Devry NR503 week 6 Evaluation of Epidemiological Problem PDF

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Runni nghead:EPI DEMI OLOGI CALPROBLEM –DI ABETES

Eval uat i onofEpi demi ol ogi calPr obl em -Di abe t es Chamber l ai nCol l egeofNur si ng NR503:Popul at i onHeal t h,Epi de mi ol ogy ,& St at i st i calPr i nci pal s Decembe r4,2016

Di abet es

EPIDEMIOLOGICAL PROBLEM – DIABETES 2

Mor et han 400 mi l l i on of peopl e ar e affec t ed by Di abe t es Me l l i t us wor l dwi de.TheCent er sf orDi seaseCont r oland Pr event i on ( CDC)es t i mat ed a 29. 1mi l l i on t henumbe rofAmer i can c hi l dr en andadul t swi t h di abe t es( CDC, 2014) .TheCDC pr oj ec t sanes t i mat eofone i nt hr eeadul t st ohavedi abe t esby 2050.Di abe t e si mposes a l ar ge economi c bur den on t he economy and t he heal t hcar esys t em.Amer i can Di abe t esAssoc i at i on ( ADA)( 2014)est i mat edt hat di abet esbr i ngappr oxi mat e l y$69bi l l i onl ossi npr oduct i vi t yand$176bi l l i oni n di r ectmedi calcos t s.Accor di ngt oVi r gi ni aHeal t hDepar t ment( 2015) ,755,469 Vi r gi ni anshavedi abe t es,t hat ’ sabout1 outofev er y11 peopl e .Oft hose755, 469 di abe t i cs,t went y fiv e per centar e due t o endogenous f act or s and t hi r t y ei ghtper centt oexogenousf act or s.Vi r gi ni ahast he22nd hi ghes tdi abet esr at e i nt henat i onwi t hadeat hr at eof18. 4per100, 000.Theageadj ust eddi abet es deat hr at ef orPr i nce Wi l l i am Count y al one i s 16. 4 pe r 100, 000.Al t hough di abet escannotbepr event edent i r e l yduet ogene t i csuscept i bi l i t y ,buti n mos t c hanges t ot he envi r onment and r ai si ng awar eness wi l l hel pr educe t he occur r ence ofdi abet es i n ourpopul at i on and communi t i es.Thi s paperwi l l di scusst hebackgr oundofdi abet esi ncl udi ng;defini t i on,descr i pt i on,si gnsand sympt oms,and st at i st i csi n Fl or i da,r evi ew c ur r entsurv ei l l ancemet hodsand r epor t i ng me t hods, descr i pt i v e epi demi ol ogy anal ysi s, scr eeni ng and pr event i on,andapl anofact i onf ormeasur i ngout comes.

