Abstract
This project aimed to describe diabetes prevalence and evaluate diabetes screening among newly arrived U.S. refugees. We included refugees ≥ 18 years who underwent domestic medical exams (DME) at three sites between January 2012–September 2022. Data was obtained from electronic health records. We identified refugees with diagnosed diabetes at DME using ICD-9/10 diagnosis codes. Refugees were classified as having undiagnosed diabetes if they had a diabetes diagnosis code or hemoglobin A1c ≥ 6.5% within 3 months of DME. Among refugees without diagnosed diabetes at DME, we used modified American Diabetes Association Standards of Care 2022 criteria to classify them as “screening-eligible.” We considered refugees as receiving diabetes screening if they had a hemoglobin A1c or fasting glucose result. Demographic data included patient age, sex, race, ethnicity, and country of origin. We provide prevalence of diagnosed and undiagnosed diabetes and evaluate diabetes screening among newly arrived refugees. We included 4,521 refugees, 127 (2.8%) had diagnosed diabetes at DME, and 244 (5.4%) were diagnosed with diabetes within 3 months. Of those without known diabetes at DME (n = 4,384), 63.3% (n = 2,863) were screening-eligible and of those, 25.4% (n = 726) had screening within 3 months. While the prevalence of overall diabetes among newly arriving refugees was lower than the general U.S. population (8.2% vs. 11.6%), this may be an underestimate as only one-fourth of screening-eligible patients were screened. Adding routine diabetes screening recommendations to DME guidance may decrease the time for diabetes diagnosis for refugee patients.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10903-025-01706-w.
Keywords: Refugees, Diabetes, Prevalence, Electronic health records
Background
An estimated 537 million individuals worldwide have diabetes (type 1 and 2), with approximately 45% of them remaining undiagnosed [1]. Within the United States (U.S.), an estimated 38 million people are living with diabetes including 8.7 million (∼ 23%) of whom are undiagnosed [2]. It is expected that diabetes will continue to increase in prevalence worldwide and will be a growing problem among displaced populations across the globe [1, 3, 4]. Complications of uncontrolled diabetes include debilitating conditions such as loss of vision, kidney failure, cardiovascular diseases, and lower limb amputations [2]. Proactive surveillance is essential for the early detection and treatment of diabetes and its complications. Early detection of diabetes can reduce the incidence of its complications [5, 6].
From 2012 to 2022, over half a million refugees were resettled in the U.S. [7]. The U.S. Centers for Disease Control and Prevention (CDC) recommends a domestic medical examination (DME) for refugees within 90 days of their arrival [8]. The DME provides a unique opportunity to screen and manage communicable and non-communicable diseases, which may not have been diagnosed prior to U.S. arrival. Current CDC overseas and DME guidance do not include routine screening for diabetes. However, available evidence suggests there may be a large number of individuals with undiagnosed diabetes within the newly arrived refugee population. Previous work suggests higher odds of undiagnosed diabetes among immigrants compared to others in the U.S. [9]. While one report identified the prevalence of diabetes among 248,850 U.S.-bound refugees ≥ 18 years during 2009 to 2014 as 2.3%, this is much lower than the estimated 10.8% global prevalence of diabetes [10]. This may be related to a lower prevalence in this population or decreased screening.
This quality improvement project aimed to (1) describe the prevalence of both diagnosed and undiagnosed diabetes among newly arrived U.S. refugees by demographic and health characteristics, and (2) evaluate diabetes screening among newly arrived U.S. refugees based on the American Diabetes Association (ADA) 2022 Standard of Care diabetes guidelines in an effort to outline future improvements in diabetes screening in refugees [11].
Theoretical/Conceptual Framework
We conducted a retrospective evaluation of de-identified, pooled data from three sites, based in Minnesota, Pennsylvania, and Colorado. These sites are engaged in a quality improvement collaborative to evaluate diabetes screening as part of the Minnesota Department of Health’s Center of Excellence in Newcomer Health, sponsored by the CDC. The protocol was reviewed by Institutional Review Boards from each local site and received either a non-human subjects research determination, expedited status, or exempt status.
