An-Najah National University
An-Najah National University
Faculty of Nursing
Nursing Research project
Dietary Routine among Diabetic Patients in West Bank
Prepared By:
Batool Salman Hashash Loa’i Hassan Al-Sayyed
Thabat Ahmad Yassen Mahdi Wassef Dwikat
Supervisor:
Dr. Marriam Amer
Submitted as the requirement for the final project thesis of the bachelor's degree in nursing. Faculty of medicine and health sciences at An-Najah National University, Nablus, Palestine.
2015-2016
|No. |Content |Page |
| |List of tables |I |
| |Acknowledgement |II |
| |List of abbreviations |III |
| |Abstract |IV |
|Chapter one |
|1 |Background |2 |
|1.1 |Problem statement |9 |
|1.2 |Significance of the study |9 |
|1.3 |Objectives |9 |
|1.4 |Research question |10 |
|1.5 |Research hypothesis |10 |
|Chapter two |
|2 |Literature review |12 |
|2.1 |Medical Nutrition Therapy (MNT) |13 |
|2.2 |Diabetes self management |15 |
|2.3 |Diabetes self management education (DSME) |16 |
|2.4 |Family routine and family rituals |18 |
|2.5 |Family support and involvement and involvement in care of diabetes |20 |
|2.6 |Family adaptation |21 |
|2.7 |Dietary routines and diabetes management |21 |
|2.8 |Diabetes and exercise |23 |
|2.9 |Barriers to non-adherence to diabetic diets and exercise |23 |
|2.10 |Monitoring blood glucose |23 |
|2.11 |Adherence to medications |24 |
|2.12 |Complications of diabetes |26 |
|Chapter three |
|3 |Research methodology |31 |
|3.1 |Introduction |31 |
|3.2 |Study design |31 |
|3.3 |Sites and settings |31 |
|3.4 |Population |31 |
|3.5 |Sample and Sampling method |31 |
|3.6 |Selection criteria |32 |
|3.7 |Data collection tool |32 |
|3.8 |Validity and reliability |33 |
|3.9 |Administrative, Fieldwork |33 |
|3.10 |Ethical considerations |34 |
|3.11 |Data Analysis |34 |
|Chapter four |
|4.1 |Result |37 |
|Chapter five |
|5.1 |Discussion |62 |
|Chapter six |
|6.1 |Conclusion , Recommendation, Limitation |70 |
| |References |V |
| |Annexes |VI |
|Table number |Table title |Pages |
| | |number |
|Table of methodology |
|Table 1 |Distribution of population and sample size according to city |32 |
|Table 2 |Variables (Dependent and independent) |35 |
|Table 3 |Conceptual and operational definitions |36 |
|Table of result |
|Table 1 |Distribution of percentage of participants’ demographics |38 |
|Table2 |Distribution of percentage of participants’ regarding DM medical history |39 |
|Table 3 |Distribution of percentage of participants’ adherence of medication |41 |
|Table 4 |Distribution of percentage of participants’ regarding their other compound NCD’s and DM complications |42 |
|Table 5 |Distribution of percentage of participants’ regarding "Adherence to Medication" |42 |
|Table 6 |Distribution of percentage of participants’ regarding their |43 |
| |“Main meals & Snacks that they regular eat” | |
|Table 7 |Distribution of percentage of participants’ regarding their “dietary routine |44 |
|Table 8 |Distribution of percentage of participants’ regarding their “dietary routine” |46 |
|Table 9 |Distribution of percentage of participants regarding the relationship between complications of DM and age |47 |
|Table 10 |Distribution of percentage of participants regarding the relationship between last HbA1C result & family Support |48 |
|Table 11 |Distribution of percentage of participants regarding the relationship between changing medication dosage depending on the |49 |
| |type of food and family support | |
|Table 12 |Distribution of percentage of participants regarding the relationship between forgotten dosage and family support |50 |
|Table 13 |Distribution of percentage of participants regarding the relationship between complications of DM and family support |51 |
|Table 14 |Distribution of percentage of participants regarding the relationship between last HbA1C results & eating pattern |52 |
|Table 15 |Distribution of percentage of participants regarding the relationship between taking the prescribed medication regularly |53 |
| |and eating pattern | |
|Table 16 |Distribution of percentage of participants regarding the relationship between changing medication dosage depending on the |54 |
| |type of food and eating pattern | |
|Table 17 |Distribution of percentage of participants regarding the relationship between last HbA1C results & meals preparation |55 |
|Table 18 |Distribution of percentage of participants regarding the relationship between educational levels & preparing meal |56 |
|Table 19 |Distribution of percentage of participants regarding the relationship between places of residency & meal preparation |57 |
|Table 20 |Distribution of percentage of participants regarding the relationship between forgotten dosage and meal preparation |58 |
|Table 21 |Distribution of participants mean and percentage regarding their agreement” |59 |
|Table 22 |Table of hypothesis results with no relationship |61 |
Acknowledgment
We would like to express our greatest gratitude to our parents who were the kind embrace for their sons, who supported us financially and emotionally to the last day of our study.
We would like also to thank “Al-Najah National University” represented by Dr. Maher Al Natsheh who always supports us and our faculty.
Great thank to our supervisor Dr. Mariam Al-Tell, the kind hearted mother for us, who supported us to accomplish our study and who was committed, cooperative and friendly all the time.
We would like to thank Dr. Aida Al-Kaissi the kind hearted mother for all of her students, who taught us the principles of research and did her best to equip us with all necessary information we need in our practical future occupations.
And we would like to thanks the course tutor Dr. Iman Shawesh, who beloved us and support us till accomplishing our study.
And I would like to thank the SPSS course tutor Dr. Mohameed Dwikat, who taught us the principles of SPSS.
Many thanks go to the Palestinian ministry of health and primary health care clinics for facilitating data collection.
Finally, sincere appreciation is extended to everybody who helped in restoring our hope and confidence in ourselves.
List of abbreviations:
DM: Diabetes Mellitus
ADA: American Diabetes Association
CDC: Centre for Disease Control
HbA1c: Glycosylated Haemoglobin A1C
MNT: Medical Nutrition Therapy
MOH: Ministry Of Health
NCD’s: Non-communicable Disease`s
LOBAG: Low Biologically Available Glucose
DSME: Diabetes Self-Management Education
KAP: Knowledge and Practice Score
LDL: low-density lipoprotein
HDL: high-density lipoprotein
FBS: Fasting Blood Sugar
BMI: Body Mass Index
OHA: Oral Hypoglycemic Agents
UK: Untied King Dome
LPD: Low Protein Diet
MI: Myocardial Infarction
PN: Peripheral Neuropathy
PHC: Primary Health Care
SD: Standard Deviation
SPSS: Statistical Package of Social Sciences program
IRB: Institutional Review Board
ANNU: An-Najah National University
WHO: World Health Organization
NIS: New Israel Shekel
IDF: International Diabetes Federation
Abstract
Introduction: Diabetes Mellitus (DM) is still considered as a public health problem all over the world, the number of those who developing type II diabetes is increasing. While dietary therapy is highly recommended to be involved in the management therapy of diabetic patient it is still neglected by patients, their families and even by health care providers.
The aim of this study was to asses’ dietary routine practices among type 1 and type2 Palestinian diabetic patients in West Bank.
Research design and method: Quantitative, a cross-sectional, descriptive analytical study was conducted in primary health care centers (Hebron, Ramallah and Nablus).350 patients were randomly selected from September to November, 2015, utilizing questionnaire including five domains; about dietary routine after diabetes.
Results: the age of 32.9% of participants was more than 60 years and 91.7% of them have type 2 DM. Their dietary routine pattern mostly characterized by poor meals preparation (49.4% poor, 10.6% very poor). 33.7%, 17.4% have been evaluated as having poor and very poor family support respectively, Regarding to eating pattern just, 3.7% of participants have a very good eating pattern while 42.3% of them have poor eating pattern. The results also indicated that there was a significant relationship between last HbA1C results and eating pattern as p-value is (0.000< 0.05).in addition, there was a relationship between complications of DM and family support as the p-value (0.018< 0.05) and also represented there was a significant relationship between educational level and meal preparation as the p-value is (0.000< 0.05).
Conclusions: the factors affecting on dietary pattern were, firstly eating pattern (60.2%), then family support (57.8%) and meals preparation (57%).
Recommendation: MOH has to pay more attention for the dietary therapy and include it in management therapy of diabetic patients and teaching session for patients to maintain optimum dietary habits is highly recommended. Family has to consider dietary therapy of diabetic patient while preparing their different meals and helping on reading the nutrition fact label before choosing the meals.
Keywords: Diabetes Mellitus, Dietary routine, family support, meal preparation
Chapter 1: Introduction
1. Background
Diabetes Mellitus (DM) is a common public health problem that is close to epidemic proportions worldwide (Wild et al., 2004). The prevalence of DM in the US population is increasing in epidemic proportions, in 2012, 29.1 million Americans, or 9.3% of the population, had diabetes (ADA, 2014b). Approximately 1.25 million American children and adults have type 1diabetes, in 2012 the incidence of DM was 1.7 million new diagnoses per year; but in 2010 it was 1.9 million (ADA, 2014b). In Europe region there is a 52 million people have diabetes there were (6.7 million, 3.5 million) cases in Russian Federation and Italy respectively, also there were 426,800 cases of diabetes in Sweden and 3,241,300 cases of diabetes in France (International Diabetes Federation, 2014).
)International Diabetes Federation, 2014) reported that 37 million people in the Mena Region have diabetes and in Syria there were 875,700 case, in Saudi Arabia about 3.8 million and 424,000 cases of diabetes in Kuwait. (International Diabetes Federation, 2013) reported that in each ten adult there is one who have diabetes in the Middle East and North Africa Region and n 42% of people have diabetes in Egypt.
In Palestine, In 2014, the total number of new reported cases of Diabetes mellitus in West Bank was 3,692 with incidence rate 145.7 per 100,000 of population; in 2013 were 178.4 per 100,000 of Population (Palestinian Ministry Of Health, 2014 ).Nablus governorate with 632 new reported cases and incidence rate 169.6 per 100,000 of Population, Ramallah & Al-Bireh 453 cases and incidence rate 133.9 per 100,000 of population, Hebron governorate with 813 new reported cases and incidence rate 298 per 100,000 of Population. South Hebron governorate with 104 new reported cases and incidence rate 41.8 per 100,000 of population (Palestinian Ministry of Health, 2014).
Normal pancreas and its function
The pancreas is located in the abdominal cavity at the left upper quadrant of the abdomen, extending from the curve of the duodenum to the spleen. Also, the pancreas is a gland with two main functions: exocrine gland that helps in digestion as well as an endocrine gland that regulates blood sugar (Scanlon et al., 2007). The endocrine component of the pancreas consists of hormone producing cells that called islets of Langerhans , it contain alpha cells that release glucagon ,which acts to raise blood sugar and beta cells that produce insulin ,which acts to decrease and lower blood glucose (Scanlon et al., 2007).
Insulin
A hormone produced by the pancreas, the major action of insulin is to decrease blood glucose by allowing entry of glucose into the cells of the muscle, liver, and other body tissues, and storage of glucose as glycogen (Suzanne et al., 2005). But, in diabetic situation the pancreas unable to produce sufficient amount of insulin or the cells of the body not responding appropriate to the insulin produced (Dolores & David, 2011).
Diabetes mellitus
Diabetes is a group of metabolic diseases characterized by hyperglycaemia, it results when pancreas unable to produce sufficient amount insulin, or defect in insulin action, or both (ADA, 2014b). The major sources of glucose are the absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food (Suzanne et al., 2005). The chronic hyperglycaemia of diabetes is associated with long-term damage, dysfunction, and failure of body, various organs and tissues, especially the eyes, kidneys, heart, nervous system and blood vessels (ADA, 2014a).
