Diabetes Mellitus
DM
Diabetes mellitus is a common metabolic disorder of multiple etiology, characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism due to defects in insulin secretion, insulin action, or both. There are four main types of diabetes mellitus: type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes and other specific types (genetic syndromes, pancreatitis, cystic fibrosis, exposure to certain drugs, etc.).
Presentation
Patients with type 1 diabetes mellitus usually present with classic acute symptoms of hyperglycemia. These include:
- Polyuria (due to osmotic diuresis when blood glucose level exceeds renal threshold)
- Thirst (as a consequence of loss of fluids and electrolytes by osmotic diuresis)
- Postural hypotension (due to reduction of plasma volume by osmotic diuresis)
- Loss of weight (due to depletion of glycogen stores by glycogenolysis and triglyceride stores by lipolysis; and the reduction of muscle mass as a consequence of the diversion of amino acids for gluconeogenesis)
- Blurring of vision (because of the exposure of the lens and retina to hyperosmolar fluids)
Around 25% of the cases of diabetes mellitus present with the acute complication of ketoacidosis.
In contrast, most of the patients of type 2 diabetes mellitus do not have acute symptoms. The disease may be present for an average of 4 to 7 years before it is detected. The patients have a history of increased urination and thirst but most are asymptomatic initially. The presenting complaints of the patients include lack of energy, delayed wound healing, visual blurring and fungal infections such as pruritis vulvae or balanitis [5].
In addition, the following complications may be the initial presenting feature in chronically undetected cases.
- Infections (such as urinary tract infections, tuberculosis and skin infections)
- Deterioration of vision (owing to diabetic retinopathy)
- Paresthesia, pain and atrophy of the leg muscles (due to neuropathy)
- Ulcerations of the foot/feet (caused by a combination of neuropathy, infection and peripheral vascular disease) [6]
- Myocardial infarction (because of atherosclerosis)
Entire Body System
Weight Loss
- Conclusions: The eating trait of being unsuccessfully dietary restrained is associated with weight-loss failure after a six-month lifestyle intervention in people with T2DM.[ncbi.nlm.nih.gov]
- In the short term, hyperglycemia causes symptoms of increased thirst, increased urination, increased hunger, and weight loss.[web.archive.org]
- Typical weight loss is 1-2 lb per week, 31 and total weight loss tends to be less than that with other procedures.[clinical.diabetesjournals.org]
- Weight Loss Surgery After weight loss surgery, many people with type 2 diabetes see their blood sugar levels return to near normal. Some experts call this a remission.[web.archive.org]
- It remains unclear which dietary intervention is best for optimising glycaemic control, or whether weight loss itself is the main reason behind observed improvements.[doi.org]
Fatigue
- Myasthenia gravis (MG) is an acquired disease of the neuromuscular junctions characterized by muscular weakness and fatigue, with a prevalence of 50-125 cases per million population in western countries.[ncbi.nlm.nih.gov]
- Since 6 months ago, she often seemed like having less concentration or daydreaming, chronic fatigue, depression, and low food intake. Her body weight had been increasing over time.[ncbi.nlm.nih.gov]
- Nine weeks after initiation, he developed fatigue and polyuria with blood glucose 336 mg/dL, c-peptide 0.6 ng/mL, A1C8.2% and GAD antibodies 28.4 U/mL (normal, 1 U/mL).[ncbi.nlm.nih.gov]
- […] intervention, there was a statistically significant reduction in the mean value of HbA1c from 9.8 to 7.7 ( P 0.001), and there was significant improvement in the mean scores of the following HRQoL scales: role limitations due to emotional problems, energy/fatigue[ncbi.nlm.nih.gov]
- The signs and symptoms of both types of diabetes include increased urine output and decreased appetite as well as fatigue .[medicinenet.com]
Coronary Artery Disease
- In the present review we discuss the evidence linking leptin levels with the presence, severity and/or prognosis of both coronary artery disease and non-cardiac vascular diseases such as stroke, carotid artery disease, peripheral artery disease (PAD)[ncbi.nlm.nih.gov]
