabetic experience at home, and given the fragility of the new-onset diabetic state, many children or adolescents presenting with type 1 diabetes require hospitalization to initiate and teach glucose monitoring techniques and to begin insulin treatment. The indication for hospitalizing a newly diagnosed child who is not drifting into ketosis depends on the availability of outpatient educational resources and the clinical judgment that the patient can be closely monitored and the family appropriately advised while developing the capabilities of diabetic self-management.

Child Adjustment to Type 1 Diabetes

A considerable amount of research has been conducted over the past three decades that examines youth adjustment to type 1 diabetes. Collectively, the extant research suggests that many of these children are well adjusted across multiple domains of emotional and behavioral functioning (e.g., Dela-mater 2007 Jacobson et al. 1997 Johnson 1980). At the same time, a consistent subset of youth with type 1 diabetes appears to be at risk for developing significant adjustment difficulties, particularly depression, anxiety, and eating disorders (e.g., Kovacs et al. 1997). However, the relative risk to these individuals for developing a significant mental disorder and the extent to which their disease directly or indirectly contributes to psychiatric symptomatology remain to be determined. Indeed, some of these youth may have experienced premorbid adjustment problems and family dysfunction prior to the diagnosis of type 1 diabetes. Although Kovacs et al. (1997) found relatively high rates of...

Parental Adjustment to Type 1 Diabetes

Although the majority of parents of children with type 1 diabetes adapt well, a subset of parents reports clinically significant psychological distress following initial diagnosis and throughout the course of their child's illness (e.g., Kovacs et al. 1990 Parker et al. 1994). Increased maternal psychological distress (e.g., symptoms of anxiety, somatiza-tion, anger, suspiciousness, depression, dysphoria) has been observed immediately following diagnosis. Parents of children with chronic illness have reported increased depressive symptoms (Mullins et al. 1995), greater negative affective states (Cadman et al. 1991), and higher global psychological distress (Chaney et al. 1997 Northam et al. 1996 Silver et al. 1998). Moreover, maternal distress after the ini tial diagnosis of child type 1 diabetes is highly predictive of subsequent maternal psychological symptomatology (Kovacs et al. 1990). The transactional association between maternal distress and child distress has also been well...

Diabetes Mellitus

Diabetes is a rapidly growing worldwide pandemic, and cigarette smoking is responsible for about 10 of the incidence of type 2 diabetes. A dose-response relationship exists, with the risk increasing in direct proportion to the number of cigarettes smoked. People who smoke more than one pack a day have about double the risk for diabetes as nonsmokers, and the risk is still 1.5 times greater for those who smoke only 1 to 14 cigarettes a day (Manson et al., 2000 Willi et al., 2007). Smoking increases the risk for development of the metabolic syndrome and its attendant cardiovascular consequences (Chiolero et al., 2008). Patients with diabetes who smoke are at increased risk for both micro- and macrovascular complications. Cigarette smoking increases the risk for diabetic nephropathy, retinopathy, and neuropathy. This association is strongest in patients requiring insulin for control. Smoking cessation is essential for preventing diabetic complications.

Oxidative Stress in Diabetes Mellitus Associated ED

Diabetes mellitus is one of the major risk factors for ED. It has been estimated that 50-75 of diabetic men have ED 41 . Compelling data from molecular, cellular, and in vivo animal studies implicate a crucial role for oxidative stress in the development and progression of ED associated with diabetes. Both hyperglycemia and free fatty acids augment ROS The mechanisms for ROS production and the source of ROS in the diabetic penis are, however, only starting to be evaluated. In type 1 diabetic animals, increased protein expression of NADPH oxidase subunit p47phox implies the role of NADPH oxidase as a ROS-producing source 50, 62 . While the role of eNOS uncoupling in diabetic ED is not known, several studies in the diabetic penis 54, 63 , and our unpublished studies (Musicki and Burnett, unpublished) indicate the role of eNOS uncoupling as another ROS source. Future studies are needed to establish the mechanism of NADPH upregulation and eNOS uncoupling in diabetes-associated ED....

Measurement of Proinsulin and C Peptide

Proinsulin is the precursor molecule for insulin and is found in the rough endoplasmic reticulum of the beta cells in the pancreatic islets. As shown in Figure 79-2, the proteolytic conversion of proinsulin results in the formation of equimo-lar amounts of insulin and its connecting peptide, C peptide. In the presence of an insulinoma, there is an elevation of both proinsulin and C peptide.1015 Furthermore, proinsulin levels, which are usually less than 20 of the total immunoreactive insulin in normal individuals, are elevated in the presence of an insulinoma. Levels higher than 50 are thought by some to be diagnostic of an islet cell carcinoma. Finally, should the diagnosis still be in doubt, measurement of circulating C peptide may be helpful. The normal C peptide level is less than 1.2 ng dL. There are two specific instances in which measurement of C peptide levels has been particularly helpful. The first is in patients with insulin-dependent diabetes mellitus. Such patients may...

Glucose and Insulin Levels

Currently, the diagnosis of insulinoma is confirmed by demonstrating a circulating insulin level that is inappropriately high for the serum glucose level, measured at the time of hypoglycemia (Fig. 79-3). When a patient presents with symptoms of hypoglycemia (i.e., coma, convulsions, or other neurologic symptoms), blood samples should be taken for the determination of both insulin and glucose levels. Samples should be drawn as early as possible to avoid complications of hypoglycemia and before treatment with glucose. Also, later, epinephrine secretion may cause mobilization of liver glycogen with a compensatory rise in serum glucose, possibly masking the hypoglycemia associated with an insulinoma. Although normal serum glucose levels are 60 to 95 mg dL, symptoms of hypoglycemia usually do not occur until levels are less than 50 mg dL. Normal serum insulin levels are typically below 30 pU mL.

Endocrine Pancreas and Type 2 Diabetes

From the previous discussions, it is clear that the endocrine pancreas is a complexly regulated organ that integrates incoming impulses of nutrient, hormonal, and neural nature. The endocrine pancreas converts these impulses to an optimal secretion of the islet hormones mainly for the regulation of carbohydrate homeostasis. An example of the consequences that follow derangement of the endocrine pancreas is type 2 diabetes. A primary event during the development of this disease is a reduced action of insulin on the activation of peripheral insulin receptors.156 This results in a compensatory increase in insulin secretion, which explains the hyperinsulinemia that accompanies states with peripheral insulin insensitivity, such as obesity. The relation between Insulin sensitivity FIGURE 78-3. Schematic illustration of the relation between insulin sensitivity and insulin secretion. During progression to insulin resistance (i.e., low insulin sensitivity), insulin secretion is increased in a...

The Gut and Insulin Secretion

It has long been known that oral ingestion of glucose results in high levels of plasma insulin, although the increase in plasma glucose is only marginal.100'101 This is due to the action of gut hormones, called incretins, that are released into the circulation during meal intake and stimulate insulin secretion. The most important incretins are glucose-dependent insulinotropic polypeptide (GIP also called gastric inhibitory polypeptide) and GLP-1.102 103 GLP-1 is a 30-amino acid peptide produced in the L cells in the distal part of the small intestine, and GIP is a 42-amino acid peptide produced in the K cells in the duodenum and proximal portion of the small intestine. They are both released into the circulation during the first 15 minutes after initiation of food intake, and they both stimulate insulin secretion. Their importance as incretin hormones is illustrated by findings that insulin secretion and glucose tolerance are impaired in mice with genetic deletion of the GIP...

Type 2 Diabetes Mellitus Prevention

Obesity and overweight are important risk factors for developing type 2 diabetes mellitus. Lifestyle modifications, including diet, have been shown to reduce the risk of developing type 2. Diets that result in long-term weight loss of 5 to 7 , along with exercise of moderate intensity for at least 150 minutes per week (30 minutes for 5 days per week), reduce the incidence of type 2 diabetes (Knowles et al., 2002). Obesity tends to increase insulin resistance, so weight loss is an important tool in the prevention and management of type 2 diabetes (see Chapter 36). Dietary recommendations for type 2 patients are similar to those for type 1 patients. It is important to emphasize the importance of other lifestyle changes, such as increasing activity by these patients. In patients with insulin resistance, reduced calorie intake and modest weight loss can improve insulin resistance and blood glucose levels in the short term. Structured programs for making lifestyle modifications (e.g.,...

Type 2 Diabetes Mellitus

According to BRFSS, the prevalence of type 2 diabetes mel-litus (T2DM) increased from 4.9 in 1990 to 7.9 in 2000 (Mokdad et al., 2003). This change has been clearly linked to the increase in obesity. The risk of T2DM is lowest below a BMI of 22 to 23 kg m2. At a BMI of 31, the risk for women in the NHS was 40-fold greater than in women with a BMI less than 22 (Colditz et al., 1995). For men in the Health Professionals Follow-up Study, the risk of T2DM above a BMI of 35 kg m2 was increased 60-fold. Up to 80 of cases of T2DM can be attributed to overweight and obesity. There appears to be a time delay of about 10 years between the development of overweight and onset of the diabetes (Bray, 2003). As weight increases, insulin resistance and compensatory insulin secretion also increase. At some point, the body's ability to secrete insulin does not meet requirements, and blood glucose rises. Weight loss is recommended to lower elevated glucose levels in overweight and obese persons with...

