Epidemiology of Diabetes Among Older Population

Diabetes is one of the metabolic disorders in which blood sugar level remains elevated for the prolonged time. Pre prandial glucose level for non-diabetic and diabetic patient should be 4.0 to 5.9 mmol/L  and 4 to 7 mmol/L  respectively. Post prandial glucose level for non-daiabetic and diabetic should be under 7.8 mmol/L and 5 to 9 mmol/L respectively.  HbA1c in normal, prediabetes and diabetes patient should be below 6 %,  6 to 6.4 % and above 6.5 % respectively. Prominent symptoms of diabetes include frequent urination (polyurea), increased thirst (polydipsia) and increase hunger (polyphagia). In type 1 diabetes, these symptoms develop very rapidly and in type 2 diabetes these symptoms develop slowly over a period of duration (Thomas & Philipson, 2015). Diabetic patient particularly in the older age is mostly associated with acute diabetic complications like diabetic ketoacidosis and hyperosmolar hyperglycemic state. Few of the symptoms are not associated specifically with the diabetes; however, these symptoms indicate onset of the disease. These symptoms include blurry vision, headache, fatigue, slow healing of cuts, and itchy skin. Alteration in the vision of the diabetes patient occurs due to absorption of glucose in the lens. Rashes on the skin of the diabetes patient are collectively known as diabetic dermadromes. Diabetic condition also produces effects like uneasy feeling, sweating, trembling, confusion, aggressiveness, seizures and unconsciousness (Wiley, 2016; Pippitt et al., 2016).

It is also associated with chronic complications like cardiovascular condition like damage to the blood vessels, stroke, peripheral artery disease, chronic kidney disease (diabetic nephropathy), foot ulcers, damage to nerves (diabetic neuropathy) and damage to the eyes (diabetic retinopathy). Diabetic retinopathy mainly caused due to damage to the blood vessels of retina and it leads to sustained vision impairment and finally blindness.  Older diabetes patients are more prone to risks like glaucoma and cataracts. Older people are more prone to eye problems due to anatomical changes in the eye due to older age. In older people, diabetes nephropathy lead to problems like tissue scarring and protein loss in the urine. Diabetic neuropathy is most common complication of diabetes and it leads to occurrence of numbness, tingling, pain, and altered sensitivity to pain. As a result of altered sensitivity to pain, skin become more susceptible to the injury. Foot problem like diabetic foot ulcer is difficult to treat.

No effective prevention measures are available for type 1 diabetes and however, type 2 diabetes can be effectively prevented. Due to complex nature of diabetes, medical, physical and nutritional interventions need to be carried for the treatment and management of diabetes (Garrison, 2015). Most prominent interventions to be carried out for the treatment and management of diabetes include healthy diet, regular physical exercise, a normal body weight, and avoiding use of tobacco. It is evident that physical activity for more than 90 minutes per day can reduce risk of diabetes in approximately 30 % of the patients. Appropriate diet can also be useful in the prevention of diabetes. Diet useful for the prevention of diabetes include whole grains, fibres, and polyunsaturated fat (Li et al., 2014; ADA, 2015). Prevention of consumption of sugary beverages and food containing saturated fats can be useful in the prevention of diabetes. Tobacco smoking can increase the susceptibility of diabetes and its complications; hence prevention of tobacco smoking can be useful in prevention of smoking (Handelsman et al., 2015).

Pathophysiology of Diabetes and Its Impact on Elderly Patients

Prevalence of diabetes in adult population above 18 years of age is approximately 10 % and it is estimated to rise upto 12 % by 2030. It is still higher in people above 65 years of age. In older people above 65 years of age, prevalence of diabetes is estimated to be 19 %. Diabetes prevalence increases with increase in the age of the patient. It has been estimated that diabetes prevalence in approximately 20 % in age group people between 60 – 70 years of age. It is approximately 22 % in age group people between 70 – 80 years of age and it is approximately 23.5 % in age group people between 80 – 90 years of age. In age group above 65 years of age, incidence of obesity is estimated to be 14 cases per 1000 adults. It has estimated that person lose life by approximately 10 years when diagnosed in the middle age of life. Mortality rate is approximately double in patients with diabetes as compared to the normal people. Prevalence of diabetes is higher in women as compared to the men (Sánchez Martínez, 2014)

