Assessment of Diabetes Mellitus Type 2 Among Adults

in Ann Arbor

Lingxiao Fan

NUTR 642

1
Background .3
1. Characterize the Community
1.1. Demographic & Economic Data
1.1.1. Population ...4
1.1.2. Education ..5
1.1.3. Occupation .....5
1.1.4. Unemployment ...6
1.1.5. Median Income of Families 7
1.1.6. Percentage of Families/Household with Incomes Below the Poverty
Level ....7
1.1.7. Percentage of Families/Household that Rent or Own Homes ..7
1.2. Health Statistic Data
1.2.1. Leading Causes of Mortality .8
1.2.2. Leading Causes of Morbidity .....9
1.2.3. Infant Mortality Rate .....10
1.2.4. Prevalence of Certain Condition such as Overweight/Obesity .....10
1.2.5. Health Insurance Coverage 11
1.3. Nutrition/Physical Activity Assessment Data
1.3.1. Dietary Intake Information ....12
1.3.2. Biochemical Information .13
1.3.3. Anthropometric Information 13
1.3.4. Physical Activity Data .14
1.3.5. Food Access Data ....15
1.3.6. Food Insecurity Data ..15
1.3.7. Breastfeeding Rate ..16
2. Community Assets and Resources
2.1. Existing Nutrition-related Community Services and Programs
2.1.1. Government Food/Nutrition Programs .16
2.1.2. Nonprofit Organizations ..16
2.1.3. Farms Markets ..16
2.1.4. Health Clinics/Hospitals 17
2.1.5. Dietitians & Nutrition Clinic ..18
2.2. Other Community Assets and Resources
2.2.1. Commuter Transportation .19
2.2.2. Recreation and Parks .19
2.3. Diabetes-related Policies
2.3.1. School Diabetes Care .20
2.3.2. Changes to the Nutrition Facts Label20
References 21

2
Diabetes mellitus type 2 is a long term metabolic disorder that is characterized by high blood
sugar, insulin resistance, and relative lack of insulin. The main symptoms include increased
thirst, frequent urination, and unexplained weight loss. It is caused by a combination of lifestyle
and genetic factors.1 Long-term high blood sugar leads to possible complications, which include
macrovascular (coronary, cerebrovascular, or peripheral arterial disease) and microvascular
(retinopathy, nephropathy, and neuropathy) complications.1 Diabetes lowers life expectancy by
up to 15 years and increases disease by 2 to 4 times.5

According to National Diabetes Statistics Report in 2014, 29.1 million people in the U.S., which
accounts for 9.3% of the U.S. population, have diabetes.2 And 86 million Americans has
prediabetes, in other words, more than 1 out of 3 adults have prediabetes. Although diabetes
has become the 7th leading cause of death in the U.S. in 20105, many people still do not attach
enough importance to it. In the U.S. in 2014, 27.8% diabetes patient were undiagnosed, and
90% people did not realize they have prediabetes.2

Among all diagnosed cases of diabetes, diabetes mellitus type 2 accounts for about 90% to 95%
globally.3 Compared to diabetes mellitus type 1 which typically begins in children and
adolescents, diabetes mellitus type 2 often happens among adults.1 Therefore, this assessment
mainly focuses on diabetes mellitus type 2 among adults.

8.1% of the adults in Washtenaw county were ever told diabetic in 2015, which was lower than
national level (9.3%).4 Based on data from Community Health Status Indicators 2015, compared
with peer counties, morbidity led by adult diabetes was more severe in Washtenaw. In 2005,
the age adjusted diabetes death rate for Washtenaw county was 18.4 per 100,000, which was
moderate among peer counties.5

