Diabetes Quiz

“As genetics and family history play such an important role in a person becoming diabetic, it is quite possible to prevent it. More important than this is the fact that your lifestyle has to change. If you come from a family of diabetics, you know you are at risk, and by taking simple preventive measures like checking obesity, taking the right diet and exercise etc. , diabetes can be prevented or delayed. It is not only life but the quality of life that one s talking about; survival of a healthy being with all his functions intact.”
- Dr. M Viswanathan (from an article in the IndianExpress-1994)



Diabetes Quiz

1. Diabetes is a condition where:

A. Blood glucose is too low
B. Blood glucose is too high
C. The body stops making blood glucose

2. People can have different types of diabetes.

A. True
B. False

3. You can control your blood glucose level if you:

A. Make healthy food choices and are active every day
B. Maintain a healthy weight
C. Take your medicine, if needed
D. Check your blood glucose
E. All of the above

4. People with diabetes can eat sweets and desserts.

A. True
B. False

5. Carbohydrate foods that are rich in fibre are:

A. White bread and white rice
B. Whole grain foods and fresh fruits and vegetables
C. Sweetened fruit drinks
D. Sweets and desserts

6. If you have diabetes, you should:

A. Get 60 minutes of physical activity every day
B. Get 20 minutes of physical activity every week
C. Limit your physical activity
D. Try to walk 10,000 steps a day
E. Both A and D

7. A source of healthy fat in the diet is:

A. Chicken skin
B. Whole milk
C. Nuts and avocado
D. Butter

8. You can get enough physical activity by just:

A. Watching TV and playing video games
B. Going for a walk on the weekend
C. Swimming at the beach in the summer
D. Being active every day in a way you enjoy

9. People with diabetes should not eat at fast food restaurants.

A. True
B. False

10. People get type 2 diabetes because:

A. They have certain genes
B. They are overweight
C. They have a family member who has diabetes
D. They are American Indian, Alaska Native, African American, Hispanic/Latino, Asian American, or Pacific Islander
E. All of the above

Answers to the Diabetes Quiz

1. B. The food you eat provides glucose which is needed for energy. However, too much glucose in your blood isn't healthy.

2. A. In type 1 diabetes, the cells in the pancreas that make insulin are destroyed. In type 2 diabetes, the pancreas still makes some insulin but cells cannot use it very well.

3. E.

4. A. Desserts contain a lot of fat as well as sugar. If you choose to eat any of these sweet foods, just have a small amount at the end of a healthy meal. Talk to your dietitian about how you can include desserts into your meal plan.

5. B. Some carbohydrates are better than others. Fibre-rich carbohydrates such as whole grain foods and fresh fruits and vegetables are better than white bread and white rice, sweetened fruit drinks, and sugary desserts. If you eat too many carbohydrates at one time, your blood glucose may get too high.

6. E. Activity is an important part of a healthy lifestyle. It energizes, and helps you focus at work. Start slowly. Do something that you like—riding a bike, some sport, or dancing or walking. Slowly work up to at least 60 minutes every day. Use a pedometer and aim for 10,000 steps a day.

7. C. Some types of fats are better than others. A quarter cup of nuts or one slice of avocado is better than chicken skin, whole milk, and butter. Choose low-fat or nonfat milk. All fats have lots of calories, so limit the size of your portion.

8. D. Physical activity can make you feel better if you are in a bad mood or stressed out. It also helps your body use blood glucose for energy. You don't have to play a sport or go to a gym. You can do something interesting like taking a walk or dancing with family members and friends instead of watching TV and playing video games.

9. B. You can, but only a limited quantity. Consult your dietitian.

10. E. Obesity, family genes, and race are all risk factors for diabetes.

Diabetic Nephropathy

Diabetes- blood sugar
Nephropathy: kidney disease

Sravanthi Allareddy
(Research Associate)
Department of Prevention of Diabetic Kidney Disease



Diabetic Nephropathy, a complication of diabetes, is a kidney disease caused by too much sugar in the blood. High levels of sugar in the blood can damage tiny blood vessels in the kidneys, making them fail to function normally. Their functions include filtering waste products from the body, regulating the balance of electrolyte and secreting essential hormones. Therefore, patients with Diabetic Nephropathy will have problems, regarding renal function.






