kok si diabetes research proposal[2] filerunning head: type 2 diabetes mellitus in kok si adults...

Running Head: TYPE 2 DIABETES MELLITUS IN KOK SI ADULTS

Type 2 Diabetes Mellitus in Kok Si Adults (≥45 years old):

A Proposal for Research Determining Dietary Habits and Physical Activity Levels in a Northeast

Thailand Community during November 2013.

Emily Hoff, Lisa White, Niyeti Shah, Yian Saechao,

Khon Kaen University

TYPE 2 DIABETES MELLITUS IN KOK SI ADULTS 2

Executive Summary

Type 2 Diabetes Mellitus (DM2) is a major health concern in Thailand that disproportionally

affects the Northeast region. Previous research found a high prevalence of DM2 in Kok Si, a

community located outside of Khon Kaen. The study aims to gain an understanding of the DM2

prevalence and prevention measures in Kok Si; specifically, “Do Kok Si community adults (≥45

years old) engage in regular physical activity and eat a healthy, balanced diet?” We expect to

find high physical activity levels and unhealthy dietary habits, as previous CIEE research

suggests. The literature demonstrates the discrepancy between the high rates of DM2 in the

Northeast and low rates of awareness, diagnosis and education regarding DM2. To conduct our

research, we will assess previous data, give surveys, conduct semi-structured interviews and hold

a focus group. The tools will produce concrete data regarding community members’ individual

dietary habits and physical activity levels as well as the community perception of DM2. If our

data is consistent with our hypothesis, potential interventions may include nutritional education

tailored to the Kok Si population.


Topic

Over the past twenty years, the prevalence of type 2 diabetes mellitus (DM2) has significantly

increased in Asia. According to a 2003 study, nearly ten percent of the Thai population

experiences diabetes and half of DM2 cases in Thailand are undiagnosed (Aekplakorn et al.).

Currently, Thailand is undergoing a nutritional transition, where processed foods high in sugar

and fat are consumed more frequently than whole foods. The transition has resulted in an

increased prevalence of DM2 in Thailand. The most impoverished region of Thailand, the

Northeast, has been disproportionately affected by the epidemic. A lack of health education and

health services in this region has produced difficulties in combating DM2. The following study

will focus on Kok Si, a 600 person community, located directly outside of Khon Kaen in the

Northeast region of Thailand. A previous CIEE student group found that the majority of villagers

in Kok Si are over the age of 45.

Objectives

The research conducted in Kok Si will aim to understand the current status and perception of

DM2 within the community. Research will focus on determining the prevalence of DM2 and the

levels of physical activity and appropriate nutritional consumption in Kok Si. Semi-structured

interviews and a focus group will be held to identify the community and stakeholder perspectives

of the current status of DM2 in the Kok Si community. To determine the prevalence of DM2, we

will assess previously collected health records and conduct a survey. To determine the levels of

physical activity, we will ask community members to state how often they engage in physical

activity. To determine the levels of appropriate nutrition consumption, we will ask community

members to identify daily eating and cooking habits.


Research Question

Regular physical activity and appropriate nutrition help prevent the development of DM2. To

identify the factors that contribute to the prevalence of DM2 in the Kok Si community, our study

asks “Do Kok Si community adults (≥45 years old) engage in regular physical activity and eat a

healthy, balanced diet?” Previous research suggests that exercise classes and soccer practices

occur daily within the Kok Si community (CIEE Student Research, 2013). If Kok Si adults

attend the community exercise events and/or frequently engage in other types of physical

activity; then, lack of physical activity would not contribute to the high prevalence of DM2

within the community. Observations from community visits suggest that Kok Si adults tend to

eat traditional Issan food: a diet high in animal products and simple starches. If Kok Si adults do

not eat a healthy, balanced diet; then, lack of appropriate nutrition contributes to the high

prevalence of DM2 within the community.

Rationale for Study

A previous CIEE student group found that out of the 30 households surveyed, three percent of

households had at least one individual with diabetes. However, in an interview with the same

student group, a community leader stated that one-third of the Kok Si population was diagnosed

with DM2. Although the community prevalence of DM2 is unclear, members believe DM2

represents the greatest health concern. Kok Si’s large elderly population (≥60 years of age)

increases the likelihood that community members will develop DM2. Additionally, DM2

represents one of the most common reasons villagers visit the hospital (Previous CIEE Study,

2013). Due to the perceived importance and inconsistent data, concrete information detailing the

factors that contribute to and the prevalence of DM2 in the Kok Si community should be

established.


Literature Review

Introduction

DM2 is largely preventable through healthy diet, weight management, and physical activity (Hu,

2010). Treatment of DM2 includes controlling blood sugar levels through diet and exercise and

prescription of pharmaceuticals to improve the body tissues' sensitivity to insulin and lower

glucose production in the liver (Mayo clinic staff, 2013). When foods containing starch or simple

sugars are digested and absorbed, insulin helps the body store the energy for later use (Hu, 2010).

