Glycemic Regulation Research Articles

Comparative Evaluation of Nutritional Compositions of Different Sri Lankan Rice Varieties on Glycemic Regulation

The main nutrition of rice (Oryza sativa) is carbohydrates in starches, sugars and fibre. The amount and type of carbohydrates can be detrimental to health as they increase blood glucose levels, leading to the risk of diabetes. As intrinsic and extrinsic factors affect the glycaemic response of foods, understanding the influence of proximate composition and mineral content of rice on Glycaemic Index (GI) is useful. The nutritional composition and glycaemic potential of twelve rice varieties grown in Sri Lanka; Bg94-1, At405, Bw367, H.H.Z.36, Ld368, At362, Bg300, Bg352, Bg406, Madathawalu, Suduheenati and Pachchaperumal were studied. The GI was calculated using fourteen healthy subjects consisting of seven males and seven females fed with cooked rice containing 50 g carbohydrate and a reference food. The nutritional composition of the rice was compared with the GI of each variety. The GI of 12 rice varieties varied from 40-69. The proximate and mineral compositions were significantly different except for the moisture level. This study suggested a significant negative correlation between GI and calcium content. Among the studied rice varieties, "Sudu heenati" showed a high level of calcium, chromium, protein and fibre values with low GI, which would claims health benefits.

Factors associated with poor glycemic control in diabetic patients in Kirkuk

Background Iraq's health-care system has faced tremendous obstacles in its recovery from the Islamic State's conflict. There is no public insurance system in place. Iraq has set targets to prevent and control noncommunicable diseases (NCDs) such as diabetes, but safety confrontation and governmental insecurity have made these objectives difficult to achieve. Better glycemic control is critical in allowing patients to perform at their best in terms of diabetes management and preventing long-term complications. The goal is to identify the roadblocks to better glycemic management. The participants in this cross-sectional study were recruited from a diabetes out-patient clinic at Baba Gurgur diabetic facility. From April to December 2019, K1 hospital – North oil company in Kirkuk city. A validated questionnaire was used to interview those with an uncontrolled glycemic index (AIC7%). Patients were asked to name the primary causes of inadequate glucose control and to select more than one response based on their opinion. The mean A1C was 8.3 2.1 percent, with 256 (22.5 percent) patients having an A1C less than 7% and 880 (77.5 percent) having an A1C equal to or greater than 7. Poor glycemic control is caused by a lack of medication and/or a lack of drug supply from PHC in 51.1 percent of cases. Diet and medication non-compliance, as well as illiteracy, account for 35.1 percent and 19.8 percent of the population, respectively. Glycemic regulation is greatly influenced by one's financial situation. However, security issues and political instability play a significant impact. Conclusion: Diabetic patients confirmed poor glycemic control, with the majority of cases being linked to Iraq's current health situation.

Glucagon, cyclic AMP, and hepatic glucose mobilization: A half‐century of uncertainty

For at least 50 years, the prevailing view has been that the adenylate cyclase (AC)/cyclic AMP (cAMP)/protein kinase A pathway is the predominant signal mediating the hepatic glucose‐mobilizing actions of glucagon. A wealth of evidence, however, supports the alternative, that the operative signal most of the time is the phospholipase C (PLC)/inositol‐phosphate (IP3)/calcium/calmodulin pathway. The evidence can be summarized as follows: (1) The consensus threshold glucagon concentration for activating AC ex vivo is 100 pM, but the statistical hepatic portal plasma glucagon concentration range, measured by RIA, is between 28 and 60 pM; (2) Within that physiological concentration range, glucagon stimulates the PLC/IP3 pathway and robustly increases glucose output without affecting the AC/cAMP pathway; (3) Activation of a latent, amplified AC/cAMP pathway at concentrations below 60 pM is very unlikely; and (4) Activation of the PLC/IP3 pathway at physiological concentrations produces intracellular effects that are similar to those produced by activation of the AC/cAMP pathway at concentrations above 100 pM, including elevated intracellular calcium and altered activities and expressions of key enzymes involved in glycogenolysis, gluconeogenesis, and glycogen synthesis. Under metabolically stressful conditions, as in the early neonate or exercising adult, plasma glucagon concentrations often exceed 100 pM, recruiting the AC/cAMP pathway and enhancing the activation of PLC/IP3 pathway to boost glucose output, adaptively meeting the elevated systemic glucose demand. Whether the AC/cAMP pathway is consistently activated in starvation or diabetes is not clear. Because the importance of glucagon in the pathogenesis of diabetes is becoming increasingly evident, it is even more urgent now to resolve lingering uncertainties and definitively establish glucagon’s true mechanism of glycemia regulation in health and disease.

