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a
c.
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1.
I
NT
RO
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Diab
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is
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p
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s
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v
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ey
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k
id
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,
a
n
d
n
er
v
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[
1
]
.
T
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p
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o
m
in
a
n
t
k
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b
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th
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b
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[
2
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.
Ov
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p
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3
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y
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s
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th
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cc
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ac
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o
s
s
all
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co
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b
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k
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[
3
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.
Ap
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x
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4
2
2
m
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[
4
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.
Ad
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B
o
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p
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s
t f
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ad
es
[
5
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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e
l
ih
o
o
d
o
f
d
y
i
n
g
f
r
o
m
an
y
o
f
t
h
e
f
o
u
r
p
r
im
a
r
y
n
o
n
co
m
m
u
n
i
ca
b
le
d
is
ea
s
es
(
ca
r
d
io
v
as
cu
la
r
d
is
e
ases
,
c
an
ce
r
,
ch
r
o
n
ic
r
es
p
i
r
a
to
r
y
d
is
e
ases
,
o
r
d
i
a
b
et
es)
b
et
wee
n
th
e
a
g
es
o
f
3
0
an
d
7
0
d
ec
li
n
e
d
b
y
2
2
%
f
r
o
m
2
0
0
0
t
o
2
0
1
9
[
8
]
.
T
y
p
e
2
d
iab
etes
m
ellitu
s
is
a
p
ath
o
p
h
y
s
io
lo
g
ical
s
tate
in
wh
i
ch
in
ef
f
ec
tiv
e
ce
llu
lar
g
lu
c
o
s
e
u
tili
za
tio
n
,
s
tem
m
in
g
f
r
o
m
in
ad
e
q
u
ate
in
s
u
lin
ac
tio
n
,
lead
s
to
p
er
s
is
ten
tly
h
ig
h
lev
els
o
f
b
lo
o
d
g
lu
co
s
e.
T
h
e
p
ath
o
p
h
y
s
io
lo
g
y
o
f
t
y
p
e
2
d
i
ab
etes
in
v
o
lv
es
th
e
p
o
ten
tial
f
o
r
s
ig
n
if
ican
t
d
am
a
g
e
to
b
o
th
th
e
n
er
v
o
u
s
a
n
d
v
ascu
lar
s
y
s
tem
s
.
T
h
e
co
n
d
itio
n
'
s
d
ev
elo
p
m
en
t is m
u
ltifa
cto
r
ial,
with
p
r
im
ar
y
r
is
k
f
ac
to
r
s
in
clu
d
in
g
o
b
esit
y
,
a
s
ed
en
tar
y
life
s
ty
le,
an
d
g
en
etic
s
u
s
ce
p
tib
ilit
y
.
C
o
n
s
eq
u
en
tly
,
ea
r
ly
d
iag
n
o
s
is
th
r
o
u
g
h
r
eg
u
la
r
m
ed
ica
l
ex
am
in
atio
n
s
an
d
b
lo
o
d
s
cr
ee
n
in
g
s
is
c
o
n
s
id
er
ed
im
p
er
ativ
e
f
o
r
ef
f
ec
tiv
e
d
is
ea
s
e
m
an
ag
em
e
n
t.
T
h
e
p
r
ev
alen
ce
is
ab
o
u
t
9
5
%,
an
d
life
s
ty
le
m
o
d
if
icatio
n
s
lik
e
m
ain
tain
in
g
a
h
ea
lth
y
weig
h
t,
en
g
ag
in
g
in
r
eg
u
lar
p
h
y
s
ical
ac
tiv
ity
,
co
n
s
u
m
in
g
a
n
u
tr
itio
u
s
d
iet,
an
d
av
o
id
in
g
to
b
ac
co
u
s
e
ca
n
h
elp
p
r
e
v
en
t
o
r
p
o
s
tp
o
n
e
th
e
d
ev
elo
p
m
en
t
o
f
ty
p
e
2
d
iab
etes
[
9
]
.
I
n
ad
eq
u
ate
g
ly
ce
m
ic
co
n
tr
o
l
in
p
atien
ts
with
d
ia
b
etes
ca
n
p
r
ec
ip
itate
a
r
a
n
g
e
o
f
s
ev
er
e
ac
u
te
an
d
ch
r
o
n
ic
co
m
p
licatio
n
s
.
Acu
te
m
etab
o
lic
d
er
an
g
em
en
ts
in
clu
d
e
h
y
p
o
g
ly
ce
m
ia,
d
i
ab
etic
k
eto
ac
id
o
s
is
,
h
y
p
er
g
ly
ce
m
ic
h
y
p
e
r
o
s
m
o
lar
s
tate,
an
d
h
y
p
er
g
ly
ce
m
ic
d
ia
b
etic
co
m
a.
C
h
r
o
n
ic
co
m
p
licatio
n
s
ar
e
ty
p
ically
ca
teg
o
r
ized
b
y
th
e
s
ize
o
f
th
e
af
f
ec
ted
b
lo
o
d
v
ess
els.
Mic
r
o
v
ascu
lar
p
ath
o
l
o
g
ies
in
clu
d
e
n
ep
h
r
o
p
at
h
y
,
n
eu
r
o
p
ath
y
,
a
n
d
r
etin
o
p
ath
y
,
wh
ich
ca
n
lead
to
r
en
al
f
ailu
r
e
an
d
v
is
io
n
lo
s
s
.
Ma
cr
o
v
as
cu
lar
co
m
p
licatio
n
s
en
co
m
p
ass
co
n
d
itio
n
s
s
u
ch
as
co
r
o
n
ar
y
ar
te
r
y
d
is
ea
s
e
(
C
AD)
,
p
er
ip
h
er
al
ar
ter
y
d
i
s
ea
s
e
(
PAD)
,
an
d
ce
r
eb
r
o
v
ascu
lar
d
is
ea
s
e,
wh
ic
h
ar
e
m
ajo
r
co
n
tr
ib
u
to
r
s
to
ca
r
d
io
v
ascu
lar
ev
en
ts
an
d
lo
wer
lim
b
am
p
u
tatio
n
s
.
I
t'
s
cr
u
cial
to
ed
u
ca
te
p
atien
ts
ab
o
u
t
b
lo
o
d
g
l
u
co
s
e
co
n
tr
o
l,
life
s
ty
le
m
a
n
ag
em
en
t,
s
elf
-
m
o
n
ito
r
in
g
,
an
d
ce
s
s
atio
n
o
f
s
m
o
k
in
g
[
1
0
]
.
Diab
etes
m
ellitu
s
(
DM
)
with
in
ad
eq
u
ate
g
l
y
ce
m
ic
co
n
t
r
o
l
is
a
s
ig
n
if
ican
t
g
lo
b
a
l
h
ea
lth
is
s
u
e,
p
ar
ticu
lar
ly
af
f
ec
tin
g
th
o
s
e
r
esid
i
n
g
in
lo
w
-
an
d
m
id
d
le
-
in
co
m
e
n
atio
n
s
,
s
u
c
h
as
T
h
ailan
d
[
1
1
]
.
DM
n
eg
ativ
ely
im
p
ac
ts
th
e
ec
o
n
o
m
y
a
n
d
q
u
ality
o
f
life
f
o
r
i
n
d
iv
id
u
als an
d
th
eir
f
a
m
ilies
.
T
h
ailan
d
,
an
u
p
p
er
-
m
id
d
le
-
in
co
m
e
n
atio
n
,
h
as
a
h
ig
h
p
r
ev
alen
ce
o
f
DM
am
o
n
g
its
p
o
p
u
latio
n
,
with
9
.
6
%
o
f
t
h
o
s
e
ag
ed
3
0
an
d
o
ld
er
.
I
n
2
0
2
0
,
ar
o
u
n
d
5
m
illi
o
n
T
h
ais
wer
e
d
iag
n
o
s
ed
with
DM
[
7
]
.
T
h
e
o
cc
u
r
r
en
ce
o
f
d
ia
b
etes
m
ellitu
s
(
DM
)
in
th
e
T
h
ai
p
o
p
u
latio
n
was
1
0
.
8
%
am
o
n
g
th
o
s
e
ag
ed
2
0
y
ea
r
s
an
d
o
ld
er
.
Ad
d
itio
n
ally
,
th
e
o
v
er
all
in
ad
eq
u
ate
m
an
ag
em
en
t
o
f
b
lo
o
d
s
u
g
ar
lev
els
was
2
9
.
5
%,
with
2
3
.
