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Chapter one
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1.1 Introduction:
Diabetes is a manageable condition, its prevalence worldwide has
increased dramatically in the previous four decades, For example, 17
million people in the United Statesalone are currently affected by diabetes
[1].
In 2011, the total number of new reported cases of Diabetes
mellitus in West Bank was (3,984) with incidence rate (154.4) per
100,000 of population. In Nablus governorate (570) new reported cases,
13.217 revisers of them in Nablus alone and the percentage of male
revisers to diabetes clinics (40.9%), while the percentage of female‘s
revisers to diabetes clinics (59.1%) [2].
The principal goal of diabetes management is to prevent the micro
vascular and macro vascular complications of the disorder, which are
associated with elevated blood glucose levels. It is now commonly
accepted that the exerciseand diet regimen is the major reason for the
diabetes and its complications.
Maintaining blood glucose levels within the normal range is the
most importance in the management of diabetes. Diet and exercisefactors
that can have a great impact upon stabilizing blood glucose levels in
diabetic patients and the commitment of it is the most important thing that
we investigate it in our culture.
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Regimen adherence problems are common in individuals with
diabetes, making glycemic control difficult to attain. Because the risk of
complications of diabetes can be reduced by proper adherence, patient
non-adherence to treatment recommendations is often frustrating for
diabetes health care professionals. This study reviews the scope of the
adherence degree and the factors affecting it.
Actually, there are no enough studies that support this version that
talking about the commitment of diabetic patient in therapeutic diet.
In fact, there are no studies have been found that investigate
commitment of diabetic patient in therapeutic diet and exercise in
Palestine,and because of the lack of knowledge about the commitment
and adherence of diabetic patient in therapeutic diet, this study conducted
to investigate the commitment of the diabetic patient in therapeutic diet
and try to figure-out the factors that have effect on the commitment level.
Hence this study was designed to assess the commitment degree of
Palestinian diabetic patient in therapeutic diet practice in Nablus and to
figure-out the factors that may affect the degree of commitment. The
major research question was ―How much the degree of commitment in
therapeutic diet practice among the participants?‖
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1.2 Significance of the study:
Diet and exercise are important lifestyle factors in the etiology of
diabetes. Improved dietary habits and increased exercise have great effect
on preventing the development of diabetic complication in the patients.
Uncontrolled blood sugar causes damage to small blood vessels in the
body, leading to cardiovascular disease, kidney disease, eye problems and
loss of sensation in the feet that can lead to amputations.
So it‘s important to all diabetic patients to commit and adhering in the
therapeutic regimen and recommended diet to minimize risks that
develops complication. However few studies were conducted about the
commitment of diabetic patients and what factor have effect on it.
Because of that it is important to study the dietary practice and adherence
and to figure-out the factor that has effect on it.
1.3Aim of the study
This study aim to assess the commitment degree of Palestinian
diabetic patient regarde to therapeutic diet practice in Nablus and to
figure-out the factors that may affect the degree of commitment.
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Chapter Two
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2.1 Research question
1-How is the degree of commitment in therapeutic diet practice among
the participants?
2-Is there significant relationship between the demographic data (age,
gender, marital status, place of residence, Income, that, academic
qualification, number of family members)andthe degree of
commitment?
3-Is there significant relationship between (Access to and use of
medication, regular checkup in the clinics, level of knowledge about
diabetes, and adherence to exercise) and the degree of commitment?
2.2 Background
Normal pancreas and their function
The pancreas is located behind the stomach and is surrounded by
other organs including the small intestine, liver, and spleen. It is about six
inches long and is shaped like a flat pear. The wide part, called the head
of the pancreas, is positioned toward the center of the abdomen; the
middle section is called the neck and the body of the pancreas; the thin
end is called the tail and extends to the left side.
The pancreas has two main functions: an exocrine function that helps in
digestion and an endocrine function that regulates blood sugar.
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1- Exocrine Function: The pancreas contains exocrine glands that
produce enzymes important to digestion. When food enters the stomach,
these pancreatic juices are released into a system of ducts that culminate
in the main pancreatic duct. The pancreatic duct joins the common bile
duct to form the ampulla of Vater which is located at the first portion of
the small intestine, called the duodenum. The common bile duct
originates in the liver and the gallbladder and produces another important
digestive juice called bile. The pancreatic juices and bile that are released
into the duodenum, help the body to digest fats, carbohydrates, and
proteins.
2-Endocrine Function: The endocrine component of the pancreas
consists of islet cells that create and release important hormones directly
into the bloodstream. Two of the main pancreatic hormones are insulin,
which acts to lower blood sugar, and glucagon, which acts to raise
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blood sugar. Maintaining proper blood sugar levels is crucial to the
functioning of key organs including the brain, liver, and kidneys [3].
Diabetes mellitus
Is a group of metabolic diseases characterized by elevated levels of
glucose in the blood (hyperglycemia) resulting from defects in insulin
secretion, insulin action, or both. Normally a certain amount of glucose
circulates in the blood. The major sources of this glucose are absorption
of ingested food in the gastrointestinal (GI) tract and formation of glucose
by the liver from food substances.
Insulin, a hormone produced by the pancreas, controls the level of
glucose in the blood by regulating the production and storage of glucose.
In the diabetic state, the cells may stop responding to insulin or the
pancreas may stop producing insulin entirely. This leads to
hyperglycemia, which may result in acute metabolic complications such
as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar
nonketotic syndrome (HHNS) [3].
Type of Diabetes Mellitus
There are three main types of diabetes mellitus (DM):
* Type 1 DM: is characterized by loss of the insulin-producing beta cells
of the islets of Langerhans in the pancreas, leading to insulin deficiency.
This type can be further classified as immune-mediated or idiopathic. The
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majority of type 1 diabetes is of the immune-mediated nature, in which
beta cell loss is a T-cell-mediated autoimmune attack.
There is no known preventive measure against type 1 diabetes, most
affected people are otherwise healthy and of a healthy weight when onset
occurs. Type 1 diabetes can affect children or adults, but was traditionally
termed "juvenile diabetes" because a majority of these diabetes cases
were in children [4].
Type 2 DM: is characterized by insulin resistance, which may be
combined with relatively reduced insulin secretion.
The defective responsiveness of body tissues to insulin is believed to
involve the insulin receptor. However, the specific defects are not known,
this form was previously referred to as non-insulin dependent diabetes
mellitus (NIDDM) or "adult-onset diabetes". Type 2 diabetes is the most
common type [5].
* Gestational diabetes: resembles type 2 diabetes in several respects,
involving a combination of relatively inadequate insulin secretion and
responsiveness. It occurs in about 2%–5% of all pregnancies and may
improve or disappear after delivery, gestational diabetes is fully treatable,
but requires careful medical supervision throughout the pregnancy. About
20%–50% of affected women develop type 2 diabetes later in life.
Though it may be transient, untreated gestational diabetes can damage the
health of the fetus or mother. Risks to the baby include macrosomia (high
birth weight), congenital cardiac and central nervous system anomalies,
and skeletal muscle malformations. In severe cases, perinatal death may
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occur, most commonly as a result of poor placental perfusion due to
vascular impairment [6].
Diabetes mellitus Signs and symptoms
The classic symptoms of untreated diabetes are loss of weight,
polyuria (frequent urination), polydipsia (increased thirst) and polyphagia
(increased hunger). Symptoms may develop rapidly (weeks or months) in
type 1 diabetes, while they usually develop much more slowly and may
be subtle or absent in type 2 diabetes [7].
Prolonged high blood glucose can cause glucose absorption in the lens of
the eye, which leads to changes in its shape, resulting in vision changes.
Blurred vision is a common complaint leading to a diabetes diagnosis;
type 1 should always be suspected in cases of rapid vision change,
whereas with type 2 change is generally more gradual, but should still be
suspected.
Causes of Diabetes mellitus and Risk factors
Type 1 diabetes is partly inherited, and then triggered by certain
infections, with some evidence pointing at Coxsackie B4 virus. A genetic
element in individual susceptibility to some of these. The onset of type 1
diabetes is unrelated to lifestyle.
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Type 2 diabetes is due primarily to lifestyle factors and genetics, such as
weight, family history,race,age and Inactivity [8].
Pathophysiology of Diabetes mellitus
Insulin is the principal hormone that regulates uptake of glucose
from the blood into most cells. Therefore, deficiency of insulin or the
insensitivity of its receptors plays a central role in all forms of diabetes
mellitus.
