Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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On Aug 2018

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : BC23 - BC27 Full Version

Assessment of Vitamin A and Vitamin E Levels in Patients with Controlled and Uncontrolled Type 2 Diabetes Mellitus: A Case-control Study

Published: June 1, 2022 | DOI:
Rajan Kumar Thakur, Sudha Ambiger, Varsha M Shindhe

1. Postgraduate Student, Department of Biochemistry, Kaher’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India. 2. Assistant Professor, Department of Biochemistry, Jagadguru Gangadhar Mahaswamigalu Moorusavirmath Medical College, Huballi, Karnataka, India. 3. Associate Professor, Department of Physiology, Jagadguru Gangadhar Mahaswamigalu Moorusavirmath Medical College, Huballi, Karnataka, India.

Correspondence Address :
Dr. Sudha Ambiger,
Assistant Professor, Department of Biochemistry, KAHER’S Jagadguru Gangadhar
Mahaswamigalu Moorusavirmath Medical College, Huballi, Karnataka, India.


Introduction: The prevalence of diabetes in India according to the International Diabetes Federation (IDF), Diabetes Atlas 2015 is reported to be 8.7%. Diabetes mellitus is a metabolic disorder, which results from body’s insensitivity to insulin and affects humankind at an alarming pose. Glycated Haemoglobin (HbA1c) is an important biomarker in assessing glucose level serologically. If HbA1c level is <7% the diabetes is said to be in controlled conditions. Vitamin A and E plays pivotal role as antioxidants in order to control oxidative stress which is an important contributing factor in diabetes mellitus by neutralising free radicals generated.

Aim: To assess the antioxidants vitamin A and vitamin E levels in controlled and uncontrolled Type 2 Diabetes Mellitus (T2DM) patients and also to correlate the vitamin A and E levels with HbA1C in controlled and uncontrolled T2DM patients.

Materials and Methods: The present case-control study was conducted for 12 months from January 2019 to December 2019 in the Department of Biochemistry, Jawaharlal Nehru Medical College Belagavi, Karnataka, India. The blood samples were collected from KLE’S Dr. Prabhakar Kore Hospital and Medical Research Center, Belagavi, Karnataka, India. A total of 110 subjects were divided into two group’s controlled Group 1 (55) and uncontrolled Group 2 diabetes (55) on the basis of HbA1c levels. Vitamin A and E levels were assessed by Enzyme Linked Immunosorbent Assay (ELISA) method. HbA1c was estimated by using Bio-Rad D-10 HbA1c program. The data was assessed using Chi-square test, Independent t-test, and Karl-Pearson corelation test.

Results: There were a total of 29 males and 26 females in controlled T2DM group and a total of 34 males and 21 females in uncontrolled T2DM group. The mean ages in controlled and uncontrolled T2DM subjects were 57.11±8.82 years and 54.22±7.93 years respectively. The HbA1c (%), vitamin E and vitamin A in controlled T2DM subjects were 6.01±0.56 years, 1.01±0.43 years and 21.66±7.94 years respectively. The HbA1c (%), vitamin E and vitamin A in uncontrolled T2DM subjects were 9.31±0.25 years, 0.58±0.29 years and 14.66±5.36 years respectively. Corelation of vitamin A and E with HbA1c was found to be non significant statistically.

Conclusion: Vitamin A and E levels were comparatively higher in controlled diabetes patients in comparison to uncontrolled T2DM patients.


Antioxidant vitamins, Oxidative stress, Metabolic disorder, Hyperglycaemia

India is a storehouse of 69.1 million diabetic people (1). Diabetes can be defined as the metabolic disorder, which results in body’s insensitivity to insulin affecting multiple metabolic and cytological systems (2). HbA1c indicates three months prior blood glucose level. The diabetic is said to be in control if HbA1C is <7% (3). If not resolved hyperglycaemia can amount to several complications in the end. These complications include neuropathy (i.e. nerve damage, for e.g. diabetic foot disorders which may require amputation later, nephropathy (kidney failure), retinopathy (i.e. retinal blood vessels getting damaged which may lead to blindness) as well as cardiovascular disorder such as heart attack and stroke (4),(5).

