diaendoСахарный диабетDiabetes mellitus2072-03512072-0378Endocrinology research centre10.14341/DM13112diaendo-13112Research ArticleОригинальные исследованияOriginal StudiesЭпизоды гипогликемии среди пациентов с диабетом 1 типа в Унайзе, Саудовская Аравия: причины, лечение и связанные с ними факторыHypoglycemic episodes among type 1 diabetic patients in Unaizah, Saudi Arabia: causes, management, and associated factorshttps://orcid.org/0009-0002-5515-9484AldekheelS.K.S.AldekheelS.K.S.

Sara K. Aldekheel - BSN, MSN, Diabetes Educator at Diabetes Center, King Saud Hospital.

Унайза

Sara K. Aldekheel - BSN, MSN, Diabetes Educator at Diabetes Center, King Saud Hospital.

Unaizah

ucs9983@gemail.comhttps://orcid.org/0000-0001-5145-3702ShahinM.A.S.ShahinM.A.S.

Mahmoud A. Shahin - BSN, MSN, PhD, Associate Professor of Medical-Surgical and Critical Care Nursing, Nursing Department, Prince Sultan Military College of Health Sciences; ResearcherID: HJH-8298-2023; Scopus Author ID: 57219535767.

Al Amal, Dhahran 34313

 

Mahmoud A. Shahin - BSN, MSN, PhD, Associate Professor of Medical-Surgical and Critical Care Nursing, Nursing Department, Prince Sultan Military College of Health Sciences; ResearcherID: HJH-8298-2023; Scopus Author ID: 57219535767.

Al Amal, Dhahran 34313

mahmood81us@yahoo.comБольница короля СаудаСаудовская АравияKing Saud Hospital, Unaizah, Qassim Health Cluster, The Kingdom of Saudi ArabiaSaudi ArabiaВоенный колледж медицинских наук принца СултанаСаудовская АравияNursing Department, Prince Sultan Military College of Health SciencesSaudi Arabia2024290220242716980Copyright © Aldekheel S., Shahin M., 20242024Aldekheel S., Shahin M.Aldekheel S., Shahin M.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.dia-endojournals.ru/jour/article/view/13112ОБОСНОВАНИЕ

ОБОСНОВАНИЕ. Сахарный диабет (СД) является распространенным заболеванием в Саудовской Аравии, им страдают примерно 20% взрослого населения, занимая шестое место в мире. Заболевание сопровождается как острыми, так и хроническими осложнениями. Среди этих осложнений особую опасность представляют эпизоды гипогликемии. У лиц с диагнозом СД 1 типа (СД1) может наблюдаться несколько эпизодов бессимптомной или симптоматической гипогликемии в неделю.

ЦЕЛЬ

ЦЕЛЬ. Оценить частоту эпизодов гипогликемии и выявить связанные с ней факторы среди лиц с СД1 в городе Унайза, Саудовская Аравия.

МАТЕРИАЛЫ И МЕТОДЫ

МАТЕРИАЛЫ И МЕТОДЫ. В апреле и мае 2023 года было проведено поперечное описательное исследование. Сформирована выборка из 280 пациентов с СД1, проживающих в районе Касим города Унайза. Участники заполнили электронную структурированную анкету, в которой собиралась информация о социально-демографических факторах и данные, связанные с гипогликемией. Для анализа данных использовались методы описательной статистики и критерий хи-квадрат, анализ проводился в программе SPSS версии 23. На протяжении всего исследования строго соблюдались этические требования.

РЕЗУЛЬТАТЫ

РЕЗУЛЬТАТЫ. Результаты показали, что более двух третей участников (72,1%) сообщили об эпизодах гипогликемии в течение последней недели. Более одной пятой из этих людей объяснили причину приступов высокими дозами инсулина (21%). Об обращении за медицинской помощью для смены лекарства при гипогликемии сообщили более половины участников (55,4%), тогда как менее половины пациентов получали помощь от других людей во время эпизодов гипогликемии (42,9%). Было замечено, что приверженность сахароснижающей терапии была выше, чем ­приверженность диете и режиму физических нагрузок. Мужчины, а также одинокие или разведенные участники сообщили о более высокой частоте эпизодов гипогликемии. Кроме того, пациенты с более высоким уровнем образования и жители сельских регионов сообщили о более высокой подверженности эпизодам гипогликемии.

