BURDEN OF DIABETES MELLITUS TYPE 2 IN MIDDLE-AGED WOMEN IN AUSTRALIA

Acknowledgement

I would like to take this moment to thank my teacher and mentor for guiding me to complete this paper successfully. I would also like to thank my parents and friends for motivating me to complete thesis paper. I am thankful to have such helpful classmates as they helped by teaching the selection criteria and the filtering process. I am thankful to the college for providing me the opportunity to conduct this paper. I am looking forward to conduct further studies on this topic.

 

 

Abstract

The study has focused on understanding the burden of type 2 diabetes mellitus; the selected population for this study is middle-aged Australian women. The age group of women lies between 45 to 65 years. The systematic review showed how good quality data examining influences of SES on burden of type 2 diabetes mellitus. The study states the possible causes, symptoms and reasons for type 2 diabetes mellitus. Computer aided search of EMBASE, Medline, CINAHL and PsychINFO had been used to select articles. Few filters were used to reduce the results. After the filtering process, 8 articles were selected for gathering information for this study. Few study followed some criteria to conduct a systematic review.

Keywords: Type 2 diabetes mellitus, systematic review, burden, middle age women and Australian women

 

Table of Contents

Introduction. 4

Materials and methods. 6

Criteria for considering studies for this review.. 6

Search strategy for identification of studies. 6

Methodological quality. 7

Data Analysis. 9

Results. 9

Identification and selection of the literature. 9

Description of the studies. 10

Methodological quality of included studies. 12

Best evidence synthesis and strength of the association. 16

Discussion. 19

Conclusion. 20

Reference List 21

 

 

Introduction

Diabetes mellitus type 2 is stated as a chronic disease and it is characterized by the high sugar level in blood. Diabetes mellitus type 2 is often called as diabetes type 2 and adult-onset diabetes. The reason behind calling it adult-onset diabetes is that it starts almost always in the late or middle adulthood. Currently, children and teens have also started developing this condition. The type 2 diabetes mellitus is more common than type 1 diabetes. Type and type 2 disease are completely different diseases. The common among them is that it shares the type 1 diabetes high blood sugar levels as well as complications of high blood sugar.

Food gets broken down into basic components during the digestion period. The carbohydrates also get broken down into simple sugars called glucose. The glucose is very crucial source of energy for the cells of the body [8]. The glucose has to leave the blood and get inside the cells to provide energy to the cells. The insulin which travels in the blood signals the cells to take glucose. The insulin is mainly a hormone that is produced by the pancreas. The pancreas produces more insulin when the level of glucose in the blood rises.

The type 2 diabetes generally occurs when a person’s body cell starts resisting to the normal effect of insulin; the glucose is driven into the cells of blood. This resistance is called insulin resistance and this causes the glucose formation in the blood.

The pancreases sees that the blood glucose level is raising then the pancreases starts making extra insulin for maintaining a normal blood sugar. If this continues for a definite period of time ten the insulin resistance of body starts getting worse [11]. At some point of time, the pancreas gets exhausted and it cannot keep up with the insulin demand which eventually leads to the rise of blood glucose level. The type 2 diabetes generally runs in families and risk of diabetes is increased through obesity.

The most common symptoms of diabetes are the increase in blood glucose levels, excessive urination, hunger and thirst. The person suffering from type 2 diabetes starts losing weight. The disease also increases the susceptibility to fungal infections and yeast. The extremely blood sugar level could also lead to a very serious disease called hyperosmolar syndrome. Hyperosmolar syndrome is a life-threatening disease in the form of dehydration [4]. In few cases, hyperosmolar syndrome becomes the first sign for the type 2 diabetes. Hyperosmolar syndrome mainly causes coma, seizure, nausea, weakness and confused thinking.