9
%
a
m
o
n
g
m
ales
an
d
3
5
.
7
%
am
o
n
g
wo
m
en
.
Diab
etic
p
atien
ts
wh
o
h
a
v
e
lo
w
s
o
cio
ec
o
n
o
m
ic
le
v
els
an
d
lim
ited
ed
u
ca
tio
n
al
attain
m
en
t
a
r
e
m
o
r
e
li
k
ely
to
ex
p
er
ie
n
ce
in
ad
eq
u
ate
g
ly
ce
m
ic
co
n
tr
o
l
[
1
2
]
.
A
r
ev
iew
o
f
th
e
r
elev
an
t
liter
at
u
r
e
r
ev
ea
ls
s
ev
er
al
s
tu
d
ies,
b
o
th
g
lo
b
ally
an
d
with
in
T
h
ailan
d
,
th
at
h
av
e
ex
am
in
ed
th
e
ef
f
ec
tiv
e
n
ess
o
f
s
elf
-
m
an
ag
em
e
n
t
p
r
o
g
r
am
s
f
o
r
g
ly
ce
m
ic
co
n
tr
o
l.
Pro
g
r
am
s
f
o
cu
s
in
g
o
n
ed
u
ca
tio
n
a
n
d
s
o
cial
s
u
p
p
o
r
t
h
av
e
b
ee
n
f
o
u
n
d
to
s
ig
n
i
f
ican
tly
im
p
r
o
v
e
p
atie
n
ts
'
s
elf
-
ca
r
e
b
eh
a
v
io
r
s
,
as
s
u
p
p
o
r
ted
b
y
v
ar
io
u
s
r
esear
ch
[
1
3
]
.
I
n
th
e
T
h
ai
co
n
tex
t,
th
e
in
v
o
lv
em
e
n
t
o
f
v
illag
e
h
ea
lth
v
o
lu
n
teer
s
(
VHVs)
h
as
b
ee
n
id
en
tifie
d
as
a
cr
itical
f
ac
to
r
f
o
r
e
n
h
an
cin
g
p
ati
en
ts
'
d
iab
etes
m
an
ag
em
en
t
[
1
4
]
.
Ho
wev
er
,
t
h
er
e
r
em
ain
s
a
g
ap
in
th
e
lit
er
atu
r
e
r
eg
ar
d
in
g
th
e
ef
f
ec
tiv
en
ess
o
f
a
p
r
o
g
r
am
th
at
in
teg
r
ates
th
e
Kan
f
er
an
d
Gae
lick
-
B
u
y
s
s
elf
-
m
an
ag
em
en
t
f
r
am
e
wo
r
k
with
s
o
cial
s
u
p
p
o
r
t
f
r
o
m
v
o
lu
n
teer
s
,
s
p
ec
if
ically
with
in
th
e
co
n
tex
t
o
f
a
p
r
im
ar
y
ca
r
e
s
ettin
g
lik
e
a
s
u
b
d
is
tr
ict
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
it
al.
T
h
is
r
esear
ch
is
th
er
ef
o
r
e
s
ig
n
if
ican
t,
as
it
ex
p
lo
r
es
an
ap
p
r
o
ac
h
th
at
co
u
ld
in
f
o
r
m
t
h
e
d
e
v
elo
p
m
e
n
t
o
f
m
o
r
e
ef
f
ec
tiv
e
co
m
m
u
n
ity
-
b
ased
d
iab
etes
ca
r
e
s
y
s
tem
s
.
Kh
ao
R
ae
n
g
Su
b
d
is
tr
ict
Hea
lt
h
Pro
m
o
tin
g
Ho
s
p
ital
is
a
p
r
im
ar
y
ca
r
e
f
ac
ilit
y
th
at
p
r
io
r
iti
ze
s
m
ee
tin
g
th
e
n
ee
d
s
o
f
th
e
p
u
b
lic
an
d
o
f
f
er
in
g
h
ig
h
-
q
u
ality
,
f
o
u
r
-
d
im
en
s
io
n
al
s
er
v
ices.
Diab
etes,
wh
ich
is
th
e
lead
in
g
ca
u
s
e
o
f
o
u
tp
atien
t
tr
ea
tm
en
t
r
eq
u
ests
in
th
e
ar
ea
,
is
o
n
e
o
f
th
e
m
ajo
r
h
ea
lth
is
s
u
es,
an
d
th
e
p
r
ev
alen
ce
o
f
d
iab
etes
ap
p
ea
r
s
to
b
e
o
n
th
e
r
is
e.
T
h
e
s
tatis
tics
f
r
o
m
2
0
1
7
to
2
0
2
3
in
d
icate
th
e
f
o
llo
win
g
n
u
m
b
er
o
f
ca
s
es:
1
7
0
,
1
8
2
,
1
9
2
,
1
8
7
,
1
9
2
,
2
0
4
,
an
d
2
1
1
,
r
esp
ec
tiv
ely
.
T
h
e
r
e
ar
e
p
er
s
is
ten
t
s
tatis
tic
s
in
d
icatin
g
th
at
d
iab
etes
p
atien
ts
wh
o
ar
e
u
n
a
b
le
to
e
f
f
ec
tiv
ely
m
an
ag
e
th
eir
b
lo
o
d
s
u
g
ar
lev
e
ls
c
o
n
tin
u
e
to
e
x
p
er
i
en
ce
n
o
r
ed
u
ctio
n
i
n
th
eir
co
n
d
itio
n
.
T
h
e
n
u
m
b
er
s
ar
e
4
1
,
6
4
,
7
3
,
6
3
,
a
n
d
6
4
ca
s
es
f
r
o
m
2
0
1
7
t
o
2
0
2
1
.
B
lo
o
d
s
u
g
ar
lev
els
in
th
is
p
atien
t
g
r
o
u
p
ar
e
m
o
n
ito
r
ed
t
o
m
ain
tain
th
em
with
in
th
e
p
r
o
p
er
r
an
g
e.
Nev
er
th
eless
,
m
an
y
in
d
iv
id
u
als
with
d
iab
etes r
em
ain
in
ca
p
a
b
le
o
f
m
ain
tain
in
g
th
eir
b
lo
o
d
s
u
g
ar
lev
els with
in
th
e
n
o
r
m
al
r
an
g
e
.
T
h
is
is
d
u
e
to
th
ei
r
in
ab
ilit
y
to
ef
f
ec
tiv
ely
r
eg
u
late
th
eir
d
iets
an
d
p
h
y
s
ical
ac
tiv
ity
.
Desp
ite
th
e
p
r
esen
ce
o
f
p
u
b
l
ic
h
ea
lth
v
o
lu
n
tee
r
s
wh
o
p
r
o
v
i
d
e
ca
r
e,
a
d
ef
ici
en
cy
in
o
n
g
o
in
g
ca
r
e
p
er
s
is
ts
.
T
o
ef
f
ec
tiv
ely
m
an
ag
e
d
ia
b
etes,
in
d
iv
id
u
als
m
u
s
t
en
g
ag
e
i
n
o
n
g
o
in
g
tr
ea
tm
e
n
t
b
y
m
a
k
in
g
c
o
n
s
is
ten
t
ad
ju
s
tm
en
ts
to
s
elf
-
ca
r
e
b
e
h
av
io
r
s
lik
e
a
co
n
tr
o
lled
d
iet,
m
ed
icatio
n
u
s
e,
ex
er
cise,
an
d
s
tr
ess
m
an
ag
em
en
t.
Self
-
m
a
n
a
g
em
en
t
ca
n
h
el
p
p
r
ev
en
t
lo
n
g
-
ter
m
p
r
o
b
lem
s
an
d
p
r
o
m
o
te
c
o
g
n
itiv
e
p
r
o
ce
s
s
es,
d
ec
is
io
n
-
m
ak
in
g
,
g
o
al
-
s
ettin
g
,
an
d
co
llab
o
r
atio
n
with
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als.