ЗАКЛЮЧЕНИЕ

ЗАКЛЮЧЕНИЕ. Эффективное лечение гипогликемии требует обучения и осведомленности пациентов о ее причинах и симптомах. Целенаправленные вмешательства необходимы для улучшения соблюдения терапевтических режимов и изменения образа жизни. Кроме того, при лечении гипогликемии важно учитывать пол, семейное положение, уровень образования и место жительства пациентов с диабетом.

BACKGROUND

BACKGROUND: Diabetes mellitus is a prevalent condition in Saudi Arabia, with approximately 20% of the adult population affected, ranking sixth highest in the world. This disease is associated with both acute and chronic complications. Among these complications, hypoglycemia is particularly dangerous and can occur during diabetes treatment. Individuals diagnosed with type 1 diabetes may experience multiple episodes of asymptomatic or symptomatic hypoglycemia per week.

AIM

AIM: To assess the frequency of hypoglycemic episodes and identify associated factors among individuals with type 1 diabetes in Unaizah City, Saudi Arabia.

MATERIALS AND METHODS

MATERIALS AND METHODS: A quantitative, cross-sectional, descriptive research design was employed in April and May of 2023. A convenience sample of 280 type 1 diabetic clients living in the Qassim region of Unaizah City was selected. Participants completed an electronic structured questionnaire that collected information on sociodemographic factors and hypoglycemia-related data. Descriptive statistics and a Chi-square test were used for data analysis, utilizing SPSS version 23. Ethical considerations were strictly adhered to throughout the study.

RESULTS

RESULTS: The findings revealed that over two-thirds of the participants (72.1%) reported experiencing hypoglycemic episodes within the past week. Furthermore, more than one-fifth of these individuals attributed the cause of the episodes to high insulin doses (21%). Seeking medical assistance to change medications for hypoglycemia was reported by more than half of the participants (55.4%), while less than half received help from others during hypoglycemic episodes (42.9%). It was observed that adherence to diabetic medication was higher than adherence to diabetic diet and exercise regimens. Males, as well as single or divorced participants, reported a higher frequency of hypoglycemic episodes. Additionally, patients with higher levels of education and those residing in rural regions reported a higher exposure to hypoglycemic episodes.

CONCLUSION

CONCLUSION: The effective management of hypoglycemia necessitates patient education and awareness regarding its causes and symptoms. Targeted interventions are required to improve adherence to therapeutic regimens and lifestyle modifications. Furthermore, when managing hypoglycemia, it is important to consider the gender, marital status, educational level, and residence of diabetic patients.

