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Understanding

Diabetes (T2)

What is Diabetes Type 2?

Type 2 Diabetes (T2D), (formerly referred to as non-insulin dependent diabetes mellitus, type II), is a chronic disorder of carbohydrate, fat and protein metabolism leading to elevated blood glucose levels and insulin resistance. (Murray and Pizzorno, 2012).

T2D occurs either when the pancreas can no longer produce enough insulin or insulin that is produced in the pancreas cannot be metabolised correctly. Insulin is a hormone which is made in the β-cells of the pancreas and allows glucose to pass from the bloodstream into the cells, (via facilitated diffusion), and used as an energy source. If the pancreas is producing insulin but not getting to the cells, this leads to raised glucose levels in the blood or ‘spillage’ in the urine, also known as hyperglycaemia. (Blacks Medical Dictionary).

 

Fig 1. Showing:- Healthy, Type 1 and Type 2 Diabetes & Insulin Receptors

Ref: (Reference, 2019)

World view of diabetes type 2

T2D, accounts for 90% of all diabetes cases. Its the most common type of adult diabetes but studies now show that T2D is on the rise in children, adolescents and young adults globally due to obesity, poor diet and sedentary lifestyles. (Idf.org, 2019)

In the Diabetics Atlas 2019 report, in 2017 there were an estimated 424 million people in the world that have been diagnosed with diabetes, ranging from ages 20-79. This figure is predicted to go up to 629 million worldwide by 2045; an increase of 48%, as can be seen in figure 2. These statistics show China has the most diabetes known cases at 114.4 million, followed by India with 72.9 million and then the USA with 30.2 million. This report also shows that two thirds of this global figures are living in urban areas. (Diabetesatlas.org, 2019)

As reported by Diabetes.co.uk, (2019), T2D affects people of different ethnicities to a different degree. People in South Asia, Polynesia, Africa, Afro-Caribbean, Middle-East and American- Indian ancestry have higher risk for T2D.

Fig.2, Global Facts & Figures for Diabetes Rates from 2017 – 2045

Ref : (Idf.org, 2019), (Diabetes Atlas, 2019)

Causes & associated Risk factors to Diabetes Type 2
  • Family history
  • Obesity – High glucose, lipid & protein diet
  • Lifestyle – Inactivity
  • Environmental factors
  • Age
  • High blood pressure
  • High Triglycerides / LDL levels (Estadella et al., 2013)
  • Ethnicity (as indicated in epidemiology)
  • Prolonged stress T2D develops slowly over many years. Often, but not always, associated with obesity and a sedentary lifestyle. (Cdc.gov, 2019)

Disease Process – How the disease develops (Hubert and VanMeter, 2018)

  1. Initial Stage – Insulin deficit leading to a reduction in transportation and use of glucose in cells
  2. Hyperglycaemia
  3. Glucosuria – excess glucose spills into urine affecting renal tubular transport
  4. Polyuria – glucose in urine exerts osmotic pressure in the filtrate
  5. Polydipsia – dehydration from fluid loss through urine and high blood glucose levels drawing water from the cells
  6. Polyphagia – lack of nutrients entering cells so stimulates appetite
  7. Progressive Effects – Catabolism of fats and proteins known as ketones in the blood
  8. Excessive amounts of ketones, known as ketoacidosis (Diabetic KA), leading to decreased pH of body fluids
  9. Glomerular filtration rate of kidney decreases, excretion of acids become more limited, resulting in compensated metabolic acidosis which can be life-threatening DKA.

How the disease affects the various tissues/ organs/ systems.