T
h
is
ap
p
r
o
ac
h
h
as
p
r
o
v
en
ef
f
e
ctiv
e
in
m
an
ag
in
g
ch
r
o
n
ic
illn
ess
es
an
d
ca
n
b
e
in
co
r
p
o
r
ated
in
to
d
aily
r
o
u
tin
es
t
o
im
p
r
o
v
e
d
is
ea
s
e
co
n
tr
o
l
b
eh
av
io
r
[
1
5
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
7
3
8
-
1
7
4
6
1740
I
n
th
e
p
r
esen
t
d
a
y
,
th
e
co
n
c
e
p
t
o
f
s
elf
-
m
an
ag
e
m
en
t
p
r
o
g
r
a
m
s
f
o
r
in
d
iv
id
u
als
with
d
iab
etes
aim
s
to
en
h
an
ce
k
n
o
wled
g
e
an
d
s
k
ills
,
en
ab
lin
g
t
h
em
to
d
ev
el
o
p
s
tr
at
eg
ies
f
o
r
m
an
ag
in
g
s
y
m
p
to
m
s
,
tr
ea
tm
en
t,
life
s
ty
le
ch
an
g
es
,
an
d
em
o
tio
n
al,
p
s
y
c
h
o
lo
g
ical,
s
o
cial,
an
d
en
v
ir
o
n
m
en
tal
asp
ec
ts
o
f
th
e
d
is
ea
s
e,
th
er
eb
y
im
p
r
o
v
in
g
b
lo
o
d
s
u
g
ar
co
n
tr
o
l
[1
6
]
.
T
h
u
s
,
at
Kh
ao
R
ae
n
g
Su
b
d
is
tr
ict
Hea
lth
Pro
m
o
tin
g
Ho
s
p
ital
in
Mu
ea
n
g
Dis
tr
ict,
R
atch
ab
u
r
i
Pro
v
in
ce
,
th
e
r
esear
ch
er
h
as
ar
r
an
g
e
d
a
r
esear
ch
p
r
o
ject
o
n
th
e
im
p
ac
t
o
f
a
s
elf
-
m
an
ag
em
en
t
p
r
o
g
r
a
m
o
n
b
lo
o
d
s
u
g
a
r
c
o
n
tr
o
l b
eh
a
v
io
r
in
p
atien
ts
with
ty
p
e
2
d
iab
etes in
co
o
p
er
atio
n
w
ith
lo
ca
l a
u
th
o
r
ities
.
Du
e
to
o
u
r
ac
k
n
o
wled
g
m
e
n
t
o
f
th
e
s
ig
n
if
ican
ce
o
f
t
h
e
n
o
tio
n
o
f
s
elf
-
m
a
n
ag
em
e
n
t.
T
h
is
d
o
cu
m
en
t
s
er
v
es
as
a
r
ef
er
en
ce
f
o
r
en
h
an
ci
n
g
th
e
e
f
f
ec
tiv
en
ess
o
f
a
d
iab
etes
ca
r
e
s
y
s
tem
b
y
m
o
d
if
y
in
g
th
e
m
an
ag
em
en
t
o
f
b
l
o
o
d
s
u
g
ar
lev
els
in
in
d
iv
id
u
als
d
iag
n
o
s
ed
with
ty
p
e
2
d
iab
etes.
Ad
d
itio
n
ally
,
it
will
aid
in
th
e
p
r
ev
en
tio
n
o
f
d
iab
etes
-
r
elate
d
is
s
u
es
th
at
m
a
y
ar
is
e
i
n
th
e
p
atien
t.
E
n
h
an
ce
s
th
e
o
v
er
a
ll
well
-
b
ein
g
o
f
p
atien
ts
.
I
n
a
d
d
itio
n
to
allev
iatin
g
th
e
f
in
an
cial
b
u
r
d
e
n
o
f
m
ed
ica
l c
o
s
ts
.
2.
P
RO
P
O
SE
D
T
h
e
o
b
jectiv
es
o
f
th
is
s
tu
d
y
wer
e:
i
)
T
o
co
m
p
ar
e
th
e
s
elf
-
m
a
n
ag
em
en
t
b
eh
a
v
io
r
s
co
r
es
an
d
b
lo
o
d
s
u
g
ar
lev
els
o
f
ty
p
e
2
d
iab
etes
p
atien
ts
in
th
e
ex
p
er
im
e
n
tal
g
r
o
u
p
b
ef
o
r
e
an
d
af
ter
p
ar
ticip
atin
g
i
n
th
e
p
r
o
g
r
am
;
ii
)
T
o
co
m
p
ar
e
t
h
e
s
elf
-
m
an
a
g
em
en
t
b
eh
av
i
o
r
s
co
r
es
a
n
d
b
lo
o
d
s
u
g
ar
lev
els
b
etwe
en
th
e
e
x
p
er
i
m
en
tal
g
r
o
u
p
,
wh
ich
r
ec
eiv
ed
th
e
s
elf
-
m
an
ag
e
m
en
t
p
r
o
g
r
a
m
,
a
n
d
th
e
co
n
tr
o
l
g
r
o
u
p
,
wh
ich
r
ec
eiv
ed
s
tan
d
ar
d
ca
r
e.
Self
-
m
an
ag
e
m
en
t
b
eh
av
io
r
was
m
ea
s
u
r
ed
u
s
in
g
a
r
esear
ch
er
-
d
ev
elo
p
ed
q
u
esti
o
n
n
air
e
c
o
v
er
i
n
g
f
o
u
r
k
ey
d
o
m
ain
s
:
ad
h
er
en
ce
to
a
r
estricte
d
d
iet,
ap
p
r
o
p
r
iate
u
t
ilizatio
n
o
f
m
ed
icin
e
,
r
eg
u
lar
en
g
ag
em
e
n
t in
ex
er
cise,
a
n
d
e
f
f
ec
tiv
e
f
o
o
t c
ar
e.
3.
M
E
T
H
O
D
T
h
is
s
tu
d
y
is
q
u
asi
-
ex
p
er
im
en
tal
in
n
atu
r
e,
co
m
p
ar
in
g
two
g
r
o
u
p
s
b
ef
o
r
e
a
n
d
af
ter
th
e
in
ter
v
en
tio
n
.
T
h
e
ex
p
er
im
en
tal
g
r
o
u
p
will
b
e
ass
ig
n
ed
th
e
p
r
o
g
r
am
ac
c
o
r
d
in
g
to
th
e
r
esear
ch
er
'
s
d
is
cr
etio
n
.
T
h
e
co
n
tr
o
l
g
r
o
u
p
will
b
e
p
r
o
v
id
ed
with
s
tan
d
ar
d
n
u
r
s
in
g
ca
r
e.
T
h
e
d
u
r
a
tio
n
o
f
th
e
in
v
esti
g
atio
n
was
1
2
wee
k
s
.
Data
was
g
ath
er
ed
f
r
o
m
b
o
th
th
e
e
x
p
er
i
m
en
tal
an
d
co
n
tr
o
l g
r
o
u
p
s
p
r
i
o
r
to
an
d
f
o
llo
win
g
th
e
e
x
p
er
i
m
en
t
at
Kh
a
o
R
ae
n
g
Su
b
d
is
tr
ict
Hea
lth
Pro
m
o
tin
g
Ho
s
p
ital,
lo
ca
ted
in
Mu
ea
n
g
D
is
tr
ict,
R
atch
ab
u
r
i Pr
o
v
in
ce
.
T
h
e
s
tu
d
y
p
o
p
u
latio
n
co
n
s
is
ted
o
f
in
d
iv
i
d
u
als
with
ty
p
e
2
DM
r
ec
eiv
in
g
ca
r
e
at
Kh
ao
R
ae
n
g
Su
b
d
is
tr
ict
Hea
lth
Pro
m
o
tin
g
Ho
s
p
ital.
T
h
e
s
am
p
le
was
s
elec
ted
u
s
in
g
p
u
r
p
o
s
iv
e
s
am
p
lin
g
b
ased
o
n
th
e
estab
lis
h
ed
in
clu
s
io
n
cr
iter
ia.
Su
b
s
eq
u
en
tly
,
6
0
elig
ib
le
p
ar
ticip
an
ts
wer
e
allo
ca
ted
in
to
eit
h
er
th
e
ex
p
er
im
e
n
tal
g
r
o
u
p
o
r
th
e
c
o
n
tr
o
l
g
r
o
u
p
(
3
0
p
a
r
ticip
an
ts
ea
ch
)
u
s
in
g
s
i
m
p
le
r
an
d
o
m
s
am
p
lin
g
.
T
h
e
ex
p
er
im
en
tal
g
r
o
u
p
r
ec
eiv
ed
t
h
e
s
elf
-
m
a
n
ag
em
e
n
t
p
r
o
g
r
am
d
e
v
elo
p
e
d
b
y
th
e
r
esear
ch
er
f
o
r
1
2
wee
k
s
,
w
h
ile
th
e
co
n
tr
o
l
g
r
o
u
p
r
ec
eiv
ed
s
tan
d
ar
d
n
u
r
s
in
g
ca
r
e.
