Home Based Case Study: The Patient With Diabetes

Abstract

The patient is a 56-year-old Mexican lady, getting diabetes treatment. In this assignment, I am conducting a family/home assessment, which must focus on the family and their home environment in relation to the patient and his or her medical condition. Family/ home assessment is important as it gives the scope of the family environment, how it will need to be modified to help in the treatment of the patient.

Home care is more holistic and more comfortable for the patient. In the home setting, there is less risk of infection, affordable and can be modified to fit the needs of the patient. In this case, the patient claims to have uncontrolled diabetes and is not suffering from any related complications as yet. The fact that she doesn’t have any immediate family living with her may be a little hard with the treatment and management of diabetes. Constant checkups, with diabetes education the patient will be able to manage the disease. These home care services provide services that one cannot easily or effectively get from family and friends.

According to the American Diabetics Association (2006), when providing home care for diabetic patients, a nursing assessment must be done. This assessment includes noting the factors that will hinder blood sugar control and medical management. The factors are; age related changes, diabetes eye and damaged nerves and the medication. This patient is a little old and is likely to develop old age related habits, like poor nutrition intake or malnutrition. The fact that she leaves alone leaves her very vulnerable. Damaged nerves are the 2^nd factor that causes neuropathy. This can lead to falls, and injuries on the patient due to lack of sensitivity in the feet.The other factor are diabetic eye disease that affects the Retina of the eye. If the patient has this condition, there might be interference of medication administration they might over/under dose. The last factor is dosage where the patient might forget to take medication at the required time. The patient might forget to take the medication, since she does not have someone to keep reminding her to take medication or take blood sugar tests.

Screening and assessment

Screening involves taking blood, urine and patients history. The blood tests comprise of fasting blood sugar levels, post prandial blood sugar and an oral glucose tolerance test (measures blood glucose). The test should give 126 mg/dL for fasting, Oral Glucose tolerance test 200mg/dL and post prandial 150mg/dL. It is important to conduct a comprehensive family, social and cultural history of the patient. It helps in establishing the risk factors associated with her characteristics. Before starting the screening lets first understand what diabetes is, it is a metabolic disease characterized by constant raised concentrations of glucose in the blood. The Autoimmune destruction of pancreatic cells leads to Type I diabetes or insulin resistance with relative insulin deficiency leading to Type II (Goroll and Mulley, 2009). According to the CDC nearly 95% of diabetes is type II, and it is caused by when the pancreas does not produce any insulin, or very little. It also happens when the body does not respond appropriately to insulin, causing insulin resistance.

Type I diabetes common in childhood and early adulthood while Type II is more common in older adults. Type I and II have varying signs and symptoms. These include; thirsts, hunger, weight loss, fatigue, rapid and early onset for Type I. symptoms for Type II are high blood pressure, recurrent illnesses and low energy levels. There are various risk factors that will help in the assessment of the patient’s probability of developing diabetes. The risk factor that help justify screening her for diabetes are, age, belonging to a high risk ethnic/ racial group and the amount of blood sugar through the tests she has been doing. With the information that is available, she can be screened for diabetes Type II since symptoms are not usually visible until there is something wrong. With proper diagnosis, there is treatment available and with lifestyle change it can be managed.

These are the step I have followed in assessment of Ms.S in relation to the diabetes condition.

1. Vital signs assessment with her weight and height. This includes gathering information on her last blood glucose test which she said varied between 200-500 mg/dL in the last 3 weeks.

• Inquiring of any complaints she might have, that I countercheck against the known symptoms of diabetes. I should follow that up with questions regarding her life style in terms of diet, sleep patterns, exercise and stress levels. In case she is taking any medication, I should note that down and the purpose of the medicine.
• This step involves doing gender appropriate tests and these tests include pap smears, mammograms, bone density etc.
• I check off other symptoms that the client might have overlooked, for example, dizziness, pain in other body parts and vision. The patient mentioned that her vision gets blurry during glucose fluctuations. This should be part of the treatment plan to avoid losing sight due to diabetic eyes disease.
• After reviewing of the case, I can start with diabetic education, change of treatment and formulation of a new one.

Comprehensive family, social and cultural history of the patient

The patient’s family history, social and cultural belief affects their understanding of the disease causes and treatment. Diabetes is a metabolic disease characterized by constant, elevated concentrations of glucose in the blood.