Diabetic Nephropathy Diabetic Glomerulopathy Renal Interstitial Syndromes

Before the DCCT, a patient with type 1 diabetes had a 30 to 40 likelihood of developing macroproteinuria (> 300 mg day), which would quickly progress to renal insufficiency and the need for renal dialysis. This process begins with pro-teinuria and increasing BP as early as 10-15 years after diagnosis of type 1 diabetes. In the early 1970s, when repeated studies showed that lowering of BP reduced cardiovascular events, diabetologists began to observe that good BP control, including use of diuretics, prolonged the interval from the onset of proteinuria to renal failure. The first studies of the angiotension-converting enzyme (ACE) inhibitor capto-pril suggested that treatment reduced macroproteinuria in patients with moderate renal insufficiency. Subsequent work in the 1990s indicated that reduced proteinuria impaired nephron loss and preserved renal function. The protein leak into the glomerular space may contribute to the mesangial proliferative reaction, starting a process that may...

Hospital Care of Diabetic Patients

Achieving diabetic control under normal ambulatory conditions is difficult enough in most patients. When illness prevents a patient from utilizing diabetic survival skills, however, and the stress of illness overcomes the patient's available insulin, care of the patient becomes a professional challenge. In the past, lack of data often resulted in less-than-optimal diabetic care in favor of managing the primary illness. Recent observations, however, demonstrate the efficacy of glycemic control in critically ill surgical patients. As a result, intensive glucose management protocols with continuous insulin infusion are now being widely applied. Good glucose control in known diabetic patients and those with marked hyperglycemia and critical illness shortens intensive care unit (ICU) and respirator time and reduces associated polymyopathy while generally improving all outcome parameters. Many post-cardiothoracic surgery units have adopted these protocols to improve myocardial energetics,...

Postpartum Gestational Diabetes

Some authorities recommend GTT at 3 months postpartum to detect evidence of persisting DM if fasting values have normalized. This nonpregnant GTT merely measures the 2-hour value after a 75-g glucose challenge. Values of 200 mg dL or greater confirm type 2 diabetes values of 160 to 200 mg dL and higher indicate impaired tolerance consistent with insulin resistance. Finding normal glucose values at 3 months does not preclude the onset of type 2 diabetes later, when further changes in body composition occur with aging. Thus a woman with a history of GDM should periodically self-monitor fasting and postprandial values to assess her inherent diabetic risk and demonstrate her motivation to suppress it indefinitely.

Gestational Diabetes Mellitus

In about 50 of women, GDM is reversible after pregnancy and does not inevitably evolve to type 2 diabetes. Asymptomatic type 1 or 2 diabetes or LADA existing before pregnancy may become clinical and irreversible. Women with no prior evidence of diabetes may demonstrate their type 2 diabetic gene during pregnancy and either remain diabetic postpartum or experience a long, normal latent period before the gene is expressed again. The expected conversion rate of women with GDM to type 2 diabetes after pregnancy can be reduced with therapeutic lifestyle changes.

Initial Treatment Insulin and Potassium

Management of DKA involves administration of insulin, water, and electrolytes safely to prevent marked fluid shifts into the brain and a precipitous drop in potassium, which would impair compensatory hyperventilation. Insulinization promptly blocks further liposis and shuts down ketogenesis. R insulin is given as an intravenous (IV) bolus of 0.1 U kg with the start of saline administration. Some suggest the initial bolus should be as much as 20 U. The bolus infusion is followed by a continuous infusion of 0.1 U kg hr, with hourly adjustments based on decline in serum glucose and reversal of acidosis. Low-dose insulin infusions are safe if the potassium value is monitored, and improving metabolic parameters should be apparent in 1 or 2 hours. Some patients may be remarkably resistant, and a significant bolus adjustment of up to 20 units may be necessary in 1 hour, with modification of the infusion concentration. The objective is not to decrease glucose precipitously but to turn off...

Supportive Care for Children and Adolescents Requiring Insulin

As subacute diabetes is stabilized, the patient and family require extensive formal diabetic education, support, and empathy to ease the anxieties associated with a new diagnosis of a long-term disorder. A maladjustment in the needed insulin therapy could adversely affect the patient's success in living with diabetes. Instruction in dietary principles includes carbohydrate counting and insulin coverage, correction and adjustment of the insulin dosages based on glucose variability and physical activities, and the standards of care to limit acute and long-term risks of diabetes, as detailed next. Following clinical stabilization, the family physician can further consider the etiology and alternative treatments according to ongoing diabetic manifestations.

Initiating Insulin for Type 2 Diabetes

The classic setting for the use of insulin is in a newly diagnosed type 1 diabetic patient. However, insulin is more frequently used in the treatment of type 2 diabetes to compensate for the secretory defect that often progresses to a profound loss of insulin secretory reserve. This is suggested when FSG or HbA1c continue to rise despite the patient's best behavioral efforts and multiple oral drugs. A patient with type 2 diabetes can also present late in its course with marked hyperglycemia and even ketosis. In these patients, insulin treatment protocols used in type 1 diabetes are appropriate until the type 2 pattern of glucose homeostasis is recognized. In most patients, convenience insulins such as human or synthetic 70 30 or 75 25 combinations can be used for several days until the effects of behavioral measures and oral agents kick in. Dosage is usually from 0.2 to 0.5 units (U) kg body weight day (in elderly patients, consider 0.1 U kg day). The initial dosage selected is a...

Overt Type 2 Diabetes

Remarkably, only 20 to 25 of individuals with hyperin-sulinemia and insulin resistance progress to overt type 2 diabetes. This progression begins when FSG becomes 100 mg dL or greater, the threshold for the diagnosis of prediabetes. Type 2 diabetes may be diagnosed at this phase if a casual postprandial glucose of 200 mg dL or higher is detected. Most patients diagnosed with type 2 diabetes may not note the typical hyperglycemic symptoms described for type 1 diabetes. The difference may be that type 2 diabetes evolves over years below the symptomatic threshold because sufficient insulin is present to prevent the marked lipolysis and ketonemia more typical of type 1 diabetes, with its obligatory water and electrolyte losses. Most patients with type 2 diabetes are discovered incidentally, such as during routine risk factor assessment for cardiovascular disease or other work-up for various symptoms, including peripheral senso-rimotor neuropathy, Bell's palsy, erectile dysfunction, visual...

Genetic Disorders of Insulin Resistance

These genetic defects may cause diabetes varying from mild to severe. Marked hyperinsulinemia activates epidermal growth factor receptors in skin, resulting in acanthosis nigricans, a darkening of skin folds at the nape of the neck or in the axilla. Marked hyperinsulinemia stimulates ovarian steroidogenesis, which can result in enlarged ovaries and a virilizing syndrome. This condition provided insight into the connection of insulin resistance to polycystic ovarian syndrome, which is now routinely treated with metformin to attenuate hirsutism and stimulate ovulation. The genetic defects in patients with generalized lipoatrophy have not been fully defined, but these patients are extremely insulin resistant because energy substrates can be stored only in liver and muscle. Impairment in fatty acid storage compromises muscle uptake and glucose oxidation.

Maturity Onset Diabetes of Young

Genetic defects of beta-cell function involve genes coding for hepatic transcription factors and glucokinase. In the MODY variant, hyperglycemia is observed during childhood or adolescence and is caused by a diminution in beta-cell secretion without impairment in insulin action. The genetic disorders are autosomal dominant, and the glucokinase defect impairs the conversion of glucose to glucose-6-phosphate, which is involved in insulin secretion. This glucokinase dysfunction causes a loss of the beta-cell glucose sensor. The resulting diabetes is generally not prone to ketosis. Many patients with milder forms of diabetes treated as type 1 eventually are found to have similar genetic defects.

Adherence Issues in Diabetes Care

A comprehensive review of treatment adherence in diabetes is beyond the scope of this chapter however, the tremendous importance of compliance with the complex medical regimen warrants a brief discussion (for additional information on adherence issues, see Delamater 2000 and Chapter 13, Treat ment Adherence, in this volume). As mentioned previously, diabetes adherence is a multifaceted construct, and children with diabetes face multiple task demands in regard to a complex treatment of a chronic illness. Although low overall adherence levels have been demonstrated in many chronic illnesses (Adams et al. 1997 Epstein and Cluss 1982), adherence levels in diabetes have often been found to be particularly poor (e.g., Johnson et al. 1986 La Greca et al. 1990 Reinehr et al. 2008). A number of types of adherence difficulties have been delineated in the research literature. Poor levels of adherence with young children and adolescents have been shown in self-monitoring of blood glucose...

Interventions for Children With Type 2 Diabetes and Their Parents

Limited research has been conducted on interventions for children and adolescents with type 2 diabetes. Indeed, the majority of research has been conducted with adults. However, given the connection between obesity and type 2 diabetes, preventive interventions for children and adolescents are becoming more common. These interventions focus on increasing dietary knowledge and promoting physical activity to help reduce the likelihood of type 2 diabetes. For example, a 1-year school-based intervention for students in grades 3-5 in Canada produced gains in dietary knowledge, overall health knowledge, and dietary self-efficacy (Saksvig et al. 2005). Similar interventions are described elsewhere (S.M. Davis et al. 1999 Macaulay et al. 1997). Other interventions that target adults diagnosed with type 2 diabetes have focused on group education programs (Davies et al. 2008) and self-management approaches (Thoolen et al. 2007). Pharmacological interventions, such as using metformin, have also...

