ASSESSMENT OF NUTRITION KNOWLEDGE OF

PALESTINIAN PHYSICIANS EMPLOYED IN

SHIFA HOSPITAL - GAZA CITY

By: Mohammad Subhi El-Lulu

Al-Azhar University of Gaza

Deanship of Postgraduate Studies and Research Affairs

Faculty of Pharmacy

Master Program of Clinical Nutrition

Assessment of Nutrition Knowledge of Palestinian Physicians

Employed in Shifa Hospital - Gaza City

A small Project

for Fulfillment of the Degree of Master of Clinical Nutrition

By

Mohammad Subhi El-Lulu

Supervisor

Dr. Jehad H. Elhissi Ass. Prof. of Public Health

Health and Nutrition Consultant

July- 2011

Dedication

I would like to dedicate this work

to the memory of my father “Subhi Salem El-Lulu”;

to my mother; to my brothers and sisters particularly

“Fawzi and Dr. Fathia”; to my wife and my lovely

children “Omar, Lana, and Balsam”

Faithful Mohammad

3

Introduction

Research Problem and Significance

Objectives

Methods and Subjects

Results

Conclusion

Recommendations

Selective References

Contents 4

Introduction 5

Introduction 6

The World Health Organization (WHO) defines health as “a state of complete physical, mental, and social well-being, not merely the absence of disease and infirmity” (Blair, 2001).

“Nutrition is important for the maintenance of life, growth, reproduction, the functioning of organs and tissues, and the production of energy” (Webster-Gandy et al,

2008).

The role of nutrition in promotion, disease prevention and treatment of chronic disease is well recognized (Schaller & James, 2005).

7

Diet is now considered to play a substantial role in

the etiology of many chronic degenerative diseases

such as coronary heart disease, atherosclerosis,

type-2 diabetes mellitus, osteoporosis, and some

cancer types such as bowel, stomach, breast and

prostate cancers (Turrell, 1997).

Introduction

Knowledge Background 8

Most individuals generally regard their physicians

as the primary source of diet and nutritional

information (Hu et al, 1997).

Survey studies revealed that physicians are hesitant

to provide nutritional information to patients due to

low levels of confidence resulting from a lack of

education and knowledge in this field (National health

promotion and disease prevention objectives, 2000).

9

Physicians have the potential to decrease morbidity and mortality if they provide effective nutrition counseling and advice (Kushner, 1995).

Rogers (1983) identified three types of knowledge:

(1) awareness (such as diet- disease relationship),

(2) Knowledge of principles (e.g. cholesterol is found in animal foods only),

(3) how to knowledge (e.g. how to select foods with less fat or how to read a food label accurately).

Knowledge Background

Nutrition in medical education in Palestine

1) Al-Azhar University provide two credit hours for general principles of nutrition at college of medicine.

2) Islamic University doesn’t provide a course of nutrition within curriculum plan.

1) An-Najah National University provides a course of nutrition that discusses the relationship of diet and diseases.

2) Al-Quds University of Abu-Dis doesn’t mention the academic plan of curriculum.

10

Gaza Universities West Bank Universities

11

Islamic University of Gaza provides Professional

Diploma in Children Health and Nutrition “Just for

Doctors” at college of Continuing Education.

Al-Azhar University of Gaza since 2006 has been a

Master Degree of Clinical Nutrition (MDCN), and

some of students in the program are doctors as many

other medical fields.

That means: the nutrition become a new developing

branch within medical education, which reveal the

importance of nutrition to help and support medicine.

Nutrition in higher education in Palestine

Research Problem and Significance 12

Research Problem & Significance 13

Five of the 10 current leading causes of death in

United States (coronary artery disease, cancer,

stroke, diabetes and atherosclerosis) are strongly

linked with unhealthy dietary habits.

Also, diet contributes importantly to the risk for

osteoporosis, obesity, hypertension and neural tube

defects (Promoting health/ preventing disease, 1989).

14

In 1990, the US Congress passed the National

Nutrition Monitoring and Related Research Act,

which mandated “that students enrolled in United

States medical schools and physicians practicing in

the United States have access to adequate training

in the field of nutrition and its relationship to

human health” (National Nutrition Monitoring and Related

Research Act, 1990).

