Commitment Of Palestinian Diabetic Patient In Therapeutic Diet In Nablus

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Chapter one Page1

1.1 Introduction:Diabetes is a manageable condition, its prevalence worldwide hasincreased dramatically in the previous four decades, For example, 17million people in the United Statesalone are currently affected by diabetes[1].In 2011, the total number of new reported cases of Diabetesmellitus in West Bank was (3,984) with incidence rate (154.4) per100,000 of population. In Nablus governorate (570) new reported cases,13.217 revisers of them in Nablus alone and the percentage of malerevisers to diabetes clinics (40.9%), while the percentage of female‘srevisers to diabetes clinics (59.1%) [2].The principal goal of diabetes management is to prevent the microvascular and macro vascular complications of the disorder, which areassociated with elevated blood glucose levels. It is now commonlyaccepted that the exerciseand diet regimen is the major reason for thediabetes and its complications.Maintaining blood glucose levels within the normal range is themost importance in the management of diabetes. Diet and exercisefactorsthat can have a great impact upon stabilizing blood glucose levels indiabetic patients and the commitment of it is the most important thing thatwe investigate it in our culture. Page2

Regimen adherence problems are common in individuals withdiabetes, making glycemic control difficult to attain. Because the risk ofcomplications of diabetes can be reduced by proper adherence, patientnon-adherence to treatment recommendations is often frustrating fordiabetes health care professionals. This study reviews the scope of theadherence degree and the factors affecting it.Actually, there are no enough studies that support this version thattalking about the commitment of diabetic patient in therapeutic diet.In fact, there are no studies have been found that investigatecommitment of diabetic patient in therapeutic diet and exercise inPalestine,and because of the lack of knowledge about the commitmentand adherence of diabetic patient in therapeutic diet, this study conductedto investigate the commitment of the diabetic patient in therapeutic dietand try to figure-out the factors that have effect on the commitment level.Hence this study was designed to assess the commitment degree ofPalestinian diabetic patient in therapeutic diet practice in Nablus and tofigure-out the factors that may affect the degree of commitment. Themajor research question was ―How much the degree of commitment intherapeutic diet practice among the participants?‖ Page3

1.2 Significance of the study:Diet and exercise are important lifestyle factors in the etiology ofdiabetes. Improved dietary habits and increased exercise have great effecton preventing the development of diabetic complication in the patients.Uncontrolled blood sugar causes damage to small blood vessels in thebody, leading to cardiovascular disease, kidney disease, eye problems andloss of sensation in the feet that can lead to amputations.So it‘s important to all diabetic patients to commit and adhering in thetherapeutic regimen and recommended diet to minimize risks thatdevelops complication. However few studies were conducted about thecommitment of diabetic patients and what factor have effect on it.Because of that it is important to study the dietary practice and adherenceand to figure-out the factor that has effect on it.1.3Aim of the studyThis study aim to assess the commitment degree of Palestiniandiabetic patient regarde to therapeutic diet practice in Nablus and tofigure-out the factors that may affect the degree of commitment. Page4

Chapter Two Page5

2.1 Research question1-How is the degree of commitment in therapeutic diet practice amongthe participants?2-Is there significant relationship between the demographic data (age,gender, marital status, place of residence, Income, that, degreeofcommitment?3-Is there significant relationship between (Access to and use ofmedication, regular checkup in the clinics, level of knowledge aboutdiabetes, and adherence to exercise) and the degree of commitment?2.2 BackgroundNormal pancreas and their functionThe pancreas is located behind the stomach and is surrounded byother organs including the small intestine, liver, and spleen. It is about sixinches long and is shaped like a flat pear. The wide part, called the headof the pancreas, is positioned toward the center of the abdomen; themiddle section is called the neck and the body of the pancreas; the thinend is called the tail and extends to the left side.The pancreas has two main functions: an exocrine function that helps indigestion and an endocrine function that regulates blood sugar. Page6

1- Exocrine Function: The pancreas contains exocrine glands thatproduce enzymes important to digestion. When food enters the stomach,these pancreatic juices are released into a system of ducts that culminatein the main pancreatic duct. The pancreatic duct joins the common bileduct to form the ampulla of Vater which is located at the first portion ofthe small intestine, called the duodenum. The common bile ductoriginates in the liver and the gallbladder and produces another importantdigestive juice called bile. The pancreatic juices and bile that are releasedinto the duodenum, help the body to digest fats, carbohydrates, andproteins.2-Endocrine Function: The endocrine component of the pancreasconsists of islet cells that create and release important hormones directlyinto the bloodstream. Two of the main pancreatic hormones are insulin,which acts to lower blood sugar, and glucagon, which acts to raise Page7

