Diabetes

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Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.[1] This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

There are three main types of diabetes mellitus (DM).

• Type 1 DM results from the body's failure to produce insulin, and presently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes.
• Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes.
• The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 DM.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.

All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be controlled with medications. Both types 1 and 2 are chronic conditions that cannot be cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and diabetic retinopathy (retinal damage). Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight.

Globally, as of 2012, an estimated 346 million people have type 2 diabetes.[2]

Classification

Comparison of type 1 and 2 diabetes[3]
Feature	Type 1 diabetes	Type 2 diabetes
Onset	Sudden	Gradual
Age at onset	Mostly in children	Mostly in adults
Body habitus	Thin or normal[4]	Often obese
Ketoacidosis	Common	Rare
Autoantibodies	Usually present	Absent
Endogenous insulin	Low or absent	Normal, decreased or increased
Concordance in identical twins	50%	90%
Prevalence	~10%	~90%

Diabetes mellitus is classified into four broad categories: Type 1, Type 2, gestational diabetes and other specific types.[1] The other specific types are a collection of a few dozen individual causes.[1] The term diabetes, without qualification, usually refers to diabetes mellitus. The rare disease diabetes insipidus has similar symptoms as diabetes mellitus, but without disturbances in the sugar metabolism (insipidus means without taste in Latin).

The term type 1 diabetes has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term type 2 diabetes has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and noninsulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature.

Type 1 diabetes

Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to insulin deficiency. This type can be further classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, in which beta cell loss is a T-cell-mediated autoimmune attack.[5] There is no known preventive measure against Type 1 diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults, but was traditionally termed juvenile diabetes because a majority of these diabetes cases were in children.

Brittle diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe to dramatic and recurrent swings in glucose levels, often occurring for no apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis and should not be used.[6] There are many reasons for Type 1 diabetes to be accompanied by irregular and unpredictable hyperglycemias, frequently with ketosis, and sometimes serious hypoglycemias, including an impaired counterregulatory response to hypoglycemia, occult infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's disease).[6] These phenomena are believed to occur no more frequently than in 1% to 2% of persons with Type 1 diabetes.[7]

Type 2 diabetes

Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion.[1] The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most common type.

In the early stage of Type 2, the predominant abnormality is reduced insulin sensitivity. At this stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver.

Gestational diabetes

Gestational diabetes mellitus (GDM) resembles Type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2%–5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. About 20%–50% of affected women develop Type 2 diabetes later in life.

Though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin may inhibit fetal surfactant production and cause respiratory distress syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A Caesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.

A 2008 study completed in the U.S. found the number of American women entering pregnancy with pre-existing diabetes is increasing. In fact, the rate of diabetes in expectant mothers has more than doubled in the past six years.[8] This is particularly problematic as diabetes raises the risk of complications during pregnancy, as well as increasing the potential for the children of diabetic mothers to become diabetic in the future.

Other types

Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of Type 2 DM. Many people destined to develop Type 2 DM spend many years in a state of prediabetes which has been termed America's largest healthcare epidemic.[9][10]

Latent autoimmune diabetes of adults (LADA) is a condition in which Type 1 DM develops in adults. Adults with LADA are frequently initially misdiagnosed as having Type 2 DM, based on age rather than etiology.

Some cases of diabetes are caused by the body's tissue receptors not responding to insulin (even when insulin levels are normal, which is what separates it from Type 2 diabetes); this form is very uncommon. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell function. Abnormal insulin action may also have been genetically determined in some cases. Any disease that causes extensive damage to the pancreas may lead to diabetes (for example, chronic pancreatitis and cystic fibrosis). Diseases associated with excessive secretion of insulin-antagonistic hormones can cause diabetes (which is typically resolved once the hormone excess is removed). Many drugs impair insulin secretion and some toxins damage pancreatic beta cells. The ICD-10 (1992) diagnostic entity, malnutrition-related diabetes mellitus (MRDM or MMDM, ICD-10 code E12), was deprecated by the World Health Organization when the current taxonomy was introduced in 1999.[10]

Signs and symptoms

Overview of the most significant symptoms of diabetes.

