Behavioral Changes in Diabetic Patients: Diabetic Education

Diabetes is an acute metabolic disorder that is characterized by high levels of blood glucose. The disease is triggered by failure of the pancreas to secrete sufficient insulin or failure of the body to effectively utilize the insulin that is produced by the pancreas. Insulin is the hormone responsible for regulation of blood glucose in the body. The condition of high levels of blood glucose in the body which is typical of diabetes is called hyperglycemia. Hyperglycemia is toxic and if uncontrolled it ends up damaging the cardio-vascular system, the respiratory system and the nervous system.

Diabetes is the illness of the chronic character that is common worldwide. Annually, thousands of people are diagnosed with one of the diabetes types. As the illness manifests itself as life-threatening if not treated on time, patients with the confirmed diagnosis of type 2 diabetes tend to dramatically change their life habits. Therefore, the transformation of one’s lifestyle triggers behavioral changes. On the basis of the concrete diagnosis, patients comply with specific interventions. Most individuals become more self-aware and stop taking their health for granted. However, some people perform a poor self-care management. Nola J. Pender did a great work describing behavioral changes in patients. The behavior change model she introduced confirms that human attitude and actions affect the outcome of diabetes treatment. If properly educated, any person with diabetes can achieve major health improvement. On the contrary, poor education and insufficient medical support lead to diabetes complications and unwanted outcomes. Thus, the current research paper investigates the issue of behavioral changes in diabetic patients, the background of these changes, achievable goals of the changes and downsides of negative behavioral responses. If methods of educations are applied correctly, the changes in behavior of diabetic patients might be predictable. However, one can also foresee negative behavioral changes in patients who did not receive education. Thus, it is vital to investigate the case and its related concepts.

Diabetes is a metabolic disorder, when the blood glucose level increases faster than the level of the insulin hormone, which is responsible for its maintenance. High levels of glucose present in blood may cause various complications to the functioning of organs in the human body. If the disease is left untreated, any person is at a high risk of kidney failure, strokes, blindness, heart attacks, amputation of the lower limbs, and even sudden death. Diabetic patient numbers has grown significantly during the last four decades. The global prevalence of patients with diabetes is at its peak in countries with low or middle income and among adults who are overweight or obese. In 2012, approximately 2.2 million deaths from high blood glucose levels were reported, while 1.5 million died from diabetes itself. However, if patients with type 2 diabetes are educated about self-care and medication appropriately, they will perform correct management of glucose levels and make sure to prevent long-term complications. Therefore, the aim of the current research proposal is to investigate behavioral changes in diabetic patients in view of obtained education or its absence and describe the outcomes in both of the cases.

Definition of Key Terms

Diabetes: is “a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both” (American Diabetes Association [ADA], 2014).

Hyperglycemia of diabetes: “long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels” (ADA, 2014).

Deficient insulin action: “inadequate insulin secretion and diminished tissue responses to insulin at one or more points in the complex pathways of hormone action” (ADA, 2014).

Glucose level: the level of sugar present in the blood, which is 70 – 130 mg/dl if a person is hungry and is lower than 180 mg/dl if a person had a meal (Cherney & Morrison, 2015).

Delimitations

This research is aimed at defining the changes of behavior in diabetic patients only. The paper does not present research concerning ethnicity, age, or gender. Patients with diabetes represent only general information about their behavioral changes, with no concrete measures and definitions exceeding the research limits.

Theoretical Rationale

The current research proposal is grounded on the theoretical model created by Nola J. Pender called the Health Promotion Model (HPM). This model encloses several constructs. The main background of the HPM is the social learning theory designed by Albert Badura in 1977, who believes that cognitive processes are vital in the aspect of behavioral changes. Initially, the social learning theory included self-attribution, self-evaluation and self-efficacy. The HPM, in its turn, is premised on self-efficacy as the general idea of the model. Another theoretical foundation that influences the HPM is the expectancy value model of human motivation created by Feather in 1982. According to Feather, “behavior is rational and economical” (Alligood, 2014), which becomes important in Pender’s model.

