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DOI: 10.1055/s-0039-3401980
Diabetes and Addictive Disorders
Abstract
Prevalence of addictive disorders among persons with diabetes mellitus (DM) (type 1 and type 2) ranges from 9.6 to 29%. Excessive and problematic use of psychoactive substances in persons with diabetes results in poor glycemic control with frequent hyperglycemic crisis. Tobacco, alcohol, cannabis, benzodiazepines, inhalants, and stimulants are common psychoactive substances used among persons with diabetes in India. The daily use of alcohol by men and women with DM should not exceed 15 and 30 g of ethanol, respectively. Use of other psychoactive substances is not recommended for persons with DM. Various screening tools exist for assessing substance abuse like WHO-ASSIST, Alcohol Use Disorders Identification Test (AUDIT), Fagerström Test for Nicotine Dependence (FTND), and Opioid Risk Tool. Integrated management of co-occurring addictive disorder and DM is recommended. Psychosocial treatments for substances include brief interventions (BIs), motivational interviewing, contingency management, relapse prevention, and cognitive behavior therapy
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Introduction
Diabetes mellitus (DM) has been recognized as a major health problem in India[1]. It is gaining the status of an epidemic with an estimated 82 million people currently diagnosed as diabetics in South-East Asia.[2] The prevalence of DM is predicted to double globally from 171 million in 2000 to 366 million in 2030, with the maximum increase recorded in India.[3]
Addictive disorders are also an important public health issue. In 2015, an estimated 29.5 million people were suffering from drug use disorders (besides alcohol and tobacco).[4] Prevalence of tobacco and alcohol use disorders is even higher. In India too, drug use disorders are a major public health concern. The National Mental Health Survey (2015) found 18.1% to be afflicted with addictive disorders.[5]
Addictive disorders constitute important and common co-occurring disorders among persons with DM. Estimates of the prevalence of addictive disorders among persons with DM (type 1 and Type 2) have ranged from 9.6 to 29%.[6] [7] [8] The impact of psychoactive substances on the course and prognosis of DM is complex and well-documented. Persons with diabetes who have excessive and problematic use of psychoactive substances have a higher prevalence of DM, often have poor glycemic control, and experience more frequent hyperglycemic crises. Certain psychoactive substances also tend to hasten the onset of complications of DM.
Therefore, the need to address specific issues in those with comorbid DM and sudden unexplained deaths (SUDs) is imperative. Tobacco, alcohol, cannabis, stimulants, benzodiazepines, inhalants, and stimulants are the psychoactive substances that are likely to be encountered among persons with DM in India. In addition, the behavioral addictions are being increasingly recognized as a growing public health problem. There is a need to address these additive disorders among persons with DM as well.
Keeping in view the importance and relevance of the theme, the Research Society for the Study of Diabetes in India (RSSDI) has come out with this position statement.
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Aim and Scope of the Current Document
The current document is the position statement of RSSDI on “Diabetes and Addictive Disorders.” This document presents the recommendations made by RSSDI with regard to the screening, diagnosis, and management of cooccurring addictive disorders among persons with DM. The document is targeted at the healthcare professionals engaged in care and management of DM. This document is an adjunct to the clinical practice guidelines on management of addictive disorders, and the readers are encouraged to refer to these guidelines as well.
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Recommendations
Use of Psychoactive Substances by Persons with DM
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Use of tobacco is not recommended for those who have either manifested DM or are at-risk of developing DM.
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Alcohol use in binge pattern is not recommended for persons with DM.
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Possible benefit of alcohol consumption in moderate quantities on DM is offset by the increased risk of developing other medical conditions.
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In any case, the daily use of alcohol by men and women with DM should not exceed one and two standard drinks that is, 15 and 30 g of ethanol, respectively.
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Use of other psychoactive substances is not recommended for persons with DM.
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Screening and Diagnosis
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All patients diagnosed with DM must be asked about psychoactive substance use.
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History of psychoactive substance use must be obtained systematically and should include details on duration, quantity, frequency, last dose, and the usual dose.