Types of Diabetes Mellitus
Type 1 DM is an autoimmune disease in which the body’s defense system attacks and destructs the pancreatic beta cells resulting in little or no production of insulin (National Institute for Digestive and Kidney Diseases, 2006). The cause of type1 DM is idiopathic, but risk factors may include autoimmune, genetic, and possibly environmental factors (Suzanne et al., 2005). Type 1 DM commonly occurs in early stage of childhood and teenagers, but it would be likely to happen at any stage of age, and requires insulin for treatment and cannot be prevented (ADA, 2010). Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes (CDC, 2005).
Type 2 DM is a metabolic disease characterized by hyperglycemia caused by either a lack of insulin or the cells inability to use insulin effectively (National Institute for Digestive and Kidney Diseases, 2006). Type2 diabetes is the most prevalent form of diabetes, which accounts for approximately 90-95% of all diagnosed cases (CDC, 2005). Type2 diabetes is associated with older age, family history of diabetes, physical inactivity and obesity (CDC, 2005). The twin epidemics of diabetes and obesity are rising significantly all over the world (International Obesity Task Force, 2006). Type2 diabetes used to be named as adult onset diabetes, however the recent studies shows that incidence of type2 diabetes among adolescents has linked with the national increase in adolescent obesity (Pinhas et al., 1996; International Obesity Task Force, 2006). It is predicted that if the obesity rates continue to increase, prevalence of type 2 diabetes will also rise quickly. In 2000, there were a Predestined 300 million obese adults around the world, a statistic which continues to grow (WHO, 2005).
Diabetes standards of medical care
Since diabetes is a disease that requires ongoing medical treatment, the American Diabetes Association has created standards of care that include general care guidelines, treatment goals, and tools to evaluate the quality of care. According to the guidelines, screening for type 2 diabetes should be performed every 3 years in individuals older than 45 years of age, especially those with body mass indexes more than 25 kg/m2 (ADA, 2006). The preferred diagnostic test for diabetes is fasting blood glucose, which measures blood glucose levels after at least 8 hours of fasting, with levels higher than 126 mg/dl considered classification for diabetes (ADA, 2006). After diagnosis, a medical evaluation should be conducted to assess presence or absence of diabetes related complications.
Hemoglobin A1C (HbA1c) is test used to detect the mean glucose level over the previous 10-12 weeks. As normal the level of HbA1c is lower than 6% (Senthil et al., 2013). An elevated glycohemoglobin indicates poor control of diabetes mellitus, the HbA1c goal for patients with diabetes is less than 7% (ADA, 2006). Every percentage point decrease in HbA1c reduces the risk of diabetes complications by 40% (CDC, 2005).Fluctuations of HbA1c value are supposed to be responsible for long term complications of diabetes such as nephropathy and neuropathy (Senthil et al., 2013).
Diabetes medical nutrition therapy
Aims of diabetes medical nutrition therapy include preservation of blood glucose levels as near to normal as possible, modification of dietary and lifestyle patterns to prevent and treat obesity, to prevent and treat diabetes as well as possible complications of the disease, such as cardiovascular problems, retinopathy and nephropathy (ADA, 2002). The ADA also recommends the comprehensive role of nutrition therapy in overall diabetes management and has historically recommended that each person with diabetes be actively involved in self-management, education, and treatment planning with his or her health care provider, which includes the interdisciplinary development of an individualized eating plan (ADA, 2013; Inzucch et al., 2012). Unfortunately, a high percentage of people with diabetes do not get any structured diabetes education and/or nutrition therapy (Siminerio et al., 2005; Siminerio et al., 2006).
The focus of medical nutrition therapy differs slightly between type 1 and type 2 diabetes. Medical nutrition therapy for individuals diagnosed with type 2 diabetes typically require changes in eating and physical activity habits to reduce insulin resistance and improve metabolic status (ADA, 2002). And for young people diagnosed with type1 diabetes aims to provide appropriate energy to promote optimal development and to prevent hypoglycemic episodes (ADA, 2002). In my opinion, medical nutrition therapy for both types of diabetes confirms the need for control of blood sugar levels and for a healthy lifestyle to prevent diabetes related complications.
The plan created by the medical team should be individualized and take in consideration the diabetic patient’s culture, financial situation and lifestyle. Moderate weight loss is usually recommended for individuals with type 2 diabetes to help improvement of glycemic control and diminish risks of developing cardiovascular disorders (ADA, 2006; Klein et al., 2004). The primary goal of medical nutrition therapy is to control blood glucose levels, dietary self -management techniques aimed to moderate blood glucose levels before, during, and after meals (ADA, 2006).
Recommendations for MNT created by the ADA are a protein intake of less than 10% of total energy consuming, carbohydrate intake between 45%-65% of total calories, fat intake of 25%-35% of total calories with saturated fat less than 7% of total energy and minimal unsaturated fat consuming (ADA, 2006). Despite carbohydrate ingestion raises blood glucose levels; it is not recommended that diabetic patients follow a low carbohydrate diet because carbohydrates are an important source of energy, fibers, minerals and vitamins (ADA, 2006). Use of non-nutritive sweeteners adopted by the Food and Drug Administration agreeable if consumed within prescribed daily limits, general recommendations for individuals with diabetes include moderate alcohol consumption and diet that rich in fibers (ADA, 2006).
Diabetes self-management
Diabetes self-management is a cost effective technique that helps optimize metabolic control, manage and prevent complications, and improve quality of life (ADA, 2006). Individuals diagnosed with diabetes are expected to rapidly integrate major lifestyle changes, primarily related to physical activity and diet, in order to manage and prevent complications of diabetes (ADA, 2004). A study performed by a Finnish Diabetes Prevention Group, revealed that the risk of developing type2 diabetes was decreased by 58% in an intervention group implementing self-management techniques (Tuomilehto et al., 2001).
The reduction in risk was primarily associated with lifestyle changes promoted in the intervention group through individualized counseling aimed to increase fiber intake and physical activity, while reducing weight and total fat consumption (Tuomilehto et al., 2001).
Complications of Diabetes Mellitus
Continuous increasing of blood glucose level may result in long term complications related to diabetes which include macrovascular complications (like stroke and ischemic heart diseases) and microvascular complications. Microvascular injuries may lead to diabetic retinopathy, neuropathy, nephropathy and sometimes sexual dysfunction (National Diabetes Information, 1999). While hypoglycaemia, hyperglycaemia, and diabetes ketoacidosis considered the most common short term complications of DM (National Diabetes Information, 1999). The rate of developing macrovascular complications among patients with DM is 2-4 times higher than general population without DM, possibly due to atherosclerosis (National Diabetes Information, 1999). Cardiovascular diseases is the leading cause of mortality among diabetic patients, and both diseases DM and cardiovascular diseases have similar risk factors which include sedentary lifestyle, smoking, lack of exercise and unhealthy dietary pattern (Welschen et al, 2007). Although, a few diabetic patients die from acute metabolic complications like diabetic ketoacidosis, long-term complications of diabetes associated with excess mortality and morbidity, the factors associated with mortality and morbidity related to DM are duration and early onset of diabetes, high HbA1c level, hypertension, hyperlipidaemia and obesity (Welschen et al, 2007). However, the risk of macrovascular and microvascular complication may be greater with type 2 DM than type1 DM (NazimekSiewniak et al, 2002).
1.1 Problem Statement:
Lack of commitment in diabetic patient to a specific dietary routine is a major problem in the management of diabetes mellitus and it increases the possibility of developing complications.
1.2 Significance of the Study:
The result of study might help the health care provider and MOH to
initiate dietary program, to help diabetic patients in their management therapy and minimizing diabetic complication more over to provide help to their families in dealing with them.
1.3 Aim and Objectives:
Aim of study to assess dietary patterns among diabetic patients.
Objectives:
• Determine factors and difficulties contributing in preventing diabetic patients to be on dietary that suits their conditions.
• Assess the adherence to medication.
• Find out the prevalence of different diabetic related complication (retinopathy and nephropathy).
• Find out the prevalence of other NCD’s among diabetic patient.
• To identify high risk population for related complication.
1.4 Problem Questions:
a. What are the dietary routine that diabetic patient follows it?
b. What are the factors and difficulties that contribute in preventing diabetic patient to be on dietary that suits their conditions?
c. Do diabetic patients adhere to take their medication?
d. What is the prevalence of different diabetic related complications?
e. Who is the high risk population for related complications?
1.5 Hypothesis:
• Elderly people more likely to have complication than the young people
1.5.1 According to family support
a. Diabetic patient who have family support their last HbA1c is lower than who didn't have.
b. Diabetic patient who change medication dosage depending on the type of food they lack of family support
c. Diabetic patient who forgotten dosage didn`t have family support
d. Family support can have a good influence in decrease the probability of complications
e. Place of residency can affect on family support
f. Take prescribed medication influenced by family support
1.5.2 According to eating pattern
a. Eating pattern can affect last HbA1C results
b. Taking prescribed medication regularly influenced by eating pattern
c. Diabetic patient change their medication dosage depending on the type of food and eating pattern
d. Complications can affected by eating pattern
e. Place of residency can make an effect on eating pattern
f. Educational level affect eating pattern
1.5.3 According to meal preparation
a. Diabetic patient who prepare their meals have good influence on last HbA1C results
b. Level of education one of the factors that affect preparing meal
c. Meal preparation can influence by place of residency
d. Diabetic patient who forgotten their medication dose didn`t prepare their meals
Chapter 2:
Literature review
2.1 Medical Nutrition Therapy
Medical nutrition therapy (MNT) is an integral and whole element in diabetes prevention, management, treatment, and preventing, or at least delaying the development of diabetes complications (ADA, 2008). The goals of MNT that apply to persons with diabetes are to maintain glucose level in blood within normal level or as near or close to normal as possible, preservation of blood pressure level in the normal or as close to normal range, establishment of a lipoprotein and lipid profile that decreases the risk for developing micro/macro vascular diseases (ADA, 2008).
Multiple Randomized Control trials in different sites have shown that HbA1c and fasting plasma glucose level in diabetic patients decline in response to use Nutrition Practise Guideline or Medical Nutrition Therapy, study conducted by (Franz et al., 1995) revealed that the HbA1c level decreased by 1-2% and the fasting plasma glucose level dropped by fifty to hundred mg/dl. Also (Kulkarni et al., 1998) study shows that the patients who obtained nutritional intervention includes the practise of nutrition guidelines attain a larger decline in HbA1c level, it was 1% (from 9.2 - 8.2%), while 0.3% (from 9.5 - 9.2%) in control group with usual nutrition. While (UKPDS Group,1990) study done on 3,042 patients newly diagnosed type2 DM, during the early stage of their research study when nutrition counselling was the initial intervention, the mean HbA1c decreased by 1.9% (from 9 -7%), fasting plasma glucose was reduced by 46 mg/dl.
(ADA, 2006) recommended for MNT a protein intake lower than 10% of total energy consuming, carbohydrate from 45 to 65% of total calories, fat intake of 25-35% of total calories with saturated fat lower than 7% and low amount of unsaturated fat consuming .The type and quantity of carbohydrates consumed may have a marked effect on blood glucose control, so it is supported that carbohydrate calculating be utilized to measure total calories of carbohydrate consumed (ADA, 2006).
Multiple reviewed studies demonstrated that increased carbohydrate intake will decline HDL levels and an increase in fasting plasma triacylglycerol levels (Parks & Hellerstein, 2000). However, several studies proved that incidence of diabetes are reduced by increased carbohydrates intake (Marshall et al., 1991; Salas-Salvado et al., 2011).Whereas a cohort study done in US by (Colditz et al., 1992) demonstrated in their result that there is no association between risk of diabetes and carbohydrate intake.
