It refers to the activities involved in searching for information on a topic and developing a comprehensive picture of the state as knowledge on that topic (Polit & Hungler, 1999).
The review of literature for the present Study has been done on knowledge regarding lifestyle modification among diabetes mellitus patients from published articles, textbooks, reports, newsletters, medline and internet search. The reviewed publications have been organized and presented as follows:
SECTION A: Literature related to diabetes mellitus
SECTION B: Literature related to effectiveness of structured teaching programme on diabetes mellitus
SECTION A: Literature related to diabetes mellitus
The retrospective cohort study was conducted among 4,368 hospitalized patients including 2,582 diabetic patients. It was conducted from Jan-2003 to Aug-2004 in general ward. The researcher analyzed the association of hypoglycemic episodes with death rate of inpatients and length of stay in the hospital with death rate of patients within one year after the discharge. Around 7.7% of hospitalized patients developed hypoglycemia. Multivariable analysis was undertaken to evaluate the associations. Around 85.3% increase of inpatient death rate and 65.8% death of patients within one year after discharge were associated with each additional day of hospitalization with hypoglycemia. During hospitalization, the number of inpatient death also peaked to threefold for every 10mg reduction of blood glucose level. For each additional day of hypoglycemia was associated with increasing of 2.5 days in the length of hospital stay. Thus the results revealed that the length of stay and death rate were increased both during and after hospitalization due to hypoglycemia. (Alexander Turchin , 2009).
A Markov model simulating individuals movement across different Body Mass Index categories, the incidence of diabetes, screening for diabetes, the natural history of diabetes and it's complications over the next 25years. The study population was 24 to 85 year old patients. Between 2009 and 2034, the number of people with diagnosed and undiagnosed diabetes will increase from 23.7 million to 44.1million. The obesity distribution in the population without diabetes will remain stable over with 65% of individuals of the population being overweight or obese. Annual diabetes related expenditure is expected to increase from 113 billion to 336 billion dollars. For the Medicare-eligible population, the diabetes population is expected to rise from 8.2 million in 2009 to 14.6 million in 2034, associated expenditure is estimated to rise from 45 billion to 171 billion dollars (Elbert S, et al., 2009).
A survey was conducted to analyze the medical records and administrative data of health plan. It was conducted as Translating Research into Action for Diabetes. The samples of the study were aged diabetic patients those who under diet, exercise and oral hypoglycemic agents at baseline, had HbA1c value of more than 7.2%. The sample size of the study was 1,093 diabetic patients. Among these patients 520 patients were undergone intensified therapy with insulin or oral hypoglycemic medications. Patients with intensified therapy were Compared with patients with not intensified therapy. Patients with intensified therapy had reduced 0.49% of HbA1c level, weight reduction of 3 pound. But there was no reduction in anxiety of patients with intensified therapy. The results revealed that there was a significant association between the HbA1c level and old age, black race, lower income and more number of physician visits (Laura N. McEwen, et al., 2009).
A randomized clinical trial was conducted as Diabetes Prevention Programme. The samples of the study were 3,234 participants who were at high risk for diabetes from 27 centers. Regression from pre diabetes to Normal Glucose Regulation during 3years follow up was identified by Cox proportional hazards model. Lower baseline fasting blood glucose (hazard ratio 1.52) and 2 hours blood glucose (hazard ratio 1.24) reduced to Normal Glucose Regulation. In the same way, younger age (hazard ratio 1.07) and better insulin secretion (hazard ratio 1.09) were resulted in regression to Normal Glucose Regulation. Further, there was a significant and independent effects on regression to Normal Glucose Regulation associated with Intensive life style modification (hazard ratio 2.05) and reduction of weight (hazard ratio 1.34). Metformin (hazard ratio 1.25), male sex (hazard ratio 1.17) and insulin sensitivity (hazard ratio 1.07) predicted a non significant regression. Results revealed that the younger age with better insulin secretion is the benchmark to restore Normal Glucose Regulation among pre diabetic people. However Normal Glucose Regulation could be achieved through reduction of weight and some other aspects of Intensive Life Style Modification (Richard F, Hamman, et al., 2009).
