Prevalence and Perceptions of Type II Diabetes in St. Kitts &

NevisDr. Jeanita Richardson Ph.D

Corinne ConnAndrew Wills

Michelle CrawfordNoellissa Swaby

Shakira KingDeega Omar

Aejari BrowneAhisha HerbertYolande Pokam

Mentor Faculty: Dr. Merissa O’Connor and Ms. Gail Mills

LITERATURE REVIEW● A total of 40 articles were reviewed● Research Foci:

● The articles reviewed all focus on prevalence and perception of diabetes mellitus in Afro-Caribbean and Black populations.

● Theoretical Frameworks:● The theoretical frameworks in each article were a reflection of the research question. For example,

the Health Belief model was used for a research project that focused on perceived susceptibility of diabetes mellitus.

● Examples of theoretical frameworks used:● Health Belief Model● Thematic Content analysis● Scoping Review● Roy Adaptation model● Cultural Consensus model

● Common Methods:● The most common methods were convenience or stratified sampling, random sampling, and two-

stage cluster sampling. Most research article’s inclusion criteria included age ranges, which mostly focused on ages 18 – 75.

DIABETES: What is it?

●Diabetes Mellitus or Type II Diabetes is a chronic condition that affects the way the body metabolizes glucose.

●The body either resists the effects of insulin or doesn’t produce enough.

●Type II diabetes generally affects people older than 45 years of age but more younger people are becoming diagnosed.

●The risk of diabetes increases with age, weight, family history, fat distribution, race, physical inactivity.

Mayo Clinic Staff (2014, July 14). Type 2 Diabetes. Retrieved July 20, 2015. http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/basics/definition/con-20031902

DIABETES: WORLD WIDE ISSUE●Type II Diabetes accounts for 90% of diabetes cases

●Affects 10% of the world's population●Diabetes accounted for 1.3 million deaths worldwide(not

including co-morbidities)●Managing diabetes and its complications is a lifelong burden.●Fiscal Burdens of type 2 diabetes are unsustainable

●On average it accounts for 15% of National healthcare budget.

●Diabetes Projection●171 million in 2000, estimated to rise to 366 million by

2030.● Barcelo, Aedo, Rajpathak, Robles, 2003; International Diabetes Federation (IDF), 2013; Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (n.d.). Global Prevalence of Diabetes: Estimates for the Year 2000 and Projections

for 2030: Response to Rathman and Giani. Diabetes Care, 2569-2570; World Health Organization. (2011, September 18). Global Status Report on Noncommunicable Diseases 2010. Retrieved July 17, 2015,. http://www.who.int/nmh/publications/ncd_report_full_en.pdf

Diabetes in the Caribbean

●Diabetes is a leading health problem in the Caribbean with a growing prevalence

●In 2000, Diabetes was the 3rd leading cause of death in the Caribbean

●The high costs of Diabetes places a heavy economic burden on the already limited health-care resources in the Caribbean

●Those of lower socioeconomic status are disproportionately affected●Based off hospital admissions (n=577 12.4% of total admissions) from

2006-2010, the prevalence of Diabetes Mellitus was determined to be 20% in St. Kitts

Pan American Health Organization(PAHO) and World Health Organization (WHO) (2012) Health in the Americas: St. Kitts and Nevis. Retrieved: April 5, 2015.http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=9&Itemid=14&lang=enPan American Health Organization(PAHO), & Caribbean Health Research Council. (2006). Managing Diabetes in Primary Care in the Caribbean. The Caribbean Public Health Agency(CARPHA).