blood sugar. Maintaining proper blood sugar levels is crucial to thefunctioning of key organs including the brain, liver, and kidneys [3].Diabetes mellitusIs a group of metabolic diseases characterized by elevated levels ofglucose in the blood (hyperglycemia) resulting from defects in insulinsecretion, insulin action, or both. Normally a certain amount of glucosecirculates in the blood. The major sources of this glucose are absorptionof ingested food in the gastrointestinal (GI) tract and formation of glucoseby the liver from food substances.Insulin, a hormone produced by the pancreas, controls the level ofglucose in the blood by regulating the production and storage of glucose.In the diabetic state, the cells may stop responding to insulin or thepancreas may stop producing insulin entirely. This leads tohyperglycemia, which may result in acute metabolic complications suchas diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolarnonketotic syndrome (HHNS) [3].Type of Diabetes MellitusThere are three main types of diabetes mellitus (DM):* Type 1 DM: is characterized by loss of the insulin-producing beta cellsof the islets of Langerhans in the pancreas, leading to insulin deficiency.This type can be further classified as immune-mediated or idiopathic. The Page8

majority of type 1 diabetes is of the immune-mediated nature, in whichbeta cell loss is a T-cell-mediated autoimmune attack.There is no known preventive measure against type 1 diabetes, mostaffected people are otherwise healthy and of a healthy weight when onsetoccurs. Type 1 diabetes can affect children or adults, but was traditionallytermed "juvenile diabetes" because a majority of these diabetes caseswere in children [4].Type 2 DM: is characterized by insulin resistance, which may becombined with relatively reduced insulin secretion.The defective responsiveness of body tissues to insulin is believed toinvolve the insulin receptor. However, the specific defects are not known,this form was previously referred to as non-insulin dependent diabetesmellitus (NIDDM) or "adult-onset diabetes". Type 2 diabetes is the mostcommon type [5].* Gestational diabetes: resembles type 2 diabetes in several respects,involving a combination of relatively inadequate insulin secretion andresponsiveness. It occurs in about 2%–5% of all pregnancies and mayimprove or disappear after delivery, gestational diabetes is fully treatable,but requires careful medical supervision throughout the pregnancy. About20%–50% of affected women develop type 2 diabetes later in life.Though it may be transient, untreated gestational diabetes can damage thehealth of the fetus or mother. Risks to the baby include macrosomia (highbirth weight), congenital cardiac and central nervous system anomalies,and skeletal muscle malformations. In severe cases, perinatal death may Page9

occur, most commonly as a result of poor placental perfusion due tovascular impairment [6].Diabetes mellitus Signs and symptomsThe 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) intype 1 diabetes, while they usually develop much more slowly and maybe subtle or absent in type 2 diabetes [7].Prolonged high blood glucose can cause glucose absorption in the lens ofthe 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 besuspected.Causes of Diabetes mellitus and Risk factorsType 1 diabetes is partly inherited, and then triggered by certaininfections, with some evidence pointing at Coxsackie B4 virus. A geneticelement in individual susceptibility to some of these. The onset of type 1diabetes is unrelated to lifestyle. P a g e 11

Type 2 diabetes is due primarily to lifestyle factors and genetics, such asweight, family history,race,age and Inactivity [8].Pathophysiology of Diabetes mellitusInsulin is the principal hormone that regulates uptake of glucosefrom the blood into most cells. Therefore, deficiency of insulin or theinsensitivity of its receptors plays a central role in all forms of diabetesmellitus.Insulin is released into the blood by beta cells (β-cells), found inthe islets of Langerhans in the pancreas, in response to rising levels ofblood glucose, typically after eating. Insulin is used by about two-thirdsof the body's cells to absorb glucose from the blood.If the amount of insulin available is insufficient, if cells respond poorly tothe effects of insulin (insulin insensitivity or resistance), or if the insulinitself is defective, then glucose will not have its usual effect, so it will notbe absorbed properly by those body cells that require it, nor will it bestored appropriately in the liver and muscles. The net effect is persistenthigh levels of blood glucose, and other metabolic derangements, such asacidosis.When the glucose concentration in the blood is raised to about 9-10mmol/L, reabsorption of glucose in the proximal renal tubuli isincomplete, and part of the glucose remains in the urine (glycosuria). Thisincreases the osmotic pressure of the urine and inhibits reabsorption ofwater by the kidney, resulting in increased urine production (polyuria) P a g e 11

and increased fluid loss. Lost blood volume will be replaced osmoticallyfrom water held in body cells and other body compartments, causingdehydration and increased thirst.Hb A1CThe (HbA1c) test (also called glycosylated hemoglobin level) is alaboratory blood test which measures your average blood glucose overthe previous weeks and gives an indication of your longer-term bloodglucose control. The test is used as a regular monitoring tool if you havebeen diagnosed with diabetes. It may also be used as one of severalscreening measures in the general population to look for elevated bloodglucose levels, which are suggestive of diabetes.Change to reporting values from October 2011. HbA1c levels havepreviously been measured as a percentage (%). However, from October2011, 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 safetarget 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 HbA1clevel. Between 7% and 8% [54 - 64mmol/mol] is a fair HbA1c level andneeds 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 levelsare extremely high [9]. P a g e 12

