1. NON DRUG MANAGEMENT OF DIABETES A Dissertation submitted to THE JAWAHARLAL NEHRU TECHNOLOGICAL UNIVERSITY, ANANTAPUR In partial fulfillment for the award of degree of BACHELOR OF PHARMACY Reg.No: 07GT1R0010 Under the supervision of K.HARI KUMAR, M.Pharm, NOVEMBER 2010 DEPARTMENT OF PHARMACEUTICAL CHEMISTRY SRI VENKATESWARA COLLEGE OF PHARMACY R.V.S. NAGAR, CHITTOOR - 517127
2. INTRODUCTION Diabetes is a disorder of metabolism- the way in which our body converts the food in to energy. Most of the food eaten is break down by digestive juices in to chemicals, including a simple sugar called glucose. Glucose is body’s main source of energy. After digestion, glucose passes in to blood stream, where it is available for cells to take in and use or store for later use. In order for our cells to take in glucose, a hormone called insulin must be present in blood. Insulin acts as a “key” that unlocks “doors” on cell surfaces to allow glucose to enter the cells. Insulin is produced by special cells called islet cells in an organ called the pancreas, which is about 6 inches long and lies behind your stomach.
3. DEFINITION OF DIABETES ACCORDING TO WORLD HEALTH DIABETES Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. Hyperglycemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels. TYPES OF DIABETES DIABETES INSIPIDUS (DI) Diabetes insipidus (DI) is a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine, with reduction of fluid intake having no effect on the latter. DIABETES MELLITUS Diabetes mellitus is a group of metabolic disease in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced.
4. TYPES OF DIABETES MELLITUS DIABETES MELLITUS TYPE 1 Diabetes mellitus type 1 (Type 1 diabetes, IDDM, or juvenile diabetes) is a form of diabetes mellitus that results from autoimmune destruction of insulin-producing beta cells of the pancreas. The subsequent lack of insulin leads to increased blood and urine glucose.
5. TYPE 2 DIABETES MELLITUS Diabetes mellitus type 2 – formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes – is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency.
6. GESTATIONAL DIABETES MELLITUS (GDM) Gestational diabetes mellitus (GDM) is a condition that develops during pregnancy when the body is not able to make enough insulin. The lack of insulin causes the blood glucose (also called blood sugar) level to become higher than normal. Gestational diabetes affects between 3 and 5 percent of women during pregnancy.
7. DIABETES IN CATS Diabetes mellitus strikes 1 in 400 cats, though recent veterinary studies (29, 30, 31) note that it is be- coming more common lately in cats . DIABETES IN DOGS This most common form of diabetes (There is another form not covered here, Diabetes insipidus) strikes 1 in 500 dogs. (33) Following is a comprehensive list of other causes of diabetes (43) Genetic defects of β-cell Function Maturity onset diabetes of the young (MODY) Mitochondrial DNA mutations Genetic defects in insulin process- ing or insulin action Defects in proinsulin conversion Insulin gene mutations Insulin receptor mutations Endocrinopathies Growth hormone excess (acromegaly) Cushing syndrome Hyperthyroidism Pheochromocytoma Glucagonoma Infections Cytomegalovirus infection Coxsackievirus B Drugs Glucocorticopid Thyroidhormone β-adrenergic agonists
8. NON DRUG MANAGEMENT FOR DIABETES MELLITUS It involves in three main steps: Life style changes which are used to controlling diabetes. Exercise activities which controls the glucose levels. Diet changes which controls the glucose levels. Non drug management involved in the controlling blood sugar levels or diabetes through education, non drug administration, patient monitoring and encouragement, Includes the non drug activity like life styles changes, exercise and diet used to achieve it. Factors that must be considered when designing appropriate procedures for controlling diabetes mellitus include the Patient’s age. Understanding of the disease state or stage. Motivation. Predisposition to hyperglycemia. As well as the age of onset and duration of the disease. LIFESTYLE CHANGES The lifestyle change involves seven principles of good diabetes care. These principles or steps will help manage diabetes and live long and lead active life. Diabetes affects almost every part of the body and good diabetes care requires a team of health care providers.