T
h
e
s
am
p
le
s
ize
was
ca
lcu
lated
with
f
r
ee
s
tatis
tical
s
o
f
twar
e
f
o
r
a
q
u
asi
-
ex
p
er
im
en
tal
d
esig
n
;
th
e
s
ig
n
if
ican
ce
lev
el
was
0
.
0
5
,
an
d
th
e
test
's
p
o
wer
was
ad
ju
s
ted
to
0
.
9
0
.
B
ased
o
n
th
e
m
ea
n
an
d
s
tan
d
ar
d
d
ev
iatio
n
o
f
two
g
r
o
u
p
s
f
r
o
m
a
p
r
e
v
io
u
s
s
tu
d
y
[
1
7
]
,
wh
ic
h
u
s
ed
co
m
p
ar
ab
le
v
ar
iab
les
an
d
r
esear
ch
d
esig
n
s
,
th
e
im
p
ac
t
s
ize
v
alu
e
was
esti
m
ated
to
b
e
0
.
8
1
2
4
;
3
0
p
ar
ticip
a
n
ts
in
ea
ch
g
r
o
u
p
wer
e
r
eq
u
ir
e
d
f
o
r
th
e
a
n
aly
s
is
,
af
ter
d
ed
u
ctin
g
1
0
% to
ac
c
o
u
n
t
f
o
r
a
n
y
s
tu
d
y
er
r
o
r
.
T
h
e
r
esear
ch
er
u
tili
ze
d
a
s
u
r
v
ey
d
esig
n
ed
b
y
t
h
em
to
g
ath
er
d
ata.
T
h
e
co
m
p
o
s
itio
n
co
m
p
r
is
ed
th
r
ee
co
m
p
o
n
en
ts
.
I
n
th
e
f
ir
s
t
s
ec
tio
n
,
a
to
tal
o
f
twelv
e
item
s
wer
e
em
p
lo
y
ed
to
g
ath
er
th
e
o
v
er
al
l
ch
ar
ac
ter
is
tics
o
f
th
e
p
ar
ticip
an
ts
.
Par
t
two
o
f
th
e
s
tu
d
y
in
v
o
l
v
ed
th
e
u
s
e
o
f
f
o
r
ty
-
t
h
r
ee
q
u
esti
o
n
s
to
g
ath
er
in
f
o
r
m
atio
n
o
n
k
n
o
wled
g
e,
p
e
r
ce
iv
ed
s
ev
er
ity
,
co
n
s
id
er
ed
s
u
s
ce
p
tib
ilit
y
,
p
er
ce
iv
ed
a
d
v
an
tag
es,
b
ar
r
ier
s
,
an
d
cu
es
to
ac
tio
n
r
elate
d
to
DM
.
Fo
r
p
ar
t
th
r
ee
,
a
to
tal
o
f
n
in
etee
n
q
u
esti
o
n
s
w
er
e
em
p
lo
y
e
d
to
g
ath
er
d
ata
o
n
s
elf
-
m
an
ag
em
e
n
t
b
eh
av
io
r
s
,
in
clu
d
in
g
ad
h
e
r
en
c
e
to
a
r
estricte
d
d
iet,
ap
p
r
o
p
r
i
ate
u
tili
za
tio
n
o
f
m
ed
icin
e,
r
e
g
u
lar
e
n
g
ag
e
m
en
t
i
n
ex
er
cise,
an
d
ef
f
ec
tiv
e
f
o
o
t
ca
r
e.
T
h
e
s
elf
-
m
a
n
ag
em
en
t
p
r
o
g
r
a
m
f
o
r
r
eg
u
latin
g
b
lo
o
d
g
lu
c
o
s
e
lev
el
s
in
in
d
iv
id
u
als
d
iag
n
o
s
ed
with
ty
p
e
2
d
iab
etes
en
c
o
m
p
ass
es
th
e
s
u
b
s
eq
u
en
t
ac
tiv
ities
:
in
f
o
r
m
atio
n
r
eg
ar
d
in
g
d
iab
etes,
d
ietar
y
p
r
o
v
is
io
n
s
f
o
r
d
iab
etics,
m
ed
icatio
n
,
p
h
y
s
ical
ac
tiv
ity
,
an
d
s
elf
-
m
a
n
ag
em
en
t
(
s
tr
ess
an
d
f
o
o
t
ca
r
e)
o
v
er
th
e
co
u
r
s
e
o
f
a
1
2
-
w
ee
k
g
o
al
-
s
ettin
g
p
er
io
d
u
tili
zin
g
th
e
s
elf
-
r
eg
u
latio
n
th
eo
r
y
.
Ut
ilize
b
lo
o
d
g
lu
co
s
e
m
o
n
ito
r
in
g
eq
u
ip
m
e
n
t
av
aila
b
le
at
th
e
Su
b
d
is
tr
ict
Hea
lth
Pro
m
o
tin
g
Ho
s
p
ital
to
ass
ess
b
lo
o
d
s
u
g
ar
lev
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Utilized
th
e
b
lo
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d
g
lu
co
s
e
m
o
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ito
r
in
g
e
q
u
ip
m
e
n
t
av
ailab
le
at
th
e
Su
b
d
i
s
tr
ict
Hea
lth
Pro
m
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tin
g
Ho
s
p
ital
to
ass
es
s
b
lo
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d
s
u
g
ar
le
v
els.
T
o
estab
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h
th
e
in
s
tr
u
m
e
n
t'
s
v
alid
ity
,
th
e
item
-
o
b
jectiv
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co
n
g
r
u
en
ce
(
I
OC
)
in
d
e
x
was
u
tili
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d
.
A
p
a
n
el
o
f
th
r
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x
ter
n
al
ex
p
er
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es
s
ed
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e
alig
n
m
en
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o
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ch
q
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tio
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item
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o
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I
tem
s
wer
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r
ed
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n
a
th
r
ee
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p
o
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t
s
ca
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-
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icate
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th
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was
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o
t
c
o
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g
r
u
en
t.
B
ef
o
r
e
b
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g
i
n
ter
p
r
et
ed
,
th
e
e
x
p
er
t r
atin
g
s
wer
e
c
o
m
b
in
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a
n
d
d
iv
id
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b
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th
r
ee
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Qu
esti
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item
s
wer
e
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em
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v
ed
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r
o
m
th
e
s
u
r
v
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y
if
t
h
eir
av
er
ag
e
s
co
r
e
was le
s
s
th
a
n
0
.
5
.
Prio
r
to
b
ein
g
in
clu
d
ed
in
t
h
e
q
u
esti
o
n
n
air
e,
q
u
esti
o
n
s
with
s
co
r
es
b
etwe
en
0
.
5
an
d
0
.
7
wer
e
r
ev
is
ed
.
T
h
e
f
in
al
v
er
s
io
n
o
f
th
e
q
u
esti
o
n
n
air
e
co
n
tain
ed
th
e
it
em
s
with
s
co
r
es
h
ig
h
er
th
an
0
.
7
.
T
h
ir
ty
p
er
s
o
n
s
wh
o
atten
d
ed
th
e
DM
clin
ic
at
Do
n
k
a
Su
b
-
d
is
tr
ict
Hea
lth
Pro
m
o
tin
g
H
o
s
p
ital
an
d
s
h
ar
e
d
s
im
ilar
ch
ar
ac
ter
is
tics
with
th
e
s
tu
d
y
g
r
o
u
p
wer
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
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lic
Hea
lth
Sci
I
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N:
2252
-
8
8
0
6
S
elf
-
ma
n
a
g
eme
n
t p
r
o
g
r
a
m
im
p
a
ct
o
n
typ
e
2
d
ia
b
etes b
lo
o
d
s
u
g
a
r
co
n
tr
o
l
(
C
h
o
n
tir
a
K
a
w
th
a
is
o
n
g
)
1741
in
clu
d
ed
in
th
e
q
u
esti
o
n
n
air
e'
s
p
ilo
t
s
tu
d
y
.
Du
r
in
g
th
is
s
tag
e,
a
n
an
aly
s
is
was
co
n
d
u
cted
t
o
as
s
ess
th
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f
ea
s
ib
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,
ap
p
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7
2
.
Af
ter
g
e
ttin
g
eth
ical
ap
p
r
o
v
al
f
r
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m
Mu
b
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h
o
m
b
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n
g
R
ajab
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at
Un
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er
s
ity
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c
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ct
th
is
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esear
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we
g
o
t
in
t
o
u
ch
with
th
e
d
ir
ec
to
r
o
f
th
e
s
u
b
-
d
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ict
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p
r
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m
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h
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d
d
is
cu
s
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ed
th
e
g
o
als
o
f
th
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tu
d
y
,
in
clu
d
in
g
th
e
i
n
ter
v
en
tio
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an
d
d
ata
co
llectio
n
.
