I
nte
rna
t
io
na
l J
o
urna
l o
f
P
u
bli
c
H
ea
lt
h Science
(
I
J
P
H
S)
Vo
l.
15
,
No
.
2
,
J
u
n
e
2
0
2
6
,
p
p
.
378
~
3
8
8
I
SS
N:
2
2
5
2
-
8
8
0
6
,
DOI
: 1
0
.
1
1
5
9
1
/ijp
h
s
.
v
1
5
i2
.
2
7
0
3
4
378
J
o
ur
na
l ho
m
ep
a
g
e
:
h
ttp
:
//
ijp
h
s
.
ia
esco
r
e.
co
m
Dev
elo
pment of
a supp
o
rtive
-
e
duca
tive hea
lth
educat
io
n
interventio
n
f
o
r
f
a
mily
careg
iv
ers o
f
dia
betes
mellit
us pa
tient
s
:
a
quas
i
-
ex
p
erime
ntal study
Siti
F
a
t
o
na
h,
Su
la
s
t
ri,
Yuni
a
s
t
ini
D
e
p
a
r
t
me
n
t
o
f
N
u
r
si
n
g
,
P
o
l
t
e
k
k
e
s
K
e
men
k
e
s
Ta
n
j
u
n
g
k
a
r
a
n
g
,
B
a
n
d
a
r
La
m
p
u
n
g
,
I
n
d
o
n
e
si
a
Art
icle
I
nfo
AB
S
T
RAC
T
A
r
ticle
his
to
r
y:
R
ec
eiv
ed
Feb
2
3
,
2
0
2
6
R
ev
is
ed
Ma
y
2
0
,
2
0
2
6
Acc
ep
ted
Ma
y
2
2
,
2
0
2
6
De
sp
it
e
g
ro
win
g
e
v
id
e
n
c
e
o
n
fa
m
il
y
in
v
o
lv
e
m
e
n
t
in
d
iab
e
t
e
s
m
a
n
a
g
e
m
e
n
t,
fe
w
stu
d
i
e
s
h
a
v
e
d
e
v
e
lo
p
e
d
a
n
d
te
st
e
d
st
ru
c
tu
r
e
d
e
d
u
c
a
t
io
n
a
l
p
ro
g
r
a
m
s
targ
e
ti
n
g
f
a
m
il
y
c
a
r
e
g
iv
e
r
s
a
s
a
c
ti
v
e
c
o
m
p
a
n
io
n
s
in
r
e
so
u
r
c
e
-
li
m
i
ted
se
tt
in
g
s.
Th
i
s
stu
d
y
a
im
e
d
to
e
v
a
lu
a
t
e
th
e
e
ff
e
c
ti
v
e
n
e
s
s
o
f
a
c
o
m
p
re
h
e
n
s
iv
e
fa
m
il
y
su
p
p
o
r
t
e
d
u
c
a
t
io
n
p
ro
g
r
a
m
b
a
s
e
d
o
n
th
e
fiv
e
p
il
la
rs
o
f
d
i
a
b
e
te
s
m
e
ll
it
u
s
(DM
)
m
a
n
a
g
e
m
e
n
t
in
e
n
h
a
n
c
in
g
f
a
m
il
y
k
n
o
wl
e
d
g
e
a
n
d
e
d
u
c
a
ti
o
n
a
l
su
p
p
o
rt
c
a
p
a
c
it
y
.
A
q
u
a
si
-
e
x
p
e
ri
m
e
n
t
a
l
d
e
sig
n
with
n
o
n
-
p
ro
b
a
b
il
it
y
sa
m
p
l
in
g
w
a
s
e
m
p
lo
y
e
d
,
in
v
o
lv
in
g
1
5
7
r
e
sp
o
n
d
e
n
t
s
(in
t
e
rv
e
n
ti
o
n
g
ro
u
p
:
7
2
;
c
o
n
t
ro
l
g
ro
u
p
:
8
5
).
S
o
c
i
a
l
su
p
p
o
rt
w
a
s
m
e
a
su
r
e
d
u
sin
g
a
m
o
d
if
ied
D
iab
e
t
e
s
S
o
c
i
a
l
S
u
p
p
o
rt
Qu
e
st
io
n
n
a
i
re
-
F
a
m
il
y
.
Da
ta
w
e
r
e
a
n
a
ly
z
e
d
u
sin
g
in
d
e
p
e
n
d
e
n
t
a
n
d
p
a
i
re
d
t
-
te
st
s.
Th
e
in
t
e
rv
e
n
ti
o
n
g
ro
u
p
d
e
m
o
n
str
a
t
e
d
a
s
ig
n
ifi
c
a
n
t
in
c
r
e
a
s
e
in
m
e
a
n
e
d
u
c
a
ti
o
n
a
l
su
p
p
o
rt
s
c
o
r
e
s
fro
m
6
1
.
8
1
to
9
0
.
8
5
(
m
e
a
n
d
iff
e
r
e
n
c
e
=
2
9
.
0
4
;
p
<
0
.
0
0
1
;
Co
h
e
n
'
s
d
=
1
.
8
2
),
in
d
i
c
a
ti
n
g
a
l
a
rg
e
e
f
fe
c
t
s
iz
e
.
Th
e
c
o
n
tro
l
g
ro
u
p
sh
o
w
e
d
n
e
g
li
g
ib
l
e
c
h
a
n
g
e
s
.
P
o
o
r
k
n
o
wl
e
d
g
e
d
e
c
re
a
s
e
d
fro
m
4
5
.
8
%
to
2
6
.
3
9
%
in
th
e
in
te
rv
e
n
t
io
n
g
ro
u
p
,
wh
il
e
in
t
e
r
m
e
d
i
a
t
e
k
n
o
wl
e
d
g
e
in
c
r
e
a
s
e
d
su
b
st
a
n
ti
a
ll
y
.
T
h
e
stru
c
tu
re
d
f
a
m
il
y
e
d
u
c
a
ti
o
n
p
ro
g
ra
m
p
ro
d
u
c
e
d
a
l
a
rg
e
a
n
d
st
a
ti
sti
c
a
ll
y
sig
n
if
ic
a
n
t
i
m
p
ro
v
e
m
e
n
t
in
c
a
re
g
iv
in
g
c
a
p
a
c
it
y
.
Th
e
s
e
fin
d
in
g
s
u
n
d
e
rs
c
o
r
e
th
e
n
e
e
d
fo
r
p
u
b
li
c
h
e
a
l
th
p
o
li
c
i
e
s
to
in
t
e
g
r
a
t
e
f
a
m
il
y
-
c
e
n
t
e
r
e
d
e
d
u
c
a
ti
o
n
a
l
in
te
rv
e
n
t
io
n
s
in
to
ro
u
ti
n
e
d
i
a
b
e
te
s
c
a
r
e
,
p
a
r
ti
c
u
la
rly
in
s
e
tt
in
g
s
w
i
th
li
m
it
e
d
h
e
a
lt
h
c
a
re
in
fr
a
stru
c
tu
re
,
to
re
d
u
c
e
d
is
e
a
s
e
b
u
rd
e
n
a
n
d
i
m
p
ro
v
e
p
a
ti
e
n
t
o
u
tco
m
e
s.
K
ey
w
o
r
d
s
:
Diab
etes m
ellitu
s
E
d
u
ca
tio
n
al
in
ter
v
en
tio
n
Fam
ily
ca
r
eg
iv
er
s
Qu
asi
-
ex
p
er
im
en
tal
s
tu
d
y
So
cial
s
u
p
p
o
r
t
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
Sit
i Fato
n
ah
Dep
ar
tm
en
t o
f
Nu
r
s
in
g
,
Po
lte
k
k
es Ke
m
en
k
es T
an
ju
n
g
k
a
r
an
g
T
an
ju
n
g
k
ar
an
g
,
B
an
d
ar
L
a
m
p
u
n
g
,
I
n
d
o
n
esia
E
m
ail:
s
itifa
to
n
ah
s
iti7
8
9
@
g
m
ail.
co
m
1.
I
NT
RO
D
UCT
I
O
N
Di
ab
e
te
s
m
el
l
itu
s
(
D
M)
i
s
a
s
ig
n
if
ic
an
t
p
u
b
li
c
h
e
al
th
i
s
s
u
e
wo
r
l
d
w
id
e,
i
m
p
ac
t
in
g
n
o
t
o
n
l
y
p
at
ie
n
t
s
b
u
t
a
l
s
o
th
eir
f
am
il
y
ca
r
eg
iv
er
s
,
wh
o
o
f
t
en
s
h
o
u
l
d
er
co
n
s
id
er
ab
l
e
r
e
s
p
o
n
s
ib
i
l
ity
in
m
a
n
ag
in
g
th
e
d
i
s
e
a
s
e.
T
h
e
in
v
o
lv
e
m
en
t
o
f
f
am
il
y
m
em
b
e
r
s
in
d
i
ab
e
te
s
m
an
ag
e
m
en
t
is
es
p
ec
ia
ll
y
cr
i
t
ica
l
d
u
e
to
th
e
ch
r
o
n
ic
an
d
co
m
p
l
ex
n
atu
r
e
o
f
th
e
il
ln
e
s
s
,
wh
ich
f
r
eq
u
en
t
ly
r
eq
u
ir
e
s
o
n
g
o
in
g
m
o
n
ito
r
in
g
,
d
i
et
ar
y
m
an
a
g
em
en
t
,
an
d
ed
u
ca
t
io
n
r
el
at
ed
to
g
lu
co
s
e
c
o
n
tr
o
l
an
d
o
v
er
al
l
h
ea
lth
m
ain
ten
a
n
ce
.
Fa
m
i
ly
ca
r
eg
iv
er
s
p
l
ay
a
cr
u
c
ia
l
r
o
l
e
i
n
en
h
an
c
in
g
th
e
q
u
a
l
ity
o
f
lif
e
f
o
r
d
iab
et
es
p
at
ien
t
s
,
p
ar
t
icu
la
r
ly
f
o
r
o
l
d
er
ad
u
l
ts
o
r
in
d
iv
id
u
al
s
w
it
h
co
m
o
r
b
id
co
g
n
i
tiv
e
im
p
a
ir
m
en
t
s
,
a
s
th
e
y
ar
e
in
teg
r
al
m
e
m
b
er
s
o
f
t
h
e
h
ea
l
t
h
ca
r
e
t
ea
m
[
1
]
-
[
3
]
.
C
a
r
eg
iv
er
s
f
ac
e
a
s
tee
p
l
ea
r
n
in
g
cu
r
v
e
to
a
cq
u
i
r
e
e
s
s
en
t
ia
l
s
k
i
ll
s
an
d
k
n
o
wl
ed
g
e
n
ec
es
s
ar
y
f
o
r
ef
f
e
ct
iv
e
d
iab
et
e
s
m
an
ag
em
en
t,
in
c
lu
d
in
g
m
e
d
i
ca
tio
n
m
an
ag
em
en
t
an
d
d
i
et
ar
y
c
o
n
tr
o
l.
Stru
ctu
r
e
d
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Dev
elo
p
men
t o
f a
s
u
p
p
o
r
tive
-
ed
u
ca
tive
h
e
a
lth
ed
u
c
a
tio
n
in
t
erven
tio
n
fo
r
fa
mily
… (
S
iti F
a
to
n
a
h
)
379
ed
u
ca
t
io
n
a
l
in
te
r
v
en
tio
n
s
f
o
r
f
am
i
ly
ca
r
eg
iv
er
s
h
av
e
b
e
en
s
h
o
wn
to
s
ig
n
if
ican
t
ly
i
m
p
r
o
v
e
th
eir
k
n
o
w
led
g
e
an
d
s
e
lf
-
ef
f
ic
ac
y
,
l
ea
d
in
g
to
b
et
ter
h
e
al
th
o
u
t
co
m
e
s
f
o
r
d
iab
ete
s
p
a
t
ien
ts
[
4
]
-
[
6
]
.
T
h
i
s
ed
u
ca
t
io
n
al
s
u
p
p
o
r
t
i
s
es
s
en
t
ia
l,
a
s
m
an
y
ca
r
eg
iv
er
s
r
ep
o
r
t
i
n
ad
e
q
u
a
te
tr
ain
in
g
an
d
in
s
u
f
f
ic
ien
t
s
u
p
p
o
r
t
s
y
s
te
m
s
,
wh
ich
c
an
lead
t
o
ca
r
eg
iv
er
b
u
r
n
o
u
t
an
d
n
eg
a
tiv
ely
im
p
ac
t p
a
ti
en
t c
ar
e
[
7
]
,
[
8
]
.
Fro
m
a
p
u
b
l
ic
h
ea
lth
s
y
s
t
em
s
p
er
s
p
ec
ti
v
e,
d
iab
et
es
m
e
ll
itu
s
r
ep
r
e
s
en
t
s
a
s
u
b
s
t
an
t
ia
l
g
l
o
b
al
b
u
r
d
en
,
wi
th
p
r
ev
a
le
n
ce
p
r
o
je
ct
ed
to
r
ea
ch
1
0
.
2
%
b
y
2
0
3
0
,
d
is
p
r
o
p
o
r
t
io
n
a
te
ly
af
f
e
ct
in
g
lo
w
-
an
d
m
id
d
le
-
in
co
m
e
co
u
n
tr
ie
s
(
L
MI
C
s
)
[
9
]
.
E
p
id
e
m
io
l
o
g
i
ca
l
d
at
a
r
ev
e
al
th
at
r
u
r
al
p
o
p
u
la
tio
n
s
f
a
ce
co
m
p
o
u
n
d
ed
d
i
s
ad
v
an
t
ag
e
s
d
u
e
to
p
o
o
r
h
ea
lt
h
ca
r
e
in
f
r
a
s
t
r
u
c
tu
r
e
,
w
o
r
k
f
o
r
ce
s
h
o
r
ta
g
es
,
an
d
l
im
it
ed
a
cc
es
s
to
s
p
ec
i
al
iz
ed
d
iab
et
e
s
s
er
v
ic
e
s
[
1
0
]
,
[
1
1
]
.
I
n
W
e
s
t
Af
r
i
ca
,
f
r
o
n
t
l
in
e
p
r
im
a
r
y
h
ea
l
th
c
ar
e
wo
r
k
er
s
f
r
eq
u
en
tly
lack
tr
a
in
in
g
in
ev
id
en
ce
-
b
a
s
ed
d
ia
b
e
te
s
m
an
ag
em
en
t
s
tan
d
ar
d
s
[
1
2
]
,
wh
i
le
i
n
So
u
th
As
ia
,
h
ea
l
th
c
ar
e
in
i
ti
at
iv
e
s
r
em
a
i
n
u
n
ev
en
ly
i
m
p
l
em
en
ted
,
p
ar
t
ic
u
lar
ly
i
n
r
u
r
a
l
ar
ea
s
[
1
3
]
.
A
m
u
lt
in
at
io
n
a
l
co
n
s
en
s
u
s
em
p
h
as
iz
ed
th
at
L
MI
C
s
s
t
r
u
g
g
l
e
w
it
h
in
s
u
f
f
ic
ien
t
c
li
n
ica
l
s
t
af
f
,
in
ad
eq
u
a
te
lab
o
r
a
to
r
y
f
a
ci
li
t
ie
s
,
a
n
d
r
e
s
t
r
i
ct
ed
ac
ce
s
s
to
d
i
ab
e
te
s
r
es
o
u
r
c
es
[
1
4
]
.
T
h
e
ch
a
ll
en
g
e
s
f
ac
ed
b
y
f
a
m
ily
c
ar
eg
iv
e
r
s
ar
e
am
p
l
if
ie
d
in
r
eg
io
n
s
lac
k
in
g
r
o
b
u
s
t
h
ea
l
th
ca
r
e
s
y
s
t
em
s
.
I
n
r
u
r
al
ar
e
a
s
,
th
e
s
e
d
if
f
icu
lt
ie
s
c
an
in
cr
e
a
s
e
d
u
e
t
o
lim
it
ed
a
cc
e
s
s
to
f
o
r
m
al
h
e
al
th
ed
u
c
at
io
n
a
n
d
s
u
p
p
o
r
t
r
e
s
o
u
r
ce
s
,
u
n
d
er
s
co
r
i
n
g
th
e
n
ec
e
s
s
ity
f
o
r
ed
u
ca
tio
n
al
p
r
o
g
r
a
m
s
ta
ilo
r
ed
to
th
e
s
p
ec
if
i
c
n
ee
d
s
o
f
th
e
s
e
p
o
p
u
la
tio
n
s
[
1
5
]
,
[
1
6
]
.
I
t
i
s
v
it
al
to
d
es
ig
n
in
ter
v
en
tio
n
s
th
at
co
n
s
id
er
t
h
e
ec
o
n
o
m
i
c
an
d
s
o
c
ia
l
co
n
t
ex
t
s
o
f
ca
r
eg
iv
in
g
,
en
s
u
r
in
g
g
u
id
el
in
e
s
ar
e
cu
ltu
r
al
ly
r
el
ev
an
t
an
d
ac
c
e
s
s
ib
le
to
v
ar
io
u
s
d
em
o
g
r
ap
h
i
c
g
r
o
u
p
s
,
p
ar
t
icu
lar
ly
in
lo
w
-
an
d
m
id
d
l
e
-
in
co
m
e
s
et
t
in
g
s
[
1
7
]
.
R
e
co
g
n
iz
in
g
th
e
v
i
tal
r
o
le
o
f
f
am
ily
ca
r
eg
iv
er
s
in
d
iab
et
e
s
m
an
ag
em
en
t
h
ig
h
lig
h
t
s
th
e
n
ee
d
f
o
r
tar
g
et
ed
s
u
p
p
o
r
t
iv
e
an
d
ed
u
ca
t
io
n
al
in
ter
v
en
tio
n
s
.
T
h
es
e
p
r
o
g
r
a
m
s
s
h
o
u
ld
f
o
cu
s
n
o
t
o
n
ly
o
n
cl
in
ica
l
k
n
o
wl
ed
g
e
b
u
t
a
l
s
o
o
n
m
e
n
ta
l
h
ea
lt
h
s
u
p
p
o
r
t
an
d
r
e
s
il
i
en
ce
-
b
u
i
ld
i
n
g
f
o
r
c
ar
eg
iv
e
r
s
,
en
ab
l
in
g
th
em
to
m
an
ag
e
ca
r
eg
iv
in
g
d
em
an
d
s
wh
i
le
m
ain
ta
i
n
in
g
th
ei
r
w
el
l
-
b
ein
g
[
8
]
,
[
1
8
]
,
[
1
9
]
.
A
s
th
e
h
ea
l
th
o
f
ca
r
eg
iv
er
s
im
p
r
o
v
e
s
,
t
h
e
q
u
al
ity
o
f
c
ar
e
th
ey
p
r
o
v
id
e
a
l
s
o
im
p
r
o
v
e
s
,
cr
e
at
in
g
a
p
o
s
i
tiv
e
f
e
ed
b
a
ck
lo
o
p
th
a
t
b
en
ef
it
s
p
at
ien
t o
u
tco
m
e
s
[
4
]
.
A
cr
i
ti
ca
l
g
ap
r
em
ai
n
s
in
th
e
d
ev
e
lo
p
m
en
t
o
f
co
m
p
r
e
h
en
s
iv
e
,
f
am
i
ly
-
u
n
i
t
-
l
ev
e
l
e
d
u
ca
tio
n
al
p
r
o
g
r
am
s
d
e
s
ig
n
ed
f
o
r
r
e
s
o
u
r
ce
-
li
m
i
ted
co
n
tex
t
s
,
wh
e
r
e
f
o
r
m
al
h
e
al
th
c
ar
e
s
u
p
p
o
r
t
is
s
ca
r
c
e
an
d
f
am
il
ie
s
co
l
lec
t
iv
e
ly
a
s
s
u
m
e
c
ar
eg
iv
in
g
r
e
s
p
o
n
s
ib
il
it
ie
s
.