A study was assessed the effectiveness of Intensive Life Style Modification on diabetes prevention and sex related risk of diabetes. The samples of the Intensive Life Style Modification randomized from the subjects of the Diabetes Prevention Programme , those who are meeting the goals of Intensive Life Style Modification. Men were higher than women in meeting the more Intensive Life Style Modification goals. However men and women had same incidence of diabetes. There was no sex difference in risk factors for diabetes mellitus among those who reduced body weight of less than 3% during the first year of preventive programme. Men had better outcome in 2hrs blood glucose, concentration of insulin and insulin resistance than women due to 3-7% of weight reduction. Men had greater improvement in reduction of 2hrs blood glucose level, HbA1c and triglyceride level than women due to reduction of more than7% of weight. (Leigh Perreault, et al., 2008).
A study to assess the knowledge, attitude and practice regarding the effectiveness of counseling on lifestyle modification including disease condition and medications among selected hospitalized diabetic patients. Counseling was provided to the diabetic patients through regular bedside meetings, distribution of leaflets during hospital stay and during their regular follow-up visits up to 2 months after the hospital discharge. Around 46 samples recruited for the study. Among these patients 19 patients were in the experimental group and 27 patients were in the control group. In experimental group, 12 samples (63.1%) were given counseling by Kannada (local language of the study area). The counseling was given nearly 30 - 60 minutes. Around 13 patients (68.4%) were taught information regarding insulin. In the experimental group,10patients(52.6%) were given education regarding oral hypoglycemic agents. Knowledge scores of patients improved in the experimental group. Whereas there was no improvement in the knowledge scores of patient in the control group. Data was analyzed by Mann-Whitney test. However attitude and practice outcomes were not improved among those patients. The results revealed that the counseling regarding lifestyle modification among diabetic patients was effective (Suish palaian , et al., 2007).
A retrospective population based matched cohort study (1984-2004) performed using the population health information system in Canada to assess the effect of diabetes on fracture rates and possible interaction with age and duration of diabetes. The cohort study consisted of 82,094 diabetic adults and 236,682 non diabetic matched controls. Diabetes was classified long term, short term and newly diagnosed. Poisson regression was used to study counts of combined hip, wrist and spine osteoporotic fractures. Independent effects of longer duration of diabetes were observed on fracture rates. Newly diagnosed diabetes mellitus patients showed a reduction in osteoporotic fractures. Long term diabetes patients showed an increase in osteoporotic fractures. The study concluded that long term diabetes is associated with increased osteoporotic fractures (Leslie William, 2007).
A study was carried out to understand the knowledge, attitude and practices (KAP) regarding diabetes mellitus among the diabetic patients attending a diabetic education programme in Nepal medical college, results showed that the majority of patients had correct knowledge regarding diabetic diet, three fourths of them were subjected themselves to blood sugar checking at good intervals and almost all were under regular contact with physicians (Shrestha L, et al., 2006).
A study to assess the awareness of diabetes in individuals attending outpatient department of Ghurki trusts teaching hospital, Lahore. The study was conducted among a sample of 50 individuals recruited by convenience sampling technique, data was collected by administering a structured questionnaire during a two week period and resulted general awareness of diabetes mellitus in the participants of the study was poor (Robert J, 2006).
A study was conducted to assess the knowledge, attitude and practice outcomes among patients with diabetes mellitus in Manipal hospital. It was conducted in the year of 2006 between the period from 22ndAug to 7thDec. Structured questionnaire was used to collect the data from the samples. The sample size of the study was 182 diabetic patients. Among these 103 (56.59%) patients were men and 79 (43.41%) patients were women. Majority of the patients were the aged between 51-60 years. Descriptive and inferential statistics were used to analyze the data. The scores of mean, knowledge, attitude and practice were 7.78 Â± 3.8, 4.90 Â± 3.34, 2.03 Â± 0.95 and 0.84 Â± 0.7 respectively. The maximum possible scores of knowledge, attitude and practice were 18, 4 and 3 respectively. The results revealed that the patients scores regarding knowledge, attitude and practice were low. So further educational programmes are essential to impart the knowledge, attitude and practice outcomes (Dinesh K. Upadhyay, et al., 2006).