Mortality Statistics in St. Kitts and Nevis

Pan American Health Organization(PAHO) and World Health Organization (WHO) (2012) Health in the Americas: St. Kitts and Nevis. Retrieved: April 5, 2015.http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=9&Itemid=14&lang=en

Geography

Worldatlasmap:St.Kitts and Nevis[onlineimage] 2015.Retrieved by July 22nd 2015.http://www.worldatlas.com/webimage/countrys/namerica/caribb/kn.htm

St.Kitts & Nevis Maps: Nevis [Online image]. (2003). Retrieved: July 7th, 2015.http://www.caribbean-on-line.com/islands/sk/nvmap.shtml

Cotton Ground

Cotton Ground

Butlers Clinic

Demographics and Economy●Population of Federation: 54,961 (2015 estimation)●A predominantly Black country, with East Indian, European and mixed races.●Middle-income economy relies on tourism after abolishment of sugar cane industry in 2005

Grayson,J.W. (2014). Carnival Roll Call . Retrieved from http://home.comcast.net/~john.middleton/triumphB2B/stKittsPortPage.html

Historical Overview❖ The federation(St.Kitts & Nevis)

became Britain’s first West Indian colony in 1623.

❖ Independence was established in September 19th 1983.

❖ In 2005, the government transition the sugar industry after years of losses

❖ Tourism has replaced the sugar industry since the 1970

Pan American Health Organization(PAHO) and World Health Organization (WHO) (2012) Health in the Americas: St. Kitts and Nevis. Retrieved: April 5, 2015. Pan American Health Organization(PAHO), & World Health Organization (WHO). (2012). Pan American Health Organization. Retrieved July 21, 2015, from http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=9&Itemid=14&lang=en

Public Health System in St. Kitts and Nevis❖The government upholds a primary

health care approach: strategies of community participation, health promotion, and intersectoral collaboration

❖The government attempts to ensure that healthcare is accessible and affordable to the population, which has barrier-free access to government services spanning the range from prevention to palliation.

❖Health care facilities are strategically located throughout the two islands and every household is within three miles of a health center.

❖17 health centers: 11 in St. Kitts and 6 in Nevis 2 hospitals: one on each island

Pan American Health Organization(PAHO) and World Health Organization (WHO) (2012) Health in the Americas: St. Kitts and Nevis. Retrieved: April 5, 2015.http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=9&Itemid=14&lang=en.

Political Structure of Health System

Perceptions and Knowledge of Diabetes in St. Kitts and NevisIRB # 2015-0183-00

General Population Health Behavior

Perceptions and Knowledge of Diabetes in St. Kitts and Nevis

● The purpose of our research is to produce qualitative data about the perceptions and knowledge of type II diabetes amongst the general populace of St. Kitts and Nevis.

● In order to develop effective, culturally sensitive interventions, this type of qualitative data was requested by the Ministry of Health.

Health Belief Model and Donabedian Model Hybrid

Donabedian A. Aspects of medical care administration: Specifying requirements for health care. (1973). Cambridge, London. Retrieved: July 7th, 2015.

Inclusion criteria and survey instrument

● Participants: Age: 18-75● The WHO STEPwise instrument used globally as a

surveillance tool for health risk factors was adapted. The instrument was used in St. Kitts in 2008 but never in Nevis.

● We used the sections of the survey known to have a relation to type 2 diabetes risk and severity and made minor adjustments to language and pictures in consultation with the Ministry of Health for cultural relevance. (Sample sections included diet, physical activity, diabetes diagnosis and knowledge, lifestyle, and cardiovascular disease.)

World Health Organization (WHO). WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS). (2014). Geneva, Switzerland. Retrieval date: 7/20/2015.

WHO Stepwise Instrument

Sample Changes in STEPwise Showcards

Procedure 1. After confirming approved data collection sites (farmers’ markets, grocery

store parking lots) 2. We were organized in two person-research teams with one person from the

US and the other from either St Kitts or Nevis. (This strategy was valuable in securing participation and understanding the responses that sometimes were articulated in local dialect.) Most of the time we wore our Global Health t-shirts

3. We approached persons appearing to be over the age of 18. 4. We described the study and secured oral consent 5. We asked the questions in the WHO STEP instrument and the additional

open ended questions (completion took between 10-15 minutes)6. Thanked Our Participants

Additional Questions

● Why do you think people have diabetes?● What do you think are the changes that diabetes causes? ● Would you tell me about the clinical and educational support that is

available to help manage diabetes on St. Kitts and Nevis?

