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1.  Frequent hypoglycemia among elderly with poor glycemic control 
Archives of internal medicine  2011;171(4):362-364.
Hypoglycemia in elderly patients with diabetes increases the risk of cardiovascular and cerebrovascular events(1), progression of dementia(2), injurious falls(3), emergency department visits, and hospitalization(4). Hypoglycemic episodes are difficult to diagnose in this population and are easily missed by intermittent finger-stick measurements. Recent large studies(5) have shown lack of benefit and sometimes higher risk of morbidity and mortality with tight glycemic control, especially in older adults. Therefore, the American Geriatric Society and the American Diabetes Association recommend relaxing glycemic control for vulnerable patients(6) (A1C<8% instead of the usual <7%). However, whether relaxing the goal to A1C>8% improves the frequency of hypoglycemia in older patients remains unknown. Thus, we evaluated hypoglycemia in older diabetic patients with A1C>8% with continuous glucose monitoring (CGM)
PMCID: PMC4123960  PMID: 21357814
3.  Impact of Reinforcement of Diabetes Self-Care on Poorly Controlled Diabetes: A Randomized Controlled Trial 
The Diabetes educator  2013;39(4):504-514.
The purpose of the study was to assess the value of reinforcing diabetes self-management for improving glycemia and self-care among adults with type 2 diabetes who had at least three hours of prior diabetes education.
In this randomized controlled trial, 134 participants (75% White, 51% female, 59±9 years old, 13±8 years with diabetes, A1C=8.4±1.2%) were randomized to either a group map-based program (Intervention) or group education on cholesterol and blood pressure (Control). Participants were assessed for A1C levels, diabetes self-care behaviors (3-day pedometer readings, 6-minute walk test, blood glucose checks, frequency of self-care), and psychosocial factors (distress, frustration, quality of life) at baseline, 3, 6 and 12 months post-intervention and health literacy at baseline.
Groups did not differ on baseline characteristics including A1C levels, health literacy, or self-care; however, the Intervention group had more years of education than Controls. Intervention arm participants modestly improved A1C levels at 3 months post-intervention but did not maintain that improvement at 6 and 12 months while Control patients did not improve A1C levels at any time during follow-up. Importantly, frequency of self-reported self-care, diabetes quality of life, diabetes-related distress and frustration with diabetes self-care improved in both groups over time.
Reinforcing self-care with diabetes education for patients who have not met glycemic targets helps improve A1C and could be considered a necessary component of ongoing diabetes care. The best method to accomplish reinforcement needs to be established.
PMCID: PMC3720792  PMID: 23640303
Type 2 diabetes; diabetes education intervention; diabetes self-care
4.  Do Older Adults Aged 60–75 Years Benefit From Diabetes Behavioral Interventions? 
Diabetes Care  2013;36(6):1501-1506.
In this secondary analysis, we examined whether older adults with diabetes (aged 60–75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education.
We measured A1C, self-care (3-day pedometer readings, blood glucose checks, and frequency of self-care), and psychosocial factors (quality of life, diabetes distress, frustration with self-care, depression, self-efficacy, and coping styles) at baseline and 3, 6, and 12 months postintervention.
Both older (age 67 ± 5 years, A1C 8.7 ± 0.8%, duration 20 ± 12 years, 30% type 1 diabetes, 83% white, 41% female) and younger (age 47 ± 9 years, A1C 9.2 ± 1.2%, 18 ± 12 years with diabetes, 59% type 1 diabetes, 82% white, 55% female) adults had improved A1C equally over time. Importantly, older and younger adults in the group conditions improved more and maintained improvements at 12 months (older structured behavioral group change in A1C −0.72 ± 1.4%, older control group −0.65 ± 0.9%, younger behavioral group −0.55 ± 1.2%, younger control group −0.43 ± 1.7%). Furthermore, frequency of self-care, glucose checks, depressive symptoms, quality of life, distress, frustration with self-care, self-efficacy, and emotional coping improved in older and younger participants at follow-up.
The findings suggest that, compared with younger adults, older adults receive equal glycemic benefit from participating in self-management interventions. Moreover, older adults showed the greatest glycemic improvement in the two group conditions. Clinicians can safely recommend group diabetes interventions to community-dwelling older adults with poor glycemic control.
PMCID: PMC3661804  PMID: 23315603
5.  Assessment of Barriers to Improve Diabetes Management in Older Adults 
Diabetes Care  2013;36(3):543-549.
To evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown.
We randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a “no-contact” period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress.
We assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by −0.45% in the intervention group vs. −0.31% in the control group. At 12 months, A1C decreased further in the intervention group by −0.21% vs. 0% in control group (linear mixed-model, P < 0.03). The intervention group showed additional benefits in scores on measures of self-care (Self-Care Inventory-R), gait and balance (Tinetti), and endurance (6MWT) compared with the control group. Diabetes-related distress improved in both groups.
Only attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.
PMCID: PMC3579376  PMID: 23193208
6.  Quality of Life and Technology: Impact on Children and Families with Diabetes 
Current diabetes reports  2012;12(6):711-720.
Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child’s QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age.
Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children’s and parents’ QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.
PMCID: PMC3521524  PMID: 22903783
Adolescents; Children; Quality of life; Type 1 diabetes; Continuous glucose; monitoring; Continuous subcutaneous insulin infusion; Insulin pump; Technology
7.  A Qualitative Study of Perceived Responsibility and Self-Blame in Type 2 Diabetes: Reflections of Physicians and Patients 
Journal of General Internal Medicine  2012;27(9):1180-1187.
Despite new treatment therapies and the emphasis on patient activation, nearly 50 % of diabetes patients have hemoglobin A1c levels above target. Understanding the impact of unmet treatment goals on the physician-patient relationship is important for maintaining quality care in clinical practice.
To explore physicians’ and type 2 diabetes patients’ views of patients’ difficulty achieving diabetes treatment goals.
Qualitative study using in-depth interviews with a semi-structured interview guide.
Nineteen endocrinologists and primary care physicians and 34 patients diagnosed with type 2 diabetes at least two years prior.
In-depth interviews with physicians and patients. A multidisciplinary research team performed content and thematic analyses.
Qualitative analysis revealed two main findings, organized by physician and patient perspectives. Physician Perspective: Physicians’ Perceived Responsibility for Patients’ Difficulty Achieving Treatment Goals: Physicians assumed responsibility for their patients not achieving goals and expressed concern that they may not be doing enough to help their patients achieve treatment goals. Physicians’ Perceptions of Patients’ Reactions: Most speculated that their patients may feel guilt, frustration, or disappointment when not reaching goals. Physicians also felt that many patients did not fully understand the consequences of diabetes. Patient Perspective: Patients’ Self-Blame for Difficulty Achieving Treatment Goals: Patients attributed unmet treatment goals to their inability to carry out self-care recommendations. Most patients blamed themselves for their lack of progress and directed their frustration and disappointment inwardly through self-deprecating comments. Patients’ Perceptions of Physicians’ Reactions: Several patients did not know how their physician felt, while others speculated that their physicians might feel disappointed or frustrated.
Physicians’ perceived responsibility and patients’ self-blame for difficulty achieving treatment goals may serve as barriers to an effective relationship. Physicians and patients may benefit from a greater understanding of each other’s frustrations and challenges in diabetes management.
PMCID: PMC3514987  PMID: 22549299
physician-patient relationship; type 2 diabetes; self-care behavior; qualitative methodology
8.  Network-Level Structural Abnormalities of Cerebral Cortex in Type 1 Diabetes Mellitus 
PLoS ONE  2013;8(8):e71304.
Type 1 diabetes mellitus (T1DM) usually begins in childhood and adolescence and causes lifelong damage to several major organs including the brain. Despite increasing evidence of T1DM-induced structural deficits in cortical regions implicated in higher cognitive and emotional functions, little is known whether and how the structural connectivity between these regions is altered in the T1DM brain. Using inter-regional covariance of cortical thickness measurements from high-resolution T1-weighted magnetic resonance data, we examined the topological organizations of cortical structural networks in 81 T1DM patients and 38 healthy subjects. We found a relative absence of hierarchically high-level hubs in the prefrontal lobe of T1DM patients, which suggests ineffective top-down control of the prefrontal cortex in T1DM. Furthermore, inter-network connections between the strategic/executive control system and systems subserving other cortical functions including language and mnemonic/emotional processing were also less integrated in T1DM patients than in healthy individuals. The current results provide structural evidence for T1DM-related dysfunctional cortical organization, which specifically underlie the top-down cognitive control of language, memory, and emotion.
PMCID: PMC3751935  PMID: 24058401
10.  Physicians’ Perceptions of the Type 2 Diabetes Multidisciplinary Treatment Team: A Qualitative Study 
The Diabetes educator  2011;37(6):794-800.
The purpose of this study was to explore physicians’ perceptions of the multidisciplinary type 2 diabetes treatment team.
Nineteen physicians (74% endocrinologists; 26% primary care) participated in semi-structured interviews. Audiorecorded data were transcribed, coded, and analyzed using thematic analysis and NVivo 8 software.