A study was conducted regarding the awareness about eye diseases among diabetics in South India. The researcher conducted a survey using a 20-point questionnaire among 1000 diabetics who attended the diabetic clinic. A structured questionnaire was used to assess the awareness regarding eye diseases due to diabetes mellitus and to receive opinion to improve the awareness regarding eye complications among diabetes patients. The study reported that amongst the population surveyed, the awareness that diabetes mellitus could affect the eye was about 84%, whereas the knowledge about diabetes among diabetics was less, only 46.9% of the persons interviewed knew that retinopathy was related to control of diabetes and 40.3% knew that it was related to duration of diabetes mellitus. Thus the report suggested that there was a definite need to increase the knowledge of diabetes patients regarding the eye complications associated with diabetes mellitus (Saikumar, et al., 2005).
A study was conducted to identify the prevalence of diabetes mellitus and the number of people affected with diabetes mellitus between the year 2000 and 2030. Prevalence of diabetes with regard to age and sex were estimated from 191 WHO states including US. In developing countries, people from urban area and rural area were separately taken for the study. Globally, people with diabetes mellitus were 2.8% in 2000 in all age groups. Whereas the prevalence diabetes mellitus is expected to increase at 4.4% by the year 2030 among all age groups. There were 171 million of patients with diabetes mellitus in 2000 and it is expected to raise the peak rate of 366 million by the year 2030. With regard to sex, men had higher prevalence of diabetes than women, but women with diabetes were higher than men. The results revealed that in developing countries, the urban people with diabetes were expected to double the number from 2000 to 2030. Further obese people had high prevalence of diabetes than non-obese people. So, obesity is one of the dangerous risk factors for diabetes mellitus (Sarah Wild, et al., 2004).
A study conducted on "knowledge and beliefs regarding Diabetes Mellitus" in overall Mexico. The findings revealed that, the glucose-screening project enrolled 521 Participants. Interviews were conducted with 37 of these with previously diagnosed Diabetes. Majority of participants received information regarding diabetes mellitus through a casual explanation and non-scientific way. Most of the informants were taught regarding one or more methods of Home remedies. Majority of the samples reported that the family members were given more social support than others. Most of the participants were liked to manage the diabetes with maximum resources. The results revealed that the dietary management, exercise management and other approaches can be modified with the help of family members and community than individual approaches (Anne Thomas, 2004).
A population based cross sectional study to assess the awareness and practices regarding diabetic retinopathy was conducted among non-medical population in south India. Semi-structured interview was held by the trained social workers with the help of structured questionnaire. The sample size of the study was 404. Among these 200 samples were paramedical personnel and 204 samples were community people. Samples were selected through randomization. Five-point likert scale was used to collect the data from the samples. More than 50% of people had no awareness regarding risk factors of diabetic retinopathy. One in five participants from the paramedics and one in ten participants from the community had awareness risk factor of diabetic retinopathy. Nearly 75% of participants had no awareness regarding either laser therapy and surgical intervention for diabetic retinopathy. Almost 80% of subjects in community group recognized the necessity of annual eye screening. But among those subjects only 43.5% of patients visited ophthalmologist. Nearly 75% of paramedics not had any resources regarding health education for diabetes mellitus. The results revealed that the maximum effort is needed to impart the awareness regarding diabetic retinopathy and to apply this improved awareness into practices (Namperumalsamy,et al.,2004).
