Adult Mumps! You are probably at risk of re-infection: Understanding Adult Mumps and the Potential Complications including Infertility

Yes, a viral infection thought to be nearly eradicated thanks to widespread vaccination, is making a comeback, particularly among adults. Recent reports indicate a significant rise in cases, emphasizing the need for greater awareness of the signs, symptoms, and potential complications of adult mumps. This resurgence acts as a wake-up call, motivating people to seek immediate help and take preventative measures.

Mumps vaccination and/or infection will give immunity, for most people for a period of 10 to 20 years. That is, if you had the injection or infection as a child, you are likely to be vulnerable when you graduate from high school.

NOTE WELL: Mumps infection is a major source of infertility in men as well as in women.

The Current Situation

The number of reported mumps cases has increased sharply, particularly among adults. A study from the Centers for Disease Control and Prevention (CDC) revealed that between 2016 and 2020, the incidence of mumps in the United States rose by approximately 25%. This rise can be linked to various factors, such as waning immunity in vaccinated individuals and changes in vaccination practices.

A high angle depiction of the mumps virus structure.

Previously, mumps was primarily a childhood disease, but the latest trends show that adults who are unvaccinated or whose immunity has faded are now at greater risk. The mumps virus spreads easily through respiratory droplets when an infected person coughs or sneezes, and it can survive on surfaces for several hours.

Signs and Symptoms

Identifying the symptoms of mumps early is vital for both personal health and preventing further outbreaks. Symptoms typically manifest 14 to 18 days after exposure to the virus. Key indications include:

• Swollen Salivary Glands: Characterized by swelling in one or both parotid glands, which are located near the jawline. This sign is commonly recognized in mumps cases. Recent studies indicate that roughly 90% of mumps patients experience this symptom.

  
  

• Fever: A moderate fever can arise, often peaking at around 104°F (40°C).

  
  

• Headache: Many people report headaches ranging from mild to intense.

  
  

• Muscle Aches: Widespread muscle pain is common, contributing to the overall feeling of illness.

  
  

• Fatigue: A profound sense of tiredness often accompanies the other symptoms.

  
  

Different respiratory viruses can share similar symptoms, making it essential to consult a healthcare provider if multiple symptoms arise concurrently.

Close-up image illustrating swollen salivary glands typical in mumps.

Possible Complications

Although many recover from mumps without severe outcomes, complications can occur, especially in adults. Understanding these risks is crucial for individuals with certain pre-existing conditions or those over 30 years old. Potential complications include:

• Orchitis: Inflammation of the testicles may affect post-pubertal males and can lead to fertility issues in about 30% of cases.

  
  

  

  Orchitis. Inflammation of the testicles. Painful, but can leave lasting problems.

  
  
  
  

• Oophoritis: In women, mumps can cause inflammation of the ovaries, resulting in pain and possible fertility complications.

  
  

  

  
  

• Meningitis: If the virus spreads to the central nervous system, it can lead to viral meningitis, which can have lasting consequences.

  
  

• Hearing Loss: Mumps can cause temporary or sometimes permanent hearing loss, affecting around 1 in 20 infected individuals.

  
  

Being aware of these complications can help individuals make informed health decisions. Prompt medical attention can aid in the early management of complications.

Mumps oophoritis, inflammation of the ovaries, can lead to infertility.

Prevention and Vaccination

Vaccination remains the most effective method to prevent mumps. The MMR vaccine, which protects against measles, mumps, and rubella, is proven safe and effective. It is typically administered in two doses during childhood. However, adults who are unvaccinated or uncertain about their vaccination history should consider getting vaccinated.

In addition to vaccination, other preventive measures include:

• Maintaining Good Hygiene: Regular handwashing and using tissues or an elbow to cover sneezes and coughs can significantly reduce the risk of transmission.

  
  

• Avoiding Close Contact: Steering clear of individuals displaying symptoms or known to be infected will help prevent the spread of the virus.

  
  

• Staying Informed: Keeping up with local outbreaks and public health advisories allows individuals to take necessary precautions.

  
  

Empowering oneself with knowledge about mumps can help protect both personal health and the wellbeing of the community.

Staying Proactive About Your Health

The recent rise in adult mumps cases underscores the critical importance of vaccination and awareness. By understanding the signs and symptoms, potential complications, and preventive measures, individuals can protect themselves from this viral illness.