The target community of Ann Arbor is an urban city in Washtenaw County, Michigan. As a
distinctive college town, there are plenty of colleges and universities located in Ann Arbor,
including The University of Michigan, Concordia University Ann Arbor, University of Phoenix and
Cleary University. According to the 2010 United States Census, Ann Arbors population was
113,956; 85.6% of the populations were adults at the age over 18 years; and 50.7% of the
populations were females. In 2014, 96.4% of persons 25+ years of age, had high school or
higher degrees, 70.9% of persons aged 25+ years had bachelors or higher degree, making Ann
Arbor one of the most educated cities in America. In Ann Arbor, the median household income
from 2010 to 2014 was $56,835, compared to the entire state of Michigan ($49,087). 22.6% of
populations were in poverty, compared to the state of Michigans (15.8%).6

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1. Characterize the Community
1.1 Demographic & Economic Data
1.1.1 Population
Based on data from the National Diabetes Statistics Report of 20142, approximately
9,780 diabetic adults 21 years old and older lived in Ann Arbor (Estimate is based on the
population of adults 21 years old and older in Ann Arbor7 and national percentage of
diabetes of adults 21 years old and older2 in the year 2014). According to Diabetes Risk
Factors Community Profile Washtenaw8, Ann Arbors population in 2013 was 115,150.
Compared to Washtenaw County and Michigan, Ann Arbor had a younger population
(70.78% of the population under 44 years old), a lower black/African American
population (7.35%), a higher Asian population (14.73%).8 Furthermore, a lower
percentage of the population was 25 years old or older and held less than a four-year
college degree compared to the rest of Washtenaw county.8

Table 1 Demographic
Diabetes Risk Factors Community Profile Washtenaw, December 2013.

4
 https://www.midiabetesprevention.org/documents/DPP-Map-Ann%20Arbor-Washtenaw-
County.pdf. Accessed October 20, 2016.

1.1.2 Education
Compared with the national level, in 2014, people 25 years old and over in Ann Abor
were more educated. In Ann Arbor, 96.4% of the population had a high school and
higher degrees, 70.9% had a bachelors or higher degrees10 and 42.1% had graduate or
professional degrees.
According to the National Center for Education Statistics, the most common major in
Ann Arbor was experimental psychology (6.3%), general economics (6%) and general
business administration & management (5.2%). A relatively high number of people
majored in Asian studies, Latin American & Caribbean studies and environmental
studies.13

Graph 1 Degrees Awarded in Ann Arbor, 2014
Sources: Data USA: Ann Arbor MI. https://datausa.io/profile/geo/ann-arbor-mi. Accessed
October 24, 2016

1.1.3 Occupation
According to the U.S. Census Bureau, from 2010 to 2014, compared with the national
level (31.5%)10, 62.4% of the population 16 years and over in Ann Arbor worked in
mangement, business, science, and the arts12. The most common jobs in Ann Arbor, MI
by number of employees, were postsecondary teachers (18.3%), executives (9.1%) and
administrative supervisors (9.1%).13 The highest paid jobs, by median earnings, were
excutives, physicians & surgeons and architects, surveyors & cartographers.13

Graph 2 Total Employees in Ann Arbor, 2014

Sources: Data USA: Ann Arbor MI. https://datausa.io/profile/geo/ann-arbor-mi. Accessed
October 24, 2016

Table 2. Modified. Occupation in Ann Arbor 2010-2014
Source: U.S. Census Bureau, 2014.
https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF.
Accessed October 20, 2016

1.1.4 Unemployment
Compared with the national (4.9%) and Michigan (4.5%) averages, in August 2016, the
unemployment rate in Ann Arbor was 3.1%, and the number of unemployed people in
Ann Arbor was 6092.14 The unemployment rate in Ann Arbor peaked in June 2009 at
9.8% and is now 6.7 percentage points lower, at 3.1% currently.14 From a post peak low
of 2.7% in July 2016, the unemployment rate has now grown by 0.4 percentage points.14

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Graph 3 Unemployment Rate
Source: Department of Numbers. Ann Arbor, Michigan Unemployment.
http://www.deptofnumbers.com/unemployment/michigan/ann-arbor/ Accessed October
24, 2016.

