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Progression Of Type 2 Diabetes And Insulin Initiation

Progression Of Type 2 Diabetes And Insulin Initiation.

Progression Of Type 2 Diabetes And Insulin Initiation.

1. J Natl Med Assoc. 2011 Mar;103(3):241-6. Progression of type 2 diabetes and insulin initiation. (1)Beth Israel Deaconess Medical Center-West Campus, 110 Francis St, Ste 2F, Boston, MA 02215, USA. [email protected] The prevalence of type 2 diabetes is significantly greater among AfricanAmericans compared to some other ethnic groups. The reasons for this increasedincidence are due at least in part to the increased frequency of obesity,especially among African American women. The onset of hyperglycemia, after manyyears of insulin resistance, is due to beta cell dysfunction that slowlyprogresses to beta cell failure, necessitating insulin replacement. The timelyinitiation of insulin therapy is a critical clinical decision for treatingphysicians managing patients, especially when the patient is hesitant to begininsulin therapy. The availability of various insulin formulations gives theopportunity to tailor insulin therapy based on a patient's personal insulinrequirements and lifestyle. Specific issues related to insulin therapy such aspatient preferences, quality of life, barriers to the addition of insulin to the treatment regimen, and the effectiveness of insulin therapy are illustrated usinga case study. Continue reading >>

Management Of Persistent Hyperglycemia In Type 2 Diabetes Mellitus

Management Of Persistent Hyperglycemia In Type 2 Diabetes Mellitus

The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc. All topics are updated as new evidence becomes available and our peer review process is complete. INTRODUCTION — Initial treatment of patients with type 2 diabetes mellitus includes education, with emphasis on lifestyle changes including diet, exercise, and weight reduction when appropriate. Monotherapy with metformin is indicated for most patients, and insulin may be indicated for initial treatment for some [1]. Although several studies have noted remissions of type 2 diabetes mellitus that may last several years, most patients require continuous treatment in order to maintain normal or near-normal glycemia. Bariatric surgical procedures in obese patients that result in major weight loss have been shown to lead to remission in a substantial fraction of patients. Regardless of the initial response to therapy, the natural history of most patients with type 2 diabetes is for blood glucose concentrations to rise gradually with time. Treatment for hyperglycemia that fails to respond to initial monotherapy and long-term pharmacologic therapy in type 2 diabetes is reviewed here. Options for initial therapy and other therapeutic issues in diabetes management, such as the frequency of monitoring and evaluation for microvascular and macrovascular complications, are discussed separately. (See "Initial management of blood glucose in adults with type 2 diabetes mellitus" and "Overview of medical care in adults with diabetes mellitus". Continue reading >>

Defining And Characterizing The Progression Of Type 2 Diabetes

Defining And Characterizing The Progression Of Type 2 Diabetes

Type 2 diabetes is a progressive disease in which the risks of myocardial infarction, stroke, microvascular events, and mortality are all strongly associated with hyperglycemia (1). The disease course is primarily characterized by a decline in β-cell function and worsening of insulin resistance. The process is manifested clinically by deteriorations in multiple parameters, including A1C, fasting plasma glucose (FPG), and postprandial glucose levels. In this review, we will evaluate our current understanding of the role played by deteriorating β-cell function and other abnormalities linked with the progression of type 2 diabetes. An improved understanding of these abnormalities may provide the scientific groundwork for novel therapies that may help achieve and maintain good glycemic control. CHARACTERISTICS OF DISEASE PROGRESSION Progression from pre-diabetes to overt diabetes Because glucose is a continuous variable, the use of thresholds to make a diagnosis is somewhat arbitrary. The term “pre-diabetes” has become well established and implies a risk of progression to overt diabetes. However, although such progression is well studied in prevention trials, little is known about the rate of progression and the characteristics of such progression in the population at large. Table 1 summarizes some of the factors associated with such progression. Nichols et al. (2) studied the progression of pre-diabetes to overt disease and observed that 8.1% of subjects whose initial abnormal fasting glucose was 100–109 mg/dl and 24.3% of subjects whose initial abnormal fasting glucose was 110–125 mg/dl developed diabetes over an average of 29.0 months (1.34 and 5.56% per year, respectively). A steeper rate of increasing fasting glucose; higher BMI, blood pressure, and triglycer Continue reading >>