The classic symptoms of untreated diabetes are loss of weight, polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).[11] Symptoms may develop rapidly (weeks or months) in Type 1 diabetes, while they usually develop much more slowly and may be subtle or absent in Type 2 diabetes.

Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a diabetes diagnosis; Type 1 should always be suspected in cases of rapid vision change, whereas with Type 2 change is generally more gradual, but should still be suspected. A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.

Diabetic emergencies

People (usually with Type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone, a rapid, deep breathing known as Kussmaul breathing, nausea, vomiting and abdominal pain, and altered states of consciousness.

A rare but equally severe possibility is hyperosmolar nonketotic state, which is more common in Type 2 diabetes and is mainly the result of dehydration.

Complications

All forms of diabetes increase the risk of long-term complications. These typically develop after many years (10–20), but may be the first symptom in those who have otherwise not received a diagnosis before that time. The major long-term complications relate to damage to blood vessels. Diabetes doubles the risk of cardiovascular disease.[12] The main macrovascular diseases (related to atherosclerosis of larger arteries) are ischemic heart disease (angina and myocardial infarction), stroke and peripheral vascular disease.

Diabetes also damages the capillaries (causes microangiopathy).[13] Diabetic retinopathy, which affects blood vessel formation in the retina of the eye, can lead to visual symptoms, reduced vision, and potentially blindness. Diabetic nephropathy, the impact of diabetes on the kidneys, can lead to scarring changes in the kidney tissue, loss of small or progressively larger amounts of protein in the urine, and eventually chronic kidney disease requiring dialysis. Diabetic neuropathy is the impact of diabetes on the nervous system, most commonly causing numbness, tingling and pain in the feet and also increasing the risk of skin damage due to altered sensation. Together with vascular disease in the legs, neuropathy contributes to the risk of diabetes-related foot problems (such as diabetic foot ulcers) that can be difficult to treat and occasionally require amputation.

Causes

The cause of diabetes depends on the type.

Type 1 diabetes is partly inherited, and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility to some of these triggers has been traced to particular HLA (Human leukocyte antigen) genotypes (i.e., the genetic self identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, Type 1 DM seems to require an environmental trigger. The onset of Type 1 diabetes is unrelated to lifestyle.

Type 2 diabetes is due primarily to lifestyle factors and genetics.[14]

The following is a comprehensive list of other causes of diabetes:[15]
Genetic defects of ß-cell function Maturity onset diabetes of the young Mitochondrial DNA mutations Genetic defects in insulin processing or insulin action Defects in proinsulin conversion Insulin gene mutations Insulin receptor mutations Exocrine pancreatic defects Chronic pancreatitis Pancreatectomy Pancreatic neoplasia Cystic fibrosis Hemochromatosis Fibrocalculous pancreatopathy	Endocrinopathies Growth hormone excess (acromegaly) Cushing syndrome Hyperthyroidism Pheochromocytoma Glucagonoma Infections Cytomegalovirus infection Coxsackie B4 virus Drugs Glucocorticoids Thyroid hormone ß-adrenergic agonists Statins[16]

Pathophysiology

The fluctuation of blood sugar (red) and the sugar-lowering hormone insulin (blue) in humans during the course of a day with three meals - one of the effects of a sugar-rich vs a starch-rich meal is highlighted.

Mechanism of insulin release in normal pancreatic beta cells - insulin production is more or less constant within the beta cells. Its release is triggered by food, chiefly food containing absorbable glucose.

Insulin is the principal hormone that regulates uptake of glucose from the blood into most cells (primarily muscle and fat cells, but not central nervous system cells). Therefore, deficiency of insulin or the insensitivity of its receptors plays a central role in all forms of diabetes mellitus.

Humans are capable of digesting some carbohydrates, in particular those most common in food; starch, and some disaccharides such as sucrose, are converted within a few hours to simpler forms, most notably the monosaccharide glucose, the principal carbohydrate energy source used by the body. The rest are passed on for processing by gut flora largely in the colon. Insulin is released into the blood by beta cells (ß-cells), found in the islets of Langerhans in the pancreas, in response to rising levels of blood glucose, typically after eating. Insulin is used by about two-thirds of the body's cells to absorb glucose from the blood for use as fuel, for conversion to other needed molecules, or for storage.