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Various screening tools exist for assessing substance use problems. The WHO-ASSIST is a freely available valid tool developed by the World Health Organization for screening of addictive disorders.[9]
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Other tools for assessing specific substance use disorders include Alcohol Use Disorders Identification Test (AUDIT), Fagerström Test for Nicotine Dependence (FTND), and Opioid Risk Tool.[10] [11] [12]
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The International Statistical Classification of Diseases and Related Health Conditions (ICD)-10 or the Diagnostic and Statistical Manual of Mental Disorders-5 can be used for making a diagnosis of addictive disorders.[13] [14]
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Management–General Issues
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Integrated management of cooccurring addictive disorder and DM is recommended.
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A comprehensive management plan, including pharmacological and nonpharmacological interventions, is recommended.
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Management–Pharmacological Interventions
The pharmacological interventions available for management of addictive disorders have been summarized in [Table 1].[15] [34]
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The treating clinician should remain vigilant about the possible interaction between these medicines and the medicines used to treat DM.
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Also, the treating clinician should be aware of the pharmacokinetic interactions between psychoactive substances and the medicines metabolized by the cytochrome P (CYP) enzymes.
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Management–Non-Pharmacological Interventions
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Psychosocial treatments for substances include brief interventions (BIs), motivational interviewing, contingency management, relapse prevention, cognitive behavior therapy, and treatments combining cognitive behavior therapy and contingency management.
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Psychosocial interventions are effective and comparable to those for other efficacious treatments in psychiatry.[35]
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BI is a useful and cost-effective treatment for reducing substance use. It is likely to be useful for persons with DM.[36]
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Motivational interviewing effectively improves treatment adherence and induces positive behavioral and psychological changes.[37]
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Other effective interventions include contingency management, relapse prevention, and cognitive behavioral therapy.[38] [39]
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Cognitive behavior therapy is also considered an effective treatment, although the evidence is of a lower quality.[40]
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Lifestyle recommendations incorporating dietary changes, physical activity must be advised.[41] [42]
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Persons with addictive disorders cooccurring with DM must be provided psychoeducation which must include the following:
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Information on addictive disorders.
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Need for treatment.
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Comparability to other chronic medical illness.
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Need for equal emphasis as DM.
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Emphasis on lifestyle modifications.
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Cooccurring Mental Disorders
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Persons with DM and addictive disorders must be actively screened for presence of cooccurring mental disorders at every follow-up, and appropriate assessment and management should be initiated at the earliest.
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Behavioral Addictions
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Besides the addictive disorders related to the use of psychoactive substances, certain other addictive disorders have been recognized in recent years. These disorders are collectively known as behavioral addictions and include conditions such as Internet addiction, Internet gaming disorders, etc. These behavioral addictions can adversely impact the diabetes care, as persons with these additive disorders have dysfunctional lifestyle and tend to ignore their daily routine including food intake, physical activity, therapeutic adherence, etc. Hence, it is recommended to screen for these behavioral addictions among individuals with DM, especially adolescents and young adults.
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Referral for Specialized Care
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Persons with DM having cooccurring addictive disorders should be referred on a priority basis to a mental health professional for specialized care in the following scenarios:
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Found to have high-risk subsect use during screening.
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Not responding to simple advice or BI.
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Suspicion of presence of cooccurring mental disorder.
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Having active suicidal ideation, plan, or attempt in recent past.
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Conclusions
To summarize, persons with DM having cooccurring addictive disorder are more likely to run a relatively poorer course. Various psychoactive substances are likely to negatively impact the DM. The high prevalence of SUDs is likely to make them a cooccurrence among individuals with DM. Those engaged in care of persons with DM should be aware of this. Like diabetes, addictive disorders are also chronic conditions and require continued management. Timely identification and management of the cooccurring addictive disorders is likely to improve the course and outcome of DM and consequently improve the quality of life. Also, there is a need to address behavioral addictions among persons with DM.
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Conflict of Interest
None declared.