Diabetes can be classified in two categories like insulin dependent diabetes mellitus (IDDM; type 1 diabetes mellitus) and non-insulin dependent diabetes mellitus (NIDDM; type 2 diabetes mellitus). IDDM is more prevalent in children and young people. It can also be termed as juvenile diabetes. In this type of diabetes, there is occurrence of abrupt onset of symptoms, it depends on the exogenous insulin and these patients are more susceptible to ketoacidosis. It can be considered as catabolic disease in which diabetic patient is with deficiency of circulating insulin, with raised levels of glucagon and pancreatic B cells become resistant to insulin stimulation. Autoimmunity plays major role in the development of IDDM. Infectious and toxic environmental substances affect immune system of people whose immune system is susceptible to autoimmune response against pancreatic B cell antigens. Genetic defect also plays important role in the impaired B cell function and replication. These patients become more susceptible for type 1 diabetes due to failure of B cells development after viral infection. Specific HLA genes can augment susceptibility to infection by diabetogenic virus. These HLA genes can also augment susceptibility of autoimmune destruction of their own islet cells. Hence, immunosuppressive drugs like cyclosporine and azathioprine are proved to useful in the management of initial stage of type 1 diabetes mellitus (ADA, 2015).

Collaboration of Team Work and Client Involvement in the Management of Diabetes

Approximately 80% of the diabetes patients are of type 2 diabetes. Patients of this type of diabetes are not reliant on the exogenous insulin source for management of ketonuria and these patients are not at risk of ketosis. However, these patients can develop ketosis due to severe  stress aggravated by the infection and trauma. Type 2 diabetes patients might require insulin for the control of fasting hyperglycaemia when it is not controllable by proper diet and after consumption of oral hypoglycaemic agents. In type 2 diabetes, body can produce optimum amount of insulin; hence it can not be used effectively by the body.  This mainly occurs because peripheral tissues become insulin resistance. Moreover, insulin receptors and other intermediate signalling pathways become insensitive to insulin. Hence, glucose can not enter in the tissues and hence, blood sugar level increases. Both lifestyle and genetic factors are responsible for the occurrence of type 2 diabetes (Selph et al., 2015).

Type 2 diabetes can be managed by medications which can improve the insulin sensitivity and reduce the glucose production by the liver. Lifestyle factors play important role in the development of type 2 diabetes. It includes obesity measured in terms of body mass index, lack of physical activity, improper diet and stress. Excess body fat is associated with approximately 50 % cases of the diabetes. Sugary sweetened drinks, saturated fats and trans fats are responsible for the development of type 2 diabetes. Polyunsaturated and monounsaturated fats can decrease the risk of development of type 2 diabetes mellitus. Approximately, 7 % cases of the develop type 2 diabetes due to lack of physical activity (Siu, 2015).  

Insulin is the principal hormone responsible for regulation of glucose uptake from blood into different cells like adipose tissue and muscle, except smooth muscle. In these tissues, insulin act through insulin-like growth factor 1  (IGF-1). Hence, deficiency of insulin or insensitivity of insulin receptors are mainly responsible for the development of diabetes mellitus (Byrne, 2012). There are three different sources of glucose for the body. These include through food absorption through intestine, glycogen breakdown which is a storage depot of glucose in the liver and gluconeogenesis which is a production of glucose from the non-carbohydrate sources present in the body (Ahmadieh & Azar, 2014).