Physicians considered the multidisciplinary team, including a physician and diabetes educator, as very important to diabetes treatment. Participants described how diabetes with its many co-morbidities and challenging lifestyle recommendations, is difficult for any single physician to treat. They further described how the team’s diverse staff offers complementary skills and more contact time for assessment and treatment of patients, developing treatment relationships, and supporting patients in learning diabetes self-care. Physicians stressed the necessity of regular and ongoing communication among team members to ensure patients receive consistent information, and some reported that institutional factors interfere with intra-team communication. They also expressed concerns about the team approach in relation to individualized treatment and patients’ reluctance to see multiple providers.
This study highlights physicians’ positive perceptions of and concerns about the type 2 diabetes multidisciplinary team. Further study of diabetes educators’ and patients’ perceptions of the team approach is needed.
PMCID: PMC3707496  PMID: 22002972
type 2 diabetes; treatment team; qualitative research
11.  Look Who’s (Not) Talking 
Diabetes Care  2012;35(7):1466-1472.
Nearly one-half of diabetic patients have glycated hemoglobin A1c (HbA1c) levels above recommended targets. Effective physician–patient communication improves glycemia and diabetes self-care; however, communication gaps may exist that prevent patients from discussing self-care problems with treatment providers.
We assessed diabetic patients’ (n = 316, 85% white, 51% female, 71% type 2 diabetes, 59 ± 11 years old, 16 ± 3 years education, 19 ± 13 years diabetes duration, and HbA1c = 7.9 ± 1.4%) HbA1c, frequency of self-care, diabetes-related distress, depressive and anxiety symptoms, coping styles, diabetes quality of life, and self-care communication in the treatment relationship. Multivariate logistic regression models examined the main and interaction effects of health and psychosocial factors associated with patients’ reluctance to discuss self-care.
Patients reported positive relationships with their doctors and valued honest communication; however, 30% of patients were reluctant to discuss self-care. Reluctant patients reported less frequent self-care (P = 0.05), lower diabetes quality of life (P = 0.002), and more diabetes-related distress (P = 0.001), depressive symptoms (P < 0.001), and anxiety symptoms (P = 0.001). Patients who reported elevated depressive symptoms, although not necessarily major depression, were more likely to be reluctant to discuss self-care (odds ratio [OR] 1.66 for 10-point change in t score; P < 0.001), whereas patients who were older (OR 0.78 for 10-year change; P = 0.05) and those who used more self-controlled coping styles (OR 0.78 for 10-point change; P = 0.007) were less likely to be reluctant.
Awareness of elevated depressive symptoms is important in clinical practice given that these patients may be more reluctant to discuss self-care. Interventions and evidence-based approaches are needed to improve both depressive symptoms and physician-patient communication about self-care.
PMCID: PMC3379588  PMID: 22619085
13.  The Impact of a Structured Behavioral Intervention on Poorly Controlled Diabetes: A Randomized Controlled Trial 
Archives of internal medicine  2011;171(22):1990-1999.
Although maintaining near normal glycemia delays onset and slows progression of diabetes complications, many diabetes patients and their physicians struggle to achieve glycemic targets. Best methods to support patients as they follow diabetes prescriptions and recommendations are unclear.
To test the efficacy of a behavioral diabetes intervention in improving glycemia in long-duration, poorly-controlled diabetes, we randomized 222 adults with diabetes (49% type 1, 53±12 years old, 18±12 years duration, hemoglobin A1c=9.0±1.1%) to attend 1) a 5-session manual-based, educator-led structured group intervention with cognitive behavioral strategies (structured behavioral arm), 2) educator-led attention-control group education program (group attention control), or 3) unlimited individual nurse and dietitian education sessions for 6 months (individual control). Outcomes were baseline, and 3, 6, and 12-month post-intervention hemoglobin A1c levels (primary), frequency of diabetes self-care, 3-day pedometer readings, 24-hour diet recalls, average number of glucose checks, physical fitness, depression, coping style, self-efficacy, and quality of life (secondary).
Linear mixed modeling found that all groups improved hemoglobin A1c (p<0.001). However, the structured behavioral arm improved more than group and individual control arms (3-month HbA1c change: −0.8% versus −0.4% and −0.4%; groupXtime interaction p-value=0.04). Further, type 2 participants improved more than type 1 participants (type of diabetesXtime interaction p-value=0.04). Quality of life, glucose monitoring, and frequency of diabetes self-care did not differ by intervention over time.
A structured, cognitive behavioral program is more effective than two control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully utilize modified psychological and behavioral strategies.
