Download Nutritional needs in T1 and T2 diabetes

Nutritional needs of people with
type 1 diabetes and type 2 diabetes
Slides current until 2008
Nutrition in diabetes
ACTIVITY
Curriculum Module III-5
Slide 2 of 59
Identify factors that need to be
considered before developing an
individual dietary plan.
Slides current until 2008
Nutrition in diabetes
Diabetes nutrition therapy
Curriculum Module III-5
Slide 3 of 59
Aims to help people with diabetes
attain a quality of life and life
expectancy similar to that of the
general population. This is
achieved through reducing
diabetes complications.
Slides current until 2008
Nutrition in diabetes
Type 1 diabetes – Diabetes Control
and Complications Trial
Curriculum Module III-5
Slide 4 of 59
Behaviours which contribute positively
to improved glycaemic control:
• Adherence to meal plan
• Consistent snacking behaviour
• Adjusted food and insulin when
hyperglycaemia detected
• Appropriate treatment of
hypoglycaemia
DCCT Research Group, 1993
Delahanty and Halford, 1993
Slides current until 2008
Nutrition in diabetes
Type 2 diabetes - United Kingdom
Prospective Diabetes Study
Curriculum Module III-5
Slide 5 of 59
Trial outcome:
Tight control of blood glucose
and blood pressure in people
with type 2 diabetes reduces the
risk of long-term micro- and
macrovascular complications.
UKPDS 1998
Slides current until 2008
Nutrition in diabetes
Type 2 Diabetes – Diabetes
Prevention Program
Curriculum Module III-5
Slide 6 of 59
Trial outcome:
Lifestyle changes such as weight
loss and moderate daily exercise
reduced the risk of developing
type 2 diabetes by 58% (over 3
years) in people with impaired
glucose tolerance.
DPP 1999
Slides current until 2008
Nutrition in diabetes
Dietary approaches to stop
hypertension (DASH)
Curriculum Module III-5
Slide 7 of 59
First trial:
• DASH diet significantly lowered
blood pressure
Second trial:
• DASH diet lowered blood
pressure at high, intermediate
and low levels of sodium
Sacks 1997, 2001
Slides current until 2008
Nutrition in diabetes
Dietary advice to control blood
pressure
Curriculum Module III-5
Slide 8 of 59
DASH diet:
• High in fruit and vegetables
• Low-fat dairy products
• Nuts
• Fish/chicken in preference to
red meat
• Small amounts of red meat
Sacks 1997, 2001
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 9 of 59
Aims of diet therapy
Attain and maintain metabolic
outcomes through:
• Good blood glucose levels
• Optimum lipid profile
• Controlled blood pressure levels
• Optimum body weight
Slides current until 2008
Nutrition in diabetes
Aims of diet therapy
Curriculum Module III-5
Slide 10 of 59
• To prevent and treat obesity,
dyslipidaemia, cardiovascular disease,
hypertension and nephropathy through
modification of diet and lifestyle
• To consider the person’s nutritional needs
while taking into account personal and
cultural preferences and lifestyle issues
• Respect the individual’s rights, decisions
and willingness to change
• Optimize quality of life
Slides current until 2008
Nutrition in diabetes
Person-centred approach to diet
therapy
Curriculum Module III-5
Slide 11 of 59
• Education/advice needs to be
individualized and holistic
• Individual assessment of the
person with diabetes is vital
• Diabetes is a progressive
condition requiring regular
review
Slides current until 2008
Nutrition in diabetes
Achieving optimum glycaemic
control in type 1 diabetes
Curriculum Module III-5
Slide 12 of 59
• Insulin action profiles selected to
suit the person’s meal pattern
with particular attention to CHO
intake and distribution
• High intake of soluble fibre
preferred
• Education for healthy food choices
should be given
• Low glycaemic index should be
encouraged
Slides current until 2008
Nutrition in diabetes
Insulin action profiles
Curriculum Module III-5
Slide 13 of 59
Rapid-acting analogue insulin
Onset: <0.5 hr Peak: 1 hr Duration: 3-4 hr