- Abstract Global longitudinal strain (GLS) at rest on two-dimensional speckle tracking echocardiography (2D STE) was demonstrated to help detect coronary artery disease (CAD).[ncbi.nlm.nih.gov]
- In fact, risk of diabetes is directly proportional to degree of obesity. 3 - 5 Furthermore, studies have conclusively shown that reductions in weight are associated with lower risks of diabetes 6 and other risk factors for coronary artery disease, such[clinical.diabetesjournals.org]
- Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke and narrowing of arteries (atherosclerosis).[mayoclinic.org]
Renal Artery Stenosis
- artery stenosis (unilateral in patient with solitary kidney) ACE inhibitors, angiotensin receptor antagonists Post stroke ACE inhibitors, angiotensin receptor antagonists, low-dose thiazide-like diuretics Type 1 or type 2 diabetes with proteinuria or[web.archive.org]
Abdominal Obesity
- Your doctor will examine you to look for: Obesity, especially abdominal obesity—a condition that greatly raises a person's risk for type 2 diabetes.[drugs.com]
Gastrointestinal
Diarrhea
- Abstract Proprotein convertase 1/3 (PC1/3) deficiency is a very rare disease characterized by severe intractable diarrhea in the first years of life, followed by obesity and several hormonal deficiencies later.[ncbi.nlm.nih.gov]
- Key words Aretaeus of Cappadocia Diabetes Galen Soranus of Ephesus Diarrhea urinosa Dipsakon This is a preview of subscription content, log in to check access. Preview Unable to display preview. Download preview PDF. References 1.[doi.org]
- Alpha-glucosidase inhibitors are less effective than other oral drugs in reducing plasma glucose, and patients often stop the drugs because they may cause dyspepsia, flatulence, and diarrhea.[msdmanuals.com]
- Contact your doctor immediately if you develop vomiting or diarrhea and are not able to drink enough fluids. Monitor your blood sugar as advised by your health care team. Report any significant deviations in blood sugar levels.[drugs.com]
- Symptoms of CD include malabsorption and malnutrition, vitamin deficiencies, iron deficiency anemia, failure to thrive, short stature, diarrhea, anorexia, constipation, vomiting, and abdominal distension.[dx.doi.org]
Polydipsia
- Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly.[web.archive.org]
- Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes, and fatigue. These symptoms may occur suddenly.[who.int]
- The renal threshold for glucose reabsorption is exceeded when blood glucose levels exceed 180 mg/dL (10 mmol/L), causing glycosuria with the typical symptoms of polyuria and polydipsia. (See Pathophysiology, Clinical, and Treatment.)[emedicine.medscape.com]
- Clinical manifestations include polyuria, polydipsia, and polyphagia. Type 1 DM (prevalence 0.4%) is caused by pancreatic islet cell destruction, usually beginning in childhood. These patients are at increased risk for diabetic ketoacidosis .[openanesthesia.org]
Abdominal Pain
- pain Types of hospitals included in HCUP HCUP is based on data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons).[hcup-us.ahrq.gov]
- They are more likely to present with nausea, vomiting, and abdominal pain, symptoms similar to food poisoning. DKA may manifest as respiratory distress.[emedicine.medscape.com]
- pain, rapid deep breathing, loss of appetite, reddened and warm skin, headache, drowsiness, fruity-smelling breath, restlessness and ketones in our urine.[nhforsythendocrineconsultants.org]
Constipation
- Symptoms of CD include malabsorption and malnutrition, vitamin deficiencies, iron deficiency anemia, failure to thrive, short stature, diarrhea, anorexia, constipation, vomiting, and abdominal distension.[dx.doi.org]
- If nerve damage strikes your digestive tract, you can have constipation or diarrhea, or bouts of both. Diabetes-related nerve damage can lead to gastroparesis, a condition in which the stomach empties too slowly or not at all.[mayoclinic.org]
- These side effects are: Insomnia Loss of appetite Constipation Weight loss Short temper Stains and bruises on the skin These effects occur due to people taking the same kratom every day without skipping any day.[idsoc.org]
- Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction. Kidney damage (nephropathy).[mayoclinic.org]
- Early complications include wound infections, deep venous thrombosis, nausea, vomiting, diarrhea, and constipation.[clinical.diabetesjournals.org]
Delayed Gastric Emptying
- Its physiological effect includes weight loss, delayed gastric emptying, and a reduction in both postprandial glucose and glucagon. The primary side effect is nausea. Pramlintide has a modest effect on A1C reduction of 0.5%.[dx.doi.org]
Liver, Gall & Pancreas
Hepatomegaly
- Abstract Glycogenic hepatopathy is a rare condition that causes significant hepatomegaly and elevated liver enzyme levels in uncontrolled type 1 diabetic patients. It develops due to excessive accumulation of glycogen in the hepatocytes.[ncbi.nlm.nih.gov]
- Children with diabetic dwarfism syndrome, which was also known as Mauriac's syndrome, suffered from stunted growth, hepatomegaly, and delayed puberty. 4 In 1936, the first commercially available, extended-action insulin, PZI (protamine zinc insulin),[dx.doi.org]
Musculoskeletal
Prayer Sign
- Consider screening with “prayer sign” (unable to approximate fingers and palms while pressing hands together). GI: consider RSI (although not supported by any evidence!!! Regardless, note that gastroparesis occurs in 25% of diabetics).[openanesthesia.org]
Skin
Pruritus
- This risk is likely outweighed by the benefits of reducing cardiovascular risk. [ 8 ] Presentation Patients with all types of diabetes may present with polyuria, polydipsia, lethargy, boils, pruritus vulvae or with frequent, recurrent or prolonged infections[patient.info]
- They can cause immediate pain or burning followed by erythema, pruritus, and induration—the latter sometimes persisting for days.[msdmanuals.com]
Flushing
- Antihyperglycemics Generic Name Daily Dosage Duration of Action Comments Acetohexamide* 250 mg once/day–750 mg bid 12–24 h No longer available in US Chlorpropamide * 100 mg once/day–750 mg once/day 24–36 h Chlorpropamide : May cause hyponatremia and flushing[msdmanuals.com]
Delayed Wound Healing
- The presenting complaints of the patients include lack of energy, delayed wound healing, visual blurring and fungal infections such as pruritis vulvae or balanitis.[symptoma.com]
Xanthelasma
- The common skin manifestations of diabetes mellitus are erythrasma, xanthomatosis, xanthelasma, phycomycetes and cutaneous infections like furuncolosis, candidiasis, carbuncle, dermatophytosis, etc.[ncbi.nlm.nih.gov]
Urogenital
Polyuria
- The patient was admitted due to polyuria and weight loss in the past few days. The initial blood glucose level was 1167mg/dL. On the basis of clinical manifestations and laboratory results, she was diagnosed with T1DM and HHS.[ncbi.nlm.nih.gov]
- Nine weeks after initiation, he developed fatigue and polyuria with blood glucose 336 mg/dL, c-peptide 0.6 ng/mL, A1C8.2% and GAD antibodies 28.4 U/mL (normal, 1 U/mL).[ncbi.nlm.nih.gov]
- This is because both disorders cause polyuria , or excessive urine output. Diabetes insipidus is a disorder of urine concentration which we will discuss in spring quarter.[courses.washington.edu]
- These include: Polyuria (due to osmotic diuresis when blood glucose level exceeds renal threshold) Thirst (as a consequence of loss of fluids and electrolytes by osmotic diuresis) Postural hypotension (due to reduction of plasma volume by osmotic diuresis[symptoma.com]
- Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes and fatigue. These symptoms may occur suddenly.[web.archive.org]
Pruritus Vulvae
- This risk is likely outweighed by the benefits of reducing cardiovascular risk. [ 8 ] Presentation Patients with all types of diabetes may present with polyuria, polydipsia, lethargy, boils, pruritus vulvae or with frequent, recurrent or prolonged infections[patient.info]
Neurologic
Stroke
- Adjusted HRs with diabetes were: 2.00 (95% CI 1.83-2.19) for coronary heart disease; 2.27 (1.95-2.65) for ischaemic stroke; 1.56 (1.19-2.05) for haemorrhagic stroke; 1.84 (1.59-2.13) for unclassified stroke; and 1.73 (1.51-1.98) for the aggregate of other[ncbi.nlm.nih.gov]