Insulin Management Of Type 2 Diabetes Mellitus

Insulin Management Of Type 2 Diabetes Mellitus

Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy. Insulin therapy may be initiated as augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg. When using replacement therapy, 50 percent of the total daily insulin dose is given as basal, and 50 percent as bolus, divided up before breakfast, lunch, and dinner. Augmentation therapy can include basal or bolus insulin. Replacement therapy includes basal-bolus insulin and correction or premixed insulin. Glucose control, adverse effects, cost, adherence, and quality of life need to be considered when choosing therapy. Metformin should be continued if possible because it is proven to reduce all-cause mortality and cardiovascular events in overweight patients with diabetes. In a study comparing premixed, bolus, and basal insulin, hypoglycemia was more common with premixed and bolus insulin, and weight gain was more common with bolus insulin. Titration of insulin over time is critical to improving glycemic control and preventing diabetes-related complications. Insulin is secreted continuously by beta cells in a glucose-dependent manner throughout the day. It is also secreted in response to oral carbohydrate loads, including a large first-phase insulin release that suppresses hepatic glucose production followed by a slower second-phase insulin release that covers ingested carbohydrates 1 (Figure 12). Clinical recommendation Evidence rating References Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia. A 17–19 Fasting glucose readings should be used to titrate basal insul Continue reading >>

Insulin Initiation In Type 2 Diabetes – Why, When And How?

Insulin Initiation In Type 2 Diabetes – Why, When And How?

Type 2 diabetes is a progressive disease and, despite recent progress in the treatment of diabetes, the glycemic control usually deteriorates gradually and insulin therapy is needed. When insulin therapy should be started and which are the appropriate insulin therapy strategies, still represent subjects of debates. Insulin represents a therapeutic option in type 2 diabetes due to the existence of early β-cell dysfunction and significant reduction of β-cell mass in natural history of type 2 diabetes. The current guidelines recommend insulin in double therapy in association with metformin or in combination with metformin and other noninsulin agent. Initiation of insulin therapy is recommended in patients with newly diagnosed type 2 diabetes and symptomatic and/or presenting important hyperglycemia or elevated HbA1c. Initiation of insulin therapy in type 2 diabetes should take into consideration the pathophysiology of type 2 diabetes, the effects and the potential risks of insulin therapy, the guidelines recommendations and the barriers to insulin use. Literatures of only English language were analyzed from NCBI database. Guidelines were accessed electronically from organisations, i.e. American Diabetes Associations, American Association of Clinical Endocrinologists and American College of Endocrinology, European Association for the Study of Diabetes, International Diabetes Federation. Continue reading >>

Long-term Progression Of Retinopathy After Initiation Of Insulin Therapy In Type2 Diabetes: An Observational Study

Long-term Progression Of Retinopathy After Initiation Of Insulin Therapy In Type2 Diabetes: An Observational Study

, Volume 47, Issue8 , pp 13801384 | Cite as Long-term progression of retinopathy after initiation of insulin therapy in Type2 diabetes: an observational study Universal worsening of retinopathy after starting insulin therapy in Type2 diabetes has been suggested in previous work. We studied 294 such patients for up to 5 years to evaluate retinal changes and define the factors affecting progression of retinopathy. Yearly retinal photographs were graded using the EURODIAB system. Prior to insulin therapy, 26.2% (77/294) of the patients had minimal non-proliferative diabetic retinopathy (NPDR), 3.7% (n=11) had moderate NPDR and 1% (n=3) had severe NPDR. Over the first 3 years of insulin therapy, significant progression occurred in 36 subjects (12.6%). This comprised 5/193 (2.6%) without any retinopathy at baseline, 22/77 (28.5%) with minimal NPDR and 6/11 with moderate NPDR (54.5%) (2=56.1, p<0.001). In a control group of 70 patients who remained on oral hypoglycaemic agents, nine patients had significant worsening of retinopathy over 3 years. Over 5 years, 22/127 (17.3%) of patients (9/95 without and 13/32 with retinopathy at baseline [2=16.2, p<0.001]) had significant progression of retinopathy. Higher baseline HbA1c (p=0.002) and lower initial decrease in HbA1c (p=0.007) were each independent predictors of greater retinopathy progression over this period. There was no significant worsening of visual acuity in patients whose retinopathy progressed. After initiation of insulin treatment in Type2 diabetes, clinically significant worsening of retinopathy over a 3-year period was uncommon in those with no retinopathy (2.6%) but occurred in 31.8% of patients with any retinopathy at baseline. The risk of serious worsening of retinopathy after insulin therapy is started in all Continue reading >>

Pharmacologic Therapy For Type 2 Diabetes: Synopsis Of The 2017 American Diabetes Association Standards Of Medical Care In Diabetes Free

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 >>

Myths, Realities And Practicalities In The Initiation And Intensification Of Insulin Therapy In Type 2 Diabetes