Insulin is released into the blood by beta cells (β-cells), found in
the islets of Langerhans in the pancreas, in response to rising levels of
blood glucose, typically after eating. Insulin is used by about two-thirds
of the body's cells to absorb glucose from the blood.
If the amount of insulin available is insufficient, if cells respond poorly to
the effects of insulin (insulin insensitivity or resistance), or if the insulin
itself is defective, then glucose will not have its usual effect, so it will not
be absorbed properly by those body cells that require it, nor will it be
stored appropriately in the liver and muscles. The net effect is persistent
high levels of blood glucose, and other metabolic derangements, such as
acidosis.
When the glucose concentration in the blood is raised to about 9-10
mmol/L, reabsorption of glucose in the proximal renal tubuli is
incomplete, and part of the glucose remains in the urine (glycosuria). This
increases the osmotic pressure of the urine and inhibits reabsorption of
water by the kidney, resulting in increased urine production (polyuria)
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and increased fluid loss. Lost blood volume will be replaced osmotically
from water held in body cells and other body compartments, causing
dehydration and increased thirst.
Hb A1C
The (HbA1c) test (also called glycosylated hemoglobin level) is a
laboratory blood test which measures your average blood glucose over
the previous weeks and gives an indication of your longer-term blood
glucose control. The test is used as a regular monitoring tool if you have
been diagnosed with diabetes. It may also be used as one of several
screening measures in the general population to look for elevated blood
glucose levels, which are suggestive of diabetes.
Change to reporting values from October 2011. HbA1c levels have
previously been measured as a percentage (%). However, from October
2011, New Zealand laboratories will be reporting HbA1c values in IFCC
(International Federation of Clinical Chemistry and Laboratory Medicine)
format, which is in mmol/mol.
Healthy HbA1c levels:
Target HbA1c levels will vary from person to person. Work out a safe
target HbA1c for you with your doctor. A general range for HbA1c levels
[equivalent IFCC values in square brackets] is:
Less than or equal to 7% [up to 53mmol/mol] is a very healthy HbA1c
level. Between 7% and 8% [54 - 64mmol/mol] is a fair HbA1c level and
needs work to improve. Between 8% and 10% [65 -
86mmol/mol] indicates your blood glucose levels are much too high.
Above 10% [87mmol/mol or higher] indicates your blood glucose levels
are extremely high [9].
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Management of Diabetes mellitus
Diabetes mellitus is a chronic disease which cannot be cured except
in very specific situations. Management concentrates on keeping blood
sugar levels as close to normal as possible, without causing
hypoglycemia. This can usually be accomplished with diet, exercise, and
use of appropriate medications (insulin in the case of type 1 diabetes, oral
medications, as well as possibly insulin, in type 2 diabetes).
Patient education, understanding, and participation is vital, since the
complications of diabetes are far less common and less severe in people
who have well-managed blood sugar levels. Attention is also paid to other
health problems that may accelerate the deleterious effects of diabetes.
These include smoking, elevated cholesterol levels, obesity, high blood
pressure, and lack of regular exercise [3].
Compliance versus non compliance
Compliance has been defined as―the extent to which a person‘s behavior
coincides with medical advice.‖1 Noncompliance then essentially means
that patients disobey the advice of theirhealth care providers [10].
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2.3 Literature Review
This chapter present several international and regional studies
regarding to adherence in management of diabetic patient, recommended
diet for diabetic patients, therapeutic diet adherence, and factors affect the
level of commitment.
Actually there is few study conducting regarding to the therapeutic
diet commitment and the factors that may affect the level of commitment
in the world.
An integral component of managing diabetes is medical nutrition
therapy (MNT).The goals of MNT are to maintain blood glucose levels
and blood pressure in the normal range, to maintain a lipid profile that
decreases the risk of cardiovascular complications, to prevent or slow the
development of the diabetic complications, to address an individual‘s
cultural and personal dietary preferences, and to maintain the pleasure of
eating[11].
Multiple clinical trials and outcome studies have demonstrated the
effectiveness of MNT in diabetics with decreases in Hemoglobin A1c
(HbA1c) of 1% to 2%, depending on the duration of diabetes. However,
the exact diet recommended remains controversial [12].
Diet constitutes the foundation of diabetes management. The
nutritional management of the patient with diabetes is geared towards
provision of all the essential food constituents, meeting energy needs,
maintenance of an ideal weight, and decrease of elevated blood lipid
levels and achievement of blood glucose levels close to normal. Type II
diabetes is treated by diet and exercise, and only when elevated glucose
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levels persist are supplements of oral agents as well as insulin injections
given [13].
Professional guidelines and recommendations for medical nutrition
therapy (MNT) in diabetes have been developed in the UK and Europe,
and in the USA and Canada.
While the guidelines for nutritional management differ slightly in
content details, but the underlying goals are similar. All recommendations
seek to:1-sustain or improve health and quality of life though healthy
food choices, 2-establish and maintain blood glucose as near to normal as
possible, thus averting the harmful consequences of hypo- or
hyperglycemia,3-address specific nutritional needs of individuals, while
also taking into account personal preferences, cultural considerations, and
lifestyle. The guidelines [below in bold]. advise an intake of 60–70% of
daily energy from carbohydrates and monounsaturated fats. This advice
allows greater flexibility to accommodate individual dietary preferences.
Sucrose (sugar) and sugar-containing foods are allowed, but should be
limited to less than 10% of energy intake, and only eaten in the context of
a healthy diet. ADA and EASD guideline suggest that saturated fats
constitute less than 10% of total energy intake [14], [15], [16].
The glycemic response to various foods has been quantified as a
‗‗glycemic index‘‘ (GI), a concept that aroused controversy among
diabetes experts. Foods classified as having a low glycemic index (LGI)
are non-starchy vegetables, fruits, legumes, milk, yogurt, and traditionally
processed grains such as wholegrain bread, pasta, and oats [17].
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Refined, starchy foods, such as white bread, processed cereals, potato,
watermelon, and most crackers, on the other hand, are classified as
having a high glycemic index (HGI)[18].
High glycemic index HGI foods are rapidly absorbed and digested and
thus can have deleterious effects on blood glucose control [19].
Within 2 hours of eating an HGI meal, blood glucose concentration is at
least double that of ingesting an LGI meal, low GI foods have been
shown to decrease postprandial blood glucose rises, increase satiety and
promote weight loss, improve insulin sensitivity, and enhance lipid
profile [18].
Several studies [20], [21]. Have found that a HGI diet in healthy
individuals is associated with an increased risk of developing type 2
diabetes. The Health Professionals Follow-up Study (1997) was a
national longitudinal study that followed 42,759 healthy male health
professionals, aged 40 to 75 years, over 6 years, and discovered 523
incident cases of confirmed type 2 diabetes over this time. Men who
consumed an HGI diet were at an increased relative risk of developing
diabetes, even after adjusting for age and other known risk factors for
diabetes. When comparing the highest GI quintile with the lowest GI
quintile, the relative risk of developing type 2 diabetes was statistically
significant [20].
The Nurses‘ Health Study II (2004) followed 91,249 healthy U.S.
women, aged 24 to 44 years, over 8 years and found 741 incident cases of
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confirmed type 2diabetes over this time. The women who consumed an
HGI diet were at an increased relative risk of developing type 2 diabetes,
even after adjusting for age and other known diabetes risk factors. There
was a 59% increased risk of developing type 2 diabetes in the highest GI
versus the lowest GI, which is statistically significant [21].
Ma et al[22] performed a pilot study to evaluate the effectiveness
of an LGI dietary intervention with personal digital assistant (PDA)
support on glycemic control in 13 adults with poorly-controlled type 2
diabetes. This study was conducted over a period of 6 months and
consisted of nutritionist-delivered education and counseling about the
LGI diet, in which all subjects were involved in an initial 2.5-hour group
session, a 1-hour individual session at week 2, a group grocery tour at
week 4, and subsequent 30-minute individual phone sessions at months 2,
3, and 5. The results of this study found a statistically significant mean
decrease in HbA1c of 0.5% after the LGI dietary intervention[22].
Several of the above studies included questionnaires to determine
subject satisfaction with the LGI diet. Burani and Longo.found that 100%
of their study subjects felt that choosing LGI foods assisted them in
improving their diabetes and that they intend to continue choosing LGI
foods and incorporate these choices into their lifestyle. Ma et al.
discovered that 7 of the 13 subjects found adherence to the LGI diet easy,
3 found it difficult, and 3 were neutral, but 12 of the 13 subjects liked the
LGI diet [23].