- Leptin levels have been positively associated with the presence, severity, extent and lesion complexity of coronary atherosclerosis as well as with the presence, severity and poor clinical outcomes of both ischemic and hemorrhagic strokes.[ncbi.nlm.nih.gov]
- Cardiovascular disease (defined as nonfatal myocardial infarction, stroke, death from cardiovascular disease, confirmed angina, or the need for coronary-artery revascularization) was assessed with standardized measures and classified by an independent[ncbi.nlm.nih.gov]
- Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure and end-stage renal disease.[ncbi.nlm.nih.gov]
- Diabetes can also cause heart disease , stroke and even the need to remove a limb. Pregnant women can also get diabetes, called gestational diabetes . Blood tests can show if you have diabetes.[nlm.nih.gov]
Peripheral Neuropathy
- We presented apical healing of the upper central incisor, retrofilled with TSC, in a diabetic patient (type 2 DM) with peripheral neuropathy.[ncbi.nlm.nih.gov]
- Patient was on hemodialysis due to the stage 5 chronic kidney failure and had various comorbid conditions: arterial hypertension, history of acute myocardial infarction, dilative cardiomyopathy, amaurosis and peripheral neuropathy.[ncbi.nlm.nih.gov]
- Also, there were significant changes in clinical findings for diabetic peripheral neuropathy. LLLT with specific exercises can promote healing of skin manifestations in individuals with type 2 diabetes mellitus.[ncbi.nlm.nih.gov]
- The Michigan Neuropathy Screening Instrument was used to identify peripheral neuropathy. Ankle brachial index was used to identify peripheral arterial disease (PAD).[ncbi.nlm.nih.gov]
- The combination of peripheral vascular disease and peripheral neuropathy can cause serious foot pathology. Smoking, hypertension, hyperlipidemia, and poor diabetic control greatly increase the risk of vascular disease.[emedicine.medscape.com]
Workup
The following investigations are helpful in establishing the diagnosis of diabetes mellitus.
- Random blood sugar: Diabetes is labelled if the random blood sugar is found to be greater than 200 mg/dL. It is not sufficient for diagnosing diabetes and fasting blood sugar should always be checked subsequently.
- Fasting blood sugar: Diabetes is confirmed if the fasting blood sugar is more than 126 mg/dL on more than one occasion.
- Glucose tolerance test: Glucose tolerance test is required for the confirmation of diabetes when the fasting blood sugar is more than normal but less than the diabetic range.
- Glycosylated hemoglobin: Level of glycosylated hemoglobin reflects the state of glycemia over the preceding 8 to 12 weeks.
- Serum fructosamine: Serum fructosamine reflects the state of glycemic control for the preceding 2 weeks.
Urine
Glycosuria
- Subsequently, hyperglycemia and glycosuria, but not ketonuria, occured. Serum immunoreactive insulin following intravenous tolbutamide rose, suggesting endogenous insulin production.[pediatrics.aappublications.org]
- He attributed the decrease in urinary sugar to a ‘temporary toxic renal effect’ (he had been expecting a compensating increase in glycosuria).[dx.doi.org]
- The renal threshold for glucose reabsorption is exceeded when blood glucose levels exceed 180 mg/dL (10 mmol/L), causing glycosuria with the typical symptoms of polyuria and polydipsia. (See Pathophysiology, Clinical, and Treatment.)[emedicine.medscape.com]
- Sodium-glucose co-transporter 2 (SGLT2) inhibitors ( canagliflozin, dapagliflozin, empagliflozin ) inhibit SGLT2 in the proximal tubule of the kidney, which blocks glucose reabsorption, thus causing glycosuria and lowering plasma glucose.[msdmanuals.com]
Ketonuria
- Although neither ketoacidosis nor ketonuria was detected, the markedly acute onset of the hyperglycemia was consistent with the typical clinical course of fulminant type I diabetes mellitus, and this diagnosis was supported by clinical data.[ncbi.nlm.nih.gov]
- Subsequently, hyperglycemia and glycosuria, but not ketonuria, occured. Serum immunoreactive insulin following intravenous tolbutamide rose, suggesting endogenous insulin production.[pediatrics.aappublications.org]
- Patients with type 1 diabetes may also present with weight loss, dehydration, ketonuria and hyperventilation. Presentation of type 1 diabetes tends to be acute with a short duration of symptoms.[patient.info]
