The New 2017 American Diabetes Statement On Standards Of Medical Care In Diabetes: Reducing Cardiovascular Risk In Patients With Diabetes
The new 2017 American Diabetes Association (ADA) Standards of Medical Care in Diabetes contains recommendations for the management of diabetes and its complications.1 The ADA statement has been updated based on the recent evidence regarding diabetes care and reiterates the focus on the control of traditional modifiable cardiovascular disease (CVD) risk factors through lifestyle and pharmacological interventions. These ADA evidenced-based recommendations for using pharmacological agents to treat risk factors are useful for minimizing CVD risk, taking into consideration the risk-benefit of treatments. In this article, we briefly discuss how the ADA recommendations can help with the management of CVD risk factors among individuals with diabetes. The ADA recommendations place substantial emphasis on the role of lifestyle modifications, including diet and physical activity, for achieving better glycemic control and cardiovascular outcomes. Prior studies have shown that dietary factors influence mealtime insulin dosing and blood glucose levels. High protein (20-30%) and low carbohydrate diet can have salutary effects on fasting blood glucose, postprandial glucose, and insulin response.2 There is no evidence that low protein intake below the recommended daily allowance (0.8 g/kg body weight/day) can delay the reduction in glomerular filtration rate.3,4 Therefore, as part of individualized medical nutrition therapy, carbohydrate, fat, and protein counting should be used to guide flexible insulin therapy. The recent ADA statement has also made separate recommendations for exercise and physical inactivity as two measures of lifestyle behavior. Individuals with diabetes are recommended to perform 150 minutes or more of moderate-to-vigorous physical activity per week (with no two c Continue reading >>
Metformin In The Treatment Of Adults With Type 2 Diabetes Mellitus
INTRODUCTION Two classes of oral hypoglycemic drugs directly improve insulin action: biguanides (only metformin is currently available) and thiazolidinediones (TZDs). In the absence of contraindications, metformin is considered the first choice for oral treatment of type 2 diabetes (table 1). A 2006 consensus statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), updated regularly, proposed that metformin therapy (in the absence of contraindications) be initiated, concurrent with lifestyle intervention, at the time of diabetes diagnosis [1-3]. The pharmacology, efficacy, and side effects of metformin for the treatment of diabetes will be reviewed here. A general discussion of initial treatment of type 2 diabetes and the role of metformin in the prevention of diabetes, in the treatment of polycystic ovary syndrome, and in gestational diabetes are reviewed separately. Continue reading >>
- Type 1 diabetes as common in adults as children, but many adults misdiagnosed
- ADA: Cardiovascular Benefits seen with Long-Term Metformin Use in Adults with Type 1 Diabetes
- Is It Time to Change the Type 2 Diabetes Treatment Paradigm? No! Metformin Should Remain the Foundation Therapy for Type 2 Diabetes
American College Of Physicians Updates Recommendations For Treatment Of Type 2 Diabetes
Newer oral medications are now available since ACP’s 2012 clinical practice guideline Philadelphia, January 3, 2017 – Physicians should prescribe metformin to patients with type 2 diabetes when medication is needed to improve high blood sugar, the American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicine. If a second oral medication is needed to improve high blood sugar, ACP recommends that physicians consider adding either a sulfonylurea, thiazolidinedione, SGLT-2 inhibitor, or DPP-4 inhibitor to metformin. The American Academy of Family Physicians has endorsed the guideline. “Metformin, unless contraindicated, is an effective treatment strategy because it has better effectiveness, is associated with fewer adverse effects, and is cheaper than most other oral medications,” said Nitin S. Damle, MD, MS, MACP, president. ACP. “The escalating rates of obesity in the U.S. are increasing the incidence and prevalence of diabetes substantially. Metformin has the added benefit of being associated with weight loss.” ACP updated its 2012 guideline on the comparative effectiveness and safety of oral medications for the treatment of type 2 diabetes because of several new studies evaluating medications for type 2 diabetes as well as recent FDA approvals of several new medications. “Adding a second medication to metformin may provide additional benefits,” Dr. Damle said. “However, the increased cost may not always support the added benefit, particularly for the more expensive, newer medications. ACP recommends that clinicians and patients discuss the benefits, adverse effects, and costs of additional medications.” Diabetes is a leading cause of death in the U.S. The disease can af Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes
- A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes
Tailoring Treatment To Reduce Disparities:
The American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes annually, based on the latest medical research. The following narrative provides a summary of the 2017 updated recommendations that have been developed for clinical practice. The ADA guidelines are not intended to aid or preclude clinical judgment. The full guidelines can be accessed at ADA’s Diabetes Pro website. Tailoring Treatment to Reduce Disparities: Updated guidelines focus on improving outcomes and reducing disparities in populations with diabetes such as: Ethnic/Cultural/Sex/Socioeconomic Differences and Disparities: Provide structured interventions that are tailored to ethnic populations and integrate culture, language, religion, and literacy skills. Food Insecurity: Evaluate hyperglycemia and hypoglycemia in the context of food insecurity (FI), which is defined as the unreliable availability of nutritious food. Recognize that homelessness and poor literacy and numeracy often occur with FI. Propose solutions and resources accordingly. Comprehensive Medical Evaluation and Assessment of Comorbidities: The clinical evaluation should include conversation about lifestyle modifications and healthy living. PAs should address barriers including patient factors (e.g., remembering to obtain or take medications, fears, depression, and health beliefs), medication factors (e.g., complex directions, cost) and system factors (e.g., inadequate follow up). Simplifying treatment regimens may improve adherence. This section highlights the elements of a patient-centered comprehensive medical exam, including the importance of assessing comorbidities such as: Cognitive Dysfunction: Tailor glycemic therapy to avoid significant hypoglycemia. Cardiovascular benefits of statin therapy outweigh Continue reading >>
- Major Study Confirms Racial Disparities Related to Key Diabetes Indicator, Hemoglobin A1c
- Disparities in Diabetes Deaths Among Children and Adolescents United States, 20002014
- Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)
General Practice Management Of Type 2 Diabetes
2016–18 Diabetes is a national health priority. The Australian National Diabetes Strategy 2016– 2020 was released by the Australian Government in November 2013. The number of people with type 2 diabetes is growing, most likely the result of rising overweight and obesity rates, lifestyle and dietary changes, and an ageing population. Within 20 years, the number of people in Australia with type 2 diabetes may increase from an estimated 870,000 in 2014, to more than 2.5 million.1 The most socially disadvantaged Australians are twice as likely to develop diabetes. If left undiagnosed or poorly managed, type 2 diabetes can lead to coronary artery disease (CAD), stroke, kidney failure, limb amputations and blindness. The early identification and optimal management of people with type 2 diabetes is therefore critical. General practice has the central role in type 2 diabetes management across the spectrum, from identifying those at risk right through to caring for patients at the end of life. These guidelines give up-to-date, evidence-based information tailored for general practice to support general practitioners (GPs) and their teams in providing high-quality management.1 In the development of the 2016–18 edition of General practice management of type 2 diabetes, The Royal Australian College of General Practitioners (RACGP) has focused on factors relevant to current Australian clinical practice. The RACGP has used the skills and knowledge of your general practice peers who have an interest in diabetes management and are members of the RACGP Specific Interests Diabetes Network. This publication has been produced in accordance with the rules and processes outlined in the RACGP’s conflict of interest (COI) policy. The RACGP’s COI policy is available at www.racgp.org.au Continue reading >>
New Ada 2017 Standards Of Medical Care In Diabetes
