PROFORMA FOR REGISTRATION OF SUBJECTS FORDISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / DUNDAPPA. MANEPPAGOL
INDIAN COLLEGE OF NURSING
TILAK NAGAR,BY PASS ROAD,CONTONMENT BELLARY
2 / NAME OF THE INSTITUTION / INDIAN COLLEGE OF NURSING
TILAK NAGAR,BY PASS ROAD,CONTONMENT BELLARY
3 / COURSE OF THE STUDY AND SUBJECT / M.Sc(NURSING)1ST YEAR
MEDICAL SURGICAL
4 / DATE OF ADMISSION / 16/06/2010
5 / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON DIABETIC DIET AND YOGA AMONG THE DIABETIC CLIENTS IN SELECTED HOSPITALS IN BELLARY.

6. BRIEF RESUME OF THE INTENDED WORK

6.1. INTRODUCTION

Diabetes mellitus is a common chronic disease and is a public health problem that
affects all levels of society, regardless of age, gender, ethnicity or race. Diabetes
mellitus is characterized as a chronic metabolic syndrome of glucose intolerance
generally involving absolute or relative insulin deficiency, insulin resistance, or both. The
hallmark of diabetes mellitus is hyperglycemia. The deranged metabolism of
carbohydrates, fats, and proteins may eventually lead to development of chronic
microvascular and macrovascular complications, including organ-specific degenerative
processes.

The report of WHO first expert committee on diabetes stated that "there was general agreement about the signs of increasing prevalence of diabetes mellitus in most parts of the world" and "there are now indications of a rapid increase in the disease".

Nevertheless, the prevalence estimates from the studies cited in the 1965 report are very low when contrasted with more up to date values. The estimates in 2002 indicate that there are at least 194 million people with diabetes in the world, and more than two-thirds of them live in developing countries1.

Diabetes mellitus is a common disease in the United States. It is estimated that over 16 million Americans are already caught with diabetes, and 5.4 million diabetics are not aware of the existing disease. Diabetes prevalence has increased steadily in the last half of this century and will continue rising among U.S. population. It is believed to be one of the main criterions for deaths in United States, every year2.

Diabetes is a metabolic disorder where in human body does not produce or properly uses insulin, a hormone that is required to convert sugar, starches, and other food into energy. Diabetes mellitus is characterized by constant high levels of blood

glucose (sugar). Human body has to maintain the blood glucose level at a very narrow range, which is done with insulin and glucagon. The function of glucagon is causing the liver to release glucose from its cells into the blood, for the production of energy.

The International Diabetes Federation recentlypublished findings revealing that in 2007, the country with the largest numbers of people with diabetes is India (40.9 million), followed by China (39.8 million), the United States (19.2 million),Russia (9.6 million) andGermany (7.4 million)3.

Some other alarming diabetes statistics include the fact that there is one person in the world dying of diabetes every ten seconds. Also, there will be two new diabetic cases in the world being identified every ten seconds. And, what’s worse, these very same diabetes statistics tell us that by the year 2025, there will be as many as seven million new diabetic cases in the world.

The two types of diabetes mellitus are Type 1 (formerly known as insulin-dependent diabetes) and Type 2 (formerly known as non-insulin-dependent diabetes). In people with Type 1 diabetes, the pancreas is no longer able to produce insulin because the insulin-producing cells (β-cells) have been destroyed by the body's immune system.

Without insulin to move glucose from the bloodstream to the body's cells, glucose builds up in the blood and is passed out of the body in the urine. In people with Type 2 diabetes, the β- cells are not able to produce enough insulin to meet the body's needs. The majority of people with Type 2 diabetes also have some degree of insulin resistance, due to which the cells in the body are not able to respond to the insulin that is produced. The
complications associated with diabetes include macrovascular complications such as
angina, myocardial infarction, cardiac failure, peripheral vascular disease, cerebral
vascular disease and microvascular complications such as diabetic retinopathy,
neuropathy and nephropathy1.

Therapeutic diet plays an important role in the treatment of diabetes.Nothing helps a Diabetic more than a Diet, custom-made by Dietician. The general principle is to control body fat means less sensitivity to Insulin, which keeps the blood sugar level in check.

A Proper diabetic diet includes a balance of high proteins, low fat and complex carbohydrates, (Whole grain cereals, whole wheat flour, vegetables) which are digested more slowly and therefore don't cause a rapid rise in blood sugar.

The diabetic diet may be used alone or else in combination with insulin doses or with oral hypoglycemic drugs. Main objective of diabetic diet is to maintain ideal body weight, by providing adequate nutrition along with normal blood sugar levels in blood.

