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Diabetes EpidemicDiabetes Epidemic
Newsweek, September 4,Newsweek, September 4, 20002000
Newsweek, September 4,Newsweek, September 4, 20002000 Time, September 4, 2000Time, September 4, 2000Time, September 4, 2000Time, September 4, 2000
Definition Definition
Diabetes is a heterogeneous group of diseases, Diabetes is a heterogeneous group of diseases, characterized by a state of chronic characterized by a state of chronic hyperglycemia, resulting from a diversity of hyperglycemia, resulting from a diversity of etiologies, environmental and genetic, acting etiologies, environmental and genetic, acting jointlyjointly
Diabetes is a metabolic Diabetes is a metabolic disease characterized by disease characterized by
hyperglycemiahyperglycemiaresulting from defects in resulting from defects in insulin secretion, insulin insulin secretion, insulin
action, or Both.action, or Both.
(American Diabetes Association 2004).(American Diabetes Association 2004).
Disease burden of DM per hourDisease burden of DM per hour
• New Cases – 4,100
• Deaths – 810
• Amputations – 230
• Kidney Failure – 120
• Blindness - 55
Derived from NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.
Diabetes means:Diabetes means:
2 x the risk of high blood pressure2 x the risk of high blood pressure 2 to 4 x the risk of heart disease2 to 4 x the risk of heart disease 2 to 4 x the risk of stroke2 to 4 x the risk of stroke #1 cause of adult blindness #1 cause of adult blindness #1 cause of kidney failure#1 cause of kidney failure Causes more than 60% of non-Causes more than 60% of non-
traumatic lower-limb amputations traumatic lower-limb amputations each yeareach year
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.
Global Prevalence of Diabetes Mellitus
2000 – 171 million
2030 – 366 million
2003 2025
Global Projections for the Diabetes Global Projections for the Diabetes Epidemic:2003-2025Epidemic:2003-2025
Diabetes Atlas Committee. Diabetes Atlas 2nd Edition: IDF 2003.
NORTH AMERICA
23.0 M36.2 M57.0%
19.2 M39.4 M105%
MIDDLE EAST48.4 M58.6 M21%
EUROPE
43.0 M 75.8 M
79%
WP
39.3 M81.6 M
108%
ASIA
7.1M15.0 M111%
AFR
14.2 M26.2 M85%
SOUTH AMERICA
World
2003 = 194 M2025 = 333 M
72%
Estimated Number of People with DiabetesEstimated Number of People with Diabetes in 2000 and 2030 (and % change) in 2000 and 2030 (and % change)
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004. In press
+176%
+26%
-13%
Estimated Number of People with Diabetes in Estimated Number of People with Diabetes in 2000 and 2030 (and % change)2000 and 2030 (and % change)
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004 In press
+308%
+247%
+189%
Estimated Number of People with Estimated Number of People with Diabetes in 2000 and 2030Diabetes in 2000 and 2030
Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004 In press
+242%
+212%
+75%
Global Burden of Diabetes MellitusGlobal Burden of Diabetes Mellitus
3.2 million deaths/yr attributable to complications of 3.2 million deaths/yr attributable to complications of diabetes.diabetes.
Leading cause of non traumatic amputation, adult blindness Leading cause of non traumatic amputation, adult blindness and chronic renal failure.and chronic renal failure.
Cardiovascular disease increased 2-5 timesCardiovascular disease increased 2-5 times
Direct costs range from 2.5% to 15% of annual health care Direct costs range from 2.5% to 15% of annual health care budgets.budgets.
Diabetes in PakistanDiabetes in Pakistan
Currently Pakistan is 7th in World according to WHO estimates with 7 million peoples with Diabetes and Expected to 4th in world with 15 million peoples by year 2025 representing 2 fold increase.