эпизоды гипогликемиибольные диабетомдиабет 1 типаСаудовская Аравияфакторы рискаhypoglycemic episodesdiabetic patientstype 1 diabetesSaudi Arabiarisk factorsNo funding was received by the researchers for this researchReferencesAgrawal S, Makuch S, Dróżdż M, et al. The Impact of Hypoglycemia on Patients with Diabetes Mellitus: A Cross-Sectional Analysis. Journal of Clinical Medicine 2022; 11: 626. https://doi.org/10.3390/jcm11030626Abdelbagi, O., Musa, I. R., Musa, S. M., ALtigani, S. A., & Adam, I. (2021). Prevalence and associated factors of hypertension among adults with diabetes mellitus in northern Sudan: a cross-sectional study. BMC cardiovascular disorders, 21, 1-7.Muche EA, Mekonen BT. Hypoglycemia prevention practice and its associated factors among diabetes patients at university teaching hospital in Ethiopia: Cross-sectional study. PLoS One 2020; 15: e0238094. https://doi.org/10.1371/journal.pone.0238094Agrawal, S., Makuch, S., Drozdz, M., Dudzik, T., Domanski, I., Poreba, R., & Mazur, G. (2022). The Impact of Hypoglycemia on Patients with Diabetes Mellitus: A Cross-Sectional Analysis. Journal of Clinical Medicine, 11(3), 626. https://doi.org/10.3390/jcm11030626Ortiz MR. Hypoglycemia in Diabetes. The Nursing clinics of North America 2017; 52: 565-574. https://doi.org/10.1016/j.cnur.2017.07.006Alagiakrishnan, K., & Mereu, L. (2010). Approach to managing hypoglycemia in elderly patients with diabetes. Postgraduate medicine, 122(3), 129-137. https://doi.org/10.3810/pgm.2010.05.2150Chaudhury A, Duvoor C, Reddy Dendi VS, et al. Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Frontiers in endocrinology 2017; 8: 6. https://doi.org/10.3389/fendo.2017.00006AlTowayan, A., Alharbi, S., Aldehami, M., Albahli, R., Alnafessah, S., Alharbi, A. M., & Alharbi, S. M. (2023). Awareness Level of Hypoglycemia Among Diabetes Mellitus Type 2 Patients in Al Qassim Region. Cureus, 15(2).Gonzalez C, Monti C, Pinzon A, et al. Prevalence of hypoglycemia among a sample of sulfonylurea-treated patients with Type 2 diabetes mellitus in Argentina: The real-life effectiveness and care patterns of diabetes management (RECAP-DM) study. Endocrinología, Diabetes y Nutrición 2018; 65: 592-602Bonds, D. E., Kurashige, E. M., Bergenstal, R., Brillon, D., Domanski, M., Felicetta, J. V., . . . Group, A. S. (2007). Severe hypoglycemia monitoring and risk management procedures in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. The American journal of cardiology, 99(12A), 80i-89i. https://doi.org/10.1016/j.amjcard.2007.03.026Hamdy O. Hypoglycemia, https://emedicine.medscape.com/article/122122-overview?icd=login_success_email_match_norm (2021)Chaudhury, A., Duvoor, C., Reddy Dendi, V. S., Kraleti, S., Chada, A., Ravilla, R., . . . Mirza, W. (2017). Clinical Review of Antidiabetic Drugs: Implications for Type 2 Diabetes Mellitus Management. Frontiers in endocrinology, 8, 6. https://doi.org/10.3389/fendo.2017.00006Torimoto K, Okada Y, Hajime M, et al. Risk Factors of Hypoglycemia in Patients with Type 2 Diabetes Mellitus: A Study Based on Continuous Glucose Monitoring. Diabetes Technol Ther 2018; 20: 603-612. https://doi.org/10.1089/dia.2018.0017Dean, A., Sullivan, K., & Soe, M. (2013, 2013/04/06). OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. Retrieved 15 Mar, 2023 from https://www.openepi.com/Menu/OE_Menu.htmShafiee G, Mohajeri-Tehrani M, Pajouhi M, et al. The importance of hypoglycemia in diabetic patients. Journal of diabetes and metabolic disorders 2012; 11: 17. https://doi.org/10.1186/2251-6581-11-17Deedwania, P. (2018). Dangers of Hypoglycemia in Cardiac Patients With Diabetes: Time to Switch to Safer, Newer Drugs. J Am Coll Cardiol, 72(15), 1787-1789. https://doi.org/10.1016/j.jacc.2018.08.2138Yale JF, Paty B, et al. Diabetes Canada Clinical Practice Guidelines Expert Committee. Hypoglycemia. Can