Adaptive controller based an extended model of glucose-insulin-glucagon system for type 1 diabetes

ABSTRACT This paper presents an automated closed-loop control for type 1 diabetes. The closed loop is designed using a new extended mathematical model that takes into account the dynamics of the insulin-antagonistic pancreatic hormone called glucagon, which stimulates hepatic glucose production. An adaptive controller is developed for an artificial pancreas based on sliding mode control (SMC) and an estimation of the system parameters obtained by the least-squares method. The system has been analyzed using Lyapunov stability theory. A comparative study between the proposed model and an existing model is presented. Furthermore, the numerical simulation for type 1 diabetes mellitus model has shown good results for the designed environment. Therefore, the model achieves better glycemic regulation with the incorporation of glucagon, with low chances of exposure to hyperglycemia and hypoglycemia events. The SMC tracks the system to the desired state.

A Three-Day Intervention With Granola Containing Cereal Beta-Glucan Improves Glycemic Response and Changes the Gut Microbiota in Healthy Individuals: A Crossover Study.

Intake of soluble fibers including beta-glucan, is known to improve post-prandial glycemic response. The mechanisms have been attributed to the viscous gel forming in the stomach and small intestine, giving a longer absorption time. However, recent evidence suggests a link between intake of beta-glucan and improved glycemic regulation at subsequent meals through the gut microbiota. We investigated the short-term effect of granola with different amounts of cereal beta-glucan on glycemic response and gut microbiota. After a two-week run-in period (baseline), fourteen healthy, normal weight adults completed a dose-response dietary crossover study. Different amounts of cereal beta-glucan (low: 0.8 g, medium: 3.2 g and high: 6.6 g) were provided in granola and eaten with 200 ml low-fat milk as an evening meal for three consecutive days. Blood glucose and insulin were measured fasted and after an oral glucose tolerance test (OGTT) the following day, in addition to peptide YY (PYY) and glucagon-like peptide (GLP-2), fasting short chain fatty acids (SCFA) in blood, breath H2, and gut microbiota in feces. Only the intervention with medium amounts of beta-glucan decreased blood glucose and insulin during OGTT compared to baseline. Fasting PYY increased with both medium and high beta-glucan meal compared to the low beta-glucan meal. The microbiota and SCFAs changed after all three interventions compared to baseline, where acetate and butyrate increased, while propionate was unchanged. Highest positive effect size after intake of beta-glucan was found with Haemophilus, followed by Veillonella and Sutterella. Furthermore, we found several correlations between different bacterial taxa and markers of glycemic response. In summary, intake of granola containing 3.2 g cereal beta-glucan as an evening meal for three consecutive days reduced the glycemic response after an OGTT 0-180 min and changed gut microbiota composition. Since we cannot rule out that other fiber types have contributed to the effect, more studies are needed to further explore the effect of cereal beta-glucan on glycemic regulation.Clinical Trial Registration[www.clinicaltrials.gov], identifier [NCT03293693].

Harnessing the Power of Leptin: The Biochemical Link Connecting Obesity, Diabetes, and Cognitive Decline.

In this review, the current understanding of leptin’s role in energy balance, glycemic regulation, and cognitive function is examined, and its involvement in maintaining the homeostatic “harmony” of these physiologies is explored. The effects of exercise on circulating leptin levels are summarized, and the results of clinical application of leptin to metabolic disease and neurologic dysfunction are reviewed. Finally, pre-clinical evidence is presented which suggests that synthetic peptide leptin mimetics may be useful in resolving not only the leptin resistance associated with common obesity and other elements of metabolic syndrome, but also the peripheral insulin resistance characterizing type 2 diabetes mellitus, and the central insulin resistance associated with certain neurologic deficits in humans.

