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Is Ketoacidosis Permanent

Cerebral Edema: An Uncommon But Devastating Complication Of Diabetic Ketoacidosis

Cerebral Edema: An Uncommon But Devastating Complication Of Diabetic Ketoacidosis

SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Poster INTRODUCTION: Cerebral edema is a complication of diabetic ketoacidosis (DKA) that is seen in about 1% of children with DKA. It typically emerges within 24 hours of initiating therapy for DKA, and has a mortality rate of 20-40%. While cerebral edema classically arises in children with newly diagnosed DM, it has been reported older patients as well. We present a case of cerebral edema due to DKA in a 30-year-old female. CASE PRESENTATION: A 30-year-old female with a PMH of gestational diabetes and normal vaginal delivery a month prior, presented to a community hospital with lethargy and “feeling sick” for a few days. Vitals and exam were significant for orthostatic hypotension. She was alert/oriented with a GCS of 14, dry oral mucosa, and diffuse abdominal tenderness. Significant labs included: WBC 23, Glucose 675, pH 6.8, Bicarb 2, K 3.5, UA: 3+ ketones. She immediately received 3 boluses of NS, 50 mEq of sodium bicarbonate, and was started on an insulin ggt at 6 units/hr. GCS decreased from 14 to 4 within 1 hour of presentation and CT scan of the head showed diffuse cerebral edema. The patient was transferred to a tertiary care center for deterioration of her mental status and acute respiratory failure secondary to cerebral edema requiring intubation. During her hospital stay, she developed critical illness myopathy, septic shock, and failed multiple extubation trials. A tracheostomy and peg tube were eventually placed and she was transferred to a SNF for rehabilitation. DISCUSSION: We highlight this case of cerebral edema because, while it is a known rare complication of DKA in children, it should be recognized that it can occur in adults as well. The incidence of cerebral edema in adults wi Continue reading >>

Type 1 Diabetes Mellitus Presenting With Diabetic Ketoacidosis (dka) In A Neonate Fareed Ahmed Aga Khan University, Fareed.ahmed@aku.edu

Type 1 Diabetes Mellitus Presenting With Diabetic Ketoacidosis (dka) In A Neonate Fareed Ahmed Aga Khan University, [email protected]

[email protected] Department of Emergency Medicine Medical College, Pakistan Sayyeda Ghazala Kazi Aga Khan University, [email protected] Waqas Khan Aga Khan University Follow this and additional works at: Part of the Emergency Medicine Commons, Endocrinology, Diabetes, and Metabolism Commons, and the Pediatrics Commons Recommended Citation Ahmed, F., Kazi, S. G., Khan, W. (2016). Type 1 diabetes mellitus presenting with diabetic ketoacidosis (DKA) in a neonate. Journal of Pakistan Medical Association, 6(8), 1026-1028. Available at: Abstract Neonatal diabetes mellitus (NDM) is a rare manifestation with an incidence of one affected individual among 400000 live births. NDM can be divided into Transient (TNDM) and Permanent (PNDM) types. A significant overlap occurs between both groups, to an extent that TNDM cannot be distinguished from PNDM based solely on clinical features. Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). DKA at diagnosis is more common in young children near the age of five years. Neonatal DKA is a rare occurrence causing it to be missed in the differential diagnosis of neonatal illness and results delay in appropriate management and increase in morbidity and mortality rate. Keywords: Neonate diabetes mellitus, Diabetic Ketoacidosis, Pakistan. Introduction Diabetes mellitus (DM) is a diverse group of metabolic diseases that has no age restriction to manifest. Neonatal diabetes mellitus is a very rare entity with an incidence of 1/90,000 to 1/210,000 live births approximately and usually affects children in their first 6 months of life.1,2 It can be divided into Transient (TNDM) and Permanent (PNDM) types. In instances of TNDM, infants develop diabetes in the first few weeks of li Continue reading >>