Soluble insulin
Onset: 1/2 hr Peak: 1-3 hr Duration: 6-8 hr
Lente insulin
Onset: 2 1/2 hr Peak: 7-15 hr Duration: 24 hr
NPH insulin
Onset: 1 1/ 2 hr Peak: 4-12 hr Duration: 24 hr
Biphasic insulin
Onset: 1/2 hr Peak: 2-8 hr Duration: 24 hr
Biphasic analogue insulin
Onset: <0.5 hr Peak: 1-4 hr Duration: 24 hr
Long-acting analogue insulin
Onset: 2-3 hr Peak: none Duration: 24 hr
Slides current until 2008
Nutrition in diabetes
Selecting insulin to suit the
individual and meal pattern
Meal pattern
Curriculum Module III-5
Slide 14 of 59
Number of injections
and insulin type
Two large meals
Twice a day: mixture of
short- and intermediateacting before meals
Three meals:
breakfast, light
lunch and dinner
Twice a day: mixture of
rapid-/short- and
intermediate-acting before
breakfast and before dinner
Slides current until 2008
Selecting insulin to suit the
individual and meal pattern
Meal pattern
Nutrition in diabetes
Curriculum Module III-5
Slide 15 of 59
Number of injections and
insulin type
3/4 meals:
breakfast, light
lunch, midafternoon and
evening meal
2-3 per day: mixture of rapid/short- and intermediate-acting
before breakfast; rapid/short for
the afternoon snack and mixture
of rapid-/short- and
intermediate-acting before the
evening meal; or long-acting
analogue 1-2/day and 3-4 rapid
acting
3 meals; 3 snacks
4-6: rapid-/short-acting before
meals and snacks, NPH or longacting analogue 1-2 per day
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 16 of 59
Achieving optimal glycaemic
control in type 2 diabetes
Type 2 diabetes is progressive
• Glycaemic control will deteriorate
with time
• Most people will require
polypharmacy including:
– glucose lowering medicines
– insulin
– anti-hypertensive, antithrombolytic and lipid-lowering
drugs
UKPDS 1995, Gaede 1999, Gaede 2003
Slides current until 2008
Nutrition in diabetes
Achieving optimal glycaemic
control in type 2 diabetes
Curriculum Module III-5
Slide 17 of 59
• Regular carbohydrate intake
essential
• Low glycaemic index
• Assessment of total energy
requirements
• Healthy eating principles
Slides current until 2008
Nutrition in diabetes
Dyslipidaemia in type 1 diabetes
and type 2 diabetes
Curriculum Module III-5
Slide 18 of 59
• An abnormal lipid profile
• Three out of four deaths are
caused by cardiovascular
disease
DCCT 1995, J Am Med Assoc 1997,
Laing et al 2000, Larsen et al 2002, DCCT 2003
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 19 of 59
Dietary influences on dyslipidaemia
• High fat intake reduces insulin
sensitivity
• Saturated and trans fats increase
LDL cholesterol
• Monounsaturated lower LDL
cholesterol and triglycerides
• High carbohydrate intake may
exaggerate the post-meal
triglyceride response
Slides current until 2008
Nutrition in diabetes
National cholesterol education
programme recommendations
Curriculum Module III-5
Slide 20 of 59
Energy distribution and
recommendations
Total fat
25-35% of total energy
Saturated fat
<7% total kcal
Polyunsaturated fat
Up to 10% total kcal
Monounsaturated fat
Up to 15% total kcal
Carbohydrates
50-60% total kcal
Protein
Approx 15% of total energy
Total calories
To achieve and maintain
healthy weight
Fibre (pref soluble)
10–25 g/day
Plant stanols/sterols (2 g/day)
Cholesterol
<200 mg/day
National Cholesterol Education Program 2004
Slides current until 2008
Nutrition in diabetes
Practical advice
Curriculum Module III-5
Slide 21 of 59
• Decrease total fat, particularly
saturated and trans fatty acids
• Increase monounsaturated fats
• Include two portions of fish in the
weekly diet (omega-3 fatty acids)
• Ensure adequate sources of
antioxidants - flavonoids, soluble
fibre and potassium (five portions
of fruit and vegetables daily)
Slides current until 2008
ACTIVITY
Nutrition in diabetes
Curriculum Module III-5
Slide 22 of 59
Identify foods in the local diet
that contribute to intake of
saturated, total and trans fats.
