الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The nutritional knowledge and eating behavior among DI play an important role in optimizing their clinical outcomes, beside preventing and delaying future complications. Many studies showed that nutritional knowledge and eating behavior have direct effect on the anthropometric and metabolic risk factors such as BMI, WC, WHtR, HbA1c, lipids and BP. Evidence also showed that CVRF like DM, HTN, dyslipidemia and obesity can be assessed by evaluating the anthropometric parameters that assess total and central obesity including BMI, WC, and WHtR. Beside the metabolic measures including HbA1c, BP and lipids such as cholesterol, TG, LDL and HDL. Such risk factors are directly influencing patients’ clinical outcomes, body weight, and quality of life. Moreover, those are considered as predictors of the CVD and mortality rates among DI. Therefore, and since those risk factors should better understood and assessed among DI, the current study aims, objectives and questions were assessing and exploring the association between nutritional knowledge and eating behavior among AWD visiting a PHCF. In addition, investigating the association between participants’ nutritional knowledge and eating behavior with their anthropometric and metabolic parameters.
Regarding the current study major objectives, the researcher was expecting similar findings to other studies which showed the association between nutritional knowledge and eating behavior. However, his expectation was rejected by the current study findings when it showed no significant association between nutritional knowledge and eating behavior among the participants. This conclusion answers the major objective of the study. Interestingly, the current study conclusion is similar to other studies’ conclusions which confirmed that nutritional knowledge is essential but not sufficient for influencing and changing the eating behavior among the general population, neither among AWD.
Findings regarding the specific objectives showed a weak significant correlation showed between nutritional knowledge with one metabolic measure (HDL). Also, a weak inverse significant correlation between eating behavior with three anthropometric parameters (Weight, WC & WHtR). In respect of HDL significant correlation, evidence showed that better HDL is associated more with other factors including pharmacological interventions, exercise, weight loss and smoking cessation, rather than nutritional knowledge. However, the significant correlation between EB and “Weight, WC & WHtR” was concluded in other studies which showed that lower EBI scores are associated with uncontrolled weight management behavior, and thus high prevalence of total and central obesity was recorded among the study participants.
Furthermore, the gender-based assessment showed a significant association with two anthropometric measures (BMI & WC) and two metabolic measures (cholesterol & LDL). Males were significantly higher in overweight prevalence based on their BMI, while females were significantly higher in the total and central obesity based on BMI and WC, respectively. Moreover, females were significantly higher in cholesterol and LDL levels than males. Such gender-based significant findings were also found in other similar studies.
In addition, study findings showed a significant association between eating behavior and smoking status. Smokers had lower EBI score than non-smokers, and thus reflected on their central obesity (WC) median score which is found to be greater than non-smokers. However, their total obesity (BMI) median score was lower than non-smokers. This finding was also concluded in other studies where smokers had lower BMI than non-smokers.
Accordingly, and based on current study findings and conclusion, the recommendations for a better diabetes management can be provided for AWD in Kuwait, regional countries and worldwide. Particularly, this study focused on the important role of the structured education programs in improving the anthropometric and metabolic risk factors among DI. Hence, evidence showed that DSMES, which is based on behavioral interventions, is a very effective approach for DM management.
6.2 Conclusion:
Study findings showed no significant association between nutritional knowledge and eating behavior among DI. However, findings showed that nutritional knowledge is significantly correlated with “HDL”, and eating behavior is significantly correlated with “Weight, WC & WHtR”.
Findings related to the major study objectives were similar to other studies which confirmed that nutritional knowledge is essential but not sufficient for influencing and changing eating behavior. Evidence showed that there are other possible factors that influence eating behavior; including but not limited to “sociodemographic, internal, external, and disease” factors. The sociodemographic factors include age, gender, marital status, educational status, monthly income, and economics. The internal factors include nutritional knowledge, personal preference in terms of religion, tradition and culture, personal control, body image, psychological status, health beliefs, health literacy, genetics, health goals, and dietary self-efficacy in respect of motivation, willingness, readiness, and ability to change. The external factors include friends, social gatherings, physical activity, dietary restraint, family and social support, time management, food environment, eating environment, media, and politics. While the disease factors include DM type, duration, treatment regimen, education method, and knowledge about DM management, figure 2.3.