Insulin can control hyperglycaemia by different mechanisms like inhibiting glycogen breakdown and gluconeogenesis; stimulating glucose transport in the fat and muscle cells and stimulating glycogenesis in which glucose is stored in the form of glycogen. Islets of Langerhans in the pancrease contain beta cells which secret insulin in response to increased levels of glucose after taking food. Approximately, two-third of the body’s cells use insulin for lowering glucose level, for conversion of glucose into the fuel, for conversion into other required substances and for storage. Reduced levels of glucose can lead to the reduced insulin secretion of beta cells which lead to the gluconeogenesis in which glycogen get converted to glucose. Gluconeogenesis process is controlled by hormone glucagon which exhibits opposite action to the insulin. Insulin action can be impaired in several ways like insufficient availability of insulin, poor response of cells to insulin which is termed as insulin resistance and defective insulin. Due to this impaired action of insulin, glucose will not be absorbed adequately by the body cells and it will not be stored in required amount in liver and muscles. It can lead to sustained raised levels of glucose, inadequate protein synthesis and acidosis. Sustained increase in the glucose level can lead to reabsorption by the kidneys and excretion in the urine which is called as glycosuria. It leads to raised osmotic pressure of the urine and inhibition of water reabsorption by the kidneys. It leads to raised urine production which is termed as polyuria. It leads to increased fluid loss. It leads to dehydration and increased thirst which is called as polydipsia (Kwak & Park, 2018; Brooks-Worrell & Palmer, 2011).

Holistic Need of the Patient

In the recent past, nutritional therapy gain importance for the management of diabetes. Main goals of this therapy include : promotion and support for maintaining healthy eating pattern, ensuring diverse nutritional foods in appropriate amount for improvement in the overall health of the adult, attainment of individual glycaemic, blood pressure, and lipid goals, attainment and maintenance body weight, prevent and control diabetic complications, ensure fulfilment of nutritional goals with respect to personal and cultural preferences and implementation of suitable diet plan and schedule for the adult diabetic patient. Through nutritional therapy, goals for different parameters of diabetic patient include Hba1c <7%, Blood pressure <140/80mmHg, LDL cholesterol <100 mg/dL, triglycerides <150 mg/dL, HDL cholesterol.>40 mg/dL for men, and HDL cholesterol .>50 mg/dL for women (Khazrai et al., 2014).

Medical nutrition therapy (MNT) comprises of implementation of both medicinal intervention and diet plan. Goal of MNT should be to improve glycaemic control and prevent hypoglycaemia. For patients with type 1 diabetes mellitus, administration of flexible insulin therapy along with carbohydrate counting meal approach in addition to the education programme can result in improved glycaemic control. For patients with fixed daily doses, regular consumption of carbohydrate according to scheduled time and measured amount can be helpful in the improved glycaemic control with reduced risk of hypoglycaemia. For type 2 diabetes patients and older people meal planning approach can be more useful in controlling the hyperglycaemia (Gosmanov & Umpierrez, 2012).  

Appropriate proportion of combination of carbohydrate, protein and fat can be helpful in meeting metabolic goals of the adult patient based on the patient’s preference of food. Total intake of calorie need to be kept in mind while diet planning for adult diabetic patient. Amount and type of glucose in the food can influence overall glucose level in the patient. Carbohydrate intake in the form of vegetables, fruits, whole grains, legumes, and dairy products is advised instead of other forms of glucose. Carbohydrate containing food in combination with fats, sugars and sodium should be avoided. Carbohydrate counting or experience-based quantitation can be useful in administering optimum amount of carbohydrate to the patient. Non-nutritive sweeteners (NNSs) has the possibility to reduce calorie and carbohydrate intake as compared to the nutritive sweeteners (Evert et al., 2014).

