La calidad de vida y la evaluación de autoefiacia se aplican cada vez más en la valoración de los pacientes con diabetes mellitus tipo 2 debido al alto impacto de la enfermedad en sus vidas. Este estudio tiene como objetivo describir la calidad de vida y autoeficacia en pacientes con diabetes mellitus tipo 2 y describir la asociación de calidad de vida y autoeficacia con variables demográficas, metabólicas y clínicas. Este estudio es un análisis secundario del estudio transversal: “Control metabólico en pacientes con diabetes mellitus tipo 2 en un hospital público del Perú: estudio de corte transversal en un país de bajos y medianos ingresos”. Los datos se obtuvieron mediante cuestionarios estandarizadas y evaluación de historias clínicas. Las herramientas de evaluación utilizadas fueron el cuestionario Diabetes -39 (D-39) para medir la calidad de vida y la escala de autoeficacia general para medir autoeficacia (GSE). Las medias del D-39 y GSE fueron 34,6 y 34, respectivamente. La dimensión con la puntuación más alta del D-39 fue "ansiedad y preocupación". Una mejor calidad de vida estuvo asociada con ser mayor de 65 años, no tener complicaciones microvasculares y la ausencia de depresión. No se encontró una asociación significativa entre la autoeficacia y calidad de vida. Los resultados sugieren que los pacientes con diabetes mellitus tipo 2 tienen una pobre calidad de vida. Las estrategias centradas en el cuidado del paciente con diabetes mellitus tipo 2 deben considerar estos factores psicosociales para mejorar el control de la enfermedad y la calidad de vida.

Authors: Irma Elizabeth Huayanay-Espinoza[1], Felix Guerra-Castañon[1], Michael Reyes-Diaz[1], María Lazo-Porras[1,2], Celso de la Cruz-Luque .[1], Diego Adrianzen Herrera[1,3], Germán Málaga[1,2,4,5]

Affiliation:
[1] Unidad de Conocimiento y Evidencia (CONEVID), Faculty of Medicine Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
[2] CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
[3] Montefiore Medical Center, New York, United States
[4] Faculty of Medicine Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
[5] Department of Internal Medicine, Hospital Cayetano Heredia, Lima, Peru

E-mail: maria.lazo.porras@gmail.com

Author address:
[1] Av. Honorio Delgado 430
San Martín de Porres 15102
Peru

Citation: Huayanay-Espinoza IE, Guerra-Castañon F, Reyes-Diaz M, Lazo-Porras M, de la Cruz-Luque C, Herrera DA, et al. Quality of life and self-efficacy in patients with type 2 diabetes mellitus in a Peruvian public hospital. Medwave 2021;21(02):e8132 doi: 10.5867/medwave.2021.02.8132

Submission date: 30/3/2020

Acceptance date: 12/12/2020

Publication date: 22/3/2021

Origin: Not commissioned.

Type of review: Externally peer-reviewed by four reviewers, double-blind.