Diabetic Ketoacidosis And Brain Function

Diabetic Ketoacidosis And Brain Function

Diabetic Ketoacidosis (DKA) is a life-threatening consequence of diabetes. DKA occurs when there is a lack of insulin in the body causing hyperglycemia. As a result of the inability of glucose to enter the cells, the body must find other means to obtain energy. As such, fat breakdown occurs resulting in the accumulation of fatty acids. The fatty acids are metabolized to ketones that cause the blood to become acidotic (pH less than7.3). Because glucose remains in the blood, there is an increase in thirst and drinking to eliminate the solute load of glucose, which also results in increased urination (polyuria and polydipsia). Thus, the combination of increased serum acidity, weight loss, polyuria, and polydipsia may lead to extreme dehydration, coma, or brain damage. Without a doubt, the most severe acute complication of DKA is cerebral edema. Many cases of new onset type 1 diabetes present DKA (15-70 percent depending on age and geographic region, according to multiple studies), hence the importance of an early diagnosis of diabetes in order to avoid potential consequences. Much research is being conducted to predict the development of severe complications of DKA, most notably on brain herniation, the swelling of the brain that causes it to push towards the spinal cord, as well as other neurological consequences. Fulminant cerebral edema, or swelling of the brain, is relatively rare and has an incidence rate of 0.5-0.9 percent. However, what about the subtler, less severe alterations in brain functions that occur after DKA? Indeed, a recent paper published in Diabetes Care 2014; 37: 1554-1562by Cameron, Scratch, Nadebaum, Northum, Koves, Jennings, Finney, Neil, Wellard, Mackay, and Inder on behalf of the DKA Brain Injury Study Group entitled "Neurological Consequences of Continue reading >>

Will There Ever Be A Cure For Diabetes? Why Or Why Not?

Will There Ever Be A Cure For Diabetes? Why Or Why Not?

For More tips,read more about diabetes Diabetes Full Control- Live a Better Life What is type 1 diabetes? Around 400,000 people in Germany are producing cells of the pancreas and destroys them. As a result, it comes within a few days to weeks for lack of insulin production. Type 1 diabetes often occurs as early as childhood and adolescence. The hormone insulin is responsible for the locks of dietary sugar from the blood into the cells that need it for energy. In insulin deficiency, the glucose in the blood accumulates - the blood sugar level rises. This can damage permanently the blood vessels, nerves and numerous organs. Patients with type 1 diabetes need throughout their lives several times daily insulin injections to prevent acute metabolic disorders and related diseases due to high blood sugar levels. What is the difference between Type 1 diabetes and Type 2? In contrast to type 1 diabetes is the type 2 diabetes, below the estimated about seven million people in Germany suffer, not the consequence of a lack of insulin, but an insulin resistance. This means that the cells no longer speak adequately to insulin, so that the hormone can not smuggle the sugar into the cells. The blood sugar level rises. To compensate, the pancreas initially produces larger amounts of insulin. Also no longer sufficient to overcome the insulin resistance, a type 2 diabetes develops. The main causes of type 2 diabetes are genetic predisposition, obesity and lack of exercise. While the type 1 diabetes is more likely in recent years, a type 2 diabetes often develops at an advanced age in patients. Training: What to know patients Typically, a person with Type 1 diabetes leads his therapy in everyday life through their own, as long as no problems or complaints arise. In children take parents th Continue reading >>

Ketoacidosis

Ketoacidosis

Ketoacidosis is a metabolic state associated with high concentrations of ketone bodies, formed by the breakdown of fatty acids and the deamination of amino acids. The two common ketones produced in humans are acetoacetic acid and β-hydroxybutyrate. Ketoacidosis is a pathological metabolic state marked by extreme and uncontrolled ketosis. In ketoacidosis, the body fails to adequately regulate ketone production causing such a severe accumulation of keto acids that the pH of the blood is substantially decreased. In extreme cases ketoacidosis can be fatal.[1] Ketoacidosis is most common in untreated type 1 diabetes mellitus, when the liver breaks down fat and proteins in response to a perceived need for respiratory substrate. Prolonged alcoholism may lead to alcoholic ketoacidosis. Ketoacidosis can be smelled on a person's breath. This is due to acetone, a direct by-product of the spontaneous decomposition of acetoacetic acid. It is often described as smelling like fruit or nail polish remover.[2] Ketosis may also give off an odor, but the odor is usually more subtle due to lower concentrations of acetone. Treatment consists most simply of correcting blood sugar and insulin levels, which will halt ketone production. If the severity of the case warrants more aggressive measures, intravenous sodium bicarbonate infusion can be given to raise blood pH back to an acceptable range. However, serious caution must be exercised with IV sodium bicarbonate to avoid the risk of equally life-threatening hypernatremia. Cause[edit] Three common causes of ketoacidosis are alcohol, starvation, and diabetes, resulting in alcoholic ketoacidosis, starvation ketoacidosis, and diabetic ketoacidosis respectively.[3] In diabetic ketoacidosis, a high concentration of ketone bodies is usually accomp Continue reading >>