(WHO, 1998 Diabetes Atlas 2003)
Etiological Classification of DiabetesEtiological Classification of Diabetes
I. Type-1 Diabetes
II. Type-2 Diabetes
III. Other Specific Types
A. Genetic defects of Beta cell function.
B. Genetic defect in Insulin Action.
C. Diseases of Exocrine Pancreas.
D. Endocrinopathies.
E. Drug or Chemical induced.
F. Infections.
G. Uncommon forms of Immune Mediated.
H. Other Genetic Syndromes associated with Diabetes.
IV. Gestational Diabetes Mellitus (GDM)(Diabetes Care, Vol 27, 2004)
Type 1 DiabetesType 1 Diabetes Formally know as IDDMFormally know as IDDM
Beta cell destruction – autoimmune Beta cell destruction – autoimmune
Tend to be under 40 yearsTend to be under 40 years
Tend to present with ketones and weight lossTend to present with ketones and weight loss
Usually LeanUsually Lean
Markers of autoimmunity – islet cell antibodiesMarkers of autoimmunity – islet cell antibodies
Family history positive in 10% of casesFamily history positive in 10% of cases
30-50% concordance in identical twins30-50% concordance in identical twins
Type 2 DiabetesType 2 Diabetes Formally known NIDDMFormally known NIDDM Disorder of insulin action and insulin Disorder of insulin action and insulin
secretionsecretion Usually obeseUsually obese Usually over 50 years – but coming Usually over 50 years – but coming
down!down! No markers of autoimmunityNo markers of autoimmunity Family history positive in 30% of Family history positive in 30% of
casescases Nearly 100% concordance in identical Nearly 100% concordance in identical
twinstwins
Common symptoms of Diabetes Common symptoms of Diabetes MellitusMellitus
Polyuria / NocturiaPolyuria / Nocturia
Excessive thirst and appetiteExcessive thirst and appetite
Weight LossWeight Loss
LethargyLethargy
Blurred VisionBlurred Vision
Skin infectionsSkin infections
Vaginal infectionsVaginal infections
Definition of Type-2 DiabetesDefinition of Type-2 Diabetes
Individual with type-2 diabetes lose the ability to produce sufficient quantities of insulin to maintain normoglycemia in the face of various degrees of Insulin Resistance.
High Risk Group for DevelopingHigh Risk Group for Developing Type-2 DM Type-2 DM
1. Obese
2. Family history of Type-2 Diabetes.
3. Age > 45.
4. Ethnicity.
5. Existing CAD, CVA, PVD, HTN.
6. Women with GDM or delivers Large Babies.
7. Women with PCOs.
8. Those with IFG and IGT Group.
Insulin ResistanceInsulin Resistance
An impaired response of a cell, tissue, organ or system, to either exogenous or endogenous insulin.
Or
State in which a given concentration of insulin produces a less than expected biological effect
It is either:
Pre receptor
Receptor
Post Receptor
Metabolic SyndromeMetabolic Syndrome
Insulin Resistance Syndrome (Metabolic Syndrome X)
Insulin Resistance & DiabetesInsulin Resistance & Diabetes
As many as 92% people
with type -2 diabetes have
insulin resistance.
Ref: Diabetes Care 1999, 22 (4)
Metabolic SyndromeMetabolic Syndrome
1. Abdominal Obesity
Diagnostic Criteria
2. Triglycerides >150mg/dl
3.HDL – Cholesterol
4.Blood Pressure
5.FBS
NCEP ATP lll (2001)
Hyperglycaemia
Euglycaemia
InsulinResistance
Insulin Action InsulinConcentration
-cell Failure
InsulinResistance
Type 2 Diabetes
-cellDysfunction
Normal IGT ± Obesity Diagnosis oftype 2 diabetes
Progression oftype 2 diabetes
Diabetes Care 1992;15:318-68
Developmental StagesDevelopmental Stages
100
-C
ell
Fu
nct
ion
(%
)*
PostprandialHyperglycemia
IGT† Type 2DiabetesPhase I Type 2
DiabetesPhase II
Type 2 DiabetesPhase III
25
75
0
50
-12 -10 -6 -2 0 2 6 10 14Years From Diagnosis
Patients treated with insulin, metformin, sulfonylureas‡
Lebovitz HE. Diabetes Rev. 1999;7:139-153.
