Strategies for the Dietary Control of Diabetes

St castgies for the Dietary oblige of DiabetesA survey of the juvenile strategies for the forageary control of diabetes in the philia atomic number 99INTRODUCTION world-shaking changes in the political and socio-economic climates have been the hallmark of the expire decade in the m whatever of the countries in the Middle East specially those located in the territories of the Arabian Gulf. These changes have impacted in no small port on the demographics of the affected countries. Notable argon the obvious shifts in progress distribution and a perceptible increase in healthy charter expectancy. Further more than, there have been alterations in the conventional lifestyles of the people living in these countries perhaps due largely to westernization, rapid urbanization and industrialization (Abdella et al 1995). It is withal worth mentioning that disease types, trends and or their prevalence have also changed dramatically. Prominent among these is diabetes.Diabetes delineat ionThe incidence and prevalence of diabetes have consistently change magnitude in the drop dead 20 years these changes have paralleled environmental shifting as well as the adjustments to changes above mentioned (Abdella et al 1995 Zimmet et al 1977). The modern findion of the World Health Organisation (WHO 2007) indicates that there forget be win increases in the prevalence of diabetes in the Middle East. A running(a) committee of the WHO on diabetes defined the disease as a metabolous disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of refined sugar, expand and protein metabolism upshoting from defects in insulin secretion, insulin action, or both the matters being long-run damage, dysfunction and failure of various organs (Alberti and Zimmet 1998). Diabetes is ca utilize by a neediness of the hormone insulin, which is produced by the -islet cells of the pancreas. Glucose is the primary energy source for all cells and is pass o nd by digestion of carbohydrates from the nutriment. Insulin enhances the body cells uptake of glucose from fall plasma. Hence, defects in insulin secretion, insulin action, or, most commonplacely, both leads to diminish uptake of glucose by the cells and an increase in blood glucose levels. Sustained increases in blood glucose level exit lead to the excretion of glucose in the peeing when such increases exceed the renal threshold of the molecule. This in turn leads to the usual symptoms of diabetes excessive production of urine (polyuria) and extreme thirst (polydipsia). Fatty acids from fatty tissue stores are metabolized as an alternative energy source when the body senses a lack of glucose, the result is weight loss and fatigue otherwise common symptoms of diabetes (Maitra and Abbas 2004). The clinical profile of diabetes varies minimally between the countries of the Middle East. In capital of capital of capital of capital of Kuwait for example, because of the marked d isparity between individuals in their age of diabetes onset, mode of presentation, and the point in date of obesity, the clinical profile of the disease is heterogeneous (Abdella et al 1995).Diabetes mellitus is not a single disease entity, but rather a group of metabolic disorders sharing the common underlying feature of hyperglycemia. Type 1 (early-onset diabetes or insulin-dependent diabetes (IDDM) and Type 2 (maturity-onset diabetes or non-insulin-dependent diabetes (NIDDM) diabetes are well kn cause types and are characterized by the different metabolic processes of the disease (Alberti and Zimmet, 1998). Type 2 accounts for closely 80% of the disease worldwide. The chronic hyperglycemia and attendant metabolic dysregulation may be associated with secondary damage in multiple organ systems, especially the kidneys, eyes, nerves, and blood vessels (Maitra and Abbas 2004).The Role of Diet in the Management of DiabetesNutritional therapy is an intact part of the focusing of d iabetes and plays a vital role in lot people with diabetes achieve and maintain optimal blood glucose level ( join terra firma (UK) Prospective Diabetes remove Group (UKPDS), 1990 Delahanty, 1998). The nutritional counselling of perseverings is establish on order-based principles and recommendations for the treatment and saloon of diabetes and related complications (American Diabetes Association, 2002). These recommendations are based on evidence published in the international literature and from consensus and unspoiled opinion as required (Ha and Lean, 1998). The benefit of tight control of both blood glucose and blood shove in people with type 1 and type 2 diabetes has been demonstrated in several well controlled randomized large-scale studies (Diabetes Control and Complications Trial query Group, 1993 UKPDS 1998a,1998b). Generally, the objectives of strategies for the fodderetic control of diabetes are complementary to the aims of medical exam treatment. Dyson (2002) writinged that these involves but not limited to the followingMaintaining blood glucose at heart predetermined target rangeMinimizing the risk of hypoglycaemia for those patient ofs taking insulin or oral hypoglycaemic agentsAchieving weight loss in the obese patientReducing the risk of long-term complications of diabetesMaintaining blood constrict and lipid levels deep down predetermined target rangesImproving and maintaining suitable quality of life. (Dyson 2002)Rationale for the projectContemporary management of diabetes places emphasis on