Glycaemic control in type 2 diabetes targets and new therapies,naturally treat diabetes type 2 2013,differentiating between type1 and type 2 diabetes,new treatment for diabetic foot ulcer - How to DIY

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Diet, exercise, and education remain the foundation of all type 2 diabetes treatment programmes. After metformin, it is reasonable to consider combination therapy with an additional 1-2 oral or injectable agents with the objective of minimising side-effects where possible. For many patients insulin therapy alone or in combination with other agents will ultimately be required to maintain glucose control.
All treatment decisions, where possible, should take into account the patient’s preferences, needs and values. Diabetes may be diagnosed based on HbA1c criteria or plasma glucose criteria, either the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT). For all patients, particularly those who are overweight or obese, testing should begin at age 45 years.
Two primary techniques are available to assess the effectiveness of glycaemic control: Patient self-monitoring of blood glucose (SMBG) or interstitial glucose and A1C.
Patients on multiple-dose insulin or insulin pump therapy should perform SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycaemic, and prior to critical tasks such as driving. Initial therapy: Most patients should begin with lifestyle changes – healthy eating, weight control, increased physical activity, and diabetes education. Advancing to dual combination therapy: If the HbA1c target is not achieved after ~3 months with metformin, there are six drug choices including a second oral agent (sulfonylurea, TZD, DPP-4 inhibitor, or SGLT2 inhibitor), a GLP-1 receptor agonist, or basal insulin. Advancing to triple combination therapy: Evidence suggests that there is some advantage in adding a third noninsulin agent to a two-drug combination not achieving the glycaemic target.
Do you agree that private hospitals should be paid via the NTPF to cut public hospital waiting lists? 4 Relation between PPG control & Achieving A1C Goal Adapted from Monnier L, Lapinski H, Collette C. Every 1% drop in HbA 1c can reduce long-term diabetes complications 43% Lower extremity amputation or fatal peripheral vascular disease 37% Microvascular disease 19% Cataract extraction 14% Myocardial infarction 16% Heart failure 12% Stroke UKPDS: Stratton et al.
Hormone BloodTissue Injection site Carrier Protein Carrier Protein Hormone Receptor Mode of Action Use of Serum Carrier Protein (e.g. Insulin analogues compared Insulin receptor affinity IGF-1R affinity Insulin receptor off rate Metabolic potency Mitogenic potency Human insulin =100 Insulin aspart 92 ± 681 ± 981 ± 8101 ± 258 ± 22 Insulin detemir 18 ± 316 ± 1204 ± 92711 Kurtzhals P, et al.
Insulin analogues compared Insulin receptor affinity IGF-1R affinity Insulin receptor off rate Metabolic potency Mitogenic potency Human insulin =100 Insulin aspart 92 ± 681 ± 981 ± 8101 ± 258 ± 22 Insulin lispro 84 ± 6156 ± 16100 ± 1182 ± 366 ± 10 Insulin glargine 86 ± 3641 ± 51152 ± 1360 ± 3783 ± 13 Insulin detemir 18 ± 316 ± 1204 ± 92711 Kurtzhals P, et al. Summary Treatment with basal analogues enables patients to reach HbA 1c target with low rate of hypoglycaemia HbA 1c improves but some patients need more Levemir® + OD is associated with: –reduced hypoglycemia in comparison to NPH, and –reduced weight gain in comparison to any other basal insulin.
Diabetes is a complex metabolic disorder characterized by hyperglycaemia, arising from insulin resistance and progressive deterioration of beta-cell function.3 However, before clinically meaningful physiological changes manifest as a result of this hyperglycaemia, deterioration of beta-cell function reaches a pathologically advanced state. Data from several landmark studies including UKPDS and Diabetes Control and Complications Trial (DCCT), suggests that aggressive management of diabetes and its associated risk factors will lead to a reduction in long-term complications associated with diabetes.8,21 Intensive insulin therapy can have long-lasting benefits in terms of glycaemic control with acceptable safety profiles over conventional therapy. Insulin intensification is essential to minimize patienta€™s exposure to chronic hyperglycaemia albeit not exacerbating the risk of hypoglycaemia, while achieving individualized fasting, postprandial, and HbA1c targets.
One of the options for prandial coverage is the basal-plus regimen involving addition of a pre-meal rapid-acting insulin analogue to ongoing basal insulin. Premixed insulin is also an alternative option for insulin intensification to achieve or maintain glycaemic targets over time.
For most patients with diabetes from India, physicians play an important role in managing T2DM by intensifying insulin regimens. Early initiation and intensification of insulin prevents prolonged exposure to hyperglycaemia and reduces the risk of associated complications.
Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). International Diabetes Federation, Guideline for Management of PostMeal Glucose in Diabetes. This analysis of the Treating to New Targets (TNT) trial aimed to identify determinants of residual risk above and beyond lipid-related risk factors among patients with stable coronary disease treated to low LDL-cholesterol targets. Hyperlipidemia has been suggested as a risk factor for stenosis of the aortic valve, but lipid-lowering studies have had conflicting results. We conducted a randomized, double-blind trial involving 1873 patients with mild-tomoderate, asymptomatic aortic stenosis.
Simvastatin and ezetimibe did not reduce the composite outcome of combined aorticvalve events and ischemic events in patients with aortic stenosis.
EAS 2016 European guidelines on cardiovascular disease prevention from the Sixth Joint Task Force provide up-to-date accessible recommendations for lipid control for clinicians in their routine practice. ACC 2016 Stephen Nicholls discusses the results of the ACCELERATE-study, in which the favourable effects of the CETP-inhibitor evacetrapib on cholesterol did not translate into any reduction in the primary endpoint.
In response to a requirement of regulatory bodies for antidiabetic trials to now include CV outcomes assessment, data of 5 such outcomes trials are now available. Daniel Rader (Philadelphia, PA, USA) looks forward to a future of personalised medicine in FH, which should benefit from specific biomarkers and novel medications, to better treat this common lipid disorder. The largest meta-analysis to date of GWAS for LDL-C lowering response to statin therapy sheds new light on the pharmacogenetic determinants of the statin response. Out-of-clinic blood pressure monitoring is increasingly regarded as a routine component of cardiovascular risk management. Infective endocarditis is a relatively rare infection of the inner layer of the heart’s valves and chambers.
The majority of patients who present to general practice with chest pain are unlikely to have an acute coronary syndrome.
Dr Stephen Allpress, Anatomical Pathologist, is currently Clinical Director of Surgical Pathology at North Shore Hospital in Auckland. Janet has worked as in-house legal counsel and privacy officer at several District Health Boards over the past 12 years. Janet will discuss some of the challenges that health providers face when balancing the need to ensure appropriate sharing and transfer of patient health information while still ensuring that legal obligations and privacy requirements are met. George Arnold leads the health programme at NZTE, and is 50% seconded to the National Health Board. Nicci works with a range of patients wishing to access this programme from single women to same-sex couples and heterosexual couples.
Nicci achieved her Bachelor of Health from Unitec and has always had an interest in Women’s health. Nicci will clarify the Donor Sperm recruitment process and what is required for sperm donors and options for recipients. He practiced for many years in Browns Bay, Auckland, and moved to Tauranga in 2005, where he continues in Specialist Practice. He holds a diploma in Musculoskeletal Medicine and a fellowship in the Australasian Faculty of Musculoskeletal Medicine.
He has spent many years looking at the relationship between ergonomics, core stability and dysfunctional breathing in the causalgia of musculoskeletal problems. Using this approach, many people who have been labeled as having chronic musculoskeletal pain can be more effectively treated, at least substantially reducing their pain, often returning them to an essentially pain free state and improving their quality of life. This is an interactive, user friendly approach to the management of neck and upper thoracic pain. His in-depth experience in the field of plastic surgery is an integral part of Mr.Bialostocki’s skill as a surgeon today, and a talent for the procedures he performs has gained him a reputation as a highly respected plastic surgeon. A practical workshop to cover diagnosis, marking out on pig skin, punch biopsy, anatomy of needles, suture choice, excision technique, borders, and simple ellipse repair, dog ear repair, principles of wound healing, and sterile wound care.
A practical workshop to demonstrate and practice on pig skin some flap repairs suitable for skin cancer work as rotation and advancement flaps. He has been a senior staff Internist at the Lahey Clinic in Burlington Massachusetts for over thirty years. He and his wife Judy have raised four children, and are enjoying their first grandchild, Leon. The obesity epidemic has caused an explosion in the number of patients with diabetes and the metabolic syndrome. Trevor is the Business Development Manager for myPractice, working alongside Ashwin to assist myPractice to achieve their market objectives.
Began career as an accountant in hometown Christchurch working for International Harvester as a manufacturing cost accountant, internal auditor and then in business development for Retail Operations.
Gained network experience as General Manager Services for Cray Communications; latterly undertook assignments as a Project Director for several large implementations in Australia. Enjoying the complexities and challenges of the Health sector, where information sharing and collaboration is the key to collective success.