Accordingly, it is highly recommended in future studies to include and analyze such factors while assessing eating behavior among DI and the general population. Considering that healthy people will not be assessed for the disease factors.
6.3 Recommendations:
1. The huge burden of the chronic NCD on patients’ health and countries’ economic, should drive the health policy makers in Kuwait to focus on improving services provided by the primary care settings and implementing interventional programs in all PHCF to approach obesity and chronic NCD like DM, HTN, dyslipidemia, and cancer. DSME is the cornerstone of treatment for people with DM, and recommendations are given for DSME to be done by the primary care centers as most DI around the world are treated in those sittings which are going to be an integral part of DM management. DSMES proved its clinical and cost effectiveness, however, majority of primary care settings in Kuwait do not include such structured educational programs for DM management although of their benefits in facilitating the approaches for nutritional education, physical activity, and weight management. Therefore, interventional programs like DSMES should be implemented in all PHCF for its proven benefits, nevertheless, decrement of DI hospital admissions, medications used, and healthcare costs.
2. DSMES should expand further in the near future by shifting from individual level to community level in order to achieve best health and economic outcomes. Particularly, evidence shows that traditional information-only education proved in many times its failure to translate the increased nutritional knowledge into dietary behavioral changes. Nutritional education, which is a critical component of DSME, is considered to be a key approach for effective diabetes management. Hence, education that focuses on improving knowledge, skills, and confidence among DI is needed for better effective self-management and lifestyle modifications. Such education has short to medium-term effects on diabetes knowledge, glycemic control, and healthy lifestyle. This education could be achieved by DSMES that is associated with improvement of self-management, confidence, satisfaction, and glucose control among DI. DSMES facilitate development of the knowledge, skill, ability, and confidence for diabetes self-care through multidisciplinary approach team which include physicians, dieticians, nurses, psychologists, and behaviorists. Therefore, DSMES should be applied at individual and community levels to achieve the best future goals by optimizing clinical outcome, preventing or delaying DM complications, and maintaining patients’ quality of life, while keeping costs acceptable.
3. Primary care physicians’ education became equally important as DI education. Many worldwide studies showed that primary care physicians had poor nutritional knowledge in some topics, and they need more nutritional training. By which, their knowledge, attitude, and self-efficacy has to be stressed in any intervention to improve their nutritional practice. Therefore, a periodic assessment and education for primary care physicians in Kuwait is essential to ensure their minimum practice knowledge and skills needed for managing NRCD such as DM, HTN, and dyslipidemia. Furthermore, assessing the other medical personnel practice regarding patients’ education became a crucial step for the DSMES programs. It will underline the gaps and deficiencies in their current practice, and provide solutions and reinforcements needed for DSME implementation in the health care system. Nevertheless, believing that “diabetes nutritional education program is considered to be a key component of diabetes management, but it is more than just nutrients”. By means, physicians, dieticians and healthcare professionals should acquire the social and emotional intelligence needed for such programs, beside taking into consideration all major possible influencing factors that influence eating behavior among DI, other than nutritional knowledge.
4. In Kuwait, the majority of PHCF do not engage dieticians and nutritionists in DI treatment plan and follow-up, although the worldwide diabetes specialized organizations -including ADA- considered dietitians and nutritionists as critical element of DM management team due to the complexity of nutritional issues. The RD have a crucial role in diabetes education and management since they are essential complementary component of the MNT approach among DI, and thus they should be engaged in diabetes management team soon after the diagnosis of DM. Evidence showed better clinical outcomes among DI when RD are engaged. Therefore, ADA stated that primary care physicians should refer patients with diabetes, and pre-diabetes, to MNT provided by RD to ensure the best healthcare. Particularly, with the evidence showing that physicians feel uncomfortable advising for issues of diet and weight loss. Beside the evidence showing that primary care staff are less enthusiastic about their role as nutritional educators. Accordingly, such defect of the current practice in Kuwait should be managed by engaging dieticians and nutritionists in each PHCF for DM, and other chronic NCD treatment plan. This will further alleviate the burden on physicians who cannot achieve alone the expected nutritional education goals regarding DM management and CVRF targets.