Evidently, there are fourteen assertions in the model. Briefly, they speak about prior behavior, challenges, barriers, positive emotions, commitment and engagement in actions that lead to positive behavioral responses. The HPM is quite similar to the health belief model in its construction and explains the disease prevention behavior. However, HPM does not put fear or threat as motivational sources. Essentially, it includes behaviors that enhance health and are applicable during the life span. The HPM is a theoretical framework that can predict “overall health-promoting lifestyles and specific behaviors such as exercise and use of hearing protection” (Alligood, 2014). The HPM may divide the population into 1) working adults; 2) older community-dwelling adults; 3) ambulatory patients with cancer; and 4) patients undergoing cardiac rehabilitation (Alligood, 2014). In addition, the Health Promotion Lifestyle instrument measures health-promoting lifestyle according to six subscales, namely health responsibility, physical activity, nutrition, interpersonal relations, spiritual growth, and stress management (Alligood, 2014). In other words, the HPM aims to identify cognitive and perceptual factors that are the major determinants of health-promoting behavior.

Problem Statement

The PICO question of the current proposal is the behavioral changes in diabetic patients to prevent complications on the basis of poor insulin-responsive illness. Here, PICO elements are explained as P – a patient with type 2 diabetes, I – patient education, which improves self-management of diabetes, C – medication (metformin) and O – management of glucose levels to prevent long-term complications.

Currently, the situation with exposure to diabetes in the world is rising. If there were approximately 108 million of diabetic patients in 1980s, in 2014, the number was 422 million (Roglic, 2016). Nowadays, these numbers are even higher. The past decade has shown that diabetes tends to prevail in countries with low and middle incomes and among individuals suffering from obesity. Therefore, partial responsibility for the development of diabetes lies in unhealthy choices in one’s lifestyle. What is more, people with diabetes and their families experience economic loss due to extensive medical costs and inability to work. With regard to health, diabetic patients might have complications of various kinds (heart attacks or strokes, loss of vision, kidney failure, limb amputation, and nerve damage) that may occur suddenly and lead to unexpected death.

Contextually, the problem of the increasing wave of diabetes is associated with inappropriate management of medical and lifestyle interventions. The most common behavior diabetic patients tend to practice is sedentary lifestyle. This behavior is characterized by “too much sitting and too little physical activity, which contribute to cardiometabolic health outcomes and premature mortality” (Dempsey, Owen, Biddle, & Dunstan, 2014). According to Walker, Smalls, Hernandez-Tejada, Campbell, and Egede (2014), self-efficacy is “a well-studied psychological construct that is consistently associated with health behavior” (p. 3). Badura, in his turn, defines self-efficacy as “the ability to perform goal-directed behaviors, when confronted with impediments, in a confident manner” (Walker et al., 2014). Numerous studies have investigated the role of self-efficacy in behavior prediction in patients with manifestations of diabetes. It was established that positive patient attitude is one of the strongest factors in self-care and leads to accurate disease management. On the basis of results, self-efficacy strategy can predict self-care management. Thus, Clark indicates that self-efficacy is “a relevant construct trying to explain the adoption of healthy behaviors such as exercise” (Walker et al., 2014).

According to Zhuo et al. (2014), the failure to change negative behavioral manifestations that prevail in patients with type 2 diabetes might lead to devastating results (Zhuo et al., 2014). On the grounds of the research conducted by Zhuo et al., the lifetime spending for diabetic patients was $124,600, $91,200, $53,800 and $35,900, when the diagnosis was given when they were forty, fifty, sixty, and sixty-five years old (Zhuo et al., 2014).

Among the presented scope of information available, there are issues, which require certain attention. For instance, behavioral changes in diabetic patients are not being discussed concerning ethnicity, age, gender, economic status and severity of type 2 diabetes. Unfortunately, the data is very broad and there is a need to investigate and group it in several years. Although some information relating to the age category and gender is present, it does not give the picture of international diabetic patients, namely a picture of every ethnic representative and their behavioral changes in view of the obtained education.

In order to solve the occurring problem, there is a need to investigate what kind of behavioral changes are present in diabetic patients, who underwent specific education, and were advised how to lead a healthier way of life. Only after finishing the current research, it will be possible to conduct further researches and deeper investigate the problem and its character.

It is crucial to handle the problem of behavioral change in diabetic patients is significant, as it can prevent negative responses of an individual and program them to lead a healthier lifestyle, eat healthy foods, exercise more and take the required medicine. Being aware of the opportunities and changing one’s way of life, a person may achieve positive outcomes and limit diabetes-related complications. People who are not properly educated on the possible changes and lifestyle interventions tend to be depressed and not willing to cooperate with doctors in any kind of treatment programs. Therefore, they consciously “kill” themselves due to sheer unawareness that there is another way of coping with type 2 diabetes.