Methods
Participants
We included newly arrived refugees ≥ 18 years seen for DME at one of the participating sites with one additional primary care (i.e., pediatrics, medicine-pediatrics, internal medicine, family medicine or obstetrics/gynecology) visit within three months following DME. Patients with DME between January 2012 and September 2022 were included at Minnesota and Pennsylvania sites, and between September 2014 and September 2022 at the Denver site. Each location employed site-specific strategies to identify refugees. These strategies included manual flagging of electronic health records (EHR) and identifying patients who attended a refugee clinic.
Data Collection and Measures
We obtained data from EHRs at the participating sites. International Classification of Diseases (ICD)-9 and − 10 codes assigned during clinical encounters were used to identify the presence of diabetes (type 1 and type 2 diabetes), cardiovascular disease (CVD), hypertension, and HIV (Supplementary Table A). We collected hemoglobin A1c (HbA1c) and fasting plasma glucose laboratory data. We also obtained patient body mass index (BMI) categorized in ranges (< 18.5, 18.5–<25, 25.0–<30, or ≥ 30.0 kg/m2) and other patient demographics at DME including age group (18–34, 35–44, 45–64, ≥65 years), race (Asian, Black, White, Other), ethnicity (Hispanic, non-Hispanic), and country of origin categorized into WHO regions (African, Americas, Eastern Mediterranean, European, Southeast Asian, Western Pacific, Other).
Our primary outcome of interest was diabetes. Refugees with a diabetes diagnosis code during the DME encounter were classified as having “diagnosed diabetes.” Refugees with either a diabetes diagnosis code assigned at an encounter or a HbA1c result ≥ 6.5% within 3 months following the DME were classified as having “undiagnosed diabetes,” as they likely had diabetes before U.S. arrival. Our secondary outcome of interest was whether diabetes screening was completed. We considered diabetes screening complete if a patient had a laboratory result for HbA1c or fasting plasma glucose [11]. The other data we collected were used to identify the “screening-eligible” group according to modified ADA criteria as detailed below.
We modified the ADA 2022 Standard of Care criteria to identify refugees in whom diabetes screening is recommended due to limited availability of certain information for our evaluation population which is included in the ADA criteria (e.g., family history of diabetes, lipid profile, history of gestational diabetes or prediabetes, or physical activity) [11]. Refugees without diagnosed diabetes at DME who had one or more of the following risk factors were classified as screening-eligible: (1) age ≥ 35 years, (2) BMI ≥ 25 kg/m2 (or ≥ 23 kg/m2 for refugees with Asian race) and high-risk race/ethnicity (i.e., Black or Hispanic), or history of hypertension or CVD, or (3) diagnosis of HIV.
Analysis
Each of the three sites generated pre-tabulated data by refugee’s sociodemographic and health characteristics, which were pooled before the data analysis. Categorical variables were reported with sample size and percentages, and continuous data were reported as means with standard deviations (SD). The prevalence of undiagnosed, diagnosed, and overall diabetes was calculated as below:
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We excluded refugees with missing data from analyses involving those characteristics. Bivariate analyses were conducted using the chi-square to evaluate the association between diabetes (diagnosed, undiagnosed, or overall) and various refugee characteristics. These associations were determined to be significant at p-value < 0.004 accounting for multiple comparisons. Due to the aggregate nature of the data, multivariate analyses were not possible.
Results
Descriptive Characteristics
From January 2012 through September 2022, 4,521 (2,332 from Minnesota, 1,287 from Colorado, and 902 from Pennsylvania) refugees met inclusion criteria. Between all three sites, 5,816 newly arrived refugees ≥ 18 years underwent DME during the evaluation period; 1,265 were excluded due to a lack of follow-up primary care visits within 3 months of DME and 30 were excluded because of documented diabetes screening prior to DME. Approximately half of the included refugees were male (50.9%, n = 2,302), age 18–34 years (58.3%, n = 2,635), and 33.5% from the Southeast Asian WHO region (n = 1,515). About 43% (n = 1,921) had a normal BMI (18.5–24.9 kg/m2) (Table 1). A few refugees had a history of CVD (0.5%, n = 22) or hypertension (8.6%, n = 389). In this sample, 127 (2.8%) refugees had diagnosed diabetes at DME, and 244 (5.4%) were identified as having undiagnosed diabetes. The overall diabetes prevalence was 8.2% (n = 371). About 20% (n = 885) of refugees without diagnosed diabetes were screened for diabetes within the first three months following the DME.