Child and Parental Adjustment to Type 2 Diabetes

Research on parent and child adjustment to type 2 diabetes is scant, especially considering the rising incidence of the disease (Naughton et al. 2008). One area of research has focused on health-related quality of life (HRQOL). Quality of life is thought to be an important factor in adjustment to the illness and has consequently been increasingly studied in patients with diabetes (e.g., de Wit et al. 2007). For instance, Pediatric Quality of Life Inventory scores were used to compare 91 children and adolescents with type 2 diabetes with approximately 300 healthy controls children with type 2 diabetes were found to have lower total health, psychosocial health, emotional functioning, social functioning, and school functioning scores (Varni et al. 2003). Another study comparing HRQOL in 257 individuals ages 8-22 years with type 2 diabetes and 2,188 same-age individuals with type 1 diabetes also revealed that participants with type 2 diabetes had lower HRQOL (Naughton et al. 2008)....

Psychosocial Interventions for Children With Type 1 Diabetes and Their Parents

Over the past three decades, a variety of psychosocial and behavioral interventions have been utilized in the context of type 1 diabetes (for comprehensive reviews of such interventions, see Delamater 2007 Clearly, knowledge about diabetes and its treatment is an essential basis for diabetes management. Thus, systematic efforts have been made to impart such information through clinic-based interventions that occur immediately after diagnosis, as well as through other avenues such as summer camps (e.g., Harkavy et al. 1983 Karaguzel et al. 2005 San-tiprabhob et al. 2008). What is also clear, however, is that diabetes knowledge is insufficient for successful diabetes management. Indeed, knowledge is inconsistently associated with HbA1c levels (e.g., Johnson 1995). To further enhance diabetes management, researchers have used a variety of approaches that build on a knowledge base, such as group coping skills training (Grey et al. 2000) or behavioral contracting (e.g., Wysocki et al....

Cognitive Changes in Children With Type 1 Diabetes

Evidence suggests that children with type 1 diabetes may experience a wide range of cognitive difficulties associated with their disease. A number of studies document that these children are at risk for learning disabilities and may experience difficulties with attention, processing speed, long-term memory, and executive functioning (e.g., McCarthy et al. 2003 Rovet and Alvarez 1997 Schoenle et al. 2002). As a result, academic problems may emerge, particularly for those children who have earlier age at onset and who tend to have severe, recurring hypoglycemic episodes. Neurocognitive screening or a complete neuropsychological evaluation should therefore be considered for youth with type 1 diabetes, particularly for those who have experienced many negative glycemic events or who are struggling with school performance. Such an evaluation may well help the school develop an Individualized Education Plan that addresses needed academic and or physical accommodations.

Eating Disorders in Children With Diabetes

An additional and somewhat unique concern in children and adolescents with diabetes is the occurrence of disordered eating. Such disordered eating is believed to be the result of both the focus that the treatment of diabetes places on dietary intake and the fact that treatment modalities often result in weight gain. However, some controversy exists regarding the prevalence of disordered eating in individuals with type 1 diabetes. Some studies have found no significant increase in diagnoses of eating disorders, yet other studies have found a higher incidence of eating disorders and eating disorder-type behaviors in individuals who have type 1 diabetes. In addition, as in the general population, younger adolescent females with type 1 diabetes appear to be the most susceptible to the development of an eating disorder (Jones et al. 2000 Meltzer et al. 2001 Verrotti et al. 1999). The treatment for diabetes itself has also been used by some adolescents to manipulate their weight....

Eating Smart When You Have Diabetes

If you're diagnosed with diabetes, you should definitely seek the nutritional advice of a registered dietitian, preferably one who is certified as a diabetes educator (credentials will read R.D., C.D.E.). The goal of nutrition therapy is to restore and maintain blood glucose levels to as near normal as possible. This means balancing your food with insulin and activity levels. What's more, you'll want to maintain appropriate cholesterol and trigylceride levels, consume the right number of calories for maintaining a reasonable weight, and improve your overall health by eating right.

Can You Prevent Diabetes

So far, despite a number of research studies now underway, there are no definitive answers on how to prevent Type 1 diabetes. Type 2 diabetes is another story. You can reduce many of the risk factors that increase your chances for developing the condition. Poor lifestyle habits such as a bad diet and lack of exercise can increase your chances for getting diabetes. Other nonnutrition related risk factors for Type 2 diabetes include being over the age of 45, having a parent or sibling with the disease, being of Latino, Native American, African American, or Pacific Islander descent, and, in a woman, having polycystic ovarian syndrome. Furthermore, there's strong evidence that even modest weight loss and exercise can significantly reduce the onset of Type 2 diabetes in people with an impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). In one study, individuals who lost 5 to 7 percent of their body weight and walked for 150 minutes each week reduced their risk of developing...

Diagnosing Diabetes Is Easy

In fact, it's one of the simplest disorders to diagnose. A simple finger prick yields a couple of drops of blood that are analyzed for the presence of sugar. In nonpregnant adults, the criteria for diagnosis is as follows a blood-sugar level of greater than 200 mg dl, a fasting blood-sugar level of greater than 126 mg dl, or a two-hour blood-sugar level of greater than 200 mg dl during an oral glucose tolerance test. All pregnant women should be tested for GDM between 24 and 28 weeks of gestation. The testing, called an oral glucose tolerance test (OGTT), is painless and reliable. A blood-sugar level is obtained, and then the patient drinks a glass of sugary liquid. One hour later, a second blood-sugar reading is obtained. If a mom-to-be has a fasting blood sugar of greater than 126 mg dl, or a random blood sugar of greater than 200 mg dl, she meets the criteria for diabetes. It's very important to diagnose GDM because, when treated with proper diet and possibly insulin therapy,...

Complications of diabetes mellitus

Cardiovascular disorders (coronary artery, cerebrovascular and peripheral vascular) are common in diabetics, and there is an increased risk of perioperative myocardial infarction. Careful preoperative assessment of cardiovascular function, appropriate choice of anaesthetic technique and precise perioperative monitoring are essential. Infection. Diabetics are prone to infection and an increased risk of septicaemia and abscess formation. Infection is associated with increased insulin requirements, which return to normal on its eradication, e.g. after surgical drainage of an abscess.

Drugs used to treat diabetes mellitus Commentary

Diabetes is common and the main clinical interest for anaesthetists lies in the maintenance of effective glucose homoeostasis. This is not, however, the focus of this question, which concentrates more on an understanding of intermediary metabolism. The range of drugs is expanding, but you will not be asked in any detail about newer agents such as the meglitinides and glitazones. You will, on the other hand, be expected to know about insulin and something about the well-established biguanides and sulphonylureas.

Physical training in the treatment of type 1 diabetes

The role of physical activity has been emphasized in improving well-being and self-esteem in type 1 diabetic patients also. Although data specifically addressing type 1 diabetic patients are not available, exercise should have the same cardiovascular benefits in type 1 diabetic as in type 2 diabetic patients, provided the insulin treatment regimen and diet can be accurately adjusted to maintain normal glucose homeostasis during exercise. Effect of physical training on glucose control and insulin requirements Most studies have found no difference in glycemic control between type 1 diabetic patients who are physically active compared to those who are inactive 64,72,73 , and no improvement in glycemic control by physical training 74-77 . On the other hand, physical training does improve and even normalize insulin sensitivity in type 1 diabetic patients 77 (Fig. 4.4.5), and this is associated with slight (5 ) decreases in insulin requirements 75,77 . Effect of physical training on...

Treatment of type 2 diabetes

Data on effects of aerobic and resistance training on glycemic control in established type 2 diabetes are summarized in Tables 4.4.1 and 4.4.2. Many studies lacked an appropriate sedentary control group. This limitation is a concern as intensified patient-doctor interaction may itself improve glycemic control and other metabolic parameters. In many studies, the patients lost weight, which may or may not be a consequence of physical activity and confounds, as does small sample size, interpretation of effects of exercise as compared to weight loss per se on metabolic control. Overall effects of physical training on glycemic control have been modest and in roughly half of the studies non-significant. There are several potential explanations for the failure of exercise to be an effective antihyperglycemic therapy. First, physical training primarily improves insulin sensitivity in skeletal muscle (see below) rather than in the liver, which is the ultimate target of any antihyperglycemic...

Prevention of type 2 diabetes

The convincing epidemiologic evidence linking physical inactivity to the development of type 2 diabetes is supported by a few intervention studies. In the 6-year Malmo feasibility study, 181 subjects with impaired glucose tolerance (IGT) and 41 type 2 diabetic patients participated in an intervention program which consisted of supervised training and dietary advice organized either as group sessions or individually for 1 year 8 . The subjects were then encouraged to continue exercise without supervision from the investigators for 5 years. At 6 years, body weight was reduced 2.3-3.7 amongst participants as compared to 0.5-1.7 in non-intervened subjects. Maximal oxygen uptake was increased by 10-14 vs. decreased by 5-9 in participants vs. control subjects. Glucose tolerance was normalized in 52 of the subjects with IGT and in 23 in those with type 2 diabetes in the intervention groups, as compared to 36 in an IGT control group 8 . These encouraging data may not, however, be generally...