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1. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev. 1999 May-Jun;15(3):205-18. | CrossRef | PubMed |
2. Federation, I. Idf diabetes atlas. International Diabetes Federation: Brussels, Belgium 2018.
3. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet. 2011 Jul 2;378(9785):31-40. | CrossRef | PubMed |
4. Bernabé-Ortiz A, Carrillo-Larco RM, Gilman RH, Miele CH, Checkley W, Wells JC, et al. Geographical variation in the progression of type 2 diabetes in Peru: The CRONICAS Cohort Study. Diabetes Res Clin Pract. 2016 Nov;121:135-145. | CrossRef | PubMed |
5. Rosenthal MJ, Fajardo M, Gilmore S, Morley JE, Naliboff BD. Hospitalization and mortality of diabetes in older adults. A 3-year prospective study. Diabetes Care. 1998 Feb;21(2):231-5. | CrossRef | PubMed |
6. Gandhi GY, Murad MH, Fujiyoshi A, Mullan RJ, Flynn DN, Elamin MB, et al. Patient-important outcomes in registered diabetes trials. JAMA. 2008 Jun 4;299(21):2543-9. | CrossRef | PubMed |
7. The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med. 1998 Jun;46(12):1569-85. | CrossRef | PubMed |
8. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L. Quality of life and associated characteristics in a large national sample of adults with diabetes. Diabetes Care. 1997 Apr;20(4):562-7. | CrossRef | PubMed |
9. Levterova B, Levterov G, Dragova E. Quality of Life in Patients with Type 2 Diabetes Mellitus in Bulgaria: A Cross - Sectional Study, European Journal of Preventive Medicine. 2016;4(1):7-12. | CrossRef |
10. Hughes LC, Keith SE, Byars A, Wiginton KL. Cognitive mapping in persons newly diagnosed with type 2 diabetes. Diabetes Educ. 2012 Nov-Dec;38(6):845-54. | CrossRef | PubMed |
11. Svedbo Engström M, Leksell J, Johansson UB, Gudbjörnsdottir S. What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient- Reported Outcome Measure for the Swedish National Diabetes Register. BMJ Open. 2016 Mar 24;6(3):e010249. | CrossRef | PubMed |
12. Liang H, Cheng J, Shen X, Chen P, Tong G, Chai J, et al. Relationships between stressful life events and impaired fasting glucose among left-behind farmers in rural China. J Psychosom Res. 2015 Feb;78(2):178-83. | CrossRef | PubMed |
13. Russell LB, Suh DC, Safford MA. Time requirements for diabetes self- management: too much for many? J Fam Pract. 2005 Jan;54(1):52-6. | PubMed |
14. Robertson SM, Stanley MA, Cully JA, Naik AD. Positive emotional health and diabetes care: concepts, measurement, and clinical implications. Psychosomatics. 2012 Jan-Feb;53(1):1-12. | CrossRef | PubMed |
15. Jing X, Chen J, Dong Y, Han D, Zhao H, Wang X, et al. Related factors of quality of life of type 2 diabetes patients: a systematic review and meta-analysis. Health Qual Life Outcomes. 2018 Sep 19;16(1):189. | CrossRef | PubMed |
16. Aalto AM, Uutela A, Aro AR. Health related quality of life among insulin- dependent diabetics: disease-related and psychosocial correlates. Patient Educ Couns. 1997 Mar;30(3):215-25. | CrossRef | PubMed |
17. Contreras F, Espinosa JC, Esguerra GA. Calidad de vida, autoeficacia, estrategias de afrontamiento y adhesión al tratamiento en pacientes con insuficiencia renal crónica sometidos a hemodiálisis. Psicología y salud. 2013;18(2): 165-79.
18. Borhaninejad V, Shati M, Bhalla D, Iranpour A, Fadayevatan R. A Population- Based Survey to Determine Association of Perceived Social Support and Self- Efficacy With Self-Care Among Elderly With Diabetes Mellitus (Kerman City, Iran). Int J Aging Hum Dev. 2017 Dec;85(4):504-517. | CrossRef | PubMed |
19. Hurley AC, Shea CA. Self-efficacy: strategy for enhancing diabetes self-care. Diabetes Educ. 1992 Mar-Apr;18(2):146-50. | CrossRef | PubMed |
20. Luszczynska A, Scholz U, Schwarzer R. The general self-efficacy scale: multicultural validation studies. J Psychol. 2005 Sep;139(5):439-57. | CrossRef | PubMed |
21. Huayanay-Espinoza IE, Guerra-Castañon F, Lazo-Porras M, Castaneda-Guarderas A, Thomas NJ, Garcia-Guarniz AL, et al. Metabolic control in patients with type 2 diabetes mellitus in a public hospital in Peru: a cross-sectional study in a low-middle income country. PeerJ. 2016 Oct 13;4:e2577. | CrossRef | PubMed |