1.1.5 Median Income of Families
Households in Ann Arbor, MI have a median income of $56,835, higher than the national
level of $53,482 as well as the Michigan level of $49,087.13

Graph 4 Median Household Income in Ann Arbor, 2014 (Yearly)
Source: Data USA: Ann Arbor MI. https://datausa.io/profile/geo/ann-arbor-mi. Accessed
October 24, 2016

1.1.6 Percentage of Families/Households with Incomes Below the Poverty Level
Based on the data from the United States Census Bureau in 2014, the percentage of
persons in poverty in Ann Arbor was 22.6%. 12

1.1.7 Percentage of Families/Households that Rent or Own Homes

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 According to the United States Census Bureau in 2014, 45.7% of the housing units in Ann
Arbor, MI are occupied by their owner, lower than the national level average of 64.4%.12

Graph 5 Rent or Own Homes in Ann Arbor, 2014
Source: Data USA: Ann Arbor MI. https://datausa.io/profile/geo/ann-arbor-mi. Accessed
October 24, 2016

1.2 Health Statistic Data
1.2.1 Leading Causes of Mortality
The top 10 leading causes of death in Michigan were heart disease (26.3%), cancer
(22.5%), chronic lower respiratory disease (C.L.R.D, 5.7%), stroke (4.9%), accidents
(4.7%), Alzheimers (3.6%), diabetes mellitus (3%), pneumonia/flu (2%), kidney disease
(2%) and suicide (1.4%).15

Graph 6 Percent Leading Causes of Death in Michigan, 2014

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 Source: Michigan Mortality Statistics. Michigan Department of Health & Human
Services. http://www.mdch.state.mi.us/pha/osr/CHI/deaths/frame.asp. Updated Oct.
2rd, 2016. Accessed October 24, 2016.

1.2.2 Leading Causes of Morbidity
According to data from the Michigan Department of Health & Human Services, from
2010 to 2012, the average number of all cancer incidents were 1,528. 15 Of them, 15.1%
had breast cancer and 15.4% had prostate cancer.15 From 2012 to 2014, on average,
1,629 people with cardiovascular diseases, 1,295 people with arthritis, and 824 people
with osteoporosis were discharged from hospitals.15

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 Table 3. Michigan Morbidity Statistics.
Source: Selected Chronic Disease Indicators,
Washtenaw County Health Department Residents 2012-2014. Michigan Department of
Health & Human Services.
http://www.mdch.state.mi.us/pha/osr/chi/profiles/frame.asp. Accessed October 26,
2016.

1.2.3 Infant Mortality Rate

The infant death rate remained stable from 2000 to 2014.17 Compared to the infant
mortality rate in Michigan State of 6.8% in 201416, Ann Arbor had a lower infant mortality
rate; which was 0.74%17.

Table 4. Modified. Infant Deaths, Live Births and Infant Death Rates. Ann Arbor City,
Washtenaw County Residents, 2000-2014
Resource: Infant Mortality 1989-2014. Michigan Department of Health & Human
Services. http://www.mdch.state.mi.us/pha/osr/chi/Indx/frame.html. Updated April 22,
2016. Accessed October 26, 2016.

1.2.4 Prevalence of Certain Conditions such as Overweight/Obesity

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 Based on Washtenaw Country data, in 2015, 4.3% of the population in Ann Arbor were
underweight, 34.4% were overweight and 21.7% were obese.16 The underweight rate
slowly grew 2% from 2005 to 2015. 16 The percentage of people with a BMI higher than 25
grew 6.3% in the same decade.16

Graph 7. Washtenaw Adults Weight Status Based on BMI (Underweight <18.5, Normal
weight 18.5-24.9, Overweight 25 - 29.9, Obese >= 30)
Source: Washtenaw Adults Weight Status. Washtenaw County Health Improvement Plan
(HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2015/BMIcat4?category=Adult
Accessed Oct 26, 2016