The dietary plan is a diet program which balances the amount of carbohydrate that the person takes per day. This plan helps to decide on the type of food to be taken, the amount of food and also the time to eat. So it will help to plan for more flexible meals as to get more knowledge about the diet for a diabetic, may be like the counting carbohydrate meal plan or constant carbohydrate. But there is no common diet that works for everyone. Nor is there any particular diet that works perfectly for any diabetic over a long period. The diabetes diet should adhere to certain important factors, they are as follows:

  • Fiber should be at least 1.4 oz / day
  • Instead of 3 heavy meals, we should go for 4-5 small mid intervals
  • Replace bakery products and fast foods by simple whole cooked cereals, and don't eat carbohydrates 2 hours before bedtime
  • Consume fresh fruit and vegetables at least 5 exchange/ day4

NEED FOR THE STUDY:

Diabetics always need to take care of their diet and also about the food they eat. Care has to be taken because all foods contain not only carbohydrate, but also some energy value. Protein and fat available in the food are converted to glucose in the body. This glucose has some effect on the blood sugar level, which has to be taken care of. Furthermore, you needn’t have to eat only the bland boring diet. Instead, you can eat more fruits, vegetables and whole grains. All it means is that you need to select foods that are high in nutrition and low in calories5.

The therapeutic use of exercise for diabetes mellitus was prescribed as early as 600 BC by the Indian physician Sushruta, Today exercise is recognized as one of the established principles of diabetes treatment. Every individual know exercise is important for everyone’s health, and it can be especially important if you have diabetes.

Exercise can lower the blood sugar and improve the body’s ability to use glucose. With regular exercise, the amount of insulin needed decreases. Exercise can also help reverse the resistance to insulin that occurs as a result of being overweight. Exercise improves risk factors for heart disease and decreases the risk of heart problems. Exercise promotes the good cholesterol, high-density lipoprotein cholesterol (HDL), which is protective against heart disease. Blood pressure is also lowered through exercise. Exercise, when combined with a meal plan, has the ability to control Type II diabetes without the need for other medications6.

An exploratory study was conducted on knowledge of diabetes mellitus, diets and nutrition in diabetic patients. In this study a multiple choice questionnaire was used to test the level of knowledge abut diabetes mellitus and diet-nutrition in diabetic patients (n = 317), non-diabetic patients (n = 70), nursing personnel (n = 53) and third-year medical students (n = 43). The results concerning diabetes were better than those for diet-nutrition. It was concluded that the piecemeal instruction system used to teach the diabetic patients is inefficient and should be replaced by a formal educational program integrated into the patient care system. The level of knowledge among nursing personnel needs to be improved7.

This study was conducted to evaluate the effect of individualized diabetes nutrition education. The nutrition education program was open to all type 2 diabetes patients visiting the clinic center and finally 67 patients agreed to join the program. To compare with 67 education group subjects, 34 subjects were selected by medical record review. The education program consisted of one class session for 1-2 hours long in a small group of 4~5 patients for 3 months. In education group, intakes of protein, calcium, phosphorus, vitamin B(2), and folate per 1,000 kcal/day were significantly increased and cholesterol intake was significantly decreased. They also showed significant reductions in body weight, body mass index (BMI), and fasting blood concentrations of glucose (FBS), HbA1c, total cholesterol, and triglyceride. The study concludes that, our individualized nutrition education was effective in adherence to diet recommendation and in improving glycemic control and lipid concentrations, while follow-up by telephone helped to encourage the adherence to diet prescription8.

A study was conducted to evaluate the concepts and attitudes of patients and their immediate family members towards diabetes, its complications, and treatment. The results showed that there was lack of awareness about diabetes and its complications among the patients of diabetes. There were major misconceptions about diet, exercise, and insulin therapy. More than 90% of study subjects had a misconception that all sweet fruits are prohibited and all bitter vegetables are beneficial. Temporary discontinuation of drug therapy was found in 189 cases. The lack of awareness and various misconceptions had no statistical relationship with the educational background of the patients. The study concludes that among patients of poorly controlled diabetes and their close family members, there was a gross lack of knowledge of complications of diabetes, causes of obesity, treatment of diabetes, and use of insulin. Denial of obesity was commonly observed9.

A study was conducted to assess the improved knowledge of diabetic patients through education of primary care staff. A sample of 142 diabetic patients was interviewed twice, in 1984 and 1986, following an educational program administered to primary care staff. Positive changes were recorded regarding several aspects. (a) Process of care - the percentage of untreated patients decreased from 15% to 4%; the proportion of patients on diet only increased from 36% to 41%, while the insulin-treated proportion decreased from 12% to 8%; the percentage of patients treated with oral drugs went up from 36% to 46%. (b) Patient knowledge - an improvement in various aspects, such as diet and exercise. (c) Patient behavior - an improvement in adherence to diet and in compliance with medications was observed10.

