Risk Factors For Diabetes Mellitus

Running head: RISK FACTORS FOR DIABETES MELLITUS

Risk Factors for Diabetes Mellitus in the Hispanic Population/Non-Hispanic Black Race

Population

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RISK FACTORS FOR DIABETES MELLITUS

Introduction

The United States and the international community have indentified the realization of

equity in healthcare as well as the elimination of disparities as one of the major priorities.

Disparities refer to the group differences that are manifested in the burden of mortality as well as

morbidity, especially those that are distributed inequitably by the race, ethnicity, gender, age, and

other differences. To combat these disparities, there is the need to address the risk factors that

expose these populations to the healthcare risks (American Diabetes Association, 2014). These

are manifested in the form of individual or proximate causes, together with the population or

upstream aspects.

The burden of diabetes mellitus has been established to have a disproportional effect on

the Hispanic speaking and non-Hispanic black populations in the United States. This means that

the Hispanic and African Americans tend to have a higher rate of prevalence of diabetes mellitus

when compared to the white Americans. In essence, diabetes is the seventh leading cause of

mortality for white Americans, but is the fourth, for African Americans.

Health disparities in healthcare, especially diabetes mellitus, their complications, as well

as co-morbidities exist across the world. In the United States, it has been established that

Hispanic speakers and non-Hispanic speaking African Americans have a high level of prevalence

of diabetes as compared to individuals who belong to the non-minority groups. Several factors

contribute towards these disparities, including biological, clinical, healthcare systems, alongside

the social aspects.

RISK FACTORS FOR DIABETES MELLITUS

Various pieces of literature on racial as well as ethnic disparities on the level of

prevalence of diabetes mellitus have established that the level of performance of behaviors

related to self-management of diabetes, access to diabetic healthcare, the level of quality of

diabetic care, risks associated with complications that are related too diabetes, and the presence

of those complications related to diabetes, are the major contributing risk factors for diabetes.

This has increased level of attention turned towards the search for predisposed biological,

psychosocial, alongside the contextual reasoning that could have contributed towards the racial

as well as ethnic differences. The primary aim is to come up with interventions that primarily

target thee aspects, as a means of helping reduce the rate if incidence of diabetes mellitus. More

recently, pieces of literature have established that the social economic status of individuals is a

strong determinant or the rate of incidence as well as the outcomes, positioning it as one of the

underling mechanisms that could be driving the racial as well as ethnic differences.

The proposed research will seek to expand on the previous studies conducted on the risk

factors that contribute toward the high rate of diabetes mellitus among the Hispanic and non-

Hispanic black race populations.

The Problem

Diabetes is a devastating health condition that is majorly affected by genetic, social,

economic, cultural, as well as historic factors, which are often interdependent. It is estimated that

at least 26 million people in the United States live with this condition, while another 79 million

individuals have a pre-diabetic condition. As such, at least a third of the population in America is

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affected by the condition. This places it among the major healthcare concerns in the country,

which need to be addressed.

Diabetes has a negative impact on the quality of life of the individuals suffering from the

disease while presenting a major economic burden to the healthcare system in the United States.

It is estimated that the country uses more than 200 billion dollars per year diagnosed as well as

non-diagnosed diabetes, including the complications associated with it. Much of the economic

burden is closely related to the complications like blindness, amputations, failure of organs, heart

attacks, alongside stroke (American Diabetes Association, 2015).

Hispanic speaking and non-Hispanic black populations tend to have a higher rate of

prevalence of this condition, compared to the other populations in the country. While there have

been several steps made towards improving healthcare, especially access to care, these racial and

ethnic disparities still exist. This place the burden on the stakeholders in the healthcare fraternity

to identify the risk factors that have places these populations in a higher level of risk than others.

Research Question

What are the determinative risk factors for the high incidence rate of diabetes mellitus in

the young adult population of Hispanic origin and non-Hispanic blacks?

Objectives

The proposed research aims at exploring the racial and ethnic difference in diabetes

mellitus, especially the risk factors that have led to the high rate of prevalence of the conduction

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among the Hispanic and non-Hispanic black populations in the United States. Specifically, the

proposed research has three objectives.

1. To establish the contributions of genetic bio geographic background against the

socioeconomic aspects of racial as well as ethnic differences in diabetes mellitus.

2. To make an analysis as well as estimation of the level of contribution of the specific

aspects related to the environment as well as neighborhoods on the racial or ethnic

differences in the level of prevalence of diabetes mellitus.