Summary of Diet Responses●Approximately 60% (n=224) of respondents reported consuming fruits and vegetables 4-7 times per week

Self reported Consumption of Fruits and Vegetables 4-7 Days/Week(% of each categories’ responses)

Summary of Diet Responses

Other Self-Reported Diet Practices(% of each categories’ responses)

❖ Approximately 62% (n = 219) of all respondents add salt often or always while cooking.❖ Approximately 61% (n=219) of all respondents eat processed food sometimes or rarely

(1-4 days/week)❖ Approximately 77% (n=201) of all respondents eat food they have not prepared (eating out) 0-3

days/week

Summary of Physical Activity at Work Responses

● Approximately 31% (n = 216) of all respondents reported doing 4-7 days of vigorous activity at work ●Approximately 51% (n = 217) of all respondents reported doing 4-7 days of moderate activity at work

●

Self-reported Physical Activity for 4-7 Days at Work (% of each categories’ responses)

Summary of Leisurely Physical Activity Responses ● Approximately 16 % (n = 210) of all respondents reported doing 4-7 days of vigorous activity at work ●Approximately 35 % (n = 211) of all respondents reported doing 4-7 days of moderate activity at work

Self-reported Leisurely Physical Activity for 4-7 Days

(% of each categories responses)

Summary of Diagnosed Diabetes, Hypertension, and High Cholesterol

● Approximately 13% (n = 224) of all respondents report being diagnosed with Diabetes● Approximately 28% (n = 224) of all respondents report being diagnosed with Hypertension● Approximately 17% (n = 224) of all respondents report being diagnosed with high cholesterol levels

Self Reported Diabetes, Hypertension and High Cholesterol Diagnoses(% of each categories’ responses)

Summary of Lifestyle Responses● Approximately 26% (n= 211) report being instructed by a clinician to reduce salt intake● Approximately 38% (n= 208) report being instructed by a clinician to eat at least five servings of fruits and

vegetables daily●Approximately 33%(n= 212) report being instructed by a clinician to reduce fat in their diet● Approximately 42% (n= 213) report being instructed by a clinician to start or do more physical activity● Approximately 50% (n= 214) report being instructed by a clinician to maintain/lose weight

Self-reported Advice Received from Health Professional

Diabetes and Comorbidities (Hypertension and High Cholesterol)

●Of the persons reporting to be diabetic (n=27):●51.8% report a hypertension diagnosis●33.3% report a high cholesterol diagnosis

Diabetes + Hypertension

% Diabetes + High Cholesterol

%

Male 5 31.3 3 21.4

Female 9 21.4 6 30

Nevis 8 26.7 5 33.3

St Kitts 6 21.4 4 21.1

Self Reported Diabetes, Hypertension and High Cholesterol Diagnoses

(% of each categories’ responses)

Conclusions from Survey (closed ended data)●A large percentage of respondents self reported consuming fruits and vegetables 4-7 times per week.

●Majority of the sample population self-reported eating out 0-3 times a week and always/often adding salt to food while preparing it

●Approximately a third of the population self reported doing moderate exercise for leisure purposes.

●Over a third of the population self reported receiving lifestyle advice from a clinician regarding diet, physical activity, body weight.

●More than half of the sample who self report as diabetics also indicated a diagnosis of hypertension. ●More common among men in our sample vs. women● Higher in Nevis vs. St. Kitts

● In the case of diabetes and high cholesterol we found that 33% of our sample population indicated having high cholesterol and diabetes.

●Self reported high cholesterol is more prevalent among women in the Federation. ●Nevisians self report having higher prevalence of diabetes with high cholesterol.