Ross Boswell practices as chemical pathologist and general physician at Counties Manukau DHB where he is Clinical Director of Laboratory Services and Clinical Director of IT. Medical practices have a legal responsibility to keep the personal health information they hold secure: that is, to preserve the information against loss or corruption, to make it available when needed, and to prevent unauthorised access. There are increasing moves in New Zealand towards the collection of personal health information in regional repositories. Dr David Bratt is first and foremost a General Practitioner who spent 30 years in front-line general practice enjoying the delivery of individual face-to-face health services. The Government has heralded a new way of working with beneficiaries so what will this mean for you at the medical coalface? The total cost per person for the course covers, test paper, manual and certificate plus any re-sit exams required. This is a level 7 NZRC Approved( 8 hrs) course, run by Jason Burns (New Zealand Resuscitation Instructor level 4-7, NZDA Approved instructor, Paediatric Advanced life support instructor).
I am responsible for organising and running workshops on “Initiating Insulin in Primary care” for General Practitioners and Practice Nurses. Muscle loss commences from the mid thirties, with an accelerating rate of muscle degradation ultimately resulting in sarcopenia, with associated frailty and impaired mobility in the elderly.
Dramatic changes in human physiology take places as the body transitions from net gain in tissue mass to one of relative stability prior to decline and senescence. Dr Stephen Child is a Canadian-trained General Physician with a Respiratory interest who immigrated to New Zealand in late 1991.
Dr Child has given numerous talks on topics of general medicine, asthma and medical education. He was a member of the DHB National Workforce Strategy Group from 2001 – 2009 and the Minister of Health’s Medical Training Board from 2007 – 2009.
Dr Child is the current Chair of the Auckland Division of the New Zealand Medical Association (NZMA) and is an elected member of the NZMA Board. Dr Child will review the current out patient investigations for the ambulatory patient presenting with Chest Pain including a review of the Differential diagnosis and the correct ordering of troponin and ECG testing.
Dr Child will present his personal approach to a patient presenting with "generalised fatigue" including tips on history taking, physical examination and judicious laboratory testing. Dr Child will review the latest treatment options for asthma including some of the recent controversy regarding single inhaler therapy. Rowan has a particular interest in colorectal disorders of the pelvic floor, including faecal incontinence and pelvic organ prolapse. Nearly 3000 New Zealanders per year will be diagnosed with colorectal cancer and over 40% of these will die of this cancer. Through a series of case studies, we will discuss the risk profiling and detection of patients who may have a colorectal malignancy, who present to their primary care practitioner.
Diabetes may be identified in seemingly low risk individuals who happen to have glucose testing, in symptomatic patients, and in higher-risk individuals who are tested because of a suspicion of diabetes. When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis (in patients intolerant, or with contraindications for, metformin, select initial drug from other treatment options). Contributions of fasting and postprandial plasnma glucose increments to the overall diurnal hyper glycemia of Type 2 diabetic patients: variations with increasing levels of HBA(1c).
Timely intensification of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications. Self-monitoring of blood glucose (SMBG) for three or more times is recommended when intensive glycaemic control is required. Overall glycaemic control (or HbA1c level) is contributed by both fasting plasma glucose (FPG), addressed by basal insulin, and postprandial glucose (PPG) addressed by prandial insulin. Therefore addition of a prandial insulin injection before the meal to counter postprandial glycaemic excursions is a logical first step in progressing insulin therapy. An ideal regimen attempts to mimic physiological, both basal and postprandial insulin secretion facilitating in the achievement and sustaining of good glycaemic control.
Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.
Beneficial effects of insulin versus sulphonylurea on insulin secretion and metabolic control in recently diagnosed type 2 diabetic patients.
Efficacy of Insulin Analogs in Achieving the Hemoglobin A1c Target of <7% in Type 2 Diabetes.
The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of Type 2 diabetes. Demonstrating strategies for initiation of insulin therapy: matching the right insulin to the right patient. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. Insulin intensification strategies in type 2 diabetes: when one injection is no longer sufficient. A stepwise approach to insulin therapy in patients with type 2 diabetes mellitus and basal insulin treatment failure.
Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomised, treat-to-target clinical trial.
Comparison of 2 intensification regimens with rapid-acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetes drugs: the step-wise randomized study. Real world outcomes of adding rapid-acting insulin versus switching to analog premix insulin among US patients with type 2 diabetes treated with insulin glargine. Optimization of insulin therapy in patients with type 2 diabetes mellitus: beyond basal insulin.
Study of Once Daily Levemir (SOLVEa„?): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice. Clinical Inertia in Individualising Care for Diabetes: Is There Time to do More in Type 2 Diabetes?
Prandial premixed insulin analogue regimens versus basal insulin analogue regimens in the management of type 2 diabetes: an evidence-based comparison. Insulin initiation and intensification in patients with T2DM for the primary care physician. Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) Study. Association of hypoglycemic symptoms with patientsa€™ rating of their health-related quality of life state: a cross sectional study. Assessment of the impact of fear of hypoglycemic episodes on glycemic and hypoglycemic management.
Association of depression with complications of type 2 diabetes the Chennai Urban Rural Epidemiology Study CURES- 102). Self-monitoring technologies for type 2 diabetes and the prevention of cardiovascular complications: Perspectives from end users. Epidemiology and correlates of weight worry in the multi-national Diabetes Attitudes, Wishes and Needs (DAWN) Study. Type 2 diabetes care and insulin intensification: is a more multidisciplinary approach needed? Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Factors associated with physician perceptions of and willingness to recommend inhaled insulin. Transition to insulin in type 2 diabetes: family physiciansa€™ misconception of patientsa€™ fears contributes to existing barriers. The patients received either 40 mg of simvastatin plus 10 mg of ezetimibe or placebo daily. Secondary outcomes were events related to aortic-valve stenosis and ischemic cardiovascular events.
Salim Yusuf discusses the results of the HOPE-3 study, which indicates that statins are effective in all patients with intermediate CVD risk, whereas blood pressure lowering is only effective in hypertensive patients. Prior to this she worked at the Health and Disability Commissioner’s Office and in private legal practice. He was one of the founders of the NZ Association of Musculoskeletal Medicine and was responsible for the name. The diagnosis must include not only the cause of the dysfunction, but also why conventional treatment has been unsuccessful.
The radiology is discussed in the first half and then the questions of: How do we approach musculoskeletal problems?
Some key management ”hands on techniques” will be demonstrated that will aid you in understanding the musculoskeletal problems pertaining to these areas. Bialostocki is a Specialist Plastic Surgeon, with a full Fellowship in Plastic & Reconstructive Surgery from the Royal Australasian College of Surgeons (FRACS). Bialostocki has an appointment at Tauranga Hospital as the visiting Plastic Surgery Consultant, is a member of the Plastic Surgery department at Waikato Public Hospital in Hamilton and has his own clinic in Tauranga, Bay Plastic Surgery.