As public health officials work diligently to manage outbreaks, remaining informed is key. Making sure your vaccinations are current not only safeguards your health but also contributes to the greater good of your community. Prioritize your health and stay vigilant—it's the best way to combat the risks associated with adult mumps.

Interestingly, you can get mumps multiple times in your lifetime. It can present like a 'mild' case of the 'flu,' but it can be devastating if you are unlucky. Being left infertile is a major life-altering situation, and hearing loss is no joke either.

If you are in doubt as to your status, go and get the MMR vaccine, and stay on the safe side.

---

Subscribe to our Blog 

Dr Klein's Facebook Page

https://www.facebook.com/stagesoflifemedicalinstitute

David S. Klein, MD FACA FACPM

David S. Klein, MD, FACA, FACPM

1917 Boothe Circle, Suite 171

Longwood, Florida 32750

Tel: 407-679-3337

Fax: 407-678-7246

www.suffernomore.com

David S. Klein, MD Functional Medicine Physician

Exploring the Complexities of Urinary Tract Infections (UTI) in Adults and Elderly Patients.

Urinary tract infections (UTIs) are one of the most common infections among adults and elderly patients, impacting their health and quality of life. As people age, physiological changes can lead to unique challenges in how UTIs present, are diagnosed, and treated. Recognizing these challenges is critical for healthcare providers and caregivers to ensure older adults receive the best possible care.

Understanding Urinary Tract Infections in the Non-Pediatric Population, the Adult and Elderly

UTIs occur when bacteria infiltrate the urinary tract, which encompasses the bladder, urethra, kidneys, and ureters. In elderly individuals, symptoms often diverge from the typical presentation seen in younger adults.

NOTE: It is Never normal to have bacteria in the urinary tract. A low intensity infection can persist in the background, and when the conditions are right, it can blossom into a life-threatening event.

In the presence of a low grade infection, one that you may not even know exists, something may occur. You may take a medication, undergo a procedure or develop an illness, and the next thing you know, you have a florid UTI.

Recently, I have found a series of patients that became ill following the use of Jardiance. Because this medication increases the amount of sugar dumped into the urine, it feeds the bacteria and they can grow very, very quickly and aggressively.

Medications that inhibit bladder emptying, such as oxybutynin, anti-histamines and opiods can worsen the situation due to incomplete bladder discharge.

Symptoms in the Non-Pediatric (Geriatric) Population

For instance, rather than experiencing the common signs of burning during urination, older adults might display confusion, increased incontinence, or vague abdominal pain. It's estimated that about 30% of older adults in nursing homes experience atypical UTI symptoms, which can complicate diagnosis and treatment.

Older adults face an elevated risk of UTIs due to various factors. For example, studies show that those with diabetes have up to a 40% higher incidence of UTI compared to their non-diabetic peers. Other contributing elements include weakened immune systems and anatomical changes in the urinary tract with age. Additionally, mobility issues, cognitive decline, and chronic conditions can further exacerbate the situation.

Urinary Tract Infections are a leading cause of death in the older adult population

Diagnosis of UTIs in the Older Adult

A correct diagnosis is vital. It relies on understanding that the symptoms in older adults may differ from those found in younger individuals. Factors such as sudden changes in mental status or a decline in daily functioning should increase suspicion for a possible UTI.

Testing Protocols for UTI in Adult and Elderly Populations

A comprehensive diagnostic approach includes taking a thorough patient history, conducting a physical examination, and performing laboratory tests like a urinalysis and urine culture. An important aspect to note is the impact of previous antibiotic use on culture results. Analysis has shown that as many as 50% of older patients may have misleading urine cultures due to recent antibiotic treatment.

The testing begins with the ubiquitous 'Test Strip.' As easy as this would appear, it is shocking how many facilitis, including stand alone clinics, doctor's offices and ER's use these devices, but NEVER calibrate them. If you use the strip without computer-driven analyzers, the interpretation can become questionable, and without the analyzer, standardization and calibration is impossible.

Secondly, the the test strip may be only 30-40% sensitive to the presence of a urinary tract infection. If there is a moderate to high indication of a UTI, the next step is to perform a 'Bacterioscan,' microscopic examination or CATALASE reaction test. This looks for the presence of live bacteria in the urine. If this is possible, you have direct feed back that there is a problem.

The next step is to proceed with culture and sensitivity, often associated with an additional microscopic examination.

If indicated, PCR studies are ordered to look for the presence and speciation of the organism to permit more precise antibiotic selection.