A randomized crossover study with a 5 weeks period carried out by (Gannon & Nuttall, 2004) consists of eight men. The study aimed at assessing the influence of a low carbohydrate, diet with high protein on controlling of blood glucose level in people with Type2 DM; they designed special diet called it a low biologically available glucose (LOBAG) diet. At the end of the study the mean twenty four hours integrated serum glucose was 198 and 126 mg/dl, respectively. The percentage of HbA1c was 9.8 decreased by 0.5 while 7.6 decreased by 0.3, respectively, the study findings shown that this diet can circulating glucose concentration without any pharmaceutical intervention in individuals with uncontrolled type2 diabetes.
Large numbers of studies show that an elevated dietary fibre intake, especially of the soluble fibre, more than the level that recommended by the ADA, improves blood glucose control, lowers hyperinsulinemia, and lowers plasma lipid concentrations in patients with type2 diabetes (ADA, 2004).
A randomized, crossover study done on thirteen patients with type2 DM which carried out by (Chandalia et al., 2000) aimed to examine the influence of increasing dietary fibre on glycemic control in patients with type 2 DM, this effect studied by following two type of diets for six week, one of diets contain moderate quantities of fibres as supported by the ADA and the second one contain a high fibre intake. They concluded in their study that the diets was very good, through the 6th week of the high fibre diet, in comparison with the 6th week diet of the ADA, and mean daily glucose excreted in the urine was 1.3 g lower (median difference, 0.23 g to 1.83; P=0.008). The high fibre diet reduced plasma total cholesterol concentrations by 6.7 %, LDL concentrations by 12.5%.
A study conducted by Nicholson et al. (1999) to know whether glycemic control and lipid control in patients with type 2 DM can be markedly improved by use a vegetarian diet, and diet with low fat without any recommendations about exercise or any lifestyle changes. 11 individuals with type2 diabetes were recruited from the Georgetown University Medical Centre and the local community was assigned by using random method to a low fat-vegetarian diet. Findings of the study stating that the use of a low fat, vegetarian diet in patients with type 2 was related with markedly decrease in fasting serum glucose concentration and body weight without any recommendations for exercise regimen.
2.2 Diabetes self management
According to ADA (2006) diabetes self management is considered a cost effective way that aids in beneficent glycemic control, optimize quality of life and helps in management and prevention of unwanted diabetes complications. Individuals who diagnosed with DM are predictable to integrate basic lifestyle changes, related primarily to physical activity and diet, in order to manage and stop complications (ADA, 2004).
Self management of DM includes comprehensive self care actions in daily life, successful integration in carbohydrate counting, healthy diet, exercise regimens, decrease smoking and blood glucose monitoring in order to manage and prevent undesirable complications of diabetes (Duke et al., 2009). Actions for diabetes self management cannot be accomplished without programme for health education of the patients, participation in program for caring of themselves and involvement in classes for diabetes education with a specialist (Song et al., 2009).
Depending on the Diabetes Control and Complications Trial Research Group (1993), the suitable self management of diabetes is linked with lower HbA1c levels, which indicate better metabolic management, delay onset and slows the progression of macrovascular or micro vascular complications, e.g. blindness, stroke or renal failure.
2.3 Diabetes self-management education (DSME)
DSME is the process of teaching individuals to control their DM, it has been considered as a substantial portion of the DM management clinically since the 1930s (Norris et al., 2002). DSME is in a top priority of diabetes care, is not just for improvement of skill deficits and knowledge (Al-khaldi & khan, 2000). Unfortunately, 50 - 80% of individuals with DM has obvious insufficient skills and knowledge; mean HbA1c levels are unaccepted elevated in individuals with type 1 and 2 DM (Norris et al., 2002).
Multiple studies have reviewed the effectiveness of DSME programmes in the world. One of these studies performed by (Van der Does & mash, 2013) on (Take Five School) group in the Western Cape, South Africa. This study examine the education programme for patients with type 2 DM in this group, 84 patients from different 6 clinics undergoing 4 health sessions for an hour for each group by using a questionnaires and interviews with focus group and health care workers. The result has shown a marked improvement in commitment to physical activity, diabetic diet, and self care. While there is no marked change in commitment to medication or cessation of smoking, and qualitative data detected that overall education was appreciated.
Another study conducted by (Malathy, 2011) in South India over a period of 9 months, to examine the basic level of knowledge, attitude and practices of patient with DM, confirmed that the KAP score improved remarkably of test group, while no noticeable changes were observed in control group patients. Also, in the test group LDL, total cholesterol, and triglycerides revealed a decrease. On the other hand, a study carried out in Texas aimed to evaluate the DSME on 70 patients who finished the training program at the community clinic. After twelve months of program involvement mean HbA1c improved in a significant way from 9.7% - 8.2% (Banister et al., 2004). Another study performed by (Al-shahrani, 2012) aimed to study the influence of the five days intensive diabetes health education program on metabolic control in Saudi Arabia for type2 diabetics, after follow up for one year the results revealed that all metabolic parameters become better in a significant way (P < 0.0001),unless for HDL (P = 0.097).
In Palestine, a descriptive follow up study was carried out by (Al-Sabbah, 2000) in a rural Palestinian community shed light on diabetes self management, showed in Kabor village that diabetic patients with poor self management among diabetic patients indicated by high HbA1c, FBS and signs of the metabolic syndrome which emphasize and indicates the importance and very necessary need for involve patients in diabetes education, which encourages and helps changes of lifestyle, and according to that achieve self management. Also, a quasi-experimental study conducted in Tulkarm at diabetic clinic, with before and after test by (Rashed, 2012). It was applied to measure the impact of diabetes education program for patients with type 2 DM, the results have shown that there were a significant reduction in weight, waist circumference, BMI, LDL, total cholesterol level, FBS and HbA1c levels after interventions.
2.4 Family Routines and Family Rituals
The terms family rituals and routines are usually used alternatively, with some research differentiate the terms and other collecting them with each other. Researchers have a hard time agreeing on the same term because everyone has their own view on what forms a family ritual or routines (Fiese et al., 2002). According to (Denham, 2002) both family routines and rituals include several family members and focus on the interaction between individuals and family level factors.
Family routines are defined by (Keltner et al., 1990, p 161) as “day to day repetitive activities that occur within the family unit in a predictable manner”. Family routines support framework and consistency through organized actions such as bed time, meal time and other activities (Denham, 1995). Families that participate in constant routines promote their children in a more organized environment. Family routines have been related with wellness and psychological health of family members (Steinglass et al., 1987) and can act as therapeutic way that help in reduce the burden and load of 35 families contend with grief, divorce, or chronic diseases.
Persons newly diagnosed with DM are need to make basic and significant changes to lifestyle, habits and day to day actions with taking into consideration for diet, no smoking, adhere to medication, exercise, foot care, and blood glucose self monitoring (ADA, 2006).
Families that have organized and structured lives to encompass daily routines it’s possible to better be able to merge aspects of disease management into their lives, whereas families that are without routine structures and less organized may find the enforcement of daily routines as a stabilizing factor to a previously confused or anarchism environment (Markson & Fiese, 2000). A structure of efficient disease management needs roles to be allocated as portion of routine practices with various family members responsible for multiple aspects of health care (Fiese et al., 2000).
A large amount of literature concentrate on the effect of family routines on the management and control of type1 DM with many studies draw conclusions that adherence to treatment regimen of DM needs the collaboration and participation of all family members (Maharaj et al., 1998; Marteau et al., 1987; Schafer et al., 1986; Wysocki, 1993).
Routines supplies important structure, arrangement, and control required to confirm coherence in the amount, timing and types of foods that are eaten by child diabetic patients (Maharaj et al., 1998). According to (Marteau et al., 1987) study, families which are characterized by consistency and lack of struggle have been linked with maximal levels of diabetic control type1 diabetic children.
In our opinion, great interest has been given to the significance of family routines of those with type1 diabetes, while less exploration has signed about family routines with type2. Diabetes researchers have studied behavioural, environmental and physical features of families that have a high possibility to develop type2 diabetes. A study conducted by (Pinhas et al., 1999) on eleven families that included adolescents with type2 DM were investigated by assigned an anthropometric measurements, eating disorder and food frequency questionnaires to the subjects (Pinhas et al., 1999). The results revealed that adolescents with type2 DM derive from their families in which both siblings and parents were had habitual lifestyle or diagnosed with type 2 diabetes this place them at high risk of developing DM (Pinhas et al., 1999). All participants have Poor eating habits consisting from low fibre and high fat diets in addition to limited exercise routines (Pinhas et al., 1999). Organization of family can help in management of diet, families with high structured routine more appreciated to buy suitable foods for diabetic patient diet and to follow expected meal plans (Chesla et al., 2003).
Researchers have found that efficient treatment programs for diabetic patients require to take into consideration the health habits and lifestyle of all family members (Pinhas et al., 1999). Families depend on routines to emphasize that medications are taken regularly, to ensure presence of scheduled medical visits, and positioned plan for control of emergency situations, e.g. in hypoglycaemia episodes (Bush & Pargament, 1997).
2.5 Family support and involvement in care of diabetes
According to kane (1988) family support includes interactions between individuals that are positive, caring and promoting each others. Deficiency of family support is a major obstacle to behavioural changes for individuals with DM (Albarran et al., 2006). Relations between family performance, family coherence and diabetic control have been found, so poor glycemic control associated with poor family coherence and poor family performance (Cardenas et al., 1987). Social support has been related with getting higher levels of adherence to diet and is an important and necessary factor for persons who participate in meals with patient who lives with DM (Garay-Sevilla et al., 1995).
2.6 Family adaptation
Family adaptation happens when routines of the family are modified by depending on the conception of family member’s individuals, relaying on the families exist or available resources, and by supporting a new resources (Gallo, 1991).
A study undertaken with 5 New York suburban families by (Gerstle et al., 2001), consisted of female heads of housekeepers newly diagnosed with DM type2, challenged diabetes self management conventional model, which gave up the involvement of family component. Family adaptation of dietary routine i.e. shopping for buying grocery, transportation to reach the grocery shop, planning of meals, nutrition education that followed by doctor were assessed to introduce if adaptations of family assisted in type2 diabetes management or not. Findings of the study summarized those family members, who were included more than person with DM, finished diabetes associated actions to assist the family members who had DM blood to maintain blood glucose level within normal (Gerstle et al., 2001). Failure of family members to assume family roles after diagnosis with DM, which includes dietation and nurse role by supplying patient self care, medical and dietary advices resulted in no any change in glycemic control (Gerstle et al., 2001).
2.7 Dietary routines and diabetes management
Individuals with type2 DM have mentioned being resistant to nutritional modification more than people with any other chronic diseases (Groop & Tuomi, 1997). Dietary modification program following is the most struggling and important portion of type2 diabetes care because many diabetics’ individuals conflict with reformulating their dietary patterns to encourage lifestyle in a healthy way (Whittemore et al., 2002). Dietary modification needs dependence of newly dietary habits whereas modifying old dietary habits. According to (Tuomilehto et al., 2001), many studies findings have shown a strong relationship between the individuals’ capability to end type 2 DM progression and capability to decrease total fat and saturated fat consumption, reduction in carbohydrate consuming, increase complex carbohydrate consuming, increase fibre intake and weight reduction.
According to Savoca & Miller (2001) study about dietary habits and diet chosen among type2 diabetic patients, struggles to dietary commitment to dietary recommendation contain personal factors i.e. a desire and willingness to eat favourable diets under emotional stress and a history of eating beyond the stage of gratification. While, according to (Nagelkerk et al., 2006) modification of eating habits needs regular dietary meal times, deprivation from eating’s spontaneity and alterations in the types and quantity of meals.