1.2.5 Health Insurance Coverage
Compared to the Michigan level of 75.0% and the Washtenaw county level of 78.4%20, in
Ann Arbor, 92.4% of the population had health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such as Medicare. The
percentage of people covered with health care grew 3.3% from 2010 to 2015.18

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1.3 Nutrition/Physical Activity Assessment Data
1.3.1 Dietary Intake Information
Based on county data from the Washtenaw County Health Improvement Plan, in 2015,
67.8% of the population in Ann Arbor consumed fruit one or more times per day; 81.2%
of the population consumed vegetable one or more times per day; 77.6% of the
population had 5 or more servings of fruit and vegetable per day and 73.8% of the
population had never been limited by distance to full service grocery store.19 According
to Washtenaw County Community Health Data, in 2015, 66.6% of residents went to a
fast food restaurant less than once per week.19 According to City Data, 54.6% of Ann
Arbor residents report that their diet is generally healthy.20 Average milk product
consumption is 20.2 servings per month.20 The biggest differences compared to state
averages is the meals not home prepared, people living in Ann Arbor eat outside the
home about 5 times per week.20

Graph 8. 2015 HIP Survey: Washtenaw Adults - Food Consumption.

Resource: Washtenaw County Community Health Data. Washtenaw County Health

Improvement Plan (HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2015/FastFood?category=Adult.
Accessed Oct 26, 2016
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Graph 9. Diet Behavior & Nutrition Summary in Ann Arbor. (The biggest differences
compared to state averages have been highlighted with a blue background)
Source: Diet Behavior & Nutrition. City Data. http://www.city-data.com/health-
nutrition/Ann-Arbor-Michigan.html#ixzz4OIP8U2qG. Accessed October 27, 2016.

1.3.2 Biochemical Information
Based on data from City Data website, in Ann Arbor, 14.5% of the population has even
been told that they had hypertension, 20.0% of people in Ann Arbor check their blood
pressure at home.20 11.5% of the population has been told that their cholesterol level is
high, 38.3% of the population frequently check their blood cholesterol.20

Graph 10. Blood Pressure & Cholesterol Summary in Ann Arbor. (The biggest differences
compared to state averages have been highlighted with a blue background)
Source: Diet Behavior & Nutrition. City Data. http://www.city-data.com/health-
nutrition/Ann-Arbor-Michigan.html#ixzz4OIP8U2qG. Accessed October 27, 2016.

1.3.3 Anthropometric Information
The average height in Ann Arbor residents 16 years and older is 67.2 inches. The average
weight is 173.4 pounds. The average BMI is 27.2.20

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Graph 11. Height and Weight Summary in Ann Arbor. (The biggest differences compared to
state averages have been highlighted with a blue background)
Source: City Data. http://www.city-data.com/health-nutrition/Ann-Arbor-
Michigan.html.Accessed October 27, 2016.

1.3.4 Physical Activity Data
According to City Data website, in Ann Arbor, 18.1% of Ann Arbor residents do vigorous-
intensity work activities daily, like carrying or lifting heavy loads, digging or construction
work for at least 10 minutes continuously, which causes large increases in breathing or
heart rate.20 33.5% of the population in Ann Arbor do moderate-intensity work activities,
which cause small increases in breathing or heart rate, such as brisk walking or carrying
light loads for at least 10 minutes continuously.20 36.3% of the population walk or ride a
bike for at least 10 minutes continuously.20 36.1% of the population do vigorous-intensity
recreational activities, like basketball and football, for at least 10 minutes continuously.20
54.7% of the population do moderate-intensity recreational activities, such as brisk
walking, bicycling, swimming or golf, for at least 10 minutes continuously.20 People in Ann
Arbor usually do sedentary activities 6.8 hours per day, watch TV or videos 2.3 hours per
day, and use computer 1.6 hours per day.20

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Graph 12. Physical Activity Summary in Ann Arbor. (The biggest differences compared to
state averages have been highlighted with a blue background)
Source: City Data. http://www.city-data.com/health-nutrition/Ann-Arbor-
Michigan.html.Accessed October 27, 2016.