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In the Mediterranean Diet, Cardiovascular Risks and Gene
Polymorphisms (Medi-RIVAGE) study, the effects of a Mediterranean
type diet or a low-fat diet on cardiovascular risk factors were evaluated in
212 men and women with moderate risk factors for cardiovascular
disease. In both dietary arms there was a significant reduction in BMI,
dyslipidemia, insulinemia, and glycemia, after 3 month with no
significant differences between the arms[24].
The Seguimiento Universidad de Navarra (SUN) project, a large Spanish
cohort study of 13,380 participants, estimated dietary intake at baseline
and the relative risk for a new diagnosis of diabetes during 4.4 years of
follow up. Participants who adhered closely to a Mediterranean diet had a
lower risk of diabetes with relative risk adjusted for sex and[25].
Another study was conducted in Australia that investigate the self-
care practices of Malaysian adults with diabetes and sub-optimal
glycogenic control by using a one-to-one interviewing approach, data
were collected from 126 diabetic adults from four settings. A 75-item
questionnaire was used to assess diabetes-related knowledge and self-care
practices regarding diet, medication, physical activity and self-monitoring
of blood glucose, the results indicated that these subjects with sub-
optimal glycaemic control had inadequate knowledge about diabetes and
self-care practices were poor. Factors that may contribute to this are the
age and education level of the subjects [26]. Fifty-four percent of the
subjects live a sedentary life style, with only 5% exercising sufficiently to
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contribute to glycaemic control. Females constituted two-thirds of the
subjects and they were noted to be less active than males[26].
Age is another factor related to physical activity in this study.
Fifty-four percent of the subjects were aged 55 years or more and were
less active. For the younger subjects, employment and family
responsibilities could limit the time available for leisure activities. This
finding is consistent with those from other studies [27, 28]. The less
active subjects in this study were found to have higher mean FBG (p=
0.02) which is also consistent with the previous findings [27, 29].
The relationship between recognition of importance and actual self
care behaviour may be explained using the ‗Theory of Reasoned Action‘.
This states that the best predictor of patient‘s behaviour is the patient‘s
intention to behave in a certain way [30].
A previous study reported a negative association between perceived
importances of exercise in diabetes with number of barriers to exercise
[31].
However, it appears that recognition of the importance of dietary
and medication self-care did not lead to the actual behaviours. One
possible explanation is that the majority of the subjects had poor dietary
knowledge and lack of access to dietary facilities[26].
Lack of adherence to medication intake could have been magnified by the
chosen definition of medication adherence. Cultural barriers to
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medication adherence in Asia such as use of alternate medicines and
replacement with non-pharmaceutical treatments might also have
contributed to this problem [32, 33].
Content analysis open-ended item concerning exercise indicated
that only 30% of the subjects reported being advised according to clinical
practice guideline (a minimum of 30 min per day and at least 5 days a
week). This may be due to inadequate diabetes knowledge among the
healthcare providers as reported by previous researchers [34].
Also it appears that sub-optimal glycaemic control patient had
inadequate knowledge about diabetes and self-care practices were poor.
Factors that may contribute to this are the age and education level of the
subjects [26].
Previous studies have consistently reported a relationship between low
level of education and older subjects with poor diabetes-related
knowledge [35, 36].
In addition to that, the dietary knowledge deficits, low functional health
literacy and nutritional transition to energy-dense food with improved
socio-economic conditions could contribute to the increased carbohydrate
consumptions by the subjects [37], [38].
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Furthermore, a local nutritional anthropology study reported that
food items other than cooked rice were commonly not considered ‗real
food‘ and therefore subjects may believe these can be taken in large
quantities [39].
Previous studies have consistently reported financial barriers to
Self-monitoring blood glucose [40], [41], [42].
In Malaysia, the Malaysian government heavily subsidises
medication, but not the cost of Self-monitoring blood glucose, which
could have contributed to its low usage. However, some studies have also
reported a poor usage of to Self-monitoring blood glucose despite free
blood glucose test strips being supplied [43], [44].
It shown that demographic factors such as ethnic minority, low
socioeconomic status, and low levels of education have been associated
with lower regimen adherence and greater diabetes-related morbidity
[45].
Study using self-care assessment instrument reported that 90% of
their sample indicated they frequently eat a healthy diet; only one-
quarterly regularly self-monitored their blood glucose; and half exercised
more than once per week [46].
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Chapter Three
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Methodology
This chapter describe and discus the methods that use to carry out
this research by describing the study design and variables concluded
technique that use in data collection and analysis.
3.1 Study Design
This study designed as a cross sectional method that compatible
with this descriptive study and its objectives, groups can be compared at
different ages with respects of independent variables so this non
experimental study.
The Cross-sectional designs (also known as cross-sectional
analysis, transversal studies, prevalence study) form a class of research
methods that involve the collection of data at one point in time; the
phenomena under study are captured during one period of data collection.
The advantages of cross-sectional studies are 1- Relatively
inexpensive and take up little time to conduct. 2- Can estimate prevalence
of outcome of interest because sample is usually taken from the whole
population. 3- Descriptive role.
And the disadvantages of cross-sectional studies: 1- Selection bias. 2-
Snapshot in time (loss to follow-up). 3- Shows association, not causality.
The study investigates factors affecting the commitment of diabetic
patient in therapeutic diet, by using self-administered questionnaires tool
to collect the data.
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3.2 Sample and Setting:
The data is taken from diabetic Patient from different clinics in
Nablus.
The population of the study is (type1&2 DM) patients. It accounts
150 out patients from Nablus who visit those clinics: ( Balata
PHC/UNRWA), (Balata PHC/MOH), (Askar PHC/UNRWA), (PHC
Directorate in Nablus/MOH), (Camp No.1 PHC/UNRWA) and (Old
Askar PHC/UNRWA).
Inclusion criteria: All participants were male and female patients who
had been diagnosed with DM (type1&2) at least 5 year earlier, and
consented to participate in the study. The sample divided into 75 male
and 75 female, population ages range between (30-60) years old.
Exclusion criteria: All patient they have gestitional diabetic, all
patients they had been diagnosed with diabetic less than 5 years, and
all patients less than 30 years and above 60 years.
3.3 Dependent and independent variable:
3.3.1 Dependent variables:
The level of commitment in therapeutic diet and diet
restrictions.
3.3.2 Independent variable
1. Gender: This has two options (male and female).
2. Age: This has three options (30-39, 40-49 and 50-60 years old).
3. Marital status: This has four options (single, married, divorced,
and widowed).
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4. Place of residence: This has three options (city, village and
Refugee camp).
5. Income: This has four options(less than 1000 NIS, 1000-2500
NIS, and 2500-4000NIS and More than 4000 NIS).
6. Academic qualification: This has four levels: ( Illiterate,
Elementary, Preparatory, Secondary and High Education).
7. Knowledge about diabetes mellitus disease and its complications
and the recommended diet therapy.
8. The adherence to exercise, and appointment for regular checkup
in the clinics.
9. Access to and use of medicines.
3.4 Period of study:
This research conducted in the beginning of the first semester in
2013-2014, and data collection done in 4 weeks from 3/10/2013 to
30/10/2013.The questionnaires take 3 minutes to introduce the
questionnaire idea of the project to the participants and to explain the
study purpose. And about 10 minutes from the patients to fulfil the
questionnaire.
3.5 Study Tool:
The study tool which had been used to collect the data was a
questionnaire(Annex II). The questionnaire was self-constructed. 150
questionnaire were distributed between 3/oct/2013 and 30/oct/2013, the
questionnaire consisting of five parts as the following:
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3.5.1. Part One:
Include introduction paper about the study title, our university and
college, type of data which we wanted to collect, objectives of the study
and the name of researchers who wanted to collect data aims to
encouraging the targeted individuals to respond frankly on the study
questions after satisfying the tested people that the information will be
secret and will not be used except for the scientific research only.
3.5.2 Part Two:
Includes patient demographic data(Gender, Age, Marital Status, Place of
Residence, Income, and Educational Level).
3.5.3Part Three:
This part contain (11) questions asked about dietary practice that
indicated the level of patient adherence in dietary regiment.
