Diabetes Research Paper Example

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Comparison of Lifestyle Intervention and Metformin

Executive Summary

This research identifies the factors that cause diabetes, elements that raise blood sugar, methods that lower the A1C, exercises that help treat prediabetes, and effects of metformin in prediabetes treatment (Krans et al., 1985). In this paper, there are also answers to frequently asked questions. In addition to these, it examines why genetic damage is necessary to produce diabetes, how inflammation may play a role, how high blood sugars lead to higher blood sugars, how to set a healthy blood sugar target that lowers your blood sugar, how to be physically active, and how to use metformin effectively. This study compares metformin with lifestyle intervention. The lifestyle intervention, achieving at least 7% weight loss by calorie restriction, modification of dietary fat to < 25%, and at least 150 minutes of physical activity per week, resulted in a 58% decrease in the development of T2DM and is a better method than metformin to cure prediabetes.

Introduction

If the blood sugars are abnormal, the patient will want to lower them to levels low enough to avoid any of these unpleasant outcomes. But before showing how to do that, one needs to understand what raised them in the first place, because the chances may not be what everyone thinks. Patients have almost certainly been told that overeating and lack of exercise cause insulin resistance, which leads to obesity that causes diabetes. These people have also probably been told that all clients need to avoid or reverse diabetes is to lose weight. But though the belief is widespread that people with diabetes have caused their condition through reprehensible gluttony and sloth, it is not valid. For starters, obesity does not, in and of itself, cause diabetes. Though more than two out of three Americans are overweight, less than one in ten will ever go on to develop diabetes. The rest won't. Nor are all people who develop Type 2 diabetes obese. Many are at healthy weights or only slightly overweight when their blood sugars begin to rise into the abnormal range (Camerini-Davalos & Cole, 2012). And that makes people with mildly abnormal blood sugars overeat so that by the time their blood sugar has risen high enough for doctors to give them a diabetes diagnosis, many of them have become quite fat.

Genetic Damage is Necessary to Produce Diabetes

Even when obesity is present, though, it isn't the obesity that causes diabetes. It is defective genes. Because what the research shows are that while it is effortless for people to gain weight, it is almost impossible for a person to develop diabetes unless they have inherited or acquired damaged genes. This is why diabetes often runs in families and why if one identical twin has diabetes, the other twin has a much higher than average chance of developing it (McAuliffe, 2012). Dozens of damaged genes are associated with diabetes, with more being discovered every year (Petit & Adamec, 2011). The specific genes that are damaged are different in each different population. This is why diabetes develops and progresses differently in people of Western European, African, Native American, Mexican, Arabic, South Asian, and Japanese heritage (Petit & Adamec, 2011). But inheritance isn't the only source of damaged diabetes genes. People also acquire the genetic damage that raises their blood sugar through exposure to everyday toxins like the pesticides in our food and water.

Other substances that have been shown to damage the genes that control blood sugar are flame retardants, plastics, and the chemicals used to make plastics flexible, PCBs. Some very commonly prescribed drugs like statins and SSRI antidepressants have also been shown by robust research studies to raise the risk of developing insulin resistance, obesity, and diabetes. Even worse, when developing fetuses are exposed to these chemicals in the womb, the likelihood of their being born with the genetic damage that makes diabetes more likely increases.

Inflammation May Play a Role

Another major factor that can lead to very high blood sugars is inflammation. One source of it is an autoimmune disease. This is because people with autoimmune disease are prone to develop inflammation. If that inflammation affects the cells in the pancreas that secrete insulin, those cells may die, leading to diabetes. Autoimmune disease of all kinds has become much more common over the past decades. So people with autoimmune thyroid disease, MS, or rheumatic arthritis are likely to experience autoimmune-related blood sugar problems (Camerini-Davalos & Cole, 2012). However, they often do not rise to the level where they are diagnosed as outright diabetes. Even inflammation that is not due to an autoimmune attack can raise blood sugar. For example, if someone has gum disease, he or she is more likely to have high blood sugar. Conversely, treating gum disease aggressively can often lower blood sugar.

High Blood Sugars Lead to Higher Blood Sugars

Once the blood sugars have risen, a vicious cycle ensues, as exposure to high blood sugars further damages patients' insulin-producing cells through what is known as "glucose toxicity." Over time, many of these cells will die off, which is why by the time most people with Type 2 diabetes are diagnosed, many have lost 50 to 80% of their insulin-secreting cells (Bernstein, 2011). Making matters worse, as the blood sugars rise to a certain level—roughly about 180 mg/dl—they also cause the muscles to become even more insulin resistant than usual, which pushes the blood sugar up further and makes it that much harder to get that blood sugar back to normal.