1.3.5 Food Access Data
According to Washtenaw County Community Health Data, in 2005, 73.8% of the
population reported that they had never been limited by distance to full service grocery
store.19

Graph 13. 2015 HIP Survey: Washtenaw Adults - Food Consumption

Resource: Washtenaw County Community Health Data. Washtenaw County Health
Improvement Plan (HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2015/FastFood?category=Adult.
Accessed Oct 26, 2016

1.3.6 Food Insecurity Data

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 According to Washtenaw data from Feeding America, there are 50,290 food insecure
people in Washtenaw, the food insecurity rate is 14.3%.27 61% of the population are below
200% poverty.27 The average cost of a meal in Washtenaw is $3.03.27 $26,920,000
additional money are required to meet food needs.27

1.3.7 Breastfeeding Rate

According to City Data, in Ann Arbor, women breastfeeding newborns rate is 65.5%, 3,2%
higher than Washtenaw level and 11.1% higher than Michigan level.20

2. Community Assets and Resources

2.1 Existing Nutrition-related Community Services and Programs
2.1.1 Government Food/Nutrition Programs
Michigan Diabetes Prevention and Control Program
Personal Action Toward Health (PATH)
Meals on Wheels
WIC
Headstart
SNAP
Commodities Supplemental Food Program
Michigans Nutrition, Physical Activity and Obesity Program (MiNPAO)
Ann Arbor YMCAs Diabetes Prevention Program
American Diabetes Association (ADA) - Walk to stop diabetes in Ann Arbor
2.1.2 Nonprofit Organizations
Ann Arbor Community Center
Catholic Social Service of Washtenaw County Northside Com
Ann Arbor Department of Park and Recreationbryant Community
Food Gather
Chelsea Community Kitchen
Hope American
2.1.3 Farmers Markets
Ann Arbor has many farmers markets, including
Ann Arbor Farmers Market
Argus Farm Stop
Arbor Farms Market
Cobblestone Farm
Kerrytown Market & Shops
Fair Food Network
Luckys Market

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 FarmLogs

Map 1. Farmers Markets in Ann Arbor.
Source: Google Map.
https://www.google.com/webhp?hl=en&sa=X&ved=0ahUKEwiPqerc3v7PAhVhxoMKHa
XMDKIQPAgD#hl=en&q=farm%27s+market+ann+arbor&rflfq=1&rlha=0&rllag=4227797
3,-83761429,1403&tbm=lcl&tbs=lf:1,lf_ui:2,lf_pqs:EAE. Accessed Oct. 28, 2016

2.1.4 Heath Clinics/Hospitals
Clinics/Hospitals in Ann Arbor includes
Otolaryngology/Audiology Clinic at Mott Childrens Hospital
Urology Clinic at Mott Childrens Hospital
C.S. Mott Childrens Hospital
University Hospital
Physical Therapy/Occupational Therapy Gym at Mott Childrens Hospital
Samuel and Jean Frankel Cardiovascular Center
Oral & Maxillofacial Surgery/ Hospital Dentistry Clinic at Med Inn
University Hospital Psychiatric Emergency Service

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Map 2. Health Clinic/Hospital in Ann Arbor
Source: Google Map.
https://www.google.com/#q=hospital%20clinic&rflfq=1&rlha=0&rllag=42283255,-
83728383,187&tbm=lcl&tbs=lf:1,lf_ui:2,lf_pqs:EAE&fll=42.282012589816496,-
83.72546715140379&fspn=0.01790749285082427,0.024290302859924395&fz=15&oll
=42.265785949999994,-
83.7146954&ospn=0.04674999629787635,0.14900556489052974&oz=12&qop=1&rlfi
=hd:;si: Accessed Oct.28, 2016