In DM2, the body either becomes resistant to insulin or does not produce enough insulin to

maintain normal glucose levels (Hu, 2010).

Background

Diabetes affects 347 million people across the world. In 2004, around 3.4 million people died

from consequences of undiagnosed or untreated diabetes. Diabetes disproportionately affects

middle and low-income countries with 80% of diabetes related deaths occurring in these

locations. By 2030, projections indicate that diabetes will represent the seventh leading cause of

death (WHO, 2013). One in 13 Thai adults has diabetes causing 6% of all deaths in Thailand

(WHO, 2012; Deerochanawong and Ferrario, 2013). In Thailand, women are more likely to be

affected by diabetes than men with 6.9% of women exhibiting signs of diabetes in 2009.

Diabetes represents the second leading cause of death in women (8.0%) and the tenth leading

cause of death in men (3.2%) in Thailand. Rates of diabetes among females in rural Northeast

Thailand match those of Bangkok as the most prevalent rates in the country. In spite of the high

prevalence, the Northeast region of Thailand demonstrates the lowest rates of awareness and

lowest rates of diabetes diagnoses (Aekplakorn et al., 2007). This gap shows that there is a


discrepancy between the large need and the low diabetes awareness. Our research aims to

address this gap in the Kok Si community.

Risk Factors

As individuals age, they are more likely to develop DM2 as cells become insulin resistant. A

family history of DM2 indicates that an individual is more likely to acquire that disease. DM2 is

more common in certain racial/ethnic groups; specifically, in people of Asian descent (Hu, 2010).

High Body Mass Index and physical inactivity contribute a greater chance of developing DM2.

An individual is more prone to develop DM2 if they have hyperlipidemia. In addition, an

individual with hypertension is more likely to acquire diabetes. Specifically in Kok Si, the risk

factors of unhealthy nutrition practices and lack physical activity of villagers must be assessed to

prevent and treat the DM2 epidemic.

Levels of DM2 Education

Globally, urban developed regions tend to have a higher understanding of DM2, while rural

developing regions generally lack medical understanding of DM2 (Zahnd, Scaife & Francis,

2009). There is a gap in the literature regarding knowledge of risk factors and treatment of DM2

in Northeast Thailand. In 2003, researchers concluded that one-half of all diabetics in Thailand

are undiagnosed (INTERASIA collaborative group, 2003). These findings reflected the lack of

education regarding DM2 among the general Thai population. It is of great importance to raise

awareness of DM2 in Kok Si because of their aging population. Furthermore, additional DM2

resources are necessary to promote access to medical services and health education.

Conclusion

DM2 represents a worldwide health crisis. Lack of physical activity and poor nutrition leads to

the development of DM2. The lack of research on the education of the Thai population relating


to DM2 is reflected in the high rates of undiagnosed individuals with DM2. The Northeast has

seen disproportionately high rates of DM2; however, little literature exists regarding prevention

methods, education and treatment in the region. The current gap in research shows the necessity

of researching DM2 in a Northeastern community such as Kok Si to address prevention and

treatment methods for DM2.

Conceptual Framework


Methods and Data Collection Plan

Study Tools

We will first examine available data in the Kok Si community. Using a data collection

instrument, we will look through individual health records to document the prevalence and

demographic information of community members with DM2. While using the study tool, we will

record data using a previously assigned household numbers from a map of Kok Si (International

Program for Development Evaluation and Training, 2007).

Next, a survey and semi-structured interviews will be conducted. The survey comprised of open

and closed questions will be administered to available community members ≥45 years of age.

Surveys will be given interview style through a translator. The survey will address dietary habits

and weekly physical activity and identify individuals with DM2.

Semi-structured interviews will be completed with community stakeholders such as village

health volunteers, the headman and village leaders. Interviews will identify the current

perception of DM2 and local health resources available to community members. The semi-

structured interviews will consist of open-ended questions and will provide an opportunity for

community leaders to discuss their perception of the status of DM2 in the community.

Finally, a focus group will be conducted to provide community members with an opportunity to

address any further topics. The focus group will address the community perception of health

personnel and DM2, while allowing community members to express concerns and needs for

potential intervention projects.

Sample

The population will consist of community members in the Kok Si community (moos 7 and 10).

The sample size depends on the volume of available records. Surveys will be conducted with


community members ≥45 years old identified by convenience in over 30 households. Semi-

structured interviews will be conducted at least five times with at least one interview from a

community leader and village health volunteer. The focus group will consist of 8-10 available

individuals (≥45 years old) with and without DM2.