Management of Diabetes mellitusDiabetes mellitus is a chronic disease which cannot be cured exceptin very specific situations. Management concentrates on keeping bloodsugar levels as close to normal as possible, without causinghypoglycemia. This can usually be accomplished with diet, exercise, anduse of appropriate medications (insulin in the case of type 1 diabetes, oralmedications, as well as possibly insulin, in type 2 diabetes).Patient education, understanding, and participation is vital, since thecomplications of diabetes are far less common and less severe in peoplewho have well-managed blood sugar levels. Attention is also paid to otherhealth problems that may accelerate the deleterious effects of diabetes.These include smoking, elevated cholesterol levels, obesity, high bloodpressure, and lack of regular exercise [3].Compliance versus non complianceCompliance has been defined as―the extent to which a person‘s behaviorcoincides with medical advice.‖1 Noncompliance then essentially meansthat patients disobey the advice of theirhealth care providers [10]. P a g e 13

2.3 Literature ReviewThis chapter present several international and regional studiesregarding to adherence in management of diabetic patient, recommendeddiet for diabetic patients, therapeutic diet adherence, and factors affect thelevel of commitment.Actually there is few study conducting regarding to the therapeuticdiet commitment and the factors that may affect the level of commitmentin the world.An integral component of managing diabetes is medical nutritiontherapy (MNT).The goals of MNT are to maintain blood glucose levelsand blood pressure in the normal range, to maintain a lipid profile thatdecreases the risk of cardiovascular complications, to prevent or slow thedevelopment of the diabetic complications, to address an individual‘scultural and personal dietary preferences, and to maintain the pleasure ofeating[11].Multiple clinical trials and outcome studies have demonstrated theeffectiveness 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. Thenutritional management of the patient with diabetes is geared towardsprovision of all the essential food constituents, meeting energy needs,maintenance of an ideal weight, and decrease of elevated blood lipidlevels and achievement of blood glucose levels close to normal. Type IIdiabetes is treated by diet and exercise, and only when elevated glucose P a g e 14

levels persist are supplements of oral agents as well as insulin injectionsgiven [13].Professional guidelines and recommendations for medical nutritiontherapy (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 incontent details, but the underlying goals are similar. All recommendationsseek to:1-sustain or improve health and quality of life though healthyfood choices, 2-establish and maintain blood glucose as near to normal aspossible, thus averting the harmful consequences of hypo- orhyperglycemia,3-address specific nutritional needs of individuals, whilealso taking into account personal preferences, cultural considerations, andlifestyle. The guidelines [below in bold]. advise an intake of 60–70% ofdaily energy from carbohydrates and monounsaturated fats. This adviceallows greater flexibility to accommodate individual dietary preferences.Sucrose (sugar) and sugar-containing foods are allowed, but should belimited to less than 10% of energy intake, and only eaten in the context ofa healthy diet. ADA and EASD guideline suggest that saturated fatsconstitute 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 amongdiabetes experts. Foods classified as having a low glycemic index (LGI)are non-starchy vegetables, fruits, legumes, milk, yogurt, and traditionallyprocessed grains such as wholegrain bread, pasta, and oats [17]. P a g e 15

Refined, starchy foods, such as white bread, processed cereals, potato,watermelon, and most crackers, on the other hand, are classified ashaving a high glycemic index (HGI)[18].High glycemic index HGI foods are rapidly absorbed and digested andthus can have deleterious effects on blood glucose control [19].Within 2 hours of eating an HGI meal, blood glucose concentration is atleast double that of ingesting an LGI meal, low GI foods have beenshown to decrease postprandial blood glucose rises, increase satiety andpromote weight loss, improve insulin sensitivity, and enhance lipidprofile [18].Several studies [20], [21]. Have found that a HGI diet in healthyindividuals is associated with an increased risk of developing type 2diabetes. The Health Professionals Follow-up Study (1997) was anational longitudinal study that followed 42,759 healthy male healthprofessionals, aged 40 to 75 years, over 6 years, and discovered 523incident cases of confirmed type 2 diabetes over this time. Men whoconsumed an HGI diet were at an increased relative risk of developingdiabetes, even after adjusting for age and other known risk factors fordiabetes. When comparing the highest GI quintile with the lowest GIquintile, the relative risk of developing type 2 diabetes was statisticallysignificant [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 P a g e 16