Review of Related Literature

The book Nursing Theorists and Their Work by Alligood (2014) is a valuable source providing information about theorists and their theoretical frameworks. Among such theorists, there is Nola Pender and her Health Promotion Model that is described in detail. This model is created to investigate behavioral changes in individuals with one of the common illnesses and trace these changes. What is more, the model of behavior of a concrete human can be projected on the basis of the way a person is educated and treated in the medical setting. Therefore, the current book is an outstanding source for the particular research.

The chapter of the book “Health Promotion Theories” by Raingruber (n. d.) also discusses health promotion theories and concepts dedicated to these theories. It mentions various theories, among which one can find that of Nola Pender. In addition, the chapter displays certain steps and processes that should be performed for changes to take place.

The article “Diagnosis and Classification of Diabetes Mellitus” by American Diabetes Association defines diabetes mellitus and explains the reasons for its occurrence, the way this disease manifests itself and the related factors. Therefore, the paper underlines every fact in relation to diabetes, the way a person can be diagnosed with diabetes, factors that show the possibility of developing diabetes and different interventions, and treatment that should be implemented in order to prevent possible complications. If not treated properly, diabetes may cause malfunction of the body organs, limb amputation and even sudden death. Thus, the given source is valuable to understand the progression of the illness and possible outcomes.

The report “WHO Global Report on Diabetes: A Summary” by Roglic (2016) is a source providing concrete data on diabetes manifestations over the past 36 years. The occurrence of diabetes has not only doubled by 2014, but also lowered the age of its sufferers. The report discusses such issues as obesity, low-income territories and poor medical support or sanitary circumstances that predispose people to the development of diabetes. This source is valid because it gives insights into the world situation with diabetic patients and marks different ways to overcome the disease.

The article “Effect of Diabetes Self-Efficacy on Glycemic Control, Medication Adherence, Self-Care Behaviors, and Quality of Life in a Predominantly Low-Income, Minority Population” by Walker et al. (2014) is a very good source of information on self-efficacy and self-management of any disease diagnosed. The paper speaks about possible interventions and how self-efficacy is important and life-changing. Glycemic control, which is one of the types of diabetes treatment, is an inevitable part of the healthy lifestyle and healthy choices. Therefore, the article is very important to the current research paper.

Another source that provides valuable information is the article “The Lifetime Cost of Diabetes and Its Implications for Diabetes Prevention” by Zhou et al. This article examines the lifetime costs that were spent on diabetic patients of certain ages. Zhou et al. believe that preventive behaviors will reduce the enormous sums diabetic patients incur and promote good lifestyles. Thus, the situation with regard to cost spending is rather crucial and needs improvements.

The article “Budgeting for Diabetes Health Costs” by Iliades (2016) elaborates on the costs of supporting a patient with the diagnosis of diabetes. According to the author, the spending is extremely high and should be reorganized (Iliades, 2016). If patients had the knowledge of positive self-care, medical institutions would not have to spend numerous dollars on maintaining the blood glucose levels of diabetic patients.

The article “Managing Sedentary Behavior to Reduce the Risk of Diabetes and Cardiovascular Disease” by Dempsey et al. (2014) defines sedentary behavior as one of the negative means leading to health complications. If patient, who have diabetes lead a sedentary life, the chances of sudden death are inevitable. Therefore, the paper discusses the gathered evidence about sedentary lifestyle and tries to improve the current lifestyle and develop targeting interventions. This article is useful in the current research, as it sheds light on the behavior of people with diabetes and the dangerous consequences it hides.

The article by Cherney and Morrison (2015) “How to Lower Blood Glucose Levels” presents information about normal levels of sugar present in blood of both normal people and people diagnosed with diabetes. Therefore, this article is valuable to the following research, as it gives an insight into why high sugar levels are dangerous for human health.

Research Design and Method

The research method chosen had the time frame of approximately 30 days. On the basis of Nola Pender’s behavioral change model, the research included two basic groups, namely the intervention group and the control group of working adults. Half of the patients of different ethnicity, gender and age (> 18 years old) were randomly allocated to the first group, and the other half constituted the second group. The intervention group had specific counseling according to the dietary needs, physical exercises, weight control program and education on medication management together with certain lifestyle changes. Several specialists, including the dietarian, specifically trained nurses and lecturer, monitored the intervention group. The control group had no education in regard to the possibility of changing their lifestyle and received the standard care (medication only). As it was predisposed, the control group had to be managed only by several nurses, who simply monitored the status of the patients’ health. By educating one group and simply observing the other one, it was meant to investigate which of the two participating groups will be more likely to develop positive diabetes treatment responses.