Physical inactivity predicts type 2 diabetes

Data from several prospective epidemiologic studies have shown an inverse association between physical activity and the incidence of type 2 diabetes 1-3 . Recently, Wei et al. extended these findings, which were based on self-reporting of physical activity and type 2 diabetes, by examining the relationship of objectively measured cardiorespiratory fitness to the incidence of impaired fasting glucose and type 2 diabetes 4 . This analysis included 8633 mostly white men with non-insulin-treated type 2 diabetes, who were followed for 6 years after baseline assessment of cardiorespiratory fitness by a maximal exercise test on a treadmill. Men in the low fitness group (the least fit 20 of the cohort) had a 1.9-fold risk for impaired fasting glucose and a 3.7-fold risk for diabetes compared to those in the high fitness group (the most fit 40 of the cohort) after adjusting for age, smoking, alcohol consumption and parental diabetes. After additional adjustment for body mass index,...

Insulindependent diabetes mellitus

In healthy children, insulin levels decrease with exercise so that glucose can be liberated from stores in the liver and blood levels are maintained despite an increase in glucose uptake into the exercising muscle. Children suffering from insulin-dependent (type 1) diabetes mellitus have to inject insulin into the subcutaneous fat tissue. In consequence, insulin is liberated at a constant rate from the subcutaneous injection site, irrespective of glucose demand. Since insulin sensitivity increases during and following exercise, these children are at a high risk of experiencing severe hypoglycemia with exercise, resulting in a loss of consciousness or epileptic seizures. Low blood glucose levels have been described for up to 24 h following exercise in patients with insulin-dependent diabetes. In a survey of parents whose children had suffered from severe hypoglycemia, many parents blamed preceding exercise as trigger. Children should therefore be advised to measure blood glucose before...

Reduction in the Incidence of Diabetes

Captopril developed diabetes than those randomized of diabetes produced by the P-blocker comparator.6 the new incidence of diabetes in the ramipril arm.98 There has been a rather consistent reduction in diabetes as assessed as a secondary end point in some of CHARM heart failure program,43 have indicated that both pharmacologic inhibitors of the RAS reduced the risk of developing new-onset diabetes. A meta- analysis showed an approximately 20 reduction in the risk of developing diabetes in subjects receiving on the pancreatic fibrosis, improving insulin sensitivity in skeletal muscle, improving insulin signaling pathways, and other mechanisms whereby RAS inhibition could influence glucose homeostasis.132 However, all the consistent and important observations from clinical trials must be considered as nondefinitive because they were derived from secondary end points from studies that were designed to address other questions. As part of a two-by-two factorial design, the Diabetes...

The Insulin Connection

Until recently, carbohydrates were ignored as a health issue. They are at least as important, and probably more so, than fats in determining weight and cardiovascular fitness. The key to carbohydrates' influence is insulin. Insulin is a hormone secreted by the pancreas in response to a carbohydrate-heavy meal. It is impossible to live without it, but it is possible to live much better without too much insulin. Insulin has many actions, but some of the most important affect body fat, cholesterol levels, and cardiovascular health. Insulin The bottom line is that insulin, certainly in excessive amounts, causes the body to produce and store fat as well as produce inordinate amounts of cholesterol. Insulin is now recognized as an important factor in the development of cardiovascular disease. It is known to act directly on the walls of arteries to produce atheroma atherosclerotic plaques that can narrow the blood vessels, limit blood flow and oxygen delivery, and result in strokes and heart...

Special Considerations in Diabetic Patients

Compared with nondiabetic patients, patients with diabetes often have a more advanced coronary atherosclerosis with diffuse disease in small-lumen vessels. With any treatment modality for coronary revascularization, diabetic patients have an inferior outcome compared with nondiabetics. This was first shown for CABG. In patients with diabetes mellitus, CABG is associated with a more rapid progression of atherosclerosis of both grafted and nongrafted vessels, as well as an accelerated degeneration of venous bypass grafts, compared with nondiabetics. Nevertheless, CASS demonstrated that in older diabetics coronary revascularization confers a substantial benefit compared with lone medical therapy.52 Likewise, PCI in patients with diabetes is associated with a substantially increased risk of adverse short-term and long-term outcome compared with PCI in non-diabetics. In particular, it the risk of restenosis after any type of PCI is substantially increased in diabet-ics.53,54 Moreover,...

Antithrombotic Therapy In Diabetes

With respect to patients undergoing PCI, the Clopidogrel for the Reduction of Events During Observation (CREDO) study randomized patients either to a 300-mg loading dose followed by 12 months of clopidogrel therapy or to no loading dose and clopidogrel treatment for 1 month on top of aspirin. Among 560 diabetic patients, the benefit of pretreatment and prolonged clopidogrel therapy was modest (RRR 11.2 ) compared with the benefit of this regimen observed among 1556 patients without diabetes (RRR 32.8 ).112 In the setting of non-ST-elevation ACS, aspirin remains a cornerstone of therapy, although specific data for diabetic patients are lacking. The Clopido-grel in Unstable angina to prevent Recurrent Events (CURE) trial randomized patients with ACS primarily medically managed to aspirin or aspirin plus clopi-dogrel for 9 to 12 months. Diabetic patients (n 2840) derived only a modest, nonsignificant benefit from the combined treatment (death, MI, or stroke rate...

Revascularization In Diabetic Patients With Stable Coronary Disease

Almost 1.5 million coronary revascularization procedures, either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), are performed each year in the United States, and approximately one quarter of them involve diabetic patients.41 The randomized data on diabetic patients are scarce and are mainly derived from subgroup analyses of revascularization trials of patients with multivessel disease initiated in the late 1980s and early 1990s. Overall, diabetic patients with multives-sel disease seem to have a better prognosis after CABG than after PCI. Although diabetic patients frequently have concurrent risk factors and comorbidities, diabetes has been identified as an independent predictor of CV events during and after revascularization, both percutaneous and surgical. Several pathophysiologic peculiarities of diabetic atherosclerosis previously discussed may negatively affect prognosis and response to coronary revascularization. Table 2-5. Indications for...

Cardiovascular Diagnostic Modalities In Diabetes Patients

Summary of Studies Using Stress Testing in the Diagnosis of Suspected Coronary Artery Disease in Diabetic Patients From Albers AR, Krichavsky MZ, Balady GJ Stress testing in patients with diabetes mellitus Diagnostic and prognostic value. Circulation 2006 113 583-592. Table 2-4. Summary of Studies Using Stress Testing in the Diagnosis of Coronary Artery Disease in Asymptomatic Diabetic Patients From Albers AR, Krichavsky MZ, Balady GJ Stress testing in patients with diabetes mellitus Diagnostic and prognostic value. Circulation 2006 113 583-592. symptoms nor evidence of cardiac or peripheral vascular disease, the ADA guidelines recommend testing for those who have two or more CV risk factors (i.e., dyslipidemia, hypertension, active smoking, family history of premature CAD, or albuminuria). Although the short-term prognosis (i.e., up to 2 years) in diabetic patients after a negative stress imaging test is excellent, multiple studies have found that those patients may suffer...

Cardiovascular Disease In Diabetes

Heart disease and stroke account for more than two thirds of all deaths among diabetic patients.2 A recent population-based study documented that diabetes confers a CV risk equivalent to aging 15 years.25 In 2001, the Adult Treatment Panel III of the National Cholesterol Education Program (NCEP ATP III) recommended that diabetes be considered a CAD risk equivalent, thus mandating aggressive CV risk pre-vention.26 The notion of diabetes as a CAD risk equivalent came initially from a Finnish population-based study with 7-year follow-up involving 1059 diabetic patients and 1373 nondiabetic patients, which showed that diabetic patients without known CAD had the same likelihood of experiencing an MI as nondiabetic counterparts with a previous history of MI.27 A similar observation was made in a registry enrolling more than 8000 patients with ACS, which showed that diabetic patients with no previous CVD had the same long-term morbidity and mortality as nondiabetic patients with established...

Diagnostic Criteria For Diabetes Prediabetes And Metabolic Syndrome

IGT or diabetes and or insulin resistance* PLUS diabetes BMI, body mass index HDL, high-density lipoprotein IDF, International Diabetes Federation IGT, impaired glucose tolerance NCEP ATP III, Adult Treatment Panel III of the National Cholesterol Education Program WHO, World Health Organization. Insulin resistance insulin sensitivity measured under hyperinsulinemic euglycemic conditions, glucose uptake below lowest quartile for background population under investigation. 'The 2001 American Diabetes Association (ADA) definition identified fasting plasma glucose of > 110 mg dL (6.1 mmol L) as elevated. This was modified in 2004 to be > 100 mg dL (5.6 mmol L), in accordance with the ADA's updated definition of impaired fasting glucose. Adapted from Alberti KG, Zimmet P, Shaw J Metabolic syndrome A new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006 23 469-480. BMI, body mass index HDL, high-density lipoprotein IDF, International...

Physical inactivity and the burden of cardiovascular disease in type 2 diabetes

Patients with type 2 diabetes have a two- to four-fold increased mortality from cardiovascular disease 6 . The ultimate goal of all therapies in type 2 diabetes is to reduce this burden. In the Aerobic Center Longitudinal Study discussed above 7 , the association between low cardiorespiratory fitness and physical inactivity and total mortality in 1263 men with type 2 diabetes was also studied. After adjustment for age, preexisting and family history of cardiovascular disease, fasting glucose and cholesterol concentrations, overweight and hypertension, type 2 diabetic men in the low fitness group had a risk for all-cause mortality of 2. i. The majority of deaths were attributable to cardiovascular disease 7 .