Nutritive sweeteners include sucrose and fructose. In comparison to the starch, sucrose has negligible effect on the glucose level. Nutritive sweeteners provide excess amount of energy because these foods provide empty calories and result in the unnecessary weight gain. Fructose is commonly used monosaccharide present in the fruits, some vegetables and honey. Fructose present in the form of free fructose which is present in the fruits can exhibit more glycaemic control over the sucrose and starch consumption. If free fructose consumed in less than 12 % quantity, it doesn’t exhibit effect on the triglycerides level (Deed et al., 2015). Diabetes patients should avoid sugar-sweetened beverages (SSBs) including high-fructose corn syrup and sucrose to keep body weight in control and limit cardiometabolic risk factors. Beverages with high level of fructose can have effects on the deposition of ectopic and visceral fat, lipid metabolism, blood pressure, and insulin sensitivity in comparison to the glucose-sweetened beverages. Non-nutritive sweeteners can exhibit can add negligible amount of calorie while providing sweet sensation. It does not exhibit any significant effect on the blood glucose and insulin concentration. Following are the FDA approved non-nutritive sweeteners : sucralose, saccharine, Acesulfame K, Neotame, Stevia and Luo han guo. It is evident that these FDA approved sweeteners do not exhibit effect on the glucose level and body weight. Sugar alcohols (polyols) are the hydrogenated monosaccharides which include sorbitol, mannitol, erythritol, xylitol and D-tagatose and hydrogeneated diasacchride which include isomalt, maltitol, lactitol and trehalose. These polyols are partially absorbed by the small intestine; hence provide less amount of calorie per gram. From the clinical studies, it is evident that polyols produce less postprandial glucose level alteration as compared to the sucrose and glucose. These polyols can produce long term effect in the form of less calorie intake and control of glucose level (Esposito et al., 2014).

Current Policies, Procedures and Strategies for Diabetes

Dietary fibre is the composition of carbohydrate and lignin. These dietary fibres are indigestible by the stomach and unobservable by the GI tract. It is evident that dietary fibres can reduce mortality rate in diabetic patients. Fibbers can produce satiety, produce less calorie, less in fat and sugar content. Hence, it can be helpful in the prevention of obesity and heart disease. Resistant starches are the starches enclosed inside the intact cell walls. These comprise of legumes, starch granules in raw potato and retrograde amylose from plants. It is difficult to digest these resistant starches and these are absorbed as glucose. Fructans like inulin are indigestible fibres and these can be used to reduce blood glucose level. Diabetes patients need to be assessed for cardiovascular conditions prior to consumption of fat containing food because fat can exaggerate both diabetes and cardiovascular disease. Amount of saturated fat consumption need to be assessed in diabetes patients because it should be below 7 %. Intake of trans fat need to be minimized because intake of trans fat raise the levels of LDL cholesterol and reduce HDL cholesterol (Esposito et al., 2015). Consumption of monounsaturated fatty acid (MUFA) containing food can be helpful in improving glucose levels in the diabetes patients. There is less evidence available for the role of omega-6 polyunsaturated fatty acids (PUFAs) in diabetes patients. It is not recommended to reduce protein consumption below usual intake in patients with diabetes and evidence of diabetic kidney disease. Protein consumption below the usual intake doesn’t affect glycemia, cardiovascular condition and glomerular filtration rate (GFR). In type 2 diabetes patients, protein consumption can improve the sensitivity of insulin action without increasing plasma blood sugar level. In RCTs it has been demonstrated that reduction in the protein consumption doesn’t have any effect on the improvement of diabetic nephropathy. Diabetes is a condition with increased oxidative stress hence vitamins with the antioxidant potential like vitamin C and E need to be administered to the diabetic older patient.

Glycemic index (GI) and glycemic load  (GL) can be used as the assessment parameters for assessing hyperglycaemia potential and insulin levels in diabetes patients. GI is applicable in ranking the carbohydrate rich foods with potential to develop hyperglycaemia. It has been established that foods with higher GI are refined grain products and potatoes; foods with moderate GI are legumes and whole grains and foods with lower GI are starchy fruits and vegetables (Kahleova & Pelikanova, 2015). Glycaemic control can be achieved effectively by replacing high GI food with low GI food. GL is the combined effect of GI and total carbohydrate content of food per serving of food. It is useful in assessing the effect of food on blood glucose level and insulin level. GL is more sensitive parameter as compared to the GI for the selection of food in older diabetic patients. Data obtained from the studies comprising of GL and GI indicate that both amount and type of carbohydrate can be helpful in assessing risk of hyperglycaemia development in diabetic patients. Intervention studies indicated that diets containing low GI exhibited positive effect on the type 2 diabetes and CVD. These studies also demonstrated that with GI food, insulin sensitivity can be improved and Hba1c can be controlled effectively (Schwingshackl & Hoffmann, 2013; Mirrahimi, 2014).  