Instruments

In order to learn the differences and behavioral changes occurring between the intervention group and the control group, a survey has been conducted after the experiment took place. The survey contained multiple questions that had to be answered individually. The questions were grounded on the possible changes/no changes in the routine diabetes management and asked whether the patients received solid education and valuable information. In addition, the survey asked whether they continued self-care on the newer and more self and diabetes aware levels or their daily life remained the same. The group that did not receive any education had to pass the survey accordingly. Another instrument was observation, meaning that nurses that handled diabetic patients observed the participants on the daily basis.

Work Plan

The method and the instrument appeared to be appropriate and helpful in the current research. The intervention group had lectures every day, which discussed information about diabetes and its manifestations. Afterwards, the intervention group participants had individual conversation with the dietarian, who advised the patients on the best type of diet; in the end, the current group had the ability to practice some exercises. As it has shown, with the help of guidance, constant support and helpful personnel, diabetic patients found it easy to change their diet and do more exercises as well as they were healthier and looked happier. On the contrary, the control group, which simply came for medication intake and chat with each other, had no visible changes in their attitudes or actions and even showed the lack of inspiration or energy.

According to the behavioral change model (Table 2), the intervention group has met four stages of change, four stages of processes of change, decisional balance, self-efficacy and temptation (Raingruber, n. d.).

Behavior Change

Therefore, the current research has shown that positive education, supportive information and general support of clinical workers make a difference to diabetes perception. With the help of the set dietary restrictions, patients became healthier, had their blood glucose level managed and did daily exercises. In thirty days, the intervention group participants reported that they felt better and appreciated the obtained help, while the control group remained unchanged. The participants did not feel any inspiration, did not eat healthy, did not exercise, and had unstable glucose levels, while some of them reported depression.

Diabetes education is a costly procedure. According to ADA, “the cost of diabetes in the United States is more than $245 billion a year, which includes direct medical costs and the cost of reduced productivity” (Iliades, 2016). For a person who lives with the diagnosis of diabetes medical spending is 2.3 times higher than for an average person. Diabetic patients receive $7,900 annually and $5,800 on the grounds of problems with health maintenance (Iliades, 2016). Therefore, the costs of the study will be dependent on the number of diabetic patients in the group, educational support of the lecturer, and services of the dietarian and specifically trained nurses. The approximate cost of such intervention as simple education of patient on how to lead a healthier life and self-care will be cardinally lower than in the absence of the particular education. Thus, the projected costs are $200,000 million annually.

Education Project on Diabetes

• Approximately 6.2% of the population in the United States suffers from diabetes. The percentage translates to 17 million people. People suffering from diabetes require extensive education in order to manage the disease effectively. They must learn how to control the level of glucose and other ways of preventing the disease from becoming complicated. The patients must therefore plan their menu and food, plan their exercise routines, take care of their skins, regulate occurrences of other diseases that are related to diabetes, learn about the cycles of the disease, and manage hyperglycemic/hypoglycemic incidents (Payrot, 2007).
• Most of the patients diagnosed with diabetes annually have no idea about the drastic changes that they are bound to make in their lifestyle and nutrition. These lifestyle changes pose the greatest challenge to diabetes patients. The main objective of this teaching plan is to empower patients suffering from diabetes with information so that they could be able to take individual initiatives towards management of the diabetes and improve the general health of their bodies.

Assessment

The assessment of the patients was based on their ability, willingness and limitations of learning, degree of knowledge about diabetes and lifestyle choices. Instead of making a standard generalized plan, the individual needs of every patient were analyzed. The metabolic needs of patients varied between newly diagnosed patients and patients in late stages of progression of the disease. Age was also taken into consideration since younger patients will be required to manage diabetes for a relatively longer time as opposed to older patients who may not have to maintain diabetes for a long time due to their advanced years. The management needs of a 40 year old patient will certainly differ from those of an 80 year old patient or those of a 60 year old patient. The younger patient has more time to develop complications, requires drastic lifestyle changes, is more likely to be depressed and therefore requires more rigorous therapy.

The lifestyles of the learners vary a lot. Some of them have daily schedules that vary widely and inconsistent patterns in their life due to the nature of their work and other social relationships. They might therefore have several combinations of medication or multiple insulin injections on a daily basis. On the other hand, patients with regular routines will require mono-therapy or regular insulin injections. The patients’ level of knowledge about diabetes will also affect the teaching program whereas more experienced patients will be called upon to share their skills with newly diagnosed patients since peer teaching is usually very effective.