Table 1.
Characteristics of refugees ≥ 18 years seen for domestic medical exam (DME) at one of three United States clinical sites, whether they were eligible for diabetes screening based on modified American diabetes Association criteria, and whether they underwent diabetes screening, 2012–2022 (N = 4,521)
| Variables | All refugees, n (column %) | Screening-eligiblea, n (row %) | Screenedb, n (row %, denominator screening-eligible) | |
|---|---|---|---|---|
| All | 4,521 (100.0%) | 2,863 (63.3%) | 726 (25.4%) | |
| Age (years) | 18–34 | 2,635 (58.3%) | 1,086 (41.2%) | 165 (15.2%) |
| 35–44 | 964 (21.3%) | 942 (97.7%) | 285 (30.3%) | |
| 45–64 | 726 (16.1%) | 659 (90.8%) | 212 (32.2%) | |
| 65+ | 196 (4.3%) | 176 (89.8%) | 64 (36.4%) | |
| Sex | Male | 2,302 (50.9%) | 1,354 (58.8%) | 351 (25.9%) |
| Female | 2,052 (45.4%) | 1,408 (68.6%) | 329 (23.4%) | |
| Unknown | 167 (3.7%) | 101 (60.5%) | 46 (45.5%) | |
| WHO region of origin | African | 1,319 (29.2%) | 794 (60.2%) | 162 (20.4%) |
| European | 72 (1.6%) | 40 (55.6%) | 22 (55.0%) | |
| E Mediterranean | 1,127 (24.9%) | 609 (54.0%) | 276 (45.3%) | |
| Americas | 145 (3.2%) | 105 (72.4%) | 71 (67.6%) | |
| Southeast Asian | 1,515 (33.5%) | 1,108 (73.1%) | 176 (15.9%) | |
| Western Pacific | 16 (0.4%) | 12 (75.0%) | 4 (33.3%) | |
| Other | 327 (7.2%) | 195 (59.6%) | 15 (7.7%) | |
| Body mass index, kg/m2 | < 18.5 | 195 (4.3%) | 52 (26.7%) | 10 (19.2%) |
| 18.5–<25 | 1,921 (42.5%) | 804 (41.9%) | 145 (18.0%) | |
| 25–<30 | 1,503 (33.2%) | 1,292 (86.0%) | 305 (23.6%) | |
| ≥ 30 | 805 (17.8%) | 686 (85.2%) | 247 (36.0%) | |
| Missing | 97 (2.1%) | 29 (29.9%) | 19 (65.5%) | |
| CVD | Yes | 22 (0.5%) | 17 (77.3%) | 9 (52.9%) |
| Hypertension | Yes | 389 (8.6%) | 311 (79.9%) | 154 (49.5%) |
| HIV | Yes | 35 (0.8%) | 35 (100.0%) | 17 (48.6%) |
aBased on a modified American Diabetes Association criteria: Refugees without diagnosed diabetes at domestic medical exam who had one or more of the following risk factors: (1) age ≥ 35 years, (2) BMI 25 kg/m2 or more (23 kg/m2 or more for Asians) and belonged to high-risk race/ethnicity (African American/Black, or Hispanic ethnicity), or have either hypertension or cardiovascular disease, or (3) HIV diagnosis
b Laboratory result for hemoglobin A1c (HbA1c) or fasting plasma glucose available within 3 months of DME
Acronyms: E Mediterranean - Eastern Mediterranean; CVD - Cardiovascular Disease; HIV - Human Immunodeficiency Virus; WHO - World Health Organization
Of 4,394 refugees without diagnosed diabetes at the DME, 63.3% (n = 2,863) met modified ADA criteria for diabetes screening. Among those, 41.2% (n = 1,086) were in the 18–34-year age group, 68.6% (n = 1,408) were female, and 72.4% (n = 1,108) from the Southeast Asian WHO region (Table 1). Over 85% of those with BMI either 25–<30 (n = 1,292) or ≥ 30 kg/m2 (n = 686) were screening-eligible. About 11% (n = 311) of screening-eligible refugees had hypertension. Among screening-eligible refugees, 25.4% (n = 726) underwent diabetes screening within 3 months of the DME, and 7.9% (n = 225) had undiagnosed diabetes. Among 1,531 for whom diabetes screening was not recommended, 10.4% (n = 156) were screened, and 1.2% (n = 19) had undiagnosed diabetes.