A study undertaken by (Schuster, 2005), which examined whether eating patterns of families influence on diabetes self management, findings of study revealed obstacles to make modification of diet to be deep rooted individual dietary routines, family support deficiency, cultures of family, socioeconomic effects, food preferences eating out of home, travelling, and holidays considered challenges for persons with DM to use the recommending meal plan continuously.Diabetic woman stated that preparing two meals, the first meal for themselves and the other for the rest of the family, regarding to adjust and meet the desire of family (Savoca & Miller, 2001). The impression that a healthy food is more costly is another obstacle for suitable diet (Sherman et al., 2000).
A study conducted by (Harris et al., 2003) reviewed evidence from literature on type2 DM life style, closely related to diet and life style and exercise changes, to determine the relation of the clinical practice to reviewed evidence. Study findings showed that direct evidence supports intervention for physical activity and diet modification for primary prevention and management of type 2diabetes. It is evident that supporting patients to make changes in their physical activity and dietary habits can prevent onset of type2 diabetes and its management translating these findings into effective recommendations for clinical practice (Harris et al., 2003).
2.8 Diabetes and Exercise
A Systematic review, prospective cohort study was done by (Jeon et al., 2007) to study the relationship between physical activity of moderate intensity and risk of type2 DM. The study is especially investigated role of walking. The findings of the study are indicating that adherence to recommendations to be included in physical activities of moderate intensity such as rapid walking can significantly reduce the risk of type2 DM.
2.9 Barriers to Non-adherence to diabetic diets and exercise
Ary et al. (1986) concluded from their own study that factors contribute to non adherence to dietary regimen include eating out of home or restaurant 26%, some conditions at home like eating unhealthy foods when being alone at home 19%, non-supportive family members friends and partner 19%, become criticism by others 13%, giving self permission for eating inappropriate meals 10%, and poor self control 10%.
As well, in the same study (Ary et al., 1986) concluded that barriers to non adherence to exercise are negative physical reactions for example chest pain 34%, being criticism by others 24%, being so busy 17%, on a trip 10% , and in places that located away from home 10%.
2.10 Monitoring of blood glucose level
A cross sectional study Danish- British multi-center survey of patients with diabetes was undertaken by (Hansen et al., 2009). Blood glucose was measured daily by 39% of the participants and 24% measured it less than weekly and 67% of participants reported to do glucose monitoring routinely, while the 33 % of the remaining participants performed test when hyper/hypoglycaemia was suspected only. The study conclusion was patient’s commitment to blood glucose monitoring continuously is limited. About 2/3 of the patients don’t do daily blood glucose measuring and 1/3 of patients doesn’t do tests routinely.
A cross sectional study was conducted by (Klungel et al., 2008) to investigate type2 diabetic patient’s perception of diabetes status related to glucose monitoring, in Netherland by using 30 items self administered questionnaire. Conclusion of the study was patients who reported their diabetes status as moderately or poorly controlled was performed self monitoring of blood glucose more than who rated it as well controlled.
Several previous studies in different settings have permanently reported financial barriers to blood glucose self monitoring in diabetic patient (Adams et al., 2003; Schiel et al., 1999; Vincze, 2004). Although, there are two studies undertaken by (Soumerai et al., 2004; Nyomba et al., 2004) have also shown a poor performing self monitoring of blood glucose in spite of provided free blood glucose strips for test.
2.11 Adherence to medications
A cross sectional study undertaken by (Sankar et al., 2013) to study the adherence to medications in 346 DM patients in India. By using the 8 item Morisky Medication Adherence Scale. Study result shown that Prevalence of poor adherence was 74%. Patients who using oral hypoglycemic agents, with slash expenditure, with infrequent blood sugar monitoring, and which concentrate on better education and enhanced family support, are likely to promote adherence in this population than who didn`t.
Patient Adherence is considered as a factor that effect Medical Treatment Outcomes so a quantitative review using Meta-Analysis study conducted by (DiMatteo et al., 2002) assessed adherence outcome association of 36 study that search the correlation .Studies were analyzing according to population, disease and type of regimen (preventive/treatment, use of medication), and rustle showed that 26% is outcome different between high and low adherence.
A systematic review study reviewed 17 studies carried out by (Davies et al., 2013) to determine the factors that impact on insulin therapy adherence in patients with type1and 2 DM. It found that patient perceived barriers to adherence in result of age, travelling, delivery device type and medication cost also fear of injection and embarrassment to take the dose in public.
Cramer (2004) studied the adherence of medications for diabetic patients, the main aim of the study to determine percentage of patient who omits doses without prescription. They collected quantitative data from literature search on commitment with oral hypoglycaemic agents (OHAs) and insulin and relation between adherence and control glucose. Rustle showed that the commitment to (OHA) therapy was 6 to 93% with people how treated for 6 to 24 month, also 67 to 85% of OHA dose took as a Doctor order. 1/3 prescribed insulin doses were filled in Young patients and in type 2 was 62 to 64%.
A study aimed to assess the impact of dosage frequency on patient compliance, done on 91 diabetic patients, who took their medication from community pharmacy using oral anti diabetic agents conducted by (Paes et al., 1997). They use a short questionnaire in their study the percentage of dose which take during the study period was defined as a compliance also prescribe regiment percentage of day which mean number of tablet that was taken as prescribed in the day .rustles showed that compliance is effected by the frequency of dose and it is 74.8% the average of o once dose daily is 79% and for three time daily 38% and all group were omit dose also 1/3 of patient were use more dose.
According to (pound et al., 2005) decrease adherence to medication it was possible magnified by the selection of definition of medication adherence. In Asia barriers to medication adherence was cultural barriers i.e. use of alternative medicines and replacement of medicine with non pharmacological treatments may also contributed to non adherence of medications (Arrif et al., 2006)
2.12 Complications of Diabetes
The results of U.K. Prospective Diabetes Study (UKPDS Group, 1998) concluded that reductions in risk of 21% for any complication related to diabetes associated with 1% HbA1c level reduction over ten years , myocardial infarctions 14% , microvascular complications was 37%, and mortality from diabetes constituted 21%. The risk of significant reduction in life quality and life expectancy increased with individuals who diagnosed with DM (Bazzano et al, 2005). In the U.S, (Caro et al. 2002) estimated that the average of diabetics complications cost over thirty years at 47,240 dollar/patient. According to (CDC & Prevention, 2004) it is the most popular cause of end stage renal disease and non traumatic amputations, and the common cause of blindness in work age adults in the U.S.
Diabetic Retinopathy is one of the most DM microvascular complications results in lesions in the retinal blood vessels, and it considered the most common reason of acquired blindness in the Western world (Klein et al., 1992). In the UKPDS group study (1998) the majority of patients with type 1 DM develop evidence of retinopathy within twenty years of diagnosis, while development of diabetic retinopathy in patients with type 2 DM was detected to be associated to both presence of hypertension and intensity of hyperglycaemia.
A study done by (Bandurska-Stankiewicz & Wiatr, 2007) discussed preventing vision loss as a complication of diabetes depends on an advance metabolic control of diabetes, on the other hand depends on implementation of a programme for early detection and treatment of diabetic retinopathy, appropriate treatment of diabetes, which revealed by good glycemic control, these things will reduce the risk of developing severe complications, improve quality of life and increase life span. Vision loss incidence due to DM is obviously higher in the countries which don’t have introduced programs preventing retinopathy, than in those which have the programme (Bandurska-Stankiewicz & Wiatr, 2007).
A quantitative semi-automated study conducted by (Da et al., 2015) to examine Changes in retinal microvascular diameter in patients with diabetes, their sample was 52 participants, 26 with diabetes and 26 without, their findings showed that Patients who had diabetes for long time 5 or more years had larger venule diameters in the upper temporal quadrant than patients without DM, and there are a positive correlation between diameter and blood glucose level.
A meta-analysis of randomized controlled trials, conducted by (Pan et al., 2008) to examine whether Low protein diet (LPD) has a significant effect to delay the progression of diabetic nephropathy or not. They search many database for 6 months one of them Cochrane Central Register of Controlled. The study revealed that the LPD didn’t affect or improve renal function. Also a human observational report examine Nutrition therapy for diabetic nephropathy by (Franz & Wheeler., 2003) showed that there was no relation between improvement of nephritic disease in protein intakes less than twenty percent, but in the other hand there was a relation between protein intakes more than twenty percent with increase albumin excretion.
In type 2 diabetic patient, diabetic peripheral neuropathy happens in up to 60 percent (Kles & Vinik, 2006), and is associated with obvious morbidity, including anxiety, depression amputations, and decreased life quality (Wu et al., 2007; Dobretsov et al., 2007). A randomized controlled 20 week pilot study with type 2 DM patient carried out by (Bunner et al., 2015) to examine dietary intervention for chronic diabetic neuropathy pain, participant were disrepute two group intervention with law fat diet plant based diet also supplement of B12 and control just supply with B12. The study concluded that loss of 6.4-9.4 of weight, foot electrochemical conducting improves of 12.4 microseimens, differences of pain between the two groups was 8.2 point.
A randomized controlled study in Rural Costa Rica conducted by (Goldhaber-Fiebert et al .,2003) to assess whether the community-based nutrition and exercise intervention improves glycemic control and cardiovascular risk factors in Type 2 Diabetic Patients, their sample was 75 diabetic patient 59 years separate to two group intervention take 11 weekly nutrition classes and control group walk twice weekly for 60 min each time the result showed that the glycemic control improved in intervention group and decreases the risk factor for developing cardiovascular problems.
A prospective observational study carried out by (Startton et al., 2000) on 4585 patient from 23 hospital in England, Scotland, and Northern Ireland, to examine the relationship between glycaemia and macro/microvascular complications of type 2 diabetes, their findings showed that there were a relation between glycaemia and incidence of clinical complications. Each 1 percent decrease in HbA1c was connected with decrease in the risk of 21 percent for any end point related to diabetes, 14 percent for MI, 37 percent for microvascular complications, and 21 percent for deaths related to diabetes.
A cross sectional study was conducted by (Kasim et al., 2000) who assessed Peripheral neuropathy (PN) in 300 type 2 diabetic patients attending diabetic clinics in Al-Azhar University Hospitals, Cairo, Egypt to describe the indecision of PN and the risk factors related with its occurrence., patient with PN considered as study cases and who without PN as controls to assess the risk factor. The rustle showed that 29.7 percent was the frequency of PN; the related risk factors were moderate to severe hypertension, ischemic heart disease, older age above 60 years, and poor control of DM and duration of DM.
A study states that almost 60,000 major lower extremity amputations were performed to individuals with DM in the US yearly. Diabetic foot ulcer constitutes a major factor in 84 percent of these amputations (Levin, 1993)
Chapter 3: Methodology
3. Methodology
3.1 Introduction:
This chapter describes the methodology that used in this study to carry out it, also describes study design, site and setting, study population, sample and sampling method, study variables, eligibility criteria, also contains explanation of each domain of the measurement tool for data collection, discuss validity and reliability, administrative, fieldwork and ethical considerations, this study conducted from September to November, 2015. Moreover discuss data analysis plan and the program that we used for analyzing data.
3.2 Study design:
Quantitative, a cross-sectional, descriptive analytical study was conducted for the purpose of assessing the dietary routine among diabetic patients and their families.
3.3 Sites and Settings:
The participants were selected from Primary Health Care Clinics, from central diabetic clinics in Nablus, Ramallah and Hebron at West Bank \ Palestine.
4. Population
The study population was consisted from type 1 and type 2 diabetic patients, who registered at Ministry of Health diabetic centers and regularly visiting it. There the total number reached about 4200, distributed as following; 1000 Nablus, 1400 Ramallah, and 1800 Hebron.
5. Sample and Sampling method:
The sample size was 350 diabetic patients proportionally divided as per table.