Teaching Plan

The main objectives of the teaching plan are as listed below:

• The patient will be able to make descriptions of diabetic medicines that have been prescribed by the doctor or any other medical officer and the instructions given regarding how and when the medication should be taken.
• The patient will be able to use a blood glucose meter effectively to self-monitor his/her glucose levels after observing a nurse or any other medical officer doing so.
• The patient will be able to take proper care of the skin and feet and be in a position to demonstrate the process.
• The patient will also be able to give detailed benefits of regular exercising and its role in improving control of blood glucose levels.

Since the teaching plan’s main aim is to encourage individual changes in lifestyle and behavior, the plan is tailor-made for each patient with regard to the abilities, needs and the respective stage of the patient in the diabetes cycle (Raid et al, 2007). Each patient must therefore have an individual meal plan that is tailor-made for his or her lifestyle, long term and short term goals on lifestyle adjustment, and knowledge on importance of undergoing a dietary therapy. The importance of adhering to the treatment regimen will be emphasized to the patient in the teaching plan.

The teaching plan is designed in such a way as to help newly diagnosed patients and patients who need to evaluate their diabetes management practices. This cannot happen at once and there must be continuous therapy since management of diabetes requires regular evaluation and changes as the disease progresses. The regular continuous education will be carried out through regular meetings between me and the patient where we can talk face to face at a convenient time.

Since patients attending the class will be at different stages of the disease, the teaching plan will be designed to entail the learning capability, the stage of the disease, and the patient’s aptitude. The strategies to be used in the teaching process will include lectures, PowerPoint presentations, group discussions, videos and demonstrations by the health practitioner. The sessions will take from two to four hours whereby the first two/three hours will be used for teaching and the remaining one hour will be used to discuss issues affecting the
group members.

The topics will be given in the following order:

• Overall overview of the disease (2hours)
• The objectives and process of monitoring blood glucose levels (3 hours)
• Insulin and other medication (2 hours)
• Role of regular exercises in diabetes management (30 minutes)
• Feet and skin care (30 minutes)
• Complications that may arise from diabetes (1 hour)
• Role of dietary therapy in diabetes (2 hours)
• How to manage and cope with diabetes (2 hours)
• Review of patient’s questions and grey areas (2 hours)
• Questions and answer session (1 hour).
• The topics will be covered within a time frame of six days.

Evidence of Implementation

Overall Overview of the Disease

A diabetes patient must understand the meaning of diabetes and the terms associated with the disease. Patients who comprehend the nature and effects of the disease are more likely to adhere to the prescribed medication and treatment therapy (Frier & Fisher, 2007). Diabetes is a serious long term disease that progresses with time and requires adjustments in lifestyle especially with regard to physical activities and nutrition. The overall objective of nutritional and medical therapy is to help the patient make self-motivated changes in his or her life in order to improve the general health of the body.

Blood glucose level should be checked before and after the meal to enable the patient to make informed choices about the food to consume at a particular time. The choice of food will be based on how the patient responds to a particular type of food. Patients are taught the specific procedure for retrieving an adequate sample of blood and the steps they should take to gett the results. Studies have shown that patients who have knowledge about using blood-glucose meters and interpreting the data read from the meter perform blood-glucose evaluation on a consistent basis.

Several blood glucose monitors are available in the market. For best results, the patient must be advised on how to get a device that is convenient and easy to use. Before selection of the blood monitoring device, an assessment of the patient’s visual acuity and his/her hands dexterity must be taken into account. The process of selection of the device must take place at a health-care facility with guidelines from a diabetic specialist or educator. The patient requires to be told the importance of recording the results of the rests in a log sheet. In the sheet the patient must include the time and date, and the symptoms he or she is experiencing at the time of obtaining the specimen. Every time the patient visits a health-care facility he/she should bring the log sheet and share the information with the doctor in charge of the patient.

The process of doing the test should include a talk on glycosylated hemoglobin (HbA1c), the test performing and interpretation of the data by the health practitioner. Laboratory tests on HbA1c serve the role of monitoring the patient and are ordered on a regular basis. The simplest way of describing HbA1 to a patient is to tell the patient that the test involves measurement of the level of sugar that is found within the proteins of the red blood cells (Corbin & Gettings, 2007). The test is able to capture the average level of sugar in the patient for the past three months. If the blood sugar is high, the level of the glycosylated hemoglobin will also be high. High levels of blood sugar over a long duration destroy small and large blood vessels putting the patient at a risk of experiencing complications that arise from diabetes.