Among screening-eligible refugees screening rates were below 20% among those 18–34 years (15.2%), Southeast Asians (15.9%) and those with BMI < 18.5 kg/m2 (19.2%) or 18.5–<25 kg/m2 (18.0%). Screening was above 50% among refugees from the European (55.0%) and Americas (67.6%) WHO regions and those with CVD (52.5%) (Table 1).
Bivariate Association Between Diabetes and Demographic and Health Characteristics
The prevalence of diagnosed, undiagnosed, and overall diabetes was higher with increasing age and BMI. Rates varied by WHO region. The screening-eligible group had significantly higher undiagnosed diabetes than those who did not meet modified ADA 2022 Standard of Care criteria for diabetes screening (Table 2).
Table 2.
Characteristics of refugees ≥ 18 years seen for domestic medical exam (DME) at one of three united States clinical sites who were diagnosed with diabetes and associations between diabetes diagnosis and demographic and health characteristics, 2012–2022, N = 4,521a,b
| Variables | All refugees | Diagnosed diabetes (Diagnosis at DME), n (%) | Undiagnosed diabetes (Diagnosis or HbA1C ≥ 6.5% within 3 months of DME), n (%) | Overall diabetes, n (%) | |
|---|---|---|---|---|---|
| All | 4,521 | 127 (2.8%) | 244 (5.4%) | 371 (8.2%) | |
| Age (years)*✝‡ | 18–34 | 2,635 | 18 (0.7%) | 61 (2.3%) | 79 (3.0%) |
| 35–44 | 964 | 22 (2.3%) | 76 (7.9%) | 98 (10.2%) | |
| 45–64 | 726 | 67 (9.2%) | 89 (12.3%) | 156 (21.5%) | |
| 65+ | 196 | 20 (10.2%) | 18 (9.2%) | 38 (19.4%) | |
| Sex | Male | 2,302 | 66 (2.9%) | 130 (5.6%) | 196 (8.5%) |
| Female | 2,052 | 55 (2.7%) | 97 (4.7%) | 152 (7.4%) | |
| Unknown | 167 | 6 (3.6%) | 17 (10.2%) | 23 (13.8%) | |
| WHO region of origin*✝‡ | African | 1,319 | 30 (2.3%) | 55 (4.2%) | 85 (6.4%) |
| European | 72 | 0 (0.0%) | 5 (6.9%) | 5 (6.9%) | |
| E Mediterranean | 1,127 | 54 (4.8%) | 75 (6.7%) | 129 (11.4%) | |
| Americas | 145 | 5 (3.4%) | 16 (11.0%) | 21 (14.5%) | |
| Southeast Asian | 1,515 | 34 (2.2%) | 72 (4.8%) | 106 (7.0%) | |
| Western Pacific | 16 | 1 (6.3%) | 2 (12.5%) | 3 (18.8%) | |
| Other | 327 | 3 (0.9%) | 19 (5.8%) | 22 (6.7%) | |
| Body mass index, kg/m2 *✝‡ | < 18.5 | 195 | 2 (1.0%) | 3 (1.5%) | 5 (2.6%) |
| 18.5–<25 | 1,921 | 26 (1.4%) | 50 (2.6%) | 76 (4.0%) | |
| 25–<30 | 1,503 | 49 (3.3%) | 94 (6.3%) | 143 (9.5%) | |
| ≥ 30 | 805 | 44 (5.5%) | 90 (11.2%) | 134 (16.6%) | |
| Missing | 97 | 6 (6.2%) | 7 (7.2%) | 13 (13.4%) | |
| Screening-eligible✝ | Yes | 2,863 | n/a | 225 (7.9%) | n/a |
| No | 1,531 | n/a | 19 (1.2%) | n/a | |
aThis table includes separate sets of analysis to describe various refugee characteristics with presence or absence of diagnosed, undiagnosed, or overall diabetes. For simplicity, the comparison data is not displayed in the table. Each association was tested using chi square test and was considered statistically significant at p < 0.002 after adjusting for multiple comparisons. Percentages may not add to 100 due to rounding to 1 decimal place
bTotal population: 4,521 for comparisons involving overall and diagnosed diabetes; 4,394 (after excluding refugees with diagnosed diabetes) for comparisons involving undiagnosed diabetes
*Indicates significant association involving diagnosed diabetes analysis
✝Indicates significant association involving undiagnosed diabetes analysis
‡Indicates significant association involving overall diabetes analysis
Acronyms:- E Mediterranean: Eastern Mediterranean; - WHO - World Health Organization
Discussion
Among 4,521 refugees seen for DMEs, 127 had diabetes diagnosis prior to DME and 244 were newly diagnosed in the three months following DME for an overall diabetes prevalence of 8.2%. This prevalence among new refugees is lower than the estimated prevalence of diabetes in both the general U.S. population (11.5%) and global population (10.5%) but higher than previous estimates among U.S.-bound refugee populations [1, 2]. Only one fourth of the screening-eligible refugees underwent screening. More than two thirds of the diabetes cases in our population were undiagnosed prior to U.S. arrival.