UKPDS: UKPDS: -Cell Loss Over Time-Cell Loss Over Time
ADA Diagnostic CriteriaADA Diagnostic Criteria
Ref: ADA Clinical Practice Recommendation 2004
Normal Normal Glucose Glucose
ToleranceTolerance
Impaired Impaired Glucose Glucose
ToleranceTolerance
Diabetes Diabetes Mellitus Mellitus
Fasting Fasting Plasma Plasma Glucose Glucose (mg/dl)(mg/dl)
<100<100 100-125100-125 ≥ ≥ 126126
Two hours Two hours after after
Glucose Glucose load.load.
(mg/dl)(mg/dl)
<140<140 ≥ ≥ 140-199140-199 ≥ ≥ 200200
SymptomsSymptoms
Frequent urinationFrequent urination Excessive thirstExcessive thirst Extreme hunger or Extreme hunger or
constant eatingconstant eating Unexplained weight Unexplained weight
loss loss Presence of glucose Presence of glucose
in the urinein the urine
Tiredness or fatigue Tiredness or fatigue Changes in vision Changes in vision Numbness or Numbness or
tingling in the tingling in the extremitiesextremities
Slow-healing Slow-healing wounds or sores wounds or sores
Abnormally high Abnormally high frequency of frequency of infection infection
Many people have Many people have no symptomsno symptoms
Diabetic ComplicationsDiabetic Complications
1. Metabolic Complication Ketoacidosis
Hyperosmolar nonketotic syndrome
Hypoglycemia
2.Macrovascular ComplicationsCardiovascular disease
Cerebrovascular disease
Peripheral vascular disease
3.Microvascular Complications
Diabetic neuropathy
Diabetic retinopathy
Diabetic nephropathy Diabetologia 2002; 45: S13-S17
Chronic complications of diabetes at diagnosisChronic complications of diabetes at diagnosis
Retinopathy:
Nephropathy:
Polyneuropathy:
Erectile dysfunction:
21%
3%
11%
20%
Macrovascular:
Abnormal ECG:
Myocardial infarction:
Stroke or TIA:
Intermittant
claudication:
Absent foot pulses:
Ischaemic skin
changes to feet:
18%
1%
1%
3%
13%
6%
50% of newly presenting patients with type 2 diabetes
already have one or more complications at diagnosis(UKPDS) United Kingdom Prospective Diabetes Study. Diabetes Research 1990; 13:1-11.
Based on failure, consider:Higher order combination therapy . . .
Stepwise Management of Type 2Stepwise Management of Type 2Diabetes: Treat-to-Failure ApproachDiabetes: Treat-to-Failure Approach
Monotherapy… wait for failure
Combination therapy… wait for failure
Diet, exercise, lifestyle…wait for failure
Slide provided by Steve Edelman, MD.
Priorities of Care for Adults with Diabetes
CVD Risk
ASA, tobacco, ACEI/ARB, statin
CVD Risk
ASA, tobacco, ACEI/ARB, statin
© 2008 International Diabetes Center.
Diagnosis–PreventionDx Fasting Gluco se > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-I GT) & Me tabolic S yndrome
Diagnosis–PreventionDx Fasting Gluco se > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-I GT) & Me tabolic S yndrome
Self-Management Knowledge and SkillMonitoring Medication Problem sol ving Food plan & nutritionRisk reduction Living & copi ng Physical ac tivity
Hemoglobin A1C Target < 7.0%
SMBGPre 70-120 mg/ dL
2 hr. post < 160 mg/dL
(~ 50% of readings)
Blood Pressure(every visit)
Dxand Rx < 130/80
Annual Lipid ProfileLDL < 100HDL > 40
Trigs < 150
DM + CVDLDL < 70
Annual ScreeningNephropathy
Microalbumin screeningCalculated GFR
RetinopathyDilated retinal exam
NeuropathyNeuro and foot exam
Sexual health
Hospital careFoot care
Dental careImmunizations
GlucoseGlucose Hyp ertensionHyp ertensionLipidsLipids MicrovascularcomplicationsMicrovascularcomplications
Other essentialsof care
Other essentialsof care
TEAM APPROACH TO THE TREATMENT TEAM APPROACH TO THE TREATMENT OF THE DIABETIC PATIENTOF THE DIABETIC PATIENT
PhysicianPhysician
Fitness TrainerFitness Trainer
NurseNurseEducatorEducator
DieticianDietician
©2006. American College of Physicians. All Rights Reserved.