( registration number: NCT000142922)
PMCID: PMC3487475  PMID: 21986346
14.  Brain Activation During Working Memory Is Altered in Patients With Type 1 Diabetes During Hypoglycemia 
Diabetes  2011;60(12):3256-3264.
To investigate the effects of acute hypoglycemia on working memory and brain function in patients with type 1 diabetes.
Using blood oxygen level–dependent (BOLD) functional magnetic resonance imaging during euglycemic (5.0 mmol/L) and hypoglycemic (2.8 mmol/L) hyperinsulinemic clamps, we compared brain activation response to a working-memory task (WMT) in type 1 diabetic subjects (n = 16) with that in age-matched nondiabetic control subjects (n = 16). Behavioral performance was assessed by percent correct responses.
During euglycemia, the WMT activated the bilateral frontal and parietal cortices, insula, thalamus, and cerebellum in both groups. During hypoglycemia, activation decreased in both groups but remained 80% larger in type 1 diabetic versus control subjects (P < 0.05). In type 1 diabetic subjects, higher HbA1c was associated with lower activation in the right parahippocampal gyrus and amygdala (R2 = 0.45, P < 0.002). Deactivation of the default-mode network (DMN) also was seen in both groups during euglycemia. However, during hypoglycemia, type 1 diabetic patients deactivated the DMN 70% less than control subjects (P < 0.05). Behavioral performance did not differ between glycemic conditions or groups.
BOLD activation was increased and deactivation was decreased in type 1 diabetic versus control subjects during hypoglycemia. This higher level of brain activation required by type 1 diabetic subjects to attain the same level of cognitive performance as control subjects suggests reduced cerebral efficiency in type 1 diabetes.
PMCID: PMC3219930  PMID: 21984582
15.  Understanding Physicians’ Challenges When Treating Type 2 Diabetic Patients’ Social and Emotional Difficulties 
Diabetes Care  2011;34(5):1086-1088.
To explore physicians’ awareness of and responses to type 2 diabetic patients’ social and emotional difficulties.
We conducted semistructured interviews with 19 physicians. Interviews were transcribed, coded, and analyzed using thematic analysis.
Three themes emerged: 1) physicians’ awareness of patients’ social and emotional difficulties: physicians recognized the frequency and seriousness of patients’ social and emotional difficulties; 2) physicians’ responses to patients’ social and emotional difficulties: many reported that intervening with these difficulties was challenging with few treatment options beyond making referrals, individualizing care, and recommending more frequent follow-up visits; and 3) the impact of patients’ social and emotional difficulties on physicians: few available patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians’ feeling frustrated, inadequate, and overwhelmed.
Recognition and understanding of physicians’ challenges when treating diabetes patients’ social and emotional difficulties are important for developing programmatic interventions.
PMCID: PMC3114520  PMID: 21411508
16.  Improvement and Emergence of Insulin Restriction in Women With Type 1 Diabetes 
Diabetes Care  2011;34(3):545-550.
To determine the distinguishing characteristics of women who report stopping insulin restriction at 11 years of follow-up from those continuing to endorse insulin restriction as well as those characteristics differing in patients who continue to use insulin appropriately from new insulin restrictors.
This is an 11-year follow-up study of 207 women with type 1 diabetes. Insulin restriction, diabetes self-care behaviors, diabetes-specific distress, and psychiatric and eating disorder symptoms were assessed using self-report surveys.
Of the original sample, 57% participated in the follow-up study. Mean age was 44 ± 12 years, diabetes duration was 28 ± 11 years, and A1C was 7.9 ± 1.3%. At follow-up, 20 of 60 baseline insulin restrictors had stopped restriction. Women who stopped reported improved diabetes self-care and distress, fewer problems with diabetes self-management, and lower levels of psychologic distress and eating disorder symptoms. Logistic regression indicated that lower levels of fear of weight gain with improved blood glucose and fewer problems with diabetes self-management predicted stopping restriction. At follow-up, 34 women (23%) reported new restriction, and a larger proportion of new insulin restrictors, relative to nonrestrictors, endorsed fear of weight gain with improved blood glucose.
Findings indicate that fear of weight gain associated with improved blood glucose and problems with diabetes self-care are core issues related to both the emergence and resolution of insulin restriction. Greater attention to these concerns may help treatment teams to better meet the unique treatment needs of women struggling with insulin restriction.
PMCID: PMC3041178  PMID: 21266653
18.  Barriers to Achieving Glycemic Targets: Who Omits Insulin and Why? 
Diabetes Care  2010;33(2):450-452.