Untreated or poorly treated, Diabetic Nephropathy will progress to renal failure rapidly.

People who have diabetes as well as high blood pressure are at greater risk of kidney problems because uncontrolled blood pressure hastens the progress of kidney damage as shown in the figure below.


Diabetic nephropathy can occur in both:
* Type 1 diabetes
* Type 2 diabetes

Causes, incidence, and risk factors

* Each kidney is made up of hundreds of thousands of small units called nephrons. These structures filter your blood and help remove wastes from your body.
* In people with diabetes, the nephrons thicken and slowly become scarred over time. The kidneys begin to leak and protein (albumin) passes into the urine.
* Poor control of blood sugar is thought to lead to kidney damage. If you also have high blood pressure, kidney damage is even more likely.
* In some cases, your family history may also play a role.
* People with diabetes who smoke and those with type 1 diabetes that started before the age of 20 have a higher risk for kidney problems.
* People of African-American, Hispanic, and American Indian origin are also more likely to have kidney damage.

Symptoms

* Often, there are no symptoms as the kidney damage starts and slowly gets worse. Kidney damage can begin 5 to 10 years before symptoms start.
* People who have more severe kidney disease may have a poor appetite, feel tired most of the time, and have a general ill feeling
* Headache, vomiting, swelling, and many other symptoms may also occur.

Signs and tests


* Once a year, people with diabetes should test their urine . The urine test looks for a protein called albumin. Because the test looks for small amounts of albumin, it is sometimes called a test for microalbuminuria. Too much protein is often a sign of kidney damage.
* High blood pressure often goes along with diabetic nephropathy. You may have high blood pressure that begins quickly or is hard to control.




Check your kidneys with the following blood tests every year:
* BUN
* Serum creatinine

Other lab tests that may be done include:

* 24-hour urine protein
* Blood levels of phosphorus, calcium, bicarbonate, PTH, and potassium
* Hemoglobin
* Hematocrit
* Protein electrophoresis - urine

A kidney biopsy confirms the diagnosis. However, biopsy is not needed all the time, but for correct diagnosis to conform.


Treatment

* Keeping blood pressure under control (under 130/80) is one of the best ways to slow kidney damage.
* To protect kidney damage, often the best types of medicine to use are ACE inhibitors and angiotensin receptor blockers (ARBs) such as ramipril, almisarton etc
* Eating a low-fat diet, taking drugs to control lipids, and getting regular exercise can also help prevent or slow kidney damage.

Urinary tract and other infections are common, and can be treated with antibiotics.

Gestational Diabetes Mellitus

Glucose intolerance recognized for the first time during pregnancy.

Dr.PRIYA JAIGANESH M.B.B.S., FCD
- Duty Doctor
MV Hospital for Diabetes,
Royapuram.


CAUSES:

Placental hormones, human placental lactogen and placental growth hormone, which are meant to shunt nutrients to the fetus, cause worsening of insulin resistance during the late 2nd trimester

Mothers are unable to produce enough insulin to overcome the overwhelming resistance to maintain normal blood glucose levels.


DIAGNOSTIC CRITERIA

All pregnant women should undergo a 2 hour 75 gm- oral glucose tolerance test between the 24th and 28th week of pregnancy.

Fasting – 92 mg/dl
1 hr - 180 mg/dl
2 hr - 153 mg/dl

Gestational diabetes mellitus is diagnosed if any 2 values are equal to, meet, or exceed the values given above.

FOLLOW UP:

* Every 3 weeks till 28 weeks of pregnancy
* Every 2 weeks from 29 weeks to 34 weeks of pregnancy
* Every week from 35 wks to term
* Every 2 weeks from 29 weeks to term, if not on insulin.


AFTER DELIVERY

RISK FACTORS FOR TYPE 2 DIABETES MELLITUS FOLLOWING GESTATIONAL DIABETES MELLITUS

Unmodifiable risk factors

Ethnicity
Age
Family history
Degree of hyperglycemia in pregnancy

Modifiable risk factors

Obesity
Future weight gain

SCREENING:

6-12 weeks after delivery, a follow up of 75 gm oral glucose tolerance test (GTT) should be performed to determine the women’s risk of developing diabetes and her status. If found normal , GTT should be repeated after 6 months and then after each year.