Table (1): distribution of population and sample size according to city
|The city |Population |= Sample size |
| |( monthly visits to the clinic )| |
|Nablus |1000 |= 84 |
|Ramallah |1400 |= 116 |
|Hebron |1800 |= 150 |
|Total |4200 |350 |
simple random method(every other patients); serial number was given to every patients came for follow up visit at the day of data collection ,patients with odd number were selected to be involved in the study.
3.6 Selection criteria
• Inclusion criteria:
- Patients with diabetes mellitus type1 and type2.
- Age 18 years old and more.
- Both male and female were included in the study.
• Exclusion criteria:
- Patients with any type of diabetes out of type1 and type 2, e.g. Gestational Diabetes.
- Age under of 18 years.
- Patients who unable to communicate due to physical or mental disability.
3.7 Data collection tool:
interviewed questioner (Annex I) was used to collect the data. It consisted of the following part :
part one; The demographics data: that included (1-8) items about gender, age, city, place of residency, marital status…etc.
part two; The medical history: it involved items (9-19) used to assess NCD’S among participants and to assess their history of diabetes mellitus as ; time of diagnosis with DM, number of family members with DM, type of DM, last HbA1C result...etc.
part three; The adherence to medication regimen: this part consisted five items (20-24) used to evaluate patients adherence to medication regimen as; type of treatment, doses per day...etc.
Part four; The dietary routine: it is pre-tested structured questionnaire developed by Collier (2007), permission was taken to used it (Annex II). This part consisted from 33 statements (25-57): with five likert scale choices (Never, Rarely, Occasionally, Usually, and Always), this parts used to assess dietary routine among diabetic patients; family support, eating habits and meal preparation.
Part five; The diabetic complications: this part consisted from three items (58-60) used to assess the presence of most common complications among diabetic patients as; neuropathy, nephropathy, retinopathy…etc.
3.8 Validity and reliability
Reviewing:
The questionnaire was translated from English to Arabic by an expert and vice versa. Then it was reviewed by 5 experts from different faculty members of Medicine and Health Sciences collage at An-Najah National University and one specialist of MOH.
Pilot study:
It was applied on 10% of the sample size (35 diabetic patients) from Nablus diabetic clinic, through the period of 14th – 17th of September, 2015 by using simple random method. It was conducted to determine the reliability of the data collection tool, to estimate the time needed for completion of the questionnaire, asses understanding and clarity of it from the patients, and to find out the obstacles that might be appear through the data collection process.
Cronbach’s Alpha: It was also tested using Cranach’s Alpha test for reliability and it was 0.60.
The reliability of the used parts that was developed by (collier, 2007) was 0.90.
3.9 Administrative, Fieldwork:
After the permission from Ministry of Health (MOH) at the Palestinian Authority was obtained to collect the data from central Primary Health Care centers (Annex III); several visits to PHC were conducted, during these visits aims and objectives of study were explained to directors of centers. In addition data collection dates was agreed upon, during visits patients were interviewed to fulfill the questionnaire.
3.10 Ethical considerations:
Approval to conduct research from the Institutional Review Board (IRB) of An-Najah National University (ANNU) was obtained (Annex IV). Permission to use the dietary pattern part from (collier, 2007) to use the dietary pattern scale was taken.
Informed consent (Annex V) to ensure the agreement of participants before involvement in the study; it included title of the study, main aim and objectives of the study. Participants also were ensured about their voluntary participation, and that they have the right to withdraw from the study, confidentiality and privacy was taken into consideration.
3.11 Data Analysis:
Data was coded and after that transferred to a specific format by using the Statistical Package of Social Sciences program (SPSS, version 21) for data entry and for statistical analysis, as per table (1 & 2) the following statistics were measured:
1. Descriptive summary measures was expressed as percentage, mean, frequency distributions and standard deviation (SD).
2. The significance level (p-value) in this study was lower than 0.05.
3. Chi-square test was used to predict correlation between dependent and independent variable.
4. Bivariate analysis used to examine the type and strength of the relationships between variables.
5. Cross tabulation used.
6. Scoring system:
After reversely coded for items (29, 33, 37, 41, 42, 47, 48, 51, 53, 55 and 56) level of dietary routine was measured as following:
• Very poor (20-39)%
• Poor (40-59)%
• Good (60-79)%
• Very good (80-100)%
It also measured for level agreements as following:
• (20-46.6)% low agreement.
• (46.7-73.3)% moderate agreement.
• (73.4-100)% high agreement.
Table (2): Dependent and independent variables
|Hypothesis |Dependent variable |Independent variable |
|There is no relationship between age and diabetic complication |Diabetic complication |Age |
|There is no relationship between last HbA1C results and family support regarding dietary|Last HbA1C result |Family Support |
|routine | | |
|There is no relationship between change the medication dose depending on the type of |Change the medication dose |Family Support |
|food and family support regarding dietary routine | | |
|There is no relationship between forgotten medication dose and family support regarding |Forgotten medication dose |Family Support |
|dietary routine | | |
|There is no relationship between diabetic complication and family support regarding |Diabetic complication |Family Support |
|dietary routine | | |
|There is no relationship between last HbA1C results and eating pattern |Last HbA1C result |Eating Pattern |
|There is no relationship between take the prescribed medication regularly and eating |Take the prescribed medication |Eating Pattern |
|pattern |regularly | |
|There is no relationship between change the medication dose depending on the type of |Change the medication dose |Eating Pattern |
|food and eating pattern | | |
|There is no relationship between last HbA1C results and meals preparation |Last HbA1C result |Meals preparation |
|There is no relationship between educational level and meals preparation |Meals preparation |Educational level |
|There is no relationship between place of residency and meals preparation |Meals preparation |Place of residency |
|There is no relationship between forgotten medication dose and meals preparation |Forgotten medication dose |Meals preparation |
Table (3): conceptual and operational definitions
|concept |Conceptual Definition |Operational Definition |
|Age |The length of time that a person has lived |The participants age grouped to four category related to their age|
| | |which it is |
| | |(18-29),(30-39),(40-49), |
| | |(50-59)year and ≥60 years old |
|Complication |Harmful effects of diabetes such as damage to the eyes, heart, |The participants answer yes if they have complication or no if |
| |blood vessels, nervous system, feet and skin, or kidneys. |they haven’t |
|HbA1C |A test that measures a person's average blood glucose level |According to the last HbA1C we put the participants in 5 group |
| |over the past 2 to 3 months |which is |
| | |(6.5-7)% ,(8-7.1)%,(8.1-9)%, >9% and who didn`t remembers |
|Medication adherence |Medication adherence usually refers to whether patients take |The participants disrupted to three level which is : |
| |their medications as prescribed (e.g., twice daily), and they |adherent , moderate adherent and not adherent |
| |continue to take it | |
|Family support |family support includes interactions between individuals that |It includes 8 element and according to the participants answer, |
| |are positive, caring and promoting each others |score given for each answer and put in 4 category as (very poor |
| | |,poor , good , very good) |
|Meals preparing |Preparing food for eating generally requires selection, |It includes 10 element and according to the participant answer, |
| |measurement and combination of ingredients in an ordered |score given for each answer and put in 4 category as (very poor |
| |procedure. |,poor , good , very good) |
|Dietary pattern |Refers to why and how people eat, which foods they eat, and |It includes 13 element and according to the participant answer, |
| |with whom they eat, as well as the ways people obtain, store, |score given for each answer and put in 4 category as (very poor |
| |use, and discard food |,poor , good , very good) |
Chapter 4: Result
|Table (1): Distribution of percentage of participants’ demographics |
|Items |(N) |% |
|Gender |Female |188 |53.7 |
| |Male |162 |46.3 |
| |Total |350 |100.0 |
|Age |(18-29) year |23 |6.6 |
| |(30-39) year |37 |10.6 |
| |(40-49) year |78 |22.3 |
| |(50-59) year |97 |27.7 |
| |≥ 60 |115 |32.9 |
| |Total |350 |100.0 |
|City |Nablus |84 |24.0 |
| |Ramallah |116 |33.1 |
| |Hebron |150 |42.9 |
| |Total |350 |100.0 |
|Place of residency |City |143 |40.9 |
| |Village |201 |57.4 |
| |Camp |6 |1.7 |
| |Total |350 |100.0 |
|Marital status |Single |31 |8.9 |
| |Separated |3 |0.9 |
| |Married |248 |70.9 |
| |Widowed |66 |18.9 |
| |Divorced |2 |0.6 |
| |Total |350 |100.0 |
|Educational level |Primary |128 |36.6 |
| |Preparative |82 |23.4 |
| |Secondary |70 |20.0 |
| |College |31 |8.9 |
| |Academic |39 |11.1 |
| |Total |350 |100.0 |
|Household Income |> 1450 NIS |83 |23.7 |
| |(1450-1999) NIS |71 |20.3 |
| |(2000-2499) NIS |84 |24.0 |
| |(2450-3000) NIS |41 |11.7 |
| |≥ 3000 NIS |71 |20.3 |
| |Total |350 |100.0 |
Table (1) showed demographic characteristics of participants. It revealed that 53.7% of participants were female, 32.9% of participants ranging in the age group of more than 60 years old. It also showed that 70.9% of the participants were married, and 57.4% of them live in village, 36.6% of them with primary education level and 24% of the participants there household income ranging in (1450-1990) NIS.
|Table (2): Distribution of percentage of participants’ regarding DM medical history |
|Item |(N) |% |
|Time of diagnosis of DM |< 1 year |28 |8.0 |
| |1-3 years |66 |18.9 |
| |4-6 years |76 |21.7 |
| |7-9 years |54 |15.4 |
| | > 9 years |126 |36.0 |
| |Total |350 |100.0 |
|Family members who have DM |No one |219 |62.6 |
| |One family member |96 |27.4 |
| |Two family member |19 |5.4 |
| |Three family member |4 |1.1 |
| |Four family member |2 |0.6 |
| | | | |
| |> 4 family member |10 |2.9 |
| |Total |350 |100.0 |
|Type of DM |Type 1 |23 |6.6 |
| |Type 2 |321 |91.7 |
| |I don't know |6 |1.7 |
| |Total |350 |100.0 |
|Last HbA1C result |6.5-7 % |23 |6.6 |
| | | | |
| | | | |
| | | | |
| |7.1-8 % |116 |33.1 |
| |8.1-9 % |110 |31.4 |
| |> 9 % |22 |6.3 |
| |I don't remember |79 |22.6 |
| |Total |350 |100.0 |
|Number of glucose measure weekly |< once a week |153 |43.7 |
| |Once a week |66 |18.9 |
| |At least once a week |19 |5.4 |
| |2-3 times a week |76 |21.7 |
| |> four times a week |36 |10.3 |
| |Total |350 |100.0 |
|Last glucose measure |Not measure |73 |20.9 |
| |100-149 mg/dl |97 |27.7 |
| |150-199 mg/dl |92 |26.3 |
| |200-249 mg/dl |28 |8.0 |
| |250-299 mg/dl |28 |8.0 |
| |≥ 300 mg/dl |32 |9.1 |
| |Total |350 |100.0 |
|Ability to control DM with eating habits |Excellent |5 |1.4 |
| |Very good |58 |16.6 |
| |Good |122 |34.9 |
| |Fair |124 |35.4 |
| |Poor |41 |11.7 |
| |Total |350 |100.0 |
|Pattern of patient lifestyle |Very organized |26 |7.4 |
| |Semi-organized |251 |71.7 |
| |unorganized |73 |20.9 |
| |Total |350 |100.0 |
|Family lifestyle |Very organized |32 |9.1 |
| |Semi-organized |249 |71.1 |
| |Unorganized |69 |19.7 |
| |Total |350 |100.0 |
Table (2) showed that participants who have been diagnosed with DM for more than 9 years ago were 36%, participants who don’t have a family history of diabetes were 62.6 %, and up to 91.7% of participants had type 2 DM.