3. To determine the contributions of factors, like the social economic, neighborhoods,

psychosocial, lifestyles, bio physiologic, as well as genetic or ancestral differences on the

rate of prevalence of diabetes mellitus.

Review of Literature

Genetic or Ancestral Factors

i. Family History

The immediate relatives to individuals who have previously had diabetes mellitus are at a

very high risk of developing the hyperglycemic conditions like resistance to insulin, reduced

functioning of then beta cells, metabolic syndrome, and they have four or five times more

chances of developing this condition than those from families without this condition. Far from

the association to family, it is suggested that there is a close association of diabetes mellitus to

genetic predisposition in ethnicity (Rodriguez, Still, Garcia, Wagenknecht, White, Bates, &

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Punzi, 2017). However, further research has established that the pathogenesis of diabetes

mellitus is similar across all the ethnicities.

ii. Bio-geographic Ancestry

While there has been some discussion on the role that genetics plays as opposed to the

environmental factors towards increasing disparities in healthcare, there are several uncertainties

over the contribution of genetic variation. Race is often viewed with respect to the biological

differences in these groups that are said to have varying biogeographically ancestries.

Nonetheless, genes that are closely associated with race make a representation of barely a small

section of the entire genes that make up the genomes. Further, only a small genetic variation

exists between, as opposed to within the racial as well as ethnic groups that are common.

Analysis of the variance genetic variations indicate that at least 75 percent of the genetic

variances are found within these ethnic and racial groups, as opposed to the 10 percent of

variances that are found between these races or ethnicities (Betancourt, Green, Carrillo, &

Owusu Ananeh-Firempong, 2016). Further, the categorizations in the US Census are at large

social constructs, something that is similar to the concept of biological race. Contrary to this,

ethnicity represents a multidimensional construct with a reflection of various factors like

biological makeup, geographic origin, historical aspects, social, cultural, alongside the economic

factors (Ferguson, Swan, & Smaldone, 2015).

The thrifty gene hypothesis is the genetic base upon which the racial or ethnic disparities of

the risks if diabetes mellitus are based. This hypothesis made a proposal that the high rate of

prevalence of diabetes mellitus among African Americans and Hispanic speakers had a high rate

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of prevalence for diabetes mellitus because of their metabolic efficiency was rendered

detrimental by the level of abundance in the western societies, combined with the turn towards

sedentary lifestyles in their accusations as well as leisure activities. While this hypothesis has

been criticized on various perspectives, it has been recently revived, especially with the

increased development of science as well as technologies that facilitate genetic research (Piccolo,

Pearce, Araujo, & McKinlay, 2014).

Considering the level of complexity in the etiology of diabetes mellitus, it could be critical to

make an account of the substantial heterogeneity existing in the populations that are admixed.

This means that the individual proportions of people from European, African, as well as Native

American ancestries could have a substantial difference from the common categories that are

used in categories like African Americans, Hispanics, alongside e the Whites. Various studies

have made a suggestion, that the biologic mechanisms that lead to increased risks to diabetes

mellitus between the Hispanic as well as non-Hispanic black populations could be closely related

to the BGA, especially considering that some genetic markets often cluster according to BGA

(Goonesekera, Fang, Piccolo, Florez, & McKinlay, 2015). While these genes account for a

minute part of the genetic variation, the fact that they are present makes a suggestion that the

genetic differences existing in the racial or ethnic groups potentially have certain implications on

the disparities (Mersha, & Abebe, 2015).

Another approach that could be used to make an examination of the role that BGA plays in

diabetes mellitus is through the Ancestry Informative Markers (AIMs), a method the genotypes

the genetic race or ethnicity of an individual. These studies have established that BGA has a

close association to diabetes mellitus among the African Americans, although this contribution is

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outweighed by the demographic as well as metabolic factors (Carter, Walker, Cutrona, Simons,

& Beach, 2016).

iii. Other Genetic Factors

According to genetic studies, approximately 70 loci are closely associated with diabetes

mellitus while 30 loci have a close relationship with the variations of fasting glucose. According

to studies, there is a substantial overlap in the level of susceptibility loci on the racial or ethnic

groups. This means that there is not likely that the loci that have been indentified cold make an

explanation for the differences in risk to diabetes mellitus on ethnicities or races. More recently,

a magnified sample consisting of African Americans as well as European Americans established

that African Americans have bigger load of diabetes mellitus allele. Nonetheless, they

established that the cumulative risk allele load had a close association with the risks of having

diabetes mellitus among the European Americans, while it was marginal among the African

Americans. With this result, it could be suggested that the total risk allele load has a differential

impact on the individuals from different ethnicities or races (Pickrell, Berisa, Liu, Ségurel, Tung,

& Hinds, 2016).