22. López-Carmona JM, Rodríguez-Moctezuma R. Adaptación y validación del instrumento de calidad de vida Diabetes 39 en pacientes mexicanos con diabetes mellitus tipo 2 [Adaptation and validation of quality of life instrument Diabetes 39 for Mexican patients with type 2 diabetes mellitus]. Salud Publica Mex. 2006 May-Jun;48(3):200-11. | CrossRef | PubMed |
23. Baessler J, Schwarcer R. Evaluación de la autoeficacia: Adaptación española de la escala de Autoeficacia General. Ansiedad y Estrés.1996;2:1-8.
24. Summary of Revisions: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018 Jan;41(Suppl 1):S4-S6. | CrossRef | PubMed |
25. Ríos CJL, Sánchez SJJ, Barrios SP, et al. Calidad de vida en pacientes con diabetes mellitus tipo 2. Rev Med Inst Mex Seguro Soc. 2004;42(2):109-116.
26. Machado-Alba JE, Medina-Morales DA, Echeverri-Cataño LF. Evaluation of the quality of life of patients with diabetes mellitus treated with conventional or analogue insulins. Diabetes Res Clin Pract. 2016 Jun;116:237-43. | CrossRef | PubMed |
27. Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, et al. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care. 2007 Sep;30(9):2222-7. | CrossRef | PubMed |
28. Stanković Z, Jašović-Gašić M, Zamaklar M. Psycho-social and clinical variables associated with depression in patients with type 2 diabetes. Psychiatr Danub. 2011 Mar;23(1):34-44. | CrossRef | PubMed |
29. Zuberi SI, Syed EU, Bhatti JA. Association of depression with treatment outcomes in Type 2 Diabetes Mellitus: a cross-sectional study from Karachi, Pakistan. BMC Psychiatry. 2011 Feb 15;11:27. | CrossRef | PubMed |
30. Egede LE, Ellis C. The effects of depression on metabolic control and quality of life in indigent patients with type 2 diabetes. Diabetes Technol Ther. 2010 Apr;12(4):257-62. | CrossRef | PubMed |
31. Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ. 1998 Mar 7;316(7133):736-41. | CrossRef | PubMed |
32. Leventhal EA, Prohaska TR. Age, symptom interpretation, and health behavior. J Am Geriatr Soc. 1986 Mar;34(3):185-91. | PubMed |
33. Redekop WK, Koopmanschap MA, Stolk RP, Rutten GE, Wolffenbuttel BH, Niessen LW. Health-related quality of life and treatment satisfaction in Dutch patients with type 2 diabetes. Diabetes Care. 2002 Mar;25(3):458-63. | CrossRef | PubMed |
34. Hu Y, Bakhotmah BA, Alzahrani OH, Wang D, Hu FB, Alzahrani HA. Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia. Diabetes Res Clin Pract. 2014 Nov;106(2):286-94. | CrossRef | PubMed |
35. Eiser C, Flynn M, Green E, Havermans T, Kirby R, Sandeman D, et al. Quality of life in young adults with type 1 diabetes in relation to demographic and disease variables. Diabet Med. 1992 May;9(4):375-8. | CrossRef | PubMed |
36. Urzúa M A, Chirino A, Valladares G. Autoreporte de la calidad de vida relacionada con la salud en diabetes mellitus tipo 2. Rev. méd. Chile [Internet]. 2011 Mar;139(3):313-320. | CrossRef |
37. Klein BE, Klein R, Moss SE. Self-rated health and diabetes of long duration. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Diabetes Care. 1998 Feb;21(2):236-40. | CrossRef | PubMed |
38. Sarkar U, Fisher L, Schillinger D. Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy? Diabetes Care. 2006 Apr;29(4):823-9. | CrossRef | PubMed |
39. Bernal H, Woolley S, Schensul JJ, Dickinson JK. Correlates of self-efficacy in diabetes self-care among Hispanic adults with diabetes. Diabetes Educ. 2000 Jul-Aug;26(4):673-80. | CrossRef | PubMed |
40. Kim G, Shim R, Ford KL, Baker TA. The relation between diabetes self-efficacy and psychological distress among older adults: do racial and ethnic differences exist? J Aging Health. 2015 Mar;27(2):320-33. | CrossRef | PubMed |
41. Mansyur CL, Rustveld LO, Nash SG, Jibaja-Weiss ML. Hispanic Acculturation and Gender Differences in Support and Self-Efficacy for Managing Diabetes. Diabetes Educ. 2016 Jun;42(3):315-24. | CrossRef | PubMed |
42. Martinez Y, Campbell SM, Hann M, Bower P. The relationship between quality of care and self-management in patients with type 2 diabetes: a cross-sectional survey in primary care in Mexico. Qual Prim Care. 2014;22(6):262-9. | PubMed |
43. Sacristán JA. Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC Med Inform Decis Mak. 2013 Jan 8;13:6. | CrossRef | PubMed |
44. Serrano V, Spencer-Bonilla G, Boehmer KR, Montori VM. Minimally Disruptive Medicine for Patients with Diabetes. Curr Diab Rep. 2017 Sep 23;17(11):104. | CrossRef | PubMed |

Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev. 1999 May-Jun;15(3):205-18. | CrossRef | PubMed |

Federation, I. Idf diabetes atlas. International Diabetes Federation: Brussels, Belgium 2018.

Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet. 2011 Jul 2;378(9785):31-40. | CrossRef | PubMed |

Bernabé-Ortiz A, Carrillo-Larco RM, Gilman RH, Miele CH, Checkley W, Wells JC, et al. Geographical variation in the progression of type 2 diabetes in Peru: The CRONICAS Cohort Study. Diabetes Res Clin Pract. 2016 Nov;121:135-145. | CrossRef | PubMed |

Rosenthal MJ, Fajardo M, Gilmore S, Morley JE, Naliboff BD. Hospitalization and mortality of diabetes in older adults. A 3-year prospective study. Diabetes Care. 1998 Feb;21(2):231-5. | CrossRef | PubMed |

Gandhi GY, Murad MH, Fujiyoshi A, Mullan RJ, Flynn DN, Elamin MB, et al. Patient-important outcomes in registered diabetes trials. JAMA. 2008 Jun 4;299(21):2543-9. | CrossRef | PubMed |

The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med. 1998 Jun;46(12):1569-85. | CrossRef | PubMed |

Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L. Quality of life and associated characteristics in a large national sample of adults with diabetes. Diabetes Care. 1997 Apr;20(4):562-7. | CrossRef | PubMed |

Levterova B, Levterov G, Dragova E. Quality of Life in Patients with Type 2 Diabetes Mellitus in Bulgaria: A Cross - Sectional Study, European Journal of Preventive Medicine. 2016;4(1):7-12. | CrossRef |

Hughes LC, Keith SE, Byars A, Wiginton KL. Cognitive mapping in persons newly diagnosed with type 2 diabetes. Diabetes Educ. 2012 Nov-Dec;38(6):845-54. | CrossRef | PubMed |

Svedbo Engström M, Leksell J, Johansson UB, Gudbjörnsdottir S. What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient- Reported Outcome Measure for the Swedish National Diabetes Register. BMJ Open. 2016 Mar 24;6(3):e010249. | CrossRef | PubMed |

Liang H, Cheng J, Shen X, Chen P, Tong G, Chai J, et al. Relationships between stressful life events and impaired fasting glucose among left-behind farmers in rural China. J Psychosom Res. 2015 Feb;78(2):178-83. | CrossRef | PubMed |

Russell LB, Suh DC, Safford MA. Time requirements for diabetes self- management: too much for many? J Fam Pract. 2005 Jan;54(1):52-6. | PubMed |

Robertson SM, Stanley MA, Cully JA, Naik AD. Positive emotional health and diabetes care: concepts, measurement, and clinical implications. Psychosomatics. 2012 Jan-Feb;53(1):1-12. | CrossRef | PubMed |

Jing X, Chen J, Dong Y, Han D, Zhao H, Wang X, et al. Related factors of quality of life of type 2 diabetes patients: a systematic review and meta-analysis. Health Qual Life Outcomes. 2018 Sep 19;16(1):189. | CrossRef | PubMed |

Aalto AM, Uutela A, Aro AR. Health related quality of life among insulin- dependent diabetics: disease-related and psychosocial correlates. Patient Educ Couns. 1997 Mar;30(3):215-25. | CrossRef | PubMed |

Contreras F, Espinosa JC, Esguerra GA. Calidad de vida, autoeficacia, estrategias de afrontamiento y adhesión al tratamiento en pacientes con insuficiencia renal crónica sometidos a hemodiálisis. Psicología y salud. 2013;18(2): 165-79.

Borhaninejad V, Shati M, Bhalla D, Iranpour A, Fadayevatan R. A Population- Based Survey to Determine Association of Perceived Social Support and Self- Efficacy With Self-Care Among Elderly With Diabetes Mellitus (Kerman City, Iran). Int J Aging Hum Dev. 2017 Dec;85(4):504-517. | CrossRef | PubMed |

Hurley AC, Shea CA. Self-efficacy: strategy for enhancing diabetes self-care. Diabetes Educ. 1992 Mar-Apr;18(2):146-50. | CrossRef | PubMed |

Luszczynska A, Scholz U, Schwarzer R. The general self-efficacy scale: multicultural validation studies. J Psychol. 2005 Sep;139(5):439-57. | CrossRef | PubMed |

Huayanay-Espinoza IE, Guerra-Castañon F, Lazo-Porras M, Castaneda-Guarderas A, Thomas NJ, Garcia-Guarniz AL, et al. Metabolic control in patients with type 2 diabetes mellitus in a public hospital in Peru: a cross-sectional study in a low-middle income country. PeerJ. 2016 Oct 13;4:e2577. | CrossRef | PubMed |

López-Carmona JM, Rodríguez-Moctezuma R. Adaptación y validación del instrumento de calidad de vida Diabetes 39 en pacientes mexicanos con diabetes mellitus tipo 2 [Adaptation and validation of quality of life instrument Diabetes 39 for Mexican patients with type 2 diabetes mellitus]. Salud Publica Mex. 2006 May-Jun;48(3):200-11. | CrossRef | PubMed |

Baessler J, Schwarcer R. Evaluación de la autoeficacia: Adaptación española de la escala de Autoeficacia General. Ansiedad y Estrés.1996;2:1-8.