PREVENTION:

Women who have had gestational diabetes mellitus are at a heightened risk for type 2 diabetes mellitus and so the best advice is:

* A LOW FAT DIET



* AVOIDANCE OF OBESITY



* REGULAR EXERCISE.

LADA (Latent Autoimmune Diabetes of Adulthood)

LADA ( Latent Autoimmune Diabetes of Adulthood), or Type 1.5 (type one-and-a-half) diabetes

Dr. Mitalee Barman, Consultant Diabetologist
M.V Hospital for Diabetes

Till recently, people had either Type 1 diabetes (where the body stops making insulin) or Type 2 diabetes (where insulin is produced but the body cannot use it). There was also gestational diabetes – high blood glucose levels during pregnancy, which with good prenatal care, returned to normal after delivery.

LADA or Latent Autoimmune Diabetes of Adulthood is a relatively new kind of diabetes that affects adults and shares some features of both Type 1 and Type 2 diabetes.

Doctors came across LADA in the 1970s while they were conducting tests to identify proteins called auto­-antibodies in the blood of people with type 1 diabetes.

As part of their study, the researchers also looked for the same auto antibodies in the general population and in people with type 2 diabetes (which is not an autoimmune disease).The proteins were almost absent in the general population, but they were seen in about 10 percent of people diagnosed with Type 2.

How is LADA different from Type 1 and Type 2 Diabetes?

LADA is a genetically-linked, hereditary autoimmune disorder where the body confuses the pancreas with foreign bodies and reacts by attacking and slowly destroying the insulin-producing beta islet cells. But the attack is a slow progressive one with LADA, compared to the fast and aggressive attack on the beta cells in Type 1 diabetes. These same proteins are absent in those with Type 2 diabetes.

LADA has genetic features of both Type 1 and Type 2. Genetic testing recently revealed that people with LADA not only have immunity-related genetic errors very similar to people with juvenile onset Type 1 diabetes but also have defects in a gene, TCF7L2, (responsible for insulin resistance), that are frequently found in people with Type 2.


So LADA appears to be between Types 1 and 2 though perhaps it is more like Type 1. The difference between LADA and classic Type 1 is the speed with which beta cells are destroyed. People with LADA may take up to a decade to lose all their insulin-secreting capacity whereas in some people with Type 1 it can happen within a week!

People with type 1 become dependent on insulin at diagnosis while those with LADA usually need it within 6 years and Type 2 takes a lot more time, if at all necessary.

Age of onset of LADA is typically over the ages of 25-30 years and the first manifestation imitates Type 2 symptoms. Type 1 diabetes is more commonly diagnosed in childhood or under the age of 25, however, LADA shows a striking resemblance to the juvenile form of Type 1.

Progression to insulin dependence in Type 1 is rapid (days or weeks).In cases of LADA it may be delayed (months to years) and in Type 2 it is very slow.


Many LADA patients are slender and active instead of being overweight and sedentary as most Type 2 diabetes patients are. But not all people with LADA are slim. People with defective autoimmune genes are also likely to get thyroid disease and rheumatoid arthritis both of which can promote obesity. Thyroid disease which is not treated correctly makes a person obese, and people with rheumatoid arthritis cannot exercise too much and in addition, this is often treated with steroids that promote weight gain.

Unlike Type 2 diabetes patients, people with LADA have little or no insulin resistance. But like Type 2 diabetes patients, those with LADA have some remaining healthy beta cells -- at least in the beginning. So, at first they can keep their blood glucose under control with diet and oral medications. The typical person with LADA requires insulin injections usually within 6 years which is much quicker than the average person with Type 2 diabetes.


How is LADA diagnosed?

Due to its similarities to Type 1 and Type 2, LADA can often be misdiagnosed as Type 2 diabetes as it initially mimics non-obese type 2 diabetes.

The main difference between LADA and Type 2 diabetes is that there is an autoimmune response present with LADA that is similar to that of Type 1 diabetes.

The only way to confirm whether a person has Type 2 diabetes or LADA is to test adults, especially those who are thin or normal weight, for the presence of auto antibodies. The antibodies tested for are: GAD antibodies, Islet cell antibodies, and more rarely, tyrosine phosphatase antibodies.