It has been witnessed that the treatment of type 2 diabetes also causes the symptoms as too much glucose lowering medicine eventually leads to low blood sugar complication which is also called hypoglycaemia. Some of the major symptoms of hypoglycaemia are confusion, hunger, dizziness, trembling and sweating.

The type 2 diabetes causes an impact on all parts of the body and it often causes potentially life threatening complication. Some of the diseases are foot problems, neuropathy, retinopathy, atherosclerosis and nephropathy. Diabetes is generally diagnosed by checking the sugar level present in the blood. The blood is generally tested in the morning when the body fasted overnight. In a normal human being body, the blood sugar level is generally between 70 and 100 milligrams per decilitre (mg/dl). If the sugar level in blood increases more than 125 mg/dl than the diabetes gets diagnosed [16]. Diabetes is a lifelong illness but people are able to restore hat blood sugar level to normal by consuming nuts and healthy food, losing weight and regular exercising. Diabetes could be prevented by maintaining an ideal body weight, eating a healthy diet, taking medications and regularly exercising.

Women are more likely to have risk of coronary heart disease than men. As per the Australian Bureau of Statistics (ABS), approximately 1 million Australian adults (5%) had the type 2-diabetes in the year 2017-18. As per the 2017-2018 survey, type 2 diabetes was slightly higher in men than women and the percentage was around 6% and 4%. The survey involved people that were 45 years and older. The result was similar in inner regional, major cities and remote areas. The survey also showed that the percentage of type of diabetes increases with age. It was found out that people above 65 years had the highest percentage [24]. The symptoms and burden of type 2 diabetes mellitus has already been discussed and this paper is going to focus on Australian middle aged women. As per the survey conducted by the ABS, it was found out that collectively type 2 diabetes mellitus was higher in the middle aged group women. The symptom and burden varies. For this paper, various findings and journals were used to gather essential and authentic information.

 

 

Materials and methods

Criteria for considering studies for this review

Slow healing, kidney damage, nerve damage, heart and blood vessel disease, eye damage and sleep apnea in an individual had suffered due to type 2 diabetes mellitus, advanced age (45 to 65 years). The burdens have to be recorded with non-composite SES parameters (education, type of residence, marital status, income or occupation). The acronyms stated above are the prime predictors. The blood sugar level rises and after some period of time pancreas is unable to control the blood sugar level and eventually hypoglycaemia takes place [2]. The study is going to include diseases, illnesses and burdens that women are experiencing and are aged between 45 to 60 years. The survey conducted by the ABS has highlighted that highest number of women suffering from type 2 diabetes victims are between 45 years to 65 years [1].

Search strategy for identification of studies

The information for this study had been gathered through relevant and authentic sources. A computerized search strategy had been followed and performed by using the CINAHL, EMBASE, Medline and PsychINFO database. The above database had been used for the purpose of citation and existing literature. The findings in the journals were used to state some information regarding the type 2 diabetes mellitus in middle-aged Australian women. The journals had been selected that were published between the years 2015 to 2019. It was important to select recent journals because the Australian demographic had changed in this period of time. In Australia, the population of old age people is increasing so the finding could have been invalid if older journals were used for extracting information for this study. The following keywords were used for selecting journals; incline resistance in Australian women, type 2 diabetes in middle aged women, causes of the type 2 diabetes and systematic review.

We also hand searched for a few journals to meet the criteria but unfortunately nothing turned out to be useful. Online search strategy had been very useful for getting all the information needed to complete this study. The journals that have been selected for this study had gone through several times to confirm whether it meets the criteria or not.

Methodological quality

In order to access the methodological quality of the selected journals, two reviewers scored them independently by using the scoring system. The scoring system is mainly made for understanding the quality of the journals selected for the study. The scoring system allows evaluating whether the journal is meeting the criteria and whether they are coherent or not. This scoring system has to be followed in every study to make it authentic and more relevant. We were able to deduce required journals as well as excluded journals that were irrelevant to the topic. 