Ou
r
s
tu
d
y
ad
v
an
c
e
s
ex
is
t
in
g
k
n
o
w
led
g
e
b
y
s
h
i
f
t
in
g
th
e
u
n
i
t
o
f
in
t
er
v
e
n
t
io
n
f
r
o
m
in
d
iv
i
d
u
al
c
ar
eg
iv
er
s
to
th
e
en
t
i
r
e
f
am
ily
s
y
s
tem
,
r
ec
o
g
n
i
z
in
g
th
at
d
iab
et
es
m
an
ag
em
en
t
in
p
r
ac
ti
ce
in
v
o
lv
e
s
d
i
s
tr
ib
u
t
ed
r
e
s
p
o
n
s
i
b
il
it
ie
s
a
m
o
n
g
m
u
l
t
ip
l
e
h
o
u
s
eh
o
ld
m
em
b
er
s
.
Fu
r
th
er
m
o
r
e,
u
n
l
ik
e
p
r
i
o
r
s
tu
d
ie
s
th
a
t
p
r
ed
o
m
in
an
tly
a
s
s
e
s
s
ed
k
n
o
w
led
g
e
a
cq
u
is
i
tio
n
a
lo
n
e,
o
u
r
p
r
o
g
r
am
in
t
eg
r
a
te
s
c
lin
ic
al
ed
u
ca
tio
n
w
ith
p
s
y
ch
o
s
o
ci
al
s
u
p
p
o
r
t
an
d
r
e
s
il
ien
ce
-
b
u
i
ld
in
g
co
m
p
o
n
en
ts
wi
th
in
a
cu
l
tu
r
a
ll
y
ad
ap
t
ed
f
r
am
e
wo
r
k
.
T
h
i
s
h
o
l
i
s
t
ic,
s
y
s
tem
s
-
o
r
i
en
t
ed
ap
p
r
o
ac
h
ad
d
r
e
s
s
e
s
th
e
in
t
er
co
n
n
ec
ted
n
ee
d
s
o
f
ca
r
eg
iv
in
g
f
a
m
i
li
es
r
a
th
e
r
th
an
i
s
o
la
ted
in
d
iv
id
u
a
l
s
,
r
ep
r
e
s
e
n
t
in
g
a
m
eth
o
d
o
lo
g
ic
al
an
d
co
n
ce
p
tu
a
l
ad
v
an
c
em
en
t
in
f
am
i
ly
-
b
a
s
ed
ch
r
o
n
i
c
d
i
s
ea
s
e
in
t
er
v
en
t
io
n
s
.
W
e
h
av
e
r
ev
is
ed
t
h
e
i
n
tr
o
d
u
ct
io
n
to
ex
p
l
ic
i
tly
ar
t
icu
la
te
th
i
s
g
ap
an
d
th
e
s
tu
d
y
'
s
d
i
s
tin
ct
co
n
tr
ib
u
t
io
n
to
p
u
b
li
c
h
e
al
t
h
s
ci
en
ce
.
2.
M
E
T
H
O
D
2
.
1
.
De
s
ig
n
T
h
i
s
s
tu
d
y
em
p
lo
y
ed
a
q
u
a
s
i
-
ex
p
er
im
en
t
al
d
e
s
ig
n
wi
th
a
n
o
n
-
eq
u
iv
a
len
t
co
n
tr
o
l
g
r
o
u
p
,
a
p
r
e
-
te
s
t
an
d
p
o
s
t
-
t
es
t
ap
p
r
o
ac
h
.
T
h
i
s
d
es
ig
n
wa
s
s
el
ec
ted
a
s
it
p
er
m
it
s
co
m
p
ar
i
s
o
n
b
e
tw
ee
n
in
te
r
v
en
t
io
n
an
d
co
n
tr
o
l
g
r
o
u
p
s
in
co
m
m
u
n
ity
-
b
a
s
ed
s
et
tin
g
s
wh
er
e
tr
u
e
r
an
d
o
m
iz
at
io
n
i
s
n
e
i
th
er
f
e
as
ib
le
n
o
r
eth
i
ca
l
d
u
e
to
p
r
a
ct
ic
al
co
n
s
tr
ain
t
s
r
e
la
ted
to
g
eo
g
r
a
p
h
ic
clu
s
ter
in
g
o
f
p
ar
ti
cip
an
t
s
wi
th
in
th
e
S
im
b
ar
w
ar
in
g
in
C
o
m
m
u
n
i
ty
Hea
l
th
C
en
te
r
c
at
ch
m
e
n
t
ar
e
a.
T
h
e
in
t
er
v
en
t
io
n
g
r
o
u
p
r
e
ce
iv
ed
a
s
tr
u
c
tu
r
ed
f
am
ily
s
u
p
p
o
r
t
ed
u
c
at
io
n
p
r
o
g
r
a
m
c
en
t
er
ed
o
n
th
e
f
iv
e
p
il
lar
s
o
f
DM
m
an
ag
em
en
t
:
i
)
d
iab
et
e
s
ed
u
ca
t
io
n
,
ii
)
m
ed
ic
al
n
u
tr
it
io
n
t
h
er
a
p
y
,
i
ii
)
p
h
y
s
i
ca
l
ex
er
c
i
s
e,
iv
)
p
h
ar
m
ac
o
lo
g
i
ca
l
th
er
ap
y
,
an
d
v
)
s
elf
-
m
o
n
ito
r
in
g
o
f
b
lo
o
d
g
lu
co
s
e
(
S
M
B
G)
.
T
h
e
co
n
tr
o
l
g
r
o
u
p
r
ec
ei
v
ed
s
t
an
d
a
r
d
c
ar
e
w
ith
o
u
t
ad
d
it
io
n
al
ed
u
c
at
io
n
a
l
in
t
er
v
en
t
io
n
o
r
f
am
ily
s
u
p
p
o
r
t p
r
o
g
r
am
m
in
g
.
T
h
e
in
te
r
v
en
tio
n
w
as
im
p
le
m
en
t
ed
o
v
e
r
th
r
ee
m
o
n
th
s
(
Feb
r
u
ar
y
–
Ap
r
il
2
0
2
5
)
,
wi
th
s
e
s
s
io
n
s
s
ch
ed
u
l
ed
tw
ic
e
w
ee
k
ly
,
ea
ch
la
s
t
in
g
ap
p
r
o
x
im
a
te
ly
1
–
2
h
o
u
r
s
.
T
h
e
in
ter
v
en
t
io
n
c
o
m
p
r
i
s
ed
th
r
ee
s
eq
u
en
ti
al
p
h
as
e
s
.
I
n
Ph
as
e
1
(
w
e
ek
s
1
–
3
)
,
s
tr
u
ctu
r
ed
d
id
a
ct
ic
s
es
s
io
n
s
wer
e
d
e
liv
er
ed
co
v
er
in
g
ea
c
h
o
f
th
e
f
i
v
e
p
il
lar
s
th
r
o
u
g
h
in
t
er
a
ct
iv
e
p
r
e
s
en
ta
t
i
o
n
s
,
v
i
s
u
a
l
a
id
s
,
an
d
p
r
in
ted
ed
u
ca
t
io
n
a
l
m
a
ter
ia
l
s
.
I
n
Ph
a
s
e
2
(
w
e
ek
s
4
–
8
)
,
s
u
p
p
o
r
t
iv
e
f
am
i
ly
g
r
o
u
p
s
w
er
e
f
o
r
m
al
ly
e
s
t
ab
l
i
s
h
ed
,
co
n
s
is
t
in
g
o
f
8
–
1
0
f
am
ily
m
e
m
b
er
s
p
er
g
r
o
u
p
,
f
ac
il
it
at
ed
b
y
tr
ain
ed
h
ea
lth
e
d
u
ca
to
r
s
.
T
h
e
s
e
s
e
s
s
io
n
s
em
p
lo
y
ed
g
r
o
u
p
d
i
s
cu
s
s
io
n
s
,
r
o
le
-
p
lay
in
g
,
an
d
ca
s
e
-
b
as
ed
p
r
o
b
le
m
-
s
o
lv
in
g
to
r
ei
n
f
o
r
ce
k
n
o
w
led
g
e
a
p
p
l
ica
t
io
n
.
I
n
P
h
a
s
e
3
(
w
ee
k
s
9
–
1
2
)
,
i
n
ten
s
iv
e
m
en
t
o
r
in
g
wa
s
p
r
o
v
id
ed
to
f
am
i
ly
c
ar
e
g
i
v
er
s
,
f
o
cu
s
in
g
o
n
p
r
ac
ti
ca
l
s
k
i
ll
-
b
u
i
ld
in
g
,
in
clu
d
in
g
m
ea
l
p
l
an
n
in
g
,
m
ed
ic
at
io
n
ad
m
in
i
s
t
r
a
tio
n
s
u
p
p
o
r
t,
b
lo
o
d
g
lu
c
o
s
e
m
o
n
i
to
r
i
n
g
tech
n
iq
u
es
,
an
d
m
o
tiv
at
io
n
a
l
s
tr
a
teg
ie
s
f
o
r
en
co
u
r
ag
in
g
p
at
ien
t
ad
h
er
en
c
e
to
p
h
y
s
ic
al
ac
ti
v
i
ty
r
eg
i
m
en
s
.
T
h
r
o
u
g
h
o
u
t
al
l
p
h
a
s
e
s
,
co
n
t
in
u
o
u
s
m
o
n
i
to
r
in
g
an
d
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.
15
,
No
.
2
,
J
u
n
e
20
26
:
3
7
8
-
3
8
8
380
f
o
r
m
a
tiv
e
ev
a
lu
a
tio
n
wer
e
co
n
d
u
ct
ed
b
y
r
es
ea
r
ch
a
s
s
i
s
tan
t
s
u
s
in
g
s
tr
u
ct
u
r
ed
o
b
s
er
v
at
io
n
ch
ec
k
l
is
t
s
to
a
s
s
e
s
s
f
id
e
li
ty
o
f
in
te
r
v
en
tio
n
d
e
liv
er
y
an
d
p
ar
t
ic
ip
a
n
t
en
g
ag
em
e
n
t.
I
t
i
s
im
p
o
r
t
an
t
t
o
ac
k
n
o
wl
ed
g
e
th
at
th
e
ab
s
en
ce
o
f
r
an
d
o
m
i
za
ti
o
n
co
n
s
t
itu
te
s
a
s
i
g
n
if
ic
an
t
m
eth
o
d
o
lo
g
ic
al
l
im
i
ta
t
io
n
,
as
it
in
tr
o
d
u
ce
s
th
e
p
o
s
s
ib
i
l
ity
o
f
s
el
ec
tio
n
b
i
a
s
an
d
co
n
f
o
u
n
d
in
g
v
ar
i
ab
l
e
s
th
at
m
ay
in
f
lu
en
ce
g
r
o
u
p
co
m
p
ar
a
b
il
ity
a
t
b
a
s
e
l
in
e.
T
o
p
a
r
t
ia
lly
m
it
ig
a
te
th
i
s
co
n
ce
r
n
,
b
a
s
e
lin
e
d
em
o
g
r
ap
h
i
c
an
d
cl
in
i
ca
l
ch
a
r
ac
ter
i
s
t
ic
s
wer
e
c
o
m
p
ar
ed
b
et
we
en
g
r
o
u
p
s
u
s
i
n
g
ch
i
-
s
q
u
ar
e
te
s
ts
f
o
r
ca
teg
o
r
ic
al
v
a
r
i
ab
l
e
s
an
d
in
d
ep
en
d
en
t
t
-
t
es
t
s
f
o
r
c
o
n
t
i
n
u
o
u
s
v
ar
i
ab
l
e
s
,
en
ab
l
in
g
id
en
t
if
i
ca
tio
n
o
f
an
y
p
r
e
-
ex
i
s
t
i
n
g
d
if
f
er
en
ce
s
th
at
co
u
ld
co
n
f
o
u
n
d
th
e
r
esu
l
ts
.
Fu
r
th
er
m
o
r
e
,
th
e
u
s
e
o
f
n
o
n
-
p
r
o
b
ab
il
i
ty
s
am
p
l
in
g
an
d
th
e
n
a
tu
r
a
li
s
ti
c
co
m
m
u
n
ity
s
e
tt
in
g
l
im
it
s
th
e
ex
ten
t
to
wh
ich
ca
u
s
al
i
n
f
e
r
en
ce
s
c
an
b
e
d
r
a
wn
,
an
d
f
i
n
d
in
g
s
s
h
o
u
ld
b
e
in
t
er
p
r
e
te
d
w
i
th
ap
p
r
o
p
r
ia
te
c
au
t
io
n
r
eg
ar
d
in
g
in
ter
n
al
v
a
li
d
ity
.
2
.
2
.
Se
t
t
i
ng
a
n
d
po
p
ula
t
io
n
T
h
is
r
esear
ch
was
co
n
d
u
cted
f
r
o
m
Feb
r
u
ar
y
to
J
u
n
e
2
0
2
5
in
th
e
wo
r
k
in
g
ar
ea
o
f
th
e
Simb
a
r
war
in
g
in
C
o
m
m
u
n
ity
Hea
lth
C
en
ter
(
P
u
s
ke
s
ma
s
)
,
C
en
tr
al
L
am
p
u
n
g
,
I
n
d
o
n
esia.
T
h
e
tar
g
et
p
o
p
u
la
tio
n
co
m
p
r
is
ed
all
f
am
ilies
o
f
p
atien
ts
d
iag
n
o
s
ed
with
d
iab
etes
m
ellitu
s
.
A
to
ta
l
o
f
3
6
5
in
d
i
v
id
u
als
wer
e
r
eg
i
s
ter
ed
at
th
e
h
ea
lth
ce
n
ter
an
d
i
n
clu
d
ed
in
th
e
p
o
p
u
latio
n
.
2
.
3
.
Sa
m
p
li
ng
t
ec
h
ni
q
ue
A
n
o
n
-
p
r
o
b
ab
i
li
ty
p
u
r
p
o
s
iv
e
s
a
m
p
l
in
g
t
ec
h
n
iq
u
e
wa
s
em
p
lo
y
ed
.
P
u
r
p
o
s
iv
e
s
am
p
lin
g
wa
s
d
el
ib
er
at
ely
s
e
le
ct
ed
b
e
ca
u
s
e
th
e
s
tu
d
y
r
eq
u
ir
ed
p
ar
ti
cip
an
t
s
wh
o
m
e
t
s
p
ec
if
ic
e
lig
ib
il
it
y
cr
i
ter
ia
th
a
t
co
u
ld
n
o
t
b
e
s
a
ti
s
f
ied
th
r
o
u
g
h
r
an
d
o
m
s
e
lec
t
io
n
f
r
o
m
th
e
g
en
er
a
l
p
o
p
u
la
tio
n
.
Sp
e
cif
ic
al
ly
,
p
ar
ti
cip
an
t
s
we
r
e
r
eq
u
ir
ed
to
h
av
e
a
f
am
i
ly
m
e
m
b
er
wi
th
a
co
n
f
i
r
m
ed
D
M
d
iag
n
o
s
i
s
an
d
th
e
ab
i
li
ty
to
co
m
m
u
n
i
ca
te
v
er
b
a
lly
in
I
n
d
o
n
e
s
i
an
,
n
ec
es
s
it
at
in
g
a
cr
i
ter
io
n
-
b
a
s
ed
s
el
ec
tio
n
p
r
o
c
es
s
.
T
h
e
au
th
o
r
s
ac
k
n
o
w
led
g
e
th
a
t
n
o
n
-
p
r
o
b
ab
i
li
ty
s
am
p
l
in
g
in
tr
o
d
u
c
e
s
in
h
er
en
t
l
im
ita
t
io
n
s
,
in
clu
d
in
g
p
o
ten
ti
al
s
el
ec
tio
n
b
i
as
an
d
r
ed
u
ce
d
g
en
er
a
li
za
b
il
it
y
o
f
f
i
n
d
in
g
s
to
th
e
b
r
o
a
d
er
p
o
p
u
la
tio
n
o
f
D
M
p
a
t
i
en
t
f
am
i
l
ie
s
.
T
h
e
p
u
r
p
o
s
iv
e
ap
p
r
o
ac
h
m
ay
h
av
e
r
es
u
l
ted
i
n
a
s
am
p
l
e
th
a
t
i
s
s
y
s
t
em
a
ti
ca
lly
d
if
f
er
en
t
f
r
o
m
th
e
tar
g
et
p
o
p
u
la
tio
n
in
u
n
m
ea
s
u
r
ed
ch
ar
ac
ter
i
s
t
ic
s
,
s
u
ch
as
m
o
tiv
at
io
n
,
h
e
al
th
l
it
er
a
cy
,
o
r
p
r
e
-
ex
i
s
t
in
g
en
g
ag
e
m
en
t
w
ith
h
ea
lth
s
er
v
ice
s
.
T
h
e
s
e
li
m
i
ta
tio
n
s
s
h
o
u
ld
b
e
co
n
s
id
er
ed
wh
en
in
t
er
p
r
e
tin
g
th
e
s
tu
d
y
f
in
d
i
n
g
s
.
2
.
4
.
Sa
m
pl
e
s
i
ze
d
et
e
rm
i
na
t
io
n
T
h
e
m
i
n
im
u
m
r
eq
u
ir
e
d
s
am
p
l
e
s
iz
e
wa
s
c
al
cu
la
ted
u
s
in
g
th
e
S
lo
v
in
f
o
r
m
u
la
,
wh
er
e
N
=
3
6
5
(
to
tal
p
o
p
u
la
ti
o
n
)
an
d
e
=
0
.
0
5
(
m
ar
g
in
o
f
er
r
o
r
)
,
y
ie
ld
in
g
a
m
in
im
u
m
r
eq
u
ir
ed
s
am
p
le
o
f
ap
p
r
o
x
i
m
a
te
ly
1
9
1
r
es
p
o
n
d
en
t
s
.
Ho
wev
e
r
,
af
t
er
ap
p
l
y
in
g
in
clu
s
io
n
an
d
e
x
clu
s
i
o
n
c
r
i
ter
ia,
1
5
7
el
ig
ib
l
e
r
e
s
p
o
n
d
e
n
t
s
wer
e
o
b
ta
in
ed
,
r
ep
r
e
s
en
t
in
g
8
2
.
2
%
o
f
th
e
ca
lcu
la
ted
m
in
i
m
u
m
.
T
h
i
s
s
h
o
r
tf
a
l
l
i
s
ac
k
n
o
wl
ed
g
ed
as
a
l
im
it
at
io
n
th
at
m
ay
r
ed
u
ce
s
ta
ti
s
ti
ca
l
p
o
w
er
an
d
in
cr
e
a
s
e
th
e
r
i
s
k
o
f
T
y
p
e
I
I
er
r
o
r
.
T
h
e
1
5
7
r
e
s
p
o
n
d
en
ts
wer
e
a
llo
ca
ted
in
to
an
in
ter
v
en
t
io
n
g
r
o
u
p
(
n
=
7
2
)
an
d
a
co
n
tr
o
l
g
r
o
u
p
(
n
=
8
5
)
.
Gr
o
u
p
al
lo
c
at
io
n
wa
s
b
a
s
ed
o
n
g
eo
g
r
a
p
h
i
c
p
r
o
x
im
ity
to
th
e
h
e
al
th
c
en
t
er
an
d
wi
ll
in
g
n
e
s
s
to
at
ten
d
s
ch
ed
u
l
ed
in
te
r
v
en
tio
n
s
e
s
s
io
n
s
,
r
ath
er
th
an
th
r
o
u
g
h
r
an
d
o
m
iza
t
io
n
,
wh
ich
f
u
r
th
er
u
n
d
er
s
co
r
e
s
t
h
e
p
o
ten
t
ia
l f
o
r
s
ele
ct
io
n
b
ia
s
.
2
.
5
.