Tests that detect LADA

1. A fasting C-peptide test. If the value is low, it suggests LADA.

2. GAD ( glutamic acid decarboxylase test)and Islets antibody tests. High levels of these antibodies show the presence of LADA and can also predict the rate of progression towards insulin dependency. Higher levels of antibodies suggest a faster progression to insulin.

Low levels of antibodies relate to type 2 diabetes and people are more likely to be over- weight , have some insulin resistance and respond to tablets that act on insulin resistance.

Very high antibody levels are similar to type 1 diabetes and people are likely to have acute symptoms (thirst, unexplained weight loss, frequent urination, dry mouth) , are less likely to be overweight and may need insulin treatment soon after diagnosis.

Symptoms:

LADA has the classic symptoms of diabetes. These are increased thirst, increased need to urinate, fatigue, dry mouth, blurry vision, and slow healing of cuts or sores.

Other indicators of LADA:



* The symptoms appear over a period of several weeks or longer,
* There is someone with Type 1 diabetes in the close family,
* The person has another autoimmune condition such as Rheumatoid Arthritis or Coeliac disease.
* Blood sugar remains high despite treatment with oral drugs and carbohydrate restriction.





It is important to know whether you have LADA or T2DM

Knowing whether you have LADA or Type 2 diabetes is important, because management of the two conditions differs. Type 1 diabetes that begins at any age requires a finely tuned insulin regimen, while people with Type 2 diabetes sometimes do not need insulin at all or, when they do, may need injections just once a day.

People with LADA are often thin, so if you are thin and have been diagnosed with Type 2 diabetes, test for LADA.

Managing LADA


* As with other types of diabetes, eat a healthy, balanced diet and be active.

*Reducing carbohydrate intake and using less starchy vegetables should help to control blood sugar levels.


*The sooner insulin is started the easier it will be to control blood sugar .Insulin injections may be able to stop the attack on beta cells completely.

*Counseling, therapy and participation in support groups can play an important and positive role in the lives of persons with LADA.

*It is important to learn about diet, exercise, stress management, and how to handle diabetes on sick- days .Patients need to understand how to recognize, treat, and prevent hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar).

*Blood glucose levels should be checked. The doctor will provide target ranges for blood glucose levels and how often it needs to be tested.

Treatment for LADA



Initially, a person with LADA may respond to oral diabetes medications and lifestyle changes, however, beta cells continue to be destroyed and LADA patients should be closely monitored. Once blood glucose can no longer be managed through lifestyle and medications, daily insulin injections will be required.

Long-term complications of LADA

The risk of long-term effects are directly related to how well the disease is managed from time of onset as well as over a period of time.

Uncontrolled diabetes results in high blood glucose levels (hyperglycemia) which, over time may cause, diabetic neuropathy, diabetic retinopathy, kidney failure, heart disease, high blood pressure, stroke, peripheral arterial disease (PAD), chronic infections and wounds that may not heal, erectile and other urologic dysfunction, gastroparesis (delayed emptying of stomach contents), blindness, amputation, lactic acidosis, and diabetic ketoacidosis (DKA).

LADA patients will become dependent on insulin to keep blood glucose control , but it is possible to lead a normal life. Patient education, motivation, and state of mental health all play an important role in how well a person with LADA will be able to manage their disease.

Food for thought

A few decades ago this was a rare syndrome. Could this rapid increase be the result of environmental pollution? Chemicals, radiation, and viruses can all cause cancer in people in which case they could also be a reason for autoimmune diabetes in people with defects in their autoimmune genes.

Painful Diabetic Neuropathy

What symptoms do people get?

Bamila S & Seena Rajsekhar

M.V. Centre for Diabetic Foot Care, Podiatry, Research & Management

Commonly reported symptoms include...


Burning sensation as if feet are on fire


Freezing sensation as if feet are on ice although they feel warm to touch.


Stabbing sensation, as if from sharp knives.


Lancinating sensation like electric shocks.

Abnormalities of the foot which worsen the effects of neuropathy or vascular disease...


High Instep


Bunions


Clawed Toes


Abnormal Toe nails


Rocker bottom deformity with neuropathic ulcer



Maceration


Very dry skin


Deformed toes which cause excessive pressure at the tip and at the top.