2.1.5 Dietitians & Nutrition Clinic
Dietitians and Nutrition Clinic in Ann Arbor includes
Ann Arbor Nutrition
Nutrition and Wellness Consulting LLC
Nutrition Services at East Ann Arbor Health and Geriatrics

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Map 3. Dietitians and Nutrition Clinic in Ann Arbor. Source: Google Map.
https://www.google.com/maps/search/dietitian/@42.2533835,-
83.760539,14z/data=!3m1!4b1. Accessed Oct.29, 2016

2.2 Other Community Assets and Resources
2.2.1 Commuter Transportation
According to Data USA, the largest share of workers in Ann Arbor drove alone to work
(72.5%).13 Additionally, the preferred secondary means of transportation to work is
carpooled.13
2.2.2 Recreation and Parks
Ann Arbor has 159 parks and 15 parks facilities play host to a variety of amenities and
activities for all age, abilities, and interested.

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Map 4. Parks and Recreation in Ann Arbor
Source: Google Map.
https://www.google.com/maps/d/viewer?mid=16anHt5z6o47_H6ox2m0ONw-sQxg
Accessed Oct.29, 2016

2.3 Diabetes-related Policies
2.3.1 School Diabetes Care
According to American Diabetes Association, federal law gives students the right to
receive the diabetes care they need to be safe and participate in school activities just like
any other child25. Schools should provide the following:
Trained staff to monitor blood glucose levels and administer insulin and glucagon
Trained staff to provide diabetes care during field trips, extracurricular events and
all school-sponsored activities
Capable students permitted to self-manage their diabetes anytime, anywhere
Schools should not:
Make family members go to school to care for a students diabetes
Transfer students to a different school to get needed diabetes care
Prevent students with diabetes from participating in field trips, sports and other
school-sponsored activities.25

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 2.3.2 Changes to the Nutrition Facts Label
On May 20 2016, the FDA announced the new Nutrition Facts label for packaged foods
to reflect new scientific information, including the link between diet and chronic
diseases such as obesity and heart disease. The new label will make it easier for
consumers to make better informed food choices.26 The changes include listing added
sugars in grams and as percent Daily Value on the nutrition label.26

Reference:
1. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients
With Diabetes. Diabetes Care. 2009;32(7):1335-1343. doi:10.2337/dc09-9032.
2. Centers for Disease Control and Prevention. National Diabetes Statistics Report:
Estimates of Diabetes and Its Burden in the United States, 2014.
http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-
burden-in-the-united-states.pdf. Accessed October 2, 2016.
3. Centers for Disease Control and Prevention. July 25, 2016.
http://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm.
Accessed October 2, 2016.
4. Washtenaw County Community Health Data. https://testhip.ewashtenaw.org/#/.
Published 2016. Accessed October 3, 2016.
5. Community Health Status Indicators 2015.
http://wwwn.cdc.gov/communityhealth/profile/currentprofile/mi/washtenaw/.
Published 2015. Accessed October 3, 2016.
6. United States Census 2015.
http://www.census.gov/quickfacts/table/PST045215/2603000,3921000. Accessed
October 3, 2016.
7. United States Census 2010.
http://www.census.gov/quickfacts/table/PST040215/2603000. Accessed October 20,
2016.
8. Diabetes Risk Factors Community Profile Washtenaw.
https://www.midiabetesprevention.org/documents/DPP-Map-Ann%20Arbor-
Washtenaw-County.pdf. Published December 2013. Accessed October 20, 2016.
9. Diabetes in Michigan Update, 2015. Michigan Department of Health and Human
Services. http://www.michigan.gov/mdhhs/0,5885,7-339-71550_2955_2980---,00.html.
Accessed October 20, 2016
10. United States Census, 2014.
https://www.census.gov/quickfacts/table/EDU635214/2603000,00. Accessed October
20, 2016