Lifestyles or Behavioral Determinants

I. Physical Activity

Physical activity is a critical risk factor toward the development of diabetes mellitus. When

an individual participates in regular physical activities, they tend to have reduced risks of

developing the condition. Light to moderate amounts of physical activities are beneficial towards

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tolerance to glucose, but sedentary could be detrimental to tolerance to glucose. According to

research, substituting these light-intensity activities in places of watching television and other

forms of sedentary time could prove to be a practical as well as achievable strategy towards

reducing the risk of getting diabetes mellitus (Colberg, Sigal, Yardley, Riddell, Dunstan,

Dempsey, & Tate, 2016). This piece of observational evidence could be bolstered by data

derived from randomized studies of obese adults. The trials demonstrated that interrupting the

time one spends sitting to take short bouts made up of light to moderate intensities when walking

could help reduce the levels of glucose after one has had meals as well as the levels of insulin,

thus, improving on the rate of glucose metabolism.

Self reported data demonstrates that White Americans tend to have a relatively increased

amount of physical activities during their leisure times, when compared to Hispanics and African

Americans. On the other hand, accelerometery data demonstrates Hispanics tend to have an

increased level of physical activity than both African Americans and White Americans. While it

is notable that accelerometery data is less prone to the self reporting as well as recall errors, this

reasoning is attributed to the nature as well as physical demands in the occupational as well as

domestic activities they are involved in (Myers, McAuley, Lavie, Despres, Arena, & Kokkinos,

2015).

Physical activity does have an impact on diabetes mellitus by affecting BMI or obesity. By

conducting regular physical activates, together with helping the body to maintain the optimum

weight could contribute towards a short-term up regulation together with a long-term down

regulation of the inflammatory markers. This is a key bio physiologic pathway towards

resistance to insulin, pre diabetes, alongside diabetes mellitus. Further, conducting exercise helps

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in improving the uptake of glucose by the skeletal muscles as well as increasing sensitivity to

insulin. It is notable that physical activities have an impact on various components related to

insulin, something that could facilitate the level of uptake of glucose in the skeletal muscles

(Heyward, & Gibson, 2014).

II. Dietary Patterns

Similar to physical activity, healthy dietary patterns contribute towards reducing the risks

involved in the development of diabetes. Long-term data has demonstrated that there are

differences between eating patterns of people from different races. Specifically, these pieces of

data show that African Americans tend to eat foods with high amounts of energy and low

amounts of vegetables, than the White Americans. Diets that have a high amount of refined

sugars, saturated fats, as well as low fibers are closely associated to inflammatory responses that

could have a contributory effect on diabetes mellitus (Ley, Hamdy, Mohan, & Hu, 2014).

III. Alcohol Consumption

Alcohol abuse is said to be among the leading risk factors for most adverse outcomes in

public health. Low and moderate use of alcohol could lead to low levels of incidence of diabetes

mellitus, while heavy consumption leads to increased levels of incidence. Moderate consumption

of alcohol augments the level of sensitivity to insulin and reduces the level of incidence of the

non-alcoholic fatty liver disease. This has a close relationship with metabolic diseases like

resistance to insulin as well as obesity (Adams, Anstee, Tilg, & Targher, 2017).

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IV. Obesity and the Distribution of Fats

Being overweight, when one has a Body Mass Index of 25kg/m2 or more, or obesity, when

one has a BMI of 30kg/m2 are among the major risk factors for resistance to insulin as well as

diabetes mellitus. Obesity increases the rate of incidence of diabetes mellitus by between 20 and

50 times. In the United States, barely a third of the population is of the normal weight, with

similar statistics being reflected across the world. While the rate of obesity and overweight are

increasing, they do vary by race, in the United States. It is estimated that at least 49.5 percent of

African Americans, 39.1 percent of Hispanics, and a further 34.3 percent of White Americans are

obese. It is notable that African Americans and Hispanic speakers have high levels of obesity,

thus, they are at a higher risk of developing diabetes mellitus (American Diabetes Association,

2016).