On
th
e
d
a
y
o
f
d
ata
co
llectio
n
,
all
p
atien
ts
with
d
iab
etes
m
ellitu
s
ty
p
e
2
wer
e
in
v
ited
to
p
ar
tic
ip
ate
in
t
h
e
s
tu
d
y
v
o
lu
n
ta
r
ily
.
T
h
e
s
tu
d
y
o
b
jectiv
es,
in
ter
v
en
tio
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,
an
d
b
l
o
o
d
s
p
ec
im
en
co
llectio
n
p
r
o
ce
s
s
wer
e
ex
p
lain
e
d
to
th
o
s
e
wh
o
ex
p
r
ess
ed
in
ter
est
in
tak
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g
p
ar
t
in
t
h
e
r
esear
c
h
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Fo
llo
win
g
th
e
p
r
o
v
is
io
n
o
f
w
r
itten
in
f
o
r
m
ed
co
n
s
en
t,
p
ar
ti
cip
an
ts
co
m
p
leted
th
e
q
u
esti
o
n
n
air
e.
Descr
ip
tiv
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s
tatis
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r
e
u
s
ed
to
s
u
m
m
ar
ize
th
e
d
em
o
g
r
a
p
h
ic
ch
a
r
ac
ter
is
tics
o
f
th
e
s
am
p
le.
T
o
an
aly
z
e
th
e
in
ter
v
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tio
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'
s
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f
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th
e
W
ilco
x
o
n
Sig
n
ed
R
an
k
T
est
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em
p
lo
y
ed
t
o
co
m
p
ar
e
p
r
e
-
an
d
p
o
s
t
-
test
s
elf
-
m
an
ag
em
en
t
s
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r
es,
wh
ile
th
e
Ma
n
n
-
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h
itn
ey
U
T
est wa
s
u
s
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to
ass
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s
d
if
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er
en
ce
s
b
etwe
en
th
e
ex
p
e
r
im
en
tal
an
d
co
n
tr
o
l g
r
o
u
p
s
.
4.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
6
3
.
3
0
%
an
d
7
3
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3
0
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f
th
e
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ar
ticip
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ts
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n
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ex
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im
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s
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esp
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tiv
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e
p
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(
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3
0
%)
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f
th
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n
tr
o
l
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p
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ed
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5
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d
5
9
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e
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g
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0
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p
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ts
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l g
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p
,
5
6
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ar
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ied
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p
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th
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p
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tal
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8
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d
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6
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t
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ity
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f
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n
ts
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th
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o
n
tr
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l
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d
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p
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tal
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m
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leted
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n
d
ar
y
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ch
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l.
Mo
s
t
o
f
th
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n
tr
o
l
g
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p
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d
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n
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al
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p
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ch
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m
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en
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d
g
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r
(
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0
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0
0
%).
T
h
e
ex
p
e
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im
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tal
g
r
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p
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r
im
ar
ily
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tay
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m
e,
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ad
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p
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d
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n
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is
ted
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f
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er
s
(
6
0
.
0
0
%).
T
h
e
co
n
t
r
o
l
g
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o
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p
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in
co
m
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f
less
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an
5
,
0
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0
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a
h
t
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er
m
o
n
th
(
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3
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3
0
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ile
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e
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p
er
im
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tal
g
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p
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ad
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in
co
m
e
b
elo
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th
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t
h
r
esh
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ld
(
5
6
.
7
0
%).
B
o
th
g
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o
u
p
s
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ad
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n
s
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f
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icien
t
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ev
en
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e
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ee
t
th
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en
s
e
s
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T
h
e
m
ajo
r
ity
d
i
d
n
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t
h
av
e
a
n
y
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th
e
r
co
m
o
r
b
id
ities
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d
h
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d
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d
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f
o
r
m
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r
e
th
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f
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y
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r
s
.
Alm
o
s
t
all
o
f
th
em
h
a
v
e
n
e
v
er
u
s
ed
t
o
b
ac
co
p
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d
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cts
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h
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l.
Mo
s
t
o
f
th
em
f
in
d
it
d
if
f
icu
lt to
co
n
tr
o
l th
eir
b
lo
o
d
s
u
g
ar
lev
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in
a
n
o
r
m
al
r
an
g
e.
Pre
-
ex
p
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im
en
t
k
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o
wled
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r
eg
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d
in
g
DM
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al
y
ze
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,
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d
th
e
r
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lts
in
d
icate
d
th
at
th
e
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im
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tal
g
r
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p
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d
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h
ig
h
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f
k
n
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(
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6
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7
0
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co
m
p
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r
ed
to
t
h
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co
n
t
r
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l
g
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p
'
s
m
o
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er
ate
lev
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(
6
3
.
3
0
%).
Fo
llo
win
g
th
e
ex
p
e
r
im
en
t,
th
e
co
n
tr
o
l g
r
o
u
p
s
h
o
wed
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p
r
ed
o
m
in
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tly
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o
d
e
r
ate
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o
f
k
n
o
wled
g
e
r
eg
ar
d
in
g
DM
,
with
6
0
.
0
0
%.
I
n
co
n
tr
ast,
th
e
ex
p
e
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im
en
tal
g
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o
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h
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ited
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p
r
ed
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m
i
n
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tly
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ig
h
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f
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e
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eg
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d
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g
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(
8
6
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0
%)
,
as sh
o
wn
in
T
ab
le
1
.
B
e
f
o
r
e
t
h
e
e
x
p
e
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m
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t
,
t
h
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t
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r
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ef
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n
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3
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t,
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tr
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ile
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tr
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ited
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6
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h
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ch
in
g
9
6
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0
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as sh
o
wn
in
T
ab
le
4
.
C
o
m
p
ar
ativ
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aly
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is
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ican
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T
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m
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r
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o
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p
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e
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f
FP
G
co
n
tr
o
l
am
o
n
g
d
iab
etic
p
atien
ts
will
b
e
g
r
ea
ter
if
th
ey
en
g
ag
e
in
m
o
r
e
s
elf
-
m
an
ag
e
m
en
t
b
eh
av
io
r
s
.
Hea
lth
p
r
ac
titi
o
n
er
s
an
d
th
er
ap
is
ts
s
h
o
u
ld
m
ak
e
an
ef
f
o
r
t
to
u
tili
ze
s
elf
-
ca
r
e
tech
n
iq
u
es
in
a
way
th
at
co
m
p
lem
en
ts
o
th
e
r
th
e
r
ap
eu
tic
an
d
ed
u
ca
tio
n
al
a
p
p
r
o
ac
h
es.
I
m
p
r
o
v
in
g
life
q
u
ality
,
en
co
u
r
ag
in
g
s
elf
-
ca
r
e
,
an
d
lo
wer
in
g
b
lo
o
d
s
u
g
ar
l
ev
els
ar
e
th
e
m
ain
o
b
jectiv
es
,
esp
ec
ially
f
o
r
th
e
eld
er
ly
wh
o
d
o
n
'
t
p
r
ac
tice
s
elf
-
ca
r
e
[
2
6
]
.
Self
-
ca
r
e
is
a
p
u
r
p
o
s
ef
u
l
s
tr
ateg
y
f
o
r
p
r
eser
v
in
g
o
n
e'
s
p
h
y
s
ical,
em
o
tio
n
al,
an
d
m
en
tal
well
-
b
e
in
g
[
2
7
]
.
I
n
d
iv
id
u
als
s
u
f
f
e
r
in
g
f
r
o
m
ch
r
o
n
ic
illn
ess
es
m
ay
u
n
d
er
g
o
alter
atio
n
s
in
th
eir
o
v
er
all
well
-
b
ein
g
an
d
w
ay
o
f
life
.
Mo
d
if
y
in
g
y
o
u
r
d
ec
i
s
io
n
s
an
d
ac
tio
n
s
is
th
e
m
o
s
t
ad
v
an
tag
e
o
u
s
asp
ec
t
o
f
s
elf
-
ca
r
e.
T
h
ese
tech
n
iq
u
es
in
v
o
lv
e
o
v
er
s
ee
in
g
c
r
u
cial
elem
en
ts
s
u
ch
as
d
r
u
g
s
,
p
h
y
s
ical
ac
tiv
ity
,
n
u
tr
itio
n
,
s
leep
,
em
o
tio
n
al
s
tate,
m
e
d
ical
r
eso
u
r
ce
s
,
an
d
ca
r
e
g
iv
in
g
.