I
n
cl
u
s
io
n a
n
d
ex
c
l
us
io
n
cr
it
e
ria
I
n
clu
s
io
n
cr
it
er
ia
w
er
e
:
i
)
wi
ll
in
g
n
e
s
s
t
o
p
ar
ti
cip
at
e
a
s
a
r
es
p
o
n
d
en
t,
co
n
f
ir
m
ed
t
h
r
o
u
g
h
wr
i
tt
en
in
f
o
r
m
ed
co
n
s
e
n
t
;
ii
)
ab
il
it
y
to
co
m
m
u
n
ic
at
e
v
er
b
al
ly
in
I
n
d
o
n
e
s
i
an
;
a
n
d
i
ii
)
h
av
in
g
a
f
am
i
ly
m
em
b
er
cu
r
r
en
tl
y
d
iag
n
o
s
ed
w
ith
d
i
ab
et
e
s
m
e
ll
itu
s
an
d
a
ct
iv
el
y
r
e
ce
iv
in
g
tr
e
atm
en
t
at
th
e
Si
m
b
ar
war
in
g
in
C
o
m
m
u
n
i
ty
He
al
th
C
en
t
er
.
E
x
clu
s
io
n
cr
i
te
r
i
a
w
er
e
:
i
)
u
n
wi
ll
in
g
n
es
s
to
p
ar
ti
cip
at
e
in
th
e
s
tu
d
y
;
ii
)
in
a
b
i
li
ty
to
co
m
m
u
n
i
ca
t
e
v
er
b
a
lly
in
I
n
d
o
n
e
s
ian
,
wh
ich
wo
u
ld
i
m
p
ed
e
co
m
p
r
eh
en
s
io
n
an
d
in
t
er
a
ct
io
n
d
u
r
in
g
ed
u
c
at
io
n
a
l
s
e
s
s
io
n
s
an
d
d
ata
co
ll
ec
tio
n
;
ii
i
)
f
am
il
ie
s
wh
o
s
e
m
em
b
er
s
wer
e
n
o
t
cu
r
r
en
tl
y
r
e
ce
iv
i
n
g
t
r
ea
tm
en
t
o
r
n
o
t
o
f
f
i
ci
al
ly
d
iag
n
o
s
ed
wi
th
DM
a
t
th
e
t
im
e
o
f
th
e
s
tu
d
y
;
an
d
iv
)
r
e
s
p
o
n
d
en
t
s
w
ith
co
m
o
r
b
id
h
e
al
th
c
o
n
d
it
io
n
s
th
a
t
co
u
l
d
in
d
ep
en
d
en
tl
y
af
f
ec
t
th
e
d
ep
e
n
d
en
t
v
ar
iab
le
s
u
n
d
er
in
v
es
t
i
g
at
io
n
.
2
.
6
.
Va
ri
a
bles
T
h
e
in
d
ep
en
d
en
t
v
ar
i
ab
l
e
s
in
th
is
s
t
u
d
y
we
r
e
s
ix
d
o
m
ain
s
o
f
f
a
m
i
ly
s
u
p
p
o
r
t
iv
e
b
eh
av
io
r
:
i
)
n
u
tr
i
tio
n
al
r
eg
u
l
at
io
n
s
u
p
p
o
r
t,
ii
)
p
h
y
s
ic
al
ex
er
c
i
s
e
s
u
p
p
o
r
t,
ii
i
)
p
h
a
r
m
a
co
lo
g
ic
al
th
er
a
p
y
s
u
p
p
o
r
t
,
iv
)
s
tr
e
s
s
m
an
ag
em
e
n
t
s
u
p
p
o
r
t,
v
)
s
e
l
f
-
b
lo
o
d
g
lu
co
s
e
te
s
t
in
g
s
u
p
p
o
r
t
,
an
d
vi
)
ed
u
ca
tio
n
al
s
u
p
p
o
r
t.
T
h
e
d
ep
en
d
en
t
v
ar
ia
b
l
e
wa
s
k
n
o
wl
ed
g
e
r
eg
ar
d
in
g
d
ia
b
e
te
s
m
el
li
tu
s
m
an
ag
em
en
t
.
Dem
o
g
r
ap
h
i
c
v
ar
iab
le
s
,
in
c
lu
d
in
g
ag
e,
s
ex
,
ed
u
c
at
io
n
lev
el
,
d
u
r
at
io
n
o
f
c
ar
eg
iv
i
n
g
,
an
d
r
e
la
tio
n
s
h
ip
to
th
e
DM
p
at
ie
n
t
,
w
er
e
co
l
lec
te
d
a
s
p
o
te
n
t
ia
l c
o
v
ar
ia
t
es
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Dev
elo
p
men
t o
f a
s
u
p
p
o
r
tive
-
ed
u
ca
tive
h
e
a
lth
ed
u
c
a
tio
n
in
t
erven
tio
n
fo
r
fa
mily
… (
S
iti F
a
to
n
a
h
)
381
2
.
7
.
M
ea
s
urem
ent
t
o
o
l
Data
wer
e
co
llected
u
s
in
g
a
m
o
d
if
ied
v
e
r
s
io
n
o
f
t
h
e
Diab
e
tes
So
cial
Su
p
p
o
r
t
Qu
esti
o
n
n
a
ir
e
-
Fam
ily
(
DSSQ
-
Fam
ily
)
,
o
r
ig
in
ally
d
e
v
elo
p
ed
to
ev
alu
ate
s
o
cial
s
u
p
p
o
r
t
r
ec
eiv
e
d
b
y
f
am
ilies
o
f
d
iab
e
tes
p
atien
ts
.
Mo
d
if
icatio
n
s
wer
e
m
ad
e
to
en
s
u
r
e
co
n
tex
tu
al
ap
p
r
o
p
r
iate
n
ess
f
o
r
th
e
I
n
d
o
n
esian
c
o
m
m
u
n
ity
s
ettin
g
an
d
r
elev
an
ce
t
o
th
e
s
ix
i
n
d
ep
e
n
d
e
n
t
v
ar
ia
b
le
d
o
m
ain
s
e
x
am
in
ed
in
t
h
is
s
tu
d
y
.
T
h
e
m
o
d
if
ied
in
s
tr
u
m
en
t
co
n
s
is
ted
o
f
item
s
r
ated
o
n
a
L
ik
er
t
-
ty
p
e
s
ca
le,
with
h
ig
h
er
s
co
r
es in
d
icatin
g
g
r
ea
ter
le
v
els o
f
f
am
ily
s
u
p
p
o
r
t.
2
.
8
.
Va
lid
it
y
a
nd
re
lia
bil
it
y
t
esting
Prio
r
to
d
ata
co
llectio
n
,
th
e
m
o
d
if
ied
DSSQ
-
Fam
ily
u
n
d
e
r
wen
t
r
ig
o
r
o
u
s
p
s
y
ch
o
m
etr
ic
ev
alu
atio
n
.
C
o
n
ten
t
v
alid
ity
was
estab
lis
h
ed
th
r
o
u
g
h
ex
p
er
t
ju
d
g
m
en
t
b
y
a
p
an
el
o
f
th
r
ee
s
p
ec
ialis
ts
in
n
u
r
s
in
g
an
d
en
d
o
cr
in
o
lo
g
y
,
wh
o
ass
ess
ed
item
r
elev
an
ce
,
clar
ity
,
an
d
r
ep
r
esen
tativ
en
ess
o
f
th
e
co
n
s
tr
u
cts
m
ea
s
u
r
ed
.
I
tem
s
wer
e
r
ev
is
ed
b
ased
o
n
e
x
p
er
t f
ee
d
b
ac
k
u
n
til co
n
s
en
s
u
s
was a
ch
iev
ed
.
C
o
n
s
tr
u
ct
v
alid
ity
was
e
v
alu
a
ted
th
r
o
u
g
h
a
p
ilo
t
test
,
with
item
-
to
tal
co
r
r
elatio
n
s
ca
lcu
la
ted
u
s
in
g
Pear
s
o
n
'
s
p
r
o
d
u
ct
-
m
o
m
en
t
c
o
r
r
elatio
n
co
e
f
f
icien
t.
I
tem
s
wer
e
r
etain
ed
o
n
l
y
if
th
e
ca
lcu
late
d
r
-
v
alu
e
ex
ce
ed
e
d
th
e
cr
itical
r
-
tab
le
v
alu
e
at
th
e
0
.
0
5
s
ig
n
if
ican
ce
lev
el,
e
n
s
u
r
in
g
th
at
ea
c
h
item
s
ig
n
if
ica
n
tly
co
n
tr
i
b
u
ted
to
th
e
o
v
er
all
co
n
s
tr
u
ct
b
ein
g
m
ea
s
u
r
ed
.
I
n
ter
n
al
co
n
s
is
ten
cy
r
eliab
ilit
y
was
as
s
ess
ed
u
s
in
g
C
r
o
n
b
ac
h
'
s
alp
h
a
co
ef
f
icien
t,
y
ield
in
g
a
v
alu
e
o
f
0
.
7
3
.
T
h
ese
p
r
o
ce
d
u
r
es
co
n
f
ir
m
ed
th
at
th
e
in
s
tr
u
m
en
t
was
p
s
y
ch
o
m
etr
ically
ad
eq
u
ate
f
o
r
u
s
e
with
th
e
s
tu
d
y
p
o
p
u
latio
n
.
2
.
9
.
O
utc
o
m
e
m
ea
s
urem
ent
At
th
e
co
n
clu
s
io
n
o
f
th
e
in
ter
v
en
tio
n
p
er
io
d
,
th
e
in
d
ep
en
d
e
n
ce
o
f
DM
p
atien
ts
was
ass
ess
ed
b
ased
o
n
s
ev
er
al
b
e
h
av
io
r
al
in
d
icato
r
s
.
T
h
ese
in
d
icato
r
s
in
clu
d
e
d
a
d
h
er
en
ce
t
o
a
h
ea
lth
y
d
iet,
en
g
ag
em
en
t in
r
e
g
u
lar
p
h
y
s
ical
ac
tiv
ity
,
s
af
e
an
d
ap
p
r
o
p
r
iate
u
s
e
o
f
d
iab
etes
m
ed
icatio
n
,
an
d
co
n
s
is
ten
t
s
elf
-
m
o
n
ito
r
in
g
o
f
b
lo
o
d
g
lu
co
s
e.
T
h
ey
wer
e
d
esig
n
e
d
to
ca
p
tu
r
e
ch
an
g
es
in
ad
ap
tiv
e
b
eh
av
io
r
s
with
th
e
p
o
ten
tial
to
im
p
r
o
v
e
q
u
ality
o
f
life
an
d
r
ed
u
ce
d
iab
etes
-
r
el
ated
co
m
p
licatio
n
s
.
2
.
1
0
.
Da
t
a
a
na
ly
s
is
Data
an
aly
s
is
was
co
n
d
u
cted
in
s
eq
u
en
tial
s
tag
es.
First,
all
co
llected
d
ata
wer
e
clea
n
ed
,
c
o
d
ed
,
a
n
d
s
cr
ee
n
ed
f
o
r
m
is
s
in
g
o
r
i
n
v
ali
d
r
esp
o
n
s
es.
Descr
ip
tiv
e
s
tati
s
tics
,
in
clu
d
in
g
f
r
eq
u
e
n
cies,
p
er
ce
n
tag
es,
m
ea
n
s
,
an
d
s
tan
d
ar
d
d
e
v
iatio
n
s
,
wer
e
co
m
p
u
ted
to
ch
ar
ac
te
r
ize
th
e
d
em
o
g
r
a
p
h
ic
p
r
o
f
ile
an
d
b
aselin
e
attr
ib
u
tes
o
f
r
esp
o
n
d
en
ts
in
b
o
th
g
r
o
u
p
s
.
B
aselin
e
eq
u
iv
alen
ce
b
etwe
en
th
e
in
ter
v
en
tio
n
a
n
d
co
n
tr
o
l
g
r
o
u
p
s
was
ass
e
s
s
ed
u
s
in
g
ch
i
-
s
q
u
ar
e
test
s
f
o
r
ca
teg
o
r
ical
v
ar
iab
les
an
d
in
d
e
p
en
d
en
t
-
s
am
p
les
t
-
test
s
f
o
r
co
n
tin
u
o
u
s
v
ar
iab
les.
T
h
is
s
tep
was
cr
it
ical
g
iv
en
th
e
n
o
n
-
r
a
n
d
o
m
ized
d
esig
n
,
as
it
en
ab
led
id
en
tific
atio
n
o
f
p
r
e
-
ex
is
tin
g
g
r
o
u
p
d
if
f
er
en
ce
s
th
at
c
o
u
ld
s
er
v
e
as c
o
n
f
o
u
n
d
e
r
s
.
No
r
m
al
ity
o
f
d
ata
d
is
tr
ib
u
tio
n
was
a
s
s
es
s
ed
u
s
in
g
th
e
Sh
ap
ir
o
-
W
ilk
test
b
ef
o
r
e
p
ar
am
etr
ic
test
in
g
.
T
h
e
p
air
ed
-
s
am
p
le
t
-
t
est
was
em
p
lo
y
ed
to
ev
alu
ate
wit
h
in
-
g
r
o
u
p
c
h
an
g
es
(
p
r
e
-
test
to
p
o
s
t
-
test
)
in
th
e
in
ter
v
en
tio
n
g
r
o
u
p
,
th
er
eb
y
d
eter
m
in
in
g
wh
eth
er
s
tatis
tical
ly
s
ig
n
if
ican
t
im
p
r
o
v
em
e
n
ts
o
cc
u
r
r
e
d
f
o
llo
win
g
th
e
ed
u
ca
tio
n
al
p
r
o
g
r
a
m
.
T
h
e
in
d
ep
en
d
e
n
t
two
-
s
am
p
le
t
-
t
est
was
ap
p
lied
to
co
m
p
ar
e
p
o
s
t
-
in
ter
v
en
tio
n
o
u
tco
m
es
b
etwe
en
th
e
in
te
r
v
en
tio
n
a
n
d
c
o
n
tr
o
l
g
r
o
u
p
s
,
ass
ess
in
g
wh
eth
er
s
ig
n
if
ica
n
t
b
etwe
en
-
g
r
o
u
p
d
if
f
er
en
ce
s
e
x
is
ted
in
k
n
o
wle
d
g
e
an
d
ad
a
p
tiv
e
b
eh
av
io
r
s
co
r
es.
A
s
ig
n
if
ican
ce
le
v
el
o
f
α
=
0
.
0
5
was
ad
o
p
ted
f
o
r
all
s
tatis
tical
test
s
.
E
f
f
ec
t
s
izes
(
C
o
h
en
'
s
d
)
wer
e
ca
lcu
lated
to
s
u
p
p
lem
e
n
t
s
ig
n
if
ican
ce
test
in
g
an
d
p
r
o
v
id
e
a
m
ea
s
u
r
e
o
f
p
r
ac
tical
s
ig
n
if
ic
an
ce
(
C
o
h
e
n
,
1
9
8
8
)
.
All
an
al
y
s
es
wer
e
p
er
f
o
r
m
ed
u
s
in
g
SP
SS
v
er
s
io
n
2
5
.
0
.
I
t
s
h
o
u
ld
b
e
n
o
ted
t
h
at
th
e
an
al
y
tical
ap
p
r
o
ac
h
d
o
es
n
o
t
in
cl
u
d
e
ad
ju
s
tm
en
t
f
o
r
p
o
ten
tial
c
o
n
f
o
u
n
d
er
s
th
r
o
u
g
h
m
u
ltiv
ar
iate
tech
n
iq
u
es
s
u
ch
as
an
aly
s
is
o
f
co
v
a
r
ian
ce
(
A
NC
OVA)
,
wh
ich
r
ep
r
esen
ts
a
lim
i
tatio
n
g
iv
en
th
e
non
-
r
a
n
d
o
m
ized
d
esig
n
.
Fu
tu
r
e
s
tu
d
ies
s
h
o
u
ld
co
n
s
id
er
in
co
r
p
o
r
atin
g
co
v
a
r
iate
ad
ju
s
tm
en
t
to
s
tr
en
g
th
en
ca
u
s
al
in
f
er
en
ce
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
T
ab
le
1
r
ev
ea
ls
th
at
b
o
th
g
r
o
u
p
s
wer
e
p
r
ed
o
m
in
an
tly
p
r
o
d
u
ctiv
e
-
a
g
e
an
d
f
e
m
ale,
with
s
lig
h
tly
h
ig
h
er
p
r
o
p
o
r
tio
n
s
in
th
e
in
te
r
v
en
tio
n
g
r
o
u
p
(
9
1
.
6
7
%
p
r
o
d
u
ctiv
e;
8
1
.
9
4
%
f
em
ale)
.
T
h
e
in
ter
v
en
tio
n
g
r
o
u
p
h
ad
m
o
r
e
p
ar
ticip
an
ts
d
iag
n
o
s
ed
with
DM
f
o
r
≥
1
y
ea
r
(
4
0
.
3
%
v
s
.
1
8
.
8
2
%).
No
tab
l
y
,
p
o
s
t
-
in
ter
v
en
tio
n
b
lo
o
d
g
lu
co
s
e
lev
els
b
elo
w
2
0
0
m
g
/d
L
wer
e
s
u
b
s
tan
tially
h
ig
h
er
in
th
e
in
ter
v
en
tio
n
g
r
o
u
p
(
7
0
.
8
3
%)
co
m
p
ar
e
d
to
th
e
co
n
tr
o
l
g
r
o
u
p
(
3
1
.
7
6
%),
s
u
g
g
esti
n
g
th
e
in
ter
v
e
n
tio
n
'
s
p
o
ten
tial
e
f
f
ec
tiv
en
ess
in
i
m
p
r
o
v
i
n
g
g
ly
ce
m
ic
co
n
tr
o
l a
m
o
n
g
p
ar
ticip
an
ts
.
T
h
e
in
ter
v
e
n
tio
n
g
r
o
u
p
s
h
o
wed
n
o
ta
b
le
im
p
r
o
v
em
en
ts
in
d
ia
b
etes
k
n
o
wled
g
e
p
o
s
t
-
in
ter
v
en
tio
n
,
with
in
ter
m
ed
iate
k
n
o
wled
g
e
r
is
in
g
f
r
o
m
1
3
.
9
%
to
4
3
.
0
6
%
an
d
p
o
o
r
k
n
o
wled
g
e
d
ec
lin
in
g
f
r
o
m
4
5
.
8
%
to
2
6
.
3
9
%,
alth
o
u
g
h
g
o
o
d
k
n
o
wled
g
e
d
ec
r
ea
s
ed
f
r
o
m
4
0
.
3
%
to
3
0
.
5
6
%
.
T
h
e
co
n
tr
o
l
g
r
o
u
p
ex
h
i
b
ited
m
in
im
al
ch
an
g
es,
with
p
o
o
r
k
n
o
w
led
g
e
r
em
ai
n
in
g
r
elativ
ely
s
tab
le
(
6
3
.
5
3
%
to
6
1
.
1
8
%)
an
d
in
ter
m
e
d
iate
k
n
o
wled
g
e
s
lig
h
tl
y
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.
15
,
No
.
2
,
J
u
n
e
20
26
:
3
7
8
-
3
8
8
382
in
cr
ea
s
in
g
(
3
5
.
2
9
%
to
3
7
.
6
5
%).
T
h
ese
f
in
d
in
g
s
s
u
g
g
est
th
e
in
ter
v
en
tio
n
ef
f
ec
tiv
ely
en
h
an
ce
d
d
iab
etes
k
n
o
wled
g
e
i
n
th
e
in
ter
v
en
tio
n
g
r
o
u
p
co
m
p
ar
ed
t
o
th
e
co
n
tr
o
l
g
r
o
u
p
,
as sh
o
wn
i
n
T
ab
le
2
.
T
ab
le
3
p
r
esen
ts
th
e
d
is
tr
ib
u
tio
n
o
f
e
d
u
ca
tio
n
al
s
u
p
p
o
r
t
s
co
r
es
f
o
r
f
am
ily
m
em
b
er
s
o
f
D
M
p
atien
ts
ac
r
o
s
s
in
ter
v
en
tio
n
an
d
co
n
tr
o
l
g
r
o
u
p
s
.