Urinalysis and Culture

Urinalysis can reveal nitrites and leukocyte esterase, indicators of a bacterial infection. However, false positives can arise from contamination or other medical issues. Therefore, urine cultures, which are considered the gold standard, are crucial for confirming UTIs and guiding effective antibiotic therapy.

Urinalysis testing kit used for diagnosing urinary tract infections.

Management Strategies for UTIs in the Elderly

Prompt and effective management of UTIs is essential to prevent severe complications, such as kidney infections or sepsis. These conditions can pose significant risks, especially among older adults.

Pharmacological Interventions

First-line antibiotic options typically include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin. Clinicians should be aware of potential drug interactions and the risks associated with polypharmacy in this age group. Research indicates that nearly 80% of elderly patients on multiple medications face significant interaction risks.

Non-Pharmacological Approaches

Beyond antibiotics, several non-drug strategies can help manage UTI symptoms and prevent recurrence. Proper hydration is essential; drinking an adequate amount of fluids daily can help flush out bacteria. Good hygiene practices also play a crucial role in minimizing the risk of reinfection, with studies showing that regular cleansing can lower UTI rates by 20%.

Preventative Measures

For those experiencing recurrent UTIs, preventive strategies may include the use of prophylactic antibiotics, cranberry products, or vaginal estrogen therapy in postmenopausal women, tailored to their individual health profiles and risks. Some evidence suggests that cranberry products can reduce UTI occurrences by as much as 30%.

Excellent Choice for Women with Recurrent UTI. Inexpensive Self Help. Extremely well Tolerated.

Special Considerations

Cognitive Impairment

Diagnosing UTIs in patients with cognitive impairments or dementia can be especially challenging. Behavioral changes, such as increased agitation or withdrawal, might be the only indicators of an underlying infection. A more thorough examination of these symptoms is essential to ensure no other medical issues are being overlooked.

Hydration and Nutrition

Proper hydration and nutrition are critical in managing UTIs in older adults. Dehydration can significantly increase the risk of infections and worsen existing symptoms. Research shows that increasing fluid intake can reduce UTI rates in the elderly by approximately 50%, emphasizing the need to monitor hydration levels closely.

Treatment

Treatment approach will differ from patient to patient, influenced by patient age, gender, co-morbidities and physician preference. There are many ways from which to choose, the recommendations, below, are simply my own preferences and are by no means the only approach to this common clinical problem.

---

Protocol 1: Uncomplicated Cystitis in Women

This applies to non-pregnant women with no structural abnormalities or significant comorbidities.

1. First-Line Antibiotics:

   • Nitrofurantoin (Macrobid): 100 mg orally twice daily for 5 days.

   • Trimethoprim-Sulfamethoxazole (TMP-SMX): 160/800 mg orally twice daily for 3 days (if local resistance is <20%).

     
     

2. Alternative Antibiotics:

   • Fosfomycin Trometamol: 3 g orally as a single dose.

   • Pivmecillinam: 400 mg orally twice daily for 5 days (in regions where available).

3. Non-Antibiotic Adjuncts:

   • Increased hydration.

   • Cranberry extract for prophylaxis (limited evidence but widely used).

     
     

References:

1. Gupta K, et al. Infectious Diseases Society of America (IDSA) guidelines for uncomplicated UTI. Clin Infect Dis. 2011;52(5):e103–e120.

   
   

2. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366(11):1028-37.

   
   

---

Protocol 2: Complicated UTIs and Pyelonephritis

Used for patients with structural urinary abnormalities, diabetes, or severe presentations (e.g., pyelonephritis).

1. First-Line Antibiotics (Outpatient):

   • Ciprofloxacin: 500 mg orally twice daily for 7 days (or 1 g extended-release once daily).

   • Levofloxacin: 750 mg orally once daily for 5–7 days.

2. First-Line Antibiotics (Inpatient):

   • Ceftriaxone: 1 g IV every 24 hours.

   • Piperacillin-Tazobactam: 4.5 g IV every 6–8 hours.

3. Monitoring and Adjustment:

   • Tailor antibiotics based on urine culture sensitivity results.

   • Repeat urinalysis after completion of treatment for persistent symptoms.

     
     

References:

1. Nicolle LE, et al. Complicated urinary tract infection in adults. Can J Infect Dis Med Microbiol. 2005;16(6):349–60.

2. Flores-Mireles AL, et al. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-284.

3. Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2019;11:CD000490.