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References
- 1 Kumar A, Goel MK, Jain RB, Khanna P, Chaudhary V. India towards diabetes control: Key issues. Australas Med J 2013; 6 (10) 524-531
- 2 Nam Han Cho. et al. International Diabetes Federation. IDF Diabete s Atlas. 8th ed. 2017: 78-79
- 3 Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27 (05) 1047-1053
- 4 United Nations Office on Drugs and Crime. World Drug Report 2017. Vol 1. Vienna: United Nations Office on Drugs and Crime; 2017: 36
- 5 Gururaj G, Varghese M, Benegal V, et al. National Mental Health Survey of India, 2015–16: Summary. Bengaluru, National Institute of Mental Health and Neuro Sciences; 2016 [cited 2017 Dec 07]. 62p NIMHANS Publication No. 128, 2016
- 6 Martínez-Aguayo A, Araneda JC, Fernandez D, Gleisner A, Perez V, Codner E. Tobacco, alcohol, and illicit drug use in adolescents with diabetes mellitus. Pediatr Diabetes 2007; 8 (05) 265-271
- 7 Wu L-T, Ghitza UE, Batch BC. et al. Substance use and mental diagnoses among adults with and without type 2 diabetes: Results from electronic health records data. Drug Alcohol Depend 2015; 156: 162-169
- 8 Ng RSH, Darko DA, Hillson RM. Street drug use among young patients with Type 1 diabetes in the UK. Diabet Med 2004; 21 (03) 295-296
- 9 Humeniuk RE, Henry-Edwards S, Ali RL, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Manual For Use In Primary Care. Geneva: World Health Organization; 2010
- 10 Saunders JB, Aasland OG, Babor TF. de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction 1993; 88 (06) 791-804
- 11 Fagerstrom K-O, Schneider NG. Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. J Behav Med 1989; 12 (02) 159-182
- 12 Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005; 6 (06) 432-442
- 13 World Health Organization. ICD-10: International statistical classification of diseases and health-related problems. Geneva: World Health Organization 1992
- 14 American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association 2013
- 15 Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165 (02) 179-187
- 16 Kaner EFS, Dickinson HO, Beyer FR. et al. Effectiveness of brief alcohol interventions in primary care populations. In: Kaner EFS. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2007: p. CD004148
- 17 Vasilaki EI, Hosier SG, Cox WM. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol Alcohol 2006; 41 (03) 328-335
- 18 Prendergast M, Podus D, Finney J, Greenwell L, Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. Addiction 2006; 101 (11) 1546-1560
- 19 Irvin JE, Bowers CA, Dunn ME, Wang MC. Efficacy of relapse prevention: a meta-analytic review. J Consult Clin Psychol 1999; 67 (04) 563-570
- 20 Windsor LC, Jemal A, Alessi EJ. Cognitive behavioral therapy: a meta-analysis of race and substance use outcomes. Cultur Divers Ethnic Minor Psychol 2015; 21 (02) 300-313
- 21 Wang D, Wang Y, Wang Y, Li R, Zhou C. Impact of physical exercise on substance use disorders: a meta-analysis. PLoS One 2014; 9 (10) e110728
- 22 Harvey JN. Psychosocial interventions for the diabetic patient. Diabetes Metab Syndr Obes 2015; 8: 29-43
- 23 Stead LF, Perera R, Bullen C. et al. Nicotine replacement therapy for smoking cessation. In: Stead LF. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2012: p. CD000146
- 24 Sweeney CT, Fant RV, Fagerstrom KO, McGovern JF, Henningfield JE. Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability. CNS Drugs 2001; 15 (06) 453-467
- 25 Mills EJ, Wu P, Lockhart I, Thorlund K, Puhan M, Ebbert JO. Comparisons of high-dose and combination nicotine replacement therapy, varenicline, and bupropion for smoking cessation: a systematic review and multiple treatment meta-analysis. Ann Med 2012; 44 (06) 588-597
- 26 Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. In: Hughes JR. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2007: p. CD000031
- 27 Kaur K, Kaushal S, Chopra SC. Varenicline for smoking cessation: A review of the literature. Curr Ther Res Clin Exp 2009; 70 (01) 35-54
- 28 Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. In: Hartmann-Boyce J. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2016. p. CD010216
- 29 Galanter M, Kleber HD, Brady K. The American Psychiatric Publishing Textbook Of Substance Abuse Treatment. . American Psychiatric Pub. 2014