Hyperglycaemia‐related Complications At The Time Of Diagnosis Can Cause Permanent Neurological Disability In Children With Neonatal Diabetes

Hyperglycaemia‐related Complications At The Time Of Diagnosis Can Cause Permanent Neurological Disability In Children With Neonatal Diabetes

Go to: Abstract Children with neonatal diabetes often present with diabetic ketoacidosis and hence are at risk of cerebral oedema and subsequent long‐term neurological deficits. These complications are difficult to identify because neurological features can also occur as a result of the specific genetic aetiology causing neonatal diabetes. Case reports We report two cases of neonatal diabetes where ketoacidosis‐related cerebral oedema was the major cause of their permanent neurological disability. Case 1 (male, 18 years, compound heterozygous ABCC8 mutation) and case 2 (female, 29 years, heterozygous KCNJ11 mutation) presented with severe diabetic ketoacidosis at 6 and 16 weeks of age. Both had reduced consciousness, seizures and required intensive care for cerebral oedema. They subsequently developed spastic tetraplegia. Neurological examination in adulthood confirmed spastic tetraplegia and severe disability. Case 1 is wheelchair‐bound and needs assistance for transfers, washing and dressing, whereas case 2 requires institutional care for all activities of daily living. Both cases have first‐degree relatives with the same mutation with diabetes, who did not have ketoacidosis at diagnosis and do not have neurological disability. Ketoacidosis‐related cerebral oedema at diagnosis in neonatal diabetes can cause long‐term severe neurological disability. This will give additional neurological features to those directly caused by the genetic aetiology of the neonatal diabetes. Our cases highlight the need for increased awareness of neonatal diabetes and earlier and better initial treatment of the severe hyperglycaemia and ketoacidosis often seen at diagnosis of these children. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Professor of Pediatric Endocrinology University of Khartoum, Sudan Introduction DKA is a serious acute complications of Diabetes Mellitus. It carries significant risk of death and/or morbidity especially with delayed treatment. The prognosis of DKA is worse in the extremes of age, with a mortality rates of 5-10%. With the new advances of therapy, DKA mortality decreases to > 2%. Before discovery and use of Insulin (1922) the mortality was 100%. Epidemiology DKA is reported in 2-5% of known type 1 diabetic patients in industrialized countries, while it occurs in 35-40% of such patients in Africa. DKA at the time of first diagnosis of diabetes mellitus is reported in only 2-3% in western Europe, but is seen in 95% of diabetic children in Sudan. Similar results were reported from other African countries . Consequences The latter observation is annoying because it implies the following: The late diagnosis of type 1 diabetes in many developing countries particularly in Africa. The late presentation of DKA, which is associated with risk of morbidity & mortality Death of young children with DKA undiagnosed or wrongly diagnosed as malaria or meningitis. Pathophysiology Secondary to insulin deficiency, and the action of counter-regulatory hormones, blood glucose increases leading to hyperglycemia and glucosuria. Glucosuria causes an osmotic diuresis, leading to water & Na loss. In the absence of insulin activity the body fails to utilize glucose as fuel and uses fats instead. This leads to ketosis. Pathophysiology/2 The excess of ketone bodies will cause metabolic acidosis, the later is also aggravated by Lactic acidosis caused by dehydration & poor tissue perfusion. Vomiting due to an ileus, plus increased insensible water losses due to tachypnea will worsen the state of dehydr Continue reading >>