3.5.4 Part Four:
This part contains 5 questions that measure the knowledge of patients
about diabetes mellitus disease, its complications and the recommended
diet therapy.
3.5.5 Part Five:
This part contains 3 questions asked about adherence to exercise, and
appointment for regular checkup in the clinics.
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3.6 Pilot testing:
A pilot study was conducted to determine the reliability and the
validity of the questionnaire study, we collected 20 sample aimed to:
1. Identify the barriers expected during the data collection process.
2. Estimate the time required for the data collection.
3. Determine the reliability of questionnaire.
4. Obtain the clarity and the content adequacy of the questionnaire.
After we doing the pilot study we analyzed it on SPSS program
using Cronapach Alpha test to measure reliability and Validity.
3.7 Validity:
The questionnaire was tested through distributed it to the teachers
in nursing department at An-Najah National University who are expert in
research, they gave us some recommendations for modification the
questionnaire before distributed to participants.
3.8 Reliability:
Pilot testing was done and tested by using Cronapach Alpha test
which was (0.601). And this result is acceptable for the study purposes.
Reliability and Validity of the questionnaire is accepted.
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3.9 Study procedures:
After determining what has been the subject of study with the supervisor,
we started search in the database containing scientific research about
previous studies which talks about the same subject, database was used to
find previous studies include Science direct, Pub Med, Google, at the first
search we obtained few articles and studies associated with subject.
Key Words that were used in the process of Search in data base include:
1. Diabetic Miletus.
2. Diabetic Management.
3. Dietary Therapy.
4. Commitment.
To facilitate the Distributed of questionnaires at clinics, it was important
to take the permission from ministry of health and UNRWA to
Distributed questionnaires. (Appendix1).
This project required Institutional Review Board (IRB) from An-Najah
National University , because it involves human subject, completion of a
degree and finish course, ensure that human subjects are not placed under
risk, comply with internationally accepted standards and ensure the
validity of study finding. Then the approval of the proposal was taken to
go furthermore and develop it as a graduation project, (Annex III).
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3.10 Statistical processing:
After collection the questionnaires, they have been codified,
entered the computer and statically processed by using the statistical
package for social science (SPSS).
After asking 11 different questions about dietary practices and
consider participant who answers 6 from 11 questions of dietary practice
or more by positive answer is high commitment participant, and less than
6 questions is low commitment participant.
3.11 Ethical Considerations
The research approved from institutional review board (IRB) from
An-Najah National University. After that approval, the permission taken
from UNRWA and ministry of health in Nablus to collect data from
patients in clinics. Consent forms obtained from participants (Annex I ).
The questionnaire was informed written. The patient‘s acceptance
to fill the questionnaire was taken in the beginning of the data collection
and participants had the right to withdraw at any time they wanted
according to Herisinki aspects that respects human rights. Data was kept
confidential. Collected data was used for research purpose, and it was
stored in private place.
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Chapter Four
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4.1 Results
Table (1) Distribution of participant demographic data.
Variable Category No %
Gender
Male 75 50.0
Female 75 50.0
Total 150 100.0
Age
30-39
40-49
50-60
14
44
92
9.3
29.3
61.3
Total 150 100.0
Place Of Residency
City 68 45.3
Village 45 30.0
Camp 37 24.7
Total 150 100.0
Level Of Education
Illiterate 30 20.0
Elementary 41 27.3
Preparatory 41 27.3
Secondary 23 15.3
High Education 15 10.0
Total 150 100.0
Marital Status
Single 14 9.3
Married 115 76.6
Divorce 3 2.0
Widow 18 12.0
Total 150 100.0
No. Of Family
Member
( 1-2 ) 20 13.3
( 3-5 ) 42 28.0
( >5 ) 88 58.7
Total 150 100.0
Income Level
Less Than 1000 NIS 57 38.0
(1000-2500 NIS) 74 49.3
(2500-4000 NIS) 12 8.0
More Than 4000 NIS 7 4.7
Total 150 100.0
Job Description
Employment
Worker
Unemployment
Other
17
28
92
13
11.3
18.7
61.3
8.7
Total 150 100.0
Length of disease
<5 years
6-10 years
11-15 years
>16 years
60
47
20
23
40
31.3
13.3
15.3
Total 150 100.0
Table (1) shows the distribution of demographic data, it shows that
(9.3%) of participants that diagnose with DM were among the age group
32 | P a g e
of 30-39years, (29.3%) were between age 40-49years,and the other
(61.3%) of participants were between age group of 50-60years.
Regarding gender, the table showed equal percentage between male and
female participants, (50%) for both genders.
According to place of residency, (45.3 %) of participants with DM from
city, (30 %) from village and the other (24.7 %) participants are from
camp.
In relation to level of education, large number of participants were
illiterate (20%) from total participants, (27.3 %) were elementary, (27.3
%) were preparatory, (15.3 %) were secondary and the last (10 %) were
high education.
Marital status shows that (9.3 %) of participants that diagnose as DM
patients were single,(76.6 %) of participants with DM were married,(2 %)
were divorce and the other percentage are widow (12 %).
Number of family member that the participants had, (13.3%) from
participants had (1-2) member, (28%) from participants consist (3-5)
members. The other (58.7 %) had more than 5 members.
In relation to income level, the income level of (38 %) of participants
were less than [1000 NIS], (49.3 %) were had income between [1000-
2500 NIS]. (8 %) of participants were [2500-4000NIS], and just (4.7 %)
had more than [4000NIS].
In relation for participants to the length of disease experience. The table
showed that (40 %) of participants length of disease is less than [5 years],
(31.3%) the length of disease is between [6-10 years],(13.3 %) the length
of disease is between [11-15 years] and (15.3 %) of participants suffer
from the disease from more than [16 years].
33 | P a g e
The Job description of participants show that (11.3 %) from participants
were employments, (18.7%) were workers, (61.3 %) were
unemployment‘s and the participants who had other job was (8.7%).
Table (2) high/low commitment distribution
High/low commitment
Frequency Percent %
Low Commitment 34 22.7
High Commitment 116 77.3
Total 150 100.0
Figure (1)
Table
(2) and figure (1) show the distribution of participants in relation to
commitment in diabetic dietary practice.
After asking 11 different questions about dietary practice, the result show
77.3% of participants had high commitment, and 22.7 had low
34 | P a g e
commitment. (This conducting by considering participant who answers 6
from 11 questions of dietary practice or more by positive answer is high
commitment participant and less than 6 questions is low commitment
participant).
Table (3): The distribution of participant regarding to dietary practice questions.
1. I have a balanced diet program that I committed in it to prevent diabetes complications.
Frequency Percent %
No 97 64.7
Yes 53 35.3
Total 150 100.0
2. I review nutritionist to follow my health status according to nutrition.
Frequency Percent %
No 114 76.0
Yes 36 24.0
Total 150 100.0
3. I am eating the meals on specific time.
Frequency Percent %
No 81 54.0
Yes 69 46.0
Total 150 100.0
4. Be aware to eat fruits and vegetables.
Frequency Percent %
No 17 11.3
Yes 133 88.7
Total 150 100.0
5. Be aware to eat black bread.
Frequency Percent %
No 104 69.3
Yes 46 30.7
Total 150 100.0
35 | P a g e
6. Be aware to decrease starchy food intake.
Frequency Percent %
No 59 39.3
Yes 91 60.7
Total 150 100.0
7. Be aware to eating meats in balance.
Frequency Percent %
No 41 27.3
Yes 109 72.7
Total 150 100.0
8. Be aware to avoid eating fatty food.
Frequency Percent %
No 29 19.3
Yes 121 80.7
Total 150 100.0
9. Be aware to drink enough amount of water.
Frequency Percent %
No 11 7.3
Yes 139 92.7
Total 150 100.0
10. Be aware to eat the breakfast meal.
Frequency Percent %
No 22 14.7
Yes 128 85.3
Total 150 100.0
11. I am eating fast food, sugars and soft drinks constantly.
Frequency Percent %
No 106 70.7
Yes 44 29.3
Total 150 100.0
36 | P a g e
Table (3) Show:
1. The distribution of the study sample according to question “I have a
balanced diet program that I committed in it to prevent diabetes
complications?”.The number of participants they have balanced diet
program that they committed in it to prevent diabetes complications
was 53 (35.3%), and those they do not have balanced diet program
that they committed in it to prevent diabetes complications was 97
(64.7%),
2. The distribution of the study sample according to question “I review
nutritionist to follow my health status according to nutrition?”