Serum
Hyponatremia
- In this T1D case with CKD, severe hyperglycemia in conjunction with other metabolic insults, such as uremia, hyponatremia, and hypocalcemia, probably provoked his seizure despite the severe ketonemia.[ncbi.nlm.nih.gov]
- Characteristics of Oral Antihyperglycemics Generic Name Daily Dosage Duration of Action Comments Acetohexamide* 250 mg once/day–750 mg bid 12–24 h No longer available in US Chlorpropamide * 100 mg once/day–750 mg once/day 24–36 h Chlorpropamide : May cause hyponatremia[msdmanuals.com]
Hypercholesterolemia
- After 10 years, the group undergoing surgery had statistically lower weight and less diabetes, hypertriglyceridemia, and hyperuricemia, but not less hypertension or hypercholesterolemia. 35 Another smaller retrospective study of diabetic patients undergoing[clinical.diabetesjournals.org]
Nodular Glomerulosclerosis
- Renal glomerulus, nodular glomerulosclerosis, microscopic. Renal glomerulus, nodular glomerulosclerosis, hyaline arteriolosclerosis, PAS stain, microscopic. Kidney, acute pyelonephritis, microscopic.[library.med.utah.edu]
Glucose Increased
- Oral antihyperglycemic drugs may Enhance pancreatic insulin secretion (secretagogues) Sensitize peripheral tissues to insulin (sensitizers) Impair GI absorption of glucose Increase glycosuria Drugs with different mechanisms of action may be synergistic[msdmanuals.com]
HLA Type
HLA-DR3
- There is around 30 to 35% concordance in monozygotic twins. 95% of the patients carry HLA-DR3, HLD-DR4 or both genes.[symptoma.com]
- Associated with HLA DR3 and DR4 and islet cell antibodies around the time of diagnosis. Patients always need insulin treatment and are prone to ketoacidosis. The most at-risk population for type 1 diabetes is Caucasian of northern European ancestry.[patient.info]
- GENETIC SUSCEPTIBILITY Many studies have reported an association of type I DM with high risk genes, HLA-DR3, -DR4 and their alleles DQB1*0302 and DQB1*0201 HLA[ 17 - 20 ]. The prevalence of these genes has been linked with age of onset of diabetes.[dx.doi.org]
- Over 90% of those with CD express HLA-DR3/DQ2 haplotype, as well as 55% of those with T1DM, compared with less than 25% of the general population[ 30 ].[dx.doi.org]
Treatment
The treatment methods available for diabetes mellitus include:
- Diet alone
- Diet and insulin
- Diet and oral hypoglycemic drugs
Diet
Around 60% of the patients can be treated adequately with diet alone. A proper diet regimen should be prepared based upon the age, sex, weight and caloric requirements of the patient. Readily absorbable carbohydrates such as sugars should be avoided. Non-nutritive sweeteners such as asparmate, saccharine or sucramate should be used if needed.
Oral hypoglycemic drugs
Oral hypoglycemic agents are useful for the treatment of type 2 diabetes mellitus. A wide number of oral hypoglycemic agents are available. They are prescribed individually or in combinations according to the patient. Common oral hypoglycemic agents include sulphonylureas (e.g. glimepride and glipizide), biguanides (e.g. metformin), alpha glucosidase inhibitors (e.g. acarbose and migitol), thiazolidinedions (e.g. pioglitazone and rosiglitazone), D-phenylalanine derivatives (e.g. nateglinide) and insulin stimulators (e.g. repaglinide) [7][8].
Insulin
Insulin is used in the treatment of all patients of type 1 diabetes mellitus and in those patients of type 2 diabetes whose hyperglycemia is not controlled by diet and oral hypoglycemic agents. Various preparations of insulin are available and are selected according to each patient.
Prognosis
Diabetes mellitus is a chronic disease that disturbs the quality of life of all the patients [4]. The patients are forced to take daily insulin injections and/or oral hypoglycemic drugs. Lifestyle and diet modifications also become essential. However, with early diagnosis and proper control of the disease, the risk of development of associated diseases and complications can be reduced and the patients enjoy a life expectancy that approaches those without the disease. Untreated diabetes mellitus is associated with a high mortality and morbidity rate.
Etiology
Diabetes mellitus may be primary or secondary.
Primary diabetes mellitus has two types [2].