Diabetes and Family history

Establishment of family history is essential in the detection of diabetes. It provides genomic information based on the interaction between the environment, behavioral and genes. When I perform this assessment, I would like Ms. S to tell me if anyone in her family has diabetes, or was told by the health care providers that they might be diabetic. Diabetes in some cases is a caused by mutation of some genes in the beta cells in the pancreas, and these genes can be passed on from the parents to their offspring, for both types of diabetes. That is why it is always good to have a diabetes screening if your immediate family/1^st degree relatives have diabetes. Other environmental factor like eating habits influence and are risk factors in developing Type II diabetes. This is because diabetes risk is 2-4 times higher in people with diabetic relatives than those without. The rate increases with the degree of relationship between the diabetic relative and the person under going diabetic screening. First degree relatives are parents and sibling, and if both parents have/had diabetes there is a twice higher chance of Ms. S being diabetic.

If she is Diabetic, her children are at risk of being diabetic too, but other factors influence this prevalence too. Personal history is also very important in this evaluation and assessment. Women who had gestational diabetes during pregnancy, have a 20% chance of developing diabetes when after birth of the child (Goroll & Mulley, 2009). She has a higher risk of developing diabetes, if her son weighed more than nine pounds at birth. She could have had gestational diabetes especially in her last trimester. This type of diabetes decreases with breast feeding and eventually disappears but the child is at risk of developing diabetes. Her son will need to be screened as early detection and treatment makes management of the disease easier. With diabetic education, they will be able to adopt a lifestyle that prevents development of type II diabetes. Her age also puts her at risk of having diabetes; she is 59 years old, anyone above the age of 45 years has a 15 % higher chance of being diabetic. According to the National Health and Nutrition Examination Survey (2005-2008)

Obesity is a high risk factor in development of type II diabetes and other cardiovascular diseases. She walks a lot, and this is good exercise since lack of exercise increases the risk factors for aged females with a family history of diabetes. Individuals with a family history of diabetes have a 2-6 times higher risk of developing diabetes. Research shows that, fat tissues prevent insulin sensitivity in a person. This means that the body requires more insulin to maintain and regulate the blood sugars. This also leads increased glycogenesis, where the liver creates energy from protein cells. The insulin is no longer able to respond to the body need and energy synthesis.

Family Ancestry also plays an important role in determining the risk factor in development of diabetes. Studies have shown that the highest prevalence of diabetics is among, Hispanic, African Americans, Native Americans. Ms. S is Mexican and that increases her chances of having diabetes than in other races/ ethnicities. Behavioral Risk Factor Surveillance System (BRFSS) did surveys to determine the diabetes prevalence rate between Hispanic and non-Hispanic white males, (Morbidity and Mortality Weekly report, 2004).Prevalence of Diabetes among the Mexicans is not just due to the genetics, but also dietary habits, physical activity and other social economic factors.

Mexican dishes consist of food cooked in a lot of food and preference for fat meat products. Their methods of cooking food allow emphasize on frying rather than boiling or even baking. This increases the level of cholesterol and leads to obesity. Obesity increases the risk of developing Type II diabetes. The same applies to the female Latina. According to the San Antonio Heart Study, Mexicans have a two times higher risk of developing diabetes because of their genetic family history than non-Mexicans. Ms.S eats a diet full of a lot of carbohydrates (tortillas, toast, and rice) sugar in the coffee and fats in the sour cream. Her diet does not contain fruits, vegetables or fiber.

The Mexicans have a higher risk of developing diabetes Type II due to a shared a common genetic factor that affects insulin secretion and resistance. Approximately 10% of all Hispanic have diabetes, while the rest are twice likely to develop diabetes. The other risk factors among the Hispanic are obesity and physical in activity. There are variations in the prevalence for diabetes according to different socioeconomic levels. This affects the access to quality health care, which determines how well the person will be able to maintain the disease and treatment. This patient is of catholic belief, and this influences the way she responds to diagnosis and treatment. Hispanics believe that most events in life are as result of fate, and their control is out our hands. They believe that sickness is punishment from God, and the Catholic faith makes them believe in saints that they pray to for protection and healing.

According to Weller and Baer (1999), from a research done to describe Latino’s beliefs about diabetes they have varying beliefs about who is susceptible and the causes as shown in the following table.