This association between race and risk of developing diabetes could be modified using

the body mass index. African and white Americans that have high levels of BMI often are

exposed to similar risk levels of developing diabetes, but African Americans with low levels of

BMI are at a higher risk than the whites. Further data demonstrates that Hispanic speakers are at

a higher risk level than the white, despite being in the same spectrum of BMI. Further, African

Americans together with the Hispanics tend to have higher levels of resistance to insulin than the

White Americans, even with adjustments for BMI. The trends of levels of prevalence of diabetes

mellitus based on gender and race demonstrates that these ethnic differences are worsening for

the populations with normal and overweight, although this is not noticed in the obese groups

(Riina, Lippert, & Brooks‐Gunn, 2016).

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One hypothesized reason for this difference could be the variations in the distribution of fats,

especially the central adiposity. Central adiposity contributes towards increasing the resistance to

insulin, which then facilitates the increase in risks for developing diabetes mellitus. The

circumference of the waits could be a strong predictor of diabetes mellitus as opposed to BMI,

especially considering that the waist circumference and diabetes mellitus risk having been

established to be existence in people in the normal BMI range. Central adiposity accounts for

half of the excess risks of diabetes mellitus in African American women against White American

women. However, there is some inconsistency in the results for men (Simopoulos, 2016).

A majority of obese people, including those with a resistance to insulin, hardly develop

hyperglycemia. For a majority of the people, the islet beta cells in the pancreas, which store as

well as release insulin, increase their rate of releasing insulin in an attempt to compensate for the

low level of efficiency of insulin action, thus, making sure that the level of tolerance to glucose

is maintained. In order to associate both obesity and insulin with diabetes mellitus, these beta

cells ought not to be able to offset the low level of sensitivity to insulin. The adipose tissue also

has an impact on the level of metabolism, through releasing the non-esterified fatty acids

(NFAs), hormones, as well as the pro-inflammatory cytokines. It is suggested that the release of

NFAs could be the most critical for the modulation of insulin sensitivity. There are high levels of

NEFA among obese people as well as diabetes mellitus, which are associated with the resistance

to insulin that is experienced in the two. When there is an acute rise in the levels of NEFA in the

plasma, insulin resistance could develop within a few hours (Cuevas-Ramos, & Fleseriu, 2014).

The manner in which fat is distributed in the body also plays a key role in determining the

level of sensitivity to insulin. Most obese people tend to be resistance to insulin. Further, lean

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people who have different variations in the distribution of fat in the body have a markedly

varying sensitivity to insulin. The lean people with more fat in the periphery tend to be more

sensitive to insulin than those whose fats are distributed towards the central. There exist

differences in both the characteristics of both the peripheral as well as central adipose tissues,

which could partly explain the differences in metabolic effects (Simopoulos, 2016).

Psychosocial

a. Sleep

Recently, there has been a growing acknowledgement of the heath consequences that that are

related to sleep, including its contribution towards obesity and subsequently development of

diabetes mellitus. It is estimated that individuals who sleep for less than five hours in a day are

very likely to develop diabetes mellitus. Further research has established that restrictions in sleep

could lead to psychological changes, which could have major implications towards developing

diabetes mellitus or other conditions that are related. There are a number of mechanisms through

which disturbances as well as deprivation of sleep could offer a contribution towards gaining

weight as well as obesity, which have a contribution towards increasing the risks of diabetes

mellitus. When one sleeps for short periods of time, the rate of secretion of cortisol as well as

insulin is increased, thus fat is stored in the body. Further, it could lead to increased ghrelin while

reducing leptin, thus, stimulating appetite while inhabiting the satieties that regulate signals in

the brain, which could lead to an increased level of intake of foods with a high amount of fats as

well as carbohydrates. Losing sleep is also associated with systemic inflammation, which is

measured in CRP concentrations. Additionally, having insufficient as well as inadequate

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amounts of sleep could lead to reduced expenditure of energy, something that is a major

contributor of gaining weights as well as obesity. With increased levels of production of insulin

in the body, together with hampered glucose metabolism, the individual is at a great risk of

diabetes mellitus (Shan, Ma, Xie, Yan, Guo, Bao, & Liu, 2015). With these considerations,

restrictions in sleep alongside poor patterns for sleeping is considered a major risk for weight

gain and subsequently diabetes mellitus, something that is similar with the common risk factors

like lack of physical activity as well as poor diet.