Prolonged uncontrolled T2D can lead to vision loss, blindness, end-stage renal disease, heart disease and even premature death. (Diabetes.co.uk, 2019)

signs and symptoms of Diabetes Type 2

WebMd, (2019) and (Murray and Pizzorno, 2012) lists the following signs and symptoms:

Common signs of T2D are listed below

  • Polydipsia

  • Polyuria – mostly seen at night

  • Polyphagia

  • Fatigue

  • Dry mouth & yeast infections due to dehydration and infections/high glucose levels

  • Itching of the skin – usually vaginal or groin area

  • Blurred vision or decreased vision due to retinopathy issues associate with T2D

  • Weight gain especially in abdominal region

  • Increase blood glucose

  • Hyperglycaemia

  • Erectile dysfunction – impotency

  • Numbness and tingling – peripheral regions of the body – hands and feet

  • Acanthosis nigricans – changes to a dark skin tone on neck, armpit, groin

  • Poor wound healing & foot ulcers – due to microvascular changes, poor circulation and

    nutritional deficiencies

  • Low eGFR reading – less than 60

  • Elevated homocysteine levels – especially diabetic neuropathy

  • Elevated LDL levels – damaging endothelial cells susceptible to damage by oxidized LDL

  • Hypertension – essential to reduce further complications of kidney disease, retinopathy and stroke

  • Nutrient deficiencies – vitamin B12 (causing numbness, tingling), low micronutrient  diets

    A  RED FLAG situation would be a hypoglycaemic state resulting in sweating, dizziness, then loss of consciousness, and finally death. In this situation an ambulance should be called, if blood glucose cannot be increased before unconsciousness.

    DIABETES TYPE 2, ALSO LOOKS LIKE….

    Diabetes Type 2 may also present similar to these other conditions. It’s important to make note of this in case you see signs. 

    Similar Pathologies

    Similarities

    Differences

    Diabetes type 1 (T1D)

    • Polyuria
    • Polydipsia
    • Ketoacidosis

    T1D weight loss / T2D weight gain, T2D excess appetite, T1D Asymptomatic, T2D symptomatic.

    Syndrome X

    (metabolic syndrome)

    • Obesity
    • Elevated triglycerides
    • BP
    • Low HDL
    • Fasting glucose 100mg/dL or higher

    More common in older people and mostly Mexican and Americans than ethnic backgrounds unlike T2D

    Stroke

    • Loss of vision
    • Sudden weakness
    • Prickling feeling in the extremities
    • Body fatigue

    Directly related to heart

    Cushings Syndrome

    • Central weight gain
    • Insulin resistance
    • Depression
    • Susceptible to infection
    • Compromise immune
    • Muscular weakness

    T2D can lead to Cushing’s syndrome/disease. The main way to tell is the moon face and extreme obesity and hump on top of the back. Measured by cortisol in the urine.

    Ref: (CNM, 2019), (Diabetes.co.uk, 2019), (Emedicine.medscape.com, 2019), (nhs.uk, 2019), (Stroke.org, 2019)

    How to diagnose & monitor Diabetes type 2

    Elevated blood glucose levels can be checked at home or by a health care professional by a simple test using a blood glucose monitor, without fasting. A sample of capillary blood from a finger prick on a portable monitor machine, gives the readings instantly (see readings chart below). (Mayoclinic.org, 2019)

    Fig. 3 NICE recommended target blood glucose level ranges

    Ref: (Diabetes.co.uk, 2019)

    Tests for Investigation are:

    HbA1C Test for Diabetes diagnosis: A Glycated haemoglobin (HbA1C) test might be carried out. Shows fasting blood test average blood sugar level over a period of up to 3 months. (Diabetes.co.uk, 2019)

    Fasting Plasma Glucose Test: Taken after 8 hours of fasting. NICE guidelines regard fasting plasma glucose to be between 5.5 and 6.9mmol/l as a higher risk of T2D and should be assessed with other risk factors as indicated in clinical signs and symptoms above. (Diabetes.co.uk, 2019)

    Oral Glucose Tolerance Test: Less commonly used is the oral glucose tolerance test, used during pregnancy. (Mayoclinic.org, 2019)

    Further Investigation: In addition blood pressure, elevated triglycerides, creatinine, urine sample to check cholesterol levels, thyroid functioning, liver functioning and kidney function through evaluation of the eGFR. (Mayoclinic.org, 2019), (Emedicine.medscape.com, 2019)

    C-peptide determination, if the pancreas is producing insulin or not.
    Urine ketone testing, to know if the body is in ketoacidosis a RED FLAG situation.