Acute and Chronic Complications of Diabetes in Older People

Management of diabetes can be effectively achieved by providing medical, nutritional and physical intervention. Hence professionals from different fields like Nurse practitioner, endocrinology-certified diabetes educator (CDE), podiatrists, optometrists, dental care professionals, primary care physician, physician assistant, dietician, community health workers, mental health professional and a pharmacist. Implementation of interdisciplinary team (IDT) in the management of diabetes can be helpful in control of glycaemia, reducing cardiometabolic risk factors and reducing risk of diabetes complications. Global Partnership for Effective Diabetes Management suggested to implement IDT for the management of type 2 diabetes (Powell et al., 2015). Nurse practitioner plays significant role in assessment of patient and in providing appropriate intervention to the diabetes patient. Along with the blood glucose evaluation and Hb 1ac estimation, feet and eye examination and urine test need to be carried out in the diabetes patient. Hence, medical professionals from different disciplines like podiatrists, optometrists, diagnostic laboratory head and technician need to be incorporated in the management of diabetes patient. Diabetes educator can play important role in the education of patient about healthy lifestyle to manage diabetes and self-management of blood glucose level. Diabetes educator can provide education to the diabetes patients based on the stage of diabetes hence diabetes educator can provide education about prevention, prediabetes and management of diabetes. Dietician can make proper diet plan and schedule for the diabetes patient. Dietician can identify food with low GI and GI, which can be helpful in controlling glycaemia (Chatterjee & Davies, 2015).

Community health worker can be helpful in the reducing disparity for accessing health education. Community health workers can act as connecting link between the healthcare professionals and patients because older patients have more belief on community workers as compared to the healthcare professionals; moreover, community workers have more understanding of the patients in the community. Hence, they can be helpful in providing holistic care by considering cultural and social aspects of the older people. Psychological and mental issues can occur in adult diabetes patients due to impaired quality of life, increased rate of hospitalizations and increased cost of care. Hence, mental health care professional conduct motivational interview and implement cognitive-behavioural therapy for improvement of morale of patient. Pharmacist can help patient to select most appropriate hypoglycaemic strategy based on the individual needs of the patient. Pharmacist can provide counselling to the patient for monitoring glucose levels on the regular basis and to control out-of-range glucose levels. Pharmacist can also help patient to follow appropriate care plan by eliminating risk of hypoglycaemia development. There should be cooperation between the healthcare professional and specialist healthcare professional (Conley et al., 2014).

Preventive Measures for Diabetes Among Older Population

There should be regular communication among these members of IDT. IDT need to be implemented in the people with low and middle class economic class people (Lall & Prabhakaran, 2014). IDT can be helpful in the minimizing health risk to the adult patient through assessment, intervention and surveillance. Problems can be identified in the earlier stage and effective intervention can be implemented in the effective manner.

Policies, procedures, tools and training for diabetes control :

National Institute for Health and Care Excellence (NICE) policies need to be implemented for elimination of the unnecessary obstacles and provide safe and effective diabetes care to the adult patients. Timely action need to be taken for the management of diabetes. Access of the adult diabetic patients need to be improved for getting better education for the management of diabetes. Diabetes people need to stay healthy and adapt healthy habits and behaviours which can be helpful in lifestyle change and improved management of chronic diabetic conditions in the older age. Diabetes education and management services need to be provided by the healthcare staff according to their clinical expertise to the diabetic patient. Policies need to be implemented for adapting updated clinical practice guidelines. Gaps and needs of the community need to be identified and diabetes education need to be given with respect to needs of the community and gaps need to be filled (Bloomfield et al., 2015).