Discuss ways of modifying diet to
decrease total dietary fat and
improve the fatty acid profile.
Slides current until 2008
Nutrition in diabetes
Weight management
Curriculum Module III-5
Slide 23 of 59
A weight management programme
includes:
• Dietary change
• Increased physical activity
• Behaviour modification
• Support and monitoring
Slides current until 2008
Nutrition in diabetes
Benefits of weight loss
Diabetes related deaths  by 30% to 40%
Risk of
developing
diabetes  by
50%
HbA1c  by
15%
10% weight loss
Total cholesterol  by 10%
LDL by 15%
Triglycerides by 30%
 HDL by 8%
Curriculum Module III-5
Slide 24 of 59
Decreased insulin
requirements
Systolic and
diastolic BP 
by 10 mmHg
Fasting glucose by
30% to 50%
(improved insulin
sensitivity)
Jung 1997, Goldstein 1992
Slides current until 2008
Nutrition in diabetes
Associated weight gain with some
glucose-lowering medicines
Curriculum Module III-5
Slide 25 of 59
UKPDS showed:
• On metformin, weight gain of
1 kg over a 6-year period
• On sulphonylurea, weight gain
of 4 kg over a 6-year period
• On insulin, weight gain of 6 kg
over a 6-year period
Slides current until 2008
Nutrition in diabetes
Assessing the patient for weight
management
Curriculum Module III-5
Slide 26 of 59
Assess the person’s agenda and
lifestyle, particularly:
• Motivation
• Cultural issues
• Importance of weight loss
• Opportunities for increased
physical activity
Slides current until 2008
Nutrition in diabetes
Dietary modification
Curriculum Module III-5
Slide 27 of 59
Practical advice
• Avoid fatty foods
• Do not add fat
• Use low-fat cooking methods
• Decrease sugary foods
• Do not add sugar
Portion size
• Use easy measures for
descriptions of food quantity
• Negotiate acceptable portion
sizes for all foods
Slides current until 2008
Nutrition in diabetes
Dietary recommendations
Curriculum Module III-5
Slide 28 of 59
Practical evidence-based dietary
recommendations
• European Association for the
Study of Diabetes (1999)
• Diabetes UK (2003)
• American Diabetes Association
(2004)
• Canadian Diabetes Association
(2004)
Slides current until 2008
Nutrition in diabetes
Dietary recommendations
Curriculum Module III-5
Slide 29 of 59
• Weight reduction for overweight/obese
people
• Regular starchy meals
• Low sugar diet
•  Total fat intake by 30%
•  Intake of fruit and vegetables
•  Protein intake by 15% to 20%
•  Salt to 6 g per day (1 teaspoon)
• Alcohol in moderation
• Diabetic products are not advised
Slides current until 2008
Nutrition in diabetes
Education tools
Curriculum Module III-5
Slide 30 of 59
Glycaemic index:
Ranks carbohydrate-rich foods
according to the increase in blood
glucose levels they cause in
comparison with a standard food
(white bread/glucose).