confirmed type 2diabetes over this time. The women who consumed anHGI diet were at an increased relative risk of developing type 2 diabetes,even after adjusting for age and other known diabetes risk factors. Therewas a 59% increased risk of developing type 2 diabetes in the highest GIversus the lowest GI, which is statistically significant [21].Ma et al[22] performed a pilot study to evaluate the effectivenessof an LGI dietary intervention with personal digital assistant (PDA)support on glycemic control in 13 adults with poorly-controlled type 2diabetes. This study was conducted over a period of 6 months andconsisted of nutritionist-delivered education and counseling about theLGI diet, in which all subjects were involved in an initial 2.5-hour groupsession, a 1-hour individual session at week 2, a group grocery tour atweek 4, and subsequent 30-minute individual phone sessions at months 2,3, and 5. The results of this study found a statistically significant meandecrease in HbA1c of 0.5% after the LGI dietary intervention[22].Several of the above studies included questionnaires to determinesubject satisfaction with the LGI diet. Burani and Longo.found that 100%of their study subjects felt that choosing LGI foods assisted them inimproving their diabetes and that they intend to continue choosing LGIfoods 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 theLGI diet [23]. P a g e 17

In the Mediterranean Diet, Cardiovascular Risks and GenePolymorphisms (Medi-RIVAGE) study, the effects of a Mediterraneantype diet or a low-fat diet on cardiovascular risk factors were evaluated in212 men and women with moderate risk factors for cardiovasculardisease. In both dietary arms there was a significant reduction in BMI,dyslipidemia, insulinemia, and glycemia, after 3 month with nosignificant differences between the arms[24].The Seguimiento Universidad de Navarra (SUN) project, a large Spanishcohort study of 13,380 participants, estimated dietary intake at baselineand the relative risk for a new diagnosis of diabetes during 4.4 years offollow up. Participants who adhered closely to a Mediterranean diet had alower risk of diabetes with relative risk adjusted for sex and[25].Another study was conducted in Australia that investigate the selfcare practices of Malaysian adults with diabetes and sub-optimalglycogenic control by using a one-to-one interviewing approach, datawere collected from 126 diabetic adults from four settings. A 75-itemquestionnaire was used to assess diabetes-related knowledge and self-carepractices regarding diet, medication, physical activity and self-monitoringof blood glucose, the results indicated that these subjects with suboptimal glycaemic control had inadequate knowledge about diabetes andself-care practices were poor. Factors that may contribute to this are theage and education level of the subjects [26]. Fifty-four percent of thesubjects live a sedentary life style, with only 5% exercising sufficiently to P a g e 18

contribute to glycaemic control. Females constituted two-thirds of thesubjects 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 wereless active. For the younger subjects, employment and familyresponsibilities could limit the time available for leisure activities. Thisfinding is consistent with those from other studies [27, 28]. The lessactive 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 selfcare behaviour may be explained using the ‗Theory of Reasoned Action‘.This states that the best predictor of patient‘s behaviour is the patient‘sintention to behave in a certain way [30].A previous study reported a negative association between perceivedimportances of exercise in diabetes with number of barriers to exercise[31].However, it appears that recognition of the importance of dietaryand medication self-care did not lead to the actual behaviours. Onepossible explanation is that the majority of the subjects had poor dietaryknowledge and lack of access to dietary facilities[26].Lack of adherence to medication intake could have been magnified by thechosen definition of medication adherence. Cultural barriers to P a g e 19

medication adherence in Asia such as use of alternate medicines andreplacement with non-pharmaceutical treatments might also havecontributed to this problem [32, 33].Content analysis open-ended item concerning exercise indicatedthat only 30% of the subjects reported being advised according to clinicalpractice guideline (a minimum of 30 min per day and at least 5 days aweek). This may be due to inadequate diabetes knowledge among thehealthcare providers as reported by previous researchers [34].Also it appears that sub-optimal glycaemic control patient hadinadequate knowledge about diabetes and self-care practices were poor.Factors that may contribute to this are the age and education level of thesubjects [26].Previous studies have consistently reported a relationship between lowlevel of education and older subjects with poor diabetes-relatedknowledge [35, 36].In addition to that, the dietary knowledge deficits, low functional healthliteracy and nutritional transition to energy-dense food with improvedsocio-economic conditions could contribute to the increased carbohydrateconsumptions by the subjects [37], [38]. P a g e 21