    COMPLICATIONS

    If T2D is not managed, over time the following are common complications as advised in the Encyclopedia of Natural Medicine (Murray and Pizzorno, 2012):-

    Acute Complications
    • Hypoglycaemia & Hyperglycaemia RED FLAG, as a result of too much insulin, poorly managed diabetes. Can occur unpredictably. Glucose under 20mg/dl is a medical emergency. Chronic Complications

    • Heart Disease & Elevated Homocysteine levels – T2D are 2-3 times more likely to have cardiovascular disease

    • Hypertension -75% T2D have high blood pressure

    • Retinopathy – A leading cause of blindness and affects 1/3rd diabetics. Increased risk of glaucoma

    • Kidney Disease – 10 times higher in T2D

    • Neuropathy – 60-70% T2D develop nervous system damages. Especially lower extremities

    • Amputations – 60% of amputations of lower limbs are T2D

    • Periodontal Disease – 33% of people with T2D have periodontal issues.

    • Pain – T2D have pain commonly from arthritis, neuropathy, circulation issues, fibromyalgia.

    • Autoimmune Disorders – Thyroid complications, inflammatory arthritis.

    • Alzheimer’s Disease – Insulin resistance, impaired insulin signalling, causing blood vessel damage in the brain. There is a 1.5 – 4-fold increased risk of Alzheimer’s if you have T2D. (Creative-peptides.com, 2018)

    • Immune System Dysfunction – causing serious infections, susceptibility to chronic hidden infections like oral, blood, respiratory and vaginal/skin yeast infections.

    • Depression – especially if diabetes is difficult to manage.

    • Nutrient Deficiency

      Contributors to Long-Term Complications

      • Poor glucose control

      • Prolonged stress

      • Increasing oxidative stress/damage – from free radicals and oxidative compounds cause body damage and increased insulin resistance. Increasing formation of inflammatory C-reactive protein, a critical goal in prevention and treatment.

    what your doctor will offer you

    Categories of medications used in managing diabetes along with method, use and side effects are listed below (brand names in brackets) (Diabetes.co.uk, 2019)

    Medication Category

    Method & Use

    Side Effects

    Alpha Glucosidase Inhibitors

    Oral medication. Blocks enzymes in the small intestine that break down carbohydrates.

    Flatulence, Diarrhoea

    Amylin Analogues

    Injected. Works in a similar way to the hormone amylin. Inhibits the release of glycogen, slowing the emptying of the stomach.

    Nausea, Headache, Hypoglycaemia – if taken with insulin, Vomiting

    Biguanides (Metformin)

    Oral drug. Prevents the production of glucose in the liver. Improves sensitivity to insulin.

    If taken with insulin – Hypoglycaemia, Weight gain

    DPP-4 Inhibitors

    Oral drug. Prescribed where metformin or sulphonylureas has not worked. Block DPP-4 – destroys incretins, and regulates blood glucose levels.

    Higher rates of pancreatitis, Gastrointestinal issues, Flue like symptoms, Skin reactions/rashes

    Incretin Mimetics

    A new injectable drug, glycogen-like peptide 1 receptor agonists given if the oral medication worked.

    Constipation, Diarrhoea, Dizziness, Headaches, Increased sweating, Indigestion, Loss of appetite, Nausea, Vomiting

    Prandial Glucose Regulators

    An oral medication, limits blood glucose spikes, by binding to ATP in the β cells of the pancreas. Rapid-acting.

    Allergic skin reactions, Abdominal pain, Constipation, Diarrhoea, Hypoglycaemia, Liver issues, Nausea

    SGLT2 Inhibitors

    A group of oral medications, to help the kidneys prevent reabsorbing glucose and lowering blood glucose levels.

    Urinary tract infections, Genital infections, Taken with other medications, increased risk of hypoglycaemia, Diabetic ketoacidosis

    Sulphonylureas

    An oral drug. Stimulates the pancreas to increase insulin production.