Other flaps as Wolfe grafting, split skin grafts, Lazy S, VY repair,and Z plasty will be presented.
He has teaching appointments with Harvard Medical School and the Tufts University School of Medicine.
There is a strong link between obesity, the metabolic syndrome and premature coronary artery disease.
Hypertension remains a major pubic health challenge and a major risk factor, particularly for end-stage kidney disease. He has a strong background in IT sales, marketing, project management and business consultancy, with some 30 years multinational senior management and sales management experience. Moved into ITC with Unisys NZ in Wellington as an Account Manager and Account Director in the Government sector with IRD and MSD and Marketing Manager for LINC.
Moved to Auckland some 3 years ago as a founding shareholder of Konnect Net in the start-up phase of this successful venture, where he gained exposure to the Health sector in product development and deployment roles. There is a high and ever-increasing rate of change in the sector and this presents both challenges and opportunities alike. I have been working as a Diabetes Nurse Specialist for Waitemata DHB at Waitakere Hospital for the last 7 yrs.
The process of muscle loss is complex, involving both increased degradation and ineffective regeneration. It is the period of stability from the 40’s on where CVD, diabetes and nutritionally-related cancer risks become evident. He will review current treatment guidelines and is open to general discussion around selected cases or questions. In 2008, colorectal cancer was the second most common cancer registered and the second most common cause of death from cancer in New Zealand. Shared decision making with the patient is important to help in the selection of therapeutic option. Since diabetes is associated with progressive beta-cell loss, many patients, especially those with long-standing disease, will ultimately need to be transitioned to insulin. Hala Aly Gamal El Din Professor Of internal medicine Faculty of Medicine - Cairo University. Given that overall hyperglycaemia is a relative contribution of both fasting and postprandial hyperglycaemia, use of basal insulin alone may not achieve optimal glucose control due to its inability to cover postprandial glucose excursions. Simply increasing basal insulin dose may still result in inadequate glycaemic control because the mealtime insulin response remains uncovered exposing the patient to high PPG levels after every meal.
This approach allows more gradual intensification of insulin therapy to full basal-bolus therapy if glycaemic targets are not achieved.
0001), the MODIFY study demonstrated that lack of experience (49%) and lack of time to educate patients (49%) are the main barriers faced by physicians in the intensification of insulin. As recommended by several guidelines, insulin therapy is initiated with basal insulin or premixed insulin and intensified with addition of bolus insulin or switching to premixed insulin when glycaemic targets are not achieved with optimal doses of basal insulin. Indian National Consensus Group: National Guidelines on Initiation and Intensification of Insulin Therapy with Premixed Insulin Analogs.
American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs study (DAWN).
The emerging field of body contouring after massive-weight loss is a fascinating new sub-area, & Mr. Principal of Theseus Management (TMG) an independent business consultancy and a director of Highfield Net Ltd. This exposure to a large multilayered organisation required a whole new set of skills and an understanding of the relatively slow pace of change possible compared to a typical small business general practice.
What has the experiences of the UK GPs been with their welfare reforms and how can we learn from this and avoid their mistakes. This presentation will cover the latest evidence linking diet and chronic disease risk, before considering how changing digestion, metabolism and physiology influences the biological impact of nutrients. The choice is based on patient and drug characteristics, with the over-riding goal of improving glycaemic control while minimising side-effects.
Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes.
Position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Intensifying therapy with addition of bolus insulin or switching to premixed insulin is a viable option in patients failing on basal alone therapy. These patients initiated on basal insulin may be intensified to basal plus one mealtime (rapid-acting) insulin therapy. In a study by Davidson et al., patients uncontrolled on basal insulin alone were randomized to receive rapid-acting insulin once, twice or three times daily. It was also observed that physicians have a misconception that patients would not cope-up with insulin intensification.55 This kind of misconception may be discouraging for an Indian patient with diabetes, who solely depends on physiciana€™s advice on insulin intensification. We will discuss posture, breathing, palpation, neuromuscular therapy and other important topics that will underscore your approach to musculoskeletal pain.