T
h
e
in
te
r
v
en
tio
n
g
r
o
u
p
d
em
o
n
s
tr
ated
s
ig
n
if
ican
t
im
p
r
o
v
e
m
en
ts
p
o
s
t
-
in
ter
v
en
tio
n
,
with
o
v
er
all
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
m
ea
n
s
co
r
es
i
n
cr
ea
s
in
g
f
r
o
m
6
1
.
8
1
to
9
0
.
8
5
.
T
h
e
co
n
tr
o
l
g
r
o
u
p
s
h
o
wed
a
c
o
m
p
a
r
ativ
ely
m
o
d
est
in
cr
ea
s
e,
f
r
o
m
5
5
.
0
5
to
6
4
.
4
5
.
T
h
ese
f
in
d
in
g
s
s
u
g
g
est
th
at
th
e
in
ter
v
en
tio
n
was
m
o
r
e
ef
f
ec
tiv
e
in
en
h
an
ci
n
g
u
n
d
e
r
s
tan
d
in
g
an
d
s
k
ills
r
elate
d
to
DM
m
an
ag
em
en
t
am
o
n
g
th
e
in
ter
v
en
tio
n
g
r
o
u
p
.
Fu
r
th
e
r
an
aly
s
is
is
war
r
an
ted
to
id
e
n
tify
f
ac
to
r
s
in
f
lu
e
n
cin
g
th
ese
o
u
tco
m
es.
T
ab
le
4
p
r
esen
ts
t
-
test
r
esu
lts
co
m
p
ar
in
g
f
am
ily
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
b
eh
av
io
r
s
b
ef
o
r
e
an
d
af
ter
in
ter
v
en
tio
n
.
T
h
e
in
ter
v
e
n
tio
n
g
r
o
u
p
s
h
o
w
ed
s
ig
n
if
ican
tl
y
g
r
ea
ter
m
ea
n
ch
a
n
g
es
ac
r
o
s
s
all
ca
teg
o
r
ies
:
n
u
tr
itio
n
al
r
eg
u
latio
n
,
p
h
y
s
ical
ex
er
cise,
p
h
ar
m
ac
o
lo
g
ical
th
er
ap
y
,
s
tr
ess
m
an
ag
em
en
t,
s
elf
-
b
lo
o
d
s
u
g
ar
test
,
an
d
o
v
er
all
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
(
all
p
≤
.
0
0
1
)
.
C
o
n
v
er
s
ely
,
th
e
co
n
tr
o
l
g
r
o
u
p
d
em
o
n
s
t
r
ated
s
ig
n
if
ican
t
ch
an
g
es
o
n
ly
in
n
u
tr
itio
n
al
r
e
g
u
latio
n
(
p
=
.
0
3
2
)
a
n
d
p
h
y
s
ical
ex
er
cise
(
p
=
.
0
0
8
)
,
with
n
o
n
-
s
ig
n
if
ican
t
r
esu
lts
in
th
e
r
em
ain
i
n
g
ca
teg
o
r
ies.
T
h
ese
f
in
d
in
g
s
in
d
icate
th
e
ed
u
ca
tio
n
al
in
ter
v
en
tio
n
ef
f
ec
tiv
e
ly
en
h
an
ce
d
f
am
ily
s
u
p
p
o
r
tiv
e
b
eh
a
v
i
o
r
s
co
m
p
a
r
e
d
to
th
e
c
o
n
tr
o
l
g
r
o
u
p
.
T
ab
le
5
p
r
esen
ts
th
e
m
ea
n
s
,
s
tan
d
ar
d
d
ev
iatio
n
s
,
an
d
s
tan
d
ar
d
er
r
o
r
s
o
f
f
a
m
ily
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
s
er
v
ices
b
ef
o
r
e
an
d
af
ter
t
h
e
in
ter
v
en
tio
n
ac
r
o
s
s
b
o
th
g
r
o
u
p
s
.
T
h
e
in
ter
v
e
n
tio
n
g
r
o
u
p
d
em
o
n
s
tr
ated
s
u
b
s
tan
tial
im
p
r
o
v
em
e
n
ts
ac
r
o
s
s
all
v
ar
iab
les:
n
u
tr
itio
n
al
r
eg
u
latio
n
(
1
8
.
5
7
to
2
4
.
5
0
)
,
p
h
y
s
ical
ex
er
cise,
p
h
ar
m
ac
o
l
o
g
ical
th
e
r
ap
y
,
an
d
o
v
er
all
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
(
6
1
.
8
1
to
9
0
.
8
5
)
.
I
n
co
n
tr
ast,
th
e
c
o
n
tr
o
l
g
r
o
u
p
s
h
o
wed
co
m
p
ar
ativ
ely
m
o
d
est
in
cr
ea
s
es,
with
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
r
is
in
g
o
n
ly
f
r
o
m
5
5
.
0
5
to
6
4
.
4
5
.
T
h
ese
f
in
d
in
g
s
s
u
g
g
est
th
at
th
e
in
ter
v
en
tio
n
ef
f
ec
ti
v
ely
en
h
an
ce
d
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
an
d
its
r
elate
d
co
m
p
o
n
e
n
ts
am
o
n
g
f
am
ily
m
em
b
er
s
o
f
D
M
p
atien
ts
.
T
ab
le
1
.
Dis
tr
ib
u
tio
n
o
f
r
esp
o
n
d
en
t c
h
a
r
ac
ter
is
tics
R
e
s
p
o
n
d
e
n
t
c
h
a
r
a
c
t
e
r
i
st
i
c
s
I
n
t
e
r
v
e
n
t
i
o
n
g
r
o
u
p
G
r
o
u
p
c
o
n
t
r
o
l
To
t
a
l
P
r
e
sen
t
a
t
i
o
n
To
t
a
l
P
r
e
sen
t
a
t
i
o
n
R
e
s
p
o
n
d
e
n
t
's
a
g
e
N
o
t
y
e
t
p
r
o
d
u
c
t
i
v
e
0
0
0
0
P
r
o
d
u
c
t
i
v
e
66
9
1
.
6
7
80
9
4
.
1
2
n
o
n
-
p
r
o
d
u
c
t
i
v
e
6
8
.
3
3
5
5
.
8
8
72
1
0
0
%
85
1
0
0
%
A
g
e
o
f
D
M
p
a
t
i
e
n
t
s
N
o
t
y
e
t
p
r
o
d
u
c
t
i
v
e
0
0
.
0
0
0
0
.
0
0
P
r
o
d
u
c
t
i
v
e
56
7
7
.
7
8
60
7
0
.
5
9
n
o
n
-
p
r
o
d
u
c
t
i
v
e
16
2
2
.
2
2
25
2
9
.
4
1
72
1
0
0
%
85
1
0
0
%
G
e
n
d
e
r
M
a
n
13
1
8
.
0
6
21
2
4
.
7
1
W
o
ma
n
59
8
1
.
9
4
64
7
5
.
2
9
72
1
0
0
%
85
1
0
0
%
Lo
n
g
-
t
i
m
e
s
u
f
f
e
r
i
n
g
f
r
o
m D
M
≥
1
y
e
a
r
29
4
0
.
3
16
1
8
.
8
2
1
.
1
-
3
y
e
a
r
s
6
8
.
3
19
2
2
.
3
5
≤
3
y
e
a
r
s
37
5
1
.
4
50
5
8
.
8
2
72
1
0
0
%
85
1
0
0
%
B
l
o
o
d
s
u
g
a
r
v
a
l
u
e
B
e
f
o
r
e
i
n
t
e
r
v
e
n
t
i
o
n
(
<
2
0
0
)
29
4
0
.
3
31
3
6
.
4
7
(
>
2
0
0
)
43
5
9
.
7
54
6
3
.
5
3
A
f
t
e
r
t
h
e
i
n
t
e
r
v
e
n
t
i
o
n
(
<
2
0
0
)
51
7
0
.
8
3
27
3
1
.
7
6
(
>
2
0
0
)
21
2
9
.
1
7
58
6
8
.
2
4
T
a
b
l
e
2
.
D
is
t
r
i
b
u
ti
o
n
o
f
k
n
o
w
l
e
d
g
e
b
e
f
o
r
e
a
n
d
a
f
t
e
r
i
n
t
e
r
v
e
n
t
io
n
i
n
t
h
e
i
n
t
e
r
v
e
n
t
i
o
n
g
r
o
u
p
a
n
d
t
h
e
c
o
n
t
r
o
l
g
r
o
u
p
K
n
o
w
l
e
d
g
e
a
b
o
u
t
D
M
I
n
t
e
r
v
e
n
t
i
o
n
g
r
o
u
p
C
o
n
t
r
o
l
g
r
o
u
p
To
t
a
l
%
To
t
a
l
%
To
t
a
l
%
To
t
a
l
%
B
e
f
o
r
e
A
f
t
e
r
B
e
f
o
r
e
A
f
t
e
r
G
o
o
d
29
4
0
.
3
22
3
0
.
5
6
1
1
.
1
8
1
1
.
1
8
I
n
t
e
r
med
i
a
t
e
10
1
3
.
9
31
4
3
.
0
6
30
3
5
.
2
9
32
3
7
.
6
5
P
o
o
r
33
4
5
.
8
19
2
6
.
3
9
54
6
3
.
5
3
52
6
1
.
1
8
T
h
e
in
d
ep
en
d
en
t
t
-
t
e
s
t
r
e
s
u
l
ts
in
T
ab
le
6
in
d
ic
at
e
th
a
t
b
ef
o
r
e
th
e
in
te
r
v
en
tio
n
,
n
o
s
i
g
n
if
ic
an
t
d
if
f
e
r
en
c
e
s
ex
i
s
t
ed
in
f
am
ily
ed
u
ca
t
io
n
a
l
s
u
p
p
o
r
t
b
e
tw
ee
n
i
n
ter
v
en
t
io
n
an
d
co
n
tr
o
l
g
r
o
u
p
s
f
o
r
ex
er
ci
s
e
(
p
=
0
.
0
7
8
)
,
p
h
ar
m
ac
o
lo
g
i
ca
l
th
er
ap
y
(
p
=
0
.
8
2
5
)
,
an
d
s
tr
e
s
s
m
an
ag
em
en
t
(
p
=
0
.
3
7
3
)
,
ex
ce
p
t
n
u
t
r
i
tio
n
(
p
<
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Dev
elo
p
men
t o
f a
s
u
p
p
o
r
tive
-
ed
u
ca
tive
h
e
a
lth
ed
u
c
a
tio
n
in
t
erven
tio
n
fo
r
fa
mily
… (
S
iti F
a
to
n
a
h
)
383
0
.
0
0
1
)
.
A
f
t
er
th
e
in
ter
v
en
t
io
n
,
al
l
a
s
p
e
ct
s
s
h
o
wed
s
ig
n
if
i
ca
n
t
d
if
f
er
en
ce
s
(
p
<
0
.
0
0
1
)
,
wi
th
th
e
h
ig
h
e
s
t
in
cr
ea
s
e
in
o
v
er
a
ll
ed
u
c
at
i
o
n
al
s
u
p
p
o
r
t
(
m
ea
n
d
if
f
er
e
n
ce
2
6
.
4
0
)
.
T
h
e
s
e
f
in
d
in
g
s
d
em
o
n
s
t
r
a
te
th
e
ef
f
e
c
t
iv
en
e
s
s
o
f
th
e
in
t
er
v
en
t
i
o
n
in
en
h
an
cin
g
f
am
i
ly
ed
u
c
at
io
n
a
l
s
u
p
p
o
r
t
f
o
r
d
i
ab
e
te
s
m
el
li
tu
s
p
at
ien
t
s
,
a
s
f
u
r
th
e
r
i
l
lu
s
tr
at
ed
in
Fig
u
r
e
1
,
wh
i
ch
c
o
m
p
ar
e
s
ed
u
ca
ti
o
n
a
l
s
u
p
p
o
r
t b
ef
o
r
e
an
d
af
ter
th
e
in
t
er
v
en
tio
n
.
T
ab
le
3
.
Dis
tr
ib
u
tio
n
o
f
m
ea
n
v
alu
es,
s
tan
d
ar
d
d
ev
iatio
n
s
,
an
d
s
tan
d
ar
d
e
r
r
o
r
s
o
f
f
am
ily
ed
u
ca
tio
n
al
s
u
p
p
o
r
t
f
o
r
f
am
ily
m
em
b
e
r
s
o
f
DM
p
a
tien
ts
b
ef
o
r
e
an
d
af
ter
in
two
g
r
o
u
p
s
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
i
v
e
su
b
-
v
a
r
i
a
b
l
e
I
n
t
e
r
v
e
n
t
i
o
n
C
o
n
t
r
o
l
M
e
a
n
S
t
d
.
d
ev
S
t
d
.
e
r
r
o
r
M
e
a
n
S
t
d
.
d
ev
S
t
d
.
e
r
r
o
r
N
u
t
r
i
t
i
o
n
a
l
r
e
g
u
l
a
t
i
o
n
B
e
f
o
r
e
1
8
.
5
7
1
1
.
5
7
1
.
3
6
1
2
.
6
6
9
.
1
4
.
9
9
A
f
t
e
r
2
4
.
5
0
8
.
7
5
1
.
0
3
1
5
.
8
5
9
.
7
1
1
.
0
5
P
h
y
s
i
c
a
l
e
x
e
r
c
i
se
B
e
f
o
r
e
1
0
.
2
2
7
.
8
8
.
9
3
8
.
1
4
6
.
8
2
.
7
4
A
f
t
e
r
1
5
.
1
0
7
.
8
6
.
9
2
6
1
0
.
8
9
6
.
9
4
.
7
5
P
h
a
r
ma
c
o
l
o
g
i
c
a
l
t
h
e
r
a
p
y
B
e
f
o
r
e
1
0
.
8
8
1
0
:
5
2
1
.
2
4
1
0
:
5
5
7
.
6
5
.
8
3
A
f
t
e
r
1
7
.
4
7
6
.
6
7
.
7
9
1
0
.
9
4
7
.
6
7
.
8
3
S
t
r
e
ss m
a
n
a
g
e
me
n
t
B
e
f
o
r
e
1
0
.
1
9
5
.
7
5
.
6
8
9
.
4
1
5
.
2
1
.
5
7
A
f
t
e
r
1
3
.
9
0
5
.
9
5
.
7
0
1
0
.
5
4
4
.
9
8
.
5
4
S
e
l
f
-
b
l
o
o
d
s
u
g
a
r
t
e
st
B
e
f
o
r
e
1
1
.
9
4
8
.
6
2
1
.
0
1
1
4
.
2
8
8
.
1
1
.
8
8
A
f
t
e
r
1
9
.
8
8
8
.
2
3
.
9
7
1
6
.
2
2
8
.
0
0
.
8
7
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
B
e
f
o
r
e
6
1
.
8
1
3
4
.
5
3
4
.
0
7
5
5
.
0
5
3
2
.
2
8
3
.
5
0
A
f
t
e
r
9
0
.
8
5
2
2
.
8
1
2
.
6
9
6
4
.
4
5
2
9
.
0
4
3
.
1
5
T
ab
le
4
.
t
-
t
est an
aly
s
is
o
f
f
am
i
ly
ed
u
ca
tio
n
al
s
u
p
p
o
r
t f
o
r
f
am
ily
m
em
b
er
s
o
f
DM
p
atien
ts
b
ef
o
r
e
an
d
af
ter
in
ter
v
en
tio
n
i
n
b
o
t
h
g
r
o
u
p
s
F
a
mi
l
y
e
d
u
c
a
t
i
o
n
a
l
su
p
p
o
r
t
i
v
e
b
e
h
a
v
i
o
r
I
n
t
e
r
v
e
n
t
i
o
n
C
o
n
t
r
o
l
M
e
a
n
S
t
d
.
d
ev
S
E
m
e
a
n
p
-
v
a
l
u
e
M
e
a
n
S
t
d
.
d
ev
S
E
m
e
a
n
p
-
v
a
l
u
e
N
u
t
r
i
t
i
o
n
a
l
r
e
g
u
l
a
t
i
o
n
-
5
.
9
3
1
2
.
7
4
1
.
5
0
.
0
0
0
-
3
.
1
9
1
3
.
5
1
1
.
4
7
.
0
3
2
P
h
y
s
i
c
a
l
e
x
e
r
c
i
se
-
4
.
8
8
1
0
.
6
0
1
.
2
5
.
0
0
0
-
2
.
7
5
9
.
3
7
1
.
0
2
.
0
0
8
P
h
a
r
ma
c
o
l
o
g
i
c
a
l
t
h
e
r
a
p
y
-
6
.
6
0
1
0
.
7
9
1
.
2
7
.
0
0
0
-
.
3
8
9
1
0
.
8
4
1
.
1
8
.
7
4
2
S
t
r
e
ss m
a
n
a
g
e
me
n
t
-
3
.
7
1
8
.
7
2
1
.
0
3
.
0
0
1
-
1
.
1
3
7
.
2
1
.
7
8
.
1
5
2
S
e
l
f
-
b
l
o
o
d
s
u
g
a
r
t
e
st
-
7
.
9
3
1
1
.
0
1
1
.
3
0
.
0
0
0
-
1
.
9
4
1
1
.
9
4
1
.
2
9
.
1
3
8
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
i
v
e
-
2
9
.
0
4
3
8
.
0
7
4
,
4
8
7
.
0
0
0
-
9
.
4
0
4
4
.
3
2
4
.
8
1
.
0
5
4
T
ab
le
5
.
Dis
tr
ib
u
tio
n
o
f
m
ea
n
,
s
tan
d
ar
d
d
e
v
iatio
n
,
a
n
d
s
tan
d
ar
d
er
r
o
r
o
f
f
am
ily
e
d
u
ca
tio
n
al
s
u
p
p
o
r
tiv
e
s
er
v
ices f
o
r
f
am
ily
m
em
b
er
s
o
f
DM
p
atien
ts
b
ef
o
r
e
an
d
a
f
ter
in
ter
v
en
tio
n
in
two
g
r
o
u
p
s
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
i
v
e
su
b
-
v
a
r
i
a
b
l
e
B
e
f
o
r
e
i
n
t
e
r
v
e
n
t
i
o
n
A
f
t
e
r
i
n
t
e
r
v
e
n
t
i
o
n
M
e
a
n
S
t
d
.
d
ev
S
t
d
.
e
r
r
o
r
M
e
a
n
S
t
d
.
d
ev
S
t
d
.
e
r
r
o
r
N
u
t
r
i
t
i
o
n
a
l
r
e
g
u
l
a
t
i
o
n
I
n
t
e
r
v
e
n
t
i
o
n
1
8
.
5
7
1
1
.
5
7
1
.
3
6
2
4
.
5
0
8
.
7
5
1
.
0
3
c
o
n
t
r
o
l
1
2
.
6
6
9
.
1
4
.
9
9
1
5
.
8
5
9
.
7
1
1
.
0
5
P
h
y
s
i
c
a
l
e
x
e
r
c
i
se
I
n
t
e
r
v
e
n
t
i
o
n
1
0
.
2
2
7
.
8
8
.
9
3
1
5
.
1
0
7
.
8
6
.
9
3
c
o
n
t
r
o
l
8
.
1
4
6
.
8
2
.
7
4
1
0
.
8
9
6
.
9
4
.
7
5
P
h
a
r
ma
c
o
l
o
g
i
c
a
l
t
h
e
r
a
p
y
I
n
t
e
r
v
e
n
t
i
o
n
1
0
.
8
8
1
0
:
5
2
1
.
2
4
1
7
.
4
7
6
.
6
7
.
7
9
c
o
n
t
r
o
l
1
0
:
5
5
7
.
6
5
.
8
3
1
0
.
9
4
7
.