Psychological health, access to care, expanded and personalized treatment options and the tracking of hypoglycemia emphasized. The ADA Standards of Medical Care in Diabetes are established and revised annually by a Professional Practice Committee. The committee is a multi-disciplinary team of 12 leading experts in the field of diabetes care, and includes physicians, diabetes educators, registered dietitians and others who have experience in areas that include adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning and pregnancy care. Members of the committee must disclose potential conflicts of interest with industry and/or other relevant organizations. Psychological health, access to care, expanded and personalized treatment options, and the tracking of hypoglycemia in people with diabetes are key areas emphasized in the American Diabetes Association’s (Association) new 2017 Standards of Medical Care in Diabetes (Standards). Produced annually by the Association, the guidelines focus on screening, diagnosis and treatment to provide better health outcomes for children, adults and older people with type 1, type 2 or gestational diabetes, and to improve the prevention and delay of type 2 diabetes. The Standards were published as a supplement to the January 2017 issue of Diabetes Care. The Standards also include the findings of a new report on diabetes staging, titled “Differentiation of Diabetes by Pathophysiology, Natural History and Prognosis” (Differentiation), which is being published at the same time in Diabetes. Produced by a joint symposium of the Association, JDRF, the European Association for the Study of Diabetes and the American Association of Clinical Endocrinologists, the Differentiation report Continue reading >>
What To Know About The Ada's 2018 Standards Of Medical Care If You Have Diabetes
Living with poorly controlled blood sugar levels may lead to potentially serious health complications for people with diabetes — including diabetic neuropathy, diabetic retinopathy, amputations, depression, sexual issues, heart disease, stroke, and even death. But luckily, if you have type 1 or type 2 diabetes, managing your diet, lifestyle, and treatment well can help you stabilize blood sugar and ultimately reduce the risk of these potential future health issues. To do this, it’s crucial to stay up to date on current treatment standards in the United States — and that starts with turning to the American Diabetes Association (ADA), which releases its Standards of Medical Care each year. What Are the ADA Standards of Care and Why Should You Care? In the ADA’s latest guidelines, released online in December 2017, the organization lists updates in areas related to heart disease and diabetes, new health technology, and more. The standards reflect the latest evidence available to help improve care and health outcomes in people with diabetes, says William T. Cefalu, MD, the chief scientific, medical, and mission officer at the ADA who is based in New Orleans, Louisiana. “The new evidence that has been available this year from published work has been incredible,” Dr. Cefalu says. Although the Standards of Medical Care are primarily geared toward the healthcare community, your diabetes management can benefit if you know about them, says Robert A. Gabbay, MD, PhD, the chief medical officer of the Joslin Diabetes Center in Boston. Following is everything you need to know about the new guidelines if you or a family member has type 1 diabetes, type 2 diabetes, or gestational diabetes. What the 2018 ADA Standards of Medical Care Say Here are some of the major changes and Continue reading >>
- What to Know About the ADA's 2018 Standards of Medical Care if You Have Diabetes
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- A Summary of ADA’s New 2018 Standards of Medical Care in Diabetes
New Treatment Guidelines For Diabetes
Authors: News Author: Miriam E Tucker; CME Author: Charles P. Vega, MD, FAAFP Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s) Family Physicians - maximum of 0.25 AAFP Prescribed credit(s) ABIM Diplomates - maximum of 0.25 ABIM MOC points Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology) Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs) This article is intended for primary care physicians, endocrinologists, obstetrician-gynecologists, nurses, pharmacists, and other clinicians who care for individuals with diabetes. The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care. Upon completion of this activity, participants will be able to: Distinguish appropriate glycemic targets for patients with diabetes Assess best practices in the pharmacologic treatment of diabetes As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest. Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content. Disclosure: Miriam E. Tucker has disclosed no relevant financial relationships. Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships. Health Sciences Clinical Professor, Univer Continue reading >>
- Diabetes Groups Issue New Guidelines on Blood Sugar
- I Have Diabetes; Now What? – Guidelines For Newly Diagnosed Diabetes Patients
- Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)
Idf Clinical Practice Recommendations For Managing Type 2 Diabetes In Primary Care