THEORETICAL CODING●Perceived Susceptibility:● Belief about the chances of ● getting a condition

●Perceived Severity:● Belief about getting the ● seriousness of a condition

● and its consequences

●Cues to Action: ●factors that activate “readiness ●to change”

National Institute of Health. (2005). Theory at a Glance: A Guide For Health Promotion Practice (2nd ed.). Baltimore, MD: Johns Hopkins University.

Summary of “Why do you think people have diabetes?”

Theme: Perceived Susceptibility

●Categories: Diet, Genetics, Weight, Don’t know

●The units of analyses used were Males, Females, St. Kitts and Nevis and the sample sizes were: M=94, F=120, SK=111, N=105. (These were consistent for every question)

●The Diet theme consisted of responses such as, diabetes is caused by “Bad eating habits”, “poor diet”, and “Not eating properly”

●77.8% (n=216) of those who responded to this question reported diet as a major contributing factor in diabetes.

● The Genetics theme consisted of participants who responded that “genetics”,” inheritance”, and “family history” causes diabetes.

●24.5% (n=216) of those who responded to this question reported genetics as a major contributing factor in diabetes.

●The Exercise theme consisted of answers such as, “not working out”, “lack of exercise”, and “exercise”.

●14.3% (n=216) of the respondents said exercise is a contributing factor in diabetes

●20% (n=94) of males who responded to this question reported lack of exercise as a major contributing factor in diabetes while 9% (n=120) females did

●The Weight theme included responses such as “overweight” and “obesity”. ●2.8% (n=216) of the respondents said weight is a contributing factor in

diabetes

●The Don’t know know theme included participants who responded “don’t know”, “not sure”.

●8.3% (n=216) of the respondents said they did not know the answer

Perceived Susceptibility

Summary of“What do you think are the changes that diabetes causes?”

Theme: Perceived Severity

❖ Categories: ➢ weight change, lifestyle changes, organ failure, amputation and

don’t know

❖ Weight change:➢ 22.7% (n=216) reported weight changes, “weight gain”, “weight loss”

as a change of Type II diabetes

❖ Lifestyle Changes:➢ 21.3 % (n=216) interviewed reported lifestyle changes, such as

“exercising more,” “taking medications” and “eating healthier,” as consequence of DM.

Perceived Severity

● Organ failure:● 15.3% (n=33) interviewed said “kidney failure”, “heart failure”, “organ

problems” are a consequence of diabetes● Amputation:

● 11.1 % (n=24) interviewed perceive “amputation” or “loss of limbs”as a severe consequence of DM

● Don’t Know:

● 16.6% (n=36) responded with “don’t know” or “not sure,”

“Would you tell me about the clinical and educational support available to help manage Type 2 Diabetes in St Kitts and Nevis?”

Theme: Cues to Action

● Categories: Positive Outlook and Negative Outlook and Don’t Know/Not Sure.

● Using the Positive Outlook theme, which consisted of answers such as “There is support” or “There is some support”, 62.2% (n = 111) of the respondents who gave such comments were from St. Kitts, while 45.7% (n = 105) of them were from Nevis.

● Using the Negative Outlook theme, which consisted of answers such as “There is no support” or “There could be more support”, 9.0% (n = 111) of those who gave such comments were from St. Kitts while 5.7% (n = 105) of them were from Nevis.

“Would you tell me about the clinical and educational support available to help manage Type 2 Diabetes in St Kitts and Nevis?”

●Based on the “Don’t know/Not Sure” theme, 39.2% of Females (n=120) and 37.2% (n=94) of Males from both islands said that they don’t know about any clinical and educational support available to help manage diabetes.

●In addition, out of the participants who said they didn’t know if there were any clinical/educational available on the Federation to manage diabetes, 28.8% (n=111) of them were from St. Kitts while 47.6% (n=105) were from Nevis.

●Some participants responses were accounted for twice because they said “There was some support” which fell under both the Positive and Negative themes.