Backgr oundandSi gni ficanceofDi abet es

EPIDEMIOLOGICAL PROBLEM – DIABETES 3

Di abe t e s Mel l i t us i s a me t abol i c di sor derchar act e r i z ed by hi gh bl ood sugarl ev el sasr esul tofdefici encyoft hepancr eat i chor monei nsul i n,i nsul i n ac t i on,orbot h( Cr ai ge tal . ,2014) . I nsul i ni s a hor mone ,secr et ed by t he pancr east hatr egul at esbl oodsugar ,orgl ucoseandhe l pst hebodyusef oodf or ener gy .I nabi l i t yoft hepancr east or espond t oi nsul i n cor r ect l yort opr oduce enough i nsul i nr esul t si nt ype1 ort ype2 di abe t es .A t hi r dt ypeofdi abe t es, gest at i onaldi abet es deve l ops dur i ng pr egnancy i n whi ch i s woman wi t hout di abet es,dev el opshi gh bl ood sugarl ev el sdur i ngpr egnancy( Mpondo,Er nest , & Dee,2015) .Oft hees t i mat ed 29. 1 mi l l i on t henumberofAmer i can chi l dr en andadul t swi t hdi abet es,5t o10pe r centhavet ype1di abe t es .Type1di abe t es ar et ypi cal l y di agnosed i n chi l dr en and young adul t s,whi ch i s why i twas pr evi ousl ycal l edj uv eni l edi abet es.Type2di abe t esaccount edf or90t o95% of di abet es and ar e usual l y di agnosed i n adul t s ov er age 40 and gest at i onal di abet es2 t o10%.I nt heear l ys t ages,di abe t esar easympt omat i c.Hence,i t ’ s pr i mor di alt hatpeopl ear eeducat edoft hesi gnsandsympt oms.Excessi veand f r equent ur i nat i on, e xcessi v et hi r st , pol yphagi a, uni nt ended we i ght l oss, i r r i t abi l i t y ,f at i gue and weakne ss,body pai n,ver y dr ys ki n,bl ur r y vi si on, r ecur r i ng i nf ec t i ons and sor es ar e t he cl assi c sympt oms of di abe t es ( Ramachandr an, 2014) .Di abe t es i s a maj or r i sk f act or f or car di ovascul ar di sease and neur opat hy .I t ’ s al so t he l eadi ng cause of l ower ext r emi t y amput at i on,bl i ndness,ki dne yf ai l ur e,wher easdeat hi sdi abe t esf arr eachi ng compl i cat i ons .I n2014,at ot alof2, 626, 418deat hswer er epor t edi nt heUni t ed

EPIDEMIOLOGICAL PROBLEM – DIABETES 4

St at es and 234, 051 of t hose deat hs l i s t ed di abe t es as under l yi ng or cont r i but i ngcauseofdeat h,maki ngdi abe t est he7t hl eadi ngcauseofdeat hi n t heUS( CDC,2014) . Thepr eval enceofdi abet eshasi ncr easedi nal lgeogr aphi car eas.Vi r gi ni a has an es t i mat e of837, 137 peopl e or 12. 2% oft he adul tpopul at i on wi t h di abet esand anot her2, 213, 000 peopl ewi t h pr edi abe t e s( Vi r gi ni aDepar t ment ofHeal t h[ VDH] ,2014) .Thei ncr easest husf armaybeonl yt hebegi nni ngas 41, 000 addi t i onalpeopl e ar e di agnosed ev er yy earwi t h di abet es.The Gr eat er Pr i nceWi l l i am Count y( GPWC)has seen an i ncr ease i n di abe t esal so ( 293. 6 cases per 100, 000) ( Gr eat er Pr i nce Wi l l i am

Ar ea Communi t y Heal t h

Assessment ,2014) .