4. Giesen LG, et al. Guidelines on management of urinary tract infections in pregnancy. BMJ. 2010;340:c220.

5. Lipsky BA, et al. Treatment of bacterial prostatitis and UTIs in men. J Urol. 2010;182(5):2431–41.

6. Wagenlehner FM, et al. Antimicrobial therapy for UTIs in 2020. Clin Microbiol Infect. 2020;26(8):871-879.

7. Harding GK, et al. UTI guidelines for adults. Can Med Assoc J. 1991;144(6):721-728.

8. Bader MS, et al. Risk factors for recurrent UTIs. Postgrad Med. 2020;132(1):26-33.

Final Thoughts

Managing UTIs in elderly patients requires a nuanced approach that prioritizes recognizing atypical symptoms, performing accurate diagnoses, and implementing tailored treatment strategies. Given the complexities associated with this age group, healthcare professionals must conduct thorough assessments and foster open dialogue with both patients and caregivers.

With attention to these details, healthcare providers can improve outcomes and enhance the quality of life for older adults. Continuous education and further research on the best practices for managing UTIs will play a vital role in advancing care for this vulnerable population.

Medical Treatment

References

1. Hooton, T. M. (2012). Urinary tract infections in the elderly. American Family Physician, 86(12), 1056-1063.

   
   

2. Albrecht, J. S., et al. (2018). The UTI incidence in adults aged ≥65 years; finding the elderly woman and the definitive diagnosis. Infection Control and Hospital Epidemiology, 39(9), 1090-1096.

   
   

3. Foxman, B. (2014). Urinary tract infection in adults: A Western perspective. Disease-a-Month, 60(12), 748-782.

   
   

4. Nicolle, L. E. (2005). Urinary tract infections in the elderly. Clinical Geriatrics, 13(1), 39-49.

   
   

5. Gumba, A., et al. (2021). A review of urinary tract infection in older adults. Geriatrics, 6(2), Article 16.

   
   

6. Ouslander, J. G., & Schnelle, J. F. (2000). Diagnosis and treatment of urinary tract infections in long-term care: Too little and too late. Journal of the American Geriatrics Society, 48(3), 218-222.

   
   

7. Schaeffer, A. J., & Schaeffer, E. M. (2005). The role of microbiology in the diagnosis of urinary tract infections. Urology, 66(5), 922-927.

   
   

8. Mody, L., et al. (2012). Recurrent urinary tract infections in older women: A qualitative study of patient and provider perspectives. Journal of the American Geriatrics Society, 60(12), 2308-2313.

   
   

9. Loeb, M., et al. (2005). Effect of a brief intervention on antibiotic prescribing for lower respiratory tract infections in older adults: A randomized controlled trial. Archives of Internal Medicine, 165(18), 2190-2197.

   
   

10. Kauffman, S. S. (2002). Urinary tract infections in the elderly: Principles of diagnosis and treatment. Current Opinion in Urology, 12(1), 75-78.

11. Ontiveros, B., et al. (2020). Management of urinary tract infections in older adults: A practical guide. Geriatric Nursing, 41(3), 364-367.

12. Magill, S. S., et al. (2014). Multistate Point-Prevalence Survey of Health Care–Associated Infections. New England Journal of Medicine, 370(13), 1198-1208.

13. Wang, C. H., et al. (2015). The impact of urinary tract infections on the quality of life for elderly patients. Annals of Long-Term Care: Clinical Care and Aging, 23(3), 20-25.

14. Sullivan, J. E., et al. (2016). Clinical guideline for the management of urinary tract infections. Canadian Journal of Urology, 23(4), 8676-8689.

15. Hossain, K. M., et al. (2021). Antibiotic management for urinary tract infections. American Family Physician, 104(3), 213-220.

---

Subscribe to our Blog 

Dr Klein's Facebook Page

https://www.facebook.com/stagesoflifemedicalinstitute

David S. Klein, MD FACA FACPM

David S. Klein, MD, FACA, FACPM

1917 Boothe Circle, Suite 171

Longwood, Florida 32750

Tel: 407-679-3337

Fax: 407-678-7246

www.suffernomore.com

Effective Mineral Chelates for Managing and Controlling Diabetes: Chromium, Vanadium, and Magnesium

What is Mineral Chelate?

A mineral chelate is a complex in which a mineral (such as magnesium, zinc, or iron) is bound to an organic molecule, typically an amino acid, peptide, or organic acid (like citrate or gluconate). This chelation process enhances the mineral’s stability and bioavailability, making it easier for the body to absorb and utilize.