9. PRINCIPLE 1: LEARN AS MUCH AS YOU CAN ABOUT DIABETES: The more know about diabetes, the better can work with health care team to manage disease and reduce risk for problems. Older than 45 Overweight Have a close family member such as parent, a brother or a sister Had a baby that weighed more than 9 pounds Had high blood pressure PRINCIPLE 2: GET REGULAR CARE FOR YOUR DIABETES Work with your health care team to get the best help to control your Diabetes Mellitus See your health care team regularly Make sure your treatment plan is working. If it is not, ask your health care team to help you change it Consult health care team regularly Make sure treatment plan
10. PRINCIPLE 3: LEARN HOW TO CONTROL DIABETES: Using the following checklist will help you learn how to control diabetes. Regular consulting health care team. Following doctor, diabetes educator, podiatrist, pharmacist or dietician suggestions. A1C (pronounced a-one-c) is a measure of average blood sugar over the last 3 months. Consult doctor at least twice a year. PRINCIPLE 4: TAKE CARE OF DIABETES ABC’S: A major goal is to control the ABC’s of diabetes: A1c (blood sugar average),blood pressure and cholesterol. We can do this in many ways, follow the meal plan correctly Be active every day. Test glucose on a routine bases. Talk to health care team about the best ways to control ABC’s and know target numbers. (48, 49) PRINCIPLE 5: MONITOR DIABETES ABC’S: To reduce your risk for diabetes problems such as blindness, kidney disease, losing a foot or leg, and early death from heart attack or stroke, you and your health care team need to monitor the diabetes ABCs: A1C, Blood pressure, and Cholesterol. Talk to your health care team about how to reach your target numbers. (50, 51, 52)
11. PRINCIPLE 6: PREVENT LONG-TERM BIABETES PROBLEMS: People with diabetes must control their long term risk factors. Here are the key self care activates to help manage diabetes and live a long and healthy life. Daily: Follow diabetes meal plan with the correct portion size. Be active every day. Check mouth daily for gums. As needed: Test blood glucose as prescribed by doctor. Check B.P. as prescribed by doctor. Reach and stay at a healthy weight. PRINCIPLE 7: GET CHECKED FOR LONG-TERM PROBLEMS AND TREAT THEM: Regular check-ups help to prevent problems or find them early when they can be treated and manage well. Some tests that we are need Triglycerides. Dilated eye exam to check for eye problems. Foot check get every visit. Urine test to check for kidney problems get early.
12. WHO ARE SUFFERING WITH DIABETES THEY MUST FOLLOW SOME BELOW ASPECTS FOR GETTING GOOD HEALTH THROUGH OUT THE LIFE HEALTH INDICATORS FOR DIABETIC PEOPLE Table 1:Normal values and goals FASTING BLOOD GLUCOSE TWO HOURS AFTER MEALS NORMAL PERSON <110 mg/dL < 140 mg/ dL BORDER LINE DIABETIC ≥ 110 mg/dL < 126 mg/dL ≤ 140 mg/dL < 200 mg/ dL DIABETIC ≥ 126 mg/dL ≥ 200 mg/ dL BIOCHEMICAL VALUES Normal person Goal for diabetic person FASTING BLOOD GLUCOSE (MG/dI) < 110 80-120 BEDTIME GLUCOSE (MG/dI) < 120 100-140 Hba1c (%) < 6 < 7
13. Table 2:Blood pressure values Table 3:Normal total cholesterol values CATAGERY *SBP (mm hg) *DBP(mm hg) OPTIMAL <120 And <80 NORMAL <130 And <85 BORDERLINE 130 – 139 Or 85-89 HYPERTENSION STAGE 1 140 – 159 Or 90-99 STAGE 2 160 – 159 Or 100-109 STAGE 3 Or 110 NORMAL 200 mg/dI BORDERLINE 200 – 240 mg/dI HIGHER >240 mg/dI
15. DOS’S AND DON’TS THINGS TO DO DAILY THINGS TO DO AT EACH DOCTOR’S VISIT TEST YOUR BLOOD SUGAR AND WRITE IT IN YOUR RECORD CHECK YOUR FEET FOR ANY BRUISIES, WOUND ETC FOLLOW A HAELTH DIET PLAN EXERCISE REGULARLY AND CONTROL YOUR WEIGHT TAKE CARE OF Y9OUR TEETH AND SKIN ALWAYS FOLLOW THE DOCTOR’S ADVICE ON DOSE AND TIMING OF THE DRUG HAVE YOUR BLOOD PRESSURE AND BLOOD GLUCOSE CHECKED AND RECORDED GET YOUR FEET CHECKED BY THE DOCTORS
16. DONT’S Do not consume direct sugar, sweets and fried food items Never miss a dose or take overdose of medicines Never change the timings and food habits unless advised by the doctors Never stop or change the medicines unless advised