the individual patients responsibility for diabetes control of blood sugars and of victuals consumption. The concept of self- commission with regard to a recommended victuals is thus considered important in order for patients to maintain normoglycaemia and dishonor or prevent diabetes-related complications (Rubin and Peyrot, 1992 Rubin et al, 1997). The diabetic patient is expected to monitor his/her carbohydrate metabolism, energy p hthisis and the effects of insulin or recommended medicaments on blood pressure and sugar levels. This inevitably demands a level of apprehension about diabetes and of the effect of diet on the rise and or management of the disease. This survey exit explore the individual patients approach to control or support the pharmacotherapeutic management of his/her diabetes using diet. The battleground go out shed light on diabetic patients adherence to guideline dietary recommendations in the Middle East or on novel dietary strategies for the control of the disease. The results of this psychoanalyse is essential to health policies makers in the region and pivotal for governmental strategies to lessen the burden of the diabetic epidemics in the Middle East.Using Kuwait as First Port of Call for the Middle East Diabetes Diet Study (MEDDS)The middle east comprise a large region that covers split of northern Africa, southwestern Asia, and south eastern Europe consisting of Bahrain, Cyp rus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi-Arabian Arabia, Sudan, Syria, Turkey, United Arab Emirates, and Yemen. The Middle East Diabetes Diet Study (MEDDS) testament focus on Kuwait in its first phase. Implementation of the instruct in other countries of the Middle East go forth stem from its success in Kuwait following sequester modifications to adapt the take aim tools to the settings and subjects of these countries.Description of First butt end web site Kuwait is a relatively small country, (17, 818 km2 in ascend area) and is situated in the North Eastern part of the Arabian Peninsula. Kuwait carry ons the north and west borders with Iraq, is bordered on the south by Saudi Arabia and on the east by the Arabian Gulf. Total commonwealth of Kuwait in 2005 was 2, 867, 000 and over 88% of these were aged 15 and over pct Urban population out of total population was 100% during the homogeneous period (WHO 2007). The prevalence of diabetes in Kuwait was 104,000 in 2000 and the projection for the year 2030 is 319,000 this result amount to about 44% of the projected total population (WHO 2007).AIM AND OBJECTIVESAimThe aim of this proposal is to develop a fancy for the conduct of a cross-sectional survey of the recent (ObjectivesTo adjudicately engage a panel of experienced diabetes practitioners/clinicians to conceive head t to each oneers assessing patients companionship of their diabetes and the effects of their intellectual nourishment types and victuals principle on glycaemia and blood pressure control (in 11 main humanss)To develop and effectualate a diabetes-diet principalnaire tool for the studyTo apply the diabetes-diet pecker during a face to face semi-structured interview designed to further explore recent dietary strategies for the control of diabetesTo administer a 7-day diet dairy to respondents.Repeat the survey in other countries of the Middle EastMETHODOLOGYDevelopment of Study InstrumentsAn initial list of 11 patients familiarity reachs as shown below leave behind be utiliseBasic companionship about diabetes fellowship of patients own current management if involving pharmacotherapyConsumption of olives, fruits and vegetables, nuts and cereals in recent times.The expenditure of legumes in cooked foods in the last 5 yearsRecent pulmonary tuberculosis of dairy and meat products.Consumption of alcohol/wine in the last 5 yearsKnowledge of other food types consumed recentlyKnowledge of feeding pattern in recent timesKnowledge of occurrences of diabetes complications and or hospitalisations in the last 5 yearsKnowledge of the effect of food types and pattern of intake on control of blood pressure in the last 5 yearsKnowledge of the effect of food types and pattern of intake on the control of blood glucose in the last 5 yearsUnder each field of view, important points regarding each topic will be identified. To break content lustiness, a panel of 10 fourth-year pract itioners in the area of diabetes management will be identified and asked to record in diabetes-diet (MEDDS) instrumentate development phase (Kline 1986 Streiner and Norman 1989). The expert reviewers will include 2 pharmacists haved in caution of diabetes patients, 3 diabetes round nurses, 3 diabetes specialist dietitians and 2 consultants in the area of diabetes. These will be identified based on their records of diabetes patient care experiences and on their knowledge of the factors impacting on the progression of the disease. The diabetes-diet (MEDDS) instruments content experts will rate each of the topic domains and indicate the percentage weight of each domain within the entire study tool. Between 6 and 12 multiple-choice questions will be created for each domain, with a focus on teaching ranked by the experts as most important for the objectives of the study. The multiple-choice question format is chosen because it is comfortable to administer and it will be easy to ps ychometrically validate the ensuing instrument (Kline 1986). Each multiple choice question will have 4 possible responses, namely one right