What Raises Blood Sugar

Despite what patients might have read in fad books promising to "reverse diabetes" diabetes is usually impossible to reverse, if by "reverse" it is meant returning to a state where the insulin-producing cells are entirely healthy and produce average amounts of insulin which the body responds to in a healthy way.

But though patients are stuck with diabetes, there is no reason to be stuck with high blood sugars. This is excellent news because it isn't the underlying condition, diabetes, that causes all the adverse outcomes. Those bad outcomes are generated almost entirely by exposure to high blood sugars (Bernstein, 2011). The so-called "diabetic complications," which, as we saw earlier, begin at prediabetic blood sugar levels are caused solely by exposure to the high blood sugars that result when your insulin is absent or not working correctly

The Importance of Diet

1.1 Overview

Lower the blood sugar to normal levels, and that person will have normal health, even if his or her pancreas continues operating at half capacity, and the flunk glucose tolerance tests for the rest of life. Lots of people who fully have diabetes have done this, and the ones to be can too—without having to lose a single pound. Nor will the patient have to become a weight lifter, amputate parts of the digestive tract, or adopt an extreme diet that cuts out whole classes of foods, including most of what patients enjoy eating. That's because it isn't "diabetes" that raises blood sugar. Nor is it being fat or inactive (Galmer, 2008). What mostly raises blood sugar—and for most of us, this is the only thing that raises blood sugar—is eating starch and sugar. Cut back on them, and the blood sugar will plummet immediately.

Sugar and Starch are Raising Blood Sugar

Starches and sugars make up the class of foods we call "carbohydrates" or "carbs" for short. Lower how much of them being eaten, and the blood sugar will drop almost immediately, long before the patient had lost a single pound. This is true, even if the client eats the same number of calories as before. As long as someone cuts back on starchy and sugary foods, the blood sugar will drop. This is so simple, and so universally true, that one might wonder why the doctor hasn't said anything about it (Galmer, 2008). The answer is that sixty years of poorly designed research had convinced most doctors, until very recently, that it was eating fat, not carbs, that caused heart disease.


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1.2 Research Questions

Why is it Not Dangerous to Lower A1c Below 6.5%

The doctor may warn that it is dangerous to lower A1c below 6.5%. This belief, common among doctors, is derived from their having read-only newsletter-provided summaries of several vital studies where participants attempted to lower their blood sugar. In these studies, there were a few more heart attacks in the group who were supposed to lower their blood sugar to a level that would produce an A1c below 6.5% than there was in the group who only aimed for an A1c of 7%.

What the summaries neglected to mention, but subsequent research revealed, is that the group who were trying to lower their blood sugar were using a cocktail of drugs, including the questionable drug Avandia, which has been shown to raise the risk of heart failure. Others were older adults who had been given aggressive but poorly managed, insulin regimens which had caused them to have dangerous hypos—attacks of low blood sugar. Not only that, but the summaries did not inform doctors that when researchers looked more closely at these studies, they found that the people in the "Lower A1c" group having heart attacks were mostly people who thought they were assigned to that group had not lowered their blood sugar. But there is zero evidence that lowering the blood sugar solely by altering the food intake will raise the heart disease risk. Nor is there any evidence that cutting back on carbs while taking the beneficial drug metformin poses any danger. If the doctor tells us that there is, a new doctor should be found. All the evidence suggests that lowering blood sugar by cutting back on carbs while taking metformin is the single best way to avoid heart attacks.

1.3 Sample Populations

Studies of large groups of people have shown that the likelihood of developing heart disease rises along with the A1c test result. As the A1c of a group of people rises above 4.6%, the risk of heart disease in that group begins to double with each additional percent rise, so that their heart disease risk is twice as high at an average A1c of 5.7% as it is for one of 4.7%. However, while the A1c is a good test for studying large populations, it is less reliable when applied to individuals. The strong link between how high the blood sugar rises after a meal and the thickness of the carotid artery is a good measure of cardiac risk.

1.4 Methodology

Setting a Healthy Blood Sugar Target

Before patients can begin working on reducing blood sugar levels, sugar is deciding how low the blood sugar needs to go. It can be seen in many different theories on what the blood sugar best level is for health. The most rigorous blood sugar targets are the "True Normal" values derived from studies of the blood sugar of people believed to have regular blood sugar. They represent the readings in the range most of these healthy people fall into (Mechanick & Brett, 2006). Not everyone with full-fledged diabetes can achieve readings this low.