- Insulin dependent diabetes mellitus (Type 1)
- Non-insulin dependent diabetes mellitus (Type 2)
Type 1 diabetes mellitus usually results from an autoimmune disease process. It is associated with a positive family history. The child of a patient having type 1 diabetes has a greater risk of developing the disease. The risk is greater with diabetic father as compared to the diabetic mother. There is around 30 to 35% concordance in monozygotic twins. 95% of the patients carry HLA-DR3, HLD-DR4 or both genes. Infection with coxsackievirus B4
Type 2 diabetes mellitus has a 100% concordance in identical twins, implying a much stronger genetic association. Around 25% of the patients have a first degree relative suffering from this disease. Overeating combined with obesity acts as a diabetogenic factor.
Epidemiology
Type 1 diabetes mellitus is the most common metabolic disease in childhood. It is present in around 1 in every 500 child or adolescent.
Type 2 diabetes mellitus is very common worldwide, particularly the US because of the high caloric diet. Its incidence is on the rise and it is said that type 2 diabetes is rapidly becoming a global “epidemic”. It is estimated that around 552 million people worldwide will be suffering from it by the year 2030.
Pathophysiology
Type 1 diabetes mellitus is caused by an autoimmune process in which there is lymphocytic infiltration and subsequent destruction of the beta cells in the pancreas. These cells are responsible for the production of insulin and their destruction causes the level of insulin to fall leading to hyperglycemia.
In type 2 diabetes mellitus, there is both reduced secretion of insulin as well as insulin resistance in the peripheral tissues [3]. As a result, hyperglycemia develops.
Prevention
There is no effective preventive measure against type 1 diabetes mellitus as it is an autoimmune disease that occurs early in childhood.
Type 2 diabetes mellitus can be prevented by adopting a healthy lifestyle. Eating a healthy diet, avoiding overeating, controlling obesity and performing daily exercise greatly reduce the risk of development of type 2 diabetes mellitus [9] [10].
Summary
Diabetes mellitus is a clinical syndrome that is characterized by chronic hyperglycemia along with disturbances in the metabolism of carbohydrates, lipids and proteins [1]. It is of two main types, type 1 and type 2 diabetes mellitus. The former is also referred to as insulin dependent diabetes mellitus while the latter is also known as non-insulin dependent diabetes mellitus.
Patient Information
Diabetes mellitus is a disease in which the level of sugar in the blood is raised. It is of two types, one usually affecting people since childhood and the other appearing late in adulthood. Diabetes is associated with many diseases and complications and should be diagnosed and treated early to ensure better expectancy and quality of life.
References
Article
- Hoogwerf BJ, Sferra J, Donley BG. Diabetes mellitus--overview. Foot and ankle clinics. Dec 2006;11(4):703-715.
- Avery L. Diabetes mellitus types 1 and 2: an overview. Nursing standard. Nov 11-17 1998;13(8):35-38.
- Ostenson CG. The pathophysiology of type 2 diabetes mellitus: an overview. Acta physiologica Scandinavica. Mar 2001;171(3):241-247.
- Ionova TI, Odin VI, Nikitina TP, Kurbatova KA, Shablovskaia NE. [Quality of life and problems posed by hypoglycemia in type 2 diabetes mellitus during oral hypoglycemic therapy]. Klinicheskaia meditsina. 2013;91(9):34-40.
- Ratner RE. Type 2 diabetes mellitus: the grand overview. Diabetic medicine : a journal of the British Diabetic Association. 1998;15 Suppl 4:S4-7.
- Bustos-Saldana R, Prieto-Miranda S, Grupo de Estudio de Factores de Riesgo de Ulceraciones en los Pies de los Pacientes Diabeticos T. [Foot ulceration risk factors in type 2 diabetes mellitus]. Revista medica del Instituto Mexicano del Seguro Social. Sep-Oct 2009;47(5):467-476.
- McAvoy KH. Oral hypoglycemic agents in the management of non-insulin-dependent diabetes mellitus among the elderly. The Diabetes educator. Sep-Oct 1991;17(5):411-413.
- Lubbos H, Miller JL, Rose LI. Oral hypoglycemic agents in type II diabetes mellitus. American family physician. Nov 15 1995;52(7):2075-2078.
- Olmsted WH. Obesity: key to the prevention of diabetes. Journal - Michigan State Medical Society. Oct 1953;52(10):1057-1061.
- Boulin R, Rambert P. [Prevention of diabetes mellitus]. La Semana medica. Oct 22 1952;28(38):429-430.