6
7
.
8
3
S
t
r
e
ss m
a
n
a
g
e
me
n
t
I
n
t
e
r
v
e
n
t
i
o
n
1
0
.
1
9
5
.
7
5
.
6
8
1
3
.
9
0
5
.
9
5
.
7
0
c
o
n
t
r
o
l
9
.
4
1
5
.
2
1
.
5
7
1
0
.
5
4
4
.
9
8
.
5
4
S
e
l
f
-
b
l
o
o
d
s
u
g
a
r
t
e
st
I
n
t
e
r
v
e
n
t
i
o
n
1
1
.
9
4
8
.
6
2
1
.
0
2
1
9
.
8
8
8
.
2
3
.
9
7
c
o
n
t
r
o
l
1
4
.
2
8
8
.
1
1
.
8
8
1
6
.
2
2
7
.
9
9
.
8
7
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
I
n
t
e
r
v
e
n
t
i
o
n
6
1
.
8
1
3
4
.
5
3
4
.
0
7
9
0
.
8
5
2
2
.
8
1
2
.
6
9
c
o
n
t
r
o
l
5
5
.
0
5
3
2
.
2
8
3
.
5
0
6
4
.
4
5
2
9
.
0
4
3
.
1
5
T
ab
le
6
.
I
n
d
ep
e
n
d
en
t
t
-
t
est an
aly
s
is
o
f
f
am
ily
ed
u
ca
tio
n
al
s
u
p
p
o
r
t f
o
r
f
a
m
ily
m
em
b
er
s
o
f
DM
p
atien
ts
b
ef
o
r
e
in
ter
v
en
tio
n
i
n
th
e
in
ter
v
en
tio
n
an
d
c
o
n
tr
o
l
g
r
o
u
p
s
F
a
mi
l
y
e
d
u
c
a
t
i
o
n
a
l
su
p
p
o
r
t
B
e
f
o
r
e
A
f
t
e
r
M
e
a
n
d
i
f
f
S
t
a
n
d
a
r
d
e
r
r
o
r
d
i
f
f
e
r
e
n
c
e
p
-
v
a
l
u
e
M
e
a
n
d
i
f
f
S
t
a
n
d
a
r
d
e
r
r
o
r
d
i
f
f
e
r
e
n
c
e
p
-
v
a
l
u
e
N
u
t
r
i
t
i
o
n
a
l
r
e
g
u
l
a
t
i
o
n
5
.
9
1
1
.
6
5
.
0
0
0
8
.
6
5
1
.
4
9
.
0
0
0
P
h
y
s
i
c
a
l
e
x
e
r
c
i
se
2
.
0
8
1
.
1
7
.
0
7
8
4
.
2
0
1
.
1
8
.
0
0
0
P
h
a
r
ma
c
o
l
o
g
i
c
a
l
t
h
e
r
a
p
y
.
3
2
1
.
4
5
.
8
2
5
6
.
5
3
1
.
1
6
.
0
0
0
S
t
r
e
ss m
a
n
a
g
e
me
n
t
.
7
8
.
8
8
.
3
7
3
3
.
3
6
.
8
7
.
0
0
0
S
e
l
f
-
b
l
o
o
d
s
u
g
a
r
t
e
st
-
2
.
3
4
1
.
3
4
.
0
8
2
3
.
6
5
1
.
3
0
.
0
0
0
Ed
u
c
a
t
i
o
n
a
l
s
u
p
p
o
r
t
i
v
e
6
.
7
6
5
.
3
4
.
2
0
7
2
6
.
4
0
4
.
2
2
.
0
0
0
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.
15
,
No
.
2
,
J
u
n
e
20
26
:
3
7
8
-
3
8
8
384
Fig
u
r
e
1
.
E
d
u
ca
tio
n
al
s
u
p
p
o
r
t: b
ef
o
r
e
v
s
.
af
ter
c
o
m
p
ar
is
o
n
T
h
e
d
at
a
f
r
o
m
T
ab
l
e
2
in
d
ica
te
a
s
ig
n
if
i
ca
n
t
im
p
r
o
v
em
en
t
in
d
iab
e
t
ic
k
n
o
w
led
g
e
am
o
n
g
p
ar
t
ic
ip
an
t
s
in
th
e
in
t
er
v
en
ti
o
n
g
r
o
u
p
.
Prio
r
to
th
e
in
te
r
v
en
t
io
n
,
4
5
.
8
%
o
f
th
e
p
ar
ti
cip
an
ts
d
em
o
n
s
tr
a
ted
p
o
o
r
k
n
o
wl
ed
g
e
o
f
d
i
ab
e
te
s
,
wh
ich
d
ec
r
ea
s
ed
to
2
6
.
3
9
%
f
o
llo
w
i
n
g
th
e
e
d
u
ca
t
io
n
a
l
in
t
er
v
e
n
t
io
n
.
C
o
n
v
e
r
s
el
y
,
th
e
p
r
o
p
o
r
t
io
n
o
f
p
a
r
t
ic
ip
an
t
s
w
it
h
in
t
er
m
ed
ia
te
k
n
o
w
led
g
e
s
u
r
g
ed
f
r
o
m
1
3
.
9
%
to
4
3
.
0
6
%
af
ter
th
e
i
n
te
r
v
en
tio
n
,
s
h
o
wca
s
in
g
a
s
u
b
s
t
an
t
ia
l
s
h
i
f
t
in
u
n
d
er
s
t
an
d
in
g
.
T
h
i
s
s
u
p
p
o
r
t
s
f
i
n
d
in
g
s
b
y
An
g
g
r
a
en
i
et
a
l.
[
2
0
]
,
wh
o
n
o
te
d
th
a
t
ed
u
ca
tio
n
al
p
r
o
g
r
a
m
s
ef
f
ec
tiv
ely
en
h
an
ce
k
n
o
w
led
g
e
lev
e
l
s
a
m
o
n
g
t
y
p
e
2
d
iab
et
es
p
at
ien
t
s
th
r
o
u
g
h
in
f
o
r
m
at
io
n
a
l
r
eso
u
r
c
es
an
d
co
u
n
s
el
l
in
g
.
Sim
i
lar
ly
,
E
l
-
Say
ed
e
t
a
l.
[
2
1
]
af
f
ir
m
ed
th
a
t
ed
u
c
at
io
n
al
in
t
er
v
en
t
io
n
s
s
ig
n
if
i
ca
n
tly
im
p
r
o
v
ed
b
o
th
k
n
o
w
led
g
e
an
d
s
e
lf
-
ef
f
i
ca
cy
,
a
li
g
n
in
g
wi
th
V
ar
m
a
's
f
in
d
in
g
s
o
n
en
h
an
c
ed
p
at
ien
t k
n
o
w
led
g
e
p
o
s
t
-
in
ter
v
en
tio
n
s
e
s
s
io
n
s
.
I
n
t
h
e
co
n
tr
o
l g
r
o
u
p
,
th
e
n
u
m
b
er
s
r
em
a
in
e
d
r
el
at
iv
e
ly
s
t
at
ic
;
th
e
p
r
o
p
o
r
t
io
n
o
f
in
d
iv
i
d
u
a
ls
c
la
s
s
if
ie
d
u
n
d
er
"g
o
o
d
"
k
n
o
wl
ed
g
e
co
n
s
is
ten
t
ly
r
e
m
ai
n
ed
a
t
1
.
1
8
%
,
in
d
ica
t
in
g
a
lac
k
o
f
s
ig
n
if
ica
n
t
i
m
p
r
o
v
em
en
t
.
T
h
is
s
t
at
ic
s
i
tu
a
ti
o
n
co
n
tr
a
s
t
s
s
ta
r
k
ly
wi
th
th
e
in
t
er
v
en
t
io
n
g
r
o
u
p
's
d
y
n
am
ic
ch
an
g
e
s
,
wh
i
ch
co
n
cu
r
w
it
h
th
e
o
b
s
e
r
v
a
tio
n
s
r
ep
o
r
ted
b
y
Hi
jr
i
an
a
et
a
l
.
[
2
2
]
,
s
u
g
g
e
s
tin
g
th
a
t
ed
u
c
at
io
n
a
l
o
u
tr
e
ac
h
th
r
o
u
g
h
s
tr
u
c
tu
r
ed
p
r
o
g
r
am
s
i
s
e
s
s
en
t
ia
l
f
o
r
k
n
o
wl
ed
g
e
en
h
a
n
ce
m
en
t,
p
ar
t
ic
u
lar
ly
in
th
e
co
n
tex
t
o
f
d
ia
b
ete
s
.
Fu
r
th
er
m
o
r
e,
R
o
c
h
m
ah
e
t
a
l.
[
2
3
]
co
r
r
o
b
o
r
ate
th
e
ef
f
e
ct
iv
en
e
s
s
o
f
ed
u
ca
tio
n
al
in
ter
v
en
tio
n
s
ac
r
o
s
s
v
a
r
ied
d
em
o
g
r
ap
h
ic
s
,
d
em
o
n
s
t
r
at
in
g
th
eir
b
r
o
ad
a
p
p
li
ca
b
il
ity
.
I
n
t
er
m
s
o
f
ed
u
ca
tio
n
al
s
u
p
p
o
r
t,
T
a
b
l
e
3
d
e
m
o
n
s
tr
at
e
s
n
o
tab
le
ev
id
en
ce
o
f
im
p
r
o
v
e
m
e
n
t
s
in
th
e
in
t
er
v
en
t
io
n
g
r
o
u
p
p
r
e
-
an
d
p
o
s
t
-
in
te
r
v
en
tio
n
.
T
h
e
m
ea
n
s
co
r
e
f
o
r
n
u
tr
it
io
n
a
l
r
eg
u
la
ti
o
n
in
cr
e
a
s
ed
f
r
o
m
1
8
.
5
7
to
2
4
.
5
0
,
an
d
f
o
r
p
h
y
s
ic
al
ex
er
ci
s
e
f
r
o
m
1
0
.
2
2
to
1
5
.
1
0
,
in
d
ic
at
in
g
th
a
t
ed
u
c
at
io
n
h
as
eq
u
ip
p
ed
f
am
il
y
m
em
b
e
r
s
to
b
et
te
r
s
u
p
p
o
r
t
d
ia
b
et
ic
p
a
ti
en
t
s
in
m
an
ag
in
g
t
h
e
ir
co
n
d
it
io
n
s
.
T
h
i
s
co
m
p
r
eh
en
s
i
v
e
en
h
an
ce
m
en
t
o
f
f
a
m
i
ly
-
s
u
p
p
o
r
ted
b
eh
av
io
r
s
i
s
cr
u
c
ia
l,
a
s
ef
f
ec
t
iv
e
d
ia
b
ete
s
m
a
n
ag
e
m
en
t
o
f
te
n
n
ec
es
s
it
at
es
in
d
iv
id
u
al
ad
h
er
en
ce
an
d
th
e
in
v
o
lv
em
e
n
t
o
f
f
a
m
i
ly
s
y
s
t
em
s
[
2
4
]
.
A
d
d
it
io
n
a
l
ly
,
t
h
e
f
in
d
in
g
s
f
r
o
m
An
d
r
i
y
an
to
e
t
a
l.
f
u
r
th
e
r
em
p
h
a
s
iz
e
th
a
t
h
ea
l
t
h
ed
u
ca
tio
n
p
lay
s
a
f
o
u
n
d
a
tio
n
al
r
o
le
in
m
o
tiv
at
in
g
in
d
iv
id
u
al
s
t
o
w
ar
d
s
s
u
s
t
ain
ab
l
e
l
if
e
s
ty
le
ch
an
g
e
s
f
o
r
d
iab
et
es
m
an
a
g
em
en
t
[
2
4
]
.
I
n
co
n
tr
as
t,
th
e
co
n
tr
o
l
g
r
o
u
p
ex
h
ib
it
ed
m
o
d
e
s
t
in
cr
ea
s
e
s
in
s
u
p
p
o
r
t
iv
e
b
eh
av
io
r
s
;
f
o
r
in
s
tan
c
e,
n
u
tr
it
io
n
al
r
eg
u
la
tio
n
in
c
r
ea
s
ed
f
r
o
m
1
2
.
6
6
to
1
5
.
8
5
.
Ho
w
ev
er
,
th
e
o
v
er
a
ll
ch
an
g
e
s
wer
e
n
o
t
s
t
at
is
t
ica
l
ly
s
ig
n
if
i
ca
n
t
co
m
p
ar
e
d
to
th
e
in
te
r
v
e
n
tio
n
g
r
o
u
p
,
wh
er
e
n
o
tab
le
im
p
r
o
v
em
en
t
s
w
er
e
d
o
cu
m
en
ted
ac
r
o
s
s
a
ll
ed
u
c
at
i
o
n
al
s
u
p
p
o
r
t
d
i
m
en
s
io
n
s
[
2
5
]
.
T
h
e
o
b
s
er
v
at
io
n
s
co
r
r
e
la
te
w
ith
f
in
d
in
g
s
b
y
H
am
d
i
an
d
J
a
s
im
[
2
5
]
,
wh
ich
em
p
h
a
s
ize
d
th
e
n
e
ed
f
o
r
s
tr
u
ctu
r
ed
ed
u
ca
tio
n
a
l
in
t
er
v
en
t
io
n
s
to
i
m
p
r
o
v
e
k
n
o
wl
ed
g
e
an
d
ca
r
e
b
eh
av
io
r
s
.
T
h
e
r
e
s
u
lt
s
o
f
th
e
t
-
t
e
s
t
an
a
ly
s
i
s
in
T
ab
le
4
r
ev
ea
l
th
e
ed
u
ca
t
io
n
a
l
im
p
ac
t
o
n
f
am
i
l
y
s
u
p
p
o
r
t
m
ea
s
u
r
es
,
p
a
r
t
icu
lar
ly
in
th
e
in
ter
v
en
t
io
n
g
r
o
u
p
.
S
ta
ti
s
ti
c
al
ly
s
ig
n
if
ic
an
t
p
-
v
a
lu
e
s
(
a
ll
<
0
.
0
5
)
a
cr
o
s
s
a
l
l
s
u
p
p
o
r
t
iv
e
b
e
h
av
io
r
s
e
m
p
h
a
s
ize
th
e
ef
f
ica
cy
o
f
th
e
in
t
er
v
en
t
io
n
.
T
h
e
in
te
r
v
en
tio
n
g
r
o
u
p
d
em
o
n
s
t
r
a
ted
a
n
o
tab
le
m
ea
n
im
p
r
o
v
em
en
t
o
f
s
u
p
p
o
r
t
iv
e
b
eh
av
io
r
s
,
r
e
in
f
o
r
cin
g
th
e
i
m
p
o
r
t
an
c
e
o
f
f
am
ily
in
v
o
lv
em
en
t
in
d
iab
et
es
s
e
lf
-
m
an
a
g
em
en
t
.
C
o
n
v
er
s
e
ly
,
th
e
co
n
tr
o
l
g
r
o
u
p
ex
h
ib
it
ed
a
p
-
v
a
l
u
e
o
f
0
.
0
5
4
f
o
r
ed
u
c
at
io
n
a
l
s
u
p
p
o
r
t
iv
e
b
eh
av
io
r
s
,
in
d
ica
tin
g
n
e
g
l
ig
ib
le
im
p
r
o
v
em
en
t
an
d
r
e
in
f
o
r
ci
n
g
th
e
a
r
g
u
m
en
t
th
at
d
e
l
ib
er
at
e
ed
u
ca
t
io
n
a
l
in
ter
v
en
t
io
n
i
s
e
s
s
en
ti
al
f
o
r
f
o
s
ter
in
g
ef
f
ec
ti
v
e
f
am
i
ly
s
u
p
p
o
r
t
b
eh
av
io
r
s
r
eg
ar
d
i
n
g
d
iab
et
e
s
m
an
ag
em
en
t
[2
6
]
.
Sar
i
et
a
l.
[2
7
]
af
f
ir
m
th
e
s
e
f
i
n
d
in
g
s
,
n
o
tin
g
th
at
s
tr
o
n
g
f
am
ily
s
u
p
p
o
r
t
s
i
g
n
if
ic
an
t
ly
co
r
r
e
la
te
s
wi
th
im
p
r
o
v
ed
s
elf
-
ef
f
i
ca
cy
an
d
b
e
tt
er
m
an
ag
em
e
n
t p
r
ac
ti
ce
s
a
m
o
n
g
d
iab
et
e
s
p
at
ien
ts
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Dev
elo
p
men
t o
f a
s
u
p
p
o
r
tive
-
ed
u
ca
tive
h
e
a
lth
ed
u
c
a
tio
n
in
t
erven
tio
n
fo
r
fa
mily
… (
S
iti F
a
to
n
a
h
)
385
Mo
r
eo
v
er
,
th
e
o
v
er
a
l
l
an
aly
s
i
s
e
m
p
h
a
s
ize
s
th
a
t
w
h
i
le
in
i
ti
a
l
k
n
o
w
le
d
g
e
lev
el
s
in
b
o
th
g
r
o
u
p
s
wer
e
in
ad
eq
u
a
te,
th
e
s
tr
u
ctu
r
ed
e
d
u
ca
t
io
n
al
m
et
h
o
d
o
l
o
g
i
es
ap
p
l
ied
in
t
h
e
in
t
er
v
en
t
io
n
g
r
o
u
p
y
ie
ld
ed
s
u
b
s
tan
ti
al
k
n
o
wl
ed
g
e
a
cq
u
is
i
tio
n
an
d
b
eh
av
io
r
al
ch
an
g
es
[
2
8
]
.
T
h
e
im
p
o
r
t
an
ce
o
f
ad
d
r
e
s
s
in
g
b
o
th
d
i
ab
e
te
s
m
an
ag
em
en
t
k
n
o
w
led
g
e
an
d
f
am
i
ly
s
u
p
p
o
r
t
d
y
n
am
ic
s
ca
n
n
o
t
b
e
o
v
er
s
ta
ted
,
a
s
th
e
s
e
f
a
cto
r
s
co
n
t
r
ib
u
te
t
o
im
p
r
o
v
ed
g
ly
ce
m
ic
co
n
tr
o
l
a
n
d
r
ed
u
c
ed
r
i
s
k
s
o
f
co
m
p
l
ic
a
tio
n
s
a
s
s
o
ci
at
ed
w
ith
d
iab
et
e
s
[
29
]
.
T
h
e
p
iv
o
t
al
r
o
le
o
f
e
d
u
ca
t
io
n
a
l
p
r
o
g
r
a
m
s
i
s
u
n
d
e
r
s
co
r
ed
b
y
th
e
r
el
at
io
n
s
h
ip
b
et
w
e
en
k
n
o
w
led
g
e
en
r
i
ch
m
en
t
an
d
b
eh
av
io
r
a
l
s
elf
-
m
an
ag
em
en
t
in
d
i
ab
e
ti
c
ca
r
e
[
3
0
]
.
Fu
tu
r
e
in
t
er
v
en
t
io
n
s
s
h
o
u
ld
n
o
t
o
n
ly
f
o
cu
s
o
n
th
e
in
d
iv
id
u
al
p
a
ti
en
t
b
u
t
a
l
s
o
ac
tiv
ely
in
v
o
lv
e
f
am
i
ly
m
em
b
e
r
s
to
cr
ea
te
a
s
u
p
p
o
r
t
iv
e
n
e
t
wo
r
k
th
a
t
en
h
a
n
ce
s
ad
h
er
en
ce
to
d
i
ab
e
te
s
m
an
a
g
e
m
en
t
p
r
a
ct
ic
es
.