T
h
e
Am
er
ican
Diab
etes
Ass
o
ciatio
n
(
ADA)
r
ec
o
m
m
en
d
s
k
ey
d
ietar
y
m
o
d
if
icatio
n
s
f
o
r
m
an
ag
i
n
g
d
iab
e
tes,
in
clu
d
in
g
m
o
n
ito
r
in
g
ca
r
b
o
h
y
d
r
ate
an
d
f
ib
e
r
in
tak
e,
p
r
o
m
o
tin
g
weig
h
t
lo
s
s
,
an
d
r
ed
u
cin
g
th
e
co
n
s
u
m
p
tio
n
o
f
c
h
o
lest
er
o
l,
s
atu
r
ate
d
f
at,
tr
a
n
s
f
at,
a
n
d
s
o
d
iu
m
.
W
h
ile
th
ese
n
u
tr
itio
n
al
s
tr
ateg
ies
ar
e
f
u
n
d
am
en
tal
f
o
r
d
is
ea
s
e
m
an
ag
em
en
t,
ef
f
ec
tiv
e
tr
ea
tm
en
t
also
r
eq
u
ir
es
s
u
p
p
lem
en
tar
y
g
u
id
elin
es th
at
ac
co
u
n
t f
o
r
p
e
r
s
o
n
al
an
d
s
o
cial
f
a
cto
r
s
to
en
h
a
n
ce
p
atien
t
o
u
tco
m
es [
2
8
]
,
[
29
].
A
co
llab
o
r
ativ
e
h
ea
lth
p
r
o
m
o
t
io
n
in
ter
v
en
tio
n
eq
u
ip
p
e
d
wit
h
th
e
n
ec
ess
ar
y
c
o
m
p
eten
cies
s
h
o
u
ld
b
e
ass
ig
n
ed
to
ass
ess
th
e
n
ee
d
s
an
d
d
ev
elo
p
,
im
p
lem
e
n
t,
a
n
d
ev
alu
ate
r
elev
a
n
t
em
p
o
wer
m
e
n
t
p
r
o
g
r
am
s
at
th
e
h
o
u
s
eh
o
ld
a
n
d
co
m
m
u
n
ity
l
ev
els
[3
0
]
.
T
ea
m
-
b
ased
ca
r
e
(
T
B
C
)
is
a
p
atien
t
-
ce
n
ter
ed
,
m
u
ltid
is
cip
lin
ar
y
ap
p
r
o
ac
h
th
at
tailo
r
s
in
ter
v
e
n
tio
n
s
to
in
d
iv
id
u
al
p
atien
t
n
ee
d
s
,
co
n
s
id
er
in
g
f
ac
to
r
s
lik
e
h
ea
lth
liter
ac
y
,
b
eh
av
io
r
al
ca
p
ac
ity
,
an
d
clin
ic
al
s
ev
er
ity
.
T
h
is
m
o
d
el
is
a
s
s
o
c
iated
with
n
u
m
er
o
u
s
p
o
s
itiv
e
o
u
tco
m
es,
in
clu
d
in
g
en
h
an
ce
d
q
u
ality
o
f
life
,
im
p
r
o
v
ed
p
h
y
s
ical
an
d
m
en
tal
h
ea
lth
,
an
d
r
ed
u
ce
d
h
ea
lth
ca
r
e
u
tili
za
tio
n
,
s
u
ch
as
f
ewe
r
h
o
s
p
italizatio
n
s
an
d
em
er
g
e
n
cy
d
ep
ar
tm
e
n
t
v
is
its
.
Ad
d
itio
n
ally
,
T
B
C
h
as
b
ee
n
s
h
o
wn
to
m
o
d
estl
y
in
cr
ea
s
e
p
atien
t
s
atis
f
ac
tio
n
.
T
B
C
in
te
r
v
en
tio
n
s
f
ac
ilit
ate
in
cr
ea
s
ed
f
r
eq
u
e
n
cy
an
d
r
eg
u
lar
ity
o
f
i
n
ter
ac
t
io
n
s
b
etwe
en
p
atien
ts
an
d
h
ea
lth
ca
r
e
p
r
o
f
es
s
io
n
als,
th
er
eb
y
p
r
o
v
id
in
g
p
at
ien
ts
with
g
r
ea
ter
o
p
p
o
r
tu
n
itie
s
to
ad
d
r
ess
h
ea
lth
co
n
ce
r
n
s
[
1
3
]
.
T
h
e
f
i
n
d
in
g
s
u
g
g
ests
th
at
th
is
s
elf
-
m
an
ag
em
en
t
p
r
o
g
r
am
ca
n
b
e
im
p
lem
e
n
ted
b
y
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
in
th
e
co
m
m
u
n
it
y
to
ef
f
ec
tiv
ely
m
an
a
g
e
b
lo
o
d
s
u
g
ar
lev
els
am
o
n
g
ty
p
e
2
d
iab
etes
p
atien
ts
to
r
ed
u
ce
th
e
i
n
cid
en
ce
o
f
co
m
p
l
icatio
n
s
,
with
r
ig
o
r
o
u
s
an
d
c
o
n
tin
u
o
u
s
m
o
n
ito
r
in
g
o
f
b
eh
a
v
io
r
s
r
eq
u
ir
e
d
.
4
.
1
.
P
r
a
ct
ica
l i
m
pli
ca
t
io
ns
f
o
r
hea
lt
hca
re
pro
f
ess
io
na
ls
T
h
e
f
in
d
i
n
g
s
f
r
o
m
th
is
s
tu
d
y
o
f
f
er
s
ev
er
al
p
r
ac
tical
ap
p
licat
io
n
s
f
o
r
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
aim
in
g
to
im
p
r
o
v
e
c
o
m
m
u
n
ity
-
b
ase
d
d
iab
etes
ca
r
e:
i
)
Pro
g
r
a
m
ad
ap
tatio
n
an
d
im
p
lem
e
n
tatio
n
:
Hea
lth
ca
r
e
p
r
o
f
ess
io
n
als
ca
n
ad
ap
t
th
e
s
tr
u
ctu
r
e
o
f
th
is
s
elf
-
m
an
a
g
em
e
n
t
p
r
o
g
r
am
—
wh
ich
in
clu
d
es
ed
u
ca
tio
n
,
p
r
ac
tical
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
4
,
Dec
em
b
er
20
25
:
1
7
3
8
-
1
7
4
6
1744
tr
ain
in
g
,
g
o
al
-
s
ettin
g
,
an
d
f
o
llo
w
-
up
—
f
o
r
im
p
lem
en
tatio
n
i
n
o
th
er
p
r
im
ar
y
ca
r
e
s
ettin
g
s
t
o
em
p
o
wer
p
atien
ts
;
ii
)
E
m
p
h
asis
o
n
c
o
llab
o
r
ativ
e
g
o
al
-
s
ettin
g
:
T
h
e
g
o
al
-
s
ettin
g
p
r
o
ce
s
s
was
a
co
r
e
c
o
m
p
o
n
e
n
t
o
f
th
e
p
r
o
g
r
am
'
s
s
u
cc
ess
.
C
lin
ician
s
s
h
o
u
ld
f
ac
ilit
ate
co
llab
o
r
ativ
e
g
o
al
-
s
etti
n
g
with
p
atien
ts
,
h
elp
in
g
th
em
d
ef
in
e
m
ea
s
u
r
ab
l
e
an
d
ac
h
ie
v
ab
le
tar
g
ets
f
o
r
d
iet,
ex
er
cise,
an
d
s
elf
-
m
o
n
ito
r
in
g
;
ii
)
L
ev
e
r
ag
in
g
co
m
m
u
n
ity
h
ea
lth
v
o
lu
n
teer
s
:
T
h
e
s
u
p
p
o
r
t
f
r
o
m
v
illag
e
h
ea
lth
v
o
lu
n
teer
s
(
VHV
s
)
th
r
o
u
g
h
h
o
m
e
v
is
its
was
cr
u
cial
f
o
r
r
ein
f
o
r
cin
g
b
e
h
av
io
r
s
a
n
d
b
u
ild
in
g
p
atien
t
co
n
f
i
d
en
ce
.