Research Problem & Significance

15

To identify the general nutrition knowledge of physicians working in Shifa hospital.

To evaluate the concepts of patient’s nutritional assessment.

To identify the role of physicians in nutrition education.

To identify the knowledge of physicians regarding nutrition situation of hospitalized patients who are taking “total parenteral nutrition or enteral feeding”.

To recommend the decision makers about the importance of nutrition in treating and preventing diseases.

Objectives

Methods and Subjects 16

Study design 17

A descriptive cross-sectional design was used to determine nutritional knowledge. The study depends on reviewed questionnaire by associated professors working in academic and medical fields.

Dependent variable (knowledge of nutrition). Discusses the general principles of nutrition knowledge, as well as disease- nutrition relationship.

Independent variable (physicians):

Age, Sex (male and female), Graduation (bachelor,

master and MD), and Department.

Sample and sampling 18

Sample size:

Purposeful non probability sample was taken; the sample consists of 36 physicians.

Study setting and period

The study was conducted in Shifa hospital in Gaza city, which is a large public hospital from March 2011 to July 2011.

Target population

All physicians who are working at Shifa hospital (Surgical and Obstetric) departments.

Ethical consideration 19

Approval letters from Deanship of Pharmacy.

Approval and permission letter from General

Administration of Human Resource Development

(the main department at Ministry of health for

scientific researches).

Approval signature from the head of department.

Informed consent from participated physicians.

Eligibility criteria

Male and female

physicians currently

employed in the

hospital.

Trainees and (Job

Creation Program)

physicians

20

Inclusion criteria Exclusion criteria

Data collection 21

Questionnaire

4 Parts

• 1st part composed of physician’s personal characteristics.

• 2nd part explains training and practice.

• 3rd ask about knowledge of principles of nutrition.

• 4th awareness of diet- disease relationship

Criterion of Distribution

• 12 completed questionnaires from obstetrics and gynecology department.

• 24 completed questionnaires from surgical department.

Study analysis 22

SPSS

Coding Entry Cleaning Analysis

Results 23

1st part: Age of participants 24

Total

No. 36 100%

More than 45 years

No. 10 27.8%

From 35 to 45 years

No. 20 55.5%

Less than 35 years

No. 6 16.7%

1st part: Physicians sex distribution 25

Total

N0. 36 100%

Female

No. 7 19.4%

Male

No. 29 80.6%

1st part: Graduation degree of physicians

26

Total

No. 36 100%

PhD

No. 5 13.9%

Master

No. 19 52.8%

Bachelor

No. 12 33.3%

1st part: Departments of physicians 27

Total

N0. 36 100%

Gynecology and Obstetrics

No. 12 33.3%

Surgery

No. 24 66.7%

2nd: Studying the nutritional therapy in

school of medicine 28

Yes

No

If Yes

• 27 out of 36

• 75%

• 9 out of 36

• 25%

• Intensive Course (7.4%)

• Just Required Course (92.6%)

2nd: Courses of nutritional therapy at hospital

29

12

33.3%

24

66.7%

Yes

N

O

2nd: Can nutrition knowledge help and

develop practical medicine 30

• 35 out of 36

• 97.2% • (suggest the place) at next slide

Yes

• 1 out of 36

• Without reasons No

2nd: The best place for teaching the

nutrition therapy 31

At Medicine school

10

28.6%

At Continued Medical

Education

25

71.4%

2nd: Importance to have nutrition

department at hospital 32

Yes 33 (91.7%)

No 3 (8.3%)

Knowledge of Principles

Knowledge of Nutrition Assessment

Part 3 of Questionnaire 33

34

Nutrition Principles (Questions) No. (%)

Stearic acid is essential fatty acid as linoleic acid

Yes

No*

I don’t know

15 (41.7%)

6 (16.6%)

15 (41.7%)

Leptin hormone is important for

Hunger

Satiety*

I don’t know

11 (30.6%)

6 (16.6%)

19 (52.8%)

Peripheral Parenteral Nutrition can lead to thrombosis

Yes*

No

I don’t know

23 (63.9%)

10 (27.8%)

3 (8.3%)

Central Venous Feeding is safe from infections

Yes

No*

I don’t know

9 (25%)