Whey protein supplementation improves postprandial glycemia in persons with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials

Whey protein (WP) can increase insulin secretion, produce an incretin effect, delay gastric emptying, and regulate appetite, resulting in improved glycemic control. We hypothesized that WP supplementation is associated with postprandial glycemia regulation in persons with type 2 diabetes mellitus (T2DM) and conducted a quantitative meta-analysis of randomized controlled trials (RCTs) to test this hypothesis. We searched PubMed, Embase, Cochrane Library, Scopus databases, and the ClinicalTrials.gov registry for relevant RCTs published before March 2022. We assessed the pooled effects using a random-effects model on glucose and insulin levels at 60 and 120 minutes, total glucagon-like peptide-1 (tGLP-1) at 30 and 60 minutes, and the incremental area under the curve (iAUC) of glucose, insulin, tGLP-1, and glucose-dependent insulinotropic polypeptide. Five RCTs involving 134 persons were included. Postprandial glycemia was significantly lower at 60 minutes (weighted mean difference: −2.67 mmol/L; 95% confidence interval, −3.62 to −1.72 mmol/L) and 120 minutes (−1.59 mmol/L; −2.91 to −0.28 mmol/L) in WP group than in placebo group. The iAUC of insulin was significantly higher in WP group (24.66 nmol/L × min, 1.65-47.66 nmol/L × min) than in placebo group. Although other results favored the WP group, differences between the groups were not statistically significant. The present study showed that premeal WP supplementation is beneficial for postprandial glycemia in persons with mild or well-controlled T2DM without substantial adverse effects. However, the level of certainty of current evidence is not high enough. Further larger and well-designed clinical trials are warranted for evaluating optimal dose and long-term effects of WP supplementation.

Representation of insulin synthesis and construction of a three-dimensional insulin model as didactic tools in basic education

ABSTRACT Proteins are essential for cell function, and their biological performance depends on three-dimensional (3D) structures. Insulin is made up of 51 amino acids and is a critical hormone involved in glycaemia regulation. In basic education, concepts involving proteins (synthesis, structure, interactions, and function) are abstract and difficult for students to understand. The use of protein 3D models that assist in visualising biomolecular structures can be an important didactic tool to understand the complexity of protein structure. Here, we propose a practical activity for the construction of a 3D model of insulin, as a tool for teaching protein synthesis and structure to students in the 9th-grade of basic education. The activity involved three classes of one hour each. 62 students role-played the insulin mRNA translation and represented the primary structure through balloons tied to a string. They also built an 3D insulin model using Styrofoam balls and wire. The activities proved to be effective, as there was a better understanding by students regarding proteins and their characteristics. Therefore, practical classes for teaching proteins can be used in basic education to improve learning of abstract and sub-microscopic concepts.

How useful are body mass index and history of diabetes in COVID-19 risk stratification?

This study examines the value of risk stratification by documented diagnosis of diabetes and objectively measured height and weight (BMI) in COVID-19 severity and mortality in a large sample of patients in an urban hospital located in Southern California. Data from a retrospective cohort study of COVID-19 patients treated at Cedars-Sinai Medical Center between March 8, 2020, and January 25, 2021, was analyzed. Sociodemographic characteristics and pre-existing conditions were extracted from electronic medical records. Univariable and multivariable logistic regression models identified associated risk factors, and a regression causal mediation analysis examined the role of diabetes in the association between obesity and illness severity. All analyses were stratified by age (<65 and ≥65). Among individuals <65yo, diabetes accounted for 19-30% of the associations between obesity and COVID-19 illness severity. Among patients ≥65yo, having a BMI <18.5 was a risk factor for mortality regardless of diabetes history. Our findings have clinical implications in documenting which patients may be at elevated risk for adverse outcomes. More in-depth prospective studies are needed to capture how glycemic regulation may influence prognosis.

Automatic Artificial Pancreas Systems Using an Intelligent Multiple-Model PID Strategy.

In this paper, an individualized intelligent multiple-model technique is proposed to design automatic artificial pancreas (AP) systems for the glycemic regulation of type 1 diabetic patients. At first, using the multiple-model concept, the insulin-glucose regulatory system is mathematically identified by constructing some local models. In this step, trade-offs between the number of local models and the complexity of the overall closed-loop system are made by defining and solving a bi-objective optimization problem. Then, optimal AP systems are designed by tuning a bank of proportional-integral-derivative (PID) controllers via the genetic algorithm (GA). A fuzzy gain scheduling strategy is employed to determine the participation percentages of the PID controllers in the control action. Finally, two safety mechanisms, called insulin on board (IOB) constraint and pump shut-off, are installed in the AP systems to enhance their performance. To assess the proposed AP systems, in silico experiments are performed on virtual patients of the UVA/Padova metabolic simulator. The obtained results reveal that the proposed intelligent multiple-model methodology leads to AP systems with limited hyperglycemia and no severe hypoglycemia.