*Only three sites agree: Mexico, Texas, and Connecticut

Symptoms and treatment of Diabetes were also varied in the study (Weller and Baer, 1999):

*Only three sites agree: Mexico, Texas, and Connecticut

The Christian faith influences their belief in western medicine and they will accept diagnoses for their ailments. A large number of Hispanics consult folk healers, especially those in the lower economic ladder that are not able to afford quality health care. They may take the folk healer’s medication and the western medication for those who can afford. The folk healers emphasize a lot on herbal treatments. According to a study done by Coronado, et al (2004), Hispanics have different views on the causes and treatment of Diabetes. To some of them diabetes is a very serious disease that can be cured by medication and change of lifestyle (more exercise and eating right). Their definition and description of the symptoms is like the clinical symptoms which are; thirst, hunger, sleepiness, tiredness etc.

However, it is believed that certain events in someone life trigger the diabetes, they are fright (susto), intense anger (coraje), or sadness and depression (tristeza). Most of the Hispanics will not take the scientific explanation regarding the diagnosis of the patient with Diabetes but will try to associate its present through a certain event (Coronado, et al, 2004). The patients need to know what is the cause of diabetes, and in case it is inherited. According to some research done by Carranza and LeBaron, interviewed 76 Mexicans Americans with Type II in Northern California, most had to be given insulin by the clinic and their explanation for the prescription by the clinic was, 28% attributed it to their lifestyle, 61% blamed susto while 32% attributed it to genetic reasons.

Most of the people, especially in native Mexico believe that they can control the disease with the use of local remedies and they don’t do any blood sugar monitoring. The management of diabetes is a burden to most families as they may not be able to make the necessary dietary changes that are needed in the treatment of the disease. Due to this guilt, some people choose to deal with it all alone so as not to burden the family. The cost for buying the medication and monitoring equipment is costly for those with low income, especially in the rural areas. With these cultural beliefs in place, its might be hard to convince the patient the importance of lifestyle changes to be able to deal with the disease.

Additional data needed for adequate assessment of the home environment and family structure. The family and the patient should give information of whether she has a history of cardiovascular disease. Cases of hypertension are common with diabetic patients and this determines the method plan for the treatment to be used. Most of the time, hypertensive and diabetics, benefit more from treatments that focus on the hyper tension. The other useful information from the family members would cover the following issues. Body mass indexes of all the members of the family are important and those with a high BMI of more than 25kg/m2 are at a high risk of diabetes. Do they do any physical activities or exercises and how often they do? If any of them have a history of delivering a baby weighing more than nine pounds. This information is used in calculating the risk score, to get the risk factor s for all the family members.

She says that she gets blurry vision; this can be caused by many things including diabetic retinopathy. Diabetic Retinopathy is a type of diabetic eye disease that is caused by the growth of abnormal cells in the retina. This causes damage to the blood cells in the retina. Once it is established that the blurry vision is caused by the fluctuation of the blood sugar, corrective measures can be taken to avoid deterioration of eye sight. Her medical history is also important as it gives a view of some of the infections she might have had. Viral infections like mumps & congenital rubella. Some toxin in the environment like vacor (rat poison) and other drugs impair insulin action. As stated earlier, social economic factors do contribute to the risk of the prevalence to diabetes. Lack of resources inhibits patient from getting the treatment they need and are not able to take care of themselves. It is therefore, important that the family be involved from diagnosis to the treatment process. When all the risk factors have been noted, I am able to determine the best method of glucose testing for the patient, to ensure the best results.

Pender’s Health Promotion Theory

No one likes to hear that that they have a condition that will stay with them for the rest of their life. The patient needs a system of adjusting and getting treatment that focuses on changing the patient’s lifestyle. With that in mind I have chosen Pender’s healthy promotion model. It defines health as a positive dynamic state not just absence of disease. This theory focuses on the individual characteristics, behavior specific cognition and behavioral outcomes (Pender, 1996). The health promotion model would work well with the patient’s treatment plan and would involve taking into consideration the modifying factors and cognitive perceptual factors.

The factors that can be modified are behavioral, situational, interpersonal and demographic. In behavioral factors the patient will change the previous habits that brought about the diabetes. She will exercise more, wear suitable shoes and take self-monitoring very seriously. Situational factors are those in the surrounding that determine how she does things. The first thing is life style change, where the patient and her family learn to cook healthier meals. When the patient continues eating with the family it part of the support system that they need and they should be encouraged to make dietary changes as a family. Interpersonal influences are the social support & expectations of other members of the community. She does belong to a community and their support and love for her will help her in adjusting to having this condition. When she is able to get help and the required resources to cope, adjustment to being diabetic is easier and faster. The demographic factors are age, gender, ethnic racial and educational background.