Take Care of Your Feet

Daily foot care should include the following:

Look at your feet - every day. Look at the top and bottom of your foot. Check between your toes and around the heel area.


What to look for:
• Bruises
• Cracks/breaks in skin
• Soggy skin
• Dry skin
• Swellings/swelling in only one foot or leg
• Corns and calluses
• Ingrown toenails
• Blisters
• Sharp toe nails
• Hot/cold spots
• Discolouration
• Anything that is not normal or that was not there yesterday


If you are unable to see your foot, use a mirror or ask someone to help you.


Check for Corns and Calluses (hardened skin).

Corns and calluses can be a problem. They cause pressure and can lead to ulceration. Never trim or cut a corn yourself. The only safe way to treat a corn or callus is to see a podiatrist.


Wash your feet every day using plain water and mild soap. Dry your feet well using a light coloured towel, especially between the toes. Look at the towel to make sure there is no blood or pus on it. If you can see any blood or pus tell your doctor immediately.


Rub cream into your feet to stop them getting dry and cracked. Do not put cream between the toes. Use the cream twice a day if your feet are very dry.

A properly cut toe nail


A poorly cut toe nail


Do not cut your nails too short. Cut your nails straight across. Always check your nails for sharp edges. To smooth sharp edges use a nail file. If you are unable to cut your nails, see a podiatrist.

Consult with your Podiatrist regularly.

You can get routine integrated examination for your feet at the M.V. Centre for Diabetic Foot Care, Podiatry, Research and Management, Royapuram. The clinic provides education on practical aspects of foot care, early recognition of the foot at risk, advice on the selection of special footwear and comprehensive care for all diabetic foot complications.

At the M.V. Hospital for Diabetes, Royapuram, you will find a wide range of foot wear to suit your requirement including custom- built foot wear with moulded insole made at our in-house facility.
The DiaStep is a specially designed shoe made in collaboration with The Central Leather Research Institute, Chennai supported by Novo Nordisk Educational Foundation. It is suitable for diabetic patients with neuropathy, minor foot deformities and for those who have had minor foot complications.
It distributes pressure effectively, has better grip and traction, is comfortable, ensures limited joint movement and prevents foot ulcers and foot infections.

Constipation

Aruna.V, Dietician

Constipation happens to everyone occasionally, but some people suffer from chronic constipation which makes their lives a misery and each bowel movement a huge relief! Constipation is a symptom, not a disease. Understanding its causes, prevention, and treatment will help most people find relief.

About one in every four diabetics experience frequent bouts of constipation, making it by far the most common gastrointestinal issue for people with diabetes. The problem afflicts both, type 1 and type 2 diabetes sufferers, and is known to be significantly more prevalent among those diabetics who also suffer from nerve damage.

Definition: Constipation is defined as having a bowel movement fewer than three times per week. With constipation, stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.

Some people think they are constipated if they do not have a bowel movement every day. Bowel habits vary from person to person. However, normal stool elimination may be three times a day or three times a week, depending on the person.

What causes constipation?

Know how the colon or large intestine works to understand constipation. As the food moves through the colon, water is absorbed during the process of forming waste products or stool. Muscle contractions in the colon then push the stool toward the rectum. By the time the stool reaches the rectum, it is solid because most of the water has been absorbed.

Constipation occurs when the colon absorbs too much water or if the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry.

Causes:

1. Occasional constipation is usually caused by the diet, the lack of exercise, stress, or drinking insufficient liquids.

2. Chronic constipation can be caused by a variety of factors, including digestive disorders such as Irritable Bowel Syndrome (IBS), the lack of fiber and fluids in the diet, depression, the lack of exercise and some medical conditions such as diabetes, colon cancer and hypothyroidism.

3. Constipation may also be a side effect of some prescription drugs, high blood pressure and pain relief. Many people also lose the natural bowel movements due to the overuse and abuse of OTC and prescription laxatives.

* The Diet


People who eat a high-fiber diet are less likely to become constipated. The most common causes of constipation are a diet low in fiber or a diet high in fats, such as cheese, eggs, and meats. Both children and adults, often eat too many refined and processed foods from which the natural fiber has been removed.