17. EATING HEALTHY DIET GETTING THE ESSENTIAL NUTRIENTS Diet should include a variety of foods that provide all the essential nutrients body needs - carbohydrates, protein, fat, vitamins, minerals, fiber, and water. CARBOHYDRATES – Starches and sugars found in fruits, vegetables, and grains, are the body’s main source of energy. There are two kinds of carbohydrates Simple carbohydrates, which are also called simple sugars, are found in fruits, vegetables, and milk as well as in table sugar, desserts, and other sweets. Complex carbohydrates are better for you than simple ones and should make up the largest portion of diet. Here are some for choosing healthy carbohydrates: Eat whole-grain foods such as whole-grain bread and crackers, bran cereal, or brown rice. They provide lots of nutrients and are high in fiber. Eat legumes (dried beans, peas, or lentils); they are an excellent source of fiber. Eat starches made with little fate. Low-fat breads include bagels, tortillas, English muffins, and pits bread.
18. PROTEIN Protein is an important part of the structure of all cells and is essential for body’s growth, mainte nance, and repair. The protein building blocks of body are supplied by protein from the food you eat. Protein is found in foods such as meat, fish poultry, dairy products, and legumes 9dried beans and peas. SOME MORE TIPS: Eat more fish and poultry than red meat. Trim all visible fat from the meat before and after cooking. Bake, roast, broil, grill, or boil instead of frying or adding fat. Drain excess fat from cooked meat. Use a vegetable oil spray or a nonstick pan for browning or frying. FAT Fat is a source of stored energy. When you eat fat, it travels in bloodstream. Insulin enables cells to take in fat and store it for when need it. Fat is found in foods such as meat, oils, nuts, milk, and other dairy products, fish and poultry, snacks, and desserts. Here are the different types: Monosaturated fats Monosaturated fats are the healthiest. These fats are found in olive oil and canola oil. Monosaturated fats can have a beneficial effect on the cholesterol (fat0 in blood. Polyunsaturated fats Like monounsaturated fats, polyunsaturated fats, in moderation, can be beneficial to cholesterol level. Polyunsaturated fats are found in vegetable oils such as safflower oil, corn oil, and soybean oil.
19. TYPE 1 DIABETES MELLITUS AND DIET This topic discusses how to manage diet in people with type 1 diabetes. The role of diet and activity in managing blood pressure and cholesterol is reviewed separately. The following factors are important in diabetes mellitus: Why is diet important Type 1 diabetes and meal timing Type 1 diabetes and carbohydrate consistency What should be eat Type 1 diabetes diet, and weight. Type 1 diabetes and Alcohol. Type 1 diabetes and eating disorders. TYPE 2 DIABETES OVERVIEW To effectively manage A1C (hemoglobin A1C) and blood sugar levels, it is important to understand how to balance food intake, physical activity, and medication. Making healthy food choices every day has both immediate and long-term effects. These following factors are considered: Type 2 diabetes and meal timing. Type 2 diabetes, diet, and weight Type 2 Diabetes And Alcohol Type 2 diabetes and carbohydrate consistency What should be eat
20. EXERCISE Exercise is just as important as diet in helping to prevent type II diabetes. If have type II diabetes, exercise is a vital part of treatment. Here are some good reasons to exercise: Exercise helps lose weight. Being over-weight makes more likely to develop diabetes. If have diabetes, excess weight make it harder for to control glucose level. Exercise can reduce blood glucose level and keep it low for several hours afterward. If you take medicine for diabetes, exercise may reduce the amount need. Exercise can reduce cholesterol level and blood pressure can lead to heart attack or stroke, which is common in people with diabetes. SOME EXTRA BENEFITS OF EXERCISE: Feel better Stronger Able to move with more ease. Learn new skills. Physical fitness can be described as the ability to carry out daily tasks with vigor and alertness, without excessive fatigue, and with ample energy to enjoy leisure time pursuits and meet unforeseen emergencies.