The number of participants they review nutritionist to follow their
health status according to nutrition was 36 (24%), and those they do
not review nutritionist to follow their health status according to
nutrition was 114 (76%).
3. The distribution of the study sample according to question “I am
eating the meals on specific time?” The number of the participants
they eat their meals on specific time was 69 (46%), and those they did
not eat the meals on specific time was 81 (54%).
4. Show the distribution of the study sample according to question “Be
aware to eat fruits and vegetables?” The number of the participants
they aware to eat fruits and vegetables was 133 (88.7%), and those
they did not aware to eat fruits and vegetables was 17 (11.3%).
5. Show the distribution of the study sample according to question “Be
aware to eat black bread?” The number of the participants they
aware to eat black bread was 46 (30.7%), and those they did not aware
to eat black bread was 104 (69.3%).
6. Show the distribution of the study sample according to question “Be
aware to decrease starchy food intake?” The number of the
37 | P a g e
participants they aware to decrease starchy food intake was 91
(60.7%), and those they did not aware to decrease starchy food intake
was 150 (39.3%).
7. Show the distribution of the study sample according to question “Be
aware to eating meats in balance?” The number of the participants
they aware to eating meats in balance was 109 (72.7%), and those they
did not aware to eating meats in balance was 41 (27.3%).
8. Show the distribution of the study sample according to question “Be
aware to avoid eating fatty food?” The number of the participants
they aware to avoid eating fatty food was 121 (80.7%), and those they
did not aware to avoid eating fatty food was 29 (19.3%).
9. Show the distribution of the study sample to question “Be aware to
drink enough amount of water?” The number of the participants
they aware to drink enough amount of water was 139 (92.7%), and
those they did not aware to drink enough amount of water was 11
(7.3%).
10. Show the distribution of the study sample according to question “Be
aware to eat the breakfast meal?” The number of the participants
they be aware to eat the breakfast meal was 128 (85.3%), and those
they did not aware to eat the breakfast meal was 22 (14.7%).
11. Show the distribution of the study sample to question “I am eating
fast food, sugars and soft drinks constantly?” The number of the
participants they eating fast food, sugars and soft drinks constantly
was 44 (29.3%), and those they did not eating fast food, sugars and
soft drinks constantly was 106 (70.7%).
38 | P a g e
Table (4): The relationship between gender and degree of commitment.
degree of Commitment
Total Sig. Low
Commitment
High
Commitment
Gender
Male Count 16 59 75
0.699
% 21.3% 78.7% 100.0%
Female Count 18 57 75
% 24.0% 76.0% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (4) represented the relationship between gender and degree
of commitment, 78.7 % of male participant had high commitment to
dietary therapy practice, and 76% of female with high commitment. From
the table there is no significant relationship between gender and degree of
commitment to dietary therapy practice as the sig.value is (0.699) which
is (>0.05).
Table (5): The relationship between age and degree of commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Age
(30- 39 Years) Count 6 8 14
0.280
% 42.9% 57.1% 100.0%
(40-49 Years) Count 9 35 44
% 20.5% 79.5% 100.0%
(50 -60 Years) Count 19 73 92
% 20.7% 79.3% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (5) showed that 57.1% of age group (30-39 years) had high
commitment ,and 79% of both age group (40-49),(50-60) had high
commitment, and it showed there is no significant relationship between
39 | P a g e
age and degree of commitment as the sig.value is (0.280) which is
(>0.05).
Table (6): The relationship between marital status and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Marital
Status
Married Count 24 91 115
0.312
% 20.9% 79.1% 100.0%
Single Count 4 10 14
% 28.6% 71.4% 100.0%
Widow Count 4 14 18
% 22.2% 77.8% 100.0%
Divorce Count 2 1 3
% 66.7% 33.3% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (6) showed that 79.1% of married group had high
commitment ,and 71.4% of single group had high commitment, and
77.8% of widow group had high commitment, and 33.3% of divorce
group had high commitment, and the table showed there is no significant
relationship between marital status and degree of commitment as the
sig.value is (0.312) which is (>0.05).
41 | P a g e
Table (7): The relationship between number of family member and degree
of commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
No. Of Family
Member
(1-2) Count 4 16 20
0.819
% 20.0% 80.0% 100.0%
(3-5) Count 11 31 42
% 26.2% 73.8% 100.0%
(> 5 ) Count 19 69 88
% 21.6% 78.4% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (7) showed that 80% of family member group (1-2) had high
commitment ,and 73.8% of family member group (3-5) had high
commitment, and 78.4% of family member group (> 5) had high
commitment, and the table showed there is no significant relationship
between number of family member and degree of commitment as the
sig.value is (0.819) which is (>0.05).
Table (8): The relationship between place of residency and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Place Of
Residency
City Count 19 49 68
0.393
% 27.9% 72.1% 100.0%
Village Count 6 39 45
% 13.3% 86.7% 100.0%
Camp Count 9 28 37
% 24.3% 75.7% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
41 | P a g e
Table (8) represent the relationship between place of residency and
degree of commitment, 72.1% of participant who live in city had high
commitment to dietary therapy practice, and 86.7% of participant who
live in village had high commitment, and 75.7% of participant who live in
camp had high commitment. From the table, there is no significant
relationship between place of residency and degree of commitment to
dietary therapy practice as the sig.value is (0.393) which is (>0.05).
Table (9): The relationship between income level and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Income
Level
Less Than 1000
NIS
Count 16 41 57
0.076
% 28.1% 71.9% 100.0%
(1000-2500 NIS) Count 17 57 74
% 23.0% 77.0% 100.0%
(2500-4000 NIS) Count 1 11 12
% 8.3% 91.7% 100.0%
More Than 4000
NIS
Count 0 7 7
% 0.0% 100.0% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (9) showed that 71.9% of income level group (Less Than
1000 NIS) had high commitment degree, and 77.0% of income level
group (1000-2500 NIS) had high commitment degree, and 91.7% of
income level group (2500-4000 NIS) had high commitment degree, and
100.0% of income group (More Than 4000 NIS) had high commitment
degree. And the table showed there is no significant relationship between
42 | P a g e
level of income and degree of commitment as the sig.value is (0.076)
which is (>0.05).
Table (10): The relationship between levelof education and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Level Of
Education
Elementary Count 7 34 41
0.381
% 17.1% 82.9% 100.0%
Preparatory Count 12 29 41
% 29.3% 70.7% 100.0%
Secondary Count 4 19 23
% 17.4% 82.6% 100.0%
High
Education
Count 0 15 15
% 0.0% 100.0% 100.0%
Illiterate Count 11 19 30
% 36.7% 63.3% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (10) showed that 82.9% of (Elementary) group had high
commitment degree, and 70.7% of (Preparatory) group had high
commitment degree, and 82.6% of (Secondary) group had high
commitment degree, and 100.0% of (High Education) group had high
commitment degree, and 63.3% of (Illiterate) group had high
commitment degree. And the table showed, there is no significant
relationship between level of education and degree of commitment as the
sig.value is (0.381) which is (>0.05).
43 | P a g e
Table (11): The relationship between job descriptionand degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Job
Description
Employment Count 4 13 17
0.160
% 23.5% 76.5% 100.0%
Worker Count 9 19 28
% 32.1% 67.9% 100.0%
Unemployment Count 20 72 92
% 21.7% 78.3% 100.0%
Other Jobs Count 1 12 13
% 7.7% 92.3% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (11) showed that 76.5% of (Employment) group had high
commitment degree, and 67.9% of (Worker) group had high commitment
degree, and 78.3% of (Unemployment) group had high commitment
degree, and 92.3% of (Other Jobs) group had high commitment degree.
And this table showed there is no significant relationship between job
description and degree of commitment as the sig.value is (0.160) which is
(>0.05).
44 | P a g e
Table (12): The relationship between length of disease and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Length of
disease
<5 years Count 15 45 60
0.452
% 25.0% 75.0% 100.0%
6-10 years Count 11 36 47
% 23.4% 76.6% 100.0%
11-15
years
Count 4 16 20
% 20.0% 80.0% 100.0%
>16 years Count 4 19 23
% 17.4% 82.6% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (12) showed that 75.0% of (<5 years) length of disease group
had high commitment degree, and 76.6% of (6-10 years) length of disease
group had high commitment degree, and 80.0% of (11-15 years) length of
disease group had high commitment degree, and 82.6% of (>16 years)
length of disease group had high commitment degree. And the table
showed, there is no significant relationship between length of disease and
degree of commitment as the sig.value is (0.452) which is (>0.05).