Lowering the Blood Sugar Level

Most other papers that promise to give normal blood sugars lay down strict rules about what someone has to eat and tell that the only way to succeed is by following those rules. This paper is different. That's because since different things are broken in each metabolism, they will each respond very differently to the same diet. The foods that raise blood sugar far too high might work correctly for someone.

In contrast, the diet that lowers the blood sugar of a 40-year-old, physically active male physician with no family history of diabetes, might put someone else's into the somewhere else. Fortunately, patients don't have to rely on anyone else's advice about what foods to eat. There is a fantastic tool one can buy at the drug store that will very quickly tell precisely what they can eat safely. That tool is the blood sugar meter. Using it, patients can put together a diet made up of foods that were selected, rather than those that appeal to some author with different tastes or family traditions (Mussatto & Greeff, 2019). The person won't have to learn to cook spa-like food at home, either. The blood sugar meter will help determine what foods can be eaten safely at restaurants and which prepared foods will keep the blood sugar down.

The Test Strategy

The following is the simple but highly effective strategy that thousands of people have used to lower their blood sugar. It is sometimes called "Jennifer's Advice" as an early version of it was first posted by a woman named Jennifer, who was active on the alt.support. Diabetes newsgroup in the early and mid-2000s (Mechanick & Brett, 2006). It's straightforward. Trying it for a week, and the patient will be amazed at how well it works.

How to Lower Blood Sugar

The more bread, potatoes, rice, noodles, fruit, or other starches and sugars (carbohydrates) there are in a meal, the higher the reading one sees after eating it. Get most of the carbs from green and non-starchy vegetables. Cutting back or eliminating these high carbohydrate foods. When one achieves chosen blood sugar targets, he or she can start cautiously adding back carbohydrates, making sure to test after each meal. The patient should stop adding carbs if the blood sugars start rising over the blood sugar targets.

Step 3: Test

Patients should keep testing more of the meals they enjoy eating. If a meal doesn't work with the chosen target, they should try eating a smaller portion of it, or replace the foods full of starches and sugars in it with something else they enjoy eating. Keep in mind that as long as you see typical values after meals, it is safe to eat fatty foods like meat and cheese. It is only when the blood sugars are rising higher than average that a high fat intake can be a problem. For this reason, it's a good rule of thumb that the more carbs one eats, the less fat that person should eat and vice versa.

Using What was Learned to Find More Foods to Eat

Once the person finds a couple of meals tasty to eat that don't raise the blood sugar, it's time to get out the nutritional reference so one can calculate how many grams of carbohydrates there were in those meals that worked.

It can be done by looking up these foods in a book like Corinne T. Netzer's Complete Book of Food Counts, or with a mobile app like MyFitnessPal (Mechanick & Brett, 2006). Just typing the name of food followed by the word "carbs" into the browser's Google search field will give this same nutritional information. The patient needs to keep in mind that the counts that are found for various foods are accurate only if the portion size used to calculate that count is correct. Many people find that weighing their food on an inexpensive food scale helps them get a better idea of correct portion sizes. Once it is calculated how many grams of carbs one can tolerate at once, he or she can scan through the nutritional reference and/or examine the labels on packaged foods, looking for other foods that would provide the same number of grams of carbohydrate as the foods that already work. That is because foods with the same amount of carbohydrate will usually have a similar impact on blood sugar. The exception to this rule is pasta and a few other foods that digest very slowly. These foods may look like they have less impact on blood sugar if the test is only after 1 or 2 hours, though they eventually release all the carbohydrates they contain. With pasta, it may take four or five hours for it to show up in the bloodstream.

Some people will be able to eat these higher carbs, slow-digesting foods without ever seeing that delayed blood sugar spike. Some won't. It depends on precisely what is broken in blood sugar control how well these high carbohydrates "slow" carbs will work. Patients need to remember that if they see an unexpectedly low reading after eating what they know is a large serving of carbohydrates, it's always wise to test again a few hours later to ensure that they didn't miss a damaging late blood sugar spike.

1.5 Limitations

In people of Western European heritage, the most common diabetes genes do not cause insulin resistance. Instead, they limit the ability to secrete insulin. But these genes are often found in association with other genetic flaws that promote insulin resistance, for example, genes restrict the strength of the mitochondria (the cell's "power plant") to burn fuel properly. As one would expect, if a person who inherits a gene that limits their ability to produce insulin is exposed to chemicals or drugs that raise their insulin resistance or further damages their insulin production, they are far more likely than others to develop diabetes.