Limitations for Survey Data●Showcards●Influence of third party observers on surveyor answers●Limited time●Loss of information due to difficulty of transcribing verbatim●Local Accents●Clarity of survey and additional questions●Not linking open ended responses to associated surveys ●In the data we had to account for different N’s for our different units of analysis

●Two genders out of 224 participants were not recorded.●Incompleted surveys●We can't tell if a large amount the survey participant know only one thing or lot about diabetes

Conclusions from Survey (open ended questionnaire)●Self reported perceived susceptibility (in order):

●Diet was the most reported cause of diabetes ●A fourth of participants cited Genetics as a cause of diabetes●A fifth of men and a tenth of women reported that Exercise was a major contributor to diabetes ●Almost 10% reported not knowing●Weight was reported as the least important cause of diabetes, specifically 3%. ● *Participants do not limit answers to just one cause.

●Self report perceived severity: ●More than 20% of respondents indicated that weight was the major change caused by diabetes ●More than 20% reported that lifestyle change is a result of diabetes●Respondents seem that diabetes cause knowledgeable organ failure●Less than 15% of respondents self report that amputation is a consequence of diabetes●The percentage of the “don’t know” theme is comparatively similar to the other themes

●Self report perceived cue to action:●General respondent have a positive outlook on the island; less than 10% of Kittitian and Nevis

believe that there is “no support” on the island●About 40% of the respondents indicated “Don’t know” to the educational or clinical support

provided

Recommendations❖We recommend that development of education resources, (e.g. pamphlets,

workshops, community cooking and exercise classes, radio broadcasts, etc.) be geared towards:

❖ Importance of weight and its link to diabetes ❖ The genetic predisposition to diabetes➢ Dietary choices/Importance of reducing salt while preparing food

(processed foods). ➢ Importance of exercise and its link to diabetes.

❖ Possible targets for educational materials:➢ Patients who have high cholesterol and/or high blood pressure with

diabetes.➢ Women with high cholesterol and men with high blood pressure.

❖We believe that targeted advertising for resources related to diabetes and related co-morbidities will help manage new and existing cases.

Determining the Prevalence and Distribution of Type 2 Diabetes in SKN

IRB #18122

➢ Charlestown Health centre ➢ BrownHill Health centre➢ Butlers Health centre➢ Combermere Health centre ➢ Cotton Ground Health centre➢ Gingerland Health centre

Participating health centres used in study

Inclusion Criteria and Chart Review Process1. Inclusion criteria:18-75 year olds as of 1/1/2010 and visited the clinic

between 1/1/2010 and 1/1/20152. Every record provided by health center staff was reviewed to determine

eligibility for inclusion by two-person teams3. Every eligible name was added to an excel spreadsheet and then

alphabetized. Records were not filed in strict alphabetical order and this process allowed us to retain the filing system used by the nurses.

4. Depending on the number of records, the random sample was identified. Clinics with under 200 records – every other one

Between 200 – 400 – every 3rd record Over 400 – every 5th record

Chart Review Process cont.

5. Relevant names were written on a paper sheet where a unique ID number was assigned

6. In research teams of two relevant files were pulled and the assigned ID number was placed on the top of the paper sheet

7. All visits within the inclusion period were recorded

Confidentiality ➢ Prior to leaving St Kitts and Nevis all spreadsheets and ID number

assignment sheets were destroyed.

➢ While in St Kitts and Nevis, the ID-patient name sheets were kept in a locked safe and the chart review forms with ID number were kept in a separate locked safe

Study Population and Sample➢ Nevis Population = 11,000 Eligible Population = 13% of Island population➢ Population Sample = 31% of Eligible records and 4% of island population

Chart Review Form

Chart Review Process

1. In research teams of two, groups of files were assigned and reviewed.

2. The relevant ID number was written on the paper chart review sheet

3. Data was recorded for every visit within the inclusion period (1/1/2010 – 1/1/2015)

➢ When handwriting was difficult to discern➢ Other members of the team were consulted➢ The nurse on staff was consulted➢ Dr. O’Connor was consulted➢ Medications were checked against the OECS

Medicine Formulary ➢ Examples of Data Collection Decisions:

➢“First Degree Relative with DM” was changed to “Relative with DM” because of inconsistencies in what was written for family history in patient charts.

➢Patients without a DOB that had an admissible clinic visit date and an age were still included in sample. We assumed the reported age was the age they were the first time they came to the clinic

Record Keeping System

Sample Demographic Data

Diabetes in the Sample

●Approximately 17% (n= 439) of the sample records note a diabetes diagnosis●Females account for 72% (n=74) of the diabetes cases●43% (n = 74) of diabetics record a relative with diabetes

Hypertension in the Sample

Clinic Hypertensive cases % of clinic sample

Brown Hill 16 21.33%

Butlers 22 29.7%

Charlestown 8 23.5%

Combermere 19 27.9%

Cotton Ground 18 19.8%

Gingerland 25 23%

●Approximately 24.6% (n=439) of the sample records note a hypertensive diagnosis●Females account for 68.5% (n=108) of the hypertensive cases

Metabolic Screenings: Risk Ranges for Diabetes

●Fasting Blood Sugar (FBS): ≥ 126 mg/dL●Blood Pressure (BP): > 130/85 mm/Hg●Combined Cholesterol (CC): ≥ 180 mg/dL●Triglycerides (TG): ≥ 150 mg/dL

What Your Cholesterol Levels Mean. (n.d.). Retrieved July 22, 2015, from http://www.heart.org/HEARTORG/Conditions/What-Your-Cholesterol-Levels-Mean_UCM_305562_Article.jsp Pan American Health Organization(PAHO), & Caribbean Health Research Council. (2006). Managing Diabetes in Primary Care in the Caribbean. The Caribbean Public Health Agency(CARPHA).

Summary of Metabolic ScreeningsOf the charts that include corresponding data for each metabolic screening:➢ Approximately 51% (n=74) of recorded FBS levels were high FBS levels ➢ Approximately 41% (n=240) have high BP➢ Approximately 72% (n=61) have high Combined cholesterol levels ➢ Approximately 14% (n=59) have high Triglyceride levels

*The sample size for each unit of analysis is drawn from the chart-reviewed participants from each unit who had the respective metabolic screenings.

Summary of Co-morbiditiesOf the persons who were identified as diabetic in the entire sample (n = 74):●Approximately 27.0% also have high cholesterol●45.9% had high blood pressure according to CARPHA guidelines

The sample size is drawn from the chart-reviewed participants who were diagnosed with DM from their respective unit of analysis. i.e~ in the case of DM and high cholesterol, 13 males were diagnosed with DM and 3 of them presented with high cholesterol.

Limitations for Chart Review

●Legibility of doctor’s handwriting●Clinic-specific filing system for doctor’s patient charts● Inconsistency in reporting health codes by doctors or nurses●Visit date or DOB/age was missing for some patient charts● Inconsistency in asking and recording family history for each patient chart.

Note: Actual patient chart from one of the clinics. All personally identifiable information has been removed from this picture.

Conclusions from Chart Review1. Out of every clinic’s sample population, Charlestown’s contains the highest percentage

of diabetic patients2. Females account for more than half of the diagnosed diabetics. 3. Hypertension is prevalent (~ >20%) in all clinic populations 4. Females account for the majority of persons with hypertension .5. Of the patients reviewed with metabolic screenings, more than half had high FBS or CC

levels and more than a third of the sample had high BPs. 6. Persons aged 18-49 and 50-75 have comparable percentages of patients with high

FBG.7. Patients aged 50-75 with recorded BP have higher BPs, than patients aged 18-49.8. Approximately half of the patients diagnosed with diabetes are also diagnosed with

hypertension.9. Approximately half of the persons aged 50-75 diagnosed with diabetes also have

hypertension.

Recommendations for Ministry Of Health

1. Based on the percentage of diabetic cases of the random sample, we recommend that particular attention be put on Charlestown clinic.

2. Recommend increased surveillance on hypertensive patients in all clinics. ➢ Recommend particular attention devoted to female patients who are

hypertensive, diabetic or at risk. 3. Recommend increased surveillance on patients diagnosed with both hypertension

and high cholesterol to better prevent diabetic cases. 4. Recommend increased surveillance on male and female patients aged 50-75 age

range who are diagnosed with both diabetes and hypertension .5. Increased surveillance on younger patients diagnosed with hypertension or are at

risk.

Comprehensive Conclusions and Recommendations

➢ Because of the possible underrepresentation of diabetic cases in our sample, we believe that adjusting clinic hours might be beneficial to the working population who may not be able to access clinics between 8 – 4 pm.

➢ Based our comorbidity data from surveys and chart reviews, we believe that educational materials targeted towards patients who are diagnosed with diabetes in addition to hypertension, high cholesterol or both will decrease prevalence and help manage existing cases.

➢ We believe that annual metabolic screenings related to diabetes mellitus, especially for those predisposed to the disease, can provide clearer evidence for reallocation of limited resources for prevention.

➢ Because of the disproportionate number of males represented in our sample, we recommend targeting the male population in order to encourage increased utilization of the clinics in Nevis.

References●Barcelo, Aedo, Rajpathak, Robles, 2003; International Diabetes Federation (IDF), 2013; Wild, S., Roglic, G., Green, A., Sicree, R., & King,

H. (n.d.). Global Prevalence of Diabetes: Estimates for the Year 2000 and Projections for 2030: Response to Rathman and Giani. Diabetes Care, 2569-2570; World Health Organization. (2011, September 18). Global Status Report on Noncommunicable Diseases 2010. Retrieved July 17, 2015,. http://www.who.int/nmh/publications/ncd_report_full_en.pdf

●Center for Disease Control (CDC). (2014, October 21). Preventing Diabetes. Retrieved July 24, 2015.●Donabedian A. Aspects of medical care administration: Specifying requirements for health care. (1973). Cambridge, London. Retrieved:

July 7th, 2015.●Grayson,J.W. (2014). Carnival Roll Call . Retrieved from http://home.comcast.net/~john.middleton/triumphB2B/stKittsPortPage.html●Mayo Clinic Staff (2014, July 14). Type 2 Diabetes. Retrieved July 20, 2015. http://www.mayoclinic.org/diseases-conditions/type-2

diabetes/basics/definition/con-20031902●Pan American Health Organization(PAHO), & Caribbean Health Research Council. (2006). Managing Diabetes in Primary Care in the

Caribbean. The Caribbean Public Health Agency(CARPHA).●Pan American Health Organization(PAHO) and World Health Organization (WHO) (2012) Health in the Americas: St. Kitts and Nevis.

Retrieved: April 5, 2015 http://www.paho.org/saludenlasamericas/index.php?option=com_content&view=article&id=9&Itemid=14&lang=en●St.Kitts & Nevis Maps: Nevis [Online image]. (2003). Retrieved: July 7th, 2015. http://www.caribbean-on-line.com/islands/sk/nvmap.shtml●What Your Cholesterol Levels Mean. (n.d.). Retrieved July 22, 2015, from http://www.heart.org/HEARTORG/Conditions/What-Your-

Cholesterol-Levels-Mean_UCM_305562_Article.jsp●Worldatlasmap:St.Kitts and Nevis[onlineimage] 2015.Retrieved by July 22nd

2015.http://www.worldatlas.com/webimage/countrys/namerica/caribb/kn.htm

We would like to acknowledge the support of:

● Chief Medical Officer Patrick Martin● Permanent Secretary Nevis Ministry of Health Nicole Slack-Liburd● Clinical staff:

● Brownhill● Charlestown● Cottonground● Combermere● Butlers● Gingerland

● Gail Mills● Merissa O’Connor, M.D● National Institute of Health