45 | P a g e
Table (13): The relationship between the level of knowledge and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
Level Of
Knowledge
Score Count 4 1 5
0.001
0 % 80.0% 20.0% 100.0%
1 Count 3 3 6
% 50.0% 50.0% 100.0%
2 Count 3 6 9
% 33.3% 66.7% 100.0%
3 Count 6 16 22
% 27.3% 72.7% 100.0%
4 Count 9 23 32
% 28.1% 71.9% 100.0%
5 Count 8 41 49
% 16.3% 83.7% 100.0%
6 Count 1 26 27
% 3.7% 96.3% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (13) showed that 20.0% of (0) level of knowledge group of
participant had high commitment degree, and 50.0% of (1) level of
knowledge group of participant had high commitment degree, and 66.7%
of (2) level of knowledge group of participant had high commitment
degree, and 72.7%of (3) level of knowledge group of participant had high
commitment degree, and 71.9% of (4) level of knowledge group of
participant had high commitment degree, and 83.7% of (5) level of
knowledge group of participant had high commitment degree, and 96.3%
of (6) level of knowledge group of participant had high commitment
degree. And the table showed that is a significant relationship between
level of knowledge and degree of commitment as the sig.value is (0.001)
which is (< 0.05).
46 | P a g e
Table (14):The relationship between the commitment in medication regimen
and degree of commitment.
Degree of commitment Total
Sig. Low
Commitment
High
Commitment
I Committed in
medication regimen
that was prescribed to
me.
No Count 7 5 12
0.002
% 58.3% 41.7% 100.0%
Yes Count 27 111 138
% 19.6% 80.4% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (14) showed that 80.4% of participant who committed in
medication regimen had high commitment degree, and 41.7% of
participant who not committed in medication regimen had high
commitment degree. And the table showed there is a significant
relationship between committed in medication regimen and degree of
commitment as the sig.value is (0.002) which is (< 0.05).
Table (15):The relationship betweenpracticing exercise and degree of commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
I practice sport
regularly.
No Count 30 72 102
0.004
% 29.4% 70.6% 100.0%
Yes Count 4 44 48
% 8.3% 91.7% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
47 | P a g e
Table (15) showed that 70.6% of participant who did not practice
exercise had high commitment degree, and 91.7% of participant who
practicing exercise had high commitment degree. And the table showed
there is a significant relationship between practicing exercise and degree
of commitment as the sig.value is (0.004) which is (< 0.05).
Table (16): The relationship between performing periodic medical
examination and degree of commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
I perform periodic
medical examination
No Count 1 4 5
0.886
% 20.0% 80.0% 100.0%
Yes Count 33 112 145
% 22.8% 77.2% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (16) showed that 80.0% of participant who did not
performing periodic medical examination had high commitment degree,
and 77.2% of participant who performing periodic medical examination
had high commitment degree. And the table showed there is no
significant relationship between performing periodic medical examination
and degree of commitment as the sig.value is (0.886) which is (> 0.05).
48 | P a g e
Table (17): The relationship between performing periodic examination of
the feet and degree of commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
I perform periodic
examination of the
feet.
No Count 10 29 39
0.609
% 25.6% 74.4% 100.0%
Yes Count 24 87 111
% 21.6% 78.4% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
Table (17) showed that 74.4%of participant who did not
performing periodic examination of the feet had high commitment
degree, and 78.4% of participant who performing periodic examination of
the feet had high commitment degree. And the table showed there is no
significant relationship between performing periodic examination of the
feet and degree of commitment as the sig.value is (0.609) which is (>
0.05).
Table (18): The relationship between health level satisfaction and degree of
commitment.
Degree of commitment
Total Sig. Low
Commitment
High
Commitment
I am satisfied with my
level of health
No Count 11 30 41
0.459
% 26.8% 73.2% 100.0%
Yes Count 23 86 109
% 21.1% 78.9% 100.0%
Total Count 34 116 150
% 22.7% 77.3% 100.0%
49 | P a g e
Table (18) showed that 73.2% of participant who did not satisfy
with their health status had high commitment degree, and 78.9% of
participant who satisfied with their health status had high commitment
degree. And the table showed there is no significant relationship between
health level satisfaction and degree of commitment as the sig.value is
(0.459) which is (> 0.05).
Table (19) show the distribution of participants according to the satisfaction of their
health level.
I am satisfied with my level of health
Frequency Percent %
No 41 27.3
Yes 109 72.7
Total 150 100.0
Table (19) show the distribution of participants according to the
satisfaction of their health level, (72.7%) satisfied and (27.3%) not
satisfied.
51 | P a g e
4.2 Result discussion
The purpose of this study was to assess the commitment degree of
Palestinian diabetic patient in therapeutic diet practice in Nablus and to
figure-out the factors that may affect the degree of commitment.
The study revealed that the age of the participants is 9.3% (30-
39years), 29.3% (40-49years), and 61.3% (50-60), with equal percentage
between male and female (75 participant for each gender), and from the
statistical analyses we found that there is no significant relationship
between the age, gender and the commitment degree. And we didn't
found previous study mention this relationship. Also the study revealed
that the academic qualification of the participants had no any significant
relationship with the commitment degree, And we didn't found previous
study that approve or reject this result.
The study results showed that the majority of the participant about
(77.3%) from our sample had a high level of commitment in therapeutic
recommended dietary practices for diabetes , and this result was
confirmed by previous studies that showed the similarities of this result.
Study using self-care assessment instrument reported that 90% of
their sample indicated they frequently eat a healthy diet; only one-
quarterly regularly self-monitored their blood glucose; and half exercised
more than once per week [46].
In our opinion, this high level of commitment to therapeutic dietary
practices in Palestine, is due to the style and pattern which is common in
our country, the usual diet which followed by Palestinian families are
almost rich in fiber and protein, low in fat, and this seems to be major
reason for this high adherence level.
51 | P a g e
According to our study result, it was shown that almost all
demographic data (gender, age, marital status, family size, place of
residency, job description, duration of the disease) have no statistical
significant relationship with dietary adherence degree, but it seems that
one of the demographic variable which is the income level was very
near to become statistically significant with the adherence to the
therapeutic diabetic diet, but it didn‘t reach the limit of being significant
(0.076), and this may be due to the small sample size that we have, this
result supported with result of study that stated―with lower
socioeconomic status frequently encounter poor quality/insufficient
patient counseling on self-care and a lack of specialist care,
compromising self-care and diabetes outcomes‖ and this also affect the
individual adherence to the therapeutic diet[47].
Despite of we didn‘t found any significance relation between
gender and diet commitment, glycemic control in males was found to be
significantly better than females in study conducted in Saudi Arabia, and
this can be due to the fact that females are usually the caregivers for the
entire family not only the husband and children but also mothers and
mothers-in-law which increases their heavy domestic responsibilities[48].
This feature could be a local phenomenon as other studies [49],
found that sex was not associated with glycemic control, however our
result supported by Charpentier study [49], and this may be due to the
small sample size that we have.
In the other hand, the educational level, which is one of the
demographic data that have no significance on the commitment with the
52 | P a g e
dietary therapy, showed that 100% of highly educated level participant
were committed to the dietary therapy.
Also, one of our major result is the significant relationship between
the level of knowledge and the healthy diabetic dietary practices, and it
was shown that the adherence to these dietary practices increases
positively when the level of knowledge increase, and this result supported
by previous study which was assessing the diabetes-related knowledge
and self-care practices regarding diet, medication, physical activity and
self-monitoring of blood glucose, the results indicated that these subjects
with sub-optimal glycemic control had inadequate knowledge about
diabetes and self-care practices were poor[26].
We found in our research study that the adherence to medication
regimen associated positively with the commitment in diabetic dietary
practices, we think that this relation is prominent because of the ability
and the self-motivation for those patients(who followed the medication
course which prescribed by the doctor) to follow a specific dietary habit
which seems to be hard sometimes, but on the other hand these dietary
habits are at all one of the things which provided by the doctors.
It was shown in our study results that there is a significant
relationship between committing in exercise and adherence to therapeutic
dietary pattern for diabetes patient, we did not find any previous study
that may agree or disagree with this result.