Furthermore, a local nutritional anthropology study reported thatfood items other than cooked rice were commonly not considered ‗realfood‘ and therefore subjects may believe these can be taken in largequantities [39].Previous studies have consistently reported financial barriers toSelf-monitoring blood glucose [40], [41], [42].In Malaysia, the Malaysian government heavily subsidisesmedication, but not the cost of Self-monitoring blood glucose, whichcould have contributed to its low usage. However, some studies have alsoreported a poor usage of to Self-monitoring blood glucose despite freeblood glucose test strips being supplied [43], [44].It shown that demographic factors such as ethnic minority, lowsocioeconomic status, and low levels of education have been associatedwith lower regimen adherence and greater diabetes-related morbidity[45].Study using self-care assessment instrument reported that 90% oftheir sample indicated they frequently eat a healthy diet; only onequarterly regularly self-monitored their blood glucose; and half exercisedmore than once per week [46]. P a g e 21

Chapter Three P a g e 22

MethodologyThis chapter describe and discus the methods that use to carry outthis research by describing the study design and variables concludedtechnique that use in data collection and analysis.3.1 Study DesignThis study designed as a cross sectional method that compatiblewith this descriptive study and its objectives, groups can be compared atdifferent ages with respects of independent variables so this nonexperimental study.The Cross-sectional designs (also known as cross-sectionalanalysis, transversal studies, prevalence study) form a class of researchmethods that involve the collection of data at one point in time; thephenomena under study are captured during one period of data collection.The advantages of cross-sectional studies are 1- Relativelyinexpensive and take up little time to conduct. 2- Can estimate prevalenceof outcome of interest because sample is usually taken from the wholepopulation. 3- Descriptive role.And the disadvantages of cross-sectional studies: 1- Selection bias. 2Snapshot in time (loss to follow-up). 3- Shows association, not causality.The study investigates factors affecting the commitment of diabeticpatient in therapeutic diet, by using self-administered questionnaires toolto collect the data. P a g e 23

3.2 Sample and Setting:The data is taken from diabetic Patient from different clinics inNablus.The population of the study is (type1&2 DM) patients. It accounts150 out patients from Nablus who visit those clinics: ( BalataPHC/UNRWA), (Balata PHC/MOH), (Askar PHC/UNRWA), (PHCDirectorate in Nablus/MOH), (Camp No.1 PHC/UNRWA) and (OldAskar PHC/UNRWA). Inclusion criteria: All participants were male and female patients whohad been diagnosed with DM (type1&2) at least 5 year earlier, andconsented to participate in the study. The sample divided into 75 maleand 75 female, population ages range between (30-60) years old. Exclusion criteria: All patient they have gestitional diabetic, allpatients they had been diagnosed with diabetic less than 5 years, andall 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 dietrestrictions.3.3.2 Independent variable1. 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). P a g e 24

4. Place of residence: This has three options (city, village andRefugee camp).5. Income: This has four options(less than 1000 NIS, 1000-2500NIS, 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 complicationsand the recommended diet therapy.8. The adherence to exercise, and appointment for regular checkupin the clinics.9. Access to and use of medicines.3.4 Period of study:This research conducted in the beginning of the first semester in2013-2014, and data collection done in 4 weeks from 3/10/2013 to30/10/2013.The questionnaires take 3 minutes to introduce thequestionnaire idea of the project to the participants and to explain thestudy purpose. And about 10 minutes from the patients to fulfil thequestionnaire.3.5 Study Tool:The study tool which had been used to collect the data was aquestionnaire(Annex II). The questionnaire was self-constructed. 150questionnaire were distributed between 3/oct/2013 and 30/oct/2013, thequestionnaire consisting of five parts as the following: P a g e 25

3.5.1. Part One:Include introduction paper about the study title, our university andcollege, type of data which we wanted to collect, objectives of the studyand the name of researchers who wanted to collect data aims toencouraging the targeted individuals to respond frankly on the studyquestions after satisfying the tested people that the information will besecret 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 ofResidence, Income, and Educational Level).3.5.3Part Three:This part contain (11) questions asked about dietary practice thatindicated the level of patient adherence in dietary regiment.3.5.4 Part Four:This part contains 5 questions that measure the knowledge of patientsabout diabetes mellitus disease, its complications and the recommendeddiet therapy.3.5.5 Part Five:This part contains 3 questions asked about adherence to exercise, andappointment for regular checkup in the clinics. P a g e 26

3.6 Pilot testing:A pilot study was conducted to determine the reliability and thevalidity 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 questionna

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

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