- 30 Palatty PL, Saldanha E. Status of disulfiram in present day alcoholic deaddiction therapy. Indian J Psychiatry 2011; 53 (01) 25-29
- 31 De Sousa A. The pharmacotherapy of alcohol dependence: a state of the art review. Mens Sana Monogr 2010; 8 (01) 69-82
- 32 Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci 2007; 9 (04) 455-470
- 33 Mattick RP, Breen C, Kimber J, Davoli M.. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. In: Mattick RP. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2014: p. CD002207
- 34 Johansson BA, Berglund M, Lindgren A. Efficacy of maintenance treatment with naltrexone for opioid dependence: a meta-analytical review. Addiction 2006; 101 (04) 491-503
- 35 Nagrebetsky A, Brettell R, Roberts N, Farmer A. Smoking cessation in adults with diabetes: a systematic review and meta-analysis of data from randomised controlled trials. BMJ Open 2014; 4 (03) e004107
- 36 Handelsman Y, Mechanick JI, Blonde L. et al; AACE Task Force for Developing a Diabetes Comprehensive Care Plan. American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan: executive summary. Endocr Pract 2011; 17 (02) 287-302
- 37 Qin R, Chen T, Lou Q, Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies. Int J Cardiol 2013; 167 (02) 342-350
- 38 Clair C, Cohen MJ, Eichler F, Selby KJ, Rigotti NA. The effect of cigarette smoking on diabetic peripheral neuropathy: a systematic review and metaanalysis. J Gen Intern Med 2015; 30 (08) 1193-1203
- 39 Baliunas DO, Taylor BJ, Irving H. et al. Alcohol as a risk factor for type 2 diabetes: A systematic review and meta-analysis. Diabetes Care 2009; 32 (11) 2123-2132
- 40 Hogendorf AM, Fendler W, Sieroslawski J. et al. Breaking the taboo: illicit drug use among adolescents with Type 1 diabetes mellitus. J Diabetes Res 2015; 00
- 41 Haire-Joshu D, Heady S, Thomas L, Schechtman K, Fisher Jr EB. Depressive symptomatology and smoking among persons with diabetes. Res Nurs Health 1994; 17 (04) 273-282
- 42 Ahmed AT, Karter AJ, Liu J. Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med 2006; 23 (07) 795-802
Address for correspondence
Publication History
Article published online:
30 March 2020
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Thieme Medical and Scientific Publishers Private Ltd.
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References
- 1 Kumar A, Goel MK, Jain RB, Khanna P, Chaudhary V. India towards diabetes control: Key issues. Australas Med J 2013; 6 (10) 524-531
- 2 Nam Han Cho. et al. International Diabetes Federation. IDF Diabete s Atlas. 8th ed. 2017: 78-79
- 3 Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27 (05) 1047-1053
- 4 United Nations Office on Drugs and Crime. World Drug Report 2017. Vol 1. Vienna: United Nations Office on Drugs and Crime; 2017: 36
- 5 Gururaj G, Varghese M, Benegal V, et al. National Mental Health Survey of India, 2015–16: Summary. Bengaluru, National Institute of Mental Health and Neuro Sciences; 2016 [cited 2017 Dec 07]. 62p NIMHANS Publication No. 128, 2016
- 6 Martínez-Aguayo A, Araneda JC, Fernandez D, Gleisner A, Perez V, Codner E. Tobacco, alcohol, and illicit drug use in adolescents with diabetes mellitus. Pediatr Diabetes 2007; 8 (05) 265-271
- 7 Wu L-T, Ghitza UE, Batch BC. et al. Substance use and mental diagnoses among adults with and without type 2 diabetes: Results from electronic health records data. Drug Alcohol Depend 2015; 156: 162-169
- 8 Ng RSH, Darko DA, Hillson RM. Street drug use among young patients with Type 1 diabetes in the UK. Diabet Med 2004; 21 (03) 295-296
- 9 Humeniuk RE, Henry-Edwards S, Ali RL, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Manual For Use In Primary Care. Geneva: World Health Organization; 2010
- 10 Saunders JB, Aasland OG, Babor TF. de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction 1993; 88 (06) 791-804
- 11 Fagerstrom K-O, Schneider NG. Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. J Behav Med 1989; 12 (02) 159-182
- 12 Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005; 6 (06) 432-442
- 13 World Health Organization. ICD-10: International statistical classification of diseases and health-related problems. Geneva: World Health Organization 1992
- 14 American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. American Psychiatric Association 2013
- 15 Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165 (02) 179-187