A descriptive study was conducted to investigate the level of diabetes knowledge in a population with type 2 diabetes (T2D) and a high prevalence of illiteracy, to identify the main gaps in the knowledge and to study the determinants of the knowledge score. The results of the study showed that the mean score for the total knowledge test was 58.9%. Knowledge deficits were apparent in the questions related to diet and self-care. The study concludes that Knowledge of diabetes in a T2D population with a high prevalence of illiteracy was poor. Limited family income and lack of self-care are other predictors of knowledge deficits. Efforts need to be focused on educational programmes with strategies to assist T2D patients of limited education and income to manage their disease more effectively11.

A descriptive study was conducted to examine the effect of yoga practice on clinical and psychological outcomes in subjects with type 2 diabetes mellitus (T2DM). A 40-day yoga camp at the Institute of Yoga and Consciousness, ambulatory subjects with T2DM not having significant complications (n = 35) participated in a 40-day yoga camp, where yogic practices were overseen by trained yoga teachers. Clinical, biochemical, and psychological well-being were studied at baseline and at the end of the camp. The results showed that At the end of the study, there was a reduction of body mass index (BMI) (26.514 +/- 3.355 to 25.771 +/- 3.40; P < 0.001) and anxiety (6.20 +/- 3.72 to 4.29 +/- 4.46; P < 0.05) and an improvement in total general well-being (48.6 +/- 11.13 to 52.66 +/- 52.66 +/- 12.87; P < 0.05). The study concludes that participation of subjects with T2DM in yoga practice for 40 days resulted in reduced BMI, improved well-being, and reduced anxiety12.

Several older books make a mention of the usefulness of yoga in the treatment of certain diseases and preservation of health in normal individuals. The effect of yogic practices on the management of diabetes has not been investigated well.

By considering the above statistical facts and the various abstracts it is clearly understands that there is a strong need for the importing the knowledge regarding diabetic diet and yoga for diabetics for controlling the diabetes, prevention of diabetic complications and maintaining health. Hence the researcher felt that there is a need to assess the knowledge regarding diabetic diet and yoga among diabetics in selected hospitals Bellary.

REVIEW OF LITERATURE

A study was conducted to assess the Patients' and family members' knowledge and views regarding diabetes mellitus and its treatment. A convenient sample of 32 diabetics and 32 family members who attended two health care facilities in the Mopani district, Limpopo Province, was drawn. Two similar questionnaires, one for each group respectivevly, were completed by the subjects. The data was analysed by a computer programme, the Statistical Package for Social Sciences. Findings revealed that the diabetics and family members lack adequate knowlege on diabetes and its treatment. Recommendations regarding the required health education and assistance to be given to these patients and their family members were made13.

A study was conducted to assess the needs, awareness and barriers to diabetes education for self management and to facilitate the initiation of an education programme promoting self care among diabetics and their families. The results showed that the participants displayed great deal of variation with respect to level of knowledge and motivation for education. Most believed that diabetes was caused by stress. Family was perceived to be a source of positive support. Relative ease of adherence to pharmacological regimens as compared to diet and exercise was reported. Participants expressed frustration at chronicity of disease and fear of developing certain specific complications and inheritance by their children. Barriers to enhancing knowledge included 'No need for further information', distance from training institutions and other priorities.the study conclude that knowledge, beliefs and fears about diabetes, family influence and accessibility of healthcare, affects management behaviours and learning. Understanding needs and expectations of people with diabetes is essential in initiating and improving the outcomes of education programme for diabetes self care14.

A quasi experimental study was conducted on Structured educational programs for geriatric patients with diabetes mellitus. In this study Two-thirds of all diabetics are older than 60 years. Owing to the presence of multimorbidity and functional impairments, one-half of these diabetics must be considered "geriatric patients". This category of patients in particular requires a special educational program aimed at improving their situation and quality of life on the basis of good diabetic control. Currently, two educational concepts aimed in particular at elderly patients with type II diabetics and cognitive deficits are available and are described in the present paper. Education for diabetics with impairment of cognitive performance is available to such diabetics irrespective of age. The educational program: "Structured Education for Persons with Type II Diabetes in Old Age", newly developed by the Working Group Diabetes and Geriatrics of the German Diabetes Society teaches self-help skills, offers opportunities for empowerment, and has proved successful also in geriatric patients with mild cognitive deficits15.

An cross sectional study was conducted on Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh. In this study 60 diabetics aged 20 years and above were identified. Their knowledge and practices regarding diet, genital hygiene, care of foot, wound, complications of diabetes and medication was assessed using a semistructured interview schedule. Most of them (60%) opined that diabetic should consume whatever is cooked in the family. Forty eight diabetics knew that sweets and fatty foods should be avoided but only 18.3% were avoiding them. Genital hygiene was maintained by 51.7% and foot care was done by 63.3% through regular washing. Monitoring of blood sugar was poor (46.7%), only 3 knew and were continuing self testing of urine. Oral anti-diabetic drug compliance rate was 62.9%. None of the patients on insulin injections knew about self therapy. Knowledge regarding diabetic complications was partial. There is a need to reorient and motivate health personnels in educating diabetics about self-care16.