J Diabetes 2018; 42 Suppl 1: S104-S108. https://doi.org/10.1016/j.jcjd.2017.10.010Diabetes Canada Clinical Practice Guidelines Expert, C., Yale, J. F., Paty, B., & Senior, P. A. (2018). Hypoglycemia. Can J Diabetes, 42 Suppl 1(42), S104-S108. https://doi.org/10.1016/j.jcjd.2017.10.010Sun C-A. The experience and the meaning of hypoglycemia to Cambodian diabetes patients: A qualitative study conducted in Phnom Penh, Cambodia. University of Oslo, 2014Elshebiny, A., Alali, H., Alamer, Z., Alsultan, Y., Alkhalaf, H., Alkishi, A., & Alsuwaylih, M. (2021). The incidence of hypoglycemia and its risk factors among diabetic patients in the Eastern Province of Saudi Arabia. International Journal of Medicine in Developing Countries, 5(2), 614-621. https://doi.org/10.24911/ijmdc.51-1609148506Kallem VR, Pandita A and Gupta G. Hypoglycemia: when to treat? Clinical Medicine Insights: Pediatrics 2017; 11: 1179556517748913Kahsay H, Fantahun B, Nedi T, et al. Evaluation of Hypoglycemia and Associated Factors among Patients with Type 1 Diabetes on Follow-Up Care at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. J Diabetes Res 2019; 2019: 9037374. https://doi.org/10.1155/2019/9037374Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and purposive sampling. American journal of theoretical and applied statistics, 5(1), 1-4.Deedwania P. Dangers of Hypoglycemia in Cardiac Patients With Diabetes: Time to Switch to Safer, Newer Drugs. J Am Coll Cardiol 2018; 72: 1787-1789. https://doi.org/10.1016/j.jacc.2018.08.2138Geller, A. I., Shehab, N., Lovegrove, M. C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA internal medicine, 174(5), 678-686. https://doi.org/10.1001/jamainternmed.2014.136Elshebiny A, Alali H, Alamer Z, et al. The incidence of hypoglycemia and its risk factors among diabetic patients in the Eastern Province of Saudi Arabia. International Journal of Medicine in Developing Countries 2021; 5: 614-621. https://doi.org/10.24911/ijmdc.51-1609148506Gonzalez, C., Monti, C., Pinzon, A., Monsanto, H., Ejzykowicz, F., & Group, A. R. (2018). Prevalence of hypoglycemia among a sample of sulfonylurea-treated patients with Type 2 diabetes mellitus in Argentina: The real-life effectiveness and care patterns of diabetes management (RECAP-DM) study. Endocrinología, Diabetes y Nutrición, 65(10), 592-602.Khardori R. Type 2 Diabetes Mellitus Treatment & Management, https://emedicine.medscape.com/article/117853-treatment (2022, accessed 29 Dec 2022)Hamdy, O. (2021). Hypoglycemia. Medscape. Retrieved 10 Oct, 2023 from https://emedicine.medscape.com/article/122122-overview?icd=login_success_email_match_normDean A, Sullivan K, Soe M. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version., https://www.openepi.com/Menu/OE_Menu.htm (2013, accessed 15 Mar, 2023)IBM Corp. (2015). IBM SPSS Statistics for Windows. In (Version 23.0) Armonk, NY: IBM Corp. https://www.ibm.com/support/pages/how-cite-ibm-spss-statistics-or-earlier-versions-spssEtikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive sampling. American journal of theoretical and applied statistics 2016; 5: 1-4International Diabetes Federation. (2021). Diabetes facts & figures. International Diabetes Federation. Retrieved 22 Oct, 2023 from https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html#:~:text=The%20IDF%20Diabetes%20Atlas%20Tenth,and%20783%20million%20by%202045.Kesmodel US. Cross‐sectional studies–what are they good for? Acta obstetricia et gynecologica Scandinavica 2018; 97: 388-393Kahsay, H., Fantahun, B., Nedi, T., & Demoz, G. T. (2019). Evaluation of Hypoglycemia and Associated Factors among Patients with Type 1 Diabetes on Follow-Up Care at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. J Diabetes Res, 2019(9037374), 9037374. https://doi.org/10.1155/2019/9037374IBM Corp. IBM SPSS Statistics for Windows. 