Insulin is also the principal control signal for conversion of glucose to glycogen for internal storage in liver and muscle cells. Lowered glucose levels result both in the reduced release of insulin from the ß-cells and in the reverse conversion of glycogen to glucose when glucose levels fall. This is mainly controlled by the hormone glucagon, which acts in the opposite manner to insulin. Glucose thus forcibly produced from internal liver cell stores (as glycogen) re-enters the bloodstream; muscle cells lack the necessary export mechanism. Normally, liver cells do this when the level of insulin is low (which normally correlates with low levels of blood glucose).

Higher insulin levels increase some anabolic (building up) processes, such as cell growth and duplication, protein synthesis, and fat storage. Insulin (or its lack) is the principal signal in converting many of the bi-directional processes of metabolism from a catabolic to an anabolic direction, and vice versa. In particular, a low insulin level is the trigger for entering or leaving ketosis (the fat-burning metabolic phase).

If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin (insulin insensitivity or resistance), or if the insulin itself is defective, then glucose will not have its usual effect, so it will not be absorbed properly by those body cells that require it, nor will it be stored appropriately in the liver and muscles. The net effect is persistent high levels of blood glucose, poor protein synthesis, and other metabolic derangements, such as acidosis.

When the glucose concentration in the blood is raised to about 9-10 mmol/L (except certain conditions, such as pregnancy), beyond its renal threshold (i.e. when glucose level surpasses the transport maximum of glucose reabsorption), reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume will be replaced osmotically from water held in body cells and other body compartments, causing dehydration and increased thirst.

Diagnosis

Diabetes diagnostic criteria[17][18]
Condition	2 Hour Glucose	Fasting glucose	HbA1c
	mmol/l(mg/dl)	mmol/l(mg/dl)	%
Normal	<7.8 (<140)	<6.1 (<110)	<6.0
Impaired fasting glycaemia	<7.8 (<140)	≥ 6.1(≥110) & <7.0(<126)	6.0–6.4
Impaired glucose tolerance	≥7.8 (≥140)	<7.0 (<126)	6.0–6.4
Diabetes mellitus	≥11.1 (≥200)	≥7.0 (≥126)	≥6.5

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:[10]

• Fasting plasma glucose level ≥7.0 mmol/l (126 mg/dl)
• Plasma glucose ≥11.1 mmol/l (200 mg/dL) two hours after a 75g oral glucose load as in a glucose tolerance test
• Symptoms of hyperglycemia and casual plasma glucose ≥11.1 mmol/l (200 mg/dl)
• Glycated hemoglobin (Hb A1C) ≥6.5%[19]

A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat of any of the above methods on a different day. It is preferable to measure a fasting glucose level because of the ease of measurement and the considerable time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test.[20] According to the current definition, two fasting glucose measurements above 126 mg/dl (7.0 mmol/l) is considered diagnostic for diabetes mellitus.

People with fasting glucose levels from 110 to 125 mg/dl (6.1 to 6.9 mmol/l) are considered to have impaired fasting glucose.[21] Patients with plasma glucose at or above 140 mg/dL (7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hours after a 75 g oral glucose load are considered to have impaired glucose tolerance. Of these two prediabetic states, the latter in particular is a major risk factor for progression to full-blown diabetes mellitus, as well as cardiovascular disease.[22]

Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause.[23]

Management

Diabetes mellitus is a chronic disease which cannot be cured except in very specific situations. Management concentrates on keeping blood sugar levels as close to normal (euglycemia) as possible, without causing hypoglycemia. This can usually be accomplished with diet, exercise, and use of appropriate medications (insulin in the case of Type 1 diabetes, oral medications, as well as possibly insulin, in Type 2 diabetes).