6.6% of the participant reported that their last HbA1c result ranging in (6.5-7)%, 43.7% of the participants reported that they measure their blood glucose level less than once a week were, 20.9% of participants don’t measure their blood glucose, while almost 28% of participants their last glucose measure between 100-149 mg/dl.
The table also showed that the participants reported that their ability to control DM with eating habits in 1.4% of participants were excellent, 71.7% of participants have a semi-organized lifestyle and also 71.1 have a semi-organized family lifestyle.
|Table (3): Distribution of percentage of participants’ adherence of medication |
|Items |(N) |% |
|Type of treatment |Insulin |160 |45.7 |
| |Oral hypoglycaemic agents |142 |40.6 |
| |No any treatment |1 |0.3 |
| |Insulin & Oral hypoglycaemic agents |46 |13.1 |
| |Diet only |1 |0.3 |
| |Total |350 |100.0 |
|The number of Doses per day |One |35 |10.0 |
| |Two |195 |55.7 |
| |Three |96 |27.4 |
| |> three |24 |6.9 |
| |Total |350 |100.0 |
| |Never |4 |1.1 |
|I take the prescribed medication regularly | | | |
| |Rarely |23 |6.6 |
| |Occasionally |68 |19.4 |
| |Usually |108 |30.9 |
| |Always |147 |42.0 |
| |Total |350 |100.0 |
| |Never |136 |38.9 |
|Change the dose depending on the type of food| | | |
| |Rarely |57 |16.3 |
| |Occasionally |91 |26.0 |
| |Usually |37 |10.6 |
| |Always |29 |8.3 |
| |Total |350 |100.0 |
| |I take medication when I remember |235 |67.1 |
|Forgotten dosage | | | |
| |I do not take medication |115 |32.9 |
| |Total |350 |100.0 |
Table (3) showed that more than 45% of participants were insulin-dependent, 40.6% of them were on oral hypoglycaemic agents. 55.7% of participants their prescribed medications have been regulated as two doses per day and 42% of participants reported that they always take their prescribed medication regularly, 26% of participants reported that they occasionally change their medication doses depending on the type of food that they take, and also 8.3% of participants reported that they don’t take the forgotten dosage.
Table (4): Distribution of percentage of participants’ regarding their other compound NCD’s and DM complications
|Item |NCD’S |(N) |% |
|Other compound NCD’s |Hypertension |185 |52.9 |
| |Heart diseases |82 |23.4 |
| |Asthma |21 |6.0 |
| |Rheumatoid arthritis |52 |14.9 |
|DM complications |Retinopathy |98 |28.0 |
| |Vascular Disease |80 |22.9 |
| |Nephropathy |23 |6.6 |
| |Diabetic foot |59 |16.9 |
| |MI |45 |12.9 |
| |Neuropathy |31 |8.9 |
Table (4) showed that 52.9% and 23.4% of participants reported that they have Hypertension and heart diseases respectively. It also showed that 28% and 22.9% reported that they have retinopathy and vascular diseases respectively.
Table (5): Distribution of percentage of participants’ regarding “Adherence to Medication”
|Item |Valid |(N) |% |
|Adherence to Medication |Adherence |95 |27.1 |
| |Moderately Adherence |251 |71.7 |
| |Non Adherence |4 |1.1 |
| |Total |350 |100.0 |
Table (5) showed that 27.1% of participants from those who reported that they were adherent to medication. 71.7% of those who reported that they were moderately adherent. It also showed that 1.1%they were non adherent.
|Table (6): Distribution of percentage of participants’ regarding their |
|“Main meals & Snacks that they regular eat” |
|Dietary routine |N |% |
| Main meals |(Breakfast/morning meal) |Yes |295 |84.3 |
| | |No |55 |15.7 |
| |Lunch/Noon meal |Yes |322 |92.0 |
| | |No |28 |8.0 |
| |Dinner/Evening meal |Yes |226 |64.6 |
| | |No |124 |35.4 |
| Snacks |morning snack |Yes |85 |24.3 |
| | |No |265 |75.7 |
| |Afternoon snack |Yes |60 |17.1 |
| | |No |290 |82.9 |
| |Evening snack |Yes |147 |42.0 |
| | |No |203 |58.0 |
Table (6) revealed that 92% of the participants from those who reported that they ate lunch (noon meal) regularly, it also showed that 42% of them ate evening snack regularly.
Table (7): Distribution of percentage of participants’ regarding their “dietary routine”
| |
|Items |
|At least one other family member offers me |92 |
|support in managing my diabetes | |
|Scale 2: Eating factors |
|I eat foods that are healthy |17 |
|Scale 3: Preparing Factors |
| I follow a routine to take care of my |105 |
|diabetes | |
|Total Mean± SD |2.937± |
| |0.381 |
Table (7) represented distribution of percentage of participants’ regarding their dietary routine which include family support factor scale, eating factor scale, and preparing factor scale.
Regarding Family support factor scale, table 7 showed that 29.1% of participants reported that “their family members eat their lunch meal at home together”, “always” and “usually” respectively. 6.3% of participants reported that it’s “always” “their family members eating habits has a good influence on their food choices”.
8% of participants mentioned that “at least on other family member “always” help them in read food labels” and 20% reported that “usually” “their family members are supportive of their food choices”.
According to Eating factor scale, 16.9% of participants reported that “always” “they eat three or more meals a day” and 4.6% of them reported that “always” “they eat five or more servings of fruits or vegetables everyday”, 29.1% of the participants reported that “during holidays and celebrations, it’s usually hard to eat the right kinds of foods to help control their blood sugar”.
In relation to meal preparation factor, table (7) also showed that 53.1% of the participants reported that “they eat homemade meals” and 12.6% of them reported that “the right type of food is always available in their house to help manage their diabetes”, 11.7% of the participants reported that “they always follow a routine to take care of their diabetes”. 7.4% of the participants reported that they “always read food labels to see how different foods will change their blood sugar” and 8.9% of them reported that “they choose food to eat based on what affect on their blood sugar”.
Table (8): Distribution of percentage of participants’ regarding their “dietary routine”
| |Scale no. |Item |
| |)18-29( y |)30-39( y |(40-49) y |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |Very Good |Good |Poor |
| |
|Table (21): Distribution of participants mean and percentage regarding their agreement |
|Rank |
|6 | At |2.85 |1.431 |positive |57% |
| |least one | | | | |
| |other | | | | |
| |family | | | | |
| |member | | | | |
| |offers me | | | | |
| |support in| | | | |
| |managing | | | | |
| |my | | | | |
| |diabetes | | | | |
|Scale 2 : Eating factors |
|7 |I eat |3.15 |0.987 |positive |63% |
| |foods that| | | | |
| |are | | | | |
| |healthy | | | | |
|Scale 3: Meal preparation factors |
|7 |I follow a|2.55 |1.349 |positive |51% |
| |routine to| | | | |
| |take care | | | | |
| |of my | | | | |
| |diabetes | | | | |
|Total Mean± SD |2.937 |0.381 |
|There is no relationship between place of residency and family support regarding dietary routine for diabetic patient |3.327 a |Accept |
| |0.767 | |
|There is no relationship between place of residency and eating pattern regarding dietary routine for diabetic patient |4.131 a |Accept |
| |0.659 | |
|There is no relationship between educational level and eating pattern for diabetic patient |10.900 a |Accept |
| |0.538 | |
|There is no relationship between take the prescribed medication regularly and family support regarding dietary routine |18.954 a |Accept |
|for diabetic patient |0.90 | |
|There is no relationship between complications of DM and eating pattern for diabetic patient |6.641 a |Accept |
| |0.084 | |
Table (22): Table of hypothesis results with no relationship
Table(22) showed that there was no significant relationship between place of residency and family support regarding dietary routine, place of residency and eating pattern regarding dietary routine, educational level and eating pattern and complications of DM and eating pattern for diabetic patient with p-value`s are (0.767, 0.659,0.538 and 0.084) respectively which is (> 0.05). Also it showed that there is no relationship between take the prescribed medication regularly and family support regarding dietary routine for diabetic patient with a p-value is (0.90) which is (> 0.05).
Chapter 5: Discussion
5. Discussion
The overall aim of this study was to asses’ dietary routine practices among type 1 and type2 Palestinian diabetic patients in West Bank, which act as a basis to understand eating pattern behaviour of them and their families.
Results of this study (table1) revealed that more than half of participants were female (53.7%); more than two quarter of them were married (70.9%). Most of participants have been diagnosed with type 2 DM (91.7%), and this agreed with Ministry Of Health (2014) statistic, which reported that 95.2% of Palestinian diabetic patients have type 2 DM.
Results of this study (table2) showed that only 6.6% of study participants had a controlled HbA1c and 22.6% of them didn't remember the last HbA1c result, in our opinion this may indicate shortage of knowledge about importance of HbA1c result which reflect degree of controlling of DM.
Study results (table2) showed that 43.7% of participants reported that they measured their blood glucose less than once a week, this result didn’t consistent with a cross sectional study that undertaken by (Hansen et.al, 2009) which revealed that 24% of type 1 diabetic patients measure their blood glucose less than once a week, and this difference maybe related to differences in the sample, in present study sample includes type1 and 2 DM, while they study only type 1 diabetics.
It also revealed (table2) that 20.9% of them reported that they didn't measure their blood glucose level. According to (Adams et al., 2003; Schiel et al., 1999; Vincze, 2004) studies on multi different settings, they reported that there were financial barriers to do blood glucose self monitoring. Another qualitative study undertaken by (Ong et.al, 2014) reported that the identified barriers that affected self monitoring of blood glucose included frustration from high blood result, cost of test strips and needles, glucose reading, fear of needles and pain, and lack of motivation. In present study these barriers maybe one of causes that prevent them from monitor blood glucose level.
Study revealed (Table 2) that 71.1% of participants had semi-organized family lifestyle structure, and 19.7% of them had unorganized family lifestyle structure. According to (Chesla et al., 2003) organization of family can help in management of diet, families with high structured routine more appreciated to buy suitable foods for diabetic patient diet and to follow expected meal plans.
The results (Table 3) presented that only 0.3% of study participants on diet and 13.1% of them on compound treatment (OHA & Insulin), and these results in agreement with Ministry Of Health (2014) statistic that revealed only 0.4% of diabetic patients in Palestine on diet and 13.1% of them on compound treatment.
It also (Table 3) revealed that nearly half of participants (45.7%) were insulin-dependent, while the results (Table 2) indicated that the majority (91.7%) of them have been diagnosed with type 2 DM. According to (Michael & Fowler, 2007) usually the first medication that used to treat type2 DM is OHA and if blood glucose level were uncontrollable, insulin considered the last treatment that used for them. So, in this study half of type 2 diabetics may their blood glucose level not controllable as a result of that they converted into insulin as a treatment.
Study results (Table 4) revealed that more than half of participants (52.9%) reported that they have hypertension and this in agreement with (Lahham, 2009) study which undertaken in Nablus, showed that 55.2% of diabetic patients have hypertension, and it’s in disagreement with the results by (Lago & Nesto, 2007) study that revealed 70% of diabetic patient have hypertension.
The results (Table 4) revealed that 12.9% of participants reported that they have MI and this in agreement with (Startton et al., 2000) study that revealed 14% of type 2 diabetic patients in their study have MI. About one third of them reported that they have neuropathy as a complications of diabetes (29.9%) and this in coherent with (Lahham, 2009 (study in Nablus which revealed 30.4% of diabetic patients have neuropathy as a complication.