Research has established that the racial disparities in sleep could be partially explained by the

other related factors, like occupation as well as financial strains. Essentially, individuals in the

low levels of income and those with poor education tend to have limited opportunities that would

allow them sleep, and often lack adequate environments that would encourage them to sleep.

Another aspect could be immigration status, which limits the opportunities that would encourage

healthy sleeping patterns. With these situations, there are more chances that the Hispanic and

African Americans are faced with these situations that hinder healthy sleep as compared to the

White Americans, aspects that contribute to the high rate of diabetes mellitus prevalence among

these populations (Gailliot, & Baumeister, 2018).

b. Depressive Symptoms

These could potentially contribute towards changing the lifestyles, something that could have

a consequential effect, facilitating the development of diabetes mellitus. Depression offers a risk

of between 25 percent and 37 percent of developing diabetes mellitus. When one is depressed,

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their bodies produce high levels of the pro inflammatory markers alongside reducing sensitivity

to insulin (Semenkovich, Brown, Svrakic, & Lustman, 2015).

Similar to sleep, the related factors to depressive symptoms differ between the races,

something that contributes towards the increase in depression for Hispanics and African

American, to levels higher than those experienced by the White Americans do. The African

Americans and Hispanics majorly experience factors like lack of immigration documents, low-

income levels, as well as low levels of education, among others. These are major contributors of

depression, thus, exposing them to high levels of risk of developing diabetes mellitus.

c. Chronic Stress

Psychosocial stress, manifested through adverse events in life, strain at the workplace, and

reduces sense to coherence, among others, is closely associated to the development of diabetes

mellitus. Perceived psychosocial stress combines with low sense of control or low levels of

helplessness easily contributes towards activating the hypothalamic-pituitary-adrenal axis

(HPA). Consequently, this contributes towards the abnormal functioning of the endocrine

functions, like increasing cortisol as well as reducing the levels of sex steroid. With this

endocrine dysregulation, the effects that insulin has are antagonized. With these imbalances, the

individuals could easily develop obesity, especially the visceral adiposity, which has a major

contribution toward the development of resistance to insulin as well as the development of

diabetes mellitus. Both internal and external senses of control are said to be primary mediators

for stressful event as well as health, especially considering that individuals who have low

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internal senses of control have a low capability to tackle the stressors (Bullon, Newman, &

Battino, 2014).

Similar to sleep and depressive symptoms, the related factors to chronic stress differ between

the races, something that contributes towards the increase in depression for Hispanics and

African American, to levels higher than those experienced by the White Americans do. The as

noted, these individuals experience factors like lack of immigration documents, low-income

levels, as well as low levels of education. These are major contributors of chronic stress, thus,

exposing them to high levels of risk of developing diabetes mellitus.

Neighborhood Influences

The built environments, referring to the surroundings that are made by man, have an

impact on setting up the conditions that allow or discourage healthy behaviors. Some aspects that

make up built environment, like grocery outlets, convenience stores, as well as fest foods have a

major impact in inspiring the eating habits of the people living in certain areas. Essentially, areas

with a big number of fast foods could have detrimental effects on the level of BMI of individuals

living there, while a high saturation of stores serving healthy foods could have positive impacts

on the level of BMI. Further, aspects like parks and other forms of green spaces could have a

positive contribution towards encouraging healthy activities, specially the physical activities.

With these facilities, the level of development of diabetes mellitus could be reduced.

It is suggested that both the social and economic aspects, which are established at the

neighborhood level, could explain a majority of racial variations of diabetes mellitus. The

socioeconomic status of the neighborhood could have a positive contribution towards obesity,

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risk factors for cardiovascular conditions, alongside the metabolic syndrome, especially among

women (Liese, Lamichhane, Garzia, Puett, Porter, Dabelea, & Liu, 2018). This socioeconomic

environment has an impact on the availability of grocery outlets, recreational facilities, as well as

resources for education, which have an impact on the diet, level of physical activity, and

subsequently, diabetes mellitus. Further, living in these neighborhoods that are derived off

economically could be a major contribution towards chronics stress, something that offers a

major contribution towards developing diabetes mellitus.

These adverse influences in the neighborhoods are more likely to affect African

Americans and Hispanics, more than they are likely to affect White American. This is so,

especially considering that most of these individuals are in the low levels of income, something

that pushes them to neighborhoods where they are deprived off recreational facilities, and

convenience shopping pushes them to eat at fast foods, among others. With this situation, the

environments where African Americans and Hispanics live are major contributors of the risk

factors for diabetes mellitus.