Sources: Virginia Department of Health

Deaths related Diabetes 2013 40

VA State Value: 18.3

EPIDEMIOLOGICAL PROBLEM – DIABETES 5

Manassas City

Prince William

Manassas Park City

Cur r entSur vei l l anceMet hods Sur vei l l ance i s cr i t i calf ort r acki ng t r ends i n di abe t e s and t ar ge t i ng di abe t es pr event i on e ffor t s.TheBehavi or alRi s k Fac t orSur vei l l anceSys t em ( BRFSS)i s at e l ephonesurv eyusedt oc ol l ectdat aaboutt hepopul at i on i nr egar dt ot hei r heal t hr e l at ed r i sk be havi or s,c hr oni cheal t hc ondi t i ons,and useofpr event i v e ser vi c es( Cent er sf orDi seaseCont r olandPr event i on,2014) .Al l50s t at es,al ong wi t h Washi ngt on DC,Guam,Puer t o Ri co and t he US Vi r gi nI sl ands col l ec t di abet esdat at hr oughputoft heyearand maket hosedat aav ai l abl et opol i cy maker s.Thosedat ear eneededi n or dert oi mpr ov epopul at i on heal t h.Beyond t he c or equest i onnai r es,st at esar eal l owed t o add t ot he l i stofques t i onsas t heyseefit .VDH conduc t edt hephonesurv eyonamont hl ybasi s. TheDepar t mentofHeal t handHumanSer vi c esl aunc hedt heHeal t hI ndi cat or s War ehouse( HI W)t o pr ovi dea si ngl e,user f r i endl y ,hi gh qual i t y ,cur at ed dat a and me t adat a sour ce f or nat i onal ,st at e,and communi t y heal t hi ndi cat or s ( CDC,2014) .HI W c ont ai ned 1, 291 i ndi cat or scat egor i z ed byt opi c,geogr aphy , ori ni t i at i v e. Vi r gi ni a Depar t ment of Heal t h( VDH) cr eat ed and mai nt ai ned a di abet es me l l i t usr egi s t r y( Vi r gi ni a Di abe t esRegi s t r y) .Ever y pr ovi deri nt hes t at ewho or der edagl yc osyl at edhemogl obi nt estshoul dr epor tt her esul tt oVDH r egi s t ry . Dat a shoul di ncl ude:pat i entname-addr ess-dat eofbi r t h-dat eoft het e st . Thi sr egi st r y al l owed VDH t o map t he epi demi ol ogy ofhyper gl yc emi a and t o

EPIDEMIOLOGICAL PROBLEM – DIABETES 6

moni t ort heepi demi c( VDH,2014) .I t ’ si mpor t antt oknow how manyVi r gi ni ans havedi abe t esandwher et heyar el ocat edt oi mpr ovecar eandout comes. Descr i pt i veEpi demi ol ogi calAnal ysi s TheAmer i can Di abet esAssoci at i on ( 2014)est i mat ed at29. 1 mi l l i on t he numberofAmer i can chi l dr en and adul t s wi t h di abe t es and t he t ot alheal t h expendi t ur e on di abe t e s exceeded 245 bi l l i on dol l ar s. Si gni ficant di abe t e s di spar i t i es exi s t among r aci aland e t hni c mi nor i t i es.The agest andar di z ed pr eval ence i s 15. 9% i n Amer i can I ndi ans/Al askan Nat i ves ,13. 2% i n Af r i can Amer i cans,12. 8% ofHi s pani cs,9. 0% i n Asi an Amer i cans and onl y 7. 6% of nonHi s pani cwhi t es( Chow,Fos t er ,Gonz al ez ,& McI ver ,2012) . Di abe t e shasr eached an epi demi cpr opor t i on i n Vi r gi ni a wi t h an es t i mat eof 837, 137 peopl eor12. 2% oft headul tpopul at i on wi t h di abet est hat ’ sabout1 outofever y11pe opl e( VDH,2014) .Thi si st het i poft hei ceber gasev er yyear 10% of2, 213, 000 Vi r gi ni ans wi t h pr edi abet es become di abet es.Ec hoi ng a nat i onalt r end,t he 2014 age adj ust ed deat hr at e per 100, 000 pe opl ef or di abet esi n Vi r gi ni a was18. 8,c ompar ed wi t h 20. 8f ort heU. S. Women have sl i ght l yhi gherr at est han men i n Vi r gi ni ar espect i v el y 10. 9% f orwomen and 9. 9% f ormen.Agi ngi sake yf ac t orTi ndi abe t es.22% oft he65+ar edi agnos ed wi t ht hedi sease.Thepr eval enceamongage5564i s21. 1% and9% f or45-54. Thec os t sofdi abe t est oVi r gi ni ansar eenor mous.I t ’ ses t i mat ed t hatdi abe t es cost$2. 5bi l l i oni nmedi calcost s,l ostwagesandpr emat ur emor t al i t yeachy ear i n Vi r gi ni a. The c os t si nc l udes compl i cat i ons t hat c oul d ar i se such as;