Cognitive –perceptual determine how the patients view the importance of their health will determine what health behavior they will modify to get the desired effects. Life style changes are brought about increased awareness and there being a suitable environment for the change to happen.

The patient has been living an unhealthy lifestyle that has put her at risk of developing diabetes, with proper health education she can know what she is doing wrong and learn new and better habits. Health behavior is the central focus on the health promotion model, because it what we seek to modify to get the desired health state. The patient is a lady who takes her health seriously, even though she has made some bad dietary choices. She monitors her glucose levels, though not consistently but takes her medication regularly. With good health education, she is able to control her diabetes by eating right, exercise and taking her medication. Her focus should be on getting the desired health behavior and protecting herself from situations that would make her health deteriorate.

Diabetes management

The components of diabetes management are education, nutritional therapy, exercises, monitoring blood sugar and taking medicine. Treatment of diabetes type two should start immediately after diagnosis of the disease, with the aim being to reduce chances of complications, changed lifestyle and control the blood sugar. In the initial 3months, the patient should see her physician and get information on what medication to take, an exercise program, blood pressure and a diabetes educator. At this stage, she should also get a dietician to help her do a proper diet plan that will help her reduce the blood sugars. The diabetes educator will be able to teach how to test and monitor blood sugar and how often she should do it. Between 3 and 6 months, she can get her A1 test that reveals blood sugar levels for the last 3 months. At this time, it would be wise to join a community diabetes class where she will be able to learn meal plans and how to handle complications that come along with diabetes. She should also increase her physical activity.

At 9 months, she should have made appointment s with the foot and eye doctor, to make sure that the diabetes has not interfered with those organs. By this time, she should be able to access her blood sugar goals. By the end of that year, she should be able to have controlled her blood sugar and can now adopt the new lifestyle habits. In details, the control of blood sugar is not that easy, but with the right information and guidance it is possible for Ms. to get it under control. It is important to check and record blood sugar levels several times during the week so that she can review them with her doctor. The patient should be able to understand different fluctuations of the blood sugar levels. The different levels can be caused by;

1. Fluctuation of hormones, due to illnesses or menopause may inhibit the insulin from functioning well and thus raising the blood sugar levels.
2. High intake of food increases the blood sugar which reaches its peak 2-3 hours after the meal.
3. Physical activity/ exercises actually avails the glucose to the body, thus lowering the blood sugar level.

The medications can either be orally taken or injected. They lower glucose production in the liver. The doctor may also prescribe some hypertension medication and aspirin. The insulin therapy may be used on some type 2 diabetes too.

Nutritional assessment

According to Gibson (2005), this is a set of medical tasks that determine the medical nutrition status of a given population. This is vital for the patient, and the family since treatment of Type II diabetes is composed of exercise, blood sugar management and probably medication. However, to control the blood sugar the client must monitor their nutrition habits. Nutritional assessment being done on the family and the patient provides the following;

• Food and nutrition history, which is determined by the food intake patterns. Food allergies and preferences are noted. Availability of food is also measured and the patient’s nutrition / health awareness. For this client, she lives alone and might not have strained budget to be able to get the entire nutritional requirement that will be recommended in the treatment plan. The son that lives in Mexico due to having one parent with diabetes is at a bigger risk of developing diabetes coupled with his Mexican ancestry. If he has not been diagnosed with diabetes yet, he should take all measures of eating right, and exercising.
• Anthropometric measurements give the height, weight, BMI, weight change rate and waist circumference. A high BMI indicates a sign of obesity which is a risk factor in developing obesity. If the weight of the patient is high, she will need to start exercising more since the 30mins walk does not seem to be working. Exercise will also prevent her from developing macro vascular diseases that are associated with women her age
• Mental state measured by accessing the patient’s and family willingness to change their eating habits and the attitude towards the disease. Most Mexicans, family is very important to them and their support in dealing with this newly diagnosed disease.
• Medical and health history is useful in nutritional assessment and their personal histories. For most patients that have diabetes they may have other preexisting conditions like high blood pressure, which will be useful in determining the right diet plan for the patient and for the rest of the family.