 

Item

Criterion

C/CC/Cs

Study population

1

Selection before disease was present or at uniform point

C/CC/CS

2

Cases and controls drawn from the same population

CC

3

Participation rate >80% for cases/cohort

C/CC/CS

4

Participation rate > 80% for controls

CC

Assessment of risk factor

5

Exposure assessment blinded

C/CC/CS

6

Exposure measurement identically for cases and controls

CC

7

Exposure assessed prior to the outcome

C/CC/CS

Assessment of outcome

8

Fracture assessed identically in studied population

C/CC/CS

9

Presence of burden assessed reproducibly

C/CC/CS

10

Type 2 diabetes mellitus identification assessed according to radiographic reports

C/CC/CS

Study design

11

Prospective design used

C/CC/CS

12

Follow-up time > 24 months

C

13

Withdrawals < 20>

C

Analysis and data presentation

14

Appropriate analysis techniques used

C/CC/CS

15

Adjusted for at least age and sex

C/CC/CS

       

C= applicable to cohort studies, CC= applicable to case-control studies, CS= applicable to cross-sectional

Figure 1: Criteria list for the assessment of study quality

 

The study has followed the criteria number 2, 5, 6, 8, 11, 12, 13, 14 and 15. The journals had been selected on the following criteria. All the journals were scored as positive (1), negative (0) or unclear (?). The CC in the table referred to applicable to case-control studies, CS referred to applicable to cross-sectional and C referred to applicable to cohort studies.  The cohort studies are generally used for design. The study design was evident in the maximum possible score and it is also the strength of the study. Some of the criteria that have been presented in figure 1 were not applicable to study type and topic. This is the reason some of the criteria were excluded. The reviewers were the ones who identified the irritancy of the study with the criteria. The third reviewer gave the final judgement of proceeding with the criteria numbers. For scoring above the means of all quality score, high quality was defined in the study.

Data Analysis

The data used in the study had been gathered through the journals, the journals had been selected deduced from the Torrens University database. All of sufficient data were not available on the college database as well as the study were heterogeneous. The study did not perform any kind of Meta analysis. The study conducted a best evidence synthesis which is presented in table 2. The best evidence synthesis used in the study is five-level evidence and it ranges from “no” to “strong” level evidence. This best evidence synthesis also reflects the study design that had been used. The best evidence was used to exclude the journals that were not relevant for the study; the journals that have excluded have been stated in the table 2 with the reason for exclusion.

Results

Identification and selection of the literature

The computer-assisted search yield approximately 1980 articles and out of all those articles, eight articles meet the criteria [2, 5, 6, 8, 11, 12, 13, 14 and 15]. The eight articles meet the selection criteria. The articles were selected after several process of filtering. The first filtering used in the search method was type 2 diabetes; the result got filtered to 1210. The second filer was age group which was set to 45 to 65 years; the result got filtered and reduced to 320. The third filter used was “Australian women” which further filtered the result to 42 results. The reviews went through all the 42 articles to identity whether they are meeting the criteria list and topic of the study. The reviewers were able to finalize with eight journals, those eight journals had been used for gathering information for the study. The most frequent reasons for the articles failing to meet the criteria were ethnicity, age group, region, country of residence and geographical position. The study had to completely focus on women that are aged between 45 to 65 years and are suffering from diabetes [18]. The eight journals that have selected were able to meet all the criteria as well as they highlighted the burdens that middle aged women in Australia are facing. The citation for these eight studies was identified. The filtering process is very effective in betting authentic and reliable information sources for the study.

Description of the studies

The total number of articles included in the study is 8 (n=8). The article was selected on the basis of criteria presented in figure 1. The selected articles that were cohort are [2, 4, 5, 7, and 8]. The selected articles that are case control designs are [1, 2, 3, 4, 5, and 8]. The articles that are cross sectionals are [2, 4, 5, and 8]. Six of the 8 studies used [1, 2, 4, 5, 7, 8] used medical and hospital reports to confirm the burden of type 2 diabetes. The table below shows that selection criteria and the filtering process followed in the study.