Medication and Insulin

Diabetic patients are very conscious about the disease and must be informed that medicine is used for the purpose of the disease management and not due to their failure to manage the nutrition regime (Merck & Co, 2009). Depression sets in once the patient starts to take insulin and/or medicines for hyperglycemia. The different types of oral diabetic agents will therefore be reviewed in the session. The review will also extend to studying the different types of insulin available and how to mix the insulin to achieve the best results. The patients will be taught on how to self-administer the prescribed oral agents and the insulin. The importance of taking the right dose according to the prescribed instructions will also be discussed. The patients will also be informed about the symptoms and signs of both hyperglycemia and hypoglycemia and the exact measures to take when they are suffering from an attack (Peyrot, 2007).

Complications Arising from Diabetes

Teaching on complications arising from the disease will emphasize the impact made by the control of blood sugar in the patient’s long-term health. The patient must be equipped with the requisite skills to manage diabetes when suffering from minor illnesses such as gastrointestinal virus, flu or cold. Similarly the patient must be taught how to look out for fatal effects of diabetes which may lead to peripheral vascular disease, heart attack and stroke. The patients must also be taught to be on the watch-out for signs and symptoms of renal disease, respiratory tract infections, and urinary tract infections (Frier & Fisher, 2007).

In the training session, the patient must be equipped with skills to detect the onset of diabetic neuropathy. Diabetes is a fatal condition since it is a leading cause of deaths in the United States. It contributes to 75% of the strokes, peripheral vascular diseases, renal failures and 50% of myocardial infections. It also causes blindness to patients. The patients must also be advised on the importance of quitting smoking, managing lipid and cholesterol intake, monitoring blood pressure, taking foot and skin care, and managing other diseases that arise as complications of the diabetes.

The patient must be taught to take effective feet care which involves daily washing, careful drying between the toes, and thorough checking for bruises, redness, blisters, corns, swellings and calluses. Any change noticed by the patient must be reported to a health practitioner immediately. The patient must avoid walking when barefoot and must wear shoes that do not constrict his legs (Lowenstein et al, 2009). Fungal infections on the feet are common in diabetes and the patients must use athlete’s foot medication that is available over the counter. If the athlete’s foot fails to improve after medication, the patient should consult the health practitioner. All cuts, blisters and assorted injuries on the feet or the legs must be treated with utmost care.

Foot problems are common to diabetic patients. While some are harmless and mild to the patient, others are fatal and toxic. Dangerous signs that the patient should look out for include: Warm feet that are red in color; Cold feet that are black or blue in color; Swellings in the feet; Pain in the feet when resting or during physical exercise; Lack of the pain when the foot is injured; Shiny skin on the lower legs and the feet; and very weak pulses in the feet (Corbin & Gettings, 2007).

Exercise and Diabetes

A sensible loss of weight of between ten to twenty pounds improves dyslipidemia, hypertension and hyperglycemia (Mertig, 2007). The target weight loss for diabetes patient must be reasonable one that culminates into healthy weight of the body. Suitable weight loss has been defined as the weight acknowledged by the health care practitioner and the patient and is maintainable and achievable within a set period. Modern perspectives on weight of diabetes patients have shifted from emphasis on the patient’s real weight to concentration on the circumference of the patient’s waist. In men, a circumference greater than 40 inches poses a danger that the individual will suffer from metabolic disease while for women the prohibited waist circumference is a circumference that is greater than 35 inches.

Weight circumferences beyond the standard ones are part and parcel of the metabolic syndrome suffered by diabetic patients (Frier & Fisher, 2007). Reducing the fat in the abdomen improves the patient’s lipid profile and sensitivity to insulin. Patients should engage in long-term regular aerobic exercises. Exercises that enhance the strength of the muscles are recommended since by preserving muscular strength they increase mobility and reduce falls especially among elderly diabetic patients (Frier&Fisher, 2007). The benefits of regular exercises for a diabetic patient cannot be exhausted. They help in decreasing weight, improving the self-esteem of the patient, quality of life, flexibility and strength, the functioning of the cardio-vascular system and blood sugar control. Exercises increase the number of cell receptors which in turn increases the uptake of glucose by the cells.

Various factors have to be taken into consideration before a patient can embark on an exercise program. Every exercise program must be designed to suit the patient’s needs according to the time that the patient has at his/her disposal. The exercise program must be build over a period of time to make sure that the patient adapts to the routine. It has been reported that absorption of insulin occurs rapidly in an exercised limb which is very dangerous as it can cause hypoglycemia (Lowenstein et al, 2009). Patients must therefore be informed that intense exercises may raise the level of blood glucose leading to hyperglycemia which can only be countered by regulatory hormones.