EPIDEMIOLOGICAL PROBLEM – DIABETES 7

amput at i on,s t r oke ,hear tdi sease,bl i ndness,endst age ki dne y di sease,and deat h. ManassasPar kCi t ywhi chi spar toft heGPWC hasapopul at i onof15, 427. The Hi s pani c make up 34. 6% of t he popul at i on or about 5, 400 peopl e. Appr oxi mat e l y36% oft heHi spani cpopul at i onhasbeendi agnosedwi t ht ype2 di abet eswhi c hr epr esent edani ncr easeof7% f r om 2013t o2014.Compar edt o t hei rwhi t ecount er par t ,t hepr eval enceoft ype2di abe t e sdecl i ned by4%.The consensusst at ementamongs t udi esi st hatobesi t y ,unheal t hydi e t ,sedent ar y l i f es t yl eand physi cali nact i vi t yaccount sf or8085% oft her i s k ofdev el opi ng t ype2di abe t e s( Ec kel ,Kahn,Fer r anni ni ,Gol dfine,Nat han,Schwar t z ,& Smi t h, 2011) .Amongt he1, 350Hi s pani cst hatar eover wei ghtorobese;28% orabout 378havebeendi agnosedwi t hdi abe t e s. Scr eeni ngandDi agnosi s One t oolt hatmy pr i mar y physi ci an used f or i dent i f yi ng peopl e atr i sk of dev el opi ng di abe t e si s a di abet i c quest i onnai r ef or m.The f or m consi s t s of si mpl e quest i ons r el at ed t o age,gender ,et hni ci t y ,and f ami l y hi st or yt o be compl e t ed by t he pat i entorwi t ht he assi st ance ofa heal t h pr of essi onalor pr ac t i ce nur se.I t ’ s si mpl e,pr act i cal ,and noni nvasi ve and accur at el yr eflect known di abet es r i s kf ac t or s. HbA1C has been adopt ed by t he Amer i can Di abe t e s Associ at i on ( ADA)as a f or malscr eeni ng t oolf or di abet es.HbA1c t e st i ngi sdoneonabl oodsampl e( dr awi ngbl ood)andsentt oal abor at or yt hat usesan NGSPcer t i fiedmet hodf orA1C anal ysi st omeasur et heHbA1cl eve l s.

EPIDEMIOLOGICAL PROBLEM – DIABETES 8

HbA1cmeasur est heamountofsugar( gl ucos e)t hati sbound ors t uc kt ot he hemogl obi ni nt her ed bl ood ce l l s.Unl i ket heot herdi abet i ct es t ssuch ast he f ast i ngpl asmagl ucose( FPG)t e standt heor algl ucoset ol er ancet es t( OGTT) ,i t doesnotr equi r epat i ent st obef ast i ng.Thi si sani mpor t antcons i der at i onwhen consi der i nghow di fficul ti tcoul d bef orpeopl enott oeatordr i nk f oratl east ei ghthour s.The cut off poi ntf ordi agnosi ng di abe t esort o be c onsi der ed at ‘ i ncr eased r i s k’f ordi abe t esi san HbA1cl ev elof48 mmol /mol( 6. 5%)on t wo separ at eoccasi ons( Chamber l ai n,Rhi ne har t ,Shaef er ,& Neuman,2016) .Al ev el be l ow 5. 7% i sc onsi der ed nor maland heal t hy;5. 7% t o 6. 4% i spr edi abe t es,

EPIDEMIOLOGICAL PROBLEM – DIABETES 9

and

gr eat er

t han

6. 4%

i s

di abe t es

( ADA,

2015) .