 

Level of Evidence

Criteria

Strong Evidence

Generally consistent finding in:

  • Multiple high quality cohort studies

Moderate Evidence

Generally consistent finding in:

  • 5 cohort studies
  • 6 case control design studies
  • 4 cross sectional studies

Limited Evidence

Generally consistent finding in:

  • Multiple cross-sectional studies
  • Only 1 single cohort study

Conflicting evidence

Inconsistent findings in less than 50% of the trials

No evidence

No studies could be found

Figure 2: Criteria list for determining the level of evidence

 

Database sources

  • CINAHL (January 2014- November 2019)
  • EMBASE (January 2014- November 2019)
  • PsychINFO (January 2014- November 2019)
  • Medline (January 2014- November 2019)

 

Identified 1980 citations

 

 

Reviewed 80 titles and abstracts

 

 

Reviewed 16citations and reference lists

 

Reviewed 42 complete articles

  • 1560 excluded- not relevant to the study topic
  • 220 excluded- not according to the age group
  • 52 excluded- the articles were not meeting the criteria
  • 37 excluded- published in different language
  • 26 excluded- urban, rural and geographical comparison
  • 15 excluded- different location
  • 10 excluded- not stated the burden
 
 
 
 

Figure 3: Summary of systematic search

Eight out of 42 studies had higher proportions of female subjects; however one of the studies was unable to state the gender breakdown. It was made sure that all of the articles selected for the study focused on middle aged women. Most of the studies were carried out in Australia as the topic of the paper was on middle-aged Australian women. The year of publication ranged from 2014 to 2019.

Methodological quality of included studies

As stated earlier, we had two reviewers and the reviewers were accountable for filtering and selecting the articles.  The two reviewers came up with 88 criteria over the 8 selected studies and independently agreed on 79 items (89.7%) as shown in table 2. Team resolved the study discrepancies in a single consensus meeting. The table 2 below is quality assessment results of the studies and shows the methodological quality in percentage. The percentage varied from 74 to 88. The maximum attainable score was 90 while the minimum score was 80. The median of the all quality score was 86.5 %. The mean value was used to understand the high quality and low quality studies, 4 out of 8 were high quality and rest were below 86.5%. There were various methodological shortcomings in the studies. Four of the studies were not perspective in study and did not identify the reproducible method of determining fractures. There was no study that was unable to take cases and controls from the same population. The studies that had been stated high quality highlighted the burden that women are facing in type 2 diabetes. The other studies highlighted the demographic women and their region. It was quite difficult to ascertain from all 8 studies whether the burden resulted in death or not. It was important to understand the impact of type 2 diabetes mellitus. The study also tried to understand whether the disease created an impact on their income, daily activities and occupation.

Income

The study used private health insurance as the proxy for higher income, the health care treatments lowered the risks of possible other diseases and burden caused due to type 2 diabetes. The studies and articles helped in understanding that women with high and medium earning had reduced risk and burden caused due to type 2 diabetes mellitus. Women with low income are more likely to have type 2 diabetes mellitus burden. As per the view of Bao et al. (2015), the risk and burden of type 2 diabetes are higher in women that are aged between 45- 60 years. So, it could be stated that income is one of the reasons why women are unable to cure their burden and disease. It could also be stated that there is significant association between the level of income and burden caused due to type 2 diabetes.