Diabetic Coma Recovery: What You Need To Know

Diabetic Coma Recovery: What You Need To Know

In people with diabetes, a diabetic coma occurs when severe levels of either high or low uncontrolled blood sugar are not corrected. If treated quickly, a person will make a rapid recovery from a diabetic coma. However, diabetic coma can be fatal or result in brain damage. It is important for people with diabetes to control their blood sugars and know what to do when their blood sugar levels are not within their target range. The severe symptoms of uncontrolled blood sugar that can come before a diabetic coma include vomiting, difficulty breathing, confusion, weakness, and dizziness. Recovery from diabetic coma If a diabetic coma is not treated within a couple of hours of it developing, it can cause irreversible brain damage. If no treatment is received, a diabetic coma will be fatal. In addition, having blood sugar levels that continue to be too low or too high can be bad for long-term health. This remains true even if they do not develop into diabetic coma. Recognizing the early signs of low or high blood sugar levels and regular monitoring can help people with diabetes keep their blood sugar levels within the healthy range. Doing so will also reduce the risk of associated complications and diabetic coma. What is diabetes? Diabetes is a long-term condition in which the body is unable to control the level of a sugar called glucose in the blood. Diabetes is caused by either a lack of insulin, the body's inability to use insulin correctly, or both. In people who don't have diabetes, insulin usually ensures that excess glucose is removed from the bloodstream. It does this by stimulating cells to absorb the glucose they need for energy from the blood. Insulin also causes any remaining glucose to be stored in the liver as a substance called glycogen. The production of insul Continue reading >>

Diabetes With Ketone Bodies In Cats

Diabetes With Ketone Bodies In Cats

Diabetes Mellitus with Ketoacidosis in Cats The term “ketoacidosis” refers to a condition in which levels of acid abnormally increased in the blood due to presence of “ketone bodies.” Meanwhile, diabetes is a medical condition in which the body cannot absorb sufficient glucose, thus causing a rise the blood sugar levels. In diabetes with ketoacidosis, ketoacidosis immediately follows diabetes. It should be considered a dire emergency, one in which immediate treatment is required to save the life of the animal. Typically, the type of condition affects older cats; in addition, female cats are more prone diabetes with ketoacidosis than males. Symptoms and Types Weakness Lethargy Depression Lack of appetite (anorexia) Muscle wasting Rough hair coat Dehydration Dandruff Sweet breath odor Causes Although the ketoacidosis is ultimately brought on by the cat's insulin dependency due to diabetes mellitus, underlying factors include stress, surgery, and infections of the skin, respiratory, and urinary tract systems. Concurrent diseases such as heart failure, kidney failure, asthma, cancer may also lead to this type of condition. Diagnosis You will need to give a thorough history of your cat’s health, including the onset and nature of the symptoms, to your veterinarian. He or she will then perform a complete physical examination, as well as a biochemistry profile and complete blood count (CBC). The most consistent finding in patients with diabetes is higher than normal levels of glucose in the blood. If infection is present, white blood cell count will also high. Other findings may include: high liver enzymes, high blood cholesterol levels, accumulation in the blood of nitrogenous waste products (urea) that are usually excreted in the urine (azotemia), low sodium levels Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

4 Evaluation 5 Management Defining features include hyperglycemia (glucose > 250mg/dl), acidosis (pH < 7.3), and ketonemia/ketonuria Leads to osmotic diuresis and depletion of electrolytes including sodium, magnesium, calcium and phosphorous. Further dehydration impairs glomerular filtration rate (GFR) and contributes to acute renal failure Due to lipolysis / accumulation of of ketoacids (represented by increased anion gap) Compensatory respiratory alkalosis (i.e. tachypnea and hyperpnea - Kussmaul breathing) Breakdown of adipose creates first acetoacetate leading to conversion to beta-hydroxybutyrate Causes activation of RAAS in addition to the osmotic diuresis Cation loss (in exchange for chloride) worsens metabolic acidosis May be the initial presenting of an unrecognized T1DM patient Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain, hypotension, decreased urine output. Perform a thorough neurologic exam (cerebral edema increases mortality significantly, especially in children) Assess for possible inciting cause (especially for ongoing infection; see Differential Diagnosis section) Ill appearance. Acetone breath. Drowsiness with decreased reflexes Tachypnea (Kussmaul's breathing) Signs of dehydration with dry mouth and dry mucosa. Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children There may be signs from underlying cause (eg pneumonia) Differential Diagnosis Insulin or oral hypoglycemic medication non-compliance Infection Intra-abdominal infections Steroid use Drug abuse Pregnancy Diabetic ketoacidosis (DKA) Diagnosis is made based on the presence of acidosis and ketonemia in the setting of diabetes. Bicarb may be normal due to compensatory and contraction alcoholosis so the Continue reading >>