Slides current until 2008
Nutrition in diabetes
Advanced education tools
Curriculum Module III-5
Slide 31 of 59
• Glycaemic index and load
• Food exchanges
• Carbohydrate counting
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 32 of 59
Blood glucose level
Glycaemic response of
glucose and lentils
Glucose
Lentils
© Reprinted with permission from Canadian Diabetes Association 2004
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 33 of 59
Factors affecting the glycaemic index
• Type of sugar
– glucose, fructose, galactose
• Nature of starch
– amylose, amylopectin
• Starch-nutrient interactions
– resistant starch
• Cooking/food processing
Slides current until 2008
Nutrition in diabetes
Curriculum Module III-5
Slide 34 of 59
Factors affecting the glycaemic index
• Processing/form of the food
– gelatinization
– particle size
– cellular structure
• Presence of other food
components
– fat and protein
– dietary fibre
Brand Miller J 1998
Slides current until 2008
Nutrition in diabetes
Glycaemic index of foods
Curriculum Module III-5
Slide 35 of 59
Low glycaemic
index foods
Intermediate
High glycaemic
glycaemic index index
Lentils/dahl
Rye bread
Glucose
Most fruit and
vegetables
Some rice (long
grain)
Mashed and
baked potatoes
Yogurt
Bananas
Processed
breakfast cereal
Milk
Pasta
White bread
Oats
Grapes
White rice
Slides current until 2008
Nutrition in diabetes
Practical advice
Curriculum Module III-5
Slide 36 of 59
• Eat more vegetables, fruit, whole
grains, and low-fat milk
• One low GI food at each meal
• Mix high and low GI food =
intermediate GI meal
• Substitute high GI
cereals/breads/rice with low GI
cereals/bread/rice
• Eat low GI snacks instead of high
GI snacks (remember to choose
lower fat snacks)
Slides current until 2008
Nutrition in diabetes
Low glycaemic index diet –
advantages
Curriculum Module III-5
Slide 37 of 59
• Promotes healthy eating
• Increases fibre intake
• Helps control appetite
• Helps control blood glucose levels
• Helps lower blood lipid levels
• Assists weight loss
• Offers a more comprehensive
approach for type 2 diabetes
• Reduces risk of type 2 diabetes and
heart disease
Slides current until 2008
Nutrition in diabetes
Low glycaemic index diet –
disadvantages
Curriculum Module III-5
Slide 38 of 59
• Mixed meal is a combination of the
glycaemic effect of all the foods
• Does not include guidance on fat
intake
• May reduce choice and flexibility
• Difficult to maintain a low glycaemic
index diet for long periods
• Requires an effort to remember
which foods have high or low
glycaemic index
Slides current until 2008
Nutrition in diabetes
Food exchanges
Curriculum Module III-5
Slide 39 of 59
• Carbohydrate exchange
• Cereal and pulse
exchange
• Fat/oil exchange
• Protein exchange
• Milk exchange
• Fruit exchange
• Vegetable exchange
Slides current until 2008
Nutrition in diabetes
Food exchanges
Curriculum Module III-5
Slide 40 of 59
• Similar food types placed in exchange
groups
• Within groups, a single food based on
weight/measure/size has the same
carbohydrate or kcal value as another and
can be interchanged
• In the case of cereal exchanges: 1 slice of
bread can be exchanged for 1/3 cup rice
• Foods from different groups cannot be
interchanged – 1 slice of bread cannot be
exchanged for 1½ tsp of butter
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting – Level 1
Curriculum Module III-5
Slide 41 of 59
• Assesses only CHO not protein
or fat
• Goal
– carbohydrate consistency with
food intake and blood levels
• Advantage
– flexible food choices
• Useful for
– all types of diabetes
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting – Level 2
Curriculum Module III-5
Slide 42 of 59
• Goal
– adjust medication/food/activities
based on blood glucose patterns
from daily records
• Advantage
– lifestyle flexibility
• Useful for
– people taking part in diets, using
glucose-lowering medicines and
insulin who can implement Level 1
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting – Level 3
Curriculum Module III-5
Slide 43 of 59
• Goal
– to be able to adjust insulin dose
using a carbohydrate/insulin ratio
• Advantage
– flexibility of food and insulin
regimen with tight glucose control
• Useful for
– people on intensive insulin therapy
– people who have mastered insulin
adjustment and supplementation
Slides current until 2008
Nutrition in diabetes