 

 

 

 

 

 

Table1: Study characteristics of the included manuscripts

Author

SES Parameter

Follow-up months

Age

Women

Study subjects

Quality Score (%)

Bao [1],  2015

Marital Status

-

45-65

51

51

90

Whitelock [2], 2018

Income Education

-

50-60

100

100

90

Becker [3],  2014

Marital Status

-

45-65

75

75

80

Wang [4], 2014

Marital Status

-

45-65

81

81

80

Ras?ka [5],  2017

Marital Status

-

55-65

65

65

90

Sullivan, [6], 2014

Occupation

-

45-50

51

51

90

Nikolova [7], 2017

Marital Status

24

45-55

85

85

90

Tenzer-Iglesias [8], 2014

Marital Status

-

45-65

151

151

80

 

 

Education

It was essential to understand women’s education level that was involved in the studies. The study focused on understanding the relationship between education level and diabetes 2 burdens in middle-aged Australian women. As per the view of Whitelock (2018), there is a link between type 2-diabetes and women’s education level. It was found out that women with lower education were more prone to type 2 diabetes mellitus. The rate of type of diabetes was higher in women with lower education. One of the reasons for type 2-diabetes is hereditary but other reasons like proper diet and workout. Women with lower education might not pay attention on proper diet or workout due to which they end up having type 2 diabetes.  As per the view of Whitelock (2018), the rate of type 2 diabetes in women increased after 65 years. However, as per the current Australian democracy, there are higher numbers of type 2 diabetes patients that are aged between 45 to 65 years.

Occupation

It was essential to understand the type 2 diabetes mellitus burden in middle-aged Australian women according to their occupation. The study also focused on finding the relationship between occupation and burden. As per the view of Nikolva et al. (2017), there is no significant relationship between occupation and type 2 diabetes mellitus. However, the study stated that the rate of type 2 diabetes was lower in employed women that unemployed women. The women age group in this study was 5 to 55. Near about 45% of the women were employed and 55% of the women were unemployed or were not working. Working women have a better schedule and they prefer having better diet and workout which decreases the risk of type 2 diabetes mellitus.

Locality

Locality was one of the most essential factors to be included in the study. The study focused on understanding the relationship between region and the burden of type 2-diabetes. As per the view of Wang (2014), women residing in rural areas are more likely to have type 2 diabetes than women restringing in town or city. The reason was very clear simple; women in rural areas are unable to detect the symptoms of type 2 diabetes and are unable to take proper measures to decrease its impact. Women in town are very conscious of their health and they are going for regular check up and this helps in identifying any type of changes in their health. Women in town are able to take early steps so the burden of type 2 diabetes is lower in women residing in town than women residing in rural areas. Women in rural areas are more likely to have diseases due to type 2-diabetes due to lack of treatment. Out of all the factors, locality was the most crucial because the difference is quite high. The age group of women were selected for this study was 45 to 65.

 

Table 2: Quality scores of the included studies

 

Criteria

 

1

2

3

4

5

6

7

8

9

10

Score

Total Score (%)

Bao [1]

1

1

1

na

1

1

1

1

1

1

9

9 (90%)

Whitelock [2]

1

n/a

1

0

1

1

1

1

1

1

8

9 (90%)

Becker [3]

1

n/a

1

0

1

0

n/a

0

1

1

8

8 (80%)

Wang [4]

1

n/a

1

1

1

1

n/a

0

1

1

7

8 (80%)

Raska [5]

1

1

1

0

1

1

n/a

0

1

1

7

9 (90%)

Sullivan [6]

1

1

1

0

0

1

n/a

1

1

1

7

9 (90%)

Nikolova [7]

1

1

1

0

0

1

n/a

1

1

1

7

9 (90%)

Tenzer [8]

1

n/a

1

1

1

1

n/a

1

1

1

8

8 (80%)

 

Marital status/living with others

Six out of eight studies examined the relationship between type 2 diabetes mellitus and marital status of women. It was important to find out whether the type 2 diabetes rate is higher in women that lives with a partner or in women that lives alone. The studies that focused on material status are [1, 3, 4, 5, 7, and 8]. The population selected in all these studies were both married and unmarried women. It was expected that the rate will be the same for both married and unmarried woman but the study finding was different. As per the view of Becker (2014), the rate of type 2 diabetes is higher in married women than single women. It was found out that most of the single women were working women and they were employed. Single women focused on their schedule, diet, and health while married women were mostly housewives and they were unable to focus on a healthy diet or exercise. This is the reason why the burden of type 2 diabetes mellitus is higher in married women that single women. It is true that type 2 diabetes could be carry forward to children by their parents but there are few other reasons why this is caused. 