answer and 3 distracters. However, in order to fully capture both emerging theme, respondents will be allowed time to comment freely on the questions and the multiple choices in a semi-structured interview. These will then be transcribe for analysis. Existing questions from previous studies may be harnessed and modified by the panel. The expert panel will also rank the questions within the domain in descending order based on its relative impressiveness to patients diabetes diet requirement/knowledge. After the initial item bank is compiled, the expert panel members will be asked to rank the overall quality of each item on a scale of 1 to 5 (1 = poor, 5 = excellent) in terms of how well it tested each information point. These rankings will be utilize to eliminate questions and create a 20-30 item cowcatcher instrument. An item bank will be developed based on this information. Questions will be written at 7th grade teaching level as determined by the Flesch/Flesch-Kincaid Readability Tests calculated from Dave Taylor and intuitive systems (2007). Respondents will also be asked to fill a 7-day diet daybook. inclusion criteriaAdult volunteers aged 18-85, living in the study site with not less than 3 years diagnosing of type 1 or type 2 diabetes.Since retinal and vascular problems associated with diabetes mellitus are common, attempts will be made to administer the tools also in carers of blind diabetic patients. elimination criteriaAnyone diagnosed with a mental illness as it may be grueling to determine the truthfulness of information collected from these patients.Patients who are deaf this is because a researcher and the interviewee would need to be proficient in sign actors line for any cockeyedingful interview to take palceData-collection toolsThree data-collection tools will at long last be used (1) the diabe tes diet questionnaire (MEDDS tool), (2) a semi-structured interview using authorise questions developed by the experts group and (3) a health diary. The interview and diet questionnaire will be the main data source. The semi-structured interview will last for 20 -30 minutes and will be conducted to further explore dietary trends for the control of diabetes in the last 5 years this will be done at any location convenient for the respondents. The MEDDS questionnaire will be self or researcher administered during the face-to-face interview. A team of 8 interviewers will be trained by the researchers for 4 days in advance the start of data collection. The questionnaire will be translated into the local language of the study site. The study tools will be pre-tested for about 1 week in diabetes patients across age and sex variables of the target diabetic cohort as shown by Abdella et al (1995) for diabetic Kuwaiti. Larger scale administration of the instrument will be for 6 months fol lowing the pre-test period.Study population ground on the household registry linked to databases of diabetes organisations in Kuwait, the survey will stratify the area of Kuwait into seven strata according to the degree of urbanization, geographic location, and administrative boundaries. Townships or regularises will be selected from each stratum with the woof probability being proportional to its size. Sample selection will involve the use of multi-stage cluster random sampling procedure at the district level to select sub districts and zones from where the study sample could be drawn. In each district, the area will be sub-divided into sub districts from which 3 zones will be selected based on population size. Within the selected zones, households will be randomly numbered, and houses assigned even numbers will be selected into the final examination sample..Instrument AdministrationDiabetes patients or their carer (as may be necessary) will be identified for face-to-face semi-s tructured interview, the administration of the diet questionnaire and the filling of a diet diary in the final sample population. Knowledge of dietary recommendations for the management of their diabetes will be investigated types of food as well as feeding pattern in the last 5 years will be evaluated for each diabetes type. Answers will also be sought to questions that will extend insight into patients recent general daily energy intake and expenditure daily amount of carbohydrate and protein in the diet, control of blood pressure and glucose levels in the last 5 years. Respondents will also provide insights into changes in local custom for dietary control of diabetes. Following the interview and administration of the diet questionnaire, each thespian will be given a 7-day diet diary to complete after each meal or at the end of each day. It will be explained that the diet diary should contain food types and time of eating and all dietary tactic taken to maintain normal blood gl ucose level (47 mmol/litre). The diet diary will further explore the truthfulness of information provided in the interview/ questionnaire as well as shed light on how the respondents have presented their recent self-care dietary strategies for the control of their diabetes.The Use of InterpretersLinguistic cleverness is central to cross-cultural studies and problems that may arise due to the researchers not understanding the local language could be overcome by the use of an transcriber (Davies, 1999). It may also be reassuring for the respondents to see someone with whom they share the same culture and language during the interview periods (Freed, 1988). Interpreters