EPIDEMIOLOGICAL PROBLEM – DIABETES 10

St udi eshavede mons t r at edt hatt hecompl i cat i onsofdi abe t escanbedel ayedor pr event edi ft heHbA1cl ev elcanbekeptbe l ow 7%.Onceani ndi vi dualr eaches t hatt hr eshol dof7% i st i mef orcounsel l i ngabouteffect i v est r at egi essuchas wei ghtl oss,heal t hyeat i ngphysi calact i vi t yt ol oweryourr i sks( Juar ez , Demar i s,Goo,Mnat z agani an,& Wong,2014) . Basedonconvent i onalcut offpoi ntof6. 5%,Dut t a,Dudhe,Deb,Dasgupt a,& Sar kar( 2016)f oundHbA1chadasensi t i vi t y ,s peci fici t yandpr edi c t i v ev al ueof 90%,72%,and76. 27%.Thei mpl i cat i oni st hati npr edi c t i ngout comesof di abet esHbA1cper f or msaswel lasandof t enbe t t ert hanFPG andOGTT HbA1ct es t i ngt ode t ec tdi abet esi nasympt omat i cpeopl eshoul dbec onsi der ed i nadul t sofanyagewhoar eover wei ghtorobeseandi nc hi l dr enand adol escent swhoar eover wei ghtorobeseandwhohavet woormor eaddi t i onal r i skf act or sf ordi abet es.TheADAr ecommendsmeasur ementofHbA1ct ypi cal l y 34t i mesperyear( ADA,2014) .Al t houghmor eexpe nsi v et hanFPG,HbA1c shoul dbenumberonec hoi cef ordet ec t i ngdi abe t es.I ti sasmal lt oken consi der i ngt hehi ghcost sassoc i at edwi t hdi abe t e s.Mor eover ,HbA1cc os t sl ess i nt er msoft i meandconveni encet ot hepat i entsi ncei t ’ sf ast i ngf r ee . Di abet esPl anofact i on Managementofdi abe t e si sc hal l engi ngt ot hec ompl exi t yoft hedi sease.I t i sof t enl i nkedt oobesi t y .Joos t ,Chadt ,Sc her neck,& Al Hasani ,( 2014)f ound t hatobesi t ycausesi nflammat i onoft hemol ec ul eLTB4whi chpr omot esi nsul i n r esi s t ance,afir s tst epi ndev el opi ngt ype2di abet es.Manassashasahi ghe r

EPIDEMIOLOGICAL PROBLEM – DIABETES 11

per cent ageofpeopl e( Hi s pani cs)whoar eover wei ghtorobeset hant hes t at e aver age.Thei rt r adi t i onaldi shesar ehi ghi nsodi um,f at ,andsugar .What makesenchi l adasde l i ci ousi st hecheeseandi ti si mpor t antpar toft hei r cul t ur e.Ther ef or e,t heywon’ tabandoni t .Howev er ,wecoul dencour aget he Hi s pani cpopul at i ont omodi f yt hei rdi e twhi l es t i l lbei ngaut hent i cand flavor f ul .Heal t hydi e tc hangesi nc l udeamoder at ei ncr easei nt hec onsumpt i on ofmi l k,vege t abl es,andf r ui t s ,andal soi nc l udeal ar gedecr easei nt he consumpt i onofl ar dandc heese.Deepf r i edf oodst e ndt ohav ehi gheramount s off at .Byboi l i ngorbaki ng,t heamountoff atcoul dbecuti nhal f . Por t i onsi zei sal soi mpor t ant .Ast heymi ghtnotwantt omodi f yt hei rdi e t ,t hey shoul dbeadvi sedt oeatl essbychoosi ngsmal l erpor t i onsandeat i ngonl y whenhungr y .Eat i ngasmal l erpor t i onmeansl esscal or i et obeconsumed. HomemadeTacosonsof tshel lcont ai nsabout510cal or i es .I nst eadof2t acos , consi der edeat i ngone.Obeseadul t sar emor el i kel yt or epor tac hi evi ng meani ngf ulwe i ghtl os si ft heyconsumesmal l erpor t i onsr at hert hanf ol l owi ng f atdi e t s( Ni c kl as,Huskey ,Davi s ,& Wee,2012) .School sshoul dbeont hef r ont l i nei nt hewaragai nstobesi t yanddi abet essi ncei ti swher echi l dr enspent mostoft hei rt i meandt hef oodt heyconsumedatschoolcont r i but edt o50 per centoft hei rdai l ycal or i ei nt ake.Schoolshoul dpr ovi deheal t hymeal s,and adi e tofhi ghnut r i t i onalqual i t y .Besi det hei nt r oduct i onofheal t hi ermenu,I woul dl i ket hesc hoolt ohi r eadi e t i ci ant ohe l ps t udent st oeatbet t er .Themai n goali sar educ t i onof3% i nt hechi l dr en’ sBodyMassI ndex( BMI ) .Thesc hool