Data Collection

To efficiently gather data, we will divide into two groups. We will first look through previous

records and gauge the amount of data can be collected. Group 1 will work through the previous

records, while group 2 will begin to conduct surveys. Surveys will be conducted with one

translator. While conducting surveys, one student will administer the survey and the other will

take notes. After previous records have been assessed, group 1 will join group 2 to continue

conducting surveys. After the survey data as been collected, we will administer semi-structured

interviews. During the interviews, one student will conduct the interview, while three students

take notes. After the interviews, we will discuss the collected data. Three hours prior to the focus

group, we will restructure questions based on collected data. The translator will be briefed an

hour before the focus group on the goals of the session. During the focus group, there will be one

main facilitator, a supporting facilitator and two note takers.

Ethical Implications

Throughout our research, we will remain aware of the ethical implications associated with

human-based research. Participation in the surveys, interviews and the focus group is completely

voluntary and participants will be informed that all questions are optional. The owner of the

available data on Kok Si will release the use of records and all collected data will be recorded

using a house number to maintain personal privacy. Semi-structured interviews will be labeled


based on occupation and participants in the focus group will be labeled using numbers for note

taking purposes.

Limitations

Several limitations may arise during the study. Translators will be used for each community tool,

which may result in miscommunication. Small exchanges may not be translated, which may

result in incomplete or skewed data. Previous records may not be complete or up to date. During

the focus group and interviews, participants may be uncomfortable answering questions

truthfully to a group of non-community members. Additionally, community members may not be

available for interviews. Finally, we will conduct research with a small population based on

convenience, which may produce a bias.

Study variables

Throughout our study, we will be referencing a number of both qualitative and quantitative

research variables to obtain data and information on DM2 in the Kok Si community.

Qualitative Variables

Prevention methods. Prevention methods are choices made to avoid the onset of DM2.

These methods occur at the primary level and include regular exercise (150 minutes or more a

week), eating healthy meals and regularly monitoring or lowering weight and blood sugar (Mayo

Clinic Staff, 2013).

Treatment methods. Treatment methods are the acts and handlings associated with

dealing with someone affected by DM2. Treatment methods aim to control the effects of such

conditions and look for long-term solutions and cures. Treatment methods can occur at the

primary level to the tertiary level and may include diet control, sodium restriction, drug therapy,

weight loss and surgery (American Diabetes Association, 2003).


Nutrition. Nutrition is the consumption of food in relation to one’s dietary needs along

with physical exercise. Regarding dietary needs, data collected will include caloric intake, types

of foods consumed and frequency of food consumption (W.H.O., n.d.).

Dietary habits. Dietary habits are the repetitive consumption patterns of an individual

including the types of foods, number of meals and caloric intake.

Healthy diet. A healthy diet includes fruits, vegetables, whole grains, low-fat dairy

products and lean protein. A healthy diet is low in saturated fats, trans fats, salt and added sugars,

while staying within an individual’s caloric need (C.D.C., 2007).

Unhealthy diet. An unhealthy diet does not focus on fruits, vegetables, whole grains,

low-fat dairy products and proteins, while including a large amount of saturated fats, trans fats,

cholesterol, salt and added sugar. An unhealthy diet may also include an excess of caloric intake

beyond an individual's need (C.D.C., 2007).

Risk factors. A risk factor is any characteristic or exposure of an individual that will

increase their likelihood of developing a disease or health condition (W.H.O., n.d.).

Risk factors for DM2. The risk factors for DM2 include a family history of DM2, obesity,

physical inactivity and an unhealthy diet (American Diabetes Association, 2013).

Social determinants of health. The social determinants of health are the conditions in

which people are born, live, grow and work that contribute to their health. This includes

education, income and the distribution of power both locally and globally. The social

determinants of health can greatly affect individual health and highlight health disparities

populations (W.H.O., n.d.).

Health education. Health education is previous knowledge gained regarding health,

formally or informally, that help individuals and communities improve their health. The


education can be provided through a formal institution, word of mouth, a village health volunteer,

a community leader or through print or media sources. For this study, health education may

include understanding the definition and development of DM2, prevention methods, risk factors

and treatment methods (W.H.O., n.d.).

Perception. Perception is an individual’s interpretation of a current situation. Perception

can include social-stigma, outlook on disease, attitudes and beliefs.

Range of perception. The participant will define good perception, sufficient perception

and poor perception. In each tool, community members will be asked if they believe a certain

system or item is good, sufficient or poor and then asked to explain their reasoning behind this

choice.

Local health resources. Local health resources are health-related materials, personnel,

facilities, funds and any other tool that can be used for providing health care and services within

the boundaries of the Kok Si community.