will either provide verbatim translation during the face to face interview or conduct the interview independently following adequate training (Baker, 1981).Psychometric analysis of the Questionnaire for the Dietary Control of DiabetesEnsuring content and construct validity are appropriate methods to develop a knowled ge instrument. Questionnaire validity is ideally established by comparing the new instrument being developed with an established acknowledge standard. There are no such standard for the target patients of this study. reliableness is also a vital attribute of a sound knowledge instrument. The diabetes-diet (MEDDS) instrument will be said to be reliable when gain ground are consistent over time within a site or as implementation moves from one site/country to another. The divergence of the instruments results should in this case be due to straight differences among the individuals patients that will be enrolled into the study (Streiner and Norman 1989). nub ValidityContent validity refers to the extent to which a set of items reflects the intended content domain (De vellis 1991). A systematic approach to identifying important domains and developing specific items based on consultations amongst experienced practitioners in the management of diabetic patients will ensure the content validity of the Middle East Diabetes Diet Survey (MEDDS) instrument. This method follows those employed by Zeolla et al (2006) in determining patients knowledge of the management of their disease.Construct ValidityConstruct validity determines the instruments ability to function for its intended purpose (Kline 1986). The contrasted group method will be used in this study to determine the construct validity of the MEDDS tool (Kline 1986).Reliability of the Diet QuestionnaireA proportion of the diabetic patients recruited into the study will be followed-up after 4 months and urged to complete the diet questionnaire only. The time elapse is considered sufficient to reduce the impact of recall (Streiner and Norman 1989). A correlation coefficient will be calculated between the test get ahead from each administration. A coefficient of 0.80 or higher is considered acceptable for demonstrating testretest dependability (Streiner and Norman 1989).Hypothesis for Construct ValidityIf the ME DDS instrument is a valid tool to assess the recent approaches for the dietary control of diabetes, patients managed for diabetes, should be more knowledgeable and achieve significantly higher scores than those not diagnosed or managed for the disease. To confirm this hypothesis, the response of diabetic patients to the final instrument will be compared with responses of age-matched subjects without diabetes in the same setting. Construct validity would be confirmed if the mean generated score for diabetic subjects were significantly higher than those not diagnosed or managed for diabetes..statistical and Data AnalysisStatistical analyses will be by SPSS haveing 14. The results of the pre-test will be excluded from the analysis. Students t-test will be used to compare the differences in mean scores of patients managed and not managed for diabetes. Using chi-square (2), demographics characteristics will be compared between patients managed and not managed for diabetes. Pearsons cor relation coefficient will be used for the testretest reliability analysis. Descriptive statistics will be used to report patient demographics. The interview transcripts and the health diaries will be deliberated upon on more than one occasion to fully understand patients self care approach and identify individual patients dietary care strategies. Themes emerging from the interview will then be compared with dietary patterns ascertained in the 7-day diet diary and the diet questionnaire. Following a expound analysis of the results of all 3 tools, perceptions of respondents conformity to recommended dietary regimen or their general philosophy/strategy of managing diabetes with diet will be reached. honourable CONSIDERATIONThe study qualitative paradigm protocol will be submitted for review and approval by the local ethics committee for the study region. A covering letter describing the goals of the study will be provided to patients agreeing to participate. The purpose of the study w ill be very carefully explained to the respondents and their consent will be individually obtained before the study tools are administered. Each participant will also complete a brief demographic questionnaire. In cases of identified illiteracy, the information contained in the form will be read by the study interpreter and informed consent sought. All respondents will assured of anonymity, confidentiality and that they could withdraw from participation in the study at any time.EXPECTED OUTPUTInterventions to prevent diabetes in the Middle East should include culturally appropriate and effective ways to improve the nutritional adequateness of the diet in line with international guidelines for the dietary control of diabetes. The result of the study will indicate the knowledge gaps if any in the study population. Tight glycaemia control associated with certain food types and feeding strategies identified in the study may become basis for its recommendation and use in other parts of t he world for the control of the worldwide diabetes epidemic.ReferencesAbdella Nabila A., Moustafa M. Khogalib, Amani D. Salman, Shaker A. 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