1.6 Further Research

It can be seen in details of the specific studies that explain why the numbers seen in the charts are used in the book Blood Sugar 101: What They Don't Tell You About Diabetes. Other research may find that people whose blood sugar rises over 155 mg/dl on a glucose tolerance test are more likely to have signs of inflammation in their blood vessels.

1.7 Conclusion

Now that the facts are revealed, it is up to the patient to decide what blood sugar level will be strived for. No matter what others might recommend, the person who has to do the work is responsible for reaching those goals. One may blow off the whole program if the goal is too stringent. The person, rather than the doctors who recommend them, are who will suffer if he lets himself be talked into settling for the lax standards promoted by the ADA. As a general rule of thumb, if the blood sugar is only mildly elevated, it's best to aim for truly regular readings. On the other hand, if one has very high blood sugars now, bringing them down even to the ADA prediabetes level will improve his health. Once the patient has achieved some success, he or she is likely to be more motivated to keep working on getting them lower until reaching the levels that are more likely to avoid blood sugar-related complications.

The Importance of Exercise

2.1 Overview

Exercise is a great stress reliever, emotionally as well as physically. Because stress is a cycle—feeling it emotionally, then reacting physically, which reinforces the emotion, which heightens the anxiety one feels—one can attack the problem either way. Relaxing physically or calming emotionally will help, and the two together are the best.

The best form of exercise is the one the person will do. The choices are all over the place. Just choosing something that is not unduly demanding, too expensive, or annoying is important (Wright, 2013). For psychological relief, there is also a range of options, from meditation or yoga to spiritual or psychological counseling to spending more time playing with children, grandchildren, or a pet. Rewarding for helping oneself is also a good strategy, whether one buys a small gift or treat.

2.2 Research Questions

How Much Exercise is Enough?

According to the Surgeon General’s 1996 report on physical activity, individuals over the age of two years should engage in 30 minutes of endurance-type physical activity that is moderately intense on all or most days of the week—with the warning that people with diabetes, cardiovascular diseases, and other chronic health problems would first consult with their doctor before starting an exercise program (Wright, 2013). Besides, all previously inactive men who are over age 40 or previously inactive women over age 50 should discuss their new fitness plans with their doctor first.

2.3 Sample Populations

In a study of male physicians who were at high risk for later developing Type 2 diabetes (due to a family history of diabetes, their hypertension, and other factors), researchers found an inverse relationship between physical activity and the onset of diabetes. The more that the men exercised, the less likely they were to develop diabetes (Parker J. M. & Parker P. M., 2004). Regular exercise also decreases the risks of developing stroke, osteoporosis, and other serious medical problems that are more commonly found among sedentary individuals.

2.4 Methodology

Being Physically Active

Physical activity has been proven even more effective than diet in terms of improving overall health and cardiovascular well-being. The rule of thumb is thirty to forty-five minutes of moderate exercise every day. Walking is excellent exercise, and one can break it up, doing ten or fifteen minutes at a clip. Taking the stairs if possible, parking the car in the farthest part of the lot, walking around the mall in bad weather, or taking the dog out (Wright, 2013). If one has a lot of leg and knee pain because of heavyweight, walking may be difficult or impossible.

Most senior citizen centers and YMCAs have exercise programs customized for people who are physically impaired. Patients could do chair exercises or water aerobics, or perhaps tai chi, which helps improve flexibility and balance. Anything physical one does progress the cardiovascular health and can help lower blood sugar.

2.5 Limitations

Although many older people have diabetes, diabetes is not an inevitable consequence of aging. Besides, of those older people who do have diabetes, there are many positive actions that an individual (or caregivers) can take to limit the often severe complications stemming from diabetes. Reasonable glycemic control, a nutritious diet, and regular exercise are as crucial to the person who is 80 years old (or older) as they are for the person who is 20 or 40 years old (Thompson, 2012). (Of course, exercise must be limited with the individual capabilities of the individual.)

2.6 Further Research

Another issue to consider about genetic manipulation is that people react differently to the news of genetic predispositions. For example, some people who learn that they have a genetic risk for diabetes (or cancer or another disease) may take appropriate actions to decrease the risk. The person at risk for diabetes might exercise, eat a healthy diet, and avoid drinking and smoking. If genetic manipulation is available as an option, they will take advantage of it.