Nutritional Therapy

The diet for a diabetic person should be based on clinical research, potion control and life style change. This therapy main focus is how to increase the amount of energy supplied by carbohydrates and fats, while liberalizing sucrose consumption. According to the American Diabetes Association (2006), the main goals of nutritional therapy in relation to diabetes control are:

1. Getting and retaining optimal metabolic outcomes. This is through maintaining normal blood sugar levels, and reduced lipids while controlling the blood pressure.
2. The prevention and treatment of chronic diseases through Getting and retaining optimal metabolic outcomes.
3. Health promotion and improvement through increased physical activity through exercises and right food choices.

There is a misconception on the amount of Carbohydrates that a diabetic patient should take. Latina population, as mentioned earlier have strong beliefs on what causes and treatment for diabetes, therefore, it might be hard to hard to change the mind set by saying that they can eat certain food but in small portions. Carbohydrates are sugars, starch and fibers found in food they provide energy for the body to perform certain functions, however in type II diabetic patients, the amount they should aim to control fasting and post prandial glucose levels. It should form 60% of the caloric daily intake, while proteins form 12-20% and 30% fats.

Fiber is an important part of the diet as it slows down digestion and the patients has a feeling of being full and this lowers the blood sugar levels with more absorption of glucose in the body. When choosing foods high in fiber, the patient should choose those with high carbohydrates and fiber levels. Fats recommended amount is 25-33% of daily caloric intake, and the patient should take the healthy options like non saturated fats especially those from nuts, fish and vegetable oils. Proteins are very important in a diabetic patient’s diet; they cause relative insulin from protein breakdown and glucogenesis. Vitamins that promote oxidation should be part of the diet since they stress levels, therefore, lowering the blood pressure a symptom of diabetes. Minerals like sodium in table salt should be taken in moderation as they increase high blood pressure; the recommended dosage is 2400mg per day. Ms. S can still enjoy traditional Mexican food that is healthy, as long as she watches the potions. Here is a sample menu of what she can eat.

Nutritional Considerations for Mexicans, adapted from Karmeen, (2011)

Mexicans use folk healers and modern medicine in the treatment of their ailments and diseases. They use “hot “and “cold” foods in their treatments. Diabetes is a hot ailment and the patient who believes in folk healing may take aloe juice, cactus and sage teas. It is important to respect cultural beliefs concerning healing and diseases. When a patient gets the support they need to help cope with the disease they get better faster than others, and are on their path to recovery.

The treatment goals should be to reduce the blood sugar and maintain it at a proper level. According to the ADA the recommended levels are, HbA1c should be less than 6.5%, pre-prandial PG value at 90-130mg/dL and bed time prandial PG value 110-150 mg/dL. The key focus is regulating blood sugar, exercises and changed lifestyle especially making better diet choices. The medical management of the disease includes regular sugar monitoring, taking medication with attention to when to adjust medication and understanding complications that are likely to come along during the management of diabetes. Taking blood glucose levels should be done many time during the day, this especially when circumstance about the patient change. If they change to strenuous activity, this will in turn affect their blood sugar.

Ms. S had been monitoring her blood sugar even though not regularly as she is supposed to, and she can get diabetics education to learn the best way to go about it. There are various sites and methods to test the blood sugar levels; they are glucose meter and continuous glucose monitors. The glucose meters test the blood sugars with a drop of blood from fingertips and other from other sites. Continuous glucose monitors measure the glucose in between the cells and does not measure blood glucose directly. It takes sample readings from various places, analyzes and gives results every 1-5 minutes.

Lifestyle changes that the patient needs to make

The client needs to make better dietary choices for herself and her family. This includes increasing intake of unsaturated fats, proteins, vitamin and minerals all in the right potions. The second is the management of healthy weight in order to reduce insulin resistance, which in turn lowers blood sugar. By losing weight, the patient reduces chances of more complications like blood pressure.

Regular exercise avails glucose for conversion by the cells into energy so this lowers blood sugars. They also reduce the amount of insulin needed, therefore, reducing the burden on the pancreas. Exercises in the management of diabetes Type II should start once the blood sugar level stabilizes. The frequency differs but to begin with 3 times a week is good, with the intensity of 60-80% maximal heart rate. The duration also matters as those doing aerobics activities it should last 20 -30 minutes with a warm up of 5 -10 minutes. The level of intensity according to the American Diabetes Association (2006) is as shown below.