    Risk of hypoglycaemia, Allergic reactions possible in the first 6 weeks, Weight gain

    Thiazolidinediones

    Oral hypoglycaemic drugs, reduce the body’s resistance to insulin.

    Many side effects, Associated drug, (Avandia) showed an increased risk of heart disease

    Warning: long term side effects of medications, in general, can be:- premature ageing, worsening diabetic vision, promoting of cancer, further obesity, atherosclerosis. (Miller et al., 2019), (New England Journal of Medicine, 2019), (Blagosklonny, 2012)

    diabetes type 2 managed the natural way!

    Natural medicine for diabetes means trying to achieve an ideal blood glucose level and ideal metabolic targets. According to Murray and Pizzorno (2012). There are 4 key areas to focus on:

    1. Providing an optimal nutritional status through a diet that is rich in complex carbohydrates, with low glycaemic index foods. Adequate protein and low lipid and low cholesterol food. (Hubert and VanMeter, 2018). It is also mentioned that food intake needs to match the calories needed for each person, as well as balance with the amount of exercise. Therefore a good meal plan for each individual is a good start.

    1. (Campbell and Campbell, 2006)

    2. Reducing after-meal increases in blood glucose readings. The inclusion of an exercise program, both aerobic and non-aerobic exercise and an overall increase of physical activity is essential for optimal health in individuals with T2D. (Sheri et al, 2010)

    3. Improving insulin sensitivity and function. Reducing dietary saturated fats which, create havoc in muscle cells and results in the accumulation of more toxic break done products such as ceramide and diacylglycerol and free radicals, should also be taken into consideration. As well as causing inflammation which disrupts the mitochondrial function (known as lipotoxicity), it can lead to saturated fat build up in the muscle and correlates to insulin resistance. (Chavez JA, 2003)

    4. Preventing oxidative stress and nutritional deficiencies. Supplementation has been found to help to balance blood glucose levels according to Murry and Pizzorno (2012), as well as reducing further complication risks. Whenever significant nutrients are increased, fibre intake is increased then medications may need to reduced.

    Supplementation that can help

    Chromium, due to its glucose tolerance factor that facilitates the action of insulin and help the uptake of insulin into the cells (supported with 20 clinical studies on chromium).

    Vitamin C enhances the update of insulin which is hard to uptake as a T2D and so more is required.


    Vitamin E which is an antioxidant helping oxidative stress and prevents free radical damage from the LDL cholesterol and lining of the vascular system, and improves blood vessels functioning. As well as helping increase the concentration of magnesium in the cells and decreases other inflammatory compounds and the level of C-Reactive protein.

    Vitamin B6 is also important for the protection against developing any diabetic neuropathy. Niacin and Niacinamide as the enzymes that contain vitamin B6, play an important role in energy production, (carbohydrate, cholesterol, fat metabolism) and is an essential element to glucose tolerance factor.

    Other supplements include
    Magnesium, Zinc, Manganese, Biotin, and Omega 3 Fatty Acids. All of these vitamins and minerals and fatty acids are abundant in plant-based foods. (Murray and Pizzorno, 2012)

    With all these controls in place then conventional medical treatments will need to be adjusted accordingly depending on the pancreatic insulin production, which can be determined by a C- Peptide levels. (Murray and Pizzorno, 2012)
    From numerous studies over the last century, including (Chen et al., 2018), show that a diet rich in fibre, plant-based nutrients, complex carbohydrate and good monounsaturated fats can combat the nutritional deficiencies, reduce excess weight, protect the heart and reduce long term complications of T2D. This can be seen in figure 5. In the EPIC-PANCACEA study with over 521,000 participants, it shows the effect of a vegan/vegetarian diet. (Wright et al., 2017), as can be seen in the figure below from the Adventist study.

    Ref: (Grantham et al., 2014)

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    Take the next step to preventing Diabetes type 2

    Join Ultimate Health, Your Journey Starts Here!