A low-fiber diet also plays an important role in constipation among older adults, who may lose interest in eating and choose foods that are quick to make or buy, such as fast foods, or prepared foods, both of which are usually low in fiber. Also, difficulties with chewing or swallowing may cause older people to eat soft foods that are processed and low in fiber.

* Liquid Intake

Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. People who have problems with constipation should try to drink liquids every day. However, liquids that contain caffeine, such as coffee and cola drinks will worsen one's symptoms by causing dehydration. Alcohol is another beverage that causes dehydration. It is important to drink fluids that hydrate the body, especially when consuming caffeine containing drinks or alcoholic beverages.

* Changes in Life or Routine

During pregnancy, women may be constipated because of hormonal changes or because the uterus compresses the intestine. Aging may also affect bowel regularity, because a slower metabolism results in less intestinal activity and muscle tone. In addition, people often become constipated when traveling, because their normal diet and daily routine are disrupted.

* Specific Diseases

Diseases that cause constipation include neurological disorders, metabolic and endocrine disorders (Diabetes, Uremia, Hypocalcaemia, poor glycemic control, Hypothyroidism), and systemic conditions that affect organ systems. These disorders can slow the movement of stool through the colon, rectum, or anus.

* Physical Activity

Constipation often occurs after an accident or during an illness when one must stay in bed and cannot exercise. Lack of physical activity is thought to be one of the reasons constipation is common in older people.

Can constipation be serious?

Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement, or anal fissures—tears in the skin around the anus—caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.

Health problems caused by constipation:

* Bad Breath * Headaches * Body Odor * Hemorrhoids * Anal fissures

* Rectal bleeding * Rectal prolapse (rare) * Fecal impaction * Varicose Veins

* Septicemia* Colon and colorectal cancer

* DEATH = There's an old saying "Death begins in the colon." That's right. Constipation can even cause death if it is not treated properly. When constipated, bacteria and toxins are stored in the body and they get reabsorbed into the bloodstream. At first, this might not cause big problems. But the bacteria levels will increase as time passes and eventually, bacteria and toxins will spread all over your body and this is when serious problems, like colon cancer and death, can happen.

How is constipation treated?

Although treatment depends on the cause, severity, and duration of the constipation, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent them from recurring.

Diet

A diet with enough fiber (20 to 35 grams each day) helps the body form soft, bulky stool. High-fiber foods include beans, whole grains and whole cereals, fresh fruits, and vegetables such as asparagus, sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as cheese, meat, and processed foods, is also important.




Drink plenty of water and fluids


Drinking plenty of water and other liquids including clear soups and fruit and vegetable juices will help prevent constipation. Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass.


Get enough exercise

Regular exercise helps your digestive system stay active and healthy. You don't need to become a great athlete. Simply taking a 20/30-minute walk everyday will help a lot.

Give yourself time

Our hectic schedules keep us feeling in a hurry all the time that we don't pay attention to our body's needs, especially to the urge to have a bowel movement. Allowing yourself enough time in the toilet will ensure that you ease your constipation troubles too.

Tips and Natural remedies


1. Drinking a glass of warm milk at the time of going to bed helps in evacuation, the next morning.

2. Do not stay up late in the night. Regulate your sleeping hours.

3. After you wake-up, drink 2 or 3 cups of water. This will help to push the faeces out of the gut.

4. Apple, papaya, banana and guava help prevent constipation and can be eaten anytime of the day. These provide roughage and clear the bowel.

5. All Greens can be eaten raw or cooked to clear the bowel system and digestive trackt. Deficiency of the mineral magnesium may contribute to constipation. Magnesium is found in natural foods such as green leafy vegetables, nuts, seeds and whole grains and in supplements and can be consumed suitably.







Reference:

1. National Digestive Diseases Information Clearinghouse (NDDIC). NIH Publication No. 07–2754, July 2007. www.digestive.niddk.nih.gov.

2. Diabetes Information Library. Diabetes And Constipation: An Awkward But Real Issue. Author: Michele Carlese, Naturopath, Herbalist. Source: Healthy Living, July 2, 2007

3. Constipation and Herbal management, Monday, October 4, 2010. http://www.siddhapedia.com/2010/10/constipation-and-herbal-management.html

4. Srilakshmi, B. Dietetics, 5th edition, 2005, 221-223.