In our evaluation, 2.8% of the refugee population had a diabetes diagnosis prior to DME. While this is lower than U.S. and global estimates of diabetes prevalence, this is similar to a CDC report evaluating the prevalence of diagnosed diabetes among U.S.-bound refugees prior to U.S. arrival [10]. The included populations had similar characteristics including younger age and lower BMI and both represent populations prior to DME. We attribute the observed lower diabetes prevalence to multiple factors including demographic differences. Two factors associated with higher diabetes prevalence are advancing age and obesity; our population tended to be younger and have lower BMIs compared to U.S. and global averages. Approximately 58% of our population was below 35 years of age, while 45% of the general U.S. population with diabetes was under 35 years of age [12]. Furthermore, 51% of our population fell into the overweight/obese categories, contrasting with 73% in the U.S. [13]. Overall, data from this project presents opportunities for intentional guideline-based screening to detect undiagnosed diabetes among refugees.
Among the 371 refugees who had a diabetes diagnosis within 3 months of DME, over two-thirds were undiagnosed prior to U.S. arrival. This is much higher than global estimates (45%) of undiagnosed diabetes [1]. In our cohort, undiagnosed diabetes was highest among those from the Americas, African and Southeast Asia WHO regions. This may be related to the variability of care provided to refugees in overseas locations in which refugees live. High rates of undiagnosed diabetes among new refugees are likely related to limited availability of affordable and accessible medical care in their country of origin or other regions of residence prior to U.S. arrival [14, 15]. Additionally, low health literacy can affect their ability to manage diabetes, a chronic condition that requires knowledge about recommended diet, physical activity, medications, follow-up care, and symptom management [16]. It is well documented that individuals with undiagnosed diabetes are disproportionately affected by diabetes-related mortality and complications [17, 18]. Consequently, the documented high rates of undiagnosed cases within the refugee community demand public health attention. Administrative changes that may improve diabetes screening among newly arrived refugees include adding dedicated recommendations for diabetes screening to the DME guidance.
Compared to the estimated 82% of the general U.S. population [19], lower numbers of new refugees (63%) were screening-eligible in our project. This is not surprising given the high percentage of younger refugees with low BMI and limited comorbidities in this project. Approximately 1 out of 4 refugees considered screening-eligible were screened in our project. This is lower than in the NHANES study where an estimated 47% were screened [20]. This is not surprising given the broad “testing” definition used in the NHANES study where any self-report of a glucose test was considered as an affirmatory response for screening, which does not satisfy ADA’s laboratory guidelines; we included both HbA1c and fasting plasma glucose as meeting the screening criteria [11]. Additionally, the NHANES study used a three-year window to get screening data, whereas we only included 3 months of data. Also, while most of our data collection was before 2022, a time when diabetes screening was recommended starting at age 45 years, we used modified ADA 2022 Standard of Care criteria to assess screening eligibility in our cohort which recommended screening all adults age ≥ 35 years [11]. This change alone substantially increased the screening-eligible refugee group and has contributed to the low screening rate. Efforts to boost screening are warranted to allow early detection of diabetes and thwart occurrences of acute and chronic diabetes complications by periodically updating clinicians on new guidelines, improving public awareness of early detection of diabetes, and implementing electronic medical record-based automated prompts. There were similarities and differences in the age distribution and region of origin between new refugees in our project and U.S./global data. Increased diabetes prevalence with age was apparent in new refugees as in the general U.S. and global population [12, 21]. Similarly, our project found similar rates of diabetes among males and females, consistent with findings in the general U.S. population [2]. However, globally, diabetes prevalence tends to be higher among males [21]. Regionally, similar to global trends, the prevalence was higher among refugees from the Eastern Mediterranean region [1]. However, there was a lower prevalence among refugees from the European region unlike the global trend, which could be due to lack of representative samples from the region. It is reasonable to speculate that the observed demographic differences are likely due to confounding factors as age and BMI. Further multivariate analysis is needed to understand the observed patterns.