Best evidence synthesis and strength of the association

The study has presented different SES indicators; the comparison between the studies was quite difficult mainly due to the heterogeneity of the selected studies. The study followed a quantitative method for stating authentic and valid finding but the statistical pooling of the extracted information was not feasible and this is reasonably evidence synthesis was conducted. The study also performed the strength of the association assessed to remove the heterogeneity of the existing literature findings. In this study, high quality studies scored above 80%. The heterogeneity was also present in the high quality work.

 

Table 3: SES factor discussed in the reviewed studies

Author [ref], year

Burden identification

Definition of SES variable

Outcome

Summary of significant association

Pit?ha [9], 2016

Hospital reports

Area based

  • Employed vs. unemployed
  • High income vs. average income
  • Median income vs. low income

Result

  • 0.6- 0.9
  • 07-0.8
  • 0.8-0.9

The burden is reduced for employed women as well as type 2 diabetes is lowest in women with high income and highest in women with low income

Bundhun [10], 2017

Hospital database

Area based

  • Employed vs. unemployed

Result

  • 0.7- 0.9

The burden is reduced for employed women

SES variable: type of locality

Niu [11], 2017

Hospital reports

Area based

  • Urban area vs. rural area

Result

  • 0.5- 0.9

Women  living in rural areas are more likely to have type 2 diabetes mellitus than women living in  urban areas

De [12], 2014

Self report

Area based

  • Urban area vs. rural area

Result

  • 0.6- 0.9

Women  living in rural areas are more likely to have type 2 diabetes mellitus than women living in  urban areas

SES: Marital Status

Lopes [13], 2015

Hospital reports

Area based

  • Living with others vs. living alone

Result

  • 0.7- 0.8

Type 2 diabetes mellitus burden is higher in married woman than women living alone

Klein, [14], 2017

Hospital reports

Area based

  • Living with others vs. living alone

Result

  • 0.6- 0.7

Type 2 diabetes mellitus burden is higher in married woman than women living alone

Carnevale [15], 2014

Hospital

Area based

  • Living with others vs. living alone

Result

  • 0.6- 0.8

Type 2 diabetes mellitus burden is higher in married woman than women living alone

 

 

 

Discussion

The study has used several criteria for finding authentic results regarding the type 2 diabetes burden in Australian middle aged women. The study has used eight articles and in most of the articles, the average age of women was 45 to 60 years. The study used the Torrens University database to select articles for the study. The Universities database is linked with Cinahl, PsychINFO, EMBASE and Medline. The articles were searched using keywords; a total of 1920 articles appeared in the first search result and after several filtering results was lowered to 42. Two reviewers analysed the 42 articles to understand whether they were meeting the criteria or not. Finally, eight articles were selected for gathering information for this study. While playing the best evidence that selected population is living in rural area or urban area, it was found that Australian middle aged women living in rural areas are more prone or likely to have type 2-diabetes when compared to women living in urban areas. The reason is very simple and clear; women living in rural areas do not focus on regular health checkups due to which the symptoms of type 2 diabetes are not detected. Women are unable to take early measures eventually they end up having burden of the disease and in most of the causes it leads to other diseases. Women living in urban area focus on regular health checkups which allow them to detect the symptoms and to take early steps to prevent the disease.