However, some people think more fatalistically and mistakenly assume that they are doomed to develop a disease. Such people are less likely to take appropriate actions because they wrongly believe that there is no point in doing so. They are also less likely to accept genetic manipulation. Some people may fear that it is wrong or even sinful to do so. Appropriate genetic study and manipulation may lead to new therapies, including vaccines. However, it also remains a complex social, religious, and scientific area that is yet unresolved.

2.7 Conclusion

It sounds simple, but it adds up to a lot. And because any change is hard for all of us, one needs and deserves help and encouragement. Regular counseling is the best way to guarantee success. So it's essential to partner with the doctor and finds a registered dietitian nutritionist or diabetes educator who can keep on track and help over the hurdles. But patients know what they say about silver linings, and there is one here. If the person is diagnosed with prediabetes, and he or she rises to the challenge, health and vitality will likely become better than ever before—and the risk of several future chronic diseases will be significantly diminished.

Metformin

3.1 Overview

One of the medications in the biguanide class that is used to treat people with Type 2 diabetes. Metformin has been available worldwide for many years but became available as Glucophage (produced by Bristol-Myers Squibb) in the United States in about 1995. The drug is only useful if a person’s body still makes some insulin; thus, it is not helpful for patients with Type 1 diabetes.

Metformin works by decreasing the amount of glucose that the liver produces, and thus, it has a good effect on fasting glucose levels. Sophisticated studies have shown that this effect is most likely due to the suppression of the synthesis of new glucose (gluconeogenesis). By improving glucose levels, the drug will diminish glucose toxicity and indirectly will also decrease resistance to insulin (Firm, & Lipha-Lyon 1985). Because it does not cause an increase in insulin secretion when used alone (as monotherapy), it will not cause hypoglycemia (low blood glucose).

3.2 Research Questions

Some diabetes drugs reduce blood-sugar levels but do not prevent the progression of prediabetes to diabetes. According to a report in the New England Journal of Medicine, people taking ramipril (Altace) to treat prediabetes benefited from improved blood-sugar levels; however, the drug did not reduce their risk of developing diabetes or dying.

Early in 2007, Eli Lilly, the maker of Zyprexa (noted previously), agreed to pay a total of $1.2 billion to 28,500 people who took the drug for bipolar disease or schizophrenia. The drug had gained a reputation for promoting both obesity and diabetes.

Likewise, in early 2007, researchers at the Cleveland Clinic published an analysis of forty-two studies involving the antidiabetes drug rosiglitazone (Avandia). They reported that the drug increased the risk of heart attack by 43 percent.

3.3 Sample Populations

Many commonly prescribed drugs have the undesirable side effect of altering the metabolism of sugars and fats. In doing so, they increase the likelihood of gaining weight and developing diabetes (Firm, & Lipha-Lyon 1985). Most prescription medications are inherently dangerous and must be used with extreme care.

In one study, researchers calculated that more than 100,000 hospitalized patients die each year from medication errors, and more than 2 million others suffer serious side effects. These numbers are shocking because everyone assumes that rigorous controls would be in place in hospitals (Parker J. M. & Parker P. M., 2004). Another 700,000 people are hospitalized each year because of adverse reactions to prescription and over-the-counter medications.

3.4 Methodology

Lifestyle interventions have proven useful in preventing the development of T2DM in at-risk individuals and lowering blood glucose in patients with T2DM. The primary lifestyle interventions for an overweight or obese individual with insulin resistance are weight loss by calorie restriction and increased physical activity. Physical activity—either structured or through increased activities of daily living of 30 minutes duration on most days of the week—should be recommended to all patients.

The Diabetes Prevention Program evaluated the prevention of T2DM in 3,234 nondiabetic, overweight, insulin-resistant individuals. This study compared metformin with both placebo and lifestyle intervention. The lifestyle intervention, achieving at least 7% weight loss by calorie restriction, modification of dietary fat to < 25%, and at least 150 minutes of physical activity per week, resulted in a 58% decrease in the development of T2DM.

Although less successful than lifestyle intervention, metformin decreased the incidence of T2DM by 31%. In individuals older than 60 years, metformin had less effect, but diet and exercise had a clinical outcome similar to the other age groups. The Finnish Diabetes Prevention Study, which evaluated the effect of reducing total and saturated fat and increasing fiber intake and physical activity in subjects with impaired glucose tolerance, showed similar decreases in the development of T2DM (Silverstein, 2012). Topics in this study also demonstrated significant weight loss, decreased triglyceride levels, increased HDL cholesterol levels, and decreased blood pressure.