21
11. American Community Survey (ACS), 2014.
https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
Accessed October 20, 2016
12. American FactFinder. United States Census, 2014..
http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed October 20,
2016.
13. Data USA: Ann Arbor MI. https://datausa.io/profile/geo/ann-arbor-mi. Accessed October
24, 2016
14. Ann Arbor, Michigan Unemployment. Department of Numbers.
http://www.deptofnumbers.com/unemployment/michigan/ann-arbor/ Accessed
October 24, 2016.
15. Selected Chronic Disease Indicators,
Washtenaw County Health Department Residents 2012-2014. Michigan Department of
Health & Human Services.
http://www.mdch.state.mi.us/pha/osr/chi/profiles/frame.asp. Accessed October 26,
2016.Michigan Department of Health & Human Services.
http://www.mdch.state.mi.us/pha/osr/Provisional/BxInfDxSelectCharacteristics2015.asp
. Updated Oct. 2rd, 2016. Accessed October 24, 2016.
16. Washtenaw Adults Weight Status Based on BMI. Washtenaw County Health
Improvement Plan (HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2015/BMIcat4?category=Adult
Accessed Oct 26, 2016
17. Infant Mortality 1989-2014. Michigan Department of Health & Human Services.
http://www.mdch.state.mi.us/pha/osr/chi/Indx/frame.html. Updated April 22, 2016.
Accessed October 26, 2016.
18. Washtenaw Adults Access to Health Care. Washtenaw County Health Improvement Plan
(HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2005/Insure?category=Adult.
Accessed Oct 26, 2016
19. Washtenaw County Community Health Data. Washtenaw County Health Improvement
Plan (HIP)
https://testhip.ewashtenaw.org/#/survey/question/HIP/2015/FastFood?category=Adult.
Accessed Oct 26, 2016
20. City Data. http://www.city-data.com/health-nutrition/Ann-Arbor-Michigan.html.
Accessed October 27, 2016
21. Farmers Markets in Ann Arbor. Google Map.
https://www.google.com/webhp?hl=en&sa=X&ved=0ahUKEwiPqerc3v7PAhVhxoMKHaX
MDKIQPAgD#hl=en&q=farm%27s+market+ann+arbor&rflfq=1&rlha=0&rllag=42277973,
-83761429,1403&tbm=lcl&tbs=lf:1,lf_ui:2,lf_pqs:EAE. Accessed Oct. 28, 2016

22
 22. Health Clinic/Hospital in Ann Arbor. Google Map.
https://www.google.com/#q=hospital%20clinic&rflfq=1&rlha=0&rllag=42283255,-
83728383,187&tbm=lcl&tbs=lf:1,lf_ui:2,lf_pqs:EAE&fll=42.282012589816496,-
83.72546715140379&fspn=0.01790749285082427,0.024290302859924395&fz=15&oll=
42.265785949999994,-
83.7146954&ospn=0.04674999629787635,0.14900556489052974&oz=12&qop=1&rlfi=
hd:;si: Accessed Oct.28, 2016
23. Dietitians and Nutrition Clinic in Ann Arbor. Google Map.
https://www.google.com/maps/search/dietitian/@42.2533835,-
83.760539,14z/data=!3m1!4b1. Accessed Oct.29, 2016
24. Parks and Recreation in Ann Arbor. Google Map.
https://www.google.com/maps/d/viewer?mid=16anHt5z6o47_H6ox2m0ONw-sQxg
Accessed Oct.29, 2016
25. State Laws, Regulation and Policies for School Diabetes Care. American Diabetes
Association. http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-
care-at-school/legal-protections/state-laws-and-policies.html. Accessed Oct.29, 2016
26. Changes to the Nutrition Facts Label. U.S. Food & Drug Administration.
http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformat
ion/LabelingNutrition/ucm385663.htm Accessed Oct. 29, 2016
27. Food Insecurity in Washtenaw County. Feeding American.
http://map.feedingamerica.org/county/2014/overall/michigan/county/washtenaw
Accessed Oct.29, 2016

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