Health personnel. Health personnel are all people whose primary purpose is to improve

health. This can include a village health volunteer, nurse, doctor, traditional healer, pharmacist or

traditional medicine practitioner (Mohr, 2006).

Quantitative Variables

Regular physical activity. Physical activity is a bodily movement produced by skeletal

muscles that requires energy expenditure (WHO). This includes walking, cycling, attending an

exercise class or participating in a sport for more than 30 minutes continuously (W.H.O., n.d.)

Utilization. Utilization is the frequency of which a specific resource or tool is provided

to an individual. Utilization will be recorded by the number of times a tool is used per month in

the Kok Si community.


Discussion

By assessing previous data, a survey, semi-structured interviews and a focus group, we will

research the prevalence of DM2 and the appropriate nutritional consumption and physical

activity levels of Kok Si community members. The success of our research will be based largely

on the completion of numerically set goals as outlined above for each study tool. The focus

group and interviews will be measured based on frequent participation and the discussion of

community needs regarding DM2. We will be using SPSS to analyze data and identify any

outliers, to ensure that we have collected accurate data.

Possible interventions may include creating a Kok Si specific food pyramid or discussion portion

control by having community members create an “ideal” meal. If we find that appropriate

nutritional consumption levels are high and physical activity levels are low, we will use the focus

group to further discuss physical activity in the Kok Si community. We will work on an

intervention addressing physical activity opportunities for community members not involved in

daily exercise classes.

After completing all research, we hope to find a community-based request for information or

programming related to DM2. These findings will allow for further work to produce an invention

that encompasses community input, community need and community health concern.


References

Aekplakorn, W., Abbott-Klafter, J., Premagamone, A., Dhanamun, B., Caikittiporn, C.,

Chongsuvivatwong, V., Suwanprapisa, T.,… Lim, S. (2007). Prevalence and

Management of Diabetes and Associated Risk Factors by Regions of Thailand: Third

national health examination survey. Diabetes Care, 3(8), 2007-2012.

American Diabetes Association. (2013). Diabetes Basics; Your Risk. Retrieved from

http://www.diabetes.org/diabetes-basics/prevention/risk-factors/

Healthy eating for a healthy weight. (2007, September 27). Retrieved November 18, 2013, from

Centers for Disease Control and Prevention website:

http://www.cdc.gov/healthyweight/healthy_eating/

Hu, F. (2010). Globalization of diabetes. American Diabetes Association, James, P. (2013,

August 1). Interview by F Fleck. All-of-government approach needed to tackle obesity.

Mayo Clinic Staff. (2013, Jan 25). DM2: risk factors [Fact sheet]. Retrieved November

18, 2013, from Mayo Clinic website:

http://www.mayoclinic.com/health/type-2-diabetes/DS00585/DSECTION=risk-factors

Mayo Clinic Staff. (2013, May 29). Obesity prevention [Fact sheet]. Retrieved November 18,

2013, from Mayo Clinic website:

http://www.mayoclinic.com/health/obesity/DS00314/DSECTION=prevention

Mayo Clinic Staff. (2013, May 30). Diabetes prevention: 5 tips for taking control [Fact sheet].

Retrieved November 18, 2013, from Mayo Clinic website:

http://www.mayoclinic.com/health/diabetes-prevention/DA00127

Mayo clinic staff. (2013). Diabetes. Retrieved from

http://www.mayoclinic.com/health/diabetes/DS01121


Mohr, J. (2006). The World Health Report: Health workers. World Health Organization.

World Health Organization (2012). Progress in diabetes control in Thailand. Retrieved from

http://www.who.int/features/2012/story_diabetes_thailand/en/

World Health Organization (2013). Diabetes Fact sheet N312. Retrieved from

www.who.int/mediacentre/factsheets/fs312/en/index.html.

World Health Organization. (n.d.). Health education. Retrieved November 18, 2013, from World

Health Organization website: http://www.who.int/topics/health_education/en/

World Health Organization. (n.d.). Nutrition. Retrieved November 18, 2013, from World Health

Organization website: http://www.who.int/topics/nutrition/en/

World Health Organization. (n.d.). Physical activity. Retrieved November 18, 2013, from World

Health Organization website: http://www.who.int/topics/physical_activity/en/

World Health Organization. (n.d.). Risk factors. Retrieved November 18, 2013, from World

Health Organization website: http://www.who.int/topics/risk_factors/en/.

World Health Organization. (n.d.). What are social determinants of health? Retrieved November

18, 2013. Retrieved from

http://www.who.int/social_determinants/sdh_definition/en/index.html

Zahnd, W., Scaife, S., & Francis, M. (2009). Health literacy skills in rural and urban

populations. American Journal of Health Behavior, 33(5), 550-557.

kok si diabetes research proposal[2] filerunning head: type 2 diabetes mellitus in kok si adults...

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