23.0 ed.: Armonk, NY: IBM Corp, 2015Kallem, V. R., Pandita, A., & Gupta, G. (2017). Hypoglycemia: when to treat? Clinical Medicine Insights: Pediatrics, 11, 1179556517748913.World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects, https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/ (2018, accessed April 14, 2020)Kesmodel, U. S. (2018). Cross‐sectional studies–what are they good for? Acta obstetricia et gynecologica Scandinavica, 97(4), 388-393.Senior P, Hramiak I. Fast-Acting Insulin Aspart and the Need for New Mealtime Insulin Analogues in Adults With Type 1 and Type 2 Diabetes: A Canadian Perspective. Canadian journal of diabetes 2019; 43: 515-523. https://doi.org/10.1016/j.jcjd.2019.01.004Khardori, R. (2022, Dec 19, 2022). Type 2 Diabetes Mellitus Treatment & Management. Medscape. Retrieved 29 Dec 2022 from https://emedicine.medscape.com/article/117853-treatmentMcAdams BH, Rizvi AA. An Overview of Insulin Pumps and Glucose Sensors for the Generalist. Journal of clinical medicine 2016; 5: 5. https://doi.org/10.3390/jcm5010005Mayo Clinic. (2022, Dec. 07, 2022). Diabetes. Retrieved 30 Dec, 2022 from https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444#:~:text=Diabetes%20mellitus%20refers%20to%20a,brain's%20main%20source%20of%20fuel.Abdelbagi O, Musa IR, Musa SM, et al. Prevalence and associated factors of hypertension among adults with diabetes mellitus in northern Sudan: a cross-sectional study. BMC cardiovascular disorders 2021; 21: 1-7McAdams, B. H., & Rizvi, A. A. (2016). An Overview of Insulin Pumps and Glucose Sensors for the Generalist. Journal of Clinical Medicine, 5(1), 5. https://doi.org/10.3390/jcm5010005Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine 2014; 174: 678-686. https://doi.org/10.1001/jamainternmed.2014.136Miller, T. A., & Dimatteo, M. R. (2013). Importance of family/social support and impact on adherence to diabetic therapy. Diabetes, metabolic syndrome and obesity: targets and therapy, 6, 421-426. https://doi.org/10.2147/DMSO.S36368Alagiakrishnan K, Mereu L. Approach to managing hypoglycemia in elderly patients with diabetes. Postgraduate Medicine 2010; 122: 129-137. https://doi.org/10.3810/pgm.2010.05.2150Morales, J., & Schneider, D. (2014). Hypoglycemia. The American journal of medicine, 127(10 Suppl), S17-24. https://doi.org/10.1016/j.amjmed.2014.07.004Morales J, Schneider D. Hypoglycemia. The American journal of medicine 2014; 127: S17-24. https://doi.org/10.1016/j.amjmed.2014.07.004Muche, E. A., & Mekonen, B. T. (2020). Hypoglycemia prevention practice and its associated factors among diabetes patients at university teaching hospital in Ethiopia: Cross-sectional study. PloS one, 15(8), e0238094. https://doi.org/10.1371/journal.pone.0238094Bonds DE, Kurashige EM, Bergenstal R, et al. Severe hypoglycemia monitoring and risk management procedures in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. The American journal of cardiology 2007; 99: 80i-89i. https://doi.org/10.1016/j.amjcard.2007.03.026Ortiz, M. R. (2017). Hypoglycemia in Diabetes. Nurs Clin North Am, 52(4), 565-574. https://doi.org/10.1016/j.cnur.2017.07.006Sircar M, Bhatia A, Munshi M. Review of hypoglycemia in the older adult: clinical implications and management. Canadian journal of diabetes 2016; 40: 66-72Polonsky, W. H., & Henry, R. R. (2016). Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient preference and adherence, 10, 1299-1307. https://doi.org/10.2147/PPA.S106821Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient preference and adherence 2016; 10: 1299-1307. https://doi.org/10.2147/PPA.S106821Robert, A. A., & Al Dawish, M. A. (2020). The Worrying Trend of Diabetes Mellitus in Saudi Arabia: An Urgent Call to Action. Curr Diabetes Rev, 16(3), 204-210. https://doi.org/10.2174/1573399815666190531093735Miller TA, Dimatteo MR. Importance of family/social support and impact on adherence to diabetic therapy. Diabetes, metabolic syndrome and obesity: targets and therapy 2013; 6: 421-426. https://doi.org/10.2147/DMSO.S36368Sancini, A., Ricci, S., Tomei, F., Sacco, C., Pacchiarotti, A., Nardone, N., . . . Tomei, G. (2017). Work related stress and blood glucose levels. Annali di Igiene – Medicina Preventiva e di Comunità, 29(2), 123-133. https://doi.org/10.7416/ai.2017.2139Sarteau AC, Kahkoska AR, Crandell J, et al. More hypoglycemia not associated with increasing estimated adiposity in youth with type 1 diabetes. Pediatric Research 2023; 93: 708-714. https://doi.org/10.1038/s41390-022-02129-1Sarteau, A. C., Kahkoska, A. R., Crandell, J., Igudesman, D., Corbin, K. D., Kichler, J. C., . . . Mayer-Davis, E. (2023). More hypoglycemia not associated with increasing estimated adiposity in youth with type 1 diabetes. Pediatric Research, 93(3), 708-714. https://doi.org/10.1038/s41390-022-02129-1Sancini A, Ricci S, Tomei F, et al. Work related stress and blood glucose levels. Annali di igiene : medicina preventiva e di comunita 2017; 29: 123-133. https://doi.org/10.7416/ai.2017.2139Senior, P., & Hramiak, I. (2019). Fast-Acting Insulin Aspart and the Need for New Mealtime Insulin Analogues in Adults With Type 1 and Type 2 Diabetes: A Canadian Perspective. Canadian journal of diabetes, 43(7), 515-523. https://doi.org/10.1016/j.jcjd.2019.01.004AlTowayan A, Alharbi S, Aldehami M, et al. Awareness Level of Hypoglycemia Among Diabetes Mellitus Type 2 Patients in Al Qassim Region. Cureus 2023; 15Shafiee, G., Mohajeri-Tehrani, M., Pajouhi, M., & Larijani, B. (2012). The importance of hypoglycemia in diabetic patients. J Diabetes Metab Disord, 11(1), 17. https://doi.org/10.1186/2251-6581-11-17Sircar, M., Bhatia, A., & Munshi, M. (2016). Review of Hypoglycemia in the Older Adult: Clinical Implications and Management. Canadian journal of diabetes, 40(1), 66-72. https://doi.org/10.1016/j.jcjd.2015.10.004Sircar, M., Bhatia, A., & Munshi, M. (2016). Review of Hypoglycemia in the Older Adult: Clinical Implications and Management. Canadian journal of diabetes, 40(1), 66-72. https://doi.org/10.1016/j.jcjd.2015.10.004Sun, C.-A. (2014). The experience and the meaning of hypoglycemia to Cambodian diabetes patients: A qualitative study conducted in Phnom Penh, Cambodia University of Oslo]. University of Oslo. https://www.duo.uio.no/handle/10852/41391Sun, C.-A. (2014). The experience and the meaning of hypoglycemia to Cambodian diabetes patients: A qualitative study conducted in Phnom Penh, Cambodia University of Oslo]. University of Oslo. https://www.duo.uio.no/handle/10852/41391Torimoto, K., Okada, Y., Hajime, M., Tanaka, K., & Tanaka, Y. (2018). Risk Factors of Hypoglycemia in Patients with Type 2 Diabetes Mellitus: A Study Based on Continuous Glucose Monitoring. Diabetes Technol Ther, 20(9), 603-612. https://doi.org/10.1089/dia.2018.0017Torimoto, K., Okada, Y., Hajime, M., Tanaka, K., & Tanaka, Y. (2018). Risk Factors of Hypoglycemia in Patients with Type 2 Diabetes Mellitus: A Study Based on Continuous Glucose Monitoring. Diabetes Technol Ther, 20(9), 603-612. https://doi.org/10.1089/dia.2018.0017World Health Organization. (2021). Diabetes. https://www.who.int/health-topics/diabetes#tab=tab_1World Health Organization. (2021). Diabetes. https://www.who.int/health-topics/diabetes#tab=tab_1World Medical Association. (2018). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. World Medical Association. Retrieved April 14, 2020, from https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/World Medical Association. (2018). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. World Medical Association. Retrieved April 14, 2020, from https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/

The authors declare that there are no conflicts of interest present.