Vitamin A is one of most vital and countable micronutrient used by organisms. In human body, it cannot be synthesised metabolically and thus should be obtained through supplementary or dietary measures. Vitamin A along with vitamin E acts as antioxidant with many other minerals and compounds. Antioxidants are not usually accounted in aetiology of T2DM but may help to improve the disorder-associated complications. Origin of free radicals due to stress by oxidative can cause damage to the blood vessels and organs (6). Studies done by Tsutsumi C et al., (7), Lobo GP et al., (8), Kato M et al., (9), Chertow BS et al., (10), Souza FI et al., (11), Musso G et al., (12), and Chaves GV et al., (13) suggest that retinoid may be contributing factor to hepatic lipid metabolism, synthesis of fat and metabolism of β-cell of pancreas. Even though there are not enough studies to identify precise mechanism by which vitamin A affects metabolic pathways in diabetic patients. Vitamin A reserve should be maintained anyway in subjects of diabetes mellitus and other carbohydrates, lipids and protein related diseases and disorders (14).

By inhibiting lipid-per-oxidation in muscles vitamin E plays one of the most pivotal roles as a potent soluble antioxidant. It decrease HbA1c level inadequate glycaemic control or low serum level of vitamin E (15). Patients with diabetes do not have vitamin E deficiency in general. In fact, with respect to incidence of diabetes mellitus, plasma and platelet content of vitamin E increases (16),(17). Vitamin E have been associated with decrease rate of cardiovascular disease risk, diabetes complications, certain cancers and cataract disease of the eye hence, it can be concluded that vitamin E is a liposoluble antioxidant which helps in scavenging peroxides radicals, produced during lipid peroxidation of the lipid membrane of cells (18),(19),(21),(22),(23),(24),(25),(20).

Few studies [4,21,22] showed high level of Vitamin A and Vitamin E in Diabetes mellitus patients, while (23),(24),(25) showed low level of Vitamin A and Vitamin E in diabetes mellitus. Studies by Firoozrai M et al., (26) and Merzouk S et al., (5) showed no significant difference in level of antioxidant vitamins in diabetes mellitus patients compared to controls. Therefore, the present study was undertaken to assess the antioxidants vitamin A and vitamin E levels in controlled and uncontrolled T2DM patients and to study the correlation of vitamin A and E levels with HbA1C in controlled and uncontrolled T2DM patients.

Material and Methods

The present cross-sectional study was conducted for 12 months from January 2019 to December 2019 in the Department of Biochemistry, Jawaharlal Nehru Medical College Belagavi, Karnataka, India. The blood samples collected from KLE’S Dr. Prabhakar Kore Hospital and Medical Research Center, Belagavi. Ethical clearance obtained from Institutional Ethical Committee (Ethical clearance approval number MDC/DOME/44).

Inclusion criteria: Fifty five patients with T2DM having HbA1c <7%, with the age group 35-70 years were included as cases in the study. Fifty five patients with T2DM having HbA1c >7%, with the age group 35-70 years were included as controls in the study.

Exclusion criteria: Patients with hyperlipidaemia and systemic disease such as kidney disease, neuropathy, cardiovascular disease, liver disease, heart disease were excluded from the study.

Sample size: Sample size was 110 calculated according to formula

n = Z2α/2 x SD2 / (P. % SD)2

At 95% confidential Interval, Z2 α/2 =1.96

20% error is estimated, i.e. 80% power taken from previous studies (27),(28) and 10% attribution HbA1c estimation in whole blood was done by using a Bio-Rad D-10 (HbA1c program) using High Performance Liquid Chromatography (HPLC) method based on the principle of ion exchange. The samples were injected into the analytical cartridge after dilution. The D-10 increase ionic strength in cartridge by delivery of buffer. With an absorbance of 415 nm, the separated haemoglobin was passed along the flow cell of the filter photometer (29).