Patient education, understanding, and participation is vital, since the complications of diabetes are far less common and less severe in people who have well-managed blood sugar levels.[24][25] The goal of treatment is an HbA1C level of 6.5%, but should not be lower than that, and may be set higher.[26] Attention is also paid to other health problems that may accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.[26]

Lifestyle

There are roles for patient education, dietetic support, sensible exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.[27]

Medications

The following table compares some common anti-diabetic agents, generalizing classes, although there may be substantial variation in individual drugs of each class. When the table makes a comparison such as "lower risk" or "more convenient" the comparison is with the other drugs on the table.

Comparison of anti-diabetic medication[28][29][30][31]
Agent[29][30][31]	Mechanism[32]	Advantages[29][30][31]	Disadvantages[29][30][31]
Sulfonylurea (glyburide, glimepiride, glipizide)	Stimulating insulin release by pancreatic beta cells by inhibiting the KATP channel	Fast onset of action No effect on blood pressure No effect on low-density lipoprotein Inexpensive Lower risk of gastrointestinal problems than with metformin More convenient dosing	Causes an average of 5-10 pounds weight gain Increased risk of hypoglycemia Glyburide has increases risk of hypoglycemia slightly more as compared with glimepiride and glipizide Higher risk of death compared with metformin[32]
Metformin	Acts on liver to cause decrease in insulin resistance	Not associated with weight gain Low risk of hypoglycemia as compared to alternatives Good effect on LDL cholesterol Decreases triglycerides No effect on blood pressure Inexpensive	Increased risk of Human gastrointestinal tract|gastrointestinal problems Contraindicated for people with moderate or severe kidney disease or heart failure because of risk of lactic acidosis Increased risk of Vitamin B12 deficiency[29][30][31] Less convenient dosing Metallic taste[29][30][31]
Alpha-glucosidase inhibitor (acarbose, miglitol)	Reduces glucose absorbance by acting on small intestine to cause decrease in production of enzymes needed to digest carbohydrates	Slightly decreased risk of hypoglycemia as compared to sulfonylurea Not associated with weight gain Decreases triglycerides No effect on cholesterol	Less effective than most other diabetes pills in decreasing glycated hemoglobin Increased risk of GI problems than other diabetes pills except metformin Inconvenient dosing Expensive
Thiazolidinediones (Actos, Avandia)	Reduce insulin resistance by activating (Peroxisome proliferator-activated receptor gamma) PPAR-γ in fat and muscle	Lower risk of hypoglycemia Slight increase in high-density lipoprotein Actos linked to decreased triglycerides Convenient dosing	Increased risk of heart failure Causes an average of 5-10 pounds weight gain Associated with higher risk of edema Associated with higher risk of anemia Increases low-density lipoprotein Avandia linked to increased triglycerides and risk of heart attack Actos linked to increased risk of bladder cancer Slower onset of action Requires monitoring for hepatoxicity Associated with increased risk of limb fractures Expensive

Most anti-diabetic agents are contraindicated in pregnancy, in which insulin is preferred.[29]

Oral medications

Metformin is generally recommended as a first line treatment for Type 2 diabetes, as there is good evidence that it decreases mortality.[33] Routine use of aspirin, however, has not been found to improve outcomes in uncomplicated diabetes.[34]

Insulin

Type 1 diabetes is typically treated with a combinations of regular and NPH insulin, or synthetic insulin analogs. When insulin is used in Type 2 diabetes, a long-acting formulation is usually added initially, while continuing oral medications.[33] Doses of insulin are then increased to effect.[33]

Support

In countries using a general practitioner system, such as the United Kingdom, care may take place mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult blood sugar control, or research projects. In other circumstances, general practitioners and specialists share care of a patient in a team approach. Optometrists, podiatrists/chiropodists, dietitians, Physical therapy|physiotherapists, nursing specialists (e.g., diabetic specialist nurses), nurse practitioners, or certified diabetes educators, may jointly provide multidisciplinary expertise. Home telehealth support can be an effective management technique.[35]