How Chelation Works

• The ligand (organic molecule) wraps around the mineral ion, forming a ring-like structure.

• This prevents the mineral from interacting with other dietary components (e.g., phytates, oxalates) that can inhibit absorption.

• The resulting neutral or slightly charged complex is more easily transported across the intestinal wall.

  
  

Examples of Common Types of Mineral Chelates

1. Amino Acid Chelates

   
   

   • Magnesium Glycinate (magnesium bound to glycine)

   • Zinc Methionine (zinc bound to methionine)

   • Iron Bisglycinate (iron bound to glycine)

     
     

2. Organic Acid Chelates

   • Magnesium Citrate (magnesium bound to citric acid)

   • Zinc Gluconate (zinc bound to gluconic acid

     
     

3. Peptide Chelates

   • Chromium Picolinate (chromium bound to picolinic acid)

     
     

Benefits of Mineral Chelates

• Enhanced Absorption: The chelated form is better recognized by transport mechanisms in the gut.

  
  

• Reduced Gastrointestinal Irritation: Chelated minerals are generally gentler on the stomach.

  
  

• Lower Risk of Mineral Interactions: Free minerals can react with dietary inhibitors, whereas chelation helps prevent this.

  
  

• Improved Stability: The structure protects the mineral from degradation before absorption.

  
  

Clinical Relevance

Mineral chelates are commonly used in dietary supplements to improve efficacy, especially for individuals with:

• Malabsorption issues (e.g., IBS, Crohn’s disease)

• Increased nutrient demands (e.g., pregnancy, athletes)

• Deficiencies due to poor dietary intake or medication interactions

Diabetesand

Diabetes mellitus, a metabolic disorder characterized by chronic hyperglycemia, has been extensively studied for its association with micronutrient imbalances. Among the various minerals implicated in glucose metabolism, chromium, vanadium, and magnesium have demonstrated potential therapeutic benefits. This review examines the role of these minerals in diabetes management, with a focus on mechanistic insights and clinical evidence.

Chromium and Its Role in Glucose Metabolism

Chromium is an essential trace element involved in carbohydrate and lipid metabolism. It enhances insulin signaling by interacting with chromodulin, a low-molecular-weight chromium-binding substance that facilitates insulin receptor activation (1). Chromium supplementation has been studied extensively for its role in improving glycemic control in type 2 diabetes mellitus (T2DM).

A meta-analysis of randomized controlled trials (RCTs) demonstrated that chromium picolinate supplementation significantly reduced fasting blood glucose and HbA1c levels (2). Furthermore, chromium enhances insulin sensitivity by upregulating insulin receptor kinase activity and inhibiting phosphotyrosine phosphatase (3).

Several clinical trials have evaluated chromium’s efficacy in diabetes management. In a double-blind, placebo-controlled study, Anderson et al. (1997) found that supplementation with 200–1000 μg/day of chromium picolinate resulted in improved insulin sensitivity and glycemic control in patients with T2DM (4). However, not all studies have confirmed its benefits, with some showing no significant improvement in glycemic indices (5). This variability in outcomes may be due to differences in study populations, baseline chromium status, and supplementation dosages.

Vanadium as an Insulin Mimetic

Vanadium, a transition metal, has been investigated for its insulin-mimetic properties. It enhances glucose uptake in skeletal muscle and adipose tissue by activating insulin receptor signaling pathways independent of endogenous insulin (6). Vanadium compounds, such as vanadyl sulfate and sodium metavanadate, have demonstrated glucose-lowering effects in animal models and human studies (7).

In a study by Cusi et al. (2001), vanadyl sulfate supplementation (100 mg/day) significantly reduced fasting plasma glucose and HbA1c in patients with T2DM (8). The proposed mechanisms include activation of phosphatidylinositol 3-kinase (PI3K) and inhibition of protein tyrosine phosphatases that negatively regulate insulin signaling (9). However, concerns regarding vanadium’s toxicity, including gastrointestinal disturbances and renal toxicity, have limited its widespread clinical use (10).

Magnesium and Its Impact on Insulin Sensitivity

Magnesium is a critical cofactor for over 300 enzymatic reactions, including those involved in glucose metabolism. Magnesium deficiency has been linked to insulin resistance and an increased risk of T2DM (11). Mechanistically, magnesium regulates insulin receptor phosphorylation, influences glucose transporter 4 (GLUT4) activity, and modulates oxidative stress (12).