A Seven Weeks Old Baby With Diabetic Ketoacidosis: A Case Report

A Seven Weeks Old Baby With Diabetic Ketoacidosis: A Case Report

Key clinical message Diabetes mellitus is rare during infancy, however, it should be suspected in infants presenting with features consistent with sepsis and hyperglycemia. This is crucial in initiating the treatment of diabetes ketoacidosis which if delayed may result in significant morbidity and death. Background Neonatal diabetes mellitus (NDM) is a rare endocrinological disorder, which affects children in the first 6 months of life, with estimated incidence of 1/90,000 to 1/210,000 live births [1, 2]. Two forms of this condition have been identified, transient and permanent neonatal diabetes mellitus (TNDM and PNDM). TNDM is a genetically mediated disorder of insulin production that remits in the postnatal period and is commonly associated with intrauterine growth retardation, it accounts for 50–60% of the cases of neonatal diabetes [3]. PNDM, a less common form that results from abnormal pancreatic development, increased apoptosis, and necrosis with cellular dysfunction and causing lifelong insulin dependency [4]. Patients develop inadequate insulin production necessitating exogenous insulin therapy, which if not well balanced results in several complications including diabetic ketoacidosis. We report the case of 7 weeks old boy with diabetic ketoacidosis that required 10 days of intensive care management. Case Report A 7-week-old baby was referred to the emergency department (ED) of Muhimbili National Hospital (MNH), Dar es Salaam because of presumed severe pneumonia and septicemia. He presented at the ED with history of fever and difficulty in breathing for 3 days, fever was of high grade with no report of convulsion. Difficulty in breathing was noted concurrently with fever and was not accompanied by cough, however, it was noted to cause difficulty in breastfe Continue reading >>

Diabetic Ketoacidosis With Acute Necrotizing Pancreatitis As First Presentation In Latent Autoimmune Diabetes In Adult

Diabetic Ketoacidosis With Acute Necrotizing Pancreatitis As First Presentation In Latent Autoimmune Diabetes In Adult

Stella Pak, David Cha, Omeed Jazayeri-Moghaddas, Dexter Nye, Jillian Costello, John-Phillip Markovic, Jim Kim Abstract This case describes delayed diagnosis of acute necrotizing pancreatitis in the setting of diabetic ketoacidosis (DKA) as the first presentation of late onset autoimmune diabetes of adulthood (LADA). Possible presentation of DKA with LADA and acute pancreatitis (AP) are explored in this paper, with an emphasis on early diagnosis of pancreatitis for appropriate management. This case is a critical reminder that although DKA can non-specifically elevate pancreatic enzymes, LADA and AP can present concurrently, and pancreatic pathology should still be considered in the differential. J Med Cases. 2017;8(11):356-358 doi: Full Text: HTML PDF Continue reading >>

Research Article Histological And Cognitive Alterations In Adult Diabetic Rats Following An Episode Of Juvenile Diabetic Ketoacidosis: Evidence Of Permanent Cerebral Injury

Research Article Histological And Cognitive Alterations In Adult Diabetic Rats Following An Episode Of Juvenile Diabetic Ketoacidosis: Evidence Of Permanent Cerebral Injury