Hea
lth
ca
r
e
s
y
s
tem
s
s
h
o
u
ld
in
v
est
in
tr
ain
in
g
an
d
em
p
o
wer
in
g
VHVs
to
ac
t
as
ess
en
tial
ex
ten
d
er
s
o
f
th
e
h
ea
l
th
ca
r
e
team
;
iv
)
Use o
f
s
elf
-
m
o
n
ito
r
in
g
to
o
ls
:
T
h
e
u
s
e
o
f
lo
g
b
o
o
k
s
a
n
d
p
er
s
o
n
al
b
lo
o
d
g
lu
co
s
e
m
o
n
ito
r
in
g
d
ev
i
ce
s
(
Dex
tr
o
s
tix
)
en
a
b
led
p
atien
ts
to
tr
ac
k
th
eir
o
wn
p
r
o
g
r
ess
an
d
u
n
d
er
s
tan
d
t
h
e
d
ir
ec
t im
p
ac
t
o
f
th
ei
r
b
e
h
av
io
r
s
.
Pro
f
ess
io
n
als s
h
o
u
ld
tr
ai
n
p
atien
ts
in
th
ese
s
k
ills
an
d
u
s
e
t
h
e
co
llected
d
ata
t
o
co
llab
o
r
ativ
ely
a
d
ju
s
t c
ar
e
p
la
n
s
.
T
h
e
s
tu
d
y
'
s
f
in
d
in
g
s
s
h
o
u
ld
b
e
in
ter
p
r
eted
in
lig
h
t
o
f
two
p
r
i
m
ar
y
lim
itatio
n
s
.
First,
d
u
e
to
b
u
d
g
etar
y
an
d
tem
p
o
r
al
co
n
s
tr
ain
ts
,
Hb
A1
c
lev
els
wer
e
n
o
t
m
ea
s
u
r
e
d
,
wh
ich
p
r
ev
e
n
ted
a
n
o
b
jectiv
e
ass
ess
m
en
t
o
f
g
ly
ce
m
ic
co
n
tr
o
l.
Seco
n
d
,
th
e
r
elian
ce
o
n
s
elf
-
r
ep
o
r
ted
d
ata
in
tr
o
d
u
ce
s
th
e
p
o
ten
tial
f
o
r
r
e
ca
ll
b
ias
an
d
s
o
cia
l
d
esira
b
ilit
y
b
ias.
I
n
ad
d
itio
n
,
a
co
m
p
ar
is
o
n
an
al
y
s
is
o
f
Hb
A1
c
v
alu
es
o
u
g
h
t
to
b
e
in
clu
d
e
d
in
f
u
tu
r
e
r
esear
c
h
.
W
e
s
h
o
u
ld
ca
r
r
y
o
u
t
lo
n
g
-
ter
m
f
o
llo
w
-
u
p
s
tu
d
ies
o
n
s
el
f
-
m
an
ag
em
en
t
b
e
h
av
io
r
to
g
u
a
r
an
tee
ef
f
ec
tiv
e
n
ess
.
E
v
alu
atin
g
im
p
r
o
v
e
m
en
ts
in
b
lo
o
d
s
u
g
ar
co
n
tr
o
l a
n
d
s
elf
-
m
a
n
ag
em
en
t
p
r
ac
tices is
th
e
g
o
al
.
5.
CO
NCLU
SI
O
N
T
h
e
d
iab
etic
s
elf
-
m
an
ag
em
en
t
p
r
o
g
r
am
s
p
ec
if
ically
tar
g
ets
th
e
b
eh
av
io
r
al
asp
ec
ts
o
f
b
lo
o
d
s
u
g
ar
co
n
tr
o
l
in
in
d
iv
id
u
als
d
iag
n
o
s
ed
with
ty
p
e
2
d
iab
etes.
W
o
r
k
s
h
o
p
s
ar
e
av
ailab
le
to
o
f
f
er
ed
u
ca
tio
n
an
d
p
r
ac
tical
tr
ain
in
g
in
a
r
a
n
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d
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m
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r
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s
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ab
l
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atien
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etr
iev
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it
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o
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ad
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itio
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aly
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is
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tiv
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tr
u
ctu
r
e
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p
h
asizes
th
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r
ac
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o
f
s
elf
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m
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t
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ch
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al
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s
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d
d
ata
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ath
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g
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f
o
r
p
atien
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p
r
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am
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esig
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r
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v
e
p
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elf
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m
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th
r
o
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g
h
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r
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s
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h
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p
r
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ce
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s
in
clu
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tag
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in
f
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m
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s
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elf
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d
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en
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B
y
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g
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in
g
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th
is
p
r
o
g
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am
,
p
ar
ticip
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ts
with
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g
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ed
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g
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ap
p
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f
o
r
p
r
o
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tiv
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l
th
m
an
a
g
em
en
t.
T
h
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ac
q
u
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o
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ic
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n
tr
i
b
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y
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atin
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ef
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p
ly
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Kan
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Gae
lick
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u
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s
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m
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em
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f
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am
ewo
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k
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o
c
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u
p
p
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t f
r
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m
h
ea
lth
v
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lu
n
teer
s
in
a
T
h
ai
p
r
im
a
r
y
ca
r
e
c
o
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tex
t
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ap
p
r
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h
th
at
h
as
b
ee
n
u
n
d
er
ex
p
lo
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ed
.
T
h
e
f
in
d
in
g
s
em
p
h
asize
th
at
em
p
o
wer
in
g
p
atien
ts
to
s
et
g
o
als
an
d
s
elf
-
m
o
n
ito
r
is
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k
ey
s
tr
ateg
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f
o
r
im
p
r
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v
in
g
g
ly
ce
m
ic
co
n
tr
o
l,
d
is
tin
g
u
is
h
in
g
th
is
in
ter
v
en
tio
n
f
r
o
m
tr
ad
iti
o
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al,
d
id
ac
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h
ea
lth
ed
u
ca
tio
n
m
o
d
els.
B
ased
o
n
th
is
s
tu
d
y
'
s
lim
itatio
n
s
,
s
ev
er
al
r
e
c
o
m
m
en
d
atio
n
s
f
o
r
f
u
tu
r
e
r
esear
ch
ar
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p
r
o
p
o
s
ed
:
i
)
L
o
n
g
-
ter
m
f
o
llo
w
-
u
p
s
tu
d
ies
s
h
o
u
ld
b
e
co
n
d
u
cted
to
ass
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th
e
s
u
s
t
ain
ab
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o
f
s
elf
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m
an
a
g
em
en
t
b
eh
av
io
r
s
an
d
th
ei
r
ef
f
ec
ts
o
v
er
tim
e;
ii
)
Fu
tu
r
e
r
e
s
ea
r
ch
s
h
o
u
ld
in
c
o
r
p
o
r
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b
je
ctiv
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clin
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in
d
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s
,
s
u
ch
as Hb
A1
c
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o
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ev
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p
r
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r
am
'
s
im
p
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o
n
g
ly
ce
m
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co
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tr
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l;
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Stu
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AUTHO
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DATA AV
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RE
F
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E
NC
E
S
[
1
]
A
.
S
y
a
r
i
p
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,
K
a
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n
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f
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p
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s
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n
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o
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:
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c
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y
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.
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.
3
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2
2
,
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0
2
3
,
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o
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:
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0
.
5
4
7
8
3
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c
.
v
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.
7
5
0
.
[
2
]
B
.
C
h
e
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.
,
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s,
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[
3
]
S
.
L
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Jame
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e
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.
,
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l
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d
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b
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l
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ses
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d
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j
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f
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5
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u
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t
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s
a
n
d
t
e
r
r
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t
o
r
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s,
1
9
9
0
–
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0
1
7
:
a
s
y
st
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ma
t
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c
a
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a
l
y
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s
f
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l
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l
B
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D
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t
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0
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7
,
”
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h
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L
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o
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:
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1
0
1
6
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0
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4
0
-
6
7
3
6
(
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8
)
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2
2
7
9
-
7.
[
4
]
M
.
S
i
n
g
h
,
O
.
B
.
A
d
a
me
,
M
.
N
i
c
k
a
s,
J
.
R
o
b
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s
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,
C
.
K
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t
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a
n
,
a
n
d
V
.
V
e
n
k
e
t
a
r
a
ma
n
,
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T
y
p
e
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d
i
a
b
e
t
e
s
c
o
n
t
r
i
b
u
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s
t
o
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l
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d
a
d
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t
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n
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p
o
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s a
n
d
v
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sc
u
l
a
r
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f
l
a
mm
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t
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n
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Fr
o
n
t
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m
m
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2
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3
3
8
9
/
f
i
mm
u
.