Vitamin A and Vitamin E estimation was done by ELISA method. 50 μL of sample were added per well. Blank well was set without any solution. 50 μL of Horseradish Peroxidase (HRP) conjugate was added to each well (not to blank well), then 50 μL antibody was added to each well. Mixed well and then incubated for 1 hour at 37°C. Each well was aspirated and then washed; the process was repeated two times for a total of three washes. Then each well was washed with wash buffer (200 μL) .After last wash, any remaining wash buffer was removed by aspirating. Then the plate was inverted and blotted against clean paper towels. 50 μL of substrate A and 50 μL of substrate B were added to each well, mixed well and incubated for 15 minutes at 37°C. 50 μL of stop solution was added to each well, and then plate was gently tapped to ensure thorough mixing. Optical density was determined of each well within 10 minutes, using a microplate reader set to 450 nm (30).

Study population divided into two groups depending on value of HbA1C,

Group 1: 55 T2DM patients in controlled group (having HbA1C <6.5-7%) and Group 2: 55 T2DM patients in uncontrolled group (having HbA1C >7%) (31),(32),(33).

Statistical Analysis

Data analysis was done by using Statistical Package for the Social Sciences (SPSS) Software version 16.0. Data was analysed using independent t-test within the groups and Karl Pearson Correlation Coefficient in between the groups. The p-value <0.05 was considered statistically significant.


The blood samples of 110 T2DM subjects were collected as per the inclusion and exclusion criteria’s in which the group 1 subjects (29 males and 26 female) (n=55) and group 2 subjects (34 males and 21 female) (n=55) were obtained based on HbA1C level. Gender distribution among group 1 and group 2 was statistically non significant (p-value=0.3353) (Table/Fig 1). The mean ages in group 1 and group 2 T2DM subjects were 57.11±8.82 years and 54.22±7.93 years respectively.

The subjects were categorised into four age groups (Table/Fig 2). In a group of 35-40 yrs there were minimum number of subjects and in groups 51-60 years and 61-70 years there were maximum number of subjects. Age distribution among group 1 and group 2 was stastisticaly significant (p-value=0.046) (Table/Fig 2).

The comparison of HbA1c (%), vitamin E and vitamin A in group 1 and group 2 was statistically significant (Table/Fig 3).

In Group 1 (controlled) type 2 diabetes mellitus subjects, the correlation between HbA1c (%) and vitamin E (mg/dL) was found to be r-value -0.0539 (Table/Fig 4) and it was not statistically significant (p value- 0.6961) .Correlation between HbA1c, and vitamin A (μg %) was found to be r-value -0.0812 which was not statistically significant (p value- 0.5557) (Table/Fig 5).

In Group 2 (uncontrolled) type 2 diabetes mellitus subjects, the correlation between HbA1c (%) and vitamin E (mg/dL) was found to be r-value -0.0635 (Table/Fig 4) and it was not statistically significant (p value- 0.6451). Correlation between HbA1c and vitamin A (μg %) was found to be r-value -0.0084 and it was not statistically significant (p value- 0.9513) (Table/Fig 5).


The main need of diabetic patients is to attain normal blood glucose. In the present study, authors have compared the levels of HbA1C, vitamin A and E in controlled and uncontrolled T2DM. Previous studies conducted by, Abahusain MA et al., (23). Firoozrai M et al., (26), Reunanen A et al., (34) and Onyesom I and Agho JE (35) have estimated vitamin A and vitamin E in diabetic groups and compared with normal groups. But in the present study authors divided DM patients like controlled and uncontrolled depending on level of HbA1C. As per the present study findings it was observed that the levels of vitamin E and vitamin A in controlled T2DM were in normal interval when compared with uncontrolled T2DM.

Present study showed that vitamin E levels were significantly lower in uncontrolled diabetes mellitus subjects as compared to the patient of controlled diabetes mellitus with t value 6.17 and p-value <0.0001. The study done by Odum EP et al., (24), Alamdari MI I(36)Ahmad M et al., (37), Veerabhadra GG et al., (38), Sawant J et al., (39), showed that vitamin E level in diabetic patients was found to be less as compared to controlled individuals

In diabetes mellitus, free radicals play a very important role which results in the development of inflammation and oxidative stress. Scavenging action of vitamin E helps to overcome the oxidative stress. Vitamin E interrupts the chain reaction of lipid peroxidation by interacting with lipid peroxy radicals. Thus it is found to protect cells against oxidative damage. Hence they concluded that decrease in vitamin E levels could be the cause of its excess utilisation (40).