Epidemiology

Prevalence of diabetes worldwide in 2000 (per 1,000 inhabitants) - world average was 2.8%.	Disability-adjusted life year for diabetes mellitus per 100,000 inhabitants in 2004.
no data 45–52.5 ≤ 7.5 52.5–60 7.5–15 60–67.5 15–22.5 67.5–75 22.5–30 75–82.5 30–37.5 ≥ 82.5 37.5–45	no data 600–700 <100 700–800 100–200 800–900 200–300 900–1,000 300–400 1,000–1,500 400–500 >1,500 500–600

Globally, as of 2010, an estimated 285 million people had diabetes, with Type 2 making up about 90% of the cases.[3] Its incidence is increasing rapidly, and by 2030, this number is estimated to almost double.[36] Diabetes mellitus occurs throughout the world, but is more common (especially Type 2) in the more developed countries. The greatest increase in prevalence is, however, expected to occur in Asia and Africa, where most patients will probably be found by 2030.[36] The increase in incidence in developing countries follows the trend of urbanization and lifestyle changes, perhaps most importantly a Western-style diet. This has suggested an environmental (i.e., dietary) effect, but there is little understanding of the mechanism(s) at present, though there is much speculation, some of it most compellingly presented.[36]

Australia

Indigenous populations in first world countries have a higher prevalence and increasing incidence of diabetes than their corresponding nonindigenous populations. In Australia, the age-standardised prevalence of self-reported diabetes in indigenous Australians is almost four times that of nonindigenous Australians.[37] Preventative community health programs, such as Sugar Man (diabetes education), are showing some success in tackling this problem.

China

Almost one Chinese adult in ten has diabetes. A 2010 study estimated that more than 92 million Chinese adults have the disease, with another 150 million showing early symptoms.[38] The incidence of the disease is increasing rapidly; a 2009 study found a 30% increase in 7 years.[39]

India

India has more diabetics than any other country in the world, according to the International Diabetes Foundation,[40] although more recent data suggest that China has even more.[38] The disease affects more than 50 million Indians - 7.1% of the nation's adults - and kills about 1 million Indians a year.[40] The average age on onset is 42.5 years.[40] The high incidence is attributed to a combination of genetic susceptibility plus adoption of a high-calorie, low-activity lifestyle by India's growing middle class.[41]

United Kingdom

About 3.8 million people in the United Kingdom have diabetes mellitus, but the charity Diabetes U.K. have made predictions that that could become high as 6.2 million by 2035/2036. Diabetes U.K. have also predicted that the National Health Service could be spending as much as 16.9 billion pounds on diabetes mellitus by 2035, a figure that means the NHS could be spending as much as 17% of its budget on diabetes treatment by 2035.[42][43][44]

United States

Diabetes rates at county levels 2004 - 2009.

For at least 20 years, diabetes rates in North America have been increasing substantially. In 2010, nearly 26 million people have diabetes in the United States, of whom 7 million people remain undiagnosed. Another 57 million people are estimated to have prediabetes.[45][46]

The Centers for Disease Control and Prevention (CDC) has termed the change an epidemic.[47] The National Diabetes Information Clearinghouse estimates diabetes costs $132 billion in the United States alone every year. About 5%–10% of diabetes cases in North America are Type 1, with the rest being Type 2. The fraction of Type 1 in other parts of the world differs. Most of this difference is not currently understood. The American Diabetes Association (ADA) cites the 2003 assessment of the National Center for Chronic Disease Prevention and Health Promotion (Centers for Disease Control and Prevention) that one in three Americans born after 2000 will develop diabetes in their lifetimes.[48][49]

According to the ADA, about 18.3% (8.6 million) of Americans age 60 and older have diabetes.[50] Diabetes mellitus prevalence increases with age, and the numbers of older persons with diabetes are expected to grow as the elderly population increases in number. The National Health and Nutrition Examination Survey (NHANES III) demonstrated, in the population over 65 years old, 18% to 20% have diabetes, with 40% having either diabetes or its precursor form of impaired glucose tolerance.[51]

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57. pmid=A

58. pmid=B

59. pmid=C

60. pmid=D

61. pmid=E

62. pmid=F

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