    At Ultimate Health we look for prevention and treating the cause. Diabetes Type 2 is a lifestyle disease and can be reversed and controlled. However the longer you are not managing this condition the poorer the functioning of your pancreas will be and the more you will be dependent on insulin. We always start by wiping the slate clean with a Reboot and then looking to help support your body to heal using natural proven principles. Naturopathic solutions and a protocol that supports your body and every system that it runs. We help you to manage the many multifunctional influences that can cause diabetes type 2 in the first place. Detoxification is key, as well as reducing internal inflammation. If you need a map we have the one clear path to support your entire being.

    Here are the Pathways we use to support you:

    1. Detoxification
    2. Education on how to control your diabetes
    3. Support and help from others like you on this very same journey
    4. The full protocol to help you to manage your condition and to eventually come off as many of your medications as possible CLICK HERE for more information

    resources list for diabetes type 2 

    Below is a useful list of resources that can support someone with diabetes.

    ASSOCIATIONS & FORUMS Diabetes UK

    www.diabetes.org.uk/

    Address: Wells Lawrence House 126 Back Church Lane London E1 1FH

    Tel 0345 123 2399 Fax 020 7424 1001

    The main diabetes website in the UK for help with diabetes of all types. A good resource to connect to for carers as well as diabetics.

    Diabetes.co.uk

    https://www.diabetes.co.uk/ https://www.diabetes.co.uk/forum/

    A great forum to get to know others with the disease, where you can ask questions or join a forum.

    NHS

    https://www.nhs.uk/conditions/Diabetes/ For Local Support
    NHS Diabetes Local Support Group

    This website helps you to find a local support group near you with help of this NHS directory.

    Diabetes Ireland

    https://www.diabetes.ie/

    Address: Head Office, Dublin, 19 Northwood House Northwood Business Campus Santry, Dublin DO9 DH30

    Helpline/T: 01 842 8118, Mon-Fri 9am-5pm Email: [email protected]

    Diabetes Research and Wellness Foundation

    www.drwf.org.uk Tel: 0239 263 7808

    Website: www.burgesshilldiabetes.co.uk Email us at: b[email protected]

    A charity that raises awareness of diabetes and provides support to people living with type 1 and type 2 diabetes.

    British Dietetic Association

    https://www.bda.uk.com/regionsgroups/groups/diabetes/home

    Address: British Dietetic Association, United Kingdom. 

    T: 0121 200 8080

    Email: https://www.bda.uk.com/about/about_bda/contact

    Diabetes support groups that can help with further questions you may start to have.

    FACTS AND FIGURES International Diabetes Federation

    https://www.idf.org

    Address: 166 Chaussee de La Hulpe B-1170 Brussels, Belgium T: +32 2 538 55 11

    F: +32 2 538 51 14

    Email: [email protected]
    An international view on diabetes and how to manage, reverse and even prevent the disease.

    Diabetes Atlas

    https://diabetesatlas.org/
    Full statistical account for the global rise in diabetes from 2017 to 2045 file:///Users/Tania/Downloads/IDF_DA_8e-EN-final.pdf

    An authoritative source for epidemiology and research for diabetes, as recommended by International Federation of Diabetes, this source is referenced to by Doctors.

    WebMD

    https://www.webmd.com/diabetes/type-2-diabetes#1
    Science backed information that you can access about diabetes and other diabetes related conditions

    PRACTITIONERS & INSTITUTIONS

    Physicians Committee for Responsible Medicine

    https://www.pcrm.org/health-topics/diabetes
    A US based website that lobbies the government for change in new science driven approach. This is a direct link to a free 21 day plant-based program.

    References

    Blagosklonny, M. (2012). Prospective Treatment of Age-Related Diseases by Slowing Down Aging. The American Journal of Pathology, 181(4), p1142-1146.

    Cdc.gov. (2019). Basics | Diabetes | CDC. [online] Available at: https://www.cdc.gov/diabetes/basics/diabetes.html [Accessed 28 Apr. 2019].

    Chen, Z., Zuurmond, M., van der Schaft, N., Nano, J., Wijnhoven, H., Ikram, M., Franco, O. and Voortman, T. (2018). Plant versus animal based diets and insulin resistance, prediabetes and type 2 diabetes: the Rotterdam Study. European Journal of Epidemiology, 33(9), pp.883-893.