Study results (Table 5) revealed that only 1.1% of participants not adherent to medication, 71.1% of them moderately adherent and about one third (27.1%) of participants adherent to medication. This study results didn’t in agreement with (Abebe et. al, 2014) study which revealed that one quarter of them (25.4%) had low adherence, and about one third of them (28.7%) of them moderately adherent to medication. These differences may be due to use a special questionnaire for measure adherence to medication and cultural differences. In addition , qualitative study by (Jeragh-Alhaddad, 2015) identified barriers that impede adherent of medication include lack of knowledge about diabetes and medication, personal factors, beliefs about disease and medication, and care providers factor. Also systematic review study reviewed 17 studies carried out by (Davies et al., 2013) to determine the factors that impact on insulin therapy adherence in patients with type1and 2 DM, it found that patient perceived barriers to adherence in result of age, travelling, delivery device type and medication cost also fear of injection and embarrassment to take the dose in public.
The results (Table 6) showed that 15.7% of participants reported that they didn’t eat breakfast/ morning meals, and approximately two third of the participants (64.6%) reported that they eat evening meals. This results in disagreement with (Tol et.al, 2014) which reported that evening meals not reported at all.
Study results (Table 7 & Table 21) from dietary routine tables showed that the highest mean score or highest agreement was on dietary pattern followed by family support and then meal preparation, in a score of (60.2± 11.39), (57.8± 17.64) and (57± 14.46) respectively. These results in agreement with (Tol et.al, 2014) study in Iran which evaluated dietary habits and related factors among type 2 diabetic patients, they use the same dietary routine scale questionnaire , and their results revealed that mean score was in family influence was (64.72 ± 14.3), in eating meals was (52.27 ± 12.13), while in meal preparation was (57.31 ± 23.82). The slightly differences in dietary or eating pattern may be due to cultural differences in dietary habits.
Regarding to results in family support factors (Table 7& 21) the highest agreement (72.2%) were on “Members of my family eat lunch meal at home together”, while more than half of them (56.6%) agreed on “Other family members’ eating habits are a good influence on my food choices”. This results in agreement of (Al-Kaabi et.al, 2008) study that most patients live and eat with their family and about half of them (45%) reported that their family members were included in their dietary choices. So this reflect that when the individuals eat their meals with their family member they influenced on them about food choices either negative or positive effect.
According to eating factors (Table 7&21) more than two third of participants (69.2%) reported that “On holidays when special or different foods are available, I eat more than I normally would” and it take the highest agreement and it negative statement which reflects that it was the highest problem that form a barrier to good dietary practices. It followed by more than two third (65.8%) of them reported that “When I travel, it is harder for me to eat the right kinds of foods to help control my blood sugar”
Study results (Table 8) showed that more than one third (33.7%) of participants had poor family support, 17.4% of them had very poor family support, and more than one third (35.4%) of them had a good family support regarding their dietary routine. This results in disagreement with (Shamsi et.al, 2011) study in Bahrain, which revealed that only 2.8% had poor family support and more than half of them (56.5%) had a good family support regarding their dietary practise. These differences may be related to cultural and behavioural differences between Palestinian and Bahrain families.
Regarding to eating pattern, only 3.7% of participants have a very good eating pattern and more than half (50.6%) of them have a good eating pattern. While according to meal preparation, only 10.6% of participants have been evaluated to have very poor meals preparation, and about half of them (49.4%) have poor meal preparation regarding their dietary routine.
Discussion of hypothesis
In this study results (Table 9) showed that there was a significant relationship between complications of DM and age as p-value is (0.000) which is (< 0.05), hypothesis was accepted. About half of participants (45.2%) from those who reported that they have diabetic complications were in the age group ≥ 60 years old and it’s the higher percentage. This results were in agreement with (Tang et.al, 2008) study which showed that a significantly higher proportion of their participants study were in the age group ≥ 60 years, and in coherent with another study undertaken by (Iraj et.al, 2010) which showed that there was a significant relationship between age and retinopathy as p-value (0.01).
Study results (Table 10) revealed that there was a significant relationship between HbA1C results and family support as p-value is (0.000) which was (< 0.05), this result in an agreement with a systematic review study undertaken by (stopford et.al, 2013), which revealed that family support associated with reduce HbA1c.
The results (Table 11) revealed that 43.2% of participants from those who reported that they “usually” “change the dosage depending on the type of food” have poor family support, that there was a significant relationship between taking the prescribed medication regularly and family support as the P-value is (0.041). This results in consistent with (fahmy et. al, 2010) study which studied family support in type 1 diabetic children and it showed a significant relationship between family supports and taking insulin regularly without change (P value = 0.000). And according to (Bush & Pargament, 1997) families depend on routines, support their patients by emphasize that medications are taken regularly, so this study support the present study results. Another cross-sectional study conducted by (Sankar et al., 2013) agreed with current study, showed that patient who attended family support, are likely to promote adherence in this population than who didn`t.
The results (Table 12) presented that one third of the participants (30.4%) from those who reported that they “don’t take their prescribed medication when they remember after forgot” have poor family support and quarter (25.2%) of them have very poor family support. It also showed that there was a significant relationship between support and forgotten dosage (p-value is 0.003). This result may due to lack of family support in remembering their about taking prescribed medication on time, so it forms a barrier for take it.
In current study results (Table 13) showed that about one third of participants (35.6%) from those who reported that they have diabetic complications have poor family support and 22.3% of them have very poor family support (P value= 0.018). According to Cardenas et al., (1987) the relations between family performance, family coherence and diabetic control have been found, it was found poor glycemic control associated with poor family coherence and poor family performance. Also, according Diabetes Control and Complications Trial Research Group (1993), better metabolic and glycemic management delay the onset and slows the progression of macrovascular or microvascular complications.
Study results (Table 14) showed that there was a significant relationship between last HbA1C results and eating pattern as p-value is (0.000) , which indicates when dietary practise improves, so HbA1c level also improves, this results in consistent with (Shamsi et.al, 2011) study which revealed that there was a significant relationship between dietary practise and HbA1c level p-value (0.001). Another study in coherent with current conducted by (Al-shahrani, 2012) aimed to study in Saudi Arabia for type2 diabetics, after follow up for one year of following dietary pattern the results revealed that HbA1c parameters become better in a significant way (P < 0.0001).
Results in current study (Table 15&16) revealed that there was a significant relationship between eating pattern and taking the prescribed medication as (p-value = 0.000), and with change the dosage depending on the type of food as (p-value = 0.016) and these relations represented adherence to medication. Present study in consistent with a study conducted in Nablus by (Saleh et. al, 2013) revealed that there was a significant relationship between degree of dietary commitment and adherence to prescribed medication as (P-value= 0.002).
Results in present study (Table 17) showed that more than one third (36.2%) of participants from those who reported that their last HbA1C result ranging in (7.1-8) % which means moderately controlled have a good meal preparation, more than tow third (63.6%) of those who reported that their last HbA1C result more than 9% have which means uncontrolled have poor meal preparation. It also showed that there was a significant relationship between HbA1C results and meals preparation as p-value is (0.002). There were no studies about this relationship, but this maybe due to the individuals who prepare and organize their dietary meals in a controllable way by take into consideration the importance of diet in their disease management, had a good influence on HbA1c result.
Results in this study (Table 18) represented that more than two third (62.5%) of the participants from those who have primary educational level have poor meal preparation, while more than two third (64.5%) from those who have college educational level have a good eating pattern. It also represented there was a significant relationship between educational level and meal preparation (p-value = 0.000). There were no evidenced studies about meal preparation and educational level, however these result may reflect that individuals with high educational level have awareness and perceptions about their disease, in order to that they prepare their meals in a way that suites their condition.
Results of the present study (Table 19) showed that more than half (54.7%) and only 11.4% of the participants from those who are living in village have poor meal preparation and very poor meal preparation respectively. It also revealed that there was a significant relationship between place of residency and meal preparation as the p-value is (0.028). There were no studies found about this relationship, but it possibly due to cultural differences between people who lives in village and city in type of food that they eat and how to prepare food, so in culture of Palestinian individuals who lives in village trend to add fat and oil in their meals more than who lives in city, this may makes people who lives in village to prepare food that control their blood glucose.
Results of present study (Table 20) revealed that more than half of participants (54.8%) from those who reported that “they don’t take their prescribed medication when they forget it” have poor meal preparation. It also represented that there was a significant relationship between forgotten dosage and meal preparation (p-value is 0.003). There were no studies found about meal preparation and forgotten dosage to support this result, it reflect that individuals who didn’t take their prescribed medication when they remember it, had a problem in meal preparation, this may be due to being careless about follow dietary routine that help them in regulate their blood glucose.
Chapter 6: Conclusion, recommendation and limitations
➢ Conclusion
The factors affecting on dietary pattern were, firstly eating pattern (60.2%), then family support (57.8%) and meals preparation (57%). Among dietary pattern, the factors that affect participant’s diet were holydays and celebrations, travelling, weekends, stress, sickness, loneless and eat meals in hurry. Among family support factor the most problem was in when “When other family members choose unhealthy foods, they are more likely to eat them too”, among meal preparation they face difficulties in planning for meals and eating in a restaurant or out of home.
➢ Recommendation
- The Palestinian Ministry of Health
• Educational program for nurses and physician to maintain optimum dietary habits among diabetic patients.
• Teaching session for patients to maintain optimum dietary habits among diabetic patients.
• Coordination and collaboration of ministry of health to provide gluco meter device, which obviously help to maintain acceptable blood sugar level, and enhance the commitment in dietary habits.
- Families of diabetic patients
• Insuring the availability of families with diabetic patients during receiving the teaching sessions, which provided by the primary health care clinics.
• Encouragement of families to avoid the unhealthy dietary pattern to help them to be adherent to suitable dietary routine.
• Considering dietary therapy of diabetic patient while preparing their different meals.
• Helping the illiterate diabetic patients, in reading and pay attention about nutrition fact label before choosing the meals.
- Diabetic patients
• Improve dietary routine pattern through choose a healthy food that help to maintain level of blood sugar.
• Pay attention about the way of preparing meals and avoid unhealthy component as fats.
• Adherence to medication as described by the medical staff and do not change dose for any reasons.
• Scheduled measurement of blood sugar level, to maintain acceptable level, and to determine the food, which will be taken.
• Reading and pay attention about nutrition fact label before choosing the meals, to make optimal choice of food.
• Small frequent meals to be engorged by all patients
• Engorging increasing the portion size of fruit and vegetables by each meal.
- Further study:
• Availability of suitable food and desserts for diabetic patients at national markets.
➢ Limitations:
• The recent Political situations in West Bank which limited the movement and transportation to Hebron and Ramallah and this lead to being late in data collection.
• Administrative challenges; delaying in receiving the approval letters and permissions from MOH and IRB from ethical committee
• The questionnaire was fulfilled by interviewing the participants to increase quality of the study, and this consumed a lot of time
• Lack of research about dietary habits among diabetic patent that we need
• Time ; to collect actual data from the file as HbA1c instead based on patients recalling
• Fund; unavailability of fund which prohibited from doing the parametric test to get more reliable data and relationships.
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Annexes
Annex I
النمط الغذائي لدى مرضى السكري في الضفة الغربية
هذه الأستبانة سوف تسألك عن عادات الأكل ومرض السكري. أنماط الأكل تتغير من يوم لآخر’ أقرأ كل عبارة بعناية، ولكن لا تنفق الكثير من الوقت في التفكير في كل جملة. أجب عن الجملة بأختيار أول ردة فعل لك و أجب عن الجملة باكثر خيار ملائم لك.
المحور الأول: معلومات شخصية
1. الجنس : ____ أنثى ____ ذكر
2. العمر : ____ (18- 29) عام ____ (30- 39) عام ____ (40-49) عام
____ (50-59) عام ____أكثر من 60 عام
3. المدينة : ____ نابلس ____ رام الله ____ الخليل.