EPIDEMIOLOGICAL PROBLEM – DIABETES 12

nur sewoul dber esponsi bl et omeasur et heBMIever y3mont hs.Fr anz , Boucher ,& Ev er t ,( 2014)obser veda1%–2% l ower i ngofhemogl obi nA1cval ues f r om nut r i t i ont her apyi nt e rv ent i ons,adecr easedof2% ofHbA1cwi t hnewl y di agnosedt ype2di abe t esandadecr easeof0. 4% wi t hal ongdur at i onoft ype 2di abe t esof9year s. St udi eshaveal soshownt hatamongadul t s,Type2Di abe t escanbepr event ed ordel ayedbyadopt i ngaf ew l i f est yl echangessuc has:r egul arphysi cal sand exams,qui tsmoki ng,s t r essmanagement ,al coholf r eeorr educi ngal cohol i nt ake ,heal t hyeat i ngchoi ces,i ncr easi ngphysi calact i vi t y ,copi ngski l l s,s t r ess management ,andpr obl em sol vi ng.Ayear l ongf r eeDi abe t esPr event i oncl ass woul deducat epar t i ci pant saboutdi abet esandt hewayst omakel i f es t yl e c hangest opr eventdi abe t es.Thec l asswoul dbel edbyat r ai nedpar t i ci pant s f ol l ow acur r i cul um l edbyat r ai nedl i f es t yl ec oac handadi e t i ci an.Thegoali s t oac hi ev ewei ghtl ossi nt her angeofi nt her angeof6t o15per centofbasel i ne bodywei ght .Ev er y3mont hst hepar t i ci pant ’ sbodywei ghtwi l lber ecor dedt o moni t orpr ogr ess.I nv est menti nadi abe t espr event i onpr ogr am hadshownt o yi el dsubst ant i alr et ur noni nv est ment .Resear cher sf oundt hatpar t i ci pant s assi gnedt ot hel i f est yl ei nt er vent i onpr ogr am had7% wei ghtl os s,engagedi nat l east150mi nut esofphysi caland r educedt hei nci denceofdi abe t esby58% compar edwi t ht hepl acebo( Tuso,2014) .Sel f managementsuppor ti scr i t i calt o managi ngandcont r ol l i ngdi abet es.Peopl eneedacc esst odi abe t esse l f managementi nf or mat i on.The ywant e dnur sesi nt hei rhomes,sc hool s,