- 16 Kaner EFS, Dickinson HO, Beyer FR. et al. Effectiveness of brief alcohol interventions in primary care populations. In: Kaner EFS. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2007: p. CD004148
- 17 Vasilaki EI, Hosier SG, Cox WM. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol Alcohol 2006; 41 (03) 328-335
- 18 Prendergast M, Podus D, Finney J, Greenwell L, Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. Addiction 2006; 101 (11) 1546-1560
- 19 Irvin JE, Bowers CA, Dunn ME, Wang MC. Efficacy of relapse prevention: a meta-analytic review. J Consult Clin Psychol 1999; 67 (04) 563-570
- 20 Windsor LC, Jemal A, Alessi EJ. Cognitive behavioral therapy: a meta-analysis of race and substance use outcomes. Cultur Divers Ethnic Minor Psychol 2015; 21 (02) 300-313
- 21 Wang D, Wang Y, Wang Y, Li R, Zhou C. Impact of physical exercise on substance use disorders: a meta-analysis. PLoS One 2014; 9 (10) e110728
- 22 Harvey JN. Psychosocial interventions for the diabetic patient. Diabetes Metab Syndr Obes 2015; 8: 29-43
- 23 Stead LF, Perera R, Bullen C. et al. Nicotine replacement therapy for smoking cessation. In: Stead LF. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2012: p. CD000146
- 24 Sweeney CT, Fant RV, Fagerstrom KO, McGovern JF, Henningfield JE. Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability. CNS Drugs 2001; 15 (06) 453-467
- 25 Mills EJ, Wu P, Lockhart I, Thorlund K, Puhan M, Ebbert JO. Comparisons of high-dose and combination nicotine replacement therapy, varenicline, and bupropion for smoking cessation: a systematic review and multiple treatment meta-analysis. Ann Med 2012; 44 (06) 588-597
- 26 Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. In: Hughes JR. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2007: p. CD000031
- 27 Kaur K, Kaushal S, Chopra SC. Varenicline for smoking cessation: A review of the literature. Curr Ther Res Clin Exp 2009; 70 (01) 35-54
- 28 Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. In: Hartmann-Boyce J. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2016. p. CD010216
- 29 Galanter M, Kleber HD, Brady K. The American Psychiatric Publishing Textbook Of Substance Abuse Treatment. . American Psychiatric Pub. 2014
- 30 Palatty PL, Saldanha E. Status of disulfiram in present day alcoholic deaddiction therapy. Indian J Psychiatry 2011; 53 (01) 25-29
- 31 De Sousa A. The pharmacotherapy of alcohol dependence: a state of the art review. Mens Sana Monogr 2010; 8 (01) 69-82
- 32 Kleber HD. Pharmacologic treatments for opioid dependence: detoxification and maintenance options. Dialogues Clin Neurosci 2007; 9 (04) 455-470
- 33 Mattick RP, Breen C, Kimber J, Davoli M.. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. In: Mattick RP. ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2014: p. CD002207
- 34 Johansson BA, Berglund M, Lindgren A. Efficacy of maintenance treatment with naltrexone for opioid dependence: a meta-analytical review. Addiction 2006; 101 (04) 491-503
- 35 Nagrebetsky A, Brettell R, Roberts N, Farmer A. Smoking cessation in adults with diabetes: a systematic review and meta-analysis of data from randomised controlled trials. BMJ Open 2014; 4 (03) e004107
- 36 Handelsman Y, Mechanick JI, Blonde L. et al; AACE Task Force for Developing a Diabetes Comprehensive Care Plan. American Association of Clinical Endocrinologists Medical Guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan: executive summary. Endocr Pract 2011; 17 (02) 287-302
- 37 Qin R, Chen T, Lou Q, Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies. Int J Cardiol 2013; 167 (02) 342-350
- 38 Clair C, Cohen MJ, Eichler F, Selby KJ, Rigotti NA. The effect of cigarette smoking on diabetic peripheral neuropathy: a systematic review and metaanalysis. J Gen Intern Med 2015; 30 (08) 1193-1203
- 39 Baliunas DO, Taylor BJ, Irving H. et al. Alcohol as a risk factor for type 2 diabetes: A systematic review and meta-analysis. Diabetes Care 2009; 32 (11) 2123-2132
- 40 Hogendorf AM, Fendler W, Sieroslawski J. et al. Breaking the taboo: illicit drug use among adolescents with Type 1 diabetes mellitus. J Diabetes Res 2015; 00
- 41 Haire-Joshu D, Heady S, Thomas L, Schechtman K, Fisher Jr EB. Depressive symptomatology and smoking among persons with diabetes. Res Nurs Health 1994; 17 (04) 273-282
- 42 Ahmed AT, Karter AJ, Liu J. Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med 2006; 23 (07) 795-802