Subgroup analysis of randomized clinical trials appears to indicate that abciximab provides substantial benefits in terms of reduced repeat revasculariza-tion and mortality among diabetic patients, with comparable effects observed with tirofiban. Clinical trial evidence with bivalirudin supports similar con clusions. In the REPLACE-2 study of bivalirudin and provisional GP IIb IIIa inhibition compared with heparin and GP IIb IIIa inhibition, bivalirudin-treated diabetic patients experienced a lower, but nonsignificant rate of mortality at 12 months (2.3 versus 3.9 , P NS). No difference in the rate of 30-day bleeding and ischemic outcomes was observed.57 Although the long-term effects of enoxaparin-based strategies in diabetic patients have not been reported, a substantial rate of concomitant GP IIb IIIa use in these studies will limit the interpretation of these data.

Gestational Diabetes

Gestational diabetes, or diabetes diagnosed in pregnancy, affects 3 to 5 of pregnant women. Pregnancy is a state of increasing insulin resistance predominantly caused by placen-tally produced hormones, in particular human placental lacto-gen, which increases with placental mass and gestational age. Although most women can compensate, a small subset of pregnant women cannot. Early impairment of glucose metabolism may have no maternal signs or symptoms, but can have fetal effects that include macrosomia, fetal distress, and fetal demise. Screening for gestational diabetes by a glucose challenge is recommended at 26 to 28 weeks of gestation. There is little evidence supporting earlier screening. The U.S. Preventive Services Task Force (USPSTF), however, concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mel-litus (GDM), either before or after 24 weeks' gestation and recommends that clinicians should...

Type 1 Diabetes

Type 1 diabetes mellitus is one of the most common of all chronic illnesses of childhood, occurring in approximately 1 of every 400-600 children. The American Diabetes Association (2009b) estimated that approximately 186,300 youth under age 20 years have been diagnosed with type 1 diabetes. The International Diabetes Federation (2006) estimated that worldwide, 440,000 children ages 0-14 years have been diagnosed with type 1 diabetes, with 70,000 new cases expected each year. Type 1 diabetes is an autoimmune disorder in which pancreatic islet cells have been destroyed, resulting in permanent insulin deficiency. Because insulin replacement is essential for survival, youth with type 1 diabetes must receive daily insulin injections or delivery of insulin through an insulin pump. Currently, the exact cause of type 1 diabetes is unknown, although both environmental and genetic factors have been implicated (American Diabetes Association 2009a). The treatment for type 1 diabetes is complex...

Type 2 Diabetes

Type 2 diabetes mellitus is the most common form of diabetes, being found in roughly 20 million Americans and accounting for 80 of cases of diabetes (National Institute of Diabetes and Digestive and Kidney Diseases 2008). Unlike type 1 diabetes, the development of type 2 is typically contingent on lifestyle (particularly dietary consumption and exercise), with obesity being the number one risk factor for this disease (American Diabetes Association 2000). In addition, type 2 diabetes historically has been considered a disease with an adult onset, often not present until an individual was beyond age 30 years. Type 2 diabetes in children was thus considered relatively rare, although children might present with a prediabetic condition. More recently, however, an alarming increase has occurred in the number of children presenting with type 2 diabetes, which is undoubtedly directly related to the increase in childhood obesity (Alberti et al. 2004 American Diabetes Association 2000 Libman...

Diabetic Nephropathy

Renal failure is a major independent predictor of cardiovascular events. Diabetes is the leading cause of renal failure in Western countries. In 2002 in the United States, diabetic nephropathy accounted for more than 40 of the new cases of renal failure, and 44,000 diabetic patients began treatment for endstage renal disease.2 The condition underlying diabetic nephropathy is microvascular disease. Even in the absence of renal failure, albuminuria is a frequent finding in diabetes. Any degree of albuminuria has been found to be a risk factor for CV events, regardless of the presence or absence of diabetes.137 In addition, diabetic nephropathy with or without renal failure is a key determinant of risk after both PCI and CABG. A single-center analysis involving 1575 diabetic patients undergoing PCI showed that patients with renal failure had significantly more in-hospital complications than those with normal renal function, including mortality (2.6 versus 0.5 , respectively), neurologic...

Fastacting Insulins

Biostructure-based drug design is not limited to design of low-molecular weight compounds based on knowledge of the structure of their biological targets. In the following text we are presenting an example on biostructure-based design of macromolecular drug molecules, i.e., insulin analogs. This design was made possible only by a detailed insight into the structure of insulin and the intermolecular interactions between the insulin molecules in the crystalline phase. Insulin is a hormone produced in the pancreas and it is responsible for the regulation of glucose uptake and storage. Insulin is most often associated with diabetes mellitus, which is a disease causing hyperglycemia. Healthy people have a basal level of insulin in the bloodstream, but in response to intake of food or to cover glucose clearance from the blood, peaks of larger insulin concentrations appear throughout the 24 h of a day. Patients with diabetes may have difficulties in maintaining the proper insulin...


Some of the insulin preparations in common use are listed in Table 35.7. The best control is achieved by twice-daily injections of short- and intermediate-acting insulin. Increasingly, younger diabetics are managed with a background once-daily ultra-long-acting preparation coupled with a pen injector delivering small doses of short-acting insulin. The type of preparation must be noted, and if a change is made in the type of insulin (bovine, porcine, human) the dose must be adjusted, because increased sensitivity to the latter two may lead to hypoglycaemia. Insulin with the human sequence of amino acids is produced biosynthetically (chain recombinant DNA technology using bacteria, CRB) or semisyn- Tabk 35.7 Newer insulin preparations Tabk 35.7 Newer insulin preparations Insulin zinc suspension amorphous semi-lenie, porcine Long-acting, insulin zinc suspension, 30 amorphous, 70 crystalline, lente, porcine Long-acting, insulin zinc suspension, crystalline CRB thetically (by enzyme...


Ninety percent of insulinomas are benign and are smaller than 2 cm in diameter. Ninety-nine percent are located in the pancreas. A variety of preoperative imaging modalities for the detection of insulinomas are currently available, such as US, CT, MRI, somatostatin receptor scintigraphy (SRS), and various invasive methods, including endosonography (ES), selective angiography (SA), selective portal venous Endosonography (ES) is the most sensitive preoperative procedure. It was introduced in the 1980s and provides direct visualization of the pancreas and is able to detect tumors down to 0.3 to 0.5 cm in diameter (Fig. 80-1). An early study by Rosch and colleagues in 19923 identified endocrine tumors by ES in the head of the pancreas in 95 of their patients and in the body and tail in 78 and 60 , respectively (Table 80-1). One year later, Palazzo and coworkers4 underlined its accuracy for localizing small endocrine pancreatic tumors. Thirteen insulinomas less than 15 mm in diameter were...

Insulin Glucose Ratio

The insulin-glucose (I G) ratio provides a relationship between these two values that aids in the determination of the presence of an insulinoma. In a normal individual, the ratio is always less 0.4, but in patients with an insulinoma the ratio approaches 1.0 and may in some cases exceed 1.0. The I G ratio is important because as many as one third of patients with an insulinoma have insulin levels within normal limits when they have symptomatic hypoglycemia. FIGURE 79-3. Plasma insulin (in microunits per milliliter) and blood glucose (milligrams per deciliter). Relationships after overnight fasting in 33 normal persons and in 22 patients with solitary beta islet cell adenomas. Both plasma insulin and blood glucose show highly significant differences between the two groups. IRI immunoreactive insulin. (From Harrison TS. Hyperinsulinism and its surgical management. In Hardy JD ed , Rhoads' Textbook of Surgery Principles and Practice. Philadelphia, JB Lippincott, 1977.)

Insulin Pump Therapy

Motivated type 1 diabetic patients who are frequently monitoring and self-managing insulin dosages but have not attained their glycemic targets should be considered for an insulin pump protocol. Ideally in these patients, the target should be HbA1c less than 7 , with fluctuations in monitored FSG limited to 50 mg dL. A key requisite for pump therapy is the patient's willingness to monitor frequently (up to 6-8 times daily) to ensure a safe transition from the flexible insulin regimen and learn to adjust basal and bolus infusion rates. Use of the insulin pump in type 2 diabetic patients who fail to achieve therapeutic targets is less clear-cut. Often, insulin resistance accounts for failed outcomes rather than beta-cell insufficiency in these patients. If planning to use the pump, patients need to maintain high daily basal rates of 3 to 5 units per hour, which would mean frequent reloading of the insulin reservoir. On a physiologic basis, pump therapy may or may not overcome insulin...

Insulin Rebound

A diabetic complication that family physicians routinely manage is caused by nighttime or very-early-morning hypo-glycemia, which leads to fasting hyperglycemia and sometimes ketosis, especially in children (Somogyi effect). If the patient and physician are not careful, they can get caught in a spiral of ever-increasing insulin doses in response to rebounding glucose values. When confronting persisting morning hyperglycemia, the first step is for the patient to monitor 3 am glucose levels. If low, reduced dosage or timing change in evening insulin administration is necessary.