Carbohydrate exchanges
Curriculum Module III-5
Slide 44 of 59
• Amount and type influences
blood glucose levels
• Sucrose can be substituted for
equal amounts of another
carbohydrate without adverse
effect
• Carbohydrate rich foods are
– grains/potatoes/legumes
– fruit
– milk
ADA 2004
Slides current until 2008
Nutrition in diabetes
Carbohydrate exchanges
Curriculum Module III-5
Slide 45 of 59
• 1 carbohydrate exchange = 10-15 g
carbohydrate
• 1 starch/cereal exchange (10-15 g)
• 1 small potato/legume exchange
(10-15 g)
• 1 fruit exchange (10-15 g)
• 1 milk exchange (10-15 g)
Example: ½ cup pasta = 1 cup milk =
1 small banana = 1/3 cup rice
Slides current until 2008
Nutrition in diabetes
Carbohydrate exchanges
Curriculum Module III-5
Slide 46 of 59
• Use exchange lists to count
carbohydrate
– 1 carbohydrate exchange = 15 g
= 1/3 cup rice
– 1 cup rice = 45 g carbohydrate
• Calculate carbohydrate amount for
each meal
– count carbohydrate as above for
each food item in the meal
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting
Curriculum Module III-5
Slide 47 of 59
Information sources
• Prepared carbohydrate exchange
lists for meal planning
• Food labels
• Nutrient reference books
• Computerized, pre-programmed
food scales
• Internet websites
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting
Curriculum Module III-5
Slide 48 of 59
Food diary
• Type of food
• Portion size
• Record amount of carbohydrate
in each food
• Time of food intake
eg 1 cup rice (45 g carbohydrate)
for lunch at 13.00 hr
Slides current until 2008
Nutrition in diabetes
Counting recipes
Moroccan chicken stew (serves 4)
Curriculum Module III-5
Slide 49 of 59
Carb (g)
2 cups chicken broth
0
¼ cup tomato paste
6
1 tsp cummin
0
1 tsp salt
0
1/8 tsp cinnamon
0
½ cup dark raisins
58
1 medium onion, finely sliced
16
1 tblsp mince garlic
1 can (440 g) of chick peas
8 chicken thighs
Total carbohydrate
Per person
4
108
0
192
48
Slides current until 2008
ACTIVITY
Nutrition in diabetes
Curriculum Module III-5
Slide 50 of 59
Examine a carbohydrate exchange
list
• Discuss how useful they would
be in meal planning
• Are carbohydrate exchanges
suitable for all people?
• What are the advantages and
disadvantages of carbohydrate
counting?
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting –
advantages
Curriculum Module III-5
Slide 51 of 59
• Focus on nutrient with greatest
impact on blood glucose
• Permits flexible food choices
• Food and insulin can be adjusted
easily and accurately
• Offers potential for improved blood
glucose, especially for those on
insulin
• People become skilled and feel more
in control
• Improves quality of life
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting –
disadvantages
Curriculum Module III-5
Slide 52 of 59
• Need for arithmetic agility and
understanding
• Requires accurate and detailed
food records
• Difficult to estimate portion sizes
initially
– requires weighing and
measuring
• Does not consider amount of fat,
protein or type of carbohydrate
Slides current until 2008
Nutrition in diabetes
Carbohydrate counting –
disadvantages
Curriculum Module III-5
Slide 53 of 59
• Does not specify fibre content
• Requires frequent blood glucose
estimations
• Difficult and expensive to record
blood glucose
• Depends on people being
motivated
• May be too complicated for some
people and detract from pleasure
of eating
Slides current until 2008
ACTIVITY
Nutrition in diabetes
Curriculum Module III-5
Slide 54 of 59
• Identify local carbohydrate
foods (staples)
• Identify local foods that may be
discouraged due to diabetes
• Discuss myths and appropriate
educational strategies
Slides current until 2008
Nutrition in diabetes
Summary
Curriculum Module III-5
Slide 55 of 59
Diabetes dietary management requires:
• Individual assessment
• Regular dietetic review
• Weight management
• HbA1c control
• Lipid management
• Control of hypertension
• Tailoring medication and/or insulin
around food patterns
Slides current until 2008
Nutrition in diabetes
Summary
Curriculum Module III-5
Slide 56 of 59
The behavioural/counselling approach
to diet management includes
identifying barriers to change and
includes:
• Dietary management/food
preferences and patterns
• Lifestyle
• Culture
• Social issues
• Physical activity
Slides current until 2008
Nutrition in diabetes
References
Curriculum Module III-5
Slide 57 of 59
1.
Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on
blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336(16): 111724.
2.
Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf
B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M; American Diabetes Association.
Evidence-based nutrition principles and recommendations for the treatment and prevention
of diabetes and related complications. Diabetes Care 2003; 26 Suppl 1: S51-61.
3.
Bailey CJ, Feher MD. Therapies for diabetes including oral agents and insulins. Sherbourne
Gibbs Ltd, 2004. ISBN 1.905036.00.0
4.
Brand Miller J, Foster-Powell K, Colagiuri S, Leeds A. The GI factor. Hodder 1998.
5.
Franz M, Montz A, Bergenstal R, et al. Outcomes and Cost-effectiveness of Medical Nutrition
Therapy for non-insulin dependent diabetes mellitus. Diabetes Spectrum 1996; 2: 122-27.
6.
DCCT Research Group. Effect of intensive diabetes management on macrovascular events
and risk factors in the Diabetes Control and Complications Trial. Am J Card 1995; 75(14):
894-903.
7.
DCCT Research Group. The effect of intensive treatment of diabetes on the development
and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J
Med 1993; 329(14): 977-86.
8.
Gillespie SJ, Kulkarni KD, Daly AE. Using carbohydrate counting in diabetes clinical practice.
J Am Diet Assoc 1998; 98(8): 897-905.
Slides current until 2008
Nutrition in diabetes
References
Curriculum Module III-5
Slide 58 of 59
9.
Diabetes Prevention Research Group. Reduction in the evidence of type 2 diabetes with
life-style intervention or metformin. N Engl J Med 2002; 346: 393-403.
10.
Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in
patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised
study. Lancet 1999; 353(9153): 617-22.
11.
Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in
patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383-93.
12.
Glycemic Index Explained (cited 2004 Nov 14) (23 pages) Available from URL:
http://www.diabetes.ca/Files/Glycemic%20Index%20Presentation.pdf
13.
Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord
1992; 16(6): 397-415.
14.
Jung RT. Obesity as a disease. British Medical Bulletin 1997; 53(2): 307-21.
15.
Laing SP, Swerdlow AJ, Slater SD, Burden AC, Morris A, Waugh NR, Gatling W, Bingley PJ,
Patterson CC. Mortality from heart disease in a cohort of 23,000 patients with insulintreated diabetes. Diabetologia 2003; 46(6): 760-5.
16.
Larsen J, Brekke M, Sandvik L, et al. Silent coronary atheromatosis in type 1 diabetic
patients and its relation to long-term glycemic control. Diabetes 2002; 51(8): 2637-41.
17.
Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. Multiple
Risk Factor Intervention Trial Research Group. JAMA 1997; 277(7): 582-94.
Slides current until 2008
Nutrition in diabetes
References
Curriculum Module III-5
Slide 59 of 59
18.
Nathan DM, Lachin J, Cleary P, et al. Diabetes Control and Complications Trial.
Epidemiology of Diabetes Interventions and Complications Research Group. Intensive
diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus. N Engl
J Med 2003; 348(23): 2294-303.
19.
Powers MA. Medical Nutrition Therapy for Diabetes, Handbook of Diabetes Medical
Nutrition Therapy, Aspen Publication. 1996.
20.
Sacks FM, Svetkey LP, Vollmer WM, et al. DASH-Sodium Collaborative Research Group.
Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop
Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med
2001; 344(1): 3-10.
21.
UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in patients with type 2 diabetes
(UKPDS 33). [erratum appears in Lancet 1999 Aug 14; 354(9178): 602]. Lancet 1998;
352: 837-53.
22.
UKPDS Group. Overview of 6 years' therapy of type II diabetes: a progressive disease.
U.K. Prospective Diabetes Study Group.(UKPDS 16). [erratum appears in Diabetes
1996; 12; 45(11):1655]. Diabetes 1995; 44(11): 1249-58.
23.
UKPDS Group. Efficacy of atenolol and captropril in reducing risk of macrovascular and
microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998; 317: 713-20.
Slides current until 2008