While paying best evidence to the existing literature, it was found out that unemployed women are likely to have type 2-diabetes than employed women. The reasons are that the employed women focus on healthy diet, regular checkups and regular exercises which prevent the causes of type 2 diabetes. It is not that unemployed women do not pay attention to their health or diet but the rate is slightly higher for unemployed women. It is quite essential to understand the symptoms of type 2 diabetes mellitus because middle aged women are more prone to this disease than any other age group.  The existing literature also helped in stating that women that are married are more likely to have type 2 diabetes mellitus than unmarried. The reason is that most of the single women are working women and they are employed. Single women are independent and they have to take care of everything by themselves so they are more focused on their health, diet and exercise. One of the major reasons behind type 2 diabetes is hereditary and it has nothing to do with marital status, income, locality or any other factor.

The existing literature has also helped in identifying that women with lower income is more likely to have type 2 diabetes mellitus burden when compared to women with high income and average income. The reason is that women with lower incomes do not focus on their health care treatments and checkups due to which they are unable to detect the symptoms of type 2 diabetes or any kind of change in their health quality. It was also indicated that women with average income are more likely to have type 2 diabetes burdens than women with higher income. However, the difference between the rate and finding was very small. It was ensured that all of the existing literature selected for this study meets all of the criteria. It was important to make the study authentic and valid so reviewers analysed all eight selected articles multiple times. 

Conclusion

Type 2 diabetes mellitus leads to several other life threatening diseases and various other burdens so it is important to detect the symptoms beforehand and take essential measures. The stud has highlighted the possible causes of diabetes and how it occurs. One of the biggest causes of type 2 diabetes is family pass over and some other reasons are diet and exercise. People need to be educated about the causes and symptoms of type 2 diabetes so they could avoid or decrease its impact. It was made sure that the selected literature met all the criteria. The articles selected for the study focused on finding results based on women's location, income, marital status and occupation. The population of this study was middle-aged Australian women. The common age group in the selected articles was 45 years to 65 years. The articles were deduced from the Torrens University database.

 

 

Reference List

 

  1. Bao, W., Yeung, E., Tobias, D., Hu, F., Vaag, A., Chavarro, J., . . . Zhang, C. (2015). Long-term risk of type 2 diabetes mellitus in relation to bmi and weight change among women with a history of gestational diabetes mellitus: A prospective cohort study. Diabetologia, 58(6), 1212-1219. doi:10.1007/s00125-015-3537-4
  2. Whitelock, V., Nouwen, A., Houben, K., Van, D., Rosenthal, M., & Higgs, S. (2018). Does working memory training improves dietary self-care in type 2 diabetes mellitus? results of a double blind randomised controlled trial. Diabetes Research and Clinical Practice, 143, 204-214. doi:10.1016/j.diabres.2018.07.005
  3. Becker, A., & Axelrad, D. (2014). Arsenic and type 2 diabetes: Commentary on association of inorganic arsenic exposure with type 2 diabetes mellitus: A meta-analysis by Wang et al. Journal of Epidemiology and Community Health, 68(5), 393-393. doi:10.1136/jech-2013-203463
  4. Wang, W., Xie, Z., Lin, Y., & Zhang, D. (2014). Association of inorganic arsenic exposure with type 2 diabetes mellitus: A meta-analysis. Journal of Epidemiology and Community Health, 68(2), 176-176. doi:10.1136/jech-2013-203114
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  11. Niu, B., Frias, A., Nguyen, B., Snowden, J., Cheng, Y., & Caughey, A. (2014). 278: The association between race/ethnicity and adverse perinatal outcomes among women with diabetes mellitus type 2 (t2dm). American Journal of Obstetrics and Gynecology, 210(1), 147.
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  25. Zhang, Y., Yatsuya, H., Li, Y., Chiang, C., Hirakawa, Y., Kawazoe, N., . . . Aoyama, A. (2017). Long-term weight-change slope, weight fluctuation and risk of type 2 diabetes mellitus in middle-aged japanese men and women: Findings of aichi workers' cohort study. Nutrition & Diabetes, 7(3), 252. doi:10.1038/nutd.2017.5
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