24 (66.7%)

3 (8.3%)

35

Nutrition Principles (Questions) No. (%)

To avoid aspiration, Enteral tube should be inserted into

Stomach

Duodenum*

I don’t know

27 (75%)

5 (13.9%)

4 (11.1%)

Clear Liquid Diet such as Plain Gelatin can provide calories for

few days

Yes*

No

I don’t know

11 (30.6%)

6 (16.6%)

19 (52.8%)

Mechanical Soft Diet can’t be used for whom suffer from difficulty

of chewing or swallowing

Yes

No*

I don’t know

9 (25%)

9 (25%)

18 (50%)

36

Assessment (Questions) No. (%)

Body Mass Index (BMI) = Weight in (kg)/Height in (cm)²

Yes

No*

I don’t know

21 (58.4%)

7 (19.4%)

8 (22.2%)

An important parameter act with BMI to assess obesity for male

Waist/hip ratio*

Hip/waist ratio

I don’t know

4 (11.1%)

5 (13.9%)

27 (75%)

Do you know Subjective Global Assessment (SGA)?

Yes

No

If the answer is Yes

SGA could be adapted to predict postsurgical nutrition

associated morbidities:

Yes*

No

I don’t know

8 (22.2%)

28 (77.8%)

7 (87.5%)

0 (-%)

1 (12.5%)

37

Assessment (Questions) No. (%)

Do you know Instant Nutritional Assessment (INA)?

Yes

No

If the answer is Yes

INA adapted for nutritional assessment of preoperative

patients:

Yes*

No

I don’t know

8 (22.2%)

28 (77.8%)

4 (50%)

4 (50%)

0 (-%)

Do you know Nutrition Risk Index (NRI)?

Yes

No

If the answer is Yes

It can’t be used as an index of malnutrition in hospitalized

patients:

Yes

No*

I don’t know

10 (27.8%)

26 (72.2%)

3 (30%)

6 (60%)

1 (10%)

Awareness of diet- disease relationship

38 Part 4 of Questionnaire

39

Diet - disease relationship (Questions) No. (%)

Excessive homocysteine level in blood associated with

Cancer

Heart disease*

I don’t know

11 (30.6%)

5 (13.9%)

20 (55.5%)

Which of the following in excessive amount is Tertogenic?

Vitamin A*

Vitamin K

I don’t know

15 (41.7%)

5 (13.9%)

16 (44.4%)

In presence of renal stone of Calcium Oxalate, we have to reduce

the intake of

Sodium*

Calcium

I don’t know

5 (13.9%)

25 (69.4%)

6 (16.7%)

Extra-abdominal fat level can be associated with breast cancer in

female

Yes*

No

I don’t know

13 (36.1%)

12 (33.3%)

11 (30.6%)

40

Diet - disease relationship (Questions) No. (%)

Anti-thrombotic nutrient is

Vitamin E

Omega 3*

I don’t know

10 (27.7%)

15 (41.7%)

11 (30.6%)

A type of fibers help lowering cholesterol level in blood

Soluble*

In-Soluble

I don’t know

12 (33.3%)

14 (38.9%)

10 (27.8%)

Disadvantages of Total Parenteral Nutrition (TPN) are Gall Stones

and Cholestasis

Yes*

No

I don’t know

20 (55.6%)

8 (22.2%)

8 (22.2%)

A nutrient prevents Neural Tube Defect

Folate*

Cyanocoblamin

I don’t know

20 (55.6%)

5 (13.9%)

11 (30.5%)

41

Diet - disease relationship (Questions) No. (%)

Daily requirement of fluids for normal adult is 2.5 ml/kcal of body

weight

Yes

No*

I don’t know

9 (25%)

9 (25%)

18 (50%)

Healthy adults require at least 50 Kcal/kg of body weight

Yes

No*

I don’t know

13 (36.1%)

6 (16.7%)

17 (47.2%)

Basal Metabolic Rate is the minimum energy required to maintain

normal physiological function during exercise

Yes

No*

I don’t know

15 (41.7%)

10 (27.8%)

11 (30.5%)

Do you know Refeeding Syndrome?