21. There are three main types of exercise: Aerobic exercise — Aerobic exercise involves exertion such as walking, running, or swimming, which increases the flow of blood through the heart. Resistance training — Resistance training is exercise designed to increase muscle strength, and includes lifting weights. Stretching exercise — Stretching exercises are movements designed to improve flexibility and prevent injury. BENEFITS OF EXERCISE Apart from improving overall physical fitness, exercise has numerous health benefits: The risk of dying is decreased in those who exercise regularly. As an example, one study found that men who engaged in moderately vigorous sports had a 23 percent lower risk of death than men who were less active. Exercise also helps to lower the risk of death in men with coronary artery disease. Exercise is an essential component of weight management programs. Exercise burns calories and may help to burn calories even while not exercising. Dieting can lead to loss of muscle, but exercise can help maintain muscle mass while dieting. Exercise improves blood sugar control in people with diabetes and can help prevent or delay the onset of type 2 diabetes. Aerobic exercise helps decrease blood pressure; this effect may be even greater in people with high blood pressure.
22. TESTING BEFORE AN EXERCISE PROGRAM People with diabetes or multiple risk factors for heart disease may need an exercise test before starting an exercise program. An exercise test is performed in a doctor's office or hospital, and usually involves walking or running on a treadmill with monitoring leads on the chest. GETTING STARTED If you do not normally get much exercise, start by exercising for a few minutes at a low intensity (e.g., walking). As physical fitness improves, you can slowly begin to exercise harder, more frequently, or for a longer time, with a goal of getting at least 30 minutes of exercise on five days each week. EXERCISE PROGRAM Exercise should contain following programs; Warm up — Exercise sessions should begin with a five to ten minute period of warm up. Start with some low level aerobic exercises (walking, stationary cycling, calisthenics). Workout — It is a good idea to mix up aerobic exercise, strength training, and stretching so as to keep the workout fun and interesting. Aerobic exercise — Walking is an excellent aerobic activity. Cycling, rowing, stair machine climbing, and other endurance-type activities are also great. Resistance training — Resistance training can be done with weights, machines, or exercise bands. Stretching — Stretching and flexibility exercises should include every major joint (hip, back, shoulder, knee, upper trunk, neck).
23. EVALUATING AN EXERCISE PROGRAM Exercise should fit into the daily schedule, should be enjoyable, and should feel safe. After beginning an exercise program, most people start to notice that they feel healthier. WHEN TO SEEK HELP Pain or pressure in the chest, arms, throat, jaw or back Nausea or vomiting during or after exercise Palpitations or heart flutters or a sudden burst of a very fast heart rate Inability to catch your breath Lightheadedness, dizziness or feeling faint during exercise (feeling lightheaded after exercise may mean that a longer cool-down period is needed) PRECAUTIONS Remember to drink fluids during and after exercise. Thirst is a good indicator that more fluids are needed. Do not exercise outdoors if the temperature is too hot or too cold. In cooler weather, it is better to wear layers of clothes while exercising outdoors. A layer of clothing can be removed if needed. Wear supportive, well-fitting running or walking shoes. Replace shoes when signs of deterioration develop (eg, cracking, separation of shoe from the sole, imprint of the foot in the insole). The amount of time exercise shoes will last depends upon a number of factors, including how often and where the shoes are worn.
24. CONCLUSION Diabetes is an iceberg disease. It is a major public health problem in the developed as well as developing countries. The number of people suffering from diabetes has soared to 282 million and disease knows kills more people than AIDS. The term diabetes mellitus is a metabolic disorder with multiple etiology characterized by chronic hyperglycemia with disturbances of carbohydrates, fats and protein metabolism resulting from defects in insulin secretion or insulin action or both. By maintaining proper life styles, diet and exercise may involve to control blood glucose levels. All these aspects are involved in insulin sensitization and regulating insulin levels in body. Finally nondrug management would involve to maintain diabetic condition and avoiding diabetic complications.