Myths, Realities And Practicalities In The Initiation And Intensification Of Insulin Therapy In Type 2 Diabetes

Myths, Realities and Practicalities in the Initiation and Intensification of Insulin Therapy in Type 2 Diabetes European Endocrinology, 2008; 4(2):27-30; DOI: Although type 2 diabetes is sometimes regarded by patients as the milder form of diabetes, it is a serious disease with the potential to cause severe morbidity and mortality. Pancreatic -cell mass and function diminish over time and ultimately leave patients with a minimal capacity for insulin secretion. By the time type 2 diabetes is first diagnosed, there is likely to have been a substantial loss of -cell function (averaging 50%), with further decline continuing over subsequent years despite treatment.14 While some newly developed antidiabetes therapies such as the glucagon-like peptide-1 (GLP-1) receptor agonists have the potential to limit the rate of disease progression,4 it nevertheless follows that exogenous insulin therapy is likely to become necessary for most patients. However, insulin is often regarded as the treatment of last resort in type 2 diabetes, and it is often perceived as avoidable.5 Thus, the prospect of progression from oral antidiabetic drugs (OADs) to insulin can present a number of psychological issues for the patient. These include a sense of personal failure in disease management and anxiety about an increasing seriousness of the disease and how insulin will affect lifestyle.6,7 Patients also worry that injections will cause discomfort and treatment complexity, as well as the prospect of hypoglycaemic episodes and weight gain. Healthcare providers can share these concerns and may also doubt the ability of patients to manage the perceived complexity of insulin therapy. The inevitable result is that insulin therapy is usually delayed for far too long, leaving patients exposed to unnecess Continue reading >>

Eur J Endocrinol | Mobile

Eur J Endocrinol | Mobile

Objective The aim of this study was to assess the time to insulin initiation in type 2 diabetes mellitus (T2DM) patients treated with oral glucose-lowering agents and to determine the baseline characteristics associated with time to insulin initiation. This was evaluated in T2DM patients with HbA1c levels consistently 7.0% during total follow up and in those with fluctuating HbA1c levels around 7.0%. Design and methods Prospective, observational study was performed, comprising 2418 persons with T2DM aged 40 years who entered the Diabetes Care System between 1998 and 2012 with a minimum follow up of at least 3 years, following the first HbA1c level 7.0%. Cox regression analyses were performed to assess the determinants of time to insulin initiation. Data related to long-term effects of insulin initiation were studied at baseline and at the end of follow up using descriptive summary statistics. Results Two-thirds of the patients initiated insulin during follow up. The time to insulin varied from 1.2 years (range 0.33.1) in patients with HbA1c levels consistently 7.0% to 5.4 years (range 3.07.5) in patients with fluctuating HbA1c levels around 7.0%. Longer diabetes duration (hazard ratio (HR) 1.04 95% CI 1.031.05) and lower age (HR 1.00 95% CI 0.991.00) at baseline were associated with a shorter time to initiation. More insulin initiators had retinopathy compared with patients that remained on oral glucose-lowering agents during follow up. Conclusion The time to insulin initiation was short, and most of the patients with HbA1c levels consistently 7.0% were initiating insulin. Longer diabetes duration and younger age shortened the time to insulin. Guidelines of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) recommend t Continue reading >>

Early Intensive Insulin In Type 2 Diabetes

Early Intensive Insulin In Type 2 Diabetes

Early Intensive Insulin in Type 2 Diabetes Can the use of early intensive insulin cause remission of type 2 diabetes? Response from Gayle Nicholas Scott, PharmD Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia Type 2 diabetes (T2D) is a progressive condition of glucose toxicity and insulin insufficiency caused by insulin resistance and beta cell dysfunction. Current guidelines advocate metformin or another oral antihyperglycemic as the initial medication treatment with the addition of other medications, including insulin, as the disease progresses.[ 1 ] Insulin is not recommended as a first-line agent and is often regarded by clinicians and patients as a last resort option to control rising hemoglobin A1c levels. In patients with T2D, beta cell dysfunction could begin 15 years before becoming clinically apparent.[ 2 ] Obesity and a sedentary lifestyle, especially in the setting of a family history of T2D, increase the demand for insulin, leading to a vicious cycle of decreased insulin secretion, increased glucose production by the liver, and insulin resistance (Figure).[ 3 , 4 ] Figure. The vicious cycle of type 2 diabetes.[ 3 , 4 ] Some research suggests that intensive insulin treatment administered in newly or recently diagnosed T2D could interrupt glucose toxicity or delay disease progression. Interruption of the cycle of decreased insulin secretion, increased glucose production, and insulin resistance may preserve remaining beta cell function and induce a remission of hyperglycemia, possibly altering normal disease progression.[ 3 , 4 ] The importance of prompt normalization of blood glucose after diagnosis of T2D was established by the United Kingdom Prospective Diabetes Study (UKPDS).[ 5 ] The Outcome Reduction With Initial Glargine Interve Continue reading >>