In contradicting to present results, few studies by Tavridou A et al., (41), Kimble MS et al., (42), Murrill WA et al., (43) showed that there was no difference in serum vitamin E concentrations between the groups. Present study showed that vitamin A levels were significantly lower in uncontrolled diabetes patients as compared with controlled diabetes mellitus with t value 5.42 and p-value<0.0001. The study done by Aliyu M et al., (2), Erikstrup C et al., (25), Oneysom and Agho JE (35), they showed vitamin A level in diabetic patients was less than control group. The reason for low vitamin A level could be due to excess utilisation which results in reducing oxidative stress (44).

In contradicting to present study results few studies done by MA abahusain et al., (23) , Basualdo C G et al., (45) and Peerapatdit T et al., (46) they showed that there was no difference in vitamin A level in diabetic individuals and control group (p<0.001). Previous studies like Abahusain MA et al., (23),Onyesom I and Agho JE (35) and Firoozrai M et al., (26) had correlated HbA1c, vitamin A and vitamin E with each other in diabetic subjects as one group, but in the present study, we have correlated HbA1c, vitamin A and vitamin E with each other in controlled and uncontrolled T2DM subjects separately. Firstly the correlation in Group 1controlled T2DM subjects was performed for vitamin E and HbA1c it showed insignificant results (r=-0.0539; p=0.6961). Then HbA1c and vitamin A were correlated and the results were insignificant (r=-0.0812; p=0.5557). The same was done in group 2 uncontrolled T2DM subjects and the correlation between HbA1c and vitamin E was insignificant (r=-0.0635; p =0.6451). Then HbA1c and vitamin A were correlated and the results were insignificant (r=-0.0084; p =0.9513). There was a weak and not significant negative correlation observed between two parameters in controlled T2DM and uncontrolled groups. Comparison of finding of present study with contrast studies is shown in (Table/Fig 6) [2,5,23,24,26,35,36,38,46].

In DM there is increased polyol pathways, increased formation of glyacation end product, activation of protein kinase C and increased hexoseamine pathway. All these increases superoxide formation, that leads to increase oxidative stress in DM (4). Formation of free radicals, causing oxidative stress and tissue damage is mainly due to non enzymatic glycation between glucose and amino group of protein (23),(47).

According to the present study authors observed low levels of vitamin A and E in Group 2 (uncontrolled) T2DM subjects than Group 1 (controlled) T2DM which may be due to excess utilisation vitamins A and E, it may be due to increased oxidative stress in uncontrolled T2DM subjects compared to controlled T2DM subjects. The other reason could be due to adequate intake of vitamins and consumption of medicine, which has good control on oxidative stress by controlled T2DM.


Measurement of other antioxidant levels may yield more meaningful data on the role of the antioxidant system in the clinical course of type 2 DM. Further follow-up studies with vitamin A and E supplementation is needed.


Present study concludes that antioxidant vitamins A and E were low in uncontrolled diabetic patients group compared to controlled type 2 diabetes group. Physician should advice uncontrolled diabetic patients to consume adequate vitamin A and E in their diet along with medication which helps them to have appropriate amount of vitamin A and E to control diabetes and prevent complications. Further studies are required to study the beneficial role of antioxidant vitamins supplementation in diabetes mellitus patients.


Authors would like to thank Dr. Anwar Mujawar MD (General Medicine), Asst. professor, Department of General Medicine Jawaharlal Nehru Medical College, for helping in collection of samples of diabetes mellitus patients.


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DOI and Others

DOI: 10.7860/JCDR/2022/53424.16517

Date of Submission: Nov 23, 2021
Date of Peer Review: Jan 10, 2022
Date of Acceptance: Mar 17, 2022
Date of Publishing: Jun 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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