He was trained in the New Zealand Plastic Surgery training program at Middlemore Hospital & Hutt Hospital.
He completed his internship and first year of medical residency at the Boston City Hospital in Boston, Massachusetts, and did his third year of training at the New England Deaconess Hospital, also in Boston. A further leap into the unknown occurred in 2007 with his appointment to the new position of Principal Health Advisor to the Ministry of Social Development. Remember 13% of working age adults live on a tax-payer funded welfare benefit and even more alarming so do 20% of all children. Although the benefits of early insulin treatment are well established, a considerable delay in intensifying insulin therapy in patients with sub-optimal glycaemic control is still observed. Alternatively, twice daily premixed insulin regimen is indicated in patients with higher HbA1c levels (a‰? 9.0%). Low knowledge on diabetes management and low rate of physician recommendations influence the use of self-monitoring devices by patients with diabetes.56 Taken together, all these physician barriers contribute to delay in insulin initiation and intensification, leading to poor glycaemic control and development of complications in patients with T2DM. In light of this, there is a demand for a flexible, alternative treatment intensification option taking individual patients into consideration to achieve glycaemic control and overcome barriers related to MDIs of insulin with reduced number of daily injections, low risk of hypoglycaemia and with less consequences of delayed or missed insulin dose. After being awarded his Fellowship in Plastic Surgery, he further honed his knowledge with extended visits to some of the most prominent plastic surgeons in Australia and Europe. He also performs a large amount of skin cancer surgery, hand surgery, gynaecomastia correction & ACC scar revision surgery. This is General Practice at a systems level – working with a population around the wider social determinants of health – employment, income, housing, education, and access to health services. In using triple combinations the essential consideration is obviously to use agents with complementary mechanisms of action. Most of the patients and physicians are reluctant to intensify therapy due to the fear of hypoglycaemia, regimen complexity, and increased burden of multiple daily injections. My comments : HbA1c measurement is invalid if red cell turnover is disturbed or if abnormal Hb is present.
In this position he had to opportunity to work on collecting together the substantial body of evidence on the health benefits of work, and the significant adverse health outcomes of worklessness. The seminar will be an opportunity to ask everything you wanted to know about the welfare delivery system here in NZ. In this context, there is a need for a flexible, alternative intensification option taking into account individual patient considerations to achieve or maintain individual glycaemic targets. Rapid-acting insulin analogues are preferred over regular human insulin because they have a more rapid onset and offset of action and are associated with less risk of hypoglycaemia.26,27 Table 1 summarizes different guidelines on glycaemic targets and insulin intensification. In these situations measurement of Fructosamine will give an idea of glycaemic control over previous 1-3 weeks. An ideal insulin regimen should mimic physiological insulin release while providing optimal glycaemic control with low risk of hypoglycaemia, weight gain and fewer daily injections.
This test is also used in monitoring Diabetes in pregnancy as HbA1c measured earlier than 2 months is of limited help. The current paper reviews the challenges of insulin intensification in patients with type 2 diabetes mellitus poorly controlled on current treatment regimens.
Higher HbA1c is always significant and indicates the degree of exposure to raised glucose which can contribute to the development of microangiopathy due to glucotoxicity and therefore needs to be corrected by lifestyle changes.
In future HbA1c may be included in the diagnosis of Diabetes(specificity 99.6%, sensitivity 99%). Low HbA1c reading, particularly in Type1 Diabetes, should be correlated with home glucose results.

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  1. ayanka

    This weight loss program to cut cold water three times a day helps to regulate blood deal.


  2. sex_xanim

    Plan serve one person people with diabetes can refined and high glycemic index carbohydrates.


  3. manyak

    Depth exercise couple of time per.


  4. qaqani

    Have been taking a beating for their putative effect on the you getting.


  5. orxideya_girl

    Any need of additional bolus insulins calorie intake and effectively.