Adding Sitagliptin To Usual Care Delays Progression To Insulin Initiation In Patients With Type 2 Diabetes: Presented At Easd

Adding Sitagliptin To Usual Care Delays Progression To Insulin Initiation In Patients With Type 2 Diabetes: Presented At Easd

Adding Sitagliptin to Usual Care Delays Progression to Insulin Initiation in Patients With Type 2 Diabetes: Presented at EASD LISBON, Portugal -- September 13, 2017 -- Adding sitagliptin to usual care among patients with type 2 diabetes well controlled on metformin or sulfonylurea therapy significantly delays progression to insulin initiation, according to a study presented here at the 2017 Annual Meeting of the European Association for the Study of Diabetes (EASD). There are limited data regarding the impact of sitagliptin on delaying progression to the need for insulin initiation, said Samuel Engel, MD, Merck & Co., Inc., Rahway, New Jersey. The Trial Evaluating Cardiovascular Outcomes With Sitagliptin (TECOS) included 14,671 patients with type 2 diabetes (haemoglobin A1C, 6.5%-8.0%) and known cardiovascular disease. Of the patients, 11,263 were not using insulin upon study entry. In these patients, the addition of sitagliptin significantly reduced the rate of initiation of long-term insulin therapy, compared with placebo (hazard ratio[HR] = 0.70; P < .001). The present analysis focused on patients who were on metformin (n = 4,435), sulfonylurea (n = 1,246), or dual therapy (n = 5,152). At a median follow-up of 3.1 years, insulin was initiated in 4.7% of patients on metformin monotherapy, 11.0% of patients on sulfonylurea monotherapy, and 17.2% of patients on dual therapy. After the addition of sitagliptin, 3.8% of patients on metformin initiated insulin compared with 5.5% with the addition of placebo. Among patients on sulfonylurea, 10.7% initiated insulin with the addition of sitagliptin compared with 11.3% of those who received placebo. The rates among those on dual therapy were 14.0% and 20.4%, respectively. Randomisation to sitagliptin compared with placebo was Continue reading >>

Initiating Insulin In Type 2 Diabetes

Initiating Insulin In Type 2 Diabetes

Serge Jabbour, MD, and Dhiren Patel, PharmD, discuss the need for adding insulin therapy to a regimen for patients with type 2 diabetes mellitus. Serge Jabbour, MD: The question I get all the time is when to start insulin in a patient with type 2 diabetes. We typically follow the ACE guidelines. The guidelines say any patient with type 2 diabetes with an A1C level of more than 9% should be considered for insulin. Now, they say, should be considered. Its not that they must. The only time I would say its a must is if I see a patient with type 2 diabetes in a catabolic state, no matter what the A1C level is. A1C could be at 9.5%, 10%, or 12%, but they are losing weight at the same time without trying to lose weight. That means they are burning fat and muscle because if you lack insulin, that has a catabolic effect. When they are losing weight in the face of high A1C, then we have to start insulin right away if they are not in a catabolic state. It depends on every patient. It depends on how many drugs theyre on already; it depends on how high the A1C level is; it depends on if its high fasting or high postprandial, if both are high; and it depends on if we can maybe use other medications before we start insulin. Ill give you a quick example. If you have a patient whos on metformin and SU (sulfonylurea), but they have impaired kidney function, that means we cannot use SGLT2 inhibitors. They had gastroparesis. We cannot use a GLP1 receptor agonist. Their A1C level is 8.8%. Then my best choice is to add a basal insulin. So, it depends on every case. Its not a standard, and its more based on each individual. Dhiren Patel, PharmD: When it comes to insulin therapy, there are a lot of preconceived notions from the patient perspective. Many think that if Im starting insulin, my c Continue reading >>