Epidemiological studies have consistently shown an inverse relationship between dietary magnesium intake and the risk of developing diabetes. In the Nurses’ Health Study, higher magnesium intake was associated with a reduced incidence of T2DM over a 20-year follow-up (13). Similarly, a meta-analysis of prospective cohort studies found that every 100 mg/day increase in magnesium intake was associated with a 15% lower risk of diabetes (14).

Clinical Evidence for Magnesium Supplementation

RCTs have evaluated the benefits of magnesium supplementation in diabetes management. In a study by Guerrero-Romero et al. (2011), daily magnesium supplementation (365 mg) for four months significantly improved fasting glucose, insulin sensitivity, and HbA1c in patients with T2DM (15). Another study found that magnesium supplementation reduced markers of systemic inflammation, suggesting additional benefits in metabolic health (16).

Despite these promising findings, magnesium supplementation has not been universally adopted in diabetes care. Variability in baseline magnesium status, dietary intake, and patient compliance may influence outcomes (17). Future research should focus on personalized approaches to optimize magnesium therapy for diabetes management.

Control of Diabetes with chelated chromium, chelated magnesium and chelated vanadium: Interactions and Synergistic Effects of Minerals

While individual minerals have shown potential benefits, their combined effects warrant further exploration. Chromium and magnesium, for instance, may act synergistically to enhance insulin sensitivity (18) and thereby help control diabetes. Similarly, vanadium has insulin-mimetic effects may be augmented by adequate magnesium levels, which support ATP-dependent insulin signaling (19). However, excessive supplementation of these minerals may lead to adverse effects, necessitating careful dosing strategies, that is, be careful when you add similar products to your regimen without paying close attention to the total dosages that will be delivered.

Conclusion and Future Directions

The role of chromium, vanadium, and magnesium in diabetes management is supported by mechanistic and clinical evidence. While these minerals offer promising adjunctive therapy, their efficacy remains variable across populations. Future research should focus on individualized supplementation strategies, biomarker-driven approaches, and long-term safety evaluations to optimize their therapeutic potential in diabetes care.

Magic Minerals is a balanced Mineral Chelate for about $28 per month

Diabet Stat is an additional dose of vanadium, chromium and alpha lipoic acid that we use with Magic Minerals to reduce blood sugar levels, reduce insulin levels and reduce HgA1c levels.

References

1. Vincent JB. J Nutr. 2000;130(4):715-718.

2. Althuis MD et al. Diabetes Care. 2002;25(5):817-821.

3. Davies S et al. Biochem J. 1995;311(Pt 3):775-779.

4. Anderson RA et al. Diabetes. 1997;46(11):1786-1791.

5. Balk EM et al. Diabetes Care. 2007;30(9):2154-2160.

6. Thompson KH et al. Chem Rev. 1999;99(9):2561-2572.

7. Goldfine AB et al. J Clin Invest. 1995;95(6):2501-2509.

8. Cusi K et al. Diabetes Care. 2001;24(3):577-582.

9. Shechter Y. Diabetes. 1990;39(1):1-5.

10. Domingo JL. Crit Rev Toxicol. 2000;30(5):415-462.

11. Barbagallo M, Dominguez LJ. Diabetes Metab. 2015;41(6):383-390.

12. Paolisso G et al. J Clin Endocrinol Metab. 1990;71(5):1215-1219.

13. Hruby A et al. Diabetes Care. 2014;37(9):2402-2410.

14. Dong JY et al. Diabetes Care. 2011;34(9):2116-2122.

15. Guerrero-Romero F et al. Diabetes Metab. 2011;37(5):456-462.

16. Simental-Mendía LE et al. Eur J Clin Nutr. 2018;72(1):62-66.

17. Song Y et al. Am J Clin Nutr. 2004;80(2):356-362.

18. Cefalu WT, Hu FB. Curr Opin Clin Nutr Metab Care. 2004;7(4):515-520.

19. Shi Y, Williamson G. J Nutr Biochem. 1996;7(4):191-210.

20. Evans GW, Bowman TD. Biochem Biophys Res Commun. 1992;182(2):992-997.

---

Subscribe to our Blog 

Dr Klein's Facebook Page

https://www.facebook.com/stagesoflifemedicalinstitute

David S. Klein, MD FACA FACPM

David S. Klein, MD, FACA, FACPM

1917 Boothe Circle, Suite 171

Longwood, Florida 32750

Tel: 407-679-3337

Fax: 407-678-7246

www.suffernomore.com

David S. Klein, MD Functional Medicine Physician