IDF Clinical Practice Recommendations for managing Type 2 Diabetes in Primary Care - 2017 2 IDF Working Group Chair: Pablo Aschner, MD,MSc, Javeriana University and San Ignacio University Hospital, Bogota, Colombia. Core Contributors: Amanda Adler, MD, PhD, FRCP, Addenbrooke´s Hospital and National Institute for Health and Care Excellence(NICE), Cambridge, UK Cliff Bailey, PhD, FRCP(Edin), FRCPath, Aston University, Birmingham,UK Juliana CN Chan, MB ChB, MD, MRCP (UK), FRCP (Lond), FRCP (Edin), FRCP (Glasgow), FHKAM (Medicine), Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong, China. Stephen Colagiuri, MB, BS Honours Class II, FRACP, The Boden Institute, University of Sydney, Sydney, Australia Caroline Day, PhD, FRSB, MedEd UK and Aston University, Birmingham, UK Juan Jose Gagliardino, MD, Cenexa (Unlp-Conicet), La Plata, Argentina Lawrence A. Leiter, MD, FRCPC, FACP, FACE, FAHA, Clinical Nutrition and Risk Factor Modification Centre, Li Ka Shing Knowledge Institute at St. Michael’s Hospital and University of Toronto, Toronto, Canada Shaukat Sadikot, MD, President International Diabetes Federation (2016-2017), Diabetes India and Jaslok Hospital, Mumbai, India Nam Han Cho, MD, PhD, President-Elect International Diabetes Federation (2016-17), Department of Preventive Medicine, Ajou University School of Medicine, Suwon, Korea Eugene Sobngwi, MD, MPhil, PhD, Central Hospital and University of Yaounde, Yaounde, Cameroon Acknowledgements Milena Garcia, MD, MSc, Javeriana University and San Ignacio University Hospital, Bogota, Colombia. Co-chaired the consensus meeting and contributed to the appraisal of the guidelines Chris Parkin - Medical writing support, CGParkin Communications, USA Martine V Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- Psychosocial care in the management of diabetes: America’s recommendations follow Indian guidelines
- IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040
Treatment Of Type 1 Diabetes: Synopsis Of The 2017 American Diabetes Association Standards Of Medical Care In Diabetes.
Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes. Chamberlain JJ, et al. Ann Intern Med. 2017. From St. Mark's Hospital and St. Mark's Diabetes Center, Salt Lake City, Utah; Johns Hopkins University, Baltimore, Maryland; SinfonaRx, Tucson, Arizona; Glytec, Marco Island, Florida; Touro University College of Osteopathic Medicine, Vallejo, California; Abington Memorial Hospital, Jenkintown, Pennsylvania; and University of Michigan, Ann Arbor, Michigan. Ann Intern Med. 2017 Oct 3;167(7):493-498. doi: 10.7326/M17-1259. Epub 2017 Sep 12. Description: The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendation: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes. Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- New ADA 2017 Standards of Medical Care in Diabetes
- What to Know About the ADA's 2018 Standards of Medical Care if You Have Diabetes
Pharmacologic Therapy For Type 2 Diabetes: Synopsis Of The 2017 American Diabetes Association Standards Of Medical Care In Diabetes Free
Abstract Description: The American Diabetes Association (ADA) annually updates the Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendations: This synopsis focuses on recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes. The American Diabetes Association (ADA) first released its Standards of Medical Care in Diabetes for health professionals in 1989. These practice guidelines provide an extensive set of evidence-based recommendations that are updated annually for the diagnosis and management of patients with diabetes. The 2017 Standards cover all aspects of patient care (1); this guideline synopsis focuses on pharmacologic approaches for patients with type 2 diabetes. Pharmacologic Therapy for Type 2 Diabetes: Recommendations Initial Treatment Approach: Metformin Assessing Response and Deciding to Intensify Therapy Recent Evidence From Cardiovascular Outcomes Trials Recent Warnings About Pharmacotherapies Insulin Therapy Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- New ADA 2017 Standards of Medical Care in Diabetes
- What to Know About the ADA's 2018 Standards of Medical Care if You Have Diabetes
Diabetes Year In Review 2017
The FDA has approved semaglutide injection as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Type 2 diabetes risk is increased in young adults through antidepressant use, specifically the duration of use and the cumulative dose. Diabetes risk greater in children, young adults on second-generation antipsychotics Type 2 diabetes is greater with second-generation antipsychotics than with non-second-generation antipsychotic psychotropic medications for patients aged 6 to 25 years. After the inclusion of recent negative studies, a statistically significant association between AD use and diabetes was observed. The statement includes advances in care since the ADA's last position statement was published in 2003. Lifestyle interventions maintain glycemic control in patients with type 2 diabetes. Consumption of alcohol 3 to 4 days weekly is associated with a significantly lower risk for diabetes in men and women. Adulthood weight gain is associated with an increased risk of major chronic diseases and mortality. HIV-infected patients on ART had approximately 4 and 1.5 greater odds of developing diabetes mellitus and metabolic syndrome, respectively. Degludec is noninferior to glargine regarding the incidence of major cardiovascular events among patients with type 2 diabetes. Adolescents with type 2 diabetes decreased HbA1c levels after using insulin pump therapy for a 3-month period. Diabetes incidence rates in the US and glucose intolerance worldwide increased per 1C increase in temperature. The Stepping Up model of care produced a clinically and significantly significant improvement in HbA1c among adults with type 2 diabetes managed in primary care. The position statement by the ADA incorporates updates in treatment and scr Continue reading >>