PMCID: PMC2809300  PMID: 20103561
20.  A Person-Focused Analysis of Resilience Resources and Coping in Diabetes Patients 
This study investigated the resilience resources and coping profiles of diabetes patients. A total of 145 patients with diabetes completed a questionnaire packet including two measurements of coping (COPE and Coping Styles questionnaires), and personal resources. Glycosylated hemoglobin (HbA1c) was also assessed. Resilience was defined by a factor score derived from measures of self-esteem, self-efficacy, self-mastery, and optimism. All of the maladaptive coping subscales were negatively associated with resilience (r's range from −.34 to −.56, all p's <.001). Of the adaptive coping subscales, only acceptance, emotional support, and pragmatism were positively associated with resilience. The upper, middle, and lower tertiles of the resilience factor were identified and the coping profiles of these groups differed significantly, with low resilience patients favoring maladaptive strategies much more than those with high or moderate resilience resources. Resilience groups did not differ in HbA1c levels; correlation coefficients of the coping subscales with HbA1c were explored. This study demonstrates a link between maladaptive coping and low resilience, suggesting that resilience impacts one's ability to manage the difficult treatment and lifestyle requirements of diabetes.
PMCID: PMC2880488  PMID: 20526415
Diabetes; Resilience; Coping; HbA1c
21.  Driving Mishaps Among Individuals With Type 1 Diabetes 
Diabetes Care  2009;32(12):2177-2180.
Hypoglycemia-related neuroglycopenia disrupts cognitive-motor functioning, which can impact driving safety. Retrospective studies suggest that drivers with type 1 diabetes experience more collisions and citations than their nondiabetic spouses. We present the first prospective data documenting the occurrence of apparent neuroglycopenia-related driving performance impairments.
We completed the initial screening of 452 drivers from three geographically diverse centers who then reported monthly occurrences of driving “mishaps,” including collisions, citations, losing control, automatic driving, someone else taking over driving, and moderate or severe hypoglycemia while driving.
Over 12 months, 52% of the drivers reported at least one hypoglycemia-related driving mishap and 5% reported six or more. These mishaps were related to mileage driven, history of severe hypoglycemia, and use of insulin pump therapy.
Many individuals with type 1 diabetes report hypoglycemia-related driving events. Clinicians should explore the recent experiences with hypoglycemia while driving and the risk of future events.
PMCID: PMC2782972  PMID: 19940224
22.  The role of resilience on psychological adjustment and physical health in patients with diabetes 
British journal of health psychology  2007;13(Pt 2):311-325.
This study used a longitudinal design to investigate the buffering role of resilience on worsening HbA1c and self-care behaviours in the face of rising diabetes-related distress.
A total of 111 patients with diabetes completed surveys and had their glycosylated hemoglobin (HbA1c) assessed at baseline and 1-year follow-up. Resilience was defined by a factor score of self-esteem, self-efficacy, self-mastery, and optimism. Diabetes-related distress and self-care behaviours were also assessed.
Baseline resilience, diabetes-related distress, and their interaction predicted physical health (HbA1c) at 1-year. Patients with low, moderate, and high resilience were identified. Those with low or moderate resilience levels showed a strong association between rising distress and worsening HbA1c across time (r=.57, .56, respectively). However, those with high resilience scores did not show the same associations (r=.08). Low resilience was also associated with fewer self-care behaviours when faced with increasing distress (r= −.55). These correlation coefficients remained significant after controlling for starting points.
In patients with diabetes, resilience resources predicted future HbA1c and buffered worsening HbA1c and self-care behaviours in the face of rising distress levels.
PMCID: PMC2899486  PMID: 17535497
23.  How Does Anger Coping Style Affect Glycemic Control in Diabetes Patients? 
Although various forms of anger have been found to influence the psychological and physical health in many chronic illness populations, little is known about the effects of anger in diabetes patients.
Associations between anger coping style, diabetes-related psychological distress, and glycosylated hemoglobin (HbA1c) were examined in 100 diabetes patients.
Participants completed the Problem Areas in Diabetes and Coping Styles questionnaires, and had HbA1c assessments at study entry (Time 1=T1), six months (T2), and 12 months after T1 (T3).
Linear regression analyses revealed T1 anger coping associated with T3 HbA1c (β=.22, p<.05) but T1 HbA1c did not associate with T3 anger coping (β=.13, p=NS). After controlling for significant covariates (of gender, age, education, type and duration of diabetes), regression analyses revealed that T2 diabetes-related psychological distress partially mediated this association.
These results suggested that higher levels of anger coping may promote poorer HbA1c in diabetes patients by provoking greater diabetes-related distress. Areas of future research on this topic are discussed.
PMCID: PMC2900155  PMID: 18696309
anger coping; psychological distress; glycemic control; diabetes

Results 1-25 (32)