EPIDEMIOLOGICAL PROBLEM – DIABETES 13

wor kpl ac es,andc hur ches.Amont hl yHeal t hf ai ri nt hecommuni t ycoul dhel p pr omot edi abet esawar eness,r e f eri ndi vi dual st oDi abe t esPr ev ent i onPr ogr ams andwher et heycange tgover nmentassi st ance. Concl usi on Di abe t e si si nar emar kabl et i me.I thasr eac hedepi demi cpr opor t i ons wor l dwi de.ThenumberofAmer i canc hi l dr enandadul t swi t hdi abe t e sr eached t he29. 1mi l l i onbar .Thecost sandcompl i cat i onsoft hedi seasemakei ta nat i onalpr i or i t y .I t ' sc l eart hatcer t ai nf ac t or ssuchasobesi t y ,i nact i vi t y ,age, f ami l yhi st or yandgenet i csi ncr easet her i sk.However ,1/3ofpeopl er emai ned undi agnosedandt heydon’ tev enknow t hatt heyar er i skal t hought he yhav e exhi bi t edt hesi gnsandsympt omsoft hedi sease.Resul t ssuchas demons t r at edt heneedf orbe t t erdi abe t eseducat i on,andbet t eraccesst o heal t hcar e.Cur r ent l y ,t her ear esi gni ficantbar r i er st ot hepr ovi si onof educat i onandsuppor tt ot hosewi t hpr edi abe t ese speci al l yt hemi nor i t i eswho ar eatevengr eat err i sk.Ast heUSpopul at i oni sagei ng;t hedemandf or di abet escar ei sev engr eat er .Sever alst udi eshav edemons t r at edt hati nt ensi v e di abet i cmanagementcanr educecanr educet her i s kofonse tandpr ogr essi on. Thest agehasbeense tf orAdvanc edNur sePr act i t i one rt obet hef r ontl i net he f r ontl i nei npr ovi di ngdi abet i ccar et hati sofequalofbet t erqual i t yt ot hat pr ov edbyphysi ci ans.

EPIDEMIOLOGICAL PROBLEM – DIABETES 14

Ref er ences

Amer i can Di abe t es Associ at i on ( 2014) .St at i st i cs about Di abe t es .Ret r i ev ed f r om: ht t p: / /www. di abe t es. or g/di abe t esbasi cs/s t at i st i cs/ Cent er sf orDi seaseCont r olandPr event i on.( 2014) .Nat i onaldi abe t ess t at i st i cs r epor t :est i mat esofdi abe t esand i t sbur den i nt heUni t e d St at es,2014. At l ant a,GA:USDepar t mentofHeal t handHumanServi ces,2014. Cent er sf orDi seaseCont r olandPr event i on( 2014) .Be havi or alRi skFac t or Sur vei l l anceSys t em:St at ebySt at eLi s t i ngofHow Dat aAr eUsed. Re t r i evedf r om:ht t p: / /www. cdc. gov/br f ss/st at e_i nf o/ Chamber l ai n,J.J. ,Rhi ne har t ,A.S. ,Shae f erJr ,C.F. ,& Neuman,A.( 2016) .

EPIDEMIOLOGICAL PROBLEM – DIABETES 15

Di agnosi sand ManagementofDi abe t e s:Synopsi soft he2016Amer i can Di abe t e s Associ at i on St andar dsofMedi calCar ei n Di abe t es .Annal sof i nt er nalmedi c i ne ,164( 8) ,542552.doi :10. 7326/M153016 Chow,E.A. ,Fost er ,H. ,Gonz al ez ,V. ,& McI ver ,L.( 2012) .Thedi s par at ei mpac t of di abe t es on r aci al /e t hni c mi nor i t y popul at i ons. Cl i ni c al Di abet es, 30( 3) ,130133.doi : 10. 2337/di ac l i n. 30. 3. 130 Cr ai g,M.E. ,Jeffer i es,C. ,Dabel ea,D. ,Bal de,N. ,Se t h,A. ,& Donaghue,K.C. ( 2014) . Defini t i on,epi demi ol ogy ,and c l assi ficat i on ofdi abe t esi nc hi l dr en andadol esc ent s.Pedi at r i cDi abet es,15417.doi : 10. 1111/pedi . 12186 Dut t a,A. ,Dudhe ,A.P. ,Deb,S. ,Dasgupt a,S. ,& Sar kar ,A.( 2016) .Ast udyon assessmentofHbA1cl ev e lasadi agnost i ccr i t e r i onoft ype2di abet es me l l i t us.Asi anJour nalOfMedi c alSc i enc es,7( 1) ,4952. doi : 10. 3126/aj ms. v7i 1. 13052 Ecke l ,R...