Support Article
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Ada Releases 2017 Standards Of Medical Care In Diabetes
ADA Releases 2017 Standards of Medical Care in Diabetes ADA Releases 2017 Standards of Medical Care in Diabetes The ADA has issued its updated Standards of Medical Care in Diabetes. The American Diabetes Association (ADA) has released the 2017 update to their Standards of Medical Care in Diabetes (Standards).1 The document is reviewed each year by a multidisciplinary committee of experts in diabetes care, which examines relevant research that informs the revisions. The most recent update to the ADA Standards of Medical Care addresses many new and important issues regarding the management of patients with diabetes, Kevin M. Pantalone, DO, staff endocrinologist and director of clinical research at the Cleveland Clinic Foundation in Ohio, told Endocrinology Advisor. The 2017 Standards contain the usual guidelines pertaining to type 2 diabetes prevention and the diagnosis and treatment of type 1, type 2, and gestational diabetes. Additionally, Dr Pantalone identified several of the most notable updates. One recommendation suggests considering metabolic surgery for patients with obesity and uncontrolled type 2 diabetes who have a body mass index (BMI) as low as 30 kg/m2 (27.5 kg/m2 for Asian Americans). This update is based on a growing body of research showing that metabolic surgery previously referred to as bariatric surgery leads to improved glycemic control and reduced cardiovascular disease (CVD) risk in this patient population compared with other medical and lifestyle interventions.2 The Committee also noted that the safety of metabolic surgery has significantly improved in the past 2 decades: Related mortality rates are 0.1% to 0.5%, which are similar to the rates associated with hysterectomy or cholecystectomy.2 Another update recommends considering 2 specific gluco Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- New ADA 2017 Standards of Medical Care in Diabetes
- What to Know About the ADA's 2018 Standards of Medical Care if You Have Diabetes
Ada Releases 2018 Standards Of Care For Diabetes
The American Diabetes Association (ADA) has released their annual Standards of Medical Care in Diabetes for 2018, highlighting several updated recommendations for diabetes care and management. Based on current research findings, the standards offer comprehensive practice evidence-based recommendations. The updated guidelines address the use of the medications with potential cardiovascular (CV) benefit. Other areas addressed include diabetes screening, technology, and A1C tests. Some of the most notable changes are summarized below. Cardiovascular Disease and Diabetes New guidelines incorporate the use of diabetes drugs with known cardiovascular benefit. For adults with type 2 diabetes and heart disease, the ADA recommends that, after lifestyle management and metformin, health care providers should include a medication proven to improve heart health. In the clip below, Dhiren Patel, PharmD, discusses the importance of the new recommendations for diabetes care, including the use of diabetes medications with CV risk. All hypertensive patients with diabetes are encouraged to monitor their blood pressure at home to help identify potential discrepancies between office vs. home blood pressure, and to improve medication-taking behavior, according to the guidelines. The new ADA standards also continue with the existing hypertension definition, as opposed to the American College of Cardiology’s recently updated blood pressure guidelines. The ADA’s guidelines state that most adults with diabetes and hypertension should have a target blood pressure of <140/90 mmHg and that risk-based individualization lowers targets, such as 130/80 mmHg, may be appropriate in some patients. In the clip below, Dhiren Patel, PharmD, discusses the importance of the new recommendations for diabetes Continue reading >>
- American Diabetes Association® Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes
- What to Know About the ADA's 2018 Standards of Medical Care if You Have Diabetes
- A Summary of ADA’s New 2018 Standards of Medical Care in Diabetes