53 | P a g e
4.3 Conclusion
From our study that asses the commitment of diabetic patients in
therapeutic diet and factors that may affect the degree of commitment, we
conclude that the majority of participants have a high degree of
commitment in the therapeutic diet. In addition, it appeared that there is
no significant relationship between the demographic characteristic and
the commitment degree, by contrast, there is significant relationship
between the level of knowledge about (diabetic disease, diabetic
management) and the commitment degree in Nablus –clinics.
4.4 Limitation
First, is the potential reporting bias associated with self-
administered questionnaire concern always exist about accuracy in these
surveys it‘s difficult to determine with certainty wither the responses
reflect what the diabetic patient actually do.
Second limitation, the availability of the previous study that talk
about the commitment in therapeutic diet was not enough, in addition to
this shortage of previous studies was an obstacle to have an idea about the
questionnaires which may be used in similar studies, the idea that drive us
to develop our own questionnaire based on the validation of the An-Najah
university doctors in nursing department.
Third, the study was conducted only in the clinics, all other
diabetic patient who went to hospitals or those who didn‘t join any health
facility were not taken, the thing that prevent the generalization process.
Finally, the sample that we did taken was small and not enough to
provide a rich data as we need.
54 | P a g e
4.5 Recommendation
For future research about the diabetic commitment with diet we
recommend to make an effort in developing the instrument or follow
qualitative – phenomenological design, to be able to assess in detail and
explore the entire context of the phenomena.
We also recommend to increase the sample size, and include a
wider geographical area, to be able to yield a results which it can be more
representative.
For nursing and doctors who work with diabetic patients, we
recommend them to provide much more education to the patient about the
diabetic self-care.
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Chapter Five
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5.1 References
1. American Diabetes Association, Economic costs of diabetes in the US in
2002, Diab. Care 26 (2003) 917–932.
2. Ministry of Health, PHIC, Health Status in Palestine 2011, May 2012.
3. Suzanne C. et al. Brunner &Suddarth's Textbook of Medical-Surgical
Nursing.USA: Wolters Kluwer health, 2005, 11th edition.
4. Rother KI (April 2007). "Diabetes treatment—bridging the divide". The New
England Journal of Medicine 356 (15): 1499–
501. doi:10.1056/NEJMp078030.PMID 17429082.
5. Shoback, edited by David G. Gardner, Dolores (2011). Greenspan's basic &
clinical endocrinology (9th ed.). New York: McGraw-Hill Medical.
pp. Chapter 17.
6. Lawrence JM, Contreras R, Chen W, Sacks DA (May 2008). "Trends in the
prevalence of preexisting diabetes and gestational diabetes mellitus among a
racially/ethnically diverse population of pregnant women, 1999–
2005". Diabetes Care 31 (5): 899–904.
7. Cooke DW, Plotnick L (November 2008). "Type 1 diabetes mellitus in
pediatrics".Pediatr Rev 29 (11): 374–84; quiz 385. doi:10.1542/pir.29-11-
374.PMID 18977856.
8. Risérus U, Willet W (January 2009). "Dietary fats and prevention of type 2
diabetes". Progress in Lipid Research 48 (1): 44–51.
9. Stratton IM, Adler AI, Neil HA, et al (2000). Association of glycaemia with
macrovascular and microvascular complications of type 2 diabetes (UKDPS
35): prospective observational study. British Medical Journal 321 (7258):
405-12.
10. Haynes RB, Taylor DW, Sackett DL (1979) Com- pliance in health care.
Baltimore, Md., Johns Hopkins University Press.
11. American Diabetes Association. Nutrition recommendations and interventions
for diabetes: a position statement of the American Diabetes Association.
Diabetes Care. 2008;31:S61-S78.
12. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K (2002) The evidence
for the effectiveness of medical nutrition therapy in diabetes management.
Diabetes Care 25:608-613.
13. Royle& Walsh 1992:597; Whitehorse etal 2002:18.
14. American Diabetes Association, Nutrition principles and recommendations in
diabetes, Diabetes Care 27 (2004) S36–S46.
57 | P a g e
15. Canadian Diabetes Association Clinical Practice Guidelines Expert
Committee, Canadian Diabetes Association 2003 Clinical Practice Guidelines
for the Prevention and Management of Diabetes in Canada, Can. J. Diabetes
27 (Suppl. 2) (2003) S1–S140.
16. Diabetes and Nutrition Study Group (DNSG) of the European Association for
the Study of Diabetes, Recommendations for the nutritional management of
patients with diabetes mellitus,Eur. J. Clin. Nutr. 54 (2000) 353–355.
17. Vaughan L. Dietary guidelines for the management of diabetes. Nurs
Stand.2005; 19:56-64.
18. M.J. Franz, J.P. Bantle, C.A. Beebe, J.D. Brunzell, J.L. Chiasson, A. Garg, et
al., Evidence-based nutrition principles and recommendations for the
treatment and prevention of diabetes and related complications, Diabetes Care
1 (2002)148–199.
19. Ludwig DS. The glycemic index: physiological mechanisms relating to
obesity, diabetes, and cardiovascular disease. JAMA. 2002; 287:2414-2423.
20. Salmeron J, Ascherio A, Rimm EB, et al. Dietary fiber, glycemic load, and
risk of NIDDM in men. Diabetes Care. 1997; 20:545-550.
21. Schulze MB, Liu S, Rimm EB, Manson JE, Willett WC, et al. Glycemic index,
glycemic load, and dietary fiber intake and incidence of type 2 diabetes in
younger and middle-aged women. Am J Clin Nutr. 2004; 80:348-356.
22. Ma Y, Olendzki BC, Chiriboga D, et al. PDA-assisted low glycemic index
dietary intervention for type II diabetes: a pilot study. Eur J ClinNutr.2006;
60:1235-1243.
23. Burani J, Longo PJ. Low-glycemic index carbohydrates: an effective
behavioral change for glycemic control and weight management in patients
with type 1 and 2 diabetes. The Diabetes Educ. 2006; 32:78-88.
24. Vincent-Baudry S, Defoort C, Gerber M, Bernard M, Verger P, Helal O et al.
The Medi-RIVAGE study: reduction of cardiovascular disease risk factors
after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet. Am
J Clin Nutr 2005;82:964–971.
25. Martinez-Gonzalez MA, Fuente-ArrillagaCdl, Nunez-Cordoba JM, Basterra-
Gortari FJ, Beunza JJ, Vazquez Z et al. Adherence to Mediterranean diet and
risk of developing diabetes: prospective cohort study. BMJ 2008; 336:1348–
135.
26. Ming Yeong Tan, Magarey. Self-care practices of Malaysian adults with
diabetes and sub-optimal glycaemic control. Patient Education and
Counseling.2008; 72: 252–267.
58 | P a g e
27. Lawton J, Ahmad N, Hallowell N, Hanna K, Douglas M. Perceptions and
experience of taking oral hypoglycaemic agents among people of Pakistani
and Indian origin: qualitative study. Brit Med J 2005;330:1247–51.
28. Kandula NR, Lauderlale DS. Leisure time, non-leisure time and occupational
physical activity in Asian Americans. Ann Epidemiol 2005;15: 257–65.
29. Fogelman Y, Bloch B, Kahan E. Assessment of participation in physical
activities and relationship to socioeconomic and health factors. The
controversial value of self-perception. Patient EducCouns 2004;53:95–9.
30. Anderson RM. The relationship between diabetes-related attitudes and
patients‘ self-reported adherence. Diabetes Educator 1993;19:287–92.
31. Dutton GR, Johnson J, Whitehead D, Bodenlos JS, Brantley P. Barriers to
physical activity among predominantly low-income African-American patients
with Type 2 diabetes. Diabetes Care 2005;28:1209–10.
32. Ariff K, Beng K. Cultural health beliefs in a rural family practice: a Malaysian
perspective. Aust J Rural Health 2006;14:2–8.
33. Pound P, Britten N, Morgan M, Yardley L, Pope C, Daker-White G, Campbell
R. Resisting medicines: a synthesis of qualitative studies of medicine taking.
SocSci Med 2005; 61:133–55.
34. Lee TW, Chan SC, Chua WT, Harbinder K, Khoo YL, OwYeang YL,
Sethuraman K, Teoh LC. Audit of Diabates Mellitus in General Practice. Med
J Malays 2004;59:317–22.
35. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and
health outcomes. J Gen Intern Med 2004;19:1228–39.