T
h
e
m
e
an
s
co
r
e
s
o
f
f
am
i
ly
e
d
u
ca
tio
n
al
s
u
p
p
o
r
t
iv
e
s
e
r
v
i
ce
s
en
co
m
p
a
s
s
in
g
n
u
tr
i
ti
o
n
a
l
r
eg
u
l
at
io
n
,
p
h
y
s
ica
l
ex
er
c
i
s
e,
p
h
ar
m
a
co
lo
g
i
ca
l
th
e
r
ap
y
,
s
tr
e
s
s
m
an
ag
em
en
t,
s
e
lf
-
b
lo
o
d
s
u
g
ar
t
es
t
s
,
an
d
o
v
e
r
a
ll
ed
u
ca
t
io
n
a
l
s
u
p
p
o
r
t
r
ev
e
al
s
i
g
n
if
i
ca
n
t
s
h
if
t
s
p
o
s
t
-
in
ter
v
en
t
io
n
,
p
ar
t
ic
u
l
ar
ly
in
th
e
in
te
r
v
en
t
io
n
g
r
o
u
p
.
Fo
r
n
u
tr
i
t
io
n
a
l
r
eg
u
l
at
io
n
,
t
h
e
m
ea
n
s
co
r
e
in
cr
e
a
s
ed
f
r
o
m
1
8
.
5
7
b
e
f
o
r
e
in
ter
v
en
tio
n
to
2
4
.
5
0
a
f
t
er
w
ar
d
s
.
C
o
n
tr
a
s
tin
g
ly
,
th
e
co
n
tr
o
l
g
r
o
u
p
's
m
ea
n
s
c
o
r
e
s
h
o
w
ed
o
n
ly
a
m
o
d
e
s
t
in
cr
e
as
e
f
r
o
m
1
2
.
6
6
to
1
5
.
8
5
.
T
h
i
s
s
t
ar
k
d
i
f
f
er
en
c
e
s
ig
n
if
i
e
s
th
e
p
o
ten
ti
al
o
f
we
ll
-
s
tr
u
c
tu
r
ed
e
d
u
ca
tio
n
al
in
t
er
v
en
ti
o
n
s
to
in
s
t
i
ll
h
e
al
th
y
d
i
et
ar
y
p
r
ac
ti
ce
s
am
o
n
g
f
am
ily
m
e
m
b
er
s
,
a
lig
n
in
g
wi
th
f
in
d
in
g
s
f
r
o
m
He
e
t
a
l.
[3
1
]
,
w
h
ich
s
u
g
g
e
s
t
th
at
p
er
s
o
n
a
li
ze
d
n
u
tr
it
io
n
al
g
u
id
an
c
e
ca
n
im
p
r
o
v
e
s
elf
-
m
an
a
g
em
en
t
c
ap
ab
i
li
ti
e
s
in
p
a
ti
e
n
t
s
w
it
h
d
i
ab
e
te
s
.
Z
h
ao
et
a
l
.
[3
2
]
f
u
r
th
er
s
u
p
p
o
r
t
th
i
s
b
y
in
d
ic
at
in
g
th
a
t
ed
u
c
at
io
n
a
l
in
t
er
v
e
n
t
io
n
s
ef
f
e
ct
iv
e
ly
p
r
o
m
o
t
e
d
ie
tar
y
ad
h
er
en
ce
am
o
n
g
D
M
p
at
ien
t
s
.
T
h
e
p
h
y
s
ic
al
ex
er
c
i
s
e
d
im
en
s
i
o
n
lik
ew
i
s
e
ex
h
i
b
it
s
co
n
s
i
d
er
ab
le
i
m
p
r
o
v
e
m
en
t;
th
e
in
ter
v
en
t
io
n
g
r
o
u
p
's
m
e
an
s
co
r
e
in
cr
ea
s
ed
f
r
o
m
1
0
.
2
2
to
1
5
.
1
0
,
wh
i
le
th
e
co
n
t
r
o
l
g
r
o
u
p
o
n
ly
d
ep
i
ct
ed
a
r
i
s
e
f
r
o
m
8
.
1
4
to
1
0
.
8
9
.
T
h
e
s
t
at
i
s
t
ic
al
s
ig
n
if
i
ca
n
c
e
o
f
th
e
s
e
ch
an
g
e
s
,
a
s
ev
id
en
ce
d
in
th
e
in
d
ep
e
n
d
en
t
t
-
te
s
t
s
(
p
-
v
al
u
e
<
0
.
0
0
1
)
,
u
n
d
er
s
c
o
r
e
s
th
e
p
i
v
o
ta
l
r
o
le
o
f
ed
u
c
at
io
n
a
l
s
u
p
p
o
r
t
in
p
r
o
m
o
t
in
g
p
h
y
s
i
ca
l
a
ct
iv
i
ty
am
o
n
g
D
M
f
am
i
l
ie
s
,
a
th
em
e
e
ch
o
ed
b
y
Ok
af
o
r
e
t
a
l
.
[3
3
]
in
th
ei
r
ex
p
lo
r
a
ti
o
n
o
f
ed
u
c
at
io
n
al
p
r
o
g
r
am
s
e
m
p
h
a
s
iz
in
g
p
h
y
s
ica
l
ac
tiv
it
y
in
d
i
ab
e
ti
c
m
an
ag
em
en
t.
Mo
r
eo
v
er
,
C
h
e
n
et
a
l.
[3
4
]
u
n
d
er
lin
ed
th
a
t
th
o
s
e
ed
u
c
at
io
n
al
in
t
er
v
en
t
io
n
s
co
u
ld
s
ig
n
i
f
i
ca
n
tly
en
h
a
n
ce
p
ar
ti
cip
an
ts
'
p
h
y
s
i
ca
l
ac
t
iv
i
ty
lev
el
s
.
E
x
am
in
in
g
p
h
ar
m
ac
o
lo
g
i
ca
l
th
er
ap
y
,
th
e
in
ter
v
en
t
io
n
g
r
o
u
p
o
b
s
er
v
ed
a
r
e
m
ar
k
ab
l
e
i
n
cr
ea
s
e
i
n
m
ea
n
s
co
r
e
s
f
r
o
m
1
0
.
8
8
to
1
7
.
4
7
.
I
n
co
n
tr
a
s
t,
th
e
co
n
t
r
o
l
g
r
o
u
p
's
s
l
ig
h
t
r
i
s
e
f
r
o
m
1
0
.
5
5
to
1
0
.
9
4
i
m
p
l
ie
s
a
lack
o
f
co
m
p
r
eh
en
s
iv
e
ed
u
c
at
io
n
a
l
s
u
p
p
o
r
t
in
m
an
ag
in
g
p
h
ar
m
a
co
th
er
ap
y
.
T
h
i
s
d
is
p
ar
i
ty
u
n
d
er
l
in
e
s
th
e
co
n
ce
p
t
th
a
t
d
i
ab
e
te
s
s
e
lf
-
m
a
n
ag
em
en
t
ed
u
c
at
io
n
(
D
SME
)
is
cr
u
ci
al
f
o
r
im
p
r
o
v
i
n
g
p
a
ti
en
t
s
'
u
n
d
er
s
tan
d
in
g
o
f
th
e
ir
m
ed
i
ca
tio
n
r
eg
im
en
s
[
3
5
]
.
R
an
jb
ar
et
a
l.
[3
6
]
em
p
h
as
iz
e
th
at
im
p
r
o
v
ed
s
e
lf
-
m
a
n
ag
em
en
t
b
eh
av
io
r
s
d
u
e
to
ed
u
ca
tio
n
al
in
ter
v
en
tio
n
s
ca
n
en
h
an
ce
ad
h
e
r
en
ce
to
p
h
ar
m
a
co
lo
g
i
ca
l th
er
ap
y
.
T
h
i
s
im
p
r
o
v
em
en
t
e
x
t
en
d
s
i
n
to
s
tr
e
s
s
m
an
ag
e
m
en
t,
wh
e
r
e
th
e
in
t
er
v
en
ti
o
n
g
r
o
u
p
's
m
ea
n
s
co
r
e
in
cr
ea
s
ed
f
r
o
m
1
0
.
1
9
to
1
3
.
9
0
,
n
o
t
ab
ly
o
u
t
p
er
f
o
r
m
in
g
th
e
co
n
tr
o
l
g
r
o
u
p
,
wh
i
ch
o
n
ly
in
c
r
ea
s
ed
f
r
o
m
9
.
4
1
to
1
0
.
5
4
.
T
h
e
r
o
b
u
s
tn
e
s
s
o
f
t
h
es
e
ed
u
c
at
io
n
al
i
n
t
er
v
en
ti
o
n
s
i
s
cr
i
ti
ca
l
in
a
ll
ev
i
at
in
g
s
tr
e
s
s
lev
el
s
o
f
ten
as
s
o
ci
at
ed
wi
th
d
iab
et
e
s
m
a
n
ag
em
en
t
,
a
s
h
ig
h
li
g
h
t
ed
b
y
C
h
aw
la
e
t
a
l.
[2
8
]
,
wh
o
n
o
te
th
a
t
s
tr
u
c
tu
r
ed
ed
u
ca
t
io
n
p
r
o
g
r
am
s
c
an
p
r
o
v
i
d
e
n
e
ce
s
s
a
r
y
co
p
in
g
m
ec
h
an
i
s
m
s
f
o
r
p
at
ien
t
s
d
ea
li
n
g
wi
th
th
e
co
m
p
lex
i
ti
es
o
f
th
e
ir
co
n
d
it
io
n
s
.
Fo
r
s
e
lf
-
b
lo
o
d
s
u
g
a
r
t
es
ti
n
g
,
an
in
cr
ea
s
e
in
m
e
an
s
co
r
e
s
f
r
o
m
1
1
.
9
4
to
1
9
.
8
8
f
o
r
th
e
in
t
er
v
en
t
io
n
g
r
o
u
p
d
em
o
n
s
tr
a
te
s
a
s
ig
n
if
i
ca
n
t
s
h
if
t
to
war
d
s
p
r
o
ac
tiv
e
s
e
lf
-
m
o
n
i
to
r
i
n
g
p
r
ac
ti
ce
s
,
a
cr
u
ci
al
co
m
p
o
n
en
t
o
f
ef
f
ec
ti
v
e
d
iab
e
te
s
m
an
ag
em
en
t.
C
o
n
v
er
s
e
ly
,
th
e
co
n
tr
o
l
g
r
o
u
p
's
m
e
an
s
c
o
r
e
s
in
cr
e
a
s
ed
,
b
u
t
th
e
g
a
in
wa
s
s
ig
n
if
ican
t
ly
le
s
s
,
r
i
s
in
g
f
r
o
m
1
4
.
2
8
to
1
6
.
2
2
.
A
lo
t
aib
i
et
a
l.
[3
7
]
n
o
t
e
th
a
t
p
at
ien
t
em
p
o
w
er
m
en
t
th
r
o
u
g
h
ed
u
c
at
io
n
en
h
an
ce
s
s
elf
-
t
es
t
in
g
b
eh
a
v
io
r
s
,
th
er
eb
y
i
m
p
r
o
v
in
g
g
ly
c
em
i
c
co
n
tr
o
l.
T
h
i
s
o
b
s
e
r
v
a
tio
n
i
s
co
m
p
l
em
en
te
d
b
y
f
in
d
in
g
s
f
r
o
m
Hu
a
n
g
et
a
l.
[3
8
]
af
f
ir
m
in
g
th
a
t
d
i
ab
e
te
s
ed
u
c
at
io
n
p
o
s
it
iv
e
ly
im
p
a
ct
s
s
el
f
-
c
ar
e
b
eh
av
io
r
s
.
I
n
t
h
e
r
ea
lm
o
f
o
v
er
al
l
ed
u
ca
t
io
n
a
l
s
u
p
p
o
r
t
,
th
e
in
te
r
v
en
tio
n
g
r
o
u
p
s
a
w
a
p
r
o
n
o
u
n
c
ed
in
c
r
ea
s
e
f
r
o
m
a
m
ea
n
o
f
6
1
.
8
1
to
9
0
.
8
5
,
e
s
tab
li
s
h
in
g
a
c
lea
r
tr
a
je
cto
r
y
o
f
i
m
p
r
o
v
e
m
en
t
co
m
p
ar
ed
to
t
h
e
co
n
tr
o
l
g
r
o
u
p
's
r
i
s
e
f
r
o
m
5
5
.
0
5
to
6
4
.
4
5
.
T
h
i
s
ex
ten
s
iv
e
s
u
p
p
o
r
t
u
n
d
er
s
co
r
es
th
e
i
m
p
o
r
tan
ce
o
f
co
m
p
r
eh
en
s
iv
e
ed
u
c
at
io
n
a
l
s
t
r
a
teg
ie
s
t
ai
lo
r
ed
to
en
h
an
ce
f
am
i
ly
i
n
v
o
lv
em
en
t
in
D
M
m
an
ag
em
en
t,
co
n
s
i
s
ten
t
w
ith
s
tu
d
ie
s
ad
v
o
c
at
in
g
f
o
r
f
a
m
i
ly
-
c
en
ter
ed
ed
u
ca
t
io
n
al
ap
p
r
o
ac
h
es
in
d
i
ab
e
te
s
m
a
n
ag
em
en
t
[
39
]
.
T
h
e
in
d
ep
en
d
en
t
t
-
te
s
t
an
al
y
s
i
s
,
r
ev
ea
l
in
g
s
tr
o
n
g
s
t
at
i
s
t
ic
al
s
i
g
n
if
i
ca
n
ce
(
p
<
0
.
0
0
1
)
,
r
e
in
f
o
r
ce
s
th
e
ar
g
u
m
en
t
f
o
r
s
y
s
te
m
at
ic
ed
u
ca
tio
n
a
l
in
t
er
v
en
t
io
n
s
th
at
en
co
m
p
a
s
s
v
ar
io
u
s
a
s
p
e
ct
s
o
f
d
iab
e
te
s
ca
r
e
[
4
0
].
4.
CO
NCLU
SI
O
N
T
h
e
ed
u
c
at
io
n
a
l
in
t
er
v
en
t
io
n
s
ig
n
if
i
ca
n
tly
i
m
p
r
o
v
ed
d
i
ab
ete
s
k
n
o
w
le
d
g
e
am
o
n
g
m
e
m
b
er
s
o
f
th
e
in
t
er
v
en
t
io
n
g
r
o
u
p
,
w
ith
p
o
o
r
k
n
o
w
led
g
e
d
e
cr
e
as
in
g
f
r
o
m
4
5
.
8
%
to
2
6
.
3
9
%
p
o
s
t
-
in
t
er
v
en
tio
n
,
wh
i
le
th
e
co
n
tr
o
l
g
r
o
u
p
s
h
o
wed
n
o
ch
a
n
g
e.
T
h
e
in
t
er
v
e
n
t
io
n
g
r
o
u
p
d
em
o
n
s
tr
at
ed
s
ig
n
if
ic
an
t
i
m
p
r
o
v
em
en
t
s
a
cr
o
s
s
a
ll
d
im
en
s
io
n
s
o
f
s
u
p
p
o
r
t
iv
e
b
eh
av
io
r
s
,
in
c
lu
d
in
g
n
u
tr
it
i
o
n
r
eg
u
la
tio
n
,
p
h
y
s
ica
l
ex
er
c
is
e,
an
d
s
tr
e
s
s
m
an
ag
em
en
t,
co
n
f
i
r
m
i
n
g
th
at
s
t
r
u
c
tu
r
ed
f
am
ily
ed
u
c
at
io
n
p
lay
s
a
cr
u
c
ia
l
r
o
le
in
d
i
ab
e
te
s
m
a
n
ag
e
m
en
t.
T
h
e
t
-
t
e
s
t
a
n
a
ly
s
i
s
v
a
lid
at
ed
t
h
e
s
e
ch
an
g
e
s
,
in
d
ic
at
in
g
en
h
an
c
e
d
u
n
d
er
s
t
an
d
in
g
an
d
f
am
i
ly
i
n
v
o
lv
e
m
en
t
in
c
ar
e
.
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.
15
,
No
.
2
,
J
u
n
e
20
26
:
3
7
8
-
3
8
8
386
Fro
m
a
p
u
b
l
ic
h
ea
lth
p
er
s
p
e
ct
iv
e,
th
e
s
e
f
in
d
in
g
s
d
e
m
o
n
s
t
r
at
e
th
at
f
am
i
ly
-
b
a
s
ed
e
d
u
ca
t
i
o
n
a
l
in
ter
v
en
tio
n
s
ca
n
s
er
v
e
a
s
a
co
s
t
-
ef
f
ec
tiv
e,
s
c
al
ab
l
e
s
tr
a
teg
y
f
o
r
r
ed
u
ci
n
g
d
iab
et
es
-
r
e
la
ted
co
m
p
l
ica
t
io
n
s
at
th
e
co
m
m
u
n
i
ty
lev
e
l,
th
e
r
eb
y
al
lev
ia
t
in
g
th
e
b
u
r
d
en
o
n
p
r
i
m
ar
y
h
ea
lth
ca
r
e
s
y
s
te
m
s
.
B
y
em
p
o
wer
in
g
f
am
i
l
ie
s
a
s
ac
tiv
e
p
ar
t
ic
ip
an
t
s
in
d
i
s
e
as
e
m
an
a
g
em
en
t,
s
u
ch
p
r
o
g
r
a
m
s
ad
d
r
es
s
s
o
ci
al
d
e
ter
m
in
an
t
s
o
f
h
e
al
th
a
n
d
s
t
r
en
g
th
en
co
m
m
u
n
ity
r
e
s
il
ien
ce
ag
ain
s
t
c
h
r
o
n
i
c
d
i
s
e
as
e.
B
a
s
ed
o
n
th
es
e
f
in
d
in
g
s
,
th
e
f
o
llo
w
i
n
g
s
p
ec
if
ic
p
o
l
icy
r
ec
o
m
m
en
d
at
io
n
s
ar
e
p
r
o
p
o
s
ed
:
i
)
L
o
ca
l
h
ea
lth
au
th
o
r
it
i
es
s
h
o
u
l
d
in
t
eg
r
a
te
s
t
r
u
c
tu
r
e
d
f
am
i
ly
d
iab
et
e
s
ed
u
ca
t
io
n
m
o
d
u
le
s
in
to
e
x
i
s
t
in
g
p
r
im
a
r
y
h
e
al
th
c
ar
e
cu
r
r
i
cu
la
a
t
co
m
m
u
n
ity
h
ea
l
th
c
e
n
ter
s
(
P
u
s
k
es
ma
s
)
;
ii
)
H
ea
lth
ca
r
e
p
r
o
v
id
er
s
s
h
o
u
ld
im
p
lem
en
t
s
t
an
d
ar
d
iz
ed
f
a
m
ily
c
ar
eg
iv
e
r
tr
a
in
i
n
g
p
r
o
to
co
l
s
en
co
m
p
a
s
s
in
g
n
u
tr
i
t
io
n
co
u
n
s
el
in
g
,
ex
er
ci
s
e
p
lan
n
in
g
,
an
d
s
t
r
e
s
s
m
an
ag
e
m
en
t
te
ch
n
i
q
u
e
s
;
an
d
ii
i
)
P
u
b
li
c
h
ea
l
th
ag
en
c
ie
s
s
h
o
u
ld
d
ev
e
lo
p
tech
n
o
lo
g
y
-
as
s
i
s
t
ed
p
la
tf
o
r
m
s
,
s
u
ch
a
s
m
o
b
il
e
h
ea
lt
h
ap
p
l
ic
at
io
n
s
,
to
s
u
s
t
ai
n
f
am
ily
en
g
ag
e
m
en
t
an
d
k
n
o
w
led
g
e
r
eten
t
io
n
b
ey
o
n
d
in
it
ia
l
in
ter
v
e
n
tio
n
s
.
Fu
tu
r
e
r
e
s
e
ar
ch
s
h
o
u
ld
ev
a
lu
a
te
t
h
e
lo
n
g
-
ter
m
s
u
s
t
ain
ab
il
ity
o
f
th
e
s
e
o
u
t
co
m
es
a
n
d
a
s
s
e
s
s
co
s
t
-
ef
f
e
ct
iv
en
e
s
s
a
cr
o
s
s
d
iv
er
s
e
s
o
c
io
d
em
o
g
r
ap
h
ic
p
o
p
u
la
ti
o
n
s
.
