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Obesity Medicine 1 (2016) 29e32

Contents lists available at ScienceDirect

Obesity Medicine
journal homepage: http://www.journals.elsevier.com/obesity-medicine

Original research

Disease-specic knowledge and lifestyle behavior in patients with


diabetes mellitus
Laskarina Digkliou a, b, *, Kyriakos Kazakos b, Kalliopi Kotsa c, Dimitrios G. Goulis a
a

Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Greece
Faculty of Nursing, Alexander Technological Educational Institute of Thessaloniki, Greece
c
1st Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Greece
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 30 October 2015
Accepted 29 December 2015

Aim: To investigate whether people with diabetes mellitus (DM) have different disease-specic
knowledge according to gender, DM type and centre of education and if they have adopted appropriate changes in their lifestyle according to their DM-related knowledge.
Patients and methods: A total of 76 patients with DM (males: 31, females: 45; age 18e82 years; DM type
1: 45, DM type 2: 31) participated in this cross-sectional, multi-center, questionnaire-based study. The
Revised Michigan Diabetes Knowledge Scale questionnaire includes disease-specic questions on DM,
diet and exercise. The Diabetes Care Prole questionnaire of the Michigan Diabetes Research and
Training Center was applied to identify the demographic characteristics of the individuals, the education
in diabetes, nutrition and exercise and the changes in lifestyle according to the given instructions.
Results: The overall score of correct answers was 69%. Gender did not present any difference in
knowledge about DM (p 0.259), diet (p 0.971) and exercise (p 0.262). In contrast, patients with DM
type 1 achieved higher scores in knowledge about DM (p < 0.001) and foot care (p 0.019) compared to
the patients with DM type 2. Patients attending private DM-specic support centers achieved more
correct answers compared to those attending public hospitals' outpatient clinics (p 0.003).
Conclusions: Patients with DM type 1 and patients who attend private DM-educational centers receive
more education on practical aspects of DM management and have superior knowledge related to it.
2016 Elsevier Ltd. All rights reserved.

Keywords:
Diabetes complications
Diabetes diet
Diabetes exercise
Diabetes education

1. Introduction
Glycemic control plays a key role in the outcome of diabetes
mellitus (DM). Diet along with exercise are important factors in
achieving glycemic control, either alone or in combination with
medication. The knowledge of a person with DM about his/her
disease contributes in a positive way to its management (ClarkeFarr et al., 2006; Dunn et al., 1990). This knowledge is related to
general issues on DM (medications, complications, control of
glucose concentrations and factors that affect them), diet (equivalents of carbohydrates, treatment of hypoglycemia, food composition) and exercise (benets).
There is evidence that many people with DM do not know the
complications that are associated with the disease, ignore the

* Corresponding author. Faculty of Nursing, Alexander Technological Educational


Institute of Thessaloniki, Greece.
E-mail address: sugarliving@gmail.com (L. Digkliou).
http://dx.doi.org/10.1016/j.obmed.2015.12.005
2451-8476/ 2016 Elsevier Ltd. All rights reserved.

symptoms of hypoglycemia, are unaware of the targets for the


fasting and the post-prandial glucose concentrations and, although
they may be aware of the signicance of a laboratory test, they
postpone or ignore it (Clarke-Farr et al., 2006; Gulabani et al.,
2008). In some cases, women seemed to have lower levels of
knowledge about DM than men, who appeared to understand
better its symptoms, its complications and the importance of
healthy eating (Hawthorne and Tomlinson, 1999; Mehrotra et al.,
2000).
The benets of education are mentioned but not limited to the
following: achieving a better metabolic control, preventing the
dysregulation of DM, reducing the risk of amputations, the treatment costs, the frequency and severity of complications and hospitalization, achieving a better quality of life and decreasing the
psychological distress (Mehrotra et al., 2000; Karamitsos, 2009;
Rubin et al., 1989; Malone et al., 1989; Asha et al., 2004). Furthermore, the structured educational programs for glucose self-control,
help to set and achieve goals about nutrition and physical activity
(Duran et al., 2010).

30

L. Digkliou et al. / Obesity Medicine 1 (2016) 29e32

A continuous interactive training in small groups seems to have


a positive effect on patients with DM, as it allows them to interact
with each other, exchange ideas and gain new information about
their disease (Garcia and Suarez, 1996). Furthermore, such activities
increase the social support, the sense of independence, promote
skills for the daily care of the disease and reduce the number of
hospital admissions and usage of emergency services (Garcia and
Suarez, 1996). In addition, education about the disease appears to
help people with DM moderate the perception of the disease as a
sad fact and show more interest for its management (Dunn et al.,
1990). The participation of people with DM in educational programs is often inuenced, among other factors, by the knowledge
they have about the disease (Clarke-Farr et al., 2006).
Although there are studies measuring the disease-specic education and knowledge of people with DM, none of them combined
the results with the changes in lifestyle through application of the
instructions.
The aim of this study was to investigate whether people with
diabetes mellitus (DM) have different disease-specic knowledge
according to gender, DM type and centre of education and if they
have adopted appropriate changes in their lifestyle according to
their DM-related knowledge.