The study was conducted on "awareness and knowledge of diabetes in Chennai"-the Chennai urban rural epidemiology study. A structured Questionnaire administered to 26,001 individuals and the result shows that only 75% (19642/26001) of the whole population reported that they know about a condition called diabetes, nearly 25% of the Chennai population was unaware of the condition called diabetes. In the study, 60.2% (15652/26001) of all participants and 76.7% (1173/1529) of the self reported diabetic subjects know that the prevalence of diabetes was increasing in India. Only 22.27% (574/26001) of the whole population and 41.0% (627/1529) of the Known diabetic subjects were aware that diabetes could be prevented. Awareness and knowledge regarding diabetes is still grossly inadequate in India. Massive diabetes education programmes are urgently needed both Urban and rural India (Mohan D, et al., 2003).
A cross sectional study describes the knowledge, attitude and practice (KAP) among 100 patients attending the diabetic clinic at Klinik Kesihatan Seri Manjung from December 2002 until January 2003. A face-to-face interview using a structured questionnaire was carried out for data collection. The results revealed that 87% of the respondents were able to answer 50% or more questions on knowledge correctly, while 98% of them had 50% or more score for the attitude questions. Ninety-nine percent of them reported 50% or more score for the questions on practice. However, only 56% of them practice all 4 of the practices that were asked regular exercise, healthy diet, monitoring blood glucose level and monitoring body weight respectively. There was a significant positive correlation between knowledge and attitude (r=0.536, p<0.01), but there was no significant correlation found between attitude and practice. The results indicate that an increase in knowledge will increase attitude, however this is not necessarily the same between attitude and practice. A better structured educational programme on diabetes and preventive measures should be conducted for all especially those with diabetes to improve their practice towards diabetes (Ranjini ambigapathy, et al., 2003).
In Bahrain, a study was done to assess the knowledge of diabetes mellitus among school teachers. A pre designed self-administered questionnaire was distributed to all the 1248 male and female teachers serving in those schools. The questionnaire was collected after one day. The response rate was 89% (n=1140). One thousand and sixty four teachers (93.3%) responded to the knowledge part of the questionnaire. The study showed that the school teachers in Bahrain are deficient in diabetic knowledge. The mean knowledge score was 5.34. Married teachers, primary school teachers and female teachers had better knowledge than other teachers. Also, knowledge was related to whether the teachers had an experience with illness, their qualifications or whether they adopt a healthy life style. Eighty one percent of teachers had university education and 19% had completed high school only. Science teachers had better diabetic knowledge (89.6%) than Arts teachers (83.6%) [P. value -0.05 Chi. Sq.value-4.505].The results reveal that teachers have inadequate knowledge of the basic facts of diabetes and its treatment (Faisal A. Latif, 2003).
A cross sectional study was conducted to assess the prevalence of diabetic retinopathy among diabetes patients. The samples of the study were diabetic patients those who aged above 50 years. Cluster sampling technique was used to select the samples. The sample size of the study was 5212 diabetic patients. Among these patients, response rate was 92%. Among 260 self reported diabetes patients, 68 (26.2%) patients had diabetic retinopathy. Nearly 5.1% of diabetic patients those who aged above 50 years had age-sex related diabetes mellitus. Whereas 26.8% of age-sex related diabetic patients had diabetic retinopathy. Further 94.1% of patients had non-proliferative diabetic retinopathy and it was the most common prevalence. The results revealed that preventive measures should be implemented to prevent the occurrence of blindness due to diabetic retinopathy (Narenderan, et al ., 2002).
A study was assessed regarding the etiology and natural history of diabetes. The purpose of the study was to reduce the risk factors of diabetes through lifestyle modifications and environmental changes. The study was organized in 25 centers. The sample size of the study was 4000 participants those who at risk for diabetes mellitus. The risk factors were old age, obesity, family history of diabetes mellitus and history of gestational diabetes. Samples were selected through randomization. Samples underwent semi-annual visits to check fasting blood glucose and yearly visit to measure oral glucose tolerance test at 75g of glucose uptake. Samples were monitored closely throughout their 3 to 6 years follow up period. The primary outcome of the study was the confirmation of non insulin diabetes mellitus based on WHO criteria. Diabetes was confirmed when the fasting blood glucose level of 140mg/dl and 2 hours blood glucose level of 200mg/dl after the uptake of 675g oral glucose tolerance test. Further the study results explored that the risk factors for cardiovascular disease alteration in blood glucose level, insulin sensitivity, insulin secretion, overweight, physical inactivity, dietary changes and poor quality of life (Berger H, 2002).