An Overview of the Cardiorenal Protective Mechanisms of SGLT2 Inhibitors.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors block glucose reabsorption in the renal proximal tubule, an insulin-independent mechanism that plays a critical role in glycemic regulation in diabetes. In addition to their glucose-lowering effects, SGLT2 inhibitors prevent both renal damage and the onset of chronic kidney disease and cardiovascular events, in particular heart failure with both reduced and preserved ejection fraction. These unexpected benefits prompted changes in treatment guidelines and scientific interest in the underlying mechanisms. Aside from the target effects of SGLT2 inhibition, a wide spectrum of beneficial actions is described for the kidney and the heart, even though the cardiac tissue does not express SGLT2 channels. Correction of cardiorenal risk factors, metabolic adjustments ameliorating myocardial substrate utilization, and optimization of ventricular loading conditions through effects on diuresis, natriuresis, and vascular function appear to be the main underlying mechanisms for the observed cardiorenal protection. Additional clinical advantages associated with using SGLT2 inhibitors are antifibrotic effects due to correction of inflammation and oxidative stress, modulation of mitochondrial function, and autophagy. Much research is required to understand the numerous and complex pathways involved in SGLT2 inhibition. This review summarizes the current known mechanisms of SGLT2-mediated cardiorenal protection.

Effect of Metformin on T2D-Induced MAM Ca2+ Uncoupling and Contractile Dysfunction in an Early Mouse Model of Diabetic HFpEF.

Diabetic cardiomyopathy (DCM) is a leading complication in type 2 diabetes patients. Recently, we have shown that the reticulum-mitochondria Ca2+ uncoupling is an early and reversible trigger of the cardiac dysfunction in a diet-induced mouse model of DCM. Metformin is a first-line antidiabetic drug with recognized cardioprotective effect in myocardial infarction. Whether metformin could prevent the progression of DCM remains not well understood. We therefore investigated the effect of a chronic 6-week metformin treatment on the reticulum-mitochondria Ca2+ coupling and the cardiac function in our high-fat high-sucrose diet (HFHSD) mouse model of DCM. Although metformin rescued the glycemic regulation in the HFHSD mice, it did not preserve the reticulum-mitochondria Ca2+ coupling either structurally or functionally. Metformin also did not prevent the progression towards cardiac dysfunction, i.e., cardiac hypertrophy and strain dysfunction. In summary, despite its cardioprotective role, metformin is not sufficient to delay the progression to early DCM.

Targeting human Glucokinase for the treatment of type 2 diabetes: an overview of allosteric Glucokinase activators.

Diabetes mellitus is a worldwide impacting disorder and the ratio through which the number of diabetic patients had increased worldwide, puts medical professionals to serious stress for its effective management. Due to its polygenic origin and involvement of multiple genes to its pathophysiology, leads to understanding of this ailment more complex. It seems that current interventions, such as dietary changes, life style changes and drug therapy such as oral hypoglycaemics and insulin, are unable to halt the trend. There are various novel and emerging targets on which the researchers are paying attention to combat with this ailment successfully. Human glucokinase (GK) enzyme is one of these novel and emerging targets for management of diabetes. Its availability in the pancreas and liver cells makes this target more lucrative. GK's presence in the pancreatic and hepatic cells plays a very important function for the management of glucose homoeostasis. Small molecules that activateGK allosterically provide an alternative strategy for restoring/improving glycaemic regulation, especially in type 2 diabetic patients. Although after enduring many setbacks in the development of the GK activators, interest has been renewed especially due to introduction of novel dual acting GK activator dorzagliatin, and a novel hepato-selective GK activator, TTP399. This review article has been formulated to discuss importance of GK in glucose homeostasis, recent updates on small molecules of GK activators, clinical status of GK activators and challenges in development of GK activators.