    Campbell, T. and Campbell, T. (2006). The China study. Dallas: www.ipgbook.com, p.153.

    Chavez JA, e. (2003). A role for ceramide, but not diacylglycerol, in the antagonism of insulin signal transduction by saturated fatty acids. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12525490 [Accessed 3 May 2019].

    Creative-peptides.com. (2018). Alzheimer’s disease and diabetes: hope for inhibitors against amyloid plaques – Creative Peptides Blog. [online] Available at: https://www.creative- peptides.com/blog/index.php/alzheimers-disease-and-diabetes-hope-for-inhibitors-against- amyloid-plaques/ [Accessed 3 May 2019].

    Diabetesatlas.org. (2019). 8940_IDF_Atlas_2017_English_Interactive. [online] Available at: https://diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/ [Accessed 28 Apr. 2019].

    Diabetesatlas.org. (2019). 8940_IDF_Atlas_2017_English_Interactive. [online] Available at: https://diabetesatlas.org/IDF_Diabetes_Atlas_8e_interactive_EN/ [Accessed 28 Apr. 2019], p87.

    Diabetes.co.uk. (2019). Diabetes Complications. [online] Available at: https://www.diabetes.co.uk/diabetes-complications/diabetes-complications.html [Accessed 29 Apr. 2019].

    Diabetes.co.uk. (2019). Diabetes Mellitus – Diabetes Type 1, Mellitus Symptoms, Risk Factors & Mortality. [online] Available at: https://www.diabetes.co.uk/diabetes-mellitus.html [Accessed 29 Apr. 2019].

    Diabetes.co.uk. (2019). Normal and Diabetic Blood Sugar Level Ranges – Blood Sugar Levels for Diabetes. [online] Available at: https://www.diabetes.co.uk/diabetes_care/blood-sugar-level- ranges.html [Accessed 30 Apr. 2019].

    Diabetes.co.uk. (2019).Thyroid Disease and Diabetes – What Does The Thyroid Do, Hypothyroidism. [online] Available at: https://www.diabetes.co.uk/conditions/thyroid-disease.html [Accessed 28 Apr. 2019].

    Ericson U, e. (2019). High intakes of protein and processed meat associate with increased incidence of type 2 diabetes. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22850191 [Accessed 29 Apr. 2019]. Emedicine.medscape.com. (2019). Type 2 Diabetes Mellitus Differential Diagnoses. [online] Available at: https://emedicine.medscape.com/article/117853-differential [Accessed 28 Apr. 2019].

    Estadella, D., da Penha Oller do Nascimento, C., Oyama, L., Ribeiro, E., Dâmaso, A. and de Piano, A. (2013). Lipotoxicity: Effects of Dietary Saturated and Transfatty Acids. Mediators of Inflammation, [online] 2013, pp.1-13. Available at: https://www.hindawi.com/journals/mi/2013/137579/.

    Fallucca F, e. (2019). Influence of diet on gut microbiota, inflammation and type 2 diabetes mellitus. First experience with macrobiotic Ma-Pi 2 diet. – PubMed – NCBI. [online]

    Grantham, J., Staub, K., Rühli, F. and Henneberg, M. (2014). Modern diet and metabolic variance – a recipe for disaster?. Nutrition Journal, 13(1).

    Idf.org. (2019). International Diabetes Federation – Facts & figures. [online] Available at: https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html [Accessed 28 Apr. 2019].

    Idf.org. (2019). International Diabetes Federation – Type 2 diabetes. [online] Available at: https://www.idf.org/aboutdiabetes/what-is-diabetes/type-2-diabetes.html [Accessed 28 Apr. 2019].

    Hubert, R. and VanMeter, K. (2018). Gould’s pathophysiology for the health professions. 6th ed. Missouri: Elsevier, p.405.

     

    LI, R. (2019). Free fatty acids and skeletal muscle insulin resistance. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24373240 [Accessed 29 Apr. 2019].