Basal Bolus Insulin

Synthetic insulin preparations designed to achieve either a prolonged steady effect or an acute action, mimicking physiologic insulin secretion, have allowed patients to develop personal and flexible injection schedules. This is known as the basal bolus regimen and is indicated in the treatment of type 1 diabetes. It provides rapidly acting or bolus insulin to cover carbohydrate ingestion in meals and snacks, and basal insulins are usually given at bedtime to achieve a steady state at breakfast, with an ideal FSG target of 120 mg dL or less. To a large extent, control of the important fasting blood (serum) glucose will depend on attaining an ideal bedtime value of 120 to 140 mg dL, which is based on rapidly active insulin given at dinner. The authors' experience indicates that basal insulin is most predictable in patients who demonstrate overnight glucose production and have controlled glucose values at bedtime. However, an occasional patient will experience hypoglycemia at 4 am, and...

Diabetes insipidus

This is caused by disease or damage affecting the hypothalamic-pos-terior pituitary axis. Common causes are pituitary tumours, craniopharyngiomas, basal skull fracture and infection, or it may occur as a sequel to pituitary surgery. In 10 of cases, diabetes insipidus is renal in origin.

Risk factor diabetes

The urine of diabetics is wonderfully sweet as if imbued with honey or sugar. Thomas Willis (1621-1675), physician to King Charles II, England Diabetes is a risk factor for coronary heart disease and stroke, and is the most common cause of amputation that is not the result of an accident. Insulin is a hormone produced by the pancreas and used by the body to regulate glucose (sugar). Diabetes occurs when the body does not produce enough insulin, or cannot use it properly, leading to too much sugar in the blood. Symptoms include thirst, excessive urination, tiredness, and unexplained weight loss. There are two main types of diabetes. Type 1 diabetes, in which the pancreas stops making insulin, accounts for 10 to 15 of cases. The majority of people with diabetes have type 2 disease, in which insulin is produced in smaller amounts than needed, or is not properly effective. This form is preventable, because it is related to physical inactivity, excess calorie intake and obesity. People...

Tropical Diabetes

A type of diabetes found primarily in many tropical areas of the world has characteristics of both type I and type II. The clinical profile involves the following (1) a different genetic pattern of diabetes than in temperate regions (2) a low prevalence rate of type I DM (3) a younger age of onset of type II (4) a sex ratio with male predominance in India and Africa, but female predominance in the West Indies (5) an association of low calorie and protein intake with underweight diabetic individuals in Old World areas but overweight individuals in the Western Hemisphere (6) the predominance of diabetes in urban areas, with the exception of rural populations in the West Indies and (7) intermittent need for insulin therapy. Information is relatively sparse on the genetics of diabetes in tropical countries. Recent studies have shown great population variability in increased susceptibility to diabetes. Genetic studies of Indian populations suggest a stronger familial factor among them...

Insulin and OPLL

Patients with OPLL and diffuse idiopathic skeletal hyperostosis (DISH) have been reported to be obese and have glucose intolerance as well 2-5 . The prevalence of OPLL is high in patients with non-insulin-dependent diabetes mellitus (NIDDM) 3,5 . Because patients with obesity and NIDDM often exhibit impaired action and increased secretion of insulin, there is a possibility that changes in the secretion or action of insulin may play a role in the progression of the disease. Our recent investigation examining the relation between glucose intolerance and the extent of ossification in OPLL patients revealed that the severity of glucose intolerance was not associated with the extent of ossification, but the insulin secretory response was 6 (Fig. 1). It is therefore speculated that the up- regulation of insulin production due to impaired insulin action may stimulate osteoprogenitor cells in the ligament to induce ossification. Insulin initiates cellular responses by binding to its...

Diabetes Prevention

The best way to prevent CV complications in diabetes is to prevent the disease itself. Several studies performed over the last decade have shown that, in subjects at high risk for development of diabetes, lifestyle modifications and pharmacologic interventions may effectively prevent or delay the onset of the disease. Regular physical activity, diet, and weight reduction in high-risk subjects with IGT were shown to reduce the risk of developing diabetes by 31 to 58 . Several drugs also were able to reduce the progression from IGT to diabetes. The risk of developing diabetes decreased with metformin by 31 over 2.8 years, with acarbose by 25 over 3.5 years, with tro-glitazone in women with a history of gestational diabetes by 56 over 5 years, and with orlistat in obese subjects with IGT by 45 over 4 years. Finally, the Diabetes REduction Assessment with ramipril and rosiglitazone Medication (DREAM) trial recently showed that rosiglitazone, administered for 3 years, reduced the incidence...

Insulin Resistance

Together with dyslipidemia, hypertension, and obesity, insulin resistance is a key feature of the metabolic syndrome. In addition, it is the first measurable metabolic disturbance among individuals who will subsequently develop type 2 diabetes. Insulin resistance describes a reduced sensitivity in body tissues to the action of insulin, which affects both glucose disposal in muscles and fat and insulin suppression of hepatic glucose output. As a consequence, higher concentrations of insulin are needed to stimulate peripheral glucose disposal and to suppress hepatic glucose production in patients with type 2 diabetes than those without diabetes. On a biologic level, insulin resistance has been associated with increased coagulation, pro-inflammation, and endothelial dysfunction, among other conditions.10 In insulin-resistant subjects, endothelium-dependent vasodilation is reduced, and the severity of the impairment correlates with the degree of insulin resistance. Abnormal...

In Diabetes

Coronary artery disease is more prevalent, is more severe, and occurs at a younger age in patients with diabetes. Several metabolic abnormalities, including chronic hyperglycemia, dyslipidemia, and insulin Table 2-1. Diagnostic Criteria for Diabetes Mellitus, Impaired Glucose Tolerance, and Impaired Fasting Glucose According to the American Diabetes Association From Diagnosis and classification of diabetes mellitus. Diabetes Care 2006 29(Suppl 1) S43-S48. Copyright American Diabetes Association.

Multifactorial Intervention

The Steno-2 study compared the efficacy of a targeted, intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for CV disease in 160 patients with diabetes and microalbuminuria.140 The primary end point was a composite of CV death, nonfatal MI, stroke, revas-cularization, and amputation. Intensive treatment was characterized by a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipid-emia, and microalbuminuria, along with secondary CV prevention with aspirin. Conventional treatment was in accordance with national guidelines. After a mean follow-up of 8 years, patients receiving intensive therapy had a significantly lower risk of CVD (HR 0.47), nephropathy (HR 0.39), retinopathy (HR 0.42), and autonomic neuropathy (HR 0.37). The authors concluded that a target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes...

Brain Diseases with BBB Dysfunction

Dysfunction of the BBB may be in the form of increased permeability or BBB breakdown to large and small molecules in brain diseases and or may take the form of alterations in endothelial transport mechanisms. Well documented in the literature is the increased BBB permeability to plasma proteins, which occurs in conditions associated with vasogenic edema such as ischemic and hemorrhagic stroke, infections, inflammation, seizures, trauma, tumors, epilepsy, and hypertensive encephalopathy (182, 183). Increased permeability to C14 sucrose implying increased ionic permeability has been reported in peripheral inflammatory pain (184). Increased BBB permeability to ions and plasma proteins has been reported in human and experimental diabetes (184, 185). Global vascular changes and altered expression of Pg-p have been implicated in the pathogenesis of degenerative diseases such as Alzheimer's disease (186, 187) and Parkinson's disease (188) as reviewed previously (136, 189).

Other Pharmacologic Approaches

In addition to the potential beneficial effect on restenosis described previously, TZD have shown antiinflammatory and anti-thrombotic properties in diabetes. From a clinical perspective, in the PROspective pioglitAzone Clinical Trial In macroVascular Events (PROACTIVE) study, pioglitazone therapy in 5238 diabetic patients was associated with a nonsignificant 10 reduction in the primary end point (composite of all-cause mortality, nonfatal MI, stroke, ACS, endovascular or surgical intervention in the coronary or leg arteries, and amputation above the ankle), compared with placebo. Allocation to piogli-tazone led to a significant 16 reduction in the main secondary end point (composite of all-cause mortality, non-fatal MI, and stroke).141 However, significantly more hospitalizations for heart failure were reported in the active treatment arm. More data will be available from BARI 2D ancillary studies, which will allow insights into the modulation of diabetes-associated inflammation,...

Factors That Affect Blood Pressure Readings

Significant drop in blood pressure may be noted on postural change from a supine to an erect position (postural hypotension) in patients with hypovolemia, following use of certain antihypertensive drugs, and in patients with diabetes with autonomic dysfunction. This is more common in type 1 diabetics.

Metabolic response to surgery

Sympathetic activity causes a rise in heart rate and blood pressure, increasing cardiac work. Mobilisation of energy stores occurs shortly after injury, causing relative hyperglycaemia and insulin resistance. ADH secretion is increased resulting in water retention and a fall in urine output. Vascular permeability is increased, predisposing to oedema formation. Inflammatory mediators (e.g. prostaglandins and leucotrienes) are produced, causing systemic effects such as pyrexia they might also be implicated in trauma pathophysiology. The immune system is impaired, predisposing to infective complications. After the initial brief mobilisation of energy stores (catabolic state) the body enters a more prolonged reparative anabolic state with increased energy and nitrogen demands. Activation of platelets leads to a hypercoagulable state.