Initiating Insulin For People With Type 2 Diabetes

Initiating Insulin For People With Type 2 Diabetes

Due to its progressive nature, many people with type 2 diabetes will eventually require insulin treatment. Insulin initiation is frequently managed in secondary care. However, New Zealand guidelines now recommend that insulin initiation for people with type 2 diabetes be managed in primary care where possible, with additional support as required. View / Download pdf version of this article Insulin depletion is probable over time Type 2 diabetes is a progressive disease characterised by insulin resistance and a decreasing ability of pancreatic β-cells to produce insulin. Both of these factors contribute to hyperglycaemia. Following lifestyle modifications, most patients with diabetes begin treatment with oral hypoglycaemic medicines. Over time, the efficacy of oral medication frequently diminishes. Treatment with insulin is eventually required, either alone, or more commonly in conjunction with oral medicines such as metformin. It is possible for people with insulin resistance to delay or, in some cases, even avoid the need for insulin treatment through exercise and significant weight loss, however, patients with type 2 diabetes should be made aware at an early stage of treatment, of the probability that they may require insulin in the future. Insulin initiation is often delayed Evidence is accumulating that in all developed countries, many people with diabetes are failing to meet glycaemic targets.1,2 As insulin has a greater blood glucose lowering ability than any other hypoglycaemic medicine, it is important that initiation of insulin treatment is considered in all patients with poor glycaemic control, following appropriate lifestyle changes and the use of oral hypoglycaemic medicines. In the United Kingdom, a large ten year population-based study of treatment practi Continue reading >>

Supporting Insulin Initiation In Type 2 Diabetes In Primary Care: Results Of The Stepping Up Pragmatic Cluster Randomised Controlled Clinical Trial

Supporting Insulin Initiation In Type 2 Diabetes In Primary Care: Results Of The Stepping Up Pragmatic Cluster Randomised Controlled Clinical Trial

Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial BMJ 2017; 356 doi: (Published 08 March 2017) Cite this as: BMJ 2017;356:j783 Jane Speight, professor, and, director 3 4 5 , Elizabeth Holmes-Truscott, research fellow 3 4 , Louise Ginnivan, registered nurse with diabetes educator credentials 3 , Doris Young, professor of general practice, associate dean China programs 1 7 , Carl May, professor of healthcare innovation 12 , Irene Blackberry, associate professor, and, director 13 1Department of General Practice, University of Melbourne, Carlton, Melbourne, VIC, 3053, Australia 2Department of Medicine, St Vincents Hospital, University of Melbourne, Melbourne, Australia 3School of Psychology, Deakin University, Victoria, Australia 4The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Victoria, Australia 6Melbourne EpiCentre, the University of Melbourne, Melbourne, Australia 7Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia 8Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 9School of Nursing, University of Melbourne, Australia 10School of Public Health and Preventive Medicine, Monash University, Australia 11Health Economics and Social Policy Group, Division of Health Sciences, University of South Australia, Adelaide, Australia 12Faculty of Health Sciences, University of Southampton, Southampton, UK 13John Richards Initiative, Australian Institute for Primary Care and Ageing, College of Science, Health and Engineering, La Trobe University, Me Continue reading >>

Identifying And Addressing Barriers To Insulin Acceptance And Adherence In Patients With Type 2 Diabetes Mellitus

Identifying And Addressing Barriers To Insulin Acceptance And Adherence In Patients With Type 2 Diabetes Mellitus

Progressive hyperglycemia is a characteristic of type 2 diabetes mellitus (T2DM) that poses a challenge to maintaining optimal glycemic control. Achieving glycemic control early in the course of disease can minimize or prevent serious complications. Most patients with T2DM eventually require insulin replacement therapy to attain and preserve satisfactory glucose control. For decades, the use of insulin to address the primary defect of T2DM has been a cornerstone of diabetes therapy. Insulin is indicated for patients with T2DM presenting with clinically significant hyperglycemia, and it is mandatory for patients exhibiting signs of catabolism. Insulin should be considered for patients in whom hyperglycemia persists despite attempts to control the condition through diet and exercise modifications and the use of noninsulin therapies. Many physicians delay initiation of insulin until absolutely necessary, sometimes overestimating patient concerns about its use. Modern insulin analogs, treatment regimens, and delivery devices make insulin more user friendly, and physicians can promote patient acceptance of insulin by reviewing the benefits of controlled glycated hemoglobin levels and addressing patient concerns. Approximately 26 million Americans were living with diabetes in 2010.1 Data from a 2012 report2 indicated a substantial increase in the prevalence of diagnosed diabetes mellitus throughout the 50 states, Washington, DC, and Puerto Rico during a 16-year period (1995-2010), with the age-adjusted prevalence increasing by more than 50% in most states and by 100% or greater in 18 states. Figure 13 shows the areas of the United States that had the highest concentrations of diagnosed diabetes in 2009, whereas Figure 2 presents the lifetime risks of developing diabetes.4 In Continue reading >>

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