The patients should be encouraged to include breaks of five to ten minutes to cool-down and warm-up. Warm-up sessions serves the purpose of preventing muscle injury through increasing the body temperature while cool-down sessions prevent pooling of blood and facilitate elimination of by-products of the metabolic process. Shorter sessions (ten minutes each) are recommended as opposed to longer sessions (30 minutes each) because research has established that shorter sessions enhance performance of the cardio respiratory system. This point must be emphasized to patients who think that they don’t have time for exercises to show them that they can create time for ten minutes sessions.

Diet and Diabetes

Diabetes organizations across various countries have established diet regimes for diabetic patients. The American Diabetes Association for instance has set guidelines which focus on optimal metabolism in relation to levels of blood pressure, lipid profiles and glycemia ( Merck&Co., 2009). Diabetic patients must keep to a health and balanced diet comprising of low-fat milk products, poultry, whole-grains, lean meats, vegetables, fish and various fruits. The standard diet can be exchanged with a diet consisting of milk, bread, protein, and vegetables containing low or intermediate carbohydrates.

The meal plan of the diabetic patient is based on the individual’s preferences, cultural beliefs, appetite and his or her food consumption schedule. Caloric needs of an individual are determined based on the amount of energy and the individual’s present weight. Adults engaging in normal daily activities require calories of about 40kcal/kg or 20kcal/lb daily.

Consistent daily intake of carbohydrates must be maintained since carbohydrates have the most profound impact on glycemia. The response of blood-sugar to food is affected by the type of starch, amount of carbohydrate, components of the monosaccharide, food processing and food cooking. Patients should be encouraged to maintain a food diary for better management of their menus. Fiber requirements for diabetic patients are similar to those of the general population.

As patients are advised about diet management they should receive similar advice about alcohol consumption. Diabetic patients should take precautions similar to those taken by the general population. However, patients suffering from diseases such as neuropathy and pancreatitis, pregnant patients and alcohol addicts must completely abstain from alcohol upon being diagnosed (Mertig, 2007). Consumption of alcohol on an empty stomach results in hypoglycemia. A patient planning to consume alcohol must include it in the food plan. Moderate consumption of alcohol when the patient has eaten properly does not affect blood sugar levels.

Coping with Diabetes

Diagnosis of diabetes just like diagnosis of other chronic diseases is usually shocking and devastating. Most patients are shocked, aggrieved and are in denial about the disease. Support by friends and families as the disease progresses assists the patient in accepting the syndrome. Patients must be informed that depression is common in diabetic cases and it should be treated since it interferes with the control of blood sugar leading to complications. The patient must also be made aware that diabetes is a life-time illness that will require long term commitment to life-style changes. The patient requires mental, physical, spiritual, personal and financial empowerment. Empowerment also comes from positive work and family relationships (Centers for Disease Control and Prevention, 2008).

Stress management is an integral aspect of coping with diabetes. The patient must be equipped with skills such as identifying the stress factors, the response of the body to stress, effect of stress on management of the disease, coping methods, and exercises to boost relaxations. Cardiovascular risk must be eliminated or minimized. The patients must learn how to deal with minor illnesses such as colds and flu since they impact heavily on glycemic levels. They must continue with insulin and other medications even when they are not sick.

Ensuring that one has a good level of hydration is important since dehydration accelerates hypovolemis (Peyrot, 2007). This can be curbed through hourly intake of liquids that are calorie-free. Monitoring of blood glucose sugar levels must take place more frequently when the patient is ill. The patient must self-administer insulin even when he or she is unable to eat during illness to avoid diabetic ketoacidosis (Peyrot, 2007). A list of foods to be consumed when experiencing hypoglycemia signs should be provided to the patient. Patients should undergo ophthalmologic inspections regularly so that diabetic retinopathy can be detected early. Consistent visits to the dentist are also advised so that areas susceptible to infections or oral lesions can be detected early.

Discussion of Teaching Materials used in the Presentation

The teaching materials used in the presentation include PowerPoint representations, diabetes conversation maps, Questions and answers cards, and live demonstrations. Diabetes conversation maps are highly colorful and they measure 3ft by 5ft .They contain simple facts about diabetes in general, exercises, nutrition therapy, self-monitoring of blood sugar levels, and complications arising from diabetes (Corbin & Gettings, 2007). The facilitator explains the issues to the patients by navigating the map from point to point. The other resources included newsletters, training manuals in hardcopy and electronic resources.