Care need to be provided to the diabetes patients at three levels like national, local and individual level. National organisations and policy makers need to implement national guideline and policies of NICE, partnerships need to be developed for delivering healthcare services, develop national workforce strategy, develop leadership from colleges and universities, develop national framework, develop and implement national incentive framework like General Practitioner contract and incentive (Haw et al., 2015). At local level, whole system approach need to be implemented to provide care in terms of more than medicines. Local guidelines and agreements need to be implemented for cross sector working, develop stering group to oversee all the operations, develop local workforce and training strategy, develop multidisciplinary team, develop local clinical leadership, develop local financial framework, develop and implement local incentives and procurements like insurance policies and coordinated procurement of medicines. At personal level care need to be given to provide care by considering needs and requirements of the patients and work in collaboration with the local authorities to implement required strategies. Details of the population need to be collected, consultation skills need to be developed in healthcare professionals, integrated muti-disciplinary team need to be recruited, education need to be provided according to the needs pf the patient and emotional and psychological support need to be given (Haw et al., 2015).

Insulin Dependent Diabetes Mellitus (IDDM) and Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Diabetes management can be effectively implemented by applying different tools like diabetes medical management plan, individualised healthcare plan and emergency care plan hyperglycaemia and hypoglycaemia. Diabetes medical management plan should be compiled by healthcare team and it should contain medical orders which are basis of healthcare and education needs. In individualised healthcare plans patient’s needs and requirements need to be considered. Emergency care plans for hypoglycemia and hyperglycemia need to provide training for identification of the hypoglycemia and hyperglycemia and strategies to control it.

Self-management education and patient-centred care, lifestyle strategies management including diet and physical activity management and medical therapy with individualised glycaemic goals need to be given for providing holistic care to the diabetes adults. Evidence based lifestyle strategies need to be implemented by providing interventions for behaviour change through counselling and motivational interview. It cab be helpful in improving health belief of the patient in medication, identifying and overcoming barriers for healthcare access and prioritising strategies to overcome risk factors. Adult patients need to be educated and trained for the self-management of the blood sugar level. These patients need to be educated for use of glucose strips and monitoring of both hyperglycaemia and hypoglycaemia. Education need to be given to the adult diabetes patients about the healthy diet (Ofori & Unachukwu, 2014).

References :

Ahmadieh H, & Azar ST. (2014). Liver disease and diabetes: association, pathophysiology, and management. Diabetes Research and Clinical Practice, 104(1), pp. 53-62.

American Diabetes Association (ADA). 2015. Classification and diagnosis of diabetes. Diabetes Care, 38, pp. S8–S16.

American Diabetes Association (ADA). 2015. Older adults. Diabetes Care, 38, pp. S67–S69.

Bloomfield GS, Wang TY, Boulware LE, Califf RM, Hernandez AF, Velazquez EJ, Peterson ED & Li JS.  (2015). Implementation of management strategies for diabetes and hypertension: from local to global health in cardiovascular diseases. Global Heart, 10(1), pp. 31-8.

Brooks-Worrell B & Palmer JP. (2011). Is diabetes mellitus a continuous spectrum? Clinical Chemistry, 57(2), pp. 158-61

Byrne CD. 2012. Dorothy Hodgkin Lecture 2012: non-alcoholic fatty liver disease, insulin resistance and ectopic fat: a new problem in diabetes management. Diabetic Medicine, 29(9), pp. 1098-107.

Chatterjee S & Davies MJ. (2015). Current management of diabetes mellitus and future directions in care. Postgraduate Medical Journal, 91(1081), pp. 612-21.

Conley MP, Chim C, Magee CE & Sullivan DJ. (2014). A review of advances in collaborative pharmacy practice to improve adherence to standards of care in diabetes management. Current Diabetes Reports, 14(3), p. 470.

Management of Diabetes in Older People

Deed G, Barlow J, Kawol D, Kilov G, Sharma A & Hwa LY.2015. Diet and diabetes. Australian Family Physician, 44(5), pp. 192-6.

Esposito K, Chiodini P, Maiorino MI, Bellastella G, Panagiotakos D &  Giugliano D. 2014. Which diet for prevention of type 2 diabetes? A meta-analysis of prospective studies. Endocrine, 47(1), pp. 107-16.

Esposito K, Maiorino MI, Bellastella G, Chiodini P, Panagiotakos D & Giugliano D. A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses. BMJ Open,  5(8):e008222. doi: 10.1136/bmjopen-2015-008222.

Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, Neumiller JJ, Nwankwo R, Verdi CL, Urbanski P, Yancy WS Jr. 2014. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care, 37(1), pp. S120-43.

Garrison A. 2015. Screening, diagnosis, and management of gestational diabetes mellitus. American Family Physician, 91(7), pp. 460–467.

Gosmanov AR & Umpierrez GE. 2012. Medical nutrition therapy in hospitalized patients with diabetes. Current Diabetes Reports,  12(1), pp. 93-100.

Handelsman Y, Bloomgarden ZT, Grunberger G, et al. 2015. American Association of Clinical Endocrinologists and American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. Endocrine Practice, 21(1), pp. 1–87.

Haw JS, Tantry S, Vellanki P & Pasquel FJ.(2015). National Strategies to Decrease the Burden of Diabetes and Its Complications. Current Diabetes Reports, 15(9), p. 65.

Haw JS, Narayan KM & Ali MK. (2015). Quality improvement in diabetes–successful in achieving better care with hopes for prevention. Annals of the New York Academy of Sciences, 1353, pp. 138-51.

Kahleova H & Pelikanova T. (2015). Vegetarian Diets in the Prevention and Treatment of Type 2 Diabetes. Journal of the American College of Nutrition, 34(5), pp. 448-58.

Khazrai YM, Defeudis G and Pozzilli P. 2014. Effect of diet on type 2 diabetes mellitus: a review. Diabetes/Metabolism Research and Reviews, 30 (1), pp. 24-33.

Kwak SH & Park KS. 2018. Pathophysiology of Type 2 Diabetes in Koreans. Endocrinology and Metabolism (Seoul), 33(1), pp. 9-16.

Lall D & Prabhakaran D. (2014). Organization of primary health care for diabetes and hypertension in high, low and middle income countries. Expert Review of Cardiovascular Therapy, 12(8), pp. 987-95.

Li G, Zhang P, Wang J, et al. 2014. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes & Endocrinology, 2(6), pp. 474–480.

Mirrahimi A, Chiavaroli L, Srichaikul K, Augustin LS, Sievenpiper JL, Kendall CW & Jenkins DJ. (2014). The role of glycemic index and glycemic load in cardiovascular disease and its risk factors: a review of the recent literature. Current Atherosclerosis Reports, 16(1), p. 381.

Ofori SN & Unachukwu CN. 2014. Holistic approach to prevention and management of type 2 diabetes mellitus in a family setting. Diabetes, Metabolic Syndrome and Obesity, 7, pp. 159-68.

Pippitt K, Li M & Gurgle HE, 2016, Diabetes Mellitus: Screening and Diagnosis. American Family Physician, 93(2), pp. 103-9.  

Powell PW, Corathers SD, Raymond J & Streisand R. (2015). New approaches to providing individualized diabetes care in the 21st century. Current Diabetes Reviews, 11(4), pp. 222-30.

Schwingshackl L & Hoffmann G. (2013). Long-term effects of low glycemic index/load vs. high glycemic index/load diets on parameters of obesity and obesity-associated risks: a systematic review and meta-analysis. Nutrition, Metabolism & Cardiovascular Diseases, 23(8), pp. 699-706.

Sánchez Martínez M, Blanco A, Castell MV, Gutiérrez Misis 4, González Montalvo JI, Zunzunegui MV, & Otero Á. 2014. Diabetes in older people: Prevalence, incidence and its association with medium- and long-term mortality from all causes. Atencion Primaria, 46(7), pp. 376-84.

Selph S, Dana T, Blazina I, Bougatsos C, Patel H & Chou R. (2015). Screening for type 2 diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 162(11), pp. 765–776.

Siu AL. 2015. Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 163(11), pp. 861–868.

Thomas CC, & Philipson LH, 2015, Update on diabetes classification. Medical Clinics of North America, 99(1), pp. 1-16.

Wiley F, 2016, Monogenic Diabetes: Not Your “Typical” Diabetes. Diabetes Self-Management, 33(4, pp. 36-7.