25. REFERENCES Perkins RM, Yuan CM, and Welch PG:&quot;Dipsogenic diabetes insipidus: report of a novel treatment strategy and literature review&quot;. Clin. Exp. Nephrol. 10 (1): 63–7(March 2006). Kalelioglu I, Kubat Uzum A, Yildirim A, Ozkan T, Gungor F, Has R, &quot;Transient gestational diabetes insipidus diagnosed in successive pregnancies: review of pathophysiology, diagnosis, treatment, and management of delivery&quot;. Pituitary 10 (1): 87–93 (2007). Finch CK, Kelley KW, Williams RB. Treatment of lithium-induced diabetes insipidus with amiloride. Pharmacotherapy:23(4):546-50;2003 Apr. .Earley LE, Orloff J. The mechanism of antidiuresis associated with the administration of hydrochlorothiazide to patients with vasopressin-resistant diabetes insipidus. J Clin Invest, 41(11):1988-97; Nov 1962. Cooke DW, Plotnick L (November 2008). &quot;Type 1 diabetes mellitus in pediatrics&quot;. Pediatr Rev 29 (11): 374-385. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care, 30 Suppl 1:S42-7; Jan 2007. Centers for Disease Control and Prevention. National Diabetes Fact Sheet. United States. 2005. Vanhorebeek I, Langouche L, Van den Berghe G. Tight blood glucose control: what is the evidence, Crit Care Med; 35(9 Suppl):S496-502; Sep 2007. Marks JB. Perioperative management of diabetes. Am Fam Physician, 67(1):93-100; Jan 1 2003.
26. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care; 27(2):553-91; Feb 2004. Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes mellitus. N Engl J Med. Dec 16 1999; 341(25):1906-12. Delamaire M, Maugendre D, Moreno M, Le Goff MC, Allannic H, Genetet B. Impaired leucocyte functions in diabetic patients. Diabet Med. Jan 1997;14(1):29-34. Handzel O, Halperin D. Necrotizing (malignant) external otitis. Am Fam Physician. Jul 15 2003; 68(2):309-12. O'Neill BM, Alessi AS, George EB, Piro J. Disseminated rhinocerebral mucormycosis: a case report and review of the literature. J Oral Maxillofac Surg. Feb 2006;64(2):326-33. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival. Am J Med Sci. 2007;333(2):111-6. Boden G. Fatty acids and insulin resistance. Diabetes Care. Apr 1996; 19(4):394-5. Gat-Yablonski G, Shalitin S, Phillip M. Maturity onset diabetes of the young--review. Pediatr Endocrinol Rev. Aug 2006; 3 Suppl 3:514-20. Holmkvist J, Almgren P, Lyssenko V, et al. Common variants in maturity-onset diabetes of the young genes and future risk of type 2 diabetes. Diabetes. Jun 2008; 57(6):1738-44. Dabelea D, Pettitt DJ, Hanson RL, et al. Birth weight, type 2 diabetes, and insulin resistance in Pima Indian children and young adults. Diabetes Care. Jun 1999; 22(6):944-50. Stern MP. Do non-insulin-dependent diabetes mellitus and cardiovascular disease share common antecedents. Ann Intern Med. Jan 1 1996; 124(1 Pt 2):110-6.