Optimizing glycemic control: the Optimizing glycemic control: the role of current treatmentsrole of current treatments
1UKPDS Group. Diabetologia 1991;34:877–890. 2Haffner S, et al. Diabetes Care 1999;22:562–568.3Baptist GallwitzRev Diabetic Stud (2006) 3:208-216.
• 50% of patients already have complications1
• Over 80% of patients are insulin resistant2
• Up to 50% of b-cell function has already been lost3
At diagnosis of type 2 diabetes:
The need to optimise type 2 diabetes management
EVERY 1%
reduction in HBA1C
Reduced Risk*
1%
Deaths from diabetes
Heart attacks
Microvascular complications
Peripheral vascular disorders
*p<0.0001
Intervention to effect better control Intervention to effect better control means fewer complicationsmeans fewer complications
- 37%
- 43%
- 14%
- 21%
UKPDS 35 BMJ 2000;321:405-412
•*Diet, only.•†Insulin or sulphonylurea + diet.•UKPDS, United Kingdom Prospective Diabetes Study; ADA, American Diabetes Association.
•Adapted from UKPDS Group. Lancet. 1998;352:837-853.
•Cross-sectional median values
Time From Randomization (years)Time From Randomization (years)
Conventional Treatment* (n=1138)Conventional Treatment* (n=1138)Intensive TreatmentIntensive Treatment†† (n=2729) (n=2729)
99
88
77
66
ADAADA targettarget
ADAADA actionactionsuggestedsuggested
0000 33 66 99 1212 1515
Med
ian
A1c (
%)
Med
ian
A1c (
%)
Type 2 Diabetes Is a Progressive Type 2 Diabetes Is a Progressive Disease: UKPDSDisease: UKPDS
Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.
UKPDS: decreased risk of diabetes-related complications UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1Cassociated with a 1% decrease in A1C
Perc
en
tag
e d
ecr
ease
in
rela
tive r
isk
corr
esp
on
din
g t
o a
1%
decr
ease
in
Hb
A1
C
Any diabetes-related
endpoint
21%
All cause
mortality
14%
Stroke
12%
Peripheral vascular disease†
43%
Myocardial infarction
14%
Micro-vascular disease
37%
Cataract extraction
19%
Observational analysis from UKPDS study data
Goals of drug therapyGoals of drug therapy1.Reduce insulin resistance, and in 1.Reduce insulin resistance, and in
turn, the demands on the beta turn, the demands on the beta cellcell
2.Increase 2.Increase -cell function-cell function
3.Sustain glucose lowering3.Sustain glucose lowering
4.Safe & Economical4.Safe & Economical
5.Reduce CVD risk5.Reduce CVD risk
Sites of action of the current and possible pharmacological Sites of action of the current and possible pharmacological therapies for the treatment of type 2 diabetes.therapies for the treatment of type 2 diabetes.
EducationEducation
Structured Patients education is an Integral Part of the Management of type-2 diabetes
It Includes:
• Knowledge of Diabetes
• SMBG, Annual Review Examination.
• Foot Care
• Medical Nutrition Therapy
• Physical Activity
Through:
• Individual Counseling
• Group Counseling
• Self Help Group
• Literature , Brochure, Diet Chart, Electronics & Print Media & Internet.
Make Healthy Food ChoicesMake Healthy Food Choices
80% of heart disease, stroke & type 2 diabetes and 40% of cancer could be prevented through
Healthy dietRegular physical activityAvoidance of tobacco products
Preventive Strategies
Make Healthy Food ChoicesMake Healthy Food Choices
Make Healthy Food ChoicesMake Healthy Food Choices
Make Healthy Food ChoicesMake Healthy Food Choices
Diabetes and LifestyleDiabetes and Lifestyle
Lifestyle changes Lifestyle changes can mean the can mean the
difference difference between between
developing developing diabetes or notdiabetes or not
•Conclusions
• Glycaemic control significantly reduces diabetes complications
• Early glycaemic control is associated with a long-lasting ‘legacy’ effect, in reducing later complications (macro + microvascular)
• Implications for patient care
• Early intervention to achieve and maintain glycaemic targets is critical
• Treatment should be individualised, to maintain an optimal balance between the benefits and risks of an intensive glucose control
• Maintain HbA1c as close to normal as safely possible
26 million with Diabetes
79 millionwith Pre-Diabetes
Problem StatementProblem Statement
Iceberg Disease Increased prevalence in newly industrialized and
developing countries. Disease acquired in the most productive period of
their life. 20% of current global diabetic population resides
in the SEAR.