An extract of hops (Humulus lupulus L.) modulates gut peptide hormone secretion and reduces energy intake in healthy-weight men: a randomized, crossover clinical trial

Gastrointestinal enteroendocrine cells express chemosensory bitter taste receptors that may play an important role in regulating energy intake (EI) and gut function. To determine the effect of a bitter hop extract (Humulus lupulus L.) on acute EI, appetite, and hormonal responses. Nineteen healthy-weight men completed a randomized 3-treatment, double-blind, crossover study with a 1-wk washout between treatments. Treatments comprised either placebo or 500mg of hop extract administered in delayed-release capsules (duodenal) at 11:00h or quick-release capsules (gastric) at 11:30h. Ad libitum EI was recorded at the lunch (12:00h) and afternoon snack (14:00h), with blood samples taken and subjective ratings of appetite, gastrointestinal (GI) discomfort, vitality, meal palatability, and mood assessed throughout the day. Total ad libitum EI was reduced following both the gastric (4473kJ; 95% CI: 3811, 5134; P = 0.006) and duodenal (4439kJ; 95% CI: 3777, 5102; P = 0.004) hop treatments compared with the placebo (5383kJ; 95% CI: 4722, 6045). Gastric and duodenal treatments stimulated prelunch ghrelin secretion and postprandial cholecystokinin, glucagon-like peptide 1, and peptide YY responses compared with placebo. In contrast, postprandial insulin, glucose-dependent insulinotropic peptide, and pancreatic polypeptide responses were reduced in gastric and duodenal treatments without affecting glycemia. In addition, gastric and duodenal treatments produced small but significant increases in subjective measures of GI discomfort (e.g., nausea, bloating, abdominal discomfort) with mild to severe adverse GI symptoms reported in the gastric treatment only. However, no significant treatment effects were observed for any subjective measures of appetite or meal palatability. Both gastric and duodenal delivery of a hop extract modulates the release of hormones involved in appetite and glycemic regulation, providing a potential "bitter brake" on EI in healthy-weight men.

Patient-Wise Methodology to Assess Glycemic Health Status: Applications to Quantify the Efficacy and Physiological Targets of Polyphenols on Glycemic Control.

A growing body of evidence indicates that dietary polyphenols could be used as an early intervention to treat glucose-insulin (G-I) dysregulation. However, studies report heterogeneous information, and the targets of the intervention remain largely elusive. In this work, we provide a general methodology to quantify the effects of any given polyphenol-rich food or formulae over glycemic regulation in a patient-wise manner using an Oral Glucose Tolerance Test (OGTT). We use a mathematical model to represent individual OGTT curves as the coordinated action of subsystems, each one described by a parameter with physiological interpretation. Using the parameter values calculated for a cohort of 1198 individuals, we propose a statistical model to calculate the risk of dysglycemia and the coordination among subsystems for each subject, thus providing a continuous and individual health assessment. This method allows identifying individuals at high risk of dysglycemia—which would have been missed with traditional binary diagnostic methods—enabling early nutritional intervention with a polyphenol-supplemented diet where it is most effective and desirable. Besides, the proposed methodology assesses the effectiveness of interventions over time when applied to the OGTT curves of a treated individual. We illustrate the use of this method in a case study to assess the dose-dependent effects of Delphinol® on reducing dysglycemia risk and improving the coordination between subsystems. Finally, this strategy enables, on the one hand, the use of low-cost, non-invasive methods in population-scale nutritional studies. On the other hand, it will help practitioners assess the effectiveness of an intervention based on individual vulnerabilities and adapt the treatment to manage dysglycemia and avoid its progression into disease.

Therapeutic Role of Curcumin on Glycemic Regulation, Lipid Parameters and Potential Benefits on Hyperandrogenemia - A Short Communication

Therapeutic Role of Curcumin on Glycemic Regulation, Lipid Parameters and Potential Benefits on Hyperandrogenemia - A Short Communication

Skeletal Muscle Hyperemia: A Potential Bridge Between Post-exercise Hypotension and Glucose Regulation.