4. مكان العيش: ____ مدينة ____ قرية ____ مخيم.
5. الحالة الأجتماعية: ____ أعزب ____ منفصل ____ متزوج ____ أرمل ____ مطلق
6. المستوى التعليمي (ضع علامة صح على أخر درجة علمية نلتها )
____ إبتدائي ____ إعدادي ____ ثانوي ____ كلية ____ جامعي
7. كم معدل دخل العائلة بالشيقل الأسرائيلي شهرياً
____ أقل من 1450 شيقل ____ ( 1450-1999) شيقل ____(2000- 2499) شيقل
____ (2450-3000) شيقل ____ أكثر من 3000 شيقل
8. كم عدد أفراد العائلة التي تعيش بالمنزل بما فيهم أنت؟ ___________ (أحسب بشكل صحيح)
المحور الثاني : ( أ) التاريخ الطبي
9.هل تعاني من احد الامراض المزمنة التالية ؟
____ إرتفاع ضغط الدم ____ أمراض القلب ____الأزمة ____ الروماتيزم ____ لا أعاني
10. متى تم تشخيص هذا المرض , ان وجد ؟ ____ قبل الإصابة بمرض السكري
____ بعد الإصابة بمرض السكري.
____ لا يوجد
المحور الثاني : (ب) التاريخ الطبي لمرض السكري:
11.متى تم تشخيصك كمريض سكري؟
_ أقل من سنة _ _ (1-3) سنوات _ _ (4-6) سنوات _ _ (7-9) سنوات _ _ أكثر من 9 سنوات
12. كم عدد أفراد عائلتك الذين يعانون من مرض السكري , إن وجد ؟
____ لا أحد ____ 1 ____ 2 ____ 3 ____ 4 ____أكثر من 4
13. ما هو نوع سكري الدم التي تعاني منه؟
____ النوع الأول ____ النوع الثاني ____ لا أعلم
14. ما هواخر معدل سكر الدم التراكمي لديك ؟
___ (6.5 - 7)% ____ (7.1-8 )% ____ ( 8.1-9)% ____أكثر من 9 % ___ لا أتذكر
15. معدل عدد مرات قياس مستوى سكر الدم أسبوعياً
____ أقل من مرة في الأسبوع ____ مرة واحدة في الأسبوع ____ على الأقل مرة واحدة أسبوعيا ____ 2-3 مرات أسبوعياً ____ أكثر من 4 مرات أسبوعياً
61. أذا كنت تقيس معدل السكر في الدم, ما هي أخر قراءة سكر لك؟ _____
17. كيف ترى قدرتك على التحكم بمرض السكر مع عادات الأكل لديك ؟
____ ممتاز ____ جيد جدا ____ جيد ____ متوسط ____ سيئة.
81. كيف تعتبر نمط حياتك؟ ____ منظم جداً ____ منظمة لحداً ما ____ غير منظمة
91. كيف تصنف عائلتك ؟ ____ منظم جداً ____ منظمة لحداً ما ____ غير منظمة
المحور الثالث : الالتزام بالعلاج
20. ما هو العلاج الذي تتبعه كمريض سكري؟
____ أنسولين ____ حبوب خفض السكر ____ أتبع حمية غذائية فقط ___ لا أتبع علاج مطلقاُ
12. عدد الجرعات في اليوم الواحد ؟ ___ 1 ___ 2 ___ 3 ___ اكثر من 3 .
22. أقوم بأخذ دوائي بإنتظام حسب الوصفة ؟ ____ مطلقاً ____ نادراً ____ أحياناً ____ عادةً ____دائماً
23. أقوم بتغيير جرعة الدواء تبعاً لنوعية الأكل الذي أقوم بأكله
____ مطلقاً ____ نادراً ____ أحياناً ____ عادةً _____دائماً
42. في حال نسيت الجرعة الدوائية
___ أقوم بأخذ الدواء عندما أتذكر ____ لا أقوم بأخذ الدواء
المحور الرابع : الروتين الغذائي لمريض السكري.
25. ضع/ي إشارة ( بجانب الوجبة التي تأكلها بشكل مستمر في معظم الأوقات :
____ فطور / وجبة الصباح ____ غداء / وجبة الظهيرة ____ عشاء / وجبة الليل
____ وجبة خفيفة صباحية ____ وجبة خفيفة وقت الظهر ____ وجبة خفيفة وقت الليل
26. ضع/ي دائرة حول عدد أيام الأسبوع التي تتناول فيه الوجبات التالية(مع الأخذ بعين الأعتبار الوجبات خارج المنزل)
وجبة الصباح: أقل من مرة 1 2 3 4 5 6 7
وجبة الظهيرة: أقل من مرة 1 2 3 4 5 6 7
وجبة الليل: أقل من مرة 1 2 3 4 5 6 7
دائماً |عادةً |أحياناً |نادراً |مطلقاً |السؤال |الرقم | | | | | | |على الأقل لدي فرد من افراد عائلتي يقدم لي الدعم في محاولة السيطرة على مرض السكري |27 | | | | | | |أقوم بتناول طعام صحي |28 | | | | | | |عندما أشعر بالتوتر, يصعب علي أختيار طعام صحي |29 | | | | | | |أقوم باختار طعام لأكله بناءاً على ما يؤثر على معدل السكر في جسمي |30 | | | | | | |على الأقل لدي أحد أفراد العائلة يساعدني على أختيار طعام صحي لتناوله |31 | | | | | | |أفكر بشكل مبكر حول أختيار طعام صحي |32 | | | | | | |في الأعياد/المناسبات عندما يكون هناك طعام خاص أو مختلف متاح,فأنني أكل أكثر من المعتاد |33 | | | | | | |أقوم باختيار طعام صحي عندما أطلب طعام من خارج المنزل لأتناوله بالبيت |34 | | | | | | |أقوم بتناول 3 وجبات فأكثر باليوم |35 | | | | | | |الوجبة التي أتناولها, أعدت بطريقة لتساعد على التحكم بمرض السكري |36 | | | | | | |عند إصابة بمرض اخر يصعب علي أن أتناول طعام يساعد على التحكم بالسكري |37 | | | | | | |جميع أفراد العائلة يتناولون طعام الغداء بالمنزل مجتمعين |38 | | | | | | |أهتم بقرائة نشر المعلومات الغذائية التي تؤثر على مستوى السكر بالدم |39 | | | | | | |يقوم أفراد عائلتي بتقديم الدعم لي في اختاياراتي للطعام المناسب لي |40 | | | | | | |يختلف جدول الغذاء الذي أتناوله في العطلة الأسبوعية عن باقي ايام الأسبوع |41 | | | | | | |عندما يقوم أحد أفراد عائلتي باختيار طعام غير صحي فانني أميل أكثر لتناول ذلك الطعام معه |42 | | | | | | |يتم التخطيط المسبق للوجبات التي سأتناولها |43 | | | | | | |الطعام الصحي متوفر لدي في المنزل للتحكم بمرض السكري |44 | | | | | | |أقوم بتناول الطعام المعد في المنزل |45 | | | | | | |على الأقل هناك واحد من أفراد عائلتي يساعدني على إختيار طعام مناسب لي كمريض سكري |46 | | | | | | |أعتبر أيام الأجازات و الأعياد كيوم متاح لتناول أي طعام أريده |47 | | | | | | |أقوم بتناول طعامي بشكل سريع |48 | | | | | | |العادات الغذائية لأفراد عائلتي جيدة ولها تأثير على أختياراتي لطعام المناسب لي كمريض سكري |49 | | | | | | |عندما اقوم بتناول طعامي في مطعم أختاره من قائمة الطعام التي تساعدني على التحكم بمعدل السكر في الدم |50 | | | | | | |أتناول طعام بشكل أكبر عندما أكون وحيداٌ |51 | | | | | | |أقوم بتناول 5 حبات أو أكثر من الفواكه و الخضروات يومياً |52 | | | | | | |خلال أيام الأجازات/الأعياد, يصعب عليي أن أتناول الطعام الجيد الذي يساعدني في التحكم بمعدل سكر الدم |53 | | | | | | |على الأقل هناك فرد من أفراد عائلتي يساعدني على قراءة نشرة المعلومات الغذاية لأيجاد كيفية تحكم الطعام بمعدل السكر بالدم |54 | | | | | | |عندما أتناول الطعام وحيداً, أميل لأختيار طعام غير صحي |55 | | | | | | |عندما أسافر, يصعب علي إيجاد الطعام الجيد الذي يساعد في التحكم بمعدل السكرفي الدم |56 | | | | | | |أتبع روتين معين للعناية بنفسي كمريض سكري. |57 | |
المحور الخامس: المضاعفات الناتجة عن مرض السكري.
58.هل تعاني من مضاعفات ناتجة عن مرض السكري؟ ____ نعم ____ لا
59. ما هي المضاعفات التي تعاني منها الآن ؟
____ إعتلال الشبكية ____ إعتلال شرايين القلب ____ إعتلال الكلى
____ قدم السكري ____ نوبة قلبية ____ إعتلال الأعصاب ____ لا يوجد
60. منذ متى و أنت تعاني من المضاعفات ؟
____ أقل من سنة ____ (1-2 ) سنة ____ (3-4) سنة
____ (4-5) سنوات ____ أكثر من 6 سنوات ____ لا يوجد
Annex II
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Annex III
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Annex IV
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Annex V
بسم الله الرحمن الرحيم
موافقة للإشتراك في البحث العلمي
جامعة النجاح الوطنية –كلية الطب وعلوم الصحة \قسم التمريض
أخي المواطن / أختي المواطنة
السلام عليكم ورحمة الله وبركاته
تحية طيبة وبعد ، ،
أنت مدعو(ة) للمشاركة ببحث علمي سيجرى في الضفة الغربية في فلسطين. الرجاء أن تأخذ(ي) الوقت الكافي لقراءة المعلومات التالية بتأن قبل أن تقرر(ي) إذا كنت تريد(ين) المشاركة أم لا. بإمكانك طلب إيضاحات أو معلومات إضافية عن أي شيء مذكور في هذه الإستمارة أو عن هذه الدراسة ككل من الباحث,ستبقى اجاباتك في غاية السرية والكتمان في حال وافقت على المشاركة في هذا البحث .
يقوم البحث بالأساس على تقييم الوضع الغذائي لمرضى السكري المتواجدين في عيادات الصحة الأولية , و ذلك عن طريق استبيان لتحقيق الأهداف التالية: أولاً . تحديد اذا ما كان هنالك علاقة ما بين مرض السكري و الحالة الغذائية , ثانيأ: المضاعفات الناتجه عن عدم اتباع حمية غذائية ,ثالثا تاثير الحمية الغذائية على قراءات السكر في الدم. لا يوجد أي تأثيرات سلبية من هذا البحث , حيث أنه لا يعتمد على تقديم نوع جديد من العلاج أو أنه من نوعية الأبحاث المعتمدة على التجربة .
موافقة المشترك:
لقد قرأت استمارة القبول هذه وفهمت مضمونها. وبناء عليه فأنني، حراً مختارا، أجيز إجراء هذا البحث و أوافق على الإشتراك فيه، كما أعرف تمام المعرفة بانني حر في الإنسحاب من هذا البحث متى شئت حتى بعد التوقيع على الموافقة دون ان يؤثر ذلك على العناية الطبية المقدمة لي.
التوقيع _________ ____ التاريخ_________ ____
إسم الباحث: 1) لؤي السيد 2) بتول حشاش 3) مهدي دويكات 4) ثبات ياسين
مشرف البحث : د. مريم الطل ( جامعة النجاح الوطنية\قسم التمريض ).
عنوان البحث: النمط الغذائي لدى مرضى السكري في الضفة الغربية
مكان إجراء البحث : نابلس, رام الله,و الخليل.
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