ACK
NO
WL
E
DG
M
E
N
T
S
T
h
e
au
th
o
r
s
wo
u
ld
l
ik
e
to
ex
p
r
es
s
s
in
ce
r
e
g
r
at
i
tu
d
e
to
a
ll
p
a
r
ti
e
s
wh
o
co
n
tr
ib
u
te
d
to
th
e
c
o
m
p
le
t
io
n
o
f
th
i
s
r
e
s
ea
r
ch
.
Fir
s
t
an
d
f
o
r
em
o
s
t
,
we
ex
t
en
d
o
u
r
ap
p
r
ec
ia
tio
n
to
th
e
E
th
ic
s
C
o
m
m
it
te
e
o
f
Po
l
tek
k
es
Kem
en
k
e
s
T
an
ju
n
g
Kar
an
g
f
o
r
g
r
an
tin
g
e
th
i
ca
l
ap
p
r
o
v
a
l
f
o
r
th
is
s
tu
d
y
.
W
e
ar
e
d
ee
p
ly
g
r
at
ef
u
l
to
th
e
H
ea
d
o
f
S
im
b
ar
w
ar
in
g
in
C
o
m
m
u
n
ity
H
ea
lth
C
en
ter
,
C
en
tr
al
L
am
p
u
n
g
,
an
d
al
l
h
ea
lth
c
ar
e
s
taf
f
f
o
r
th
ei
r
co
o
p
er
at
io
n
an
d
s
u
p
p
o
r
t
in
f
a
ci
li
ta
tin
g
th
i
s
r
e
s
ea
r
ch
.
Sp
e
ci
a
l
th
a
n
k
s
ar
e
ex
t
en
d
ed
to
a
ll
1
5
7
r
es
p
o
n
d
en
t
s
an
d
th
e
ir
f
a
m
i
li
e
s
wh
o
w
il
li
n
g
ly
p
ar
t
ic
ip
a
ted
in
th
i
s
s
tu
d
y
,
d
ed
i
ca
t
in
g
th
e
ir
tim
e
an
d
ef
f
o
r
t
th
r
o
u
g
h
o
u
t
th
e
th
r
ee
-
m
o
n
th
in
ter
v
en
t
io
n
p
er
io
d
.
AUTHO
R
CO
NT
RI
B
UT
I
O
NS ST
A
T
E
M
E
N
T
T
h
is
jo
u
r
n
al
u
s
es
th
e
C
o
n
t
r
ib
u
to
r
R
o
les
T
a
x
o
n
o
m
y
(
C
R
ed
iT)
to
r
ec
o
g
n
ize
in
d
iv
i
d
u
al
au
th
o
r
co
n
tr
ib
u
tio
n
s
,
r
ed
u
ce
au
th
o
r
s
h
ip
d
is
p
u
tes,
an
d
f
ac
ilit
ate
co
llab
o
r
atio
n
.
Na
m
e
o
f
Aut
ho
r
C
M
So
Va
Fo
I
R
D
O
E
Vi
Su
P
Fu
Sit
i Fato
n
ah
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Su
last
r
i
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Yu
n
iast
in
i
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
C
:
C
o
n
c
e
p
t
u
a
l
i
z
a
t
i
o
n
M
:
M
e
t
h
o
d
o
l
o
g
y
So
:
So
f
t
w
a
r
e
Va
:
Va
l
i
d
a
t
i
o
n
Fo
:
Fo
r
mal
a
n
a
l
y
s
i
s
I
:
I
n
v
e
s
t
i
g
a
t
i
o
n
R
:
R
e
so
u
r
c
e
s
D
:
D
a
t
a
C
u
r
a
t
i
o
n
O
:
W
r
i
t
i
n
g
-
O
r
i
g
i
n
a
l
D
r
a
f
t
E
:
W
r
i
t
i
n
g
-
R
e
v
i
e
w
&
E
d
i
t
i
n
g
Vi
:
Vi
su
a
l
i
z
a
t
i
o
n
Su
:
Su
p
e
r
v
i
s
i
o
n
P
:
P
r
o
j
e
c
t
a
d
mi
n
i
st
r
a
t
i
o
n
Fu
:
Fu
n
d
i
n
g
a
c
q
u
i
si
t
i
o
n
CO
NF
L
I
C
T
O
F
I
N
T
E
R
E
S
T
ST
A
T
E
M
E
NT
Au
th
o
r
s
s
tate
n
o
co
n
f
lict o
f
in
t
er
est
.
E
T
H
I
CAL AP
P
RO
V
AL
T
h
is
r
esear
ch
h
as
r
ec
eiv
e
d
et
h
ical
ap
p
r
o
v
al
f
r
o
m
th
e
Ma
tar
am
Min
is
tr
y
o
f
Hea
lth
Po
ly
te
ch
n
ic
with
th
e
n
u
m
b
er
:
No
.
4
4
1
/
KE
P
K
-
T
J
K
/
V/2
0
2
5
.
DATA AV
AI
L
AB
I
L
I
T
Y
T
h
e
d
ata
th
at
s
u
p
p
o
r
t
th
e
f
in
d
in
g
s
o
f
th
is
s
tu
d
y
ar
e
a
v
ailab
l
e
f
r
o
m
th
e
co
r
r
esp
o
n
d
i
n
g
au
t
h
o
r
,
[
SF
]
,
u
p
o
n
r
ea
s
o
n
ab
le
r
eq
u
est.
RE
F
E
R
E
NC
E
S
[
1
]
W
.
W
a
n
t
o
n
o
r
o
,
K
.
K
o
mar
u
d
i
n
,
D
.
R
.
I
man
i
a
,
S
.
H
a
r
u
n
,
a
n
d
T.
V
N
g
u
y
e
n
,
“
T
h
e
i
n
f
l
u
e
n
c
e
o
f
6
-
mo
n
t
h
i
n
t
e
r
d
i
sc
i
p
l
i
n
a
r
y
a
c
c
o
m
p
a
n
i
m
e
n
t
o
n
f
a
mi
l
y
c
a
r
e
g
i
v
e
r
s’
k
n
o
w
l
e
d
g
e
a
n
d
se
l
f
-
e
f
f
i
c
a
c
y
r
e
g
a
r
d
i
n
g
d
i
a
b
e
t
i
c
w
o
u
n
d
c
a
r
e
,
”
S
AG
E
O
p
e
n
N
u
rs
i
n
g
,
v
o
l
.
9
,
n
o
.
1
,
p
p
.
1
–
1
1
,
Ja
n
.
2
0
2
3
,
d
o
i
:
1
0
.
1
1
7
7
/
2
3
7
7
9
6
0
8
2
3
1
1
6
7
8
0
1
.
[
2
]
K
.
A
.
H
.
A
c
h
j
a
r
,
K
.
G
a
ma
,
A
.
S
.
Le
s
t
a
r
i
,
K
.
S
u
d
i
a
n
t
a
r
a
,
a
n
d
W
.
S
u
a
r
d
a
n
a
,
“
Emp
o
w
e
r
i
n
g
f
a
mi
l
i
e
s
i
n
t
e
r
v
e
n
t
i
o
n
a
n
d
e
l
d
e
r
l
y
g
r
o
u
p
s
t
o
r
e
d
u
c
e
t
h
e
a
n
x
i
e
t
y
l
e
v
e
l
s
o
f
e
l
d
e
r
l
y
w
i
t
h
d
i
a
b
e
t
e
s
me
l
l
i
t
u
s
i
n
I
n
d
o
n
e
si
a
,
”
J
o
u
r
n
a
l
o
f
Pu
b
l
i
c
H
e
a
l
t
h
a
n
d
D
e
v
e
l
o
p
m
e
n
t
,
v
o
l
.
2
2
,
n
o
.
2
,
p
p
.
1
0
7
–
1
1
8
,
M
a
y
2
0
2
4
,
d
o
i
:
1
0
.
5
5
1
3
1
/
J
p
h
d
/
2
0
2
4
/
2
2
0
2
0
9
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Dev
elo
p
men
t o
f a
s
u
p
p
o
r
tive
-
ed
u
ca
tive
h
e
a
lth
ed
u
c
a
tio
n
in
t
erven
tio
n
fo
r
fa
mily
… (
S
iti F
a
to
n
a
h
)
387
[
3
]
W
.
S
h
e
n
,
J.
Li
n
,
S
.
C
h
a
n
,
L.
Y
u
h
‐
S
h
i
o
w
,
a
n
d
J.
W
a
n
g
,
“
Ex
p
l
o
r
i
n
g
c
a
r
e
c
h
a
l
l
e
n
g
e
s
a
n
d
n
e
e
d
s
o
f
p
e
o
p
l
e
w
i
t
h
d
i
a
b
e
t
e
s
c
o
m
o
r
b
i
d
c
o
g
n
i
t
i
v
e
i
m
p
a
i
r
me
n
t
f
r
o
m
t
h
e
t
r
i
a
n
g
u
l
a
r
p
e
r
s
p
e
c
t
i
v
e
s,
”
N
u
rsi
n
g
&
H
e
a
l
t
h
S
c
i
e
n
c
e
s
,
v
o
l
.
2
7
,
n
o
.
1
,
p
p
.
1
–
8
,
2
0
2
5
,
d
o
i
:
1
0
.
1
1
1
1
/
N
h
s
.
7
0
0
8
1
.
[
4
]
V
.
S
.
Ç
a
k
ma
k
,
Z.
A
k
e
r
e
n
,
E
.
S
.
S
a
r
ı
,
a
n
d
S
.
K
a
l
y
o
n
c
u
o
,
“
Th
e
e
f
f
e
c
t
o
f
h
e
a
l
t
h
l
i
t
e
r
a
c
y
l
e
v
e
l
o
f
c
a
r
e
g
i
v
e
r
s
o
f
i
n
d
i
v
i
d
u
a
l
s
w
i
t
h
d
i
a
b
e
t
e
s
o
n
c
a
r
e
a
c
t
i
v
i
t
i
e
s
a
n
d
s
u
p
p
o
r
t
i
v
e
b
e
h
a
v
i
o
u
r
s
,
”
J
o
u
rn
a
l
o
f
Ev
a
l
u
a
t
i
o
n
i
n
C
l
i
n
i
c
a
l
Pr
a
c
t
i
c
e
,
v
o
l
.
3
1
,
n
o
.
1
,
p
p
.
1
–
9
,
2
0
2
5
,
d
o
i
:
1
0
.
1
1
1
1
/
J
e
p
.
7
0
0
0
0.
[
5
]
J.
K
i
m,
J
.
S
o
n
g
,
A
.
T
a
r
k
,
S
.
P
a
r
k
,
a
n
d
K
.
W
o
o
,
“
D
o
c
a
r
e
g
i
v
e
r
s’
i
n
v
o
l
v
e
m
e
n
t
i
n
t
y
p
e
2
d
i
a
b
e
t
e
s
e
d
u
c
a
t
i
o
n
a
f
f
e
c
t
p
a
t
i
e
n
t
s’
h
e
a
l
t
h
o
u
t
c
o
mes
?
:
A
s
y
st
e
ma
t
i
c
r
e
v
i
e
w
a
n
d
m
e
t
a
-
a
n
a
l
y
si
s
,
”
J
o
u
r
n
a
l
o
f
H
e
a
l
t
h
S
c
i
e
n
c
e
s
,
v
o
l
.
1
,
n
o
.
1
1
,
p
p
.
1
–
9
,
N
o
v
.
2
0
2
3
,
d
o
i
:
1
0
.
1
7
5
3
2
/
Jh
s
.
2
0
2
3
.
2
1
8
2
.
[
6
]
A
.
P
.
N
e
r
i
e
t
a
l
.
,
“
P
r
o
p
o
sa
l
f
o
r
e
d
u
c
a
t
i
o
n
a
l
i
n
t
e
r
v
e
n
t
i
o
n
i
n
p
e
o
p
l
e
l
i
v
i
n
g
w
i
t
h
t
y
p
e
2
d
i
a
b
e
t
e
s
me
l
l
i
t
u
s
a
n
d
i
n
t
h
e
i
r
f
a
m
i
l
y
c
a
r
e
g
i
v
e
r
,
”
E
u
r
o
p
e
a
n
J
o
u
r
n
a
l
o
f
N
u
t
r
i
t
i
o
n
&
F
o
o
d
S
a
f
e
t
y
,
v
o
l
.
1
5
,
n
o
.
2
,
p
p
.
1
4
–
2
5
,
2
0
2
3
,
d
o
i
:
1
0
.
9
7
3
4
/
Ej
n
f
s/
2
0
2
3
/
V
1
5
i
2
1
2
9
1
.
[
7
]
L
.
S
.
A
l
m
a
s
o
u
d
i
,
G
.
J
.
A
l
q
a
s
i
m
i
,
R
.
A
.
A
l
h
a
r
b
i
,
R
.
S
.
A
l
o
t
a
i
b
i
,
a
n
d
S
.
A
.
A
l
h
a
r
b
i
,
“
A
w
a
r
e
n
e
s
s
o
f
s
t
e
m
c
e
l
l
t
h
e
r
a
p
y
f
o
r
d
i
a
b
e
t
e
s
a
m
o
n
g
t
y
p
e
i
i
d
i
a
b
e
t
i
c
p
a
t
i
e
n
t
s
i
n
M
a
k
k
a
h
:
a
c
r
o
s
s
-
s
e
c
t
i
o
n
a
l
s
t
u
d
y
,
”
C
u
r
e
u
s
,
v
o
l
.
1
,
n
o
.
6
,
p
p
.
1
–
9
,
2
0
2
3
,
d
o
i
:
1
0
.
7
7
5
9
/
C
u
r
e
u
s
.
4
0
9
8
1
.
[
8
]
N
.
D
.
K
r
i
st
a
n
i
n
g
r
u
m,
D
.
A
.
R
a
ma
d
h
a
n
i
,
Y
.
S
.
H
a
y
a
t
i
,
a
n
d
S
e
t
y
o
a
d
i
,
“
C
o
r
r
e
l
a
t
i
o
n
b
e
t
w
e
e
n
t
h
e
b
u
r
d
e
n
o
f
f
a
mi
l
y
c
a
r
e
g
i
v
e
r
s
a
n
d
h
e
a
l
t
h
st
a
t
u
s
o
f
p
e
o
p
l
e
w
i
t
h
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
,
”
J
o
u
r
n
a
l
o
f
Pu
b
l
i
c
H
e
a
l
t
h
R
e
se
a
rc
h
,
v
o
l
.
1
0
,
n
o
.
2
,
p
p
.
1
–
1
2
,
2
0
2
1
,
d
o
i
:
1
0
.
4
0
8
1
/
J
p
h
r
.
2
0
2
1
.
2
2
2
7
.
[
9
]
M
d
.
J
.
H
o
ssa
i
n
,
M
d
.
A
l
‐
M
a
m
u
n
,
a
n
d
M
d
.
R
.
I
sl
a
m,
“
D
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
,
t
h
e
f
a
s
t
e
s
t
g
r
o
w
i
n
g
g
l
o
b
a
l
p
u
b
l
i
c
h
e
a
l
t
h
c
o
n
c
e
r
n
:
e
a
r
l
y
d
e
t
e
c
t
i
o
n
s
h
o
u
l
d
b
e
f
o
c
u
s
e
d
,
”
H
e
a
l
t
h
S
c
i
e
n
c
e
Re
p
o
rt
s
,
v
o
l
.
7
,
n
o
.
3
,
p
p
.
1
–
5
,
M
a
r
.
2
0
2
4
,
d
o
i
:
1
0
.
1
0
0
2
/
H
sr
2
.
2
0
0
4
.
[
1
0
]
M
.
B
a
a
z
e
e
m
,
E
.
K
r
u
g
e
r
,
a
n
d
M
.
T
e
n
n
a
n
t
,
“
C
u
r
r
e
n
t
s
t
a
t
u
s
o
f
t
e
r
t
i
a
r
y
h
e
a
l
t
h
c
a
r
e
s
e
r
v
i
c
e
s
a
n
d
i
t
s
a
c
c
e
s
si
b
i
l
i
t
y
i
n
r
u
r
a
l
a
n
d
r
e
mo
t
e
A
u
st
r
a
l
i
a
:
a
s
y
st
e
ma
t
i
c
r
e
v
i
e
w
,
”
H
e
a
l
t
h
S
c
i
e
n
c
e
s
R
e
v
i
e
w
,
v
o
l
.
1
1
,
n
o
.
6
,
p
p
.
1
–
7
,
2
0
2
4
,
d
o
i
:
1
0
.
1
0
1
6
/
J
.
H
sr
.
2
0
2
4
.
1
0
0
1
5
8
.
[
1
1
]
A
.
S
h
e
t
h
,
S
.
C
.
T
h
o
m
p
so
n
,
a
n
d
N
.
M
a
v
a
d
d
a
t
,
“
R
u
r
a
l
g
e
n
e
r
a
l
p
r
a
c
t
i
t
i
o
n
e
r
s’
p
e
r
c
e
p
t
i
o
n
s
o
f
t
h
e
b
a
r
r
i
e
r
s
a
n
d
f
a
c
i
l
i
t
a
t
o
r
s
o
f
c
h
r
o
n
i
c
d
i
s
e
a
se
a
n
d
c
a
r
d
i
o
me
t
a
b
o
l
i
c
r
i
sk
f
a
c
t
o
r
c
a
r
e
t
h
r
o
u
g
h
l
i
f
e
st
y
l
e
ma
n
a
g
e
m
e
n
t
—
a
W
e
st
e
r
n
A
u
s
t
r
a
l
i
a
n
q
u
a
l
i
t
a
t
i
v
e
st
u
d
y
,
”
H
e
a
l
t
h
c
a
re
,
v
o
l
.
1
4
,
n
o
.
1
,
p
p
.
1
–
1
6
,
2
0
2
6
,
D
o
i
:
1
0
.
3
3
9
0
/
H
e
a
l
t
h
c
a
r
e
1
4
0
1
0
1
1
3
.
[
1
2
]
A.
-
B.
A
b
d
u
l
-
S
a
m
e
d
e
t
a
l
.
,
“
B
a
r
r
i
e
r
s
a
n
d
f
a
c
i
l
i
t
a
t
o
r
s
o
f
p
r
i
m
a
r
y
c
a
r
e
m
a
n
a
g
e
m
e
n
t
o
f
t
y
p
e
I
I
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
i
n
t
h
e
W
e
s
t
A
f
r
i
c
a
n
s
u
b
-
r
e
g
i
o
n
:
a
s
c
o
p
i
n
g
r
e
v
i
e
w
,
”
P
L
O
S
G
l
o
b
a
l
P
u
b
l
i
c
H
e
a
l
t
h
,
v
o
l
.
5
,
n
o
.
5
,
p
p
.
1
–
2
8
,
M
a
y
2
0
2
5
,
d
o
i
:
1
0
.
1
3
7
1
/
J
o
u
r
n
a
l
.
P
g
p
h
.
0
0
0
3
7
3
3
.
[
1
3
]
M
d
.
M
.
R
a
h
m
a
n
e
t
a
l
.
,
“
P
r
o
g
r
e
s
s
t
o
w
a
r
d
s
u
n
i
v
e
r
sa
l
h
e
a
l
t
h
c
o
v
e
r
a
g
e
i
n
S
o
u
t
h
A
si
a
,
2
0
0
0
–
2
0
3
0
:
a
n
e
x
a
mi
n
a
t
i
o
n
o
f
t
h
e
t
w
i
n
e
l
e
m
e
n
t
s
o
f
p
r
i
m
a
r
y
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
si
o
n
a
n
d
f
i
n
a
n
c
i
a
l
p
r
o
t
e
c
t
i
o
n
,
”
BM
J
G
l
o
b
a
l
H
e
a
l
t
h
,
v
o
l
.
1
0
,
n
o
.
1
1
,
p
p
.