A study was conducted to assess the knowledge and practice on management of diabetes among 150 diabetic residents in Pondicherry. The study findings shown that, most of the diabetic patients were aware of the need for dietary care or medication, but only 50% modified their diet. Of the 97% were using anti-diabetic agents, some were using them wrongly and only 10.6% of the subjects tested their urine, although 71% were aware of the need for urine test. None of the patients had any formal education regarding diabetes and only 34% consulted the physician regularly. The results of these studies showed a large gap between knowledge and action and a need to reorient and motivate health personnel toward patient education regarding diabetes (Gopalan R, 2002).
A cross sectional study that examined the relationship between chronic physical activity and impaired blood flow in patients with type II diabetes mellitus and control subjects. Participants were separated into four groups based on a physical activity questionnaire - control exercise, control sedentary, diabetic exercise and sedentary subjects. Observation included a physical examination, neuropathic testing and skin blood flow measured non invasively by continuous laser Doppler assessment of lower limb blood flow in response to various stimuli. Control exerciser had greater perfusion than diabetic exerciser. Blood flow was higher in the control sedentary group than in the diabetic sedentary group. Regular exercise is associated with better skin blood flow (Colberg S.R, et al., 2002).
A randomized controlled trial on evaluation of clinical practice management of diabetes mellitus. Implementing a clinical practice guidelines for diabetes mellitus was the main purpose of the study. The study was carried out among diabetic patients in 2 diabetic outpatient department for 15 months during their follow up period. Around 144 type 2 diabetic patients those who aged 25-65 years were participated for the study. More than 75% of patients were African- Americans and Hispanic. Remaining participants were doctors and staffs who were trained regarding diabetes management practice guideline. A problem based teaching programme was provided regarding step by step approach to control diabetes mellitus. HbA1c value was checked during baseline, 9th month and 15th month of follow up. Descriptive and inferential statistics were used to analyze the data. From the analysis, the mean value of change in HbA1c was 0.90% in the experimental group. Whereas the mean value of change in HbA1c was 0.62% in the 15-month in the experimental group. The results revealed that there was a significant improvement in HbA1c value of experimental group. Whereas in the control group, there was no significant improvement in HbA1c level. The patients from the experimental group also followed standard of care as per doctor's guidelines. The results revealed that effective management of diabetes can be achieved by the clinical practice guidelines (Benjamin E.M, 2000).
A study to evaluate the long term feasibility of a high fiber diet composed exclusively of natural food stuffs and the efficacy of this diet in controlling blood glucose levels and incidence of hypoglycemic episode in diabetic clients. The diet which was introduced to randomized parallel groups of 63 patients of diabetes aged 25- 35 yrs were included in the study. The result showed that when compared with low fiber diet, the high fiber diet after 24 weeks increased both mean daily blood glucose concentration (11.8+3.3 vs 14.5+4.5 mmol/L. F=3.9; p<0.05) and number of hypoglycemic events (0.73+0.7 vs 1.5+1.2 events per patient per month, p<0.01). The compliance to high fiber diet was 83% and to low-fiber diet was 45%. The study conducted that a high fiber diet is feasible in the long term when compared with low fiber diet, improves glycemic control and reduces the number of hypoglycemic events in diabetic patients (Giaco, et al., 2000).