Social and Economic Aspects

Literature reveals that health tends to follow a social gradient, such that people in the

high socioeconomic positions will have higher chances of having healthier lives than those in the

lower positions (Elrayah‐Eliadarous, Östenson, Eltom, Johansson, Sparring, & Wahlström,

2017). In the past, the socioeconomic differences existing between morbidity as well as mortality

have increased. This led to the proposal of various interrelated pathways seeking to make an

explanation of these social inequalities in healthcare. These include healthy behaviors,

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psychological aspects, alongside access to materials that promote health such as healthy foods

and quality healthcare (Wiebe, Helgeson, & Berg, 2016).

One of the contributions of the socioeconomic status is the status during childhood,

which has an impact on the health status if the individual after they have grown up.

Observational studies together with systematic reviews have shown a close association between

the socioeconomic status of children with increased risks of obesity, heart conditions, stroke, as

well as diabetes mellitus. Further, it has been closely associated with precursors of diabetes

mellitus, like metabolic syndrome, resistance to insulin, as well as increase levels of glucose in

blood. One of the ways through which the circumstances during the early life affect the health of

an individual is through the latent effect (Wiebe, Helgeson, & Berg, 2016). It could also have an

effect it through exposure to the socioeconomic adversity, which has a cumulative impact over

the course of life. Lastly, this status could have a pathway effect into adult life.

Adult socioeconomic situation is also another major risk factor, which has a major impact

on the complex processes that play a critical role towards enhancing access to healthcare

services, access to information, access to healthy foods, access to facilities for physical activity,

economic opportunities, alongside behaviors as an individual. For instance, unhealthy behaviors

like poor dietary behaviors and lack of physical activities are said to be higher among the adults

who have low socioeconomic statuses. With this consideration, African Americans and

Hispanics, being in the low socioeconomic levels are at a high level of exposure to diabetes

mellitus.

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Health Literacy and Access

Low levels of literacy in healthcare matters, lack of ability to obtain, access, as well as

understand various forms of health information that is required to make the necessary heath

decisions is a major challenges in healthcare, especially among the African Americans and

Hispanics. Most healthcare materials are taught at high school and higher levels of education,

levels that a good number of individuals in this population hardly realize. Being in a

disadvantaged position, this population will be exposed to the risks related to poor levels of

literacy, including diabetes mellitus (Goeman, Conway, Norman, Morley, Weerasuriya, Osborne,

& Beauchamp, 2016).

Methodology

Conceptual Model

The conceptual framework makes a combination of the population health framework

together with a causal framework for modeling, in an attempt to come up with the risk factors for

ethical differences in diabetes mellitus. Through this model, the research will be in a position to

identify the distal, intermediate, alongside the proximate aspects that have an influence on

diabetes mellitus. The distal aspects that could be determinants on a population level include the

conditions on a personal as well as individual level, like the socioeconomic factors,

discrimination on ethical lines, and others. Intermediate determinants of diabetes mellitus are

aspects related to the environments in the neighborhood as well as the community. Lastly, the

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proximate determinants of diabetes mellitus are the biophysical as well as genetic aspects,

together with the behaviors of an individual with respect to healthcare.

This conceptual model seeks to overcome a couple of constrains that could be faced in

modern epidemiologic study into diabetes mellitus disparities. The first is that instead of putting

its focus on the proximate risk factors, it attempts to put emphasis on the upstream analysis of the

disparities in development of diabetes mellitus among the African Americans and Hispanics.

Secondly, rather than putting much focus on the individual level as a site for etiological action,

putting much emphasis context of the neighborhoods as well as the social environments. The

conceptual framework could as well be presented in the form of a Directed Acyclic Graph that

could be used in informing the development of the various models of structural equations that

contribute towards the ethnic disparities in diabetes mellitus.

Sample

Being an empirical research, the proposed research will conduct multiple case studies,

focus studies, as well as surveys. However, the proposed research will primarily rely on survey

research, examining an array of real-life studies that will be used as a foundation of most

thoughts as well as expanding the methods that exist. Through the survey research approach, the

proposed research will be in a position to collect information from a large pool of respondents as

well as making generalized results across the population. Further, the proposed research will

include other methods like panel studies, as well as focus studies.

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Data Analysis

The proposed research will incorporate both qualitative and quantitative data analysis

approaches. Data from survey research will be summarized into charts, maps and other

familiarization thematic frameworks.

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