Relay Stations Placed Inside Proteins Can Carry An Electric Current

Diabetics have a need for a glucose meter that would show the glucose concentration in the blood at any moment without having to take a sample. If the glucose builds up too much, the meter would send out a signal telling the wearer of the need for insulin. Glucose gets oxidized with the cooperation of an enzyme called glucose oxidase, which has a molecular diameter of 86 A. Suppose we could immobilize glucose oxidase on an organic semiconductor such as polypyrrole, and the electrons produced when glucose in the blood is oxidized could be brought out through the glucose oxidase to work a meter on the wrist our aim would be achieved, and diabetics could monitor their condition at any time by a glance at the wrist.10

To Artificially Sweeten or

People often have to use artificial sweeteners because of a medical condition. For example, sugar substitutes can be great for diabetics, who can't tolerate real sugar because their bodies can't produce the hormone insulin. Insulin delivers the sugar from our blood to our cells, where we utilize it as energy. When your body doesn't have enough insulin, sugar builds up in the blood and doesn't get into the cells. This condition is known as high blood-sugar and can be extremely dangerous for people with diabetes. Because sugar substitutes do not contain any glucose (and therefore do not require insulin), they can be effective sweeteners for people with diabetes.

Secondary Prevention Following MI

Prior to hospital discharge for secondary prevention. Guidelines from the ACQ AHA suggest that in the absence of contraindications, following MI from either STE ACS or NSTEACS, patients should receive indefinite treatment with ASA, a ft-blocker, and an ACE inhibitor.2'3'47 For NSTE ACS, clopidogrel should be added to ASA for at least 1 month and ideally for up to 12 months and for STE ACS for at least 2 weeks (unless they undergo PCI where the duration of clopidogrel therapy depends on stent type), and up to 1 year.3 Most patients will receive a statin to reduce low-density lipoprotein cholesterol to less than 100 mg dL (2.59 mmol L), and ideally less than 70 mg dL (1.81 mmol L). Newer therapies include eplerenone, an aldosterone antagonist. For all ACS patients, treatment and control of modifiable risk factors such as HTN, dyslipidemia, and diabetes mellitus (DM) is essential. Benefits and adverse effects of long-term treatment with these medications are discussed in more detail...

Evidence Based Prevention Definitions

In contrast, tertiary prevention services are provided to individuals who clearly have a disease, and the goal is to prevent them from developing further complications. For example, diabetes care, including regular retinal examinations, foot care, and management of blood sugar levels, is tertiary prevention because the care provided is focused on limiting the complications of a disease that has already been identified. Many believe tertiary prevention is outside the scope of traditional prevention and should be a part of disease management.

Clinical applications of ACE inhibition

ACE inhibitors are established in the treatment of hypertension they decrease morbidity and mortality in congestive cardiac failure, and improve left ventricular dysfunction after myocardial infarction. They delay the progression of diabetic nephropathy and have a protective effect in non-diabetic chronic renal failure, although they are associated with proteinuria in approximately 1 of patients. ACE inhibitors improve vascular endothelial function by their effects on A-II and bradykinin the clinical importance of this in patients with vascular disease is unknown. the elderly or those receiving NSAIDs, and renal function should be checked before starting ACE inhibitor therapy, and monitored subsequently. Hyperkalaemia (plasma K+ concentration usually increases by 0.1-0.2 mmol L 1 because of decreased aldosterone concentrations) may be more marked in those with impaired renal function or in patients taking potassium supplements or potassium-sparing diuretics. The mechanism of cough is...

Stents And The Leveling Of The Anatomic Playing Field

In clinical success are major components of the broadening of the anatomic application of PCI to relief of myocardial ischemia. A major test of this leveling of the anatomic playing field hypothesis will be whether the proportion of screened patients who are enrolled in the trials of drug-eluting stents versus CABG, such as the National Institutes of Health (NIH)-sponsored Future Revascularization Evaluation in patiEnts with Diabetes mellitus Optimal Management of multivessel disease (FREEDOM) trial, is not considerably higher than the

Pathophysiology Of Renal Dysfunction

The most common reason for renal dysfunction after cardiac catheterization and PCI is related to the use of intravascular contrast agents. Despite their widespread use in imaging studies, the exact mechanisms responsible for the development of contrast-related nephropathy remain unknown.1 Most studies suggest that both direct toxic injury to the renal tubules and ischemic injury to the renal medulla from vasomotor changes and decreased perfusion are responsible. The latter appears to be mediated partly by the development of reactive oxygen species such as superoxide and has important implications for treatment with scavenging agents.2 Diabetes mellitus and heart failure also may exacerbate contrast-related

Renal Dysfunction Risk Factors And Prognosis

In addition to CKD, several other risk factors for developing renal dysfunction after cardiac catheter-ization and PCI have been identified (Table 5-2). Most importantly, these appear to be related to demographic factors such as advanced age, comor-bidities (e.g., diabetes mellitus), periprocedural factors such as hemodynamic instability or heart failure, and evidence of volume depletion.9 Additional factors include the use of intra-aortic balloon pumps and nephrotoxic medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). A key and potentially modifiable factor is the use of high volumes of contrast agents. Several investigators have suggested a maximum allowable contrast dose that is dependent on the degree of CKD at baseline (Fig. 5-1).10,11 Advanced age Female gender Chronic kidney disease Diabetes mellitus Peripheral vascular disease Hypertension Ejection fraction < 40 Importantly, both the presence of CKD at baseline and the development of renal dysfunction after...

Relationship of Chronic Kidney Disease and ESRD with Clinical Outcomes

Patients with CKD often have existing comorbidities that may complicate their procedure and postproce-dure management. As always, developing a systematic approach that incorporates the patient's history, physical examination, and laboratory studies is critical. As described earlier, the clinician needs to pay particular attention to accurate assessment of the degree of CKD at baseline, as well as several clinical risk factors that have been consistently associated with poor outcomes in patients with CKD (e.g., diabetes mellitus, hemodynamic instability). Most of the approaches described here are designed to minimize the risk of contrast-related nephropathy, which is the most likely cause of renal dysfunction after

Minimizing The Risk Of Renal Dysfunction

Normal saline infusions at a rate of 1 mL kg hour for 6 to 12 hours before the procedure and continuing after the procedure.53 Data from a large trial suggested that the substitution of isotonic saline for 0.45 normal saline may modestly reduce the incidence of contrast-related nephropathy, particularly among patients with diabetes mellitus and those receiving large doses of contrast agents.54 In a small clinical trial of 36 patients with serum creatinine levels at baseline equal to or greater than 1.4 mg dL, it was demonstrated that 1 L orally followed by 6 hours of intravenous hydration starting at the time of contrast agent exposure was equivalent to prepro-cedural intravenous hydration.55 This approach may be more realistic for outpatients who come in the day of their procedure.

Effectiveness of Early Detection and Intervention

No studies have examined the direct effect of screening on clinical outcomes however, treating a patient for hypertension detected through screening appears to provide morbidity and mortality benefits. The benefits of screening and treatment depend on the degree of BP elevation and the presence of other cardiovascular risk factors, such as age, gender, lipid disorders, and diabetes. Potential harms from screening include labeling and exposure to the side effects of antihy-pertensive treatment.

Burden of Disease

The risk assessment tool below uses recent data from the Framingham Heart Study to estimate 10-year risk for hard coronary heart disease outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Use the calculator below to estimate 10-year risk.

The Supplement Shambles

Government Accountability Office (GAO) conducted an investigation. The GAO 2010 report indicated that dietary supplement products often were still promoted with deceptive and unfounded disease-related claims, encouraging consumers to use the products to prevent or treat diabetes, cancer, heart disease, Alzheimer's disease, and other serious conditions. The GAO investigation also found that most of the herbal supplement products tested were contaminated with heavy metals such as lead or pesticide residues, but usually at low levels.

Other Important Medical Conditions to Consider in Sports Participation

There are a multitude of medical conditions that may require special consideration during the PPE, depending on the individual's needs and the sport involved. For example, diabetic athletes need to pay special attention to hydration, diet, and insulin therapy. Sickle cell disease patients may be allowed limited participation of noncontact noncollision sports, but must avoid overheating, dehydration, and chilling.

Long Term Adaptation to

Long-term adaptation to chronic illness. Studies have found that in patients with juvenile diabetes, primary control (or problem-focused coping) predicted better adjustment than secondary control (or emotion-focused coping) (Band 1990). The relative adaptiveness of problem-focused coping versus emotion-focused coping over the course of an illness characterized by relapses and remissions is an area for further research, because different coping strategies may be found to be effective during relapses and during remissions.

Changing Paradigms Of Coronary Revascularization

Various studies demonstrated that stents reduce the need for reintervention compared with plain balloon angioplasty,1-3 restenosis rates continued to be relevant, ranging from just above 10 in the most simple lesions to more than 50 with diffuse disease in patients with diabetes. with Diabetes Mellitus Optimal Management Diabetics

ROS in Cell Physiology and Sperm Activation First Data and Clinical Relevance

The number of reports on the essential role of ROS in cell activation increased strikingly over the last 10 years. It is now recognized that activating stimuli, whether physiological (e.g., hormone, such as insulin) or pharmacological (e.g., medication, enzyme activators, or inhibitors), often promote ROS formation 3, 8, 15-18 via oxidases, such as those of the NOX family for O2'- 25-28 and NOS (endothelial, neuronal, and epithelial isoforms) for NO' 29-34 .