Highlights • • A role for diabetic ketoacidosis (DKA) in causing cognitive changes has recently been suggested. • Adult rats exposed to DKA as juveniles have hippocampal astrogliosis and cortical neuron loss. • Adult rats exposed to DKA as juveniles also have deficits in associative memory. • DKA causes long-term alterations in cerebral microstructure and cognitive deficits in rats. Abstract Evidence suggests that diabetic ketoacidosis (DKA) may cause subtle cognitive alterations in children but the mechanisms are poorly understood. Acute DKA is associated with reactive astrogliosis and microglial activation in a rat model. Whether these inflammatory changes permanently alter brain histology is unknown. We aimed to determine whether DKA results in permanent alterations in brain histology and whether these changes are associated with cognitive deficits in a rat model. We induced diabetes in juvenile rats with streptozotocin at 4 weeks of age. We induced DKA in one group (n = 21) at 5 weeks of age and compared this group to rats with diabetes without DKA episodes (n = 13). Beginning at 7 weeks, rats underwent a series of cognitive tests to evaluate memory. At 15 weeks, rat brains were harvested and examined using immunohistochemistry (IHC). In tests of novel object recognition and social recognition, both groups performed similarly, however, the DKA group performed more poorly in object-place recognition tests, suggesting alterations in hippocampal function. IHC studies demonstrated increased glial fibrillary acidic protein staining intensity in the hippocampus of DKA rats suggesting astrogliosis, and decreased NeuN positive cell counts in the cortex suggesting neuron loss. These studies demonstrate that DKA results in permanent alterations in brain microstructu Continue reading >>

Effects Of Diabetic Ketoacidosis On Visual And Verbal Neurocognitive Function In Young Patients Presenting With New-onset Type 1 Diabetes

Effects Of Diabetic Ketoacidosis On Visual And Verbal Neurocognitive Function In Young Patients Presenting With New-onset Type 1 Diabetes

Go to: Abstract To evaluate the effects of diabetic ketoacidosis (DKA) on neurocognitive functions in children and adolescents presenting with new-onset type 1 diabetes. Newly diagnosed patients were divided into two groups: those with DKA and those without DKA (non-DKA). Following metabolic stabilization, the patients took a mini-mental status exam prior to undergoing a baseline battery of cognitive tests that evaluated visual and verbal cognitive tasks. Follow-up testing was performed 8-12 weeks after diagnosis. Patients completed an IQ test at follow-up. Results: There was no statistical difference between the DKA and non-DKA groups neither in alertness at baseline testing nor in an IQ test at follow-up. The DKA group had significantly lower baseline scores than the non-DKA group for the visual cognitive tasks of design recognition, design memory and the composite visual memory index (VMI). At follow-up, Design Recognition remained statistically lower in the DKA group, but the design memory and the VMI tasks returned to statistical parity between the two groups. No significant differences were found in verbal cognitive tasks at baseline or follow-up between the two groups. Direct correlations were present for the admission CO2 and the visual cognitive tasks of VMI, design memory and design recognition. Direct correlations were also present for admission pH and VMI, design memory and picture memory. Pediatric patients presenting with newly diagnosed type 1 diabetes and severe but uncomplicated DKA showed a definite trend for lower cognitive functioning when compared to the age-matched patients without DKA. Keywords: diabetic ketoacidosis, Cognition, dehydration, neuroinflammation Neurocognitive tasks. Mean (standard deviation) and median (range) of standard scores of Continue reading >>

What Is The Difference Between Ketogenic Diet And Starvation?

What Is The Difference Between Ketogenic Diet And Starvation?

I really must track down how the unscientific drivel that the ketogenic diet is some sort of a starvation response got started. The only link between starvation and the ketogenic diet is the production of ketones in the body. I know certain Quora gurus posit such crap repeatedly but it’s not true. Ketones as a natural process in the body The body produces ketones naturally. It’s likely a protective mechanism due to the evolutionary instability of the food supply. Most of the time ketone levels are quite low. However, anytime the food supply gets interrupted, even short times like at night during sleep, the body starts to produce ketones. Ketones and fat metabolism Ketones are made in the liver from fat. One of the reasons people measure ketone levels in the body is that they are a marker for increased fat utilization in the body. There are two fuel partitioning schemes in the human body. The body can utilize glucose and glycogen or the body can utilize fats (dietary and body) and ketones. There are some overlaps in the utilization of these schemes but when foods that are easily broken down into glucose are withdrawn the body will start to burn fats and ketones as sources of energy. Ketones and starvation The similarity between starvation and the ketogenic diet is that both involve higher levels of circulating ketones in the body. This makes sense since in both situations foods that are easily broken down into glucose have been withdrawn. In both situations, levels of blood glucose and glycogen stores are lower and the body must fuel with other substances. Some tissues in the body are perfectly happy (and in many ways) prefer utilizing fats as fuels. However, some tissues need levels of glucose. These tissues when faced with lower glucose intake in the diet must rely Continue reading >>

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