2
0
2
2
.
8
3
3
3
5
5
.
[
5
]
L.
R
y
d
é
n
e
t
a
l
.
,
“
ESC
G
u
i
d
e
l
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d
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s,
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sc
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l
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o
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l
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b
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w
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t
h
t
h
e
EA
S
D
:
Th
e
T
a
s
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d
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a
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s,
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a
n
d
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l
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E
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u
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rt
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o
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l
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4
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o
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3
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7
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3
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d
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:
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1
0
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3
/
e
u
r
h
e
a
r
t
j
/
e
h
t
1
0
8
[
6
]
O
EC
D
a
n
d
W
o
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l
d
H
e
a
l
t
h
O
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g
a
n
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z
a
t
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n
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e
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G
l
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n
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e
:
A
si
a
/
P
a
c
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f
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c
2
0
2
2
:
M
e
a
s
u
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p
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t
o
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sal
h
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a
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t
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c
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v
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g
e
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O
EC
D
,
2
0
2
2
,
d
o
i
:
1
0
.
1
7
8
7
/
c
7
4
6
7
f
6
2
-
e
n
.
[
7
]
T.
V
o
s
e
t
a
l
.
,
“
G
l
o
b
a
l
,
r
e
g
i
o
n
a
l
,
a
n
d
n
a
t
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l
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n
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r
s l
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v
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d
w
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d
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sa
b
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t
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f
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r
3
2
8
d
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s a
n
d
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r
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s f
o
r
1
9
5
c
o
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t
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1
9
9
0
–
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0
1
6
:
A
s
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st
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B
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D
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6
,
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a
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t
,
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9
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6
7
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6
(
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)
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2
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5
4
-
2
.
[
8
]
P
.
P
a
h
o
l
p
a
k
,
“
W
h
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t
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s
d
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a
b
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l
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man
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d
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p
p
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t
?
,
”
V
a
j
i
r
a
Me
d
i
c
a
l
J
o
u
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l
:
J
o
u
rn
a
l
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f
U
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M
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e
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l
.
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7
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o
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p
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8
8
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3
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:
1
0
.
1
4
4
5
6
/
v
mj
.
2
0
2
3
.
2
2
.
[
9
]
U
.
G
a
l
i
c
i
a
-
G
a
r
c
i
a
e
t
a
l
.
,
“
P
a
t
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p
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y
s
i
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l
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y
o
f
T
y
p
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D
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a
b
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M
e
l
l
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t
u
s,
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n
t
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rn
a
t
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n
a
l
J
o
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l
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M
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3
3
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j
ms2
1
1
7
6
2
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5
.
[
1
0
]
P
.
F
a
r
m
a
k
i
,
C
.
D
a
mas
k
o
s,
N
.
G
a
r
mp
i
s,
A
.
G
a
r
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,
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.
S
a
v
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n
i
s,
a
n
d
E
.
D
i
a
man
t
i
s
,
“
C
o
m
p
l
i
c
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t
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s o
f
t
h
e
t
y
p
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d
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t
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m
e
l
l
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t
u
s
,
”
C
u
rr
e
n
t
C
a
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d
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y
Re
v
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e
w
s
,
v
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l
.
1
6
,
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o
.
4
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p
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2
4
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0
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1
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:
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2
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7
4
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7
3
4
0
3
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1
6
0
4
2
0
1
2
2
9
1
1
5
5
3
1
.
[
1
1
]
R
.
E
k
n
i
t
h
i
se
t
a
n
d
R
.
S
a
mr
o
n
g
t
h
o
n
g
,
“
Ef
f
e
c
t
i
v
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n
e
ss
o
f
a
d
i
a
b
e
t
e
s
me
l
l
i
t
u
s
p
i
c
t
o
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i
a
l
d
i
a
r
y
h
a
n
d
b
o
o
k
p
r
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g
r
a
m
f
o
r
mi
d
d
l
e
-
a
g
e
d
a
n
d
e
l
d
e
r
l
y
t
y
p
e
2
d
i
a
b
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t
e
s
me
l
l
i
t
u
s
p
a
t
i
e
n
t
s
:
A
q
u
a
si
-
e
x
p
e
r
i
me
n
t
a
l
s
t
u
d
y
a
t
T
a
l
a
d
n
o
i
P
r
i
mar
y
C
a
r
e
U
n
i
t
,
S
a
r
a
b
u
r
i
,
T
h
a
i
l
a
n
d
,
”
J
o
u
r
n
a
l
o
f
Mu
l
t
i
d
i
sc
i
p
l
i
n
a
ry
H
e
a
l
t
h
c
a
re
,
v
o
l
.
1
0
,
p
p
.
3
2
7
–
3
3
4
,
2
0
1
7
,
d
o
i
:
1
0
.
2
1
4
7
/
J
M
D
H
.
S
1
3
8
8
1
5
.
[
1
2
]
W
.
A
e
k
p
l
a
k
o
r
n
e
t
a
l
.
,
“
E
v
a
l
u
a
t
i
o
n
o
f
a
c
o
mm
u
n
i
t
y
-
b
a
se
d
d
i
a
b
e
t
e
s
p
r
e
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n
t
i
o
n
p
r
o
g
r
a
m
i
n
T
h
a
i
l
a
n
d
:
A
c
l
u
st
e
r
r
a
n
d
o
m
i
z
e
d
c
o
n
t
r
o
l
l
e
d
t
r
i
a
l
,
”
J
o
u
r
n
a
l
o
f
Pr
i
m
a
r
y
C
a
r
e
&
C
o
m
m
u
n
i
t
y
H
e
a
l
t
h
,
2
0
1
9
,
d
o
i
:
1
0
.
1
1
7
7
/
2
1
5
0
1
3
2
7
1
9
8
4
7
3
7
4
.
[
1
3
]
T.
W
.
Le
v
e
n
g
o
o
d
e
t
a
l
.
,
“
T
e
a
m
-
b
a
se
d
c
a
r
e
t
o
i
m
p
r
o
v
e
d
i
a
b
e
t
e
s
ma
n
a
g
e
m
e
n
t
:
A
c
o
mm
u
n
i
t
y
g
u
i
d
e
met
a
-
a
n
a
l
y
s
i
s,
”
Am
e
ri
c
a
n
J
o
u
r
n
a
l
o
f
Pre
v
e
n
t
i
v
e
M
e
d
i
c
i
n
e
,
v
o
l
.
5
7
,
n
o
.
1
,
p
p
.
e
1
7
–
e
2
6
,
2
0
1
9
,
d
o
i
:
1
0
.
1
0
1
6
/
j
.
a
m
e
p
r
e
.
2
0
1
9
.
0
2
.
0
0
5
.
[
1
4
]
S
.
S
a
n
i
t
k
l
a
n
g
,
S
.
La
g
a
m
p
a
n
,
a
n
d
P
.
P
i
c
h
a
y
a
p
i
n
y
o
,
“
Ef
f
e
c
t
s
o
f
a
s
e
l
f
-
ma
n
a
g
e
men
t
n
u
r
s
i
n
g
s
u
p
p
o
r
t
p
r
o
g
r
a
m
w
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t
h
h
e
a
l
t
h
c
a
r
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v
o
l
u
n
t
e
e
r
s
f
o
r
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n
su
l
i
n
d
e
p
e
n
d
e
n
t
t
y
p
e
2
d
i
a
b
e
t
e
s
mel
l
i
t
u
s
p
a
t
i
e
n
t
s,
”
T
h
a
i
J
o
u
r
n
a
l
o
f
P
u
b
l
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c
H
e
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l
t
h
,
v
o
l
.
5
2
,
n
o
.
3
,
p
p
.
2
0
5
–
2
2
1
,
2
0
2
2
.
[
1
5
]
M
.
D
.
A
d
u
,
U
.
H
.
M
a
l
a
b
u
,
A
.
E.
O
.
M
a
l
a
u
-
A
d
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l
i
,
a
n
d
B
.
S
.
M
a
l
a
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-
A
d
u
l
i
,
“
E
n
a
b
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e
r
s
a
n
d
b
a
r
r
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e
r
s
t
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f
f
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t
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v
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d
i
a
b
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s
se
l
f
-
man
a
g
e
me
n
t
:
A
mu
l
t
i
-
n
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t
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o
n
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l
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n
v
e
s
t
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g
a
t
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o
n
,
”
PLo
S
.
O
N
E
.
,
v
o
l
.
1
4
,
n
o
.
6
,
p
p
.
e
0
2
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