Yes

No

7 (19.4%)

29 (80.6%)

Conclusion 42

Mean of grades of physicians knowledge

(general principles and nutrition assessment) 43

Mean

Minimum score: 0/12

3.11 SD: ±2.05

Maximum score: 9/12

Mean of grades of physicians knowledge

about awareness of diet- disease relationship 44

Mean

Minimum score: 0/12

3.66 SD: ±2.04

Maximum score: 9/12

45

Mean

Minimum Score

1/24 (4.16%)

6.77

(28.23%)

SD: ±3.22

Maximum Score

13/24 (54.16%)

Mean of Total Score No (%)

Relationship between age of participant physicians

and their percentage of nutrition knowledge 46

Age Percentage of knowledge

Less than 20%

No. (%)

20% - 40%

No. (%)

More than 40%

No. (%)

Less than 35 2 (33.3%) 2 (33.3%) 2 (33.3%)

35 – 45 5 (25%) 11 (55%) 4 (20%)

More than 45 1 (10%) 8 (80%) 1 (10%)

The result shows that:

less age / more knowledge

Relationship between age of participant physicians

and their percentage of nutrition knowledge 47

Pearson Chi- Square Value

Not Statistically Significant

(0.460)

Relationship between percentage of

knowledge and participants department 48

Departments

Percentage of knowledge

Less than 20%

No. (%)

20% - 40%

No. (%)

More than 40%

No. (%)

Surgery 5 (20.8%) 17 (70.8%) 2 (8.3%)

Obstetrics 3 (25%) 4 (33.3%) 5 (41.7%)

The result shows that: Physicians of obstetric department have higher

and more knowledge than physicians of surgery department

49

(0.038)

Pearson Chi-

Square Value

Statistically Significant

Relationship between percentage of

knowledge and participants department

Recommendations 50

51

Nutrition department at hospital is important request, because it

helps in clinical assessment, diet management, & status follow-up.

Physicians should take courses about basic and essentials of

nutrition, to get a proper understanding of nutrition.

School of medicines should have adequate course about nutrition.

Good training and practice at hospital through continued medical

education.

Physicians should take intensive course of nutrition therapy

according to their specialty.

Selective References 52

Blair S., (2001). Clinical exercise physiology for cancer, cardiovascular and pulmonary rehabilitation. Exercise Physiology. (Eds. McArdle W.D., Katch F.I., Katch V.L.). Fifth Edition. Lippinocott Williams and Wilkins. Philadelphia. PP: 912- 965.

Hu S.P., Wu M.Y. and Liu J.F., (1997). Nutrition knowledge, attitude and practice among primary care physicians in Taiwan. J. Am. College Nutr. 16: 439- 442.

Kushner R.F., (1995). Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Preventive Medicine. 24: 546- 552.

National health promotion and disease prevention objectives, (2000).US Department of Health and Human Services. Office of disease prevention and health promotion, healthy people 2010. US Public Health Service. Washington, DC. Government Printing Office.

53

National Nutrition Monitoring and Related Research Act of 1990, (1990). Public Law. 101- 445.

Promoting health/ preventing disease: year 2000 objectives for the nation, (1989). US Department of Health and Human Services. Washington, DC: US Government Printing Office.

Rogers E.M., (1983). Diffusion of Innovations. New York: Free Press.

Schaller C. and James E., (2005). The nutritional knowledge of Australian nurses. Nurse education today. Australia. 25: 405- 412.

Turrell G., (1997). Department of gender differences in dietary behavior. Nutr. Res. 17: 1105- 1120.

Webster-Gandy J., Madden A. and Holdsworth M., (2008). Oxford Handbook of Nutrition and Dietetics. Oxford. Oxford Medical Publications.

Selective References

Al-Azhar University of Gaza

Deanship of Postgraduate Studies and Research Affairs

Faculty of Pharmacy

Master Program of Clinical Nutrition

Assessment of Nutrition Knowledge of Palestinian Physicians

Employed in Shifa Hospital - Gaza City

A small Project

for Fulfillment of the Degree of Master of Clinical Nutrition

By

Mohammad Subhi El-Lulu

Supervisor

Dr. Jehad H. Elhissi Ass. Prof. of Public Health

Health and Nutrition Consultant

July- 2011