Undiagnosed or inadequately treated patients develop multiple chronic complications.
Lack of awareness about interventions for prevention and management of complications.
Epidemiological DeterminantsEpidemiological Determinants
AGENT FACTORSAGENT FACTORS
Pancreatic disorders
Defects in formn of insulin
Destruction of beta cells
Decreased insulin sensitivity
Genetic defects
Autoimmunity
AgeSexGenetic factorsGenetic markers – HLA-B8, B15, HLA
DR3 & DR4Immune mechanismsObesityMaternal diabetes
HOST FACTORSHOST FACTORS
Sedentary lifestyleDietDietary fiberMalnutritionAlcoholViral infectionsChemical agentsStressOthers
ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS
Prevention And CarePrevention And Care
PRIMARY PREVENTION Population Strategy High Risk Strategy
SECONDARY PREVENTION
TERTIARY PREVENTION
Screening for DMScreening for DM
TARGET POPULATION
Questionnaires used alone tend to work poorly;
Biochemical tests alone or in combination with assessment of risk factors are a better alternative.
G.C.T; Gold standard testHBA1c test
Diabetes and Obesity, Time to Act, p.33, IDF 2004
Study Year Interventions Outcome
DaQing (China)
1997 Diet, physical activity or both (control group: general)
Reduction in diabetes incidence 31% in diet group, 46% in physical activity and 42% in diet and physical activity compared to control group
Finnish Diabetes Prevention Study
2001 Diet and physical activity (control group: general advice)
Reduction by 58% of the risk of diabetes compared to control group
Diabetes Prevention Program (USA)
2002 Diet, physical activity, metformin and placebo
58% reduction in incidence of diabetes with lifestyle intervention, 31% with metformin
STOP-NIDDM
2002 Acarbose or placebo
32% patients randomised to acarbose and 42% randomised to placebo developed diabetes
Primary Prevention of Type 2 Diabetes Primary Prevention of Type 2 Diabetes
The Diabetes Prevention Program (DPP): The The Diabetes Prevention Program (DPP): The New Frontier: Lifestyle Modifications or New Frontier: Lifestyle Modifications or
MedicationMedication Goal: To prevent or delay the development of type 2 Goal: To prevent or delay the development of type 2
diabetes in persons with impaired glucose tolerance (IGT)diabetes in persons with impaired glucose tolerance (IGT)
High-risk individuals with IGT and elevated FPG (N=3234) High-risk individuals with IGT and elevated FPG (N=3234) randomized torandomized to
• PlaceboPlacebo
• Intensive lifestyle intervention; at least monthly contact Intensive lifestyle intervention; at least monthly contact with case managers with case managers
• Metformin titrated to 850 mg bidMetformin titrated to 850 mg bid Reduction at 2.8 yearsReduction at 2.8 years
• 58%58% in the intensive lifestyle intervention group in the intensive lifestyle intervention group• 31%31% in the metformin group in the metformin group
The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.NIDDK. http://www.niddk.nih.gov/welcome/releases/8_8_01.htm.
National Diabetes Prevention ProgramNational Diabetes Prevention Program
Goal:Goal: Systematically scale the translated Systematically scale the translated
model of the Diabetes Prevention model of the Diabetes Prevention Program (DPP) for high risk persons Program (DPP) for high risk persons in collaboration with community-in collaboration with community-based organizations that have based organizations that have necessary infrastructure, health necessary infrastructure, health payers, health care professionals, payers, health care professionals, public health, academia, and others public health, academia, and others to reduce the incidence of type 2 to reduce the incidence of type 2 diabetes in the United Statesdiabetes in the United States.