Levels of intensity are proportional to your maximal heart rate.

• Very Light…………<35%
• Light………………..35-54%
• Moderate………….55-69%
• Hard…………………70-89%
• Very Hard…………>90%
• Maximal……………100%

220-65 = 155 HR max <54 55-87 86-109 110-139 140-154 155 Target American Diabetes Association

The fourth, is wearing comfortable shoes to avoid chances of feet infection. Diabetes may damage nerves in the feet making them loose their sensitivity. This loss of sensitivity to the feet is known as neuropathy is caused by high blood sugars /unsteady sugar range. The patient has been wearing fitting sneakers and this needs to change, so she should wear comfortable leather shoes that allow free circulation of air to avoid infections or nerve damage to the feet. A mono filament is used to test the sensitivity of the foot. Feet care for diabetes patients is necessary as some time the diabetes causes insensitivity of the nerves and this can lead to a lot of damage on the feet as they cannot rely on the sensitivity to warn them of danger. It can also deprive oxygen from the feet by reduced blood flow to the feet and might deprive them of nutrients. Any blisters, sores or wound will therefore take longer to heal.

After the 1^st step of treating diabetes through diabetes education, monitoring blood sugar and making lifestyle changes, the second step may be addition of some medicine that normalizes blood glucose. The medications reduce the amount of glucose that the liver produces, increase insulin production and inhibit blood sugar absorption. Some of the medication may be taken with insulin. The benefits of having low blood sugars are numerous like reduction of insulin over the course of the day and slower digestion reduces the hunger pangs in the patient. High glucose levels have a negative effect on the patient’s health as they cause Loss of nerve action that could affect nerves and in turn digestion. The high blood sugar could lead to obesity and blurry vision.

Diabetes education and Self-management

The aspect of education involves teaching the patient how to understand and incorporate the disease into their live. The patient is trained on how to monitor blood sugar levels and management due to fluctuations. The patient is taught how to interpret the result she gets and how frequent she should do the blood sugar monitoring. This involves self-monitoring of blood sugar by the patient, she needs to know her blood sugar goals, carbohydrates count and the medication they are on. They gain knowledge through regular follow ups and reinforcement. The duration matters from one person to another and with the right attitude the patient will self-manage this disease. This is seen in change in lifestyle behavior. The patients make dietary changes, maintain a healthy weight and are physically active. These activities are not just to regulate the blood sugar and make diabetes management easier, but become part of they are. It becomes learned behavior.

Their psychological and improved outlook towards life improves. During the diabetes Education, the patients should be given success stories of people who have managed their diabetes and leading good lives. They get encouragement knowing that others went through similar situations and came out successful. There is complete elimination of cardio vascular risk factors like strokes& heart attacks in the patient. At the onset of diabetes, the patient had risk factors for both diabetes and cardio vascular diseases, by with improved self-care they eliminate all those factors and are able to live with diabetes. Once the patient learns self-management the trips to the emergency room reduce drastically and reduced medical bills. This become cost effective to manage a chronic illness, because unless one gets complications that affect others parts of the body they can be able to live healthy lives through good dietary habits, plenty of exercise and the medication provided by the doctor.

References

American Diabetes Association (2006). Standards of Medical Care in Diabetes. New York: Sage Publication:

Coronado, G.D, Thompson, B., Tejeda. S, Godina. R. (2004). Attitudes and beliefs among Mexican Americans about type 2 diabetes. J Health Care Poor Underserved, Volume No.15:576-588.

Gibson, R., S. (2005). Principles of Nutritional Assessment, 2^nd (End). Oxford: Oxford University Press

Goroll, A.H., Mulley, A.G. (2009). Primary Care Medicine: Office Evaluation and Management. New York: Lippincott Williams & Wilkins.

Karmeen, D.K. (2004). Food, Culture and Diabetes in the United States. Clinical Diabetes, Volume No.22 190-192.Pennesylvania.

National Health and Nutrition Examination Survey (2005-2008). Racial and Ethnic differences in diabetes. National Diabetes Information. Clearinghouse: MD

Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.). Stamford, CT: Appleton & Lange.

Weller, S., C &Baer, R.D. (2001).Intra- and Intercultural Variation in the Definition of Five Illnesses: AIDS, Diabetes, the Common Cold, Empacho, and Mal de Ojo. Cross cultural research, Volume 35 no.201-226.