The second questionnaire consisted of queries about the demographic characteristics of the individuals, such as gender, age,
educational level and profession, and questions about the duration
of the disease, the control of glucose concentrations, medication,
existing complications, education in diabetes, foot care, nutrition
and exercise and application of the given instructions. This questionnaire was part of the Diabetes Care Prole (DCP) questionnaire (Section IX e Diet Adherence Scale, Section XII e Monitoring
Barriers and Understanding Management Practice Subscales) of the
Michigan Diabetes Research and Training Center (University of
Michigan, 2015).
The individuals were informed about the purpose of this study
and were asked to ll a consent form which was given separately
from the questionnaires, so as to keep anonymity.

2. Patients and methods

3.1. Overall DM knowledge

2.1. Patient selection

The score of total correct answers were 69% (range 28%e95%).


Correct answers about issues related to DM were 58% (9%e100%),
nutrition 80% (29%e100%) and exercise 80% (0%e100%).

In Greece, DM-specic education is fullled in public hospitals


or private patients' support centers. Thus, the sample was recruited
from two outpatients DM clinics of public hospitals (General Hospital of Thessaloniki Papanikolaou, General Hospital of Thessaloniki AHEPA) and two private centers [one DM-specic patient
support group (Diabetes Association of the Prefecture of Thessaloniki Agios Dimitrios) and one outpatient DM clinic of private
hospital].

2.5. Statistical analysis


The statistical analysis of the data was carried out with SPSS for
Windows software (version 19).
3. Results

3.2. Knowledge according to gender


There was no signicant difference between men and women in
mean age, disease duration, BMI, education and knowledge about
diabetes, foot care, diet, exercise and application of the given instructions (Table 1).

2.2. Sample size estimation


Based on a small pilot study, we assumed a difference of 35% in
the main study parameters (education about DM, knowledge about
DM) between the groups (males vs. females, DM1 vs. DM2, public
hospitals vs. private centers). On the basis of these assumptions, we
needed to enroll 66 subjects for the study to have a power of 80%
with a type I error rate of 0.05 to detect a 35% absolute difference
between study groups, assuming equal numbers in each comparison. Study power was calculated with GPower 3 (version 3.1.9.2,
t Kiel, Germany).
Universita
2.3. Patients
A total of 76 patients with DM [males: 31 (41%), females: 45
(59%); age 18e82 years; DM type 1: 45 (59%), DM type 2: 31(41%)]
participated in this cross-sectional, multi-center, questionnairebased study.
2.4. Questionnaires
The rst questionnaire was a True/False-type, simplied form
of the multiple choice format questionnaire Revised Diabetes
Knowledge Scale (University of Michigan, 2015). Comparison between the two forms revealed that the simplied True/False-type
was easier to get completed (Collins et al., 2011). The total score was
reported as a percentage of correct answers, with no negative
marking for the wrong answers, or the ones that were answered as
do not know.

3.3. Knowledge according to DM type


Type of DM seems to affect related to the disease knowledge, as
there were statistically signicant differences between the two
types of DM (Table 2).

Table 1
Baseline characteristics and disease-specic knowledge according to gender.

Age (years)
Duration of DM (years)
BMI (kg/m2)
Education
about DM (%)
about foot care (%)
about diet (%)
about exercise (%)
Knowledge
about DM (%)
about diet (%)
about exercise (%)
General score of knowledge (%)
Changes in lifestyle
related to diet
related to exercise

Men (n 31)

Women (n 45)

p value

47.3 19.3
15.4 10.8
28.6 5.0

49.6 17.0
18.7 12.6
27.7 5.7

0.587
0.257
0.503

61.3
77.4
93.5
67.7

77.8
88.9
93.3
77.8

0.259
0.164
0.971
0.262

56
77
79
67

60
81
80
71

0.377
0.450
0.822
0.134

3.3 0.2
3.0 0.2

3.6 0.2
3.0 0.2

0.378
0.764

Data are expressed as mean standard error of the mean (SEM) or as percentage (%)
of correct answers. BMI: body mass index; DM: diabetes mellitus. Application of the
instructions is expressed on a 1e5 scale, where 1 never, 2 rarely 3