Summary of Revisions: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018 Jan;41(Suppl 1):S4-S6. | CrossRef | PubMed |

Ríos CJL, Sánchez SJJ, Barrios SP, et al. Calidad de vida en pacientes con diabetes mellitus tipo 2. Rev Med Inst Mex Seguro Soc. 2004;42(2):109-116.

Machado-Alba JE, Medina-Morales DA, Echeverri-Cataño LF. Evaluation of the quality of life of patients with diabetes mellitus treated with conventional or analogue insulins. Diabetes Res Clin Pract. 2016 Jun;116:237-43. | CrossRef | PubMed |

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, et al. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care. 2007 Sep;30(9):2222-7. | CrossRef | PubMed |

Stanković Z, Jašović-Gašić M, Zamaklar M. Psycho-social and clinical variables associated with depression in patients with type 2 diabetes. Psychiatr Danub. 2011 Mar;23(1):34-44. | CrossRef | PubMed |

Zuberi SI, Syed EU, Bhatti JA. Association of depression with treatment outcomes in Type 2 Diabetes Mellitus: a cross-sectional study from Karachi, Pakistan. BMC Psychiatry. 2011 Feb 15;11:27. | CrossRef | PubMed |

Egede LE, Ellis C. The effects of depression on metabolic control and quality of life in indigent patients with type 2 diabetes. Diabetes Technol Ther. 2010 Apr;12(4):257-62. | CrossRef | PubMed |

Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ. 1998 Mar 7;316(7133):736-41. | CrossRef | PubMed |

Leventhal EA, Prohaska TR. Age, symptom interpretation, and health behavior. J Am Geriatr Soc. 1986 Mar;34(3):185-91. | PubMed |

Redekop WK, Koopmanschap MA, Stolk RP, Rutten GE, Wolffenbuttel BH, Niessen LW. Health-related quality of life and treatment satisfaction in Dutch patients with type 2 diabetes. Diabetes Care. 2002 Mar;25(3):458-63. | CrossRef | PubMed |

Hu Y, Bakhotmah BA, Alzahrani OH, Wang D, Hu FB, Alzahrani HA. Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia. Diabetes Res Clin Pract. 2014 Nov;106(2):286-94. | CrossRef | PubMed |

Eiser C, Flynn M, Green E, Havermans T, Kirby R, Sandeman D, et al. Quality of life in young adults with type 1 diabetes in relation to demographic and disease variables. Diabet Med. 1992 May;9(4):375-8. | CrossRef | PubMed |

Urzúa M A, Chirino A, Valladares G. Autoreporte de la calidad de vida relacionada con la salud en diabetes mellitus tipo 2. Rev. méd. Chile [Internet]. 2011 Mar;139(3):313-320. | CrossRef |

Klein BE, Klein R, Moss SE. Self-rated health and diabetes of long duration. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Diabetes Care. 1998 Feb;21(2):236-40. | CrossRef | PubMed |

Sarkar U, Fisher L, Schillinger D. Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy? Diabetes Care. 2006 Apr;29(4):823-9. | CrossRef | PubMed |

Bernal H, Woolley S, Schensul JJ, Dickinson JK. Correlates of self-efficacy in diabetes self-care among Hispanic adults with diabetes. Diabetes Educ. 2000 Jul-Aug;26(4):673-80. | CrossRef | PubMed |

Kim G, Shim R, Ford KL, Baker TA. The relation between diabetes self-efficacy and psychological distress among older adults: do racial and ethnic differences exist? J Aging Health. 2015 Mar;27(2):320-33. | CrossRef | PubMed |

Mansyur CL, Rustveld LO, Nash SG, Jibaja-Weiss ML. Hispanic Acculturation and Gender Differences in Support and Self-Efficacy for Managing Diabetes. Diabetes Educ. 2016 Jun;42(3):315-24. | CrossRef | PubMed |

Martinez Y, Campbell SM, Hann M, Bower P. The relationship between quality of care and self-management in patients with type 2 diabetes: a cross-sectional survey in primary care in Mexico. Qual Prim Care. 2014;22(6):262-9. | PubMed |

Sacristán JA. Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC Med Inform Decis Mak. 2013 Jan 8;13:6. | CrossRef | PubMed |

Serrano V, Spencer-Bonilla G, Boehmer KR, Montori VM. Minimally Disruptive Medicine for Patients with Diabetes. Curr Diab Rep. 2017 Sep 23;17(11):104. | CrossRef | PubMed |