    Marcovitch H, (2017). Black’s medical dictionary 42nd ed. A & C Black London, p181.

    Mayoclinic.org. (2019). Type 2 diabetes – Diagnosis and treatment – Mayo Clinic. [online] Available at: https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis- treatment/drc-20351199 [Accessed 28 Apr. 2019].

    Miller, M., Williamson, J., Gerstein, H., Byington, R., Cushman, W., Ginsberg, H., Ambrosius, W., Lovato, L. and Applegate, W. (2019). Effects of Randomization to Intensive Glucose Control on Adverse Events, Cardiovascular Disease, and Mortality in Older Versus Younger Adults in the ACCORD Trial. [online] American Diabetes Association. Available at: http://care.diabetesjournals.org/content/37/3/634 [Accessed 29 Apr. 2019].

    Murray, M. and Pizzorno, J. (2012). The encyclopedia of natural medicine, 2012. New York: Atria Books, p.503 & p526, p.521 – p528

    Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24532292 [Accessed 28 Apr. 2019].

    New England Journal of Medicine. (2019). Effects of Intensive Glucose Lowering in Type 2 Diabetes | NEJM. [online] Available at: https://www.nejm.org/doi/pdf/10.1056/NEJMoa0802743 [Accessed 29 Apr. 2019].

    nhs.uk. (2019). Some type 1 diabetes cases in adults misdiagnosed as type 2. [online] Available at: https://www.nhs.uk/news/diabetes/some-type-1-diabetes-cases-adults-misdiagnosed-type-2/ [Accessed 28 Apr. 2019].

    Nolan, J. and Later, C. (2019). Lipotoxicity: Why do saturated fatty acids cause and monounsaturates protect against it?jgh_5823 703..•• P703. [online] Gsartor.org. Available at: http://www.gsartor.org/pro/ricerca/9HSA/Lipotoxicity..why%20do%20saturated%20fatty%20acids%20cause%20and%20monounsaturates%20protect%20against%20it. pdf [Accessed 29 Apr. 2019].

    Reference, G. (2019).Type 2 diabetes. [online] Genetics Home Reference. Available at: https://ghr.nlm.nih.gov/condition/type-2-diabetes [Accessed 7 May 2019].

    Ricchi M, e. (2019). Differential effect of oleic and palmitic acid on lipid accumulation and apoptosis in cultured hepatocytes. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+19207680 [Accessed 29 Apr. 2019].

    Sheri R. Colberg, Ronald J. Sigal, Bo Fernhall, Judith G. Regensteiner, Bryan J. Blissmer, Richard R. Rubin, Lisa Chasan-Taber, Ann L. Albright, and Barry Braun, (2010). Exercise and. Type 2 Diabetes: The American College of Sports Medicine and the American Diabetes Association. Availale at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992214/

    Shi Z, e. (2019). Egg consumption and the risk of diabetes in adults, Jiangsu, China. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20471806 [Accessed 29 Apr. 2019].

    Stroke.org. (2019). Diabetes and Stroke – National Stroke Association. [online] Available at: https://www.stroke.org/diabetesbrochure/ [Accessed 28 Apr. 2019].

    WebMD. (2019). Symptoms of Type 2 Diabetes. [online] Available at: https://www.webmd.com/diabetes/type-2-diabetes-symptoms [Accessed 30 Apr. 2019].

    Wright, N., Wilson, L., Smith, M., Duncan, B. and McHugh, P. (2017). The BROAD study: A randomised controlled trial using a whole food plant-based diet in the community for obesity, ischaemic heart disease or diabetes. Nutrition & Diabetes, [online] 7(3), pp.e256-e256. Available at: https://docs.wixstatic.com/ugd/0bb022_764888736e4547afb8ad5b06a24d77d0.pdf.

    Zhuo Fu, D. (2019). Regulation of Insulin Synthesis and Secretion and Pancreatic Beta-Cell Dysfunction in Diabetes. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934755/ [Accessed 28 Apr. 2019].

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