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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].

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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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risk of NIDDM in men. Diabetes Care. 1997; 20:545-550.

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risk of developing diabetes: prospective cohort study. BMJ 2008; 336:1348–

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27. Lawton J, Ahmad N, Hallowell N, Hanna K, Douglas M. Perceptions and

experience of taking oral hypoglycaemic agents among people of Pakistani

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physical activity in Asian Americans. Ann Epidemiol 2005;15: 257–65.

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activities and relationship to socioeconomic and health factors. The

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30. Anderson RM. The relationship between diabetes-related attitudes and

patients‘ self-reported adherence. Diabetes Educator 1993;19:287–92.

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with Type 2 diabetes. Diabetes Care 2005;28:1209–10.

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perspective. Aust J Rural Health 2006;14:2–8.

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Sethuraman K, Teoh LC. Audit of Diabates Mellitus in General Practice. Med

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health outcomes. J Gen Intern Med 2004;19:1228–39.

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2002;5:191–5.

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5:87–109.

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anthropology—the socio-cultural construction of diet.

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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.

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selfmonitoring in insulin treated type 2 diabetes mellitus: a cross-sectional

study with an intervention group. Diabetes Metab 1999;25:334–40.

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selfmonitoring of blood glucose among persons with diabetes. Diabetes

Educator 2004;30:112–25.

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D. Effects of health maintenance organization coverage of self-monitoring

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reagents increase blood glucose self-monitoring frequency and improves

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Rubin R, Wysocki T: Psychosocial therapies in diabetes: report of the

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(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).

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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