27. Haffner SM, D'Agostino R Jr, Mykkanen L, et al. Insulin sensitivity in subjects with type 2 diabetes. Relationship to cardiovascular risk factors: the Insulin Resistance Atherosclerosis Study. Diabetes is. Apr 1999; 22(4):562-8. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. National Diabetes Information Clearinghouse; March 30, 2009. Crowther, CA, Hiller, JE, Moss, JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352:2477. Dodd, JM, Crowther, CA, Antoniou, G, et al. Screening for gestational diabetes: The effect of varying blood glucose definitions in the prediction of adverse maternal and infant health outcomes. Aust N Z J Obstet Gynaecol 2007; 47:307. Gestational diabetes mellitus. Diabetes Care 2004; 27 Suppl 1:S88. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol 2001; 98:525. Lobner, K, Knopff, A, Baumgarten, A, et al. Predictors of postpartum diabetes in women with gestational diabetes mellitus. Diabetes 2006; 55:792. Jovanovic, L (Ed). Diabetes and Pregnancy: What to Expect, American Diabetes Association, Alexandria, VA, revised 2007. Fat Cats Facing Diabetes Epidemic, The Guardian, August 7, 2007. . Feline Diabetes is Nutrition Key, Vet Tech Blog, Feb 2006. Understanding Feline Diabetes Mellitus, Rand, J.S. and Marshall, R, Waltham Focus Journal 2005, 15:3
28. McCann TM, Simpson KE, Shaw DJ, Butt JA, Gunn-Moore DA (August 2007). &quot;Feline diabetes mellitus in the UK: the prevalence within an insured cat population and a questionnaire-based putative risk factor analysis&quot;. J. Feline Med. Surg. 9 (4): 289–99 Pet Diabetes Month. &quot;How Common Is It (Diabetes)&quot;. Intervet; 16 April 2010. Pet Diabetes Month. &quot;Lifespan of Diabetic Dogs)&quot;. Intervet: 17 March 2010. Foster, Race. &quot;Juvenile Onset Diabetes Mellitus (Sugar Diabetes) in Dogs & Puppies&quot;. Drs. Foster & Smith-Pet Education: 17 March 2010. Bruyette, David (2001). &quot;Diabetes Mellitus: Treatment Options&quot; World Small Animal Veterinary Association (WSAVA); 17 March 2010. Fleeman, Linda; Rand, Jacqueline (2005). &quot;Beyond Insulin Therapy: Achieving Optimal Control in Diabetic Dogs&quot;. Centre for Companion Animal Health, School of Veterinary Science, The University of Queensland, Brisbane, Australia; 17 March 2010. Alberti, KGMM; Aschner, P., et. al (1999). &quot;Definition, Diagnosis and Classification of Diabetes Mellitus&quot; World Health Organization; 17 March 2010. Vetsulin. &quot;Difference between Type 1 and Type 2 Diabetes&quot; Intervet; 17 March 2010. Greco, Deborah. &quot;Ask Dr. Greco&quot; BD Diabetes; 17 March 2010. Rand, Jacqueline; Marshall, Rhett (2005). &quot;Understanding Feline Diabetes Mellitus&quot;. Centre for Companion Animal Health, School of Veterinary Science, The University of Queensland, Brisbane, Australia. Unless otherwise specified, reference is: Table 20-5 in Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology. ; 1-4160-2973-7. 8th edition. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010; 33 Suppl 1:S62-S69.
29. Handelsman, Yehuda, MD. &quot;A Doctor's Diagnosis: Prediabetes.&quot; Power of Prevention, Vol 1, Issue 2, 2009. American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010; 33 Suppl 1:S11-S61. In the clinic. Type 2 diabetes. Ann Intern Med. 2007; 146: ITC-1-15. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009 Mar; 122(3):248-256. American Diabetes Association: Standards of medical care for patients with diabetes mellitus (Position Statement). Diabetes Care 26 (Suppl. 1):S33–S50, 2003. Sacks DB, Bruns DE, Goldstein DE, MacLaren NK, McDonald JM, Parrott M: Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 25:750–786, 2002. Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 157:2413–2446, 1997. U.K. Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S: Effects of intensive blood-pressure lowering and low-dose aspirin on patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 351:1755–1762, 1998.
30. Pastors, JG, Warshaw, H, Daly, A, et al. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002; 25:608. Zinman, B, Ruderman, N, Campaigne, BN, et al. Physical activity/exercise and diabetes. Diabetes Care 2004; 27 Suppl 1:S58. Polonsky, WH, Anderson, BJ, Lohrer, PA, et al. Insulin omission in women with IDDM. Diabetes Care 1994; 17:1178. Bantle, JP, Wylie-Rosett, J, Albright, AL, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008; 31 Suppl 1:S61. Sheard, NF, Clark, NG, Brand-Miller, JC, et al. Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the American diabetes association. Diabetes Care 2004; 27:2266. Wannamethee, SG, Shaper, AG, Walker, M. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation 2000; 102:1358. Dunn, AL, Marcus, BH, Kampert, JB, et al. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: A randomized trial. JAMA 1999; 281:32.