Adolescents Ages 1318 Years

Few studies have examined the relationship between illness duration and adjustment in children with chronic illnesses. Some investigators have reported that children with chronic illnesses that require strict disease management, such as juvenile diabetes, perceive their illness as increasingly difficult to manage over time (Kovacs et al. 1990). Additionally, age at illness onset may play a role one study found that boys with early-onset diabetes had more behavior problems than either girls with early-onset diabetes or youngsters of either gender with late-onset diabetes (Rovet et al. 1987). Age at onset may not be related to self-reported distress, suggesting a complex relationship between illness experience and adaptation (Kovacs et al. 1990). Maternal depression and anxiety play important roles in child adjustment to chronic illnesses and child behavior during procedures (Wallander and Thompson 1995). One reason for the interest in assessing parental distress is that it has...

Role of Clinical Presentation

The benefit from the invasive strategy compared with the conservative strategy is not uniform across the spectrum of acute coronary syndromes. The major, more recent clinical studies, FRISC-2, TACTICS-TIMI 18, and RITA-3,15-17 consistently show that the benefit from the invasive strategy is linked to various markers of risk, whereas patients without these risk markers may be treated according to the same principles as patients with stable angina. The risk factors that could be established in previous studies include elevated myocardial marker proteins, dynamic ST-segment changes, ongoing myocardial ischemia, hemodynamic instability, and diabetes mellitus.18

Lessons from Studies with Drug Eluting Stents

Least one third had three-vessel disease to achieve a number of treatable lesions per patient comparable to ARTS I. Compared with ARTS I, ARTS II comprised a higher-risk cohort 53.5 had three-vessel disease, and diabetes was present in 26.2 . Mean stented length was 72.5 mm, with 3.7 stents implanted per patient. The 1-year survival rate was 99.0 , the composite of death stroke and MI-free survival was 96.9 , and freedom from revascularization was 91.5 . In the unadjusted comparison with the historical control arms of ARTS I-CABG and ARTS I-PCI, the respective relative risks and 95 CIs for the end points were (1) freedom from repeat revascularization, 2.03 (1.23-3.34) and 0.44 (0.31-0.61), respectively and (2) freedom from death, stroke, MI, and revascularization, 0.89 (0.65-1.23) and 0.39 (0.300.51), respectively. The authors concluded that surgery still afforded a lower need for repeat revascu-larization, although overall event rates in ARTS II approached those of the surgical...

Studies with Bare Metal Stents

Of the studies comparing bare metal stents with bypass surgery, ARTS, AWESOME, and ERACI-2 reported subgroup analyses for diabetics (Fig. 6-9). Of the 1205 patients included in ARTS, 112 diabetics were randomly assigned to stent implantation and 69 to bypass surgery.69 The incidence of major adverse events during hospital stay was similar in both groups except for stroke, which was significantly more frequent in the surgical patients than in the interventional patients (0 vs. 4.2 P .04). During 1-year follow-up, this trend continued to prevail (1.8 vs. 6.3 P .10). Mortality during 1-year follow-up, however, was higher in the stent group (6.3 ) than in the surgical group (3.1 ) although statistical significance was missed (P .294). The incidence of MI was also higher by trend in the PCI group than in the CABG group (6.3 vs. 3.1 P .294). As in the entire ARTS cohort, the need for repeat intervention (mostly catheter intervention) was significantly higher in the PCI group than in the...

Studies with Drug Eluting Stents

Drug-eluting stents are particularly appealing for patients with diabetes mellitus because they offer a solution to the most crucial problem of PCI in this patient subset, restenosis. A recently published meta-analysis of the diabetic patients in randomized studies comparing drug-eluting stents with bare metal stents confirmed that drug-eluting stents confer a similar relative reduction in restenosis in diabetics and in nondiabetics, compared with bare metal stents.72 The same meta-analysis did not reveal any safety issues with respect to the 1-year incidence of death or the composite of death and nonfatal MI. Based on the older studies for PCI in diabetes, it may be anticipated that the reduction in restenosis conferred by drug-eluting stents compared with bare metal stents may confer a survival benefit during longer-term follow-up. As of this writing, the role of drug-eluting stents in the treatment of multivessel disease in patients with diabetes cannot be judged by evidence-based...

Accuracy of Screening Tests

Three tests have been used to screen for diabetes fasting plasma glucose (FPG), 2-hour post-load plasma glucose (2-hour PG), and hemoglobin A1c (HbA1c). Sensitivity and specificity are in the range of 75 to 80 for all three tests using these thresholds FPG 126 mg dL, 2-hour PG 200 mg dL, and HbA1c 6.4 (Harris et al., 2002). The American Diabetes Association (ADA) has recommended the FPG or 2-hour PG test for screening the FPG is easier and faster to perform, more convenient, and acceptable to patients, and it is less expensive than other screening tests. The FPG is also more reproducible than the 2-hour PG test and has less intraindividual variation.

Associated Neurological Findings

Decreased position, vibratory, temperature, and pain appreciation occurs in several neuropathies associated with hyposmia. These include diabetes, the neuropathy of renal and hepatic failures, and a large variety of toxic neuropathies. In patients with pernicious anemia, the large myelinated central fibers carrying position and vibration senses are preferentially affected. In the context of hepatitis, the acquired immune deficiency syndrome (AIDS), and other virus-related illnesses, hyposmia can occur along with an ascending polyneuropathy of the Guillain-Barre type. In seizure patients with uncal or temporal lobe foci that induce dysosmic auras, altered sensations in a hemibody distribution can occur as part of the seizure or as a postictal transient sequela.

Percutaneous Coronary Intervention

More than 1 million PCIs are performed annually in the United States, and an estimated 33 of patients undergoing PCI are women.1,2 Compared with men, women undergoing PCI are 5 years older and have higher prevalences of hypertension, diabetes, and other comorbidities.3-5 They are less likely to have had a history of MI, PCI, or coronary artery bypass grafting (CABG). At the time of PCI, they have less multivessel disease and are more likely to present with unstable angina.3-5 Unlike men, they require more urgent procedures and are more likely to have rotational atherectomy. Paradoxically, given their higher risk profile, women tend to have similar lesion types, less multivessel disease, and more preserved left ventricular (LV) function than men.3-5 However,

Prevalence and risk factors

Lacunar infarcts are formed on a risk-factor profile that comprises age, gender, hypertension, diabetes, smoking, previous TIA and possibly ischemic heart disease. In particular, hypertension was initially thought to be a prerequisite for the development of small-vessel occlusion. However, later studies have demonstrated that the vascular risk-factor profile is not specific for lacunar infarction, but is largely similar to other stroke types 30 . Lacunar infarcts are also part of the clinical spectrum of cerebral autosomal dominant arteriopathy with subcortical infarcts and leuken-cephalopathy (CADASIL), a genetic disease affecting the small arteries of the brain (see Chapter 9).

Transdermal patch systems

The drugs that have made it into the transdermal market include sco-polamine, nitroglycerine, nicotine, clonidine, fantanyl, estradiol, testosterone, lidocaine, and oxybutinin (Langer, 2004). Recent additions to this list include lidocaine-tetracaine, selegiline, methyl phenidate, and rotigotine. However, the future focus is production of transdermal systems capable of delivering peptides and proteins including insulin, growth hormone, and vaccine across the skin.

Acute Coronary Syndromes

In ACS, African American patients are more likely to be younger and to have hypertension, diabetes, heart failure, and renal insufficiency. They are also less likely to have insurance coverage or specialist care.96,97 Recently, the investigator of CRUSADE, a large NSTEMI registry, found that African American patients were likely to receive more older ACS treatments, such as aspirin, P-blockers, and ACE inhibitors, but were significantly less likely to receive newer ACS therapies such as GP IIb IIIa inhibitors, clopido-grel, and statin therapy.96 Also, African Americans were less likely to receive cardiac catheterization, revascularization, or smoking cessation counseling. The rates of in-hospital death and postadmission MI were similar between African American and Caucasian patients in CRUSADE (adjusted OR 0.92 95 CI 0.81 to 1.05).96 However, in TACTICS-TIMI 18, African American patients were had an increased risk of death, MI, or rehospitalization (adjusted OR 1.34 95 CI 1.14 to...

Written History of Mr John

Over the past 6 months, the patient has had increasing chest pain with radiation down his left arm despite atenolol, 50 mg daily, and isosorbide dinitrate, 10 mg qid. The patient's chest pain is produced by exercise, emotion, and sexual intercourse. The patient takes nitroglycerin as needed, with relief within 5 minutes. One-block dyspnea on exertion is also present. This has worsened in the past 6 months, before which he could walk two to three blocks. The patient's risk factors for coronary artery disease include a history of untreated hypertension, a 40-pack-year history of smoking (2 packs per day for 20 years), and a brother with a myocardial infarction at the age of 40 years. The patient's brother is now 45 years of age. The patient denies any history of diabetes or hyperlipidemia. At his physician's and wife's request, he has entered the hospital for elective cardiac catheterization. The patient has a significant denial of his illness and a secondary depression. Although...

Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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