SECTION B: Literature related to effectiveness of structured teaching programme on diabetes mellitus
A randomized controlled trial was conduced among of 184 diabetic patients. Samples of the study were newly diagnosed type 2 diabetic patients and were not under insulin and they were selected through randomization. A planned teaching programme and planned teaching programme with additional guidelines and education regarding self-monitoring of blood glucose. Patients underwent regular follow up visits for once in every three months and they were followed the treatment guidelines according to HbA1c level. Nearly 66% of patients from the group of self monitoring of blood glucose. These patients were completed more than 80% of required treatment measures. With regard to HbA1C and hypoglycemia, there was no significant difference between the two groups. HbA1c level was 6.9% in both groups; the value of mean difference was 0.07% in the incidence of hypoglycemia. The patients in the group of self monitoring of blood glucose had high well being scores (O'kane M.J, et al., 2008).
The impact of diabetes education in maintaining lifestyle changes and stated that self-management education had a significant positive impact on regimen adherence and healthy eating sustained at 2 years. Areas of improvement included self-testing, exercise, foot care and multiple aspects of healthy eating. Long-term improvement in diabetes specific quality of life, degree of diabetes interference and self-efficacy were also found. Predictor analyses indicated that self-management education was more effective for those with a more recent diagnosis, previous diabetes education and less psychological impact from the disease. Age, duration of diabetes and regular meal patterns predicted long-term metabolic benefit. Finally, those with a higher initial body mass index and more psychosocial problems were more likely to drop out of self-management education (Michael Vallis, et al ., 2005).
A study to evaluate the possible influence of a structured teaching programme for interactive group education of diabetic patients on their overall wellbeing and metabolic control. The study included 110 diabetic patients. They were followed for one year after a 4 day structured teaching programme performed at University Department of Endocrinology, School of Medicine in Skopje. A re-education session one year after education, a significant improvement in metabolic control was noticed, HbA1c decrease from 9.2+ 1.3 to 7.7+1.8% (P<0.0005), diabetes related knowledge improved from 49.1+16.8 to 85.4+14.3% (P<0.05) and patient overall wellbeing improved from 46.6+8.3 to 54.8+5.9 (P<0.05) . Study results confirmed the improvement of overall wellbeing, metabolic control and diabetes related knowledge in diabetic patients after a structured teaching programme (Tatjana Milenkovic, 2004).
A structured teaching programme was conducted by 2 trained health care personnel for 6 hrs among newly diagnosed type 2 diabetic patients. The experimental group was compared with control group those who received usual care. At the end of the educational programme, researchers checked the level of HbA1c, weight, Bp, blood lipid levels, smoking habit of the patients, physical inactivity, quality of life, health-illness beliefs, emotional status of diabetic patients during baseline and up to one year period. During the 12th month 1.49% of reduction in the level of HbA1c was found in the experimental group. Whereas in the control group, 1.21% of reduction in the HbA1c value was observed. There was no significant difference between the experimental and control group in the level of HbA1c at 5% level of significance. But there were greater improvements in reduction of weight, quitting of smoking, positive beliefs in health and illness among patients with newly diagnosed type 2 diabetes mellitus. So the structured teaching programme was effective in improving the patient outcomes (Simmons, et al., 2003).
A meta analysis of 62 randomized controlled trials of educational and behavioral interventions to improve diabetic control in 8076 diabetic patients over a median of 4 months follow up, showing a fall in HbA1C of 0.45%. They currently employed educational and behavioral interventions in patients with type II diabetes mellitus produce measurable modest improvement in glycemic control (Garry, et al., 2002).
A study to assess the effectiveness of diabetes education programme was conducted among eighty three diabetic patients. The education was focused regarding self management of diabetes, self monitoring of blood glucose, motivational teaching and care of foot. The findings of the study shown that no amputations, no worsening foot risk category, only one admission for vascular related problems, reduced HbA1c, increased quality of life and improvement in self management behavior in the study group. Whereas in the control group, five amputations, worsening of foot risk category, ten vascular-related admissions, increased HbA1c, no improvement in quality of life and self management behavior were observed. So the education programme was effective. (Murray, 2000).