5. Establishing new tools for assessing major factors influencing the eating behavior among DI became essential for DM management in Kuwait. KANKQ was designed to assess general nutritional knowledge among adult students and not DI. This enforces toward establishing a new tool which covers the major factors influencing eating behavior among DI, beside the aspects of dietary management. This will lead to in-depth analysis and assessment of the DI knowledge and behavior, which in turn will lead to better understanding of their EB. Consequently, a better diabetes management, and thus improvement in their health and clinical outcomes.
6. Although Kuwait is considered among the top five world countries with DM prevalence, however, there is still no official and accurate statistics regarding diabetes health burden and economic costs on the state. Hence, estimating the direct medical costs of treatment, interventions and complications, beside the indirect costs of productivity loss due to increased death and illness, and the need for informal care, is considered a basic approach for the successful governmental strategies in managing DM.
7. For better exploration of the eating behavior among DI, it is recommended in future studies to include and analyze -within the same study- the possible influencing factors which affect diabetics’ eating behavior such as “sociodemographic, internal, external, and disease” factors, figure 2.3. Moreover, to include and analyze the possible factors, other than nutritional knowledge and eating behavior, that affect their anthropometric and metabolic risk factors including “age, health condition, dietary adherence, medications, physical activity, weight management, smoking status, diabetes duration, and other presenting health conditions”. Such overall assessment of those factors will give in-depth analysis and better evaluation of the major factors influencing diabetics’ eating behavior and their anthropometric and metabolic outcomes. Subsequently, better understanding of those risk factors, and thus better health and economic outcomes.
8. The EBI is better to be modified to go hand in hand with the current improved medical technologies. EBI was established in 1979 and it include aspects which are not applicable anymore. For example, the question which stated (I keep a graph of my weight), such graphs nowadays can be automatically recorded and saved by the electronic medical devices which are homely used. Therefore, participants may answer that question by (never) keep graph and score 1 point instead of scoring 5 points if their answer it (always) keeping a graph in their medical devices. Therefore, if that question is modified to (I keep, or use electronic devices which keeps, a graph of my weight), the chances of getting higher scores increases, and such modification will help in getting more accurate eating behavior assessment.
In addition, it is better to modify some EBI questions by giving examples in order to make them easier to be understood, and more precise in their meaning even if the EBI questions were translated from English to other languages. For instant, the EBI question which states (I snack after supper) can go far from its actual meaning after translation, by which, if snack translated into Arabic, it will be written as “light meal”, while in fact that question is not asking about eating meals rather than snacks. For example, nuts and apple can be eaten as snack, however, the Arabic translation might mislead the participants by answering that they (never) snack although they are (always) snacking nuts after dinner. Therefore, giving examples within the questions like (I snack after supper. e.g., eating nuts) will give more accurate EBI scores regarding the actual meaning of the questions, even after the EBI translation from English to other languages.
Similarly, the question which states (I serve food family style), this phrasing can lead to different responses according to participants’ ethnicities, cultures and nationalities. For instant, after translation of (family style) into Arabic, it can mean that family members are used to eat from one big plate by their hands without using spoons or plates, since this is a common traditional way of eating among some Arab cultures. However, this is not the actual meaning of the EBI (family style) serving. This is also applicable for all other ethnicities, cultures and nationalities who can have different perceptions and practices of the (family style) eating. Hence, Asians have different family style serving than Africans, Europeans different than Americans, and thus different responses for the same question after EBI translation into their languages. Therefore, mentioning some examples within EBI questions can help in delivering the accurate meaning of such question to different ethnicities, cultures and nationalities. For example, (I serve food family style. e.g., serving from one buffet to my plate using utensils), and thus more accurate EBI scores regarding the actual meaning of the question even after EBI translation into other languages.