For both healthy individuals and patients with type 2 diabetes (T2D), the hemodynamic response to regular physical activity is important for regulating blood glucose, protecting vascular function, and reducing the risk of cardiovascular disease. In addition to these benefits of regular physical activity, evidence suggests even a single bout of dynamic exercise promotes increased insulin-mediated glucose uptake and insulin sensitivity during the acute recovery period. Importantly, post-exercise hypotension (PEH), which is defined as a sustained reduction in arterial pressure following a single bout of exercise, appears to be blunted in those with T2D compared to their non-diabetic counterparts. In this short review, we describe research that suggests the sustained post-exercise vasodilation often observed in PEH may sub-serve glycemic regulation following exercise in both healthy individuals and those with T2D. Furthermore, we discuss the interplay of enhanced perfusion, both macrovascular and microvascular, and glucose flux following exercise. Finally, we propose future research directions to enhance our understanding of the relationship between post-exercise hemodynamics and glucose regulation in healthy individuals and in those with T2D.

Metabolic and hormonal responses to chronic blood-flow restricted resistance training in chronic kidney disease: a randomized trial.

Maintenance of glycemic and lipemic homeostasis can limit the progression of diabetic kidney disease. Resistance training (RT) is effective in controlling glycemia and lipemia in kidney disease; however, the effect of RT with blood flow restriction (RT+BFR) on these metabolic factors has not been investigated. We aimed to verify if chronic (6 months) RT and RT+BFR performed by patients with stage-2 chronic kidney disease (CKD) improves their glycemic homeostasis and immunometabolic profiles. Patients with CKD under conservative treatment (n = 105 (33 females)) from both sexes were randomized into control (n = 35 (11 females); age 57.6 ± 5.2years), RT (n = 35 (12 females); age 58.0 ± 6.2years), and RT+BFR (n = 35 (10 females); 58.0 ± 6.4years) groups. Chronic RT or RT+BFR (6 months) was performed 3 times per week on non-consecutive days with training loading adjusted every 2 months, RT 50%-60%-70% of 1RM, and RT+BFR 30%-40%+50% of 1RM and fixed repetition number. Renal function was estimated with the glomerular filtration rate and serum albumin level. Metabolic, hormonal, and inflammatory assessments were analyzed from blood samples. Six months of RT and RT+BFR were similarly effective in improving glucose homeostasis and hormone mediators of glucose uptake (e.g., irisin, adiponectin, and sirtuin-1), decreasing pro-inflammatory and fibrotic proteins, and attenuating the progression of estimated glomerular filtration rate. Thus, RT+BFR can be considered an additional exercise modality to be included in the treatment of patients with stage 2 chronic kidney disease. Trial registration number: U1111-1237-8231. URL: http://www.ensaiosclinicos.gov.br/rg/RBR-3gpg5w/, no. RBR-3gpg5w. Novelty: Glycemic regulation induced by resistance training prevents the progression of CKD. Chronic RT and RT+BFR promote similar changes in glycemic regulation. RT and RT+BFR can be considered as non-pharmacological tools for the treatment of CKD.

GESTATIONAL DIABETES AND MEDITERRANEAN DIET

The incidence of Type 2 diabetes mellitus (DM) and gestational diabetes has also increased with the increase in obesity. Gestational diabetes can cause various complications during pregnancy that can adversely affect birth, mother and baby. The Mediterranean diet both reduces the risk of developing gestational diabetes and is efficient in regulating glycemia after gestational diabetes has occurred. Aim: In this study, we aimed to review the literature regarding the role of the Mediterranean diet in gestational diabetes. Material and Method: This review contains current information about Gestational Diabetes and the Mediterranean diet. In the research, a literature search was performed using databases such as Science Direct and PubMed. Current and comprehensive data were used to collect this research. Results: Many studies have indicated that the Mediterranean diet is the healthiest diet model in the world. It has been proven that it reduces the risk of preterm birth, prevents the formation of gestational diabetes and is effective in glycemic regulation. Conclusion: All expectant mothers and pregnant women at risk of developing gestational diabetes should be encouraged to adopt the Mediterranean diet because of its effects during pregnancy and childbirth, as well as the long-term health benefits of mothers and babies. Keywords: Diabetes in Pregnancy, Gestational Diabetes, Medical Nutrition Therapy, Mediterranean Diet, Mediterranean Nutrtion

Glycemic Regulation in Patients with Type 2 Diabetes Mellitus: Effects of Motivational Interviewing

Glycemic Regulation in Patients with Type 2 Diabetes Mellitus: Effects of Motivational Interviewing