36. Persell SD, Keating NL, Landrum MB, Landon BE,Ayanian JZ,
BorbasC,Guadagnoli E. Relationship of diabetes-specific knowledge to self-
management activities, ambulatory preventive care and metabolic outcomes.
Prev Med 2004;39:746–52.
37. Noor M. The nutritional and health transition in Malaysia. Public Health Nutr
2002;5:191–5.
38. Tee ES. Nutrition of Malaysia: where are we heading? Malays J Nutr 1999;
5:87–109.
39. Research methods in nutritional anthropology. Research methods in nutritional
anthropology—the socio-cultural construction of diet.
http://www.umu.edu/unu[ress/unupbooks/80632e/80632E04.htm; 2006.
59 | P a g e
40. Adam A, Mah C, Soumerai SB, Zhang F, Barton MB, Ross-Degnam B.
Barriers to self-monitoring of blood glucose among adults with diabetes in an
HMO: a cross sectional study. BMC Health Serv Res 2003;3:6–10.
41. Schiel R, Miuller UA, Rauchfub J, Sprott H, Muller R. Blood-glucose
selfmonitoring in insulin treated type 2 diabetes mellitus: a cross-sectional
study with an intervention group. Diabetes Metab 1999;25:334–40.
42. Vincze G, Barner JC, Lopez D. Factors associated with adherence to
selfmonitoring of blood glucose among persons with diabetes. Diabetes
Educator 2004;30:112–25.
43. Soumerai SB, Mah C, Fang Z, Adams A, Barton M, Fajtova V, Ross-Degnam
D. Effects of health maintenance organization coverage of self-monitoring
devices on diabetes self-care and glycaemic control. Arch Intern Med
2004;164:645–52.
44. Nyomba BLG, Berard L, Murphy LJ. Facilitating access to glucometer
reagents increase blood glucose self-monitoring frequency and improves
glycaemic control: a prospective study in insulin-treated diabetic patients.
Diabetic Med 2003;21:129–35.
45. Delamater AM, Jacobson AM, Anderson BJ, Cox D, Fisher L, Lustman P,
Rubin R, Wysocki T: Psychosocial therapies in diabetes: report of the
Psychosocial Therapies Working Group. Dia- betes Care 24:1286–1292, 2001.
46. Lin, E., Katon, W., Von Korff, M., Rutter, C., Simon, G. E., Oliver, M., et al.
(2004). Relationship of depression and diabetes self-care, medication
adherence, and preventive care. Diabetes Care, 27(21), 2154–2160.
47. Harris, M. I. (2000). Health care and health status and outcomes for patients
with type 2 diabetes. Diabetes Care, 23(6), 754–758.
48. Al-Rowais, N.A. Glycemic control in diabetic patients in King Khalid
University Hospital (KKUH) – Riyadh – Saudi Arabia. Saudi Pharmaceutical
Journal (2013).
49. Charpentier, G., Genes, N., Vaur, L., Amar, J., Clerson, P., Cambou,J.P.,
Gueret, P., 2003. On behalf of the ESPOIR diabetes studyinvestigators.
Control of diabetes and cardiovascular risk factors in patients with type 2
diabetes: a national wide French Survey.Diabetes Metab. 29, 152–158.
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5.2Annexes
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Annex I
INFORMED CONSENT
موافقه لالشتراك ف البحث العلم
.دمحم صالح, اوب امواس, مهند بشارات, انس شحادة: سم الباحثإ
. التزام مرضى السكري الفلسطنن بالعالج الغذائ ف نابلسعنوان البحث
أنت .مدنه نابلس الواقعة ف ستم اجراء هذا البحث ف عادات السكريمكان إجراء البحث:
جامعة النجاح الوطنة. \ف كلة التمرض ه طلبةدعو)ة( للمشاركة ببحث علم سجرم
الرجاء أن تأخذ)ي( الوقت الكاف لقراءة المعلومات التالة بتأن قبل أن تقرر)ي( إذا كنت
إضاحات أو معلومات إضافة عن أي شء مذكور ترد)ن( المشاركة أم ال. بإمكانك طلب
ف هذه اإلستمارة أو عن هذه الدراسة ككل من الباحثن.
هجوىعت هي الوسضقىم البحث عل أخر :وصف البحث العلو وهدفه وتفسس هجساته .أ
هدي التصام ,وتىشع استباى واحد لكل ههن وذلك بهدف هي عاداث السكس ف هدت ابلس
الوىص الهن والتعسف عل العىاهل الوؤثسة ف خطت العالج الغرائتهسض السكس ف
. دزجت االلتصام شتراك ف هذا البحثتأثرات سلبة مكن ان سببها اإلال وجد أي .ب
:من الفوائد الت نرجو تحققها:الفوائد الت قد تنتج عن هذا البحث . ج
. كري بالخطة الغذائة درجة االلتزام عند مرضى الس. قاس 1
مدى االتزام لدهم.. معرفة أهم االمور و العوامل الت تؤثرعلى 2
:معلوماتكسرة
ف حال وافقت على المشاركة ف هذه الدراسة، سبقى إسمك ط الكتمان . لن كون ألي
ان هذه علما باالستمارة بعد تعبئتها حق اإلطالع على -ما لم نص القانون على ذلك -شخص
المعلومات لن تستخدم اال لغرض البحث العمل فقط و بدرجة عالة من السرة و
الخصوصة.
:اإلنسحابفىحقك
سلبةعلكعواقبلذلكاواقاعأسبابإبداءدونوقتيافىالبحثمناإلنسحابمنحقك
اوتنفذشرطجزائبحقك.
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موافقة الباحث:
. السلبة االجببة طبعحو مجربجو جأثراجو علمالبحث الببلحفصل للمشحرك ف جم الشرحرات علم المشحرك بأي جغأسف . سحطعأجبث على كل أسئلحو بضح على خر مب ألقد
.ثنبء البحثأف مجربت ىذا البحث أ جأثراجو السلبة أ فائده ف حبل حصليب
وافقة المشتركعلى م إسم الباحث او الشخص المولى الحصول
.دمحم صالح , اوب امواس, انس شحادة, مهند بشارات
_____________________
/ /: التارخ
:موافقة المشترك
وبناء لقد قرأت استمارة القبول هذه وفهمت مضمونها. تمت األجابة على أسئلت جمعها.
علم ان أ إنو ،شتراك فهوافق على اإلأ لبحث وجراء هذا اإجز ، حرا مختارا، أعله فأنن
تصال بهم نه باستطاعت اإلأو ،سئلتأجابة على سكونون مستعدن لإل فرق البحث العلم
حد أتصل بأضاح فسوف د من اإلزواذا شعرت الحقا ان األجوبة تحتاج الى م,ف أي وقت
سحاب من هذا البحث متى شئت حتى نعرف تمام المعرفة بانن حر ف اإلأكما البحث اعضاء
ل. بعد التوقع على الموافقة دون ان ؤثر ذلك على العناة الطبة المقدمة
/ / لتارخا
ـباإلتصالمكنكلدكستفسارإيأ وجود عند
1532555232 :بلفون رقم -دمحم صالح الباحثالرئس:
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Annex II
بسم ميحرلا نمحرلا هللا
:ة وبعد تحة طب
نوي طالب التمرض ف دائرة التمرض لكلة الطب وعلوم الصحة ف جامعة النجاح الوطنة
التزام مرضى السكري الفلسطنن بالعالج الغذائ ف نابلسالقام ببحث علم تحت عنوان :
,
مدى وذلك بهدف البحث فوالت ستتم ف العادات الحكومة وعادات وكالة الغوث الدولة
الموصى الهم والتعرف على العوامل المؤثرة خطة العالج الغذائة التزام مرضى السكري ف
ف درجة االلتزام .
مع االحتفاظ دقة, ااالستبانبالرجاء تعبئة هذوتعتبر مشاركتك ف هذا البحث ذات قمة علمة,
مع العلم ,ف اإلجابة عنها أو عدم الرد على أي أسئلة ال ترغب عدم المشاركة ف الدراسة بحق
أن هذه المعلومات ستستخدم ألغراض البحث العلم فقط وستعامل بسرة تامة.
دقائق( . 01) ال تتجاوز وستغرق ملئ االستبان مدة
ولكم جزل الشكر ..
.س شحادة, مهند بشاراتانالمشاركن : دمحم صالح, اوب امواس, الطالب
ة: شروق قادوس باشراف االستاذ
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Annex III