Our project is unique in that it is one of the first U.S.-based investigations documenting diabetes prevalence among new refugees. Additionally, our project benefits from a large sample size and access to real-world medical data, enhancing the relevance of our findings to medical providers across the U.S. Despite these strengths, there are also limitations that must be considered when interpreting the findings. First, this project focused on refugee patients for whom we have more complete information about time of U.S. arrival and for whom health screening within 90 days of U.S. arrival is recommended. The findings may not be generalizable to other newcomer populations as we have evaluated data specific to refugee DME. Second, data were available in aggregate form only, so we were unable to adjust for confounders in a multivariable analysis. Third, our project did not incorporate data on family history, gestational diabetes, cholesterol levels, or prediabetes when assessing screening eligibility, which may have underestimated screening-eligible population. This project utilized updated ADA guidelines, extending screening eligibility to ≥ 35-year-olds, whereas our data predates this change. By adopting the new 2022 guidelines, our aim was to align the project results more closely with current practice guidelines, however because of this, our screening rate may be lower than if we were using more current data. Finally, the data collection period was limited to three months following the DME as it seemed that a diagnosis made within this time period after U.S. arrival likely reflected pre-existing, undiagnosed diabetes. Included refugees may have had diabetes screening after this timeframe, resulting in selection bias.
New Contribution to the Literature
This project underscores the overall low prevalence of diabetes among newly arrived refugees, while also highlighting significant variation in prevalence across demographic and health characteristics. Additionally, our findings indicate a concerning trend of underscreening for diabetes within the refugee population. To address this gap in care, we suggest the inclusion of routine diabetes screening in the refugee DME which to our knowledge is not routinely collected for all newly arriving refugees in any country. By incorporating such recommendations, healthcare providers may expedite the diagnosis of diabetes for refugee patients, ultimately improving health outcomes and quality of care within this vulnerable population.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Author Contributions
G.K.S drafted the main manuscript and text. M.B.D., A. Settgast, A. Steiner, C.P., M.F., and K.K.R.made substantial contributions to the conception or design of the work.E.C., A. Steiner, and C.P. made substantial contributions to the acquisition and analysis of data. G.K.S., M.B.D., A. Settgast, A. Steiner, P.W., C.P., M.F., K.K.R., and R.B. made substantial contributions to the interpretation of data. All authors provided critical revision of the manuscript and approved the version to be published.
Funding
This work was supported by federal funds (CFDA 93.317 grant 1 NU50CK000563) obtained through the Centers for Disease Control and Prevention, Centers for Excellence in Newcomer Health.
Data Availability
All data supporting the findings of this study are available within the paper.
Declarations
Competing Interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Sun H, Saeedi P, Karuranga S, et al. IDF diabetes atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. 10.1016/j.diabres.2021.109119. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report website. (https://www.cdc.gov/diabetes/php/data-research/index.html).