3.5 Limitations

To cure prediabetes so that you don't need medication for life, a prescription is often beneficial in the short run. Lowering blood sugar is critical. Until patients are confident that they can bring it under control naturally, it's essential for them that practitioners monitor their progress and take whatever medications are necessary daily without fail.

3.6 Further Research

The concept of using botanicals in diabetes management is not unlike other branches of medicine where traditional pharmaceuticals are derived from plant extracts. The biguanide metformin was derived from the guanidine-rich medicinal plant Galega officinalis (goat’s rue or French lilac). Many of the anti-diabetic botanicals have been researched extensively in India. Still, these represent only a small proportion of the over 400 reported in the literature, and even a lower percentage of the over 250,000 estimated higher plants with potential medicinal activity. Adusumilli et al. surveyed 2,186 respondents undergoing elective surgery. They found that 57% admitted to using herbal remedies (most common: echinacea [48%], aloe vera [30%], ginseng [28%], garlic [27%], and ginkgo Biloba [22%]) but herbal use was relatively low among diabetic patients (odds ratio 0.46).

Diabetes Research Paper: Conclusion

Patients spend six months to a year to lose weight and adjust their lifestyle before being prescribed any drugs. But the best intentions have a way of stretching out from weeks to months before petering out to daydreams in which patients imagine what they'll do when they're ready. Sometimes "now" simply feels too stressful. People plan to make all those functional changes after the baby is born, after the child is married, after they get a new job, after their next birthday when their nerves calm down when their boss goes on vacation. But more recently people learned that elevated glucose of any sort damages tiny blood vessels in the peripheral nerves, retina, kidneys, and elsewhere much sooner than they'd imagined, and the excess sugar circulating in their bodies contributes to so-called hardening and obstruction of the arteries at a very early stage.

It is usually given to motivated patients two to three months before handing them a prescription and recommending a nutritionist. These days a functional nutritionist recommends appropriate physical activity as well as dietary plans. If the patient has no impulse to lose weight or exercise, It is recommended to take a single drug, usually metformin, immediately. If the lifestyle changes are successful and the counts go down sufficiently, then he or she would be weaned from the drugs. The priorities changed: first, getting that blood sugar down, then focusing on keeping it down naturally so that the pharmaceuticals can be dispensed with.

References

Bernstein, R. K. (2011). Dr. Bernstein’s diabetes solution : the complete guide to achieving normal blood sugars. Little, Brown And Co.

Camerini-Davalos, R. A., & Cole, H. S. (2012). Prediabetes. Springer Verlag.

Challem, J., & Hunninghake, R. E. (2009). Stop prediabetes now : the ultimate plan to lose weight and prevent diabetes. John Wiley & Sons.

Galmer, A. (2008). Diabetes. Westport, Conn: Greenwood Press.

Krans, J., Society, R., Zyma-Nederland (Firm, & Lipha-Lyon (Firm. (1985). Diabetes and metformin : a research and clinical update. Royal Society Of Medicine ; Oxford.

McAuliffe, B. (2012). Diabetes. Mankato, MN: Creative Education.

Mechanick, J. I., & Brett, E. M. (2006). Nutritional strategies for the diabetic & prediabetic patient. Crc/Taylor & Francis.

Mussatto, C., & Greeff, N. (2019). The prediabetes action plan and cookbook : a simple guide to getting healthy and reversing prediabetes. Rockridge Press.

Parker, J. N., & Parker, P. M. (2004). The official patient’s sourcebook on diabetes. Icon Health Publications.

Parker, J. N., Parker, P. M., & Icon Group International, Inc. (2002). The official patient’s sourcebook on gestational diabetes. Icon Health Publications.

Petit, W. A., & Adamec, C. A. (2011). The encyclopedia of diabetes. Infobase Learning.

Saudek, C. D., & Margolis, S. (2011). Diabetes. Baltimore, MD: Johns Hopkins Medicine.

Silverstein, A., Silverstein, V. B., & Nunn, L. S. (2002). Diabetes. New York: Franklin Watts.

Thompson, R. (2012). The glycemic-load diabetes solution : six steps to optimal control of your adult-onset (type 2) diabetes. Mcgraw-Hill.

Wright, H. (2013). The prediabetes diet plan : how to reverse prediabetes and prevent diabetes through healthy eating and exercise. Ten Speed Press.

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