1
–
1
4
,
2
0
2
5
,
d
o
i
:
1
0
.
1
1
3
6
/
B
m
j
gh
-
2
0
2
5
-
0
2
0
0
5
2
.
[
1
4
]
J.
C
.
M
i
r
a
n
d
a
e
t
a
l
.
,
“
E
n
h
a
n
c
i
n
g
d
i
a
b
e
t
e
s
c
a
r
e
i
n
L
M
I
C
S
:
i
n
si
g
h
t
s
f
r
o
m
a
mu
l
t
i
n
a
t
i
o
n
a
l
c
o
n
se
n
su
s
,
”
Pa
k
i
s
t
a
n
J
o
u
r
n
a
l
o
f
M
e
d
i
c
a
l
S
c
i
e
n
c
e
s
,
v
o
l
.
3
9
,
n
o
.
6
,
p
p
.
1
–
8
,
2
0
2
3
,
d
o
i
:
1
0
.
1
2
6
6
9
/
P
j
ms
.
3
9
.
7
.
8
8
8
1
.
[
1
5
]
M
.
M
p
h
a
s
h
a
,
L.
S
k
a
a
l
,
a
n
d
T.
M
.
M
o
t
h
i
b
a
,
“
D
e
v
e
l
o
p
m
e
n
t
o
f
a
f
a
m
i
l
y
-
c
e
n
t
r
e
d
n
u
t
r
i
t
i
o
n
a
n
d
e
x
e
r
c
i
s
e
d
i
a
b
e
t
e
s
c
a
r
e
p
r
o
g
r
a
mm
e
f
o
r
b
e
t
t
e
r
d
i
a
b
e
t
e
s
o
u
t
c
o
mes
i
n
r
u
r
a
l
a
r
e
a
s
o
f
Li
m
p
o
p
o
:
p
r
a
c
t
i
c
e
-
o
r
i
e
n
t
e
d
t
h
e
o
r
y
,
”
T
h
e
O
p
e
n
P
u
b
l
i
c
H
e
a
l
t
h
J
o
u
r
n
a
l
,
v
o
l
.
1
5
,
n
o
.
1
,
p
p
.
1
–
1
2
,
2
0
2
2
,
d
o
i
:
1
0
.
2
1
7
4
/
1
8
7
4
9
4
4
5
-
V
1
5
-
E
2
2
0
5
1
9
1
.
[
1
6
]
Y
.
Zh
e
n
g
e
t
a
l
.
,
“
A
ss
o
c
i
a
t
i
o
n
s
b
e
t
w
e
e
n
i
m
p
l
e
me
n
t
a
t
i
o
n
o
f
t
h
e
c
a
r
e
g
i
v
e
r
a
d
v
i
s
e
r
e
c
o
r
d
e
n
a
b
l
e
(
C
A
R
E)
a
c
t
a
n
d
h
e
a
l
t
h
serv
i
c
e
u
t
i
l
i
z
a
t
i
o
n
f
o
r
o
l
d
e
r
a
d
u
l
t
s
w
i
t
h
d
i
a
b
e
t
e
s:
r
e
t
r
o
s
p
e
c
t
i
v
e
o
b
ser
v
a
t
i
o
n
a
l
s
t
u
d
y
,
”
J
MIR
A
g
i
n
g
,
v
o
l
.
5
,
n
o
.
2
,
p
p
.
1
–
9
,
2
0
2
2
,
d
o
i
:
1
0
.
2
1
9
6
/
3
2
7
9
0
.
[
1
7
]
M
.
N
d
o
u
,
N
.
S
.
R
a
l
i
p
h
a
sw
a
,
a
n
d
A
.
R
.
T
sh
i
l
i
l
o
,
“
C
h
a
l
l
e
n
g
e
s
o
f
c
a
r
e
g
i
v
e
r
s
r
e
g
a
r
d
i
n
g
h
o
mec
a
r
e
t
o
t
y
p
e
1
d
i
a
b
e
t
i
c
c
h
i
l
d
r
e
n
i
n
V
h
e
m
b
e
d
i
s
t
r
i
c
t
,
S
o
u
t
h
A
f
r
i
c
a
:
a
q
u
a
l
i
t
a
t
i
v
e
st
u
d
y
r
e
p
o
r
t
,
”
N
u
rs
i
n
g
R
e
p
o
r
t
s
,
v
o
l
.
1
2
,
n
o
.
4
,
p
p
.
8
8
4
–
8
9
3
,
N
o
v
.
2
0
2
2
,
d
o
i
:
1
0
.
3
3
9
0
/
N
u
r
sr
e
p
1
2
0
4
0
0
8
5
.
[
1
8
]
T
.
D
.
N
g
u
y
e
n
e
t
a
l
.
,
“
P
e
r
c
e
i
v
e
d
k
n
o
w
l
e
d
g
e
o
n
t
y
p
e
-
2
d
i
a
b
e
t
e
s
o
f
i
n
f
o
r
m
a
l
c
a
r
e
g
i
v
e
r
s
i
n
r
u
r
a
l
c
o
m
m
u
n
i
t
i
e
s
o
f
T
h
a
i
B
i
n
h
,
V
i
e
t
n
a
m
:
i
m
p
l
i
c
a
t
i
o
n
s
f
o
r
h
e
a
l
t
h
e
d
u
c
a
t
i
o
n
,
”
P
u
b
l
i
c
H
e
a
l
t
h
i
n
P
r
a
c
t
i
c
e
,
v
o
l
.
2
,
n
o
.
1
1
,
p
p
.
1
–
1
2
,
N
o
v
.
2
0
2
1
,
d
o
i
:
1
0
.
1
0
1
6
/
J
.
P
u
h
i
p
.
2
0
2
1
.
1
0
0
2
1
0
.
[
1
9
]
N
.
B
.
N
d
a
h
u
r
a
,
J.
M
u
n
g
a
,
J
.
K
i
mi
y
w
e
,
a
n
d
E
.
M
u
p
e
r
e
,
“
C
a
r
e
g
i
v
e
r
s’
n
u
t
r
i
t
i
o
n
k
n
o
w
l
e
d
g
e
a
n
d
d
i
e
t
a
r
y
i
n
t
a
k
e
o
f
t
y
p
e
1
d
i
a
b
e
t
i
c
c
h
i
l
d
r
e
n
a
g
e
d
3
–
1
4
y
e
a
r
s
i
n
U
g
a
n
d
a
,
”
D
i
a
b
e
t
e
s
,
Me
t
a
b
o
l
i
c
S
y
n
d
ro
m
e
a
n
d
O
b
e
si
t
y
,
v
o
l
.
1
4
,
n
o
.
1
,
p
p
.
1
2
7
–
1
3
7
,
Jan
.
2
0
2
1
,
d
o
i
:
1
0
.
2
1
4
7
/
D
ms
o
.
S
2
8
5
9
7
9
.
[
2
0
]
N
.
D
.
A
n
g
g
r
a
e
n
i
,
A
.
A
.
N
o
v
a
r
i
a
,
R
.
P
.
U
t
a
mi
,
a
n
d
W
.
W
i
r
y
a
n
t
o
,
“
Th
e
e
f
f
e
c
t
i
v
e
n
e
ss
o
f
l
e
a
f
l
e
t
a
n
d
v
i
d
e
o
e
d
u
c
a
t
i
o
n
a
l
m
e
d
i
a
t
o
w
a
r
d
t
h
e
k
n
o
w
l
e
d
g
e
o
f
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,”
J
o
u
r
n
a
l
o
f
H
e
a
l
t
h
a
n
d
N
u
t
ri
t
i
o
n
Re
se
a
r
c
h
,
v
o
l
.
3
,
n
o
.
2
,
p
p
.
1
7
2
–
1
7
6
,
2
0
2
4
,
d
o
i
:
1
0
.
5
6
3
0
3
/
J
h
n
r
e
se
a
r
c
h
.
V
3
i
2
.
2
0
0
.
[
2
1
]
S
.
E
l
-
S
a
y
e
d
,
N
.
T
a
h
a
,
M
.
E
l
k
h
a
s
h
a
b
,
a
n
d
M
.
S
a
k
r
,
“
E
f
f
e
c
t
o
f
a
n
e
d
u
c
a
t
i
o
n
a
l
p
r
o
g
r
a
m
o
n
k
n
o
w
l
e
d
g
e
,
p
r
a
c
t
i
c
e
,
a
n
d
s
e
l
f
-
e
f
f
i
c
a
c
y
o
f
p
a
t
i
e
n
t
s
w
i
t
h
t
y
p
e
2
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
,
”
M
a
n
s
o
u
r
a
N
u
r
s
i
n
g
J
o
u
r
n
a
l
,
v
o
l
.
6
,
n
o
.
1
,
p
p
.
2
3
–
3
7
,
2
0
1
9
,
d
o
i
:
1
0
.
2
1
6
0
8
/
M
n
j
.
2
0
1
9
.
1
7
5
7
5
4
.
[
2
2
]
I
.
H
i
j
r
i
a
n
a
,
I
.
Y
u
n
i
t
a
,
S
.
W
a
t
i
,
M
.
C
h
a
i
z
u
r
a
n
,
a
n
d
A
.
N
a
d
a
si
a
h
,
“
T
h
e
i
m
p
a
c
t
o
f
f
o
o
t
c
a
r
e
e
d
u
c
a
t
i
o
n
o
n
k
n
o
w
l
e
d
g
e
o
f
p
r
e
v
e
n
t
i
o
n
t
h
e
r
i
sk
f
o
r
d
i
a
b
e
t
i
c
u
l
c
e
r
s
a
mo
n
g
d
i
a
b
e
t
i
c
p
a
t
i
e
n
t
s,
”
Pro
c
e
e
d
i
n
g
s
o
f
t
h
e
I
n
t
e
r
n
a
t
i
o
n
a
l
C
o
n
f
e
r
e
n
c
e
o
n
N
u
rs
i
n
g
a
n
d
H
e
a
l
t
h
S
c
i
e
n
c
e
s
,
v
o
l
.
4
,
n
o
.
1
,
p
p
.
1
7
1
–
1
7
8
,
M
a
y
2
0
2
3
,
d
o
i
:
1
0
.
3
7
2
8
7
/
P
i
c
n
h
s.V4
i
1
.
1
7
2
2
.
[
2
3
]
N
.
R
o
c
h
ma
h
e
t
a
l
.
,
“
Th
e
i
m
p
a
c
t
o
f
e
d
u
c
a
t
i
o
n
a
l
i
n
t
e
r
v
e
n
t
i
o
n
o
n
k
n
o
w
l
e
d
g
e
a
b
o
u
t
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
a
m
o
n
g
I
n
d
o
n
e
si
a
n
h
i
g
h
s
c
h
o
o
l
st
u
d
e
n
t
s
,
”
I
n
t
e
rn
a
t
i
o
n
a
l
J
o
u
r
n
a
l
o
f
Fro
n
t
i
e
rs
i
n
Me
d
i
c
i
n
e
a
n
d
S
u
r
g
e
r
y
Re
se
a
rc
h
,
v
o
l
.
2
,
n
o
.
2
,
p
p
.
0
1
0
–
0
1
5
,
2
0
2
2
,
d
o
i
:
1
0
.
5
3
2
9
4
/
I
j
f
msr
.
2
0
2
2
.
2
.
2
.
0
0
7
1
.
[
2
4
]
A
.
A
n
d
r
i
y
a
n
t
o
,
E
.
R
e
k
a
w
a
t
i
,
a
n
d
D
.
C
.
R
a
h
ma
d
i
y
a
h
,
“
I
n
c
r
e
a
si
n
g
k
n
o
w
l
e
d
g
e
,
a
t
t
i
t
u
d
e
s
,
s
k
i
l
l
s
,
a
n
d
g
l
u
c
o
s
e
c
o
n
t
r
o
l
i
n
t
y
p
e
-
2
d
i
a
b
e
t
i
c
p
a
t
i
e
n
t
s
t
h
r
o
u
g
h
E
M
A
S
i
n
t
e
r
v
e
n
t
i
o
n
s
,
”
N
u
rse
M
e
d
i
a
J
o
u
rn
a
l
o
f
N
u
rsi
n
g
,
v
o
l
.
9
,
n
o
.
2
,
p
p
.
1
4
1
–
1
5
0
,
2
0
1
9
,
d
o
i
:
1
0
.
1
4
7
1
0
/
N
m
j
n
.
V
9
i
2
.
2
2
9
8
9
.
[
2
5
]
M
.
H
a
m
d
i
a
n
d
A
.
J
a
si
m
,
“
A
ssessm
e
n
t
o
f
d
i
a
b
e
t
i
c
p
a
t
i
e
n
t
’
s
k
n
o
w
l
e
d
g
e
a
b
o
u
t
e
a
r
l
y
c
o
m
p
l
i
c
a
t
i
o
n
s
o
f
t
y
p
e
I
a
n
d
t
y
p
e
I
I
d
i
a
b
e
t
e
s
mel
l
i
t
u
s
,
”
Mo
s
u
l
J
o
u
rn
a
l
o
f
N
u
rsi
n
g
,
v
o
l
.
1
0
,
n
o
.
3
,
p
p
.
1
1
2
–
1
1
9
,
2
0
2
2
,
d
o
i
:
1
0
.
3
3
8
9
9
/
M
j
n
.
2
0
2
2
.
1
7
5
4
0
7
.
[2
6
]
O
.
S
.
P
u
r
w
a
n
t
i
a
n
d
E.
N
o
v
i
t
a
sari
,
“
T
h
e
c
o
r
r
e
l
a
t
i
o
n
o
f
k
n
o
w
l
e
d
g
e
o
f
p
r
e
v
e
n
t
i
o
n
w
i
t
h
n
e
u
r
o
p
a
t
h
y
t
r
e
a
t
me
n
t
i
n
d
i
a
b
e
t
e
s
m
e
l
l
i
t
u
s
p
a
t
i
e
n
t
s i
n
S
u
k
o
h
a
r
j
o
r
e
g
e
n
c
y
,
”
B
a
l
i
Me
d
i
c
a
l
J
o
u
rn
a
l
,
v
o
l
.
1
0
,
n
o
.
3
,
p
p
.
1
3
4
2
–
1
3
4
6
,
2
0
2
1
,
d
o
i
:
1
0
.
1
5
5
6
2
/
B
m
j
.
V
1
0
i
3
.
2
9
1
0
.
[2
7
]
L.
A
.
S
a
r
i
,
A
.
A
st
u
t
i
,
a
n
d
D
.
M
e
r
d
e
k
a
w
a
t
i
,
“
K
n
o
w
l
e
d
g
e
a
n
d
se
l
f
-
e
f
f
i
c
a
c
y
t
o
w
a
r
d
s
e
a
t
i
n
g
b
e
h
a
v
i
o
r
s
b
y
p
e
o
p
l
e
l
i
v
i
n
g
w
i
t
h
d
i
a
b
e
t
e
s
mel
l
i
t
u
s
,
”
K
n
e
L
i
f
e
S
c
i
e
n
c
e
s
,
v
o
l
.
1
,
n
o
.
3
,
p
p
.
2
8
8
–
2
9
8
,
2
0
2
1
,
d
o
i
:
1
0
.
1
8
5
0
2
/
K
l
s.V6
i
1
.
8
6
1
7
.
[2
8
]
S
.
S
.
C
h
a
w
l
a
e
t
a
l
.
,
“
I
mp
a
c
t
o
f
h
e
a
l
t
h
e
d
u
c
a
t
i
o
n
o
n
k
n
o
w
l
e
d
g
e
,
a
t
t
i
t
u
d
e
,
p
r
a
c
t
i
c
e
s
a
n
d
g
l
y
c
e
m
i
c
c
o
n
t
r
o
l
i
n
t
y
p
e
2
d
i
a
b
e
t
e
s
mel
l
i
t
u
s
,
”
J
o
u
r
n
a
l
o
f
F
a
m
i
l
y
Me
d
i
c
i
n
e
a
n
d
Pr
i
m
a
r
y
C
a
r
e
,
v
o
l
.
8
,
n
o
.
1
,
p
p
.
2
6
1
–
2
7
1
,
2
0
1
9
,
d
o
i
:
1
0
.
4
1
0
3
/
Jf
m
p
c
.
Jf
mp
c
_
2
2
8
_
1
8
.
[
29
]
A
.
T.
C
u
n
n
i
n
g
h
a
m
e
t
a
l
.
,
“
I
h
a
d
n
o
o
t
h
e
r
c
h
o
i
c
e
b
u
t
t
o
c
a
t
c
h
i
t
t
o
o
’
:
t
h
e
r
o
l
e
s
o
f
f
a
mi
l
y
h
i
st
o
r
y
a
n
d
e
x
p
e
r
i
e
n
c
e
s
w
i
t
h
d
i
a
b
e
t
e
s
i
n
i
l
l
n
e
ss re
p
r
e
se
n
t
a
t
i
o
n
s
,
”
BM
C
E
n
d
o
c
r
i
n
e
D
i
s
o
r
d
e
rs
,
v
o
l
.
2
0
,
n
o
.
1
,
p
p
.
9
5
–
1
0
5
,
D
e
c
.
2
0
2
0
,
d
o
i
:
1
0
.
1
1
8
6
/
S
1
2
9
0
2
-
0
2
0
-
0
0
5
8
0
-
X.
[3
0
]
A
.
M
u
t
ma
i
n
a
h
,
A
.
D
a
l
l
e
,
a
n
d
M
.
A
s
k
a
r
,
“
L
i
t
e
r
a
t
u
r
e
st
u
d
y
o
f
t
h
e
r
e
l
a
t
i
o
n
sh
i
p
o
f
k
n
o
w
l
e
d
g
e
a
n
d
d
i
sea
se
p
e
r
c
e
p
t
i
o
n
o
f
d
i
a
b
e
t
e
s
mel
l
i
t
u
s
w
i
t
h
sel
f
-
c
a
r
i
n
g
b
e
h
a
v
i
o
r
s o
f
d
i
a
b
e
t
e
s
me
l
l
i
t
u
s
p
a
t
i
e
n
t
s
,
”
J
o
u
rn
a
l
o
f
Ap
p
l
i
e
d
H
e
a
l
t
h
M
a
n
a
g
e
m
e
n
t
a
n
d
T
e
c
h
n
o
l
o
g
y
,
v
o
l
.
3
,
n
o
.
2
,
p
p
.
5
9
–
6
6
,
M
a
y
2
0
2
1
,
d
o
i
:
1
0
.
3
1
9
8
3
/
J
a
h
m
t
.
V
1
i
2
.
6
8
1
3
.
[3
1]
R
.
H
e
,
Q
.
Le
i
,
H
.
H
u
,
H
.
L
i
,
D
.
Ti
a
n
,
a
n
d
Z
.
L
a
i
,
“
T
h
e
e
f
f
e
c
t
o
f
h
e
a
l
t
h
e
d
u
c
a
t
i
o
n
c
o
m
b
i
n
e
d
w
i
t
h
p
e
r
s
o
n
a
l
i
z
e
d
p
sy
c
h
o
l
o
g
i
c
a
l
n
u
r
s
i
n
g
i
n
t
e
r
v
e
n
t
i
o
n
o
n
p
r
e
g
n
a
n
c
y
o
u
t
c
o
m
e
o
f
p
r
e
g
n
a
n
t
w
o
me
n
w
i
t
h
g
e
st
a
t
i
o
n
a
l
d
i
a
b
e
t
e
s
me
l
l
i
t
u
s,
”
B
i
o
Me
d
Re
se
a
rc
h
I
n
t
e
r
n
a
t
i
o
n
a
l
,
v
o
l
.
2
0
2
2
,
n
o
.
1
,
p
p
.
1
–
1
1
,
Ja
n
2
0
2
2
,
doi
:
1
0
.
1
1
5
5
/
2
0
2
2
/
3
1
5
7
9
8
6
.
Evaluation Warning : The document was created with Spire.PDF for Python.