Goal:Goal: Systematically scale the translated Systematically scale the translated
model of the Diabetes Prevention model of the Diabetes Prevention Program (DPP) for high risk persons Program (DPP) for high risk persons in collaboration with community-in collaboration with community-based organizations that have based organizations that have necessary infrastructure, health necessary infrastructure, health payers, health care professionals, payers, health care professionals, public health, academia, and others public health, academia, and others to reduce the incidence of type 2 to reduce the incidence of type 2 diabetes in the United Statesdiabetes in the United States.
www.cdc.gov/diabetes/prevention
Type 2 diabetesType 2 diabetes, ,
the the metabolic syndromemetabolic syndrome
and and cardiovascular diseasecardiovascular disease
in Europein Europe
70%–80% of people with diabetes die of 70%–80% of people with diabetes die of cardiovascular disease.cardiovascular disease.
For each risk factor present, the risk of For each risk factor present, the risk of cardiovascular death is about three times greater cardiovascular death is about three times greater in people with diabetes as compared to people in people with diabetes as compared to people without the condition. without the condition.
Cardiovascular disease is the number one cause Cardiovascular disease is the number one cause of death in industrialized countries. It is also set of death in industrialized countries. It is also set to overtake infectious diseases as the most to overtake infectious diseases as the most common cause of death in many parts of the less common cause of death in many parts of the less developed world.developed world.
Diabetes and cardiovascular diseaseDiabetes and cardiovascular disease
The annual direct healthcare costs of diabetes The annual direct healthcare costs of diabetes worldwide, for people in the 20 – 79 age bracket, worldwide, for people in the 20 – 79 age bracket, is estimated to be at least 153 billion is estimated to be at least 153 billion international dollars. international dollars.
It is estimated that diabetes accounts for It is estimated that diabetes accounts for between 5% and 10% of total healthcare between 5% and 10% of total healthcare spending in most countries and up to 25% spending in most countries and up to 25% in some.in some.
If predictions of diabetes prevalence are fulfilled, If predictions of diabetes prevalence are fulfilled, total direct healthcare expenditure on diabetes total direct healthcare expenditure on diabetes worldwide will be between 213 billion and 396 worldwide will be between 213 billion and 396 billion international dollars in 2025.billion international dollars in 2025.
The cost of diabetes The cost of diabetes
Direct health care costs of diabetes are high and Direct health care costs of diabetes are high and risingrising
Direct health care costs of the metabolic Direct health care costs of the metabolic syndrome dominate health care budgetssyndrome dominate health care budgets
Preventing or delaying the onset of Preventing or delaying the onset of type 2 diabetes results in considerable type 2 diabetes results in considerable cost reductioncost reduction
Improving metabolic control can also reduce Improving metabolic control can also reduce health care resource usehealth care resource use
The cost of diabetesThe cost of diabetes
Implications for health systemsImplications for health systems
The human and economic costs of diabetes could The human and economic costs of diabetes could be significantly reduced by investing in be significantly reduced by investing in prevention, particularly early detection, in prevention, particularly early detection, in order to avoid the onset of diabetic complications.order to avoid the onset of diabetic complications.
At least 50% of all people with diabetes At least 50% of all people with diabetes are unaware of their condition. are unaware of their condition.
In some countries this figure may rise In some countries this figure may rise to 80%.to 80%.
Managing Diabetes and Managing Diabetes and Diabetic ComplicationsDiabetic Complications
CONCLUSIONSCONCLUSIONS A growing diabetes pandemic is unfolding with rapid A growing diabetes pandemic is unfolding with rapid
increases in the prevalence of type 2 diabetes.increases in the prevalence of type 2 diabetes.
effective interventions to prevent diabetes and its effective interventions to prevent diabetes and its complications is availablecomplications is available
diabetes education as an essential intervention.diabetes education as an essential intervention.
interventions at the level of the patient, provider, and interventions at the level of the patient, provider, and system that could help address the overall suboptimal system that could help address the overall suboptimal quality of diabetes care;quality of diabetes care;
Thank youThank you