Description of the Evaluation Strategies

The evaluation was geared towards assessing whether the goals and objectives of the training had been achieved. The purpose was to get the feedback of the learners with regard to the teaching program carried out so as to make improvements in future projects. The evaluation was based on four major approaches: the utilization-focused approach; the empowerment evaluation technique; the stake-holder evaluation approach; and while the goal-free evaluation approach.

The formative and summative types of evaluation were considered for the project. Formative evaluation involves assessing the project to make sure that the goals and aims of the teaching program are achieved. Summative evaluation concentrates on the overall effectiveness of the training being carried out (Centers for Disease Control and Prevention, 2008). Summative evaluation was found out to be the best mode of evaluation for this program.

The summative evaluation involved evaluation of whether the program had achieved the targeted outcome for the learners; impact evaluation was conducted to determine the effects of the teaching program whether intended or un-intended; a cost-benefit and cost-effectiveness analysis to determine effectiveness of the program in relation to the value obtained from each dollar spent; secondary analysis conducted by reviewing the impact of tools that were not employed in the study; and meta-analysis which integrated the outcome from all the types of evaluation carried out and types of evaluation techniques utilized to reach an eventual process outcome. Process indicators were used as a basis for providing the functioning and nature of the teaching program .The process indicators for the program included exposure to the program, involvement of the patient and the perceptions about the program.

Process and Outcome Evaluation

The class was surveyed immediately upon completion of the six training sessions. 97% of the patients reported that they found the sessions to have been very valuable for them. 96% of the patients said that they felt empowered to discuss issues related to their diabetes with their health practitioners. On the teaching format used, 92% rated PowerPoint presentations as the most effective format. They found it to be better than learning about diabetes from books and manuals. 86% of the participants rated group discussions as the best session of the training. The interaction with other patients made them realize that they were not alone in the battle against the disease and that they shared similar experiences with others.

The teacher was rated as effective and interactive though some of the patients felt that the teacher ought to have managed time effectively so as not to extend the sessions. The evaluation discloses that after the training session most of the patients were able to use their blood sugar meters appropriately, regulate the intake of carbohydrates in meals and snacks, read labels of foods more keenly to check for the calorie, fat and carbohydrate percentage, and discuss their health status with their families.

Strengths of the Training Program

• Improved knowledge and understanding about diabetes.
• Adoption of healthy exercise routines and techniques.
• Adoption of healthy nutritional regime, foot care, and skin care.
• Reduction of stress, anxiety and depression.
• Consistent correct self-administration of insulin and self-monitoring of blood glucose levels.
• Knowledge of how to handle diseases and complications arising from diabetes and how to cope with diabetes in general.
• The feeling of being in control of the disease and the overall health of the body.

Limitations of the Training Program

• Lack of sufficient resources to facilitate the training.
• Learners at different stages of the disease posed obstacles in integrating the teaching process.

Conclusion

The current research proposal aimed to investigate behavioral changes of patients suffering from diabetes. It was found that people with the diagnosis of diabetes tend to practice a sedentary way of life with possible consequential complications. It was also established that with the help of experts, a person can change their lifestyle, feel healthier, display more affection towards life and learn to manage blood glucose levels on their own. People who can maintain self-care are healthier and happier than those who have no knowledge about its management. Therefore, the study has concluded that human behavior changes into a positive outcome with the help of diabetes education, including dietary needs and physical exercises.

The program of teaching diabetic patients was designed to be held for six times, each session taking 3-4 hours. The duration was limited or extended depending on the needs and insights from the audience. The main objective of three to four hour sessions was to enable the patients to internalize the subject matter being taught and to be able to ask questions without undue haste or time pressure. The main focus of the teaching program was management of glycemic levels and prevention of complications that arise from diabetic condition. The patients were taught about the multiple diseases and syndromes that are associated with diabetes, and the factors responsible for occurrence of the diseases. Management of diabetes when the patient is suffering from other illnesses is crucial to survival of the diabetic patient.

The patients have been informed about how to respond to signs of hypoglycemia and hyperglycemia. In case of any doubts or ignorance of the recommended measures, the patients have been advised to contact their health practitioner immediately. The patients have been left with free handouts and brochures on management of diabetes. The handouts are also freely available at many health care agencies. At the end of the program, the patients are expected to fill in an evaluation sheet anonymously to estimate the effectiveness of the teaching program.