- 3.Harris MI, Eastman RC. Early detection of undiagnosed diabetes mellitus: a US perspective. Diabetes Metab Res Rev. 2000;16(4):230–6. 10.1002/1520-7560(2000)9999:9999%3C::aid-dmrr122%3E3.0.co;2-w. [DOI] [PubMed]
- 4.Tabish SA. Is diabetes becoming the biggest epidemic of the Twenty-first century?? Int J Health Sci (Qassim). 2007;1(2):V–VIII. https://www.ncbi.nlm.nih.gov/pubmed/21475425. [PMC free article] [PubMed] [Google Scholar]
- 5.Kahn R, Alperin P, Eddy D, et al. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. Lancet. 2010;375(9723):1365–74. 10.1016/S0140-6736(09)62162-0. [DOI] [PubMed] [Google Scholar]
- 6.Griffin SJ, Borch-Johnsen K, Davies MJ, et al. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trial. Lancet. 2011;378(9786):156–67. 10.1016/S0140-6736(11)60698-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.US Department of Homeland Security OoHSS. Yearbook 2022. (https://ohss.dhs.gov/topics/immigration/yearbook/2022).
- 8.Centers for Disease Control and Prevention (CDC). Refugee Health Domestic Guidance. (https://www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/?CDC_AAref_Val=https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic-guidelines.html).
- 9.Hsueh L, Wu W, Hirsh AT, de Groot M, Mather KJ, Stewart JC. Undiagnosed diabetes among immigrant and Racial/ethnic minority adults in the united States: National health and nutrition examination survey 2011–2018. Ann Epidemiol. 2020;51:14–9. 10.1016/j.annepidem.2020.07.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Benoit SR, Gregg EW, Zhou W, Painter JA. Diabetes among united States-Bound adult refugees, 2009–2014. J Immigr Minor Health. 2016;18(6):1357–64. 10.1007/s10903-016-0381-7. [DOI] [PubMed] [Google Scholar]
- 11.American Diabetes A. Standards of medical care in Diabetes-2022 abridged for primary care providers. Clin Diabetes. 2022;40(1):10–38. 10.2337/cd22-as01. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.United States Census Bureau. Exploring Age Groups in the 2020 Census. (https://www.census.gov/library/visualizations/interactive/exploring-age-groups-in-the-2020-census.html).
- 13.Fryar C, Carroll M, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: united States, 1960–1962 through 2017–2018. NCHS Health E-Stats, Centers for Disease Control and Prevention 2021 (https://www.cdc.gov/nchs/data/hestat/obesity-child-17-18/overweight-obesity-child-H.pdf).
- 14.Zhang X, Geiss LS, Cheng YJ, Beckles GL, Gregg EW, Kahn HS. The missed patient with diabetes: how access to health care affects the detection of diabetes. Diabetes Care. 2008;31(9):1748–53. 10.2337/dc08-0572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Misra A, Gopalan H, Jayawardena R, et al. Diabetes in developing countries. J Diabetes. 2019;11(7):522–39. 10.1111/1753-0407.12913. [DOI] [PubMed] [Google Scholar]
- 16.Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy and health outcomes in diabetes: a systematic review. J Gen Intern Med. 2013;28(3):444–52. 10.1007/s11606-012-2241-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wild SH, Smith FB, Lee AJ, Fowkes FG. Criteria for previously undiagnosed diabetes and risk of mortality: 15-year follow-up of the Edinburgh artery study cohort. Diabet Med. 2005;22(4):490–6. 10.1111/j.1464-5491.2004.01433.x. [DOI] [PubMed] [Google Scholar]
- 18.Heydari I, Radi V, Razmjou S, Amiri A. Chronic complications of diabetes mellitus in newly diagnosed patients. Int J Diabetes Mellitus. 2010;2(1):61–3. [Google Scholar]
- 19.O’Brien MJ, Zhang Y, Bailey SC, et al. Clinical performance and health equity implications of the American diabetes association’s 2023 screening recommendation for prediabetes and diabetes. Front Endocrinol (Lausanne). 2023;14:1279348. 10.3389/fendo.2023.1279348. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ali MK, Imperatore G, Benoit SR, et al. Impact of changes in diabetes screening guidelines on testing eligibility and potential yield among adults without diagnosed diabetes in the united States. Diabetes Res Clin Pract. 2023;197:110572. 10.1016/j.diabres.2023.110572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Collaborators GBDD. Global, regional, and National burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021. Lancet. 2023;402(10397):203–34. 10.1016/S0140-6736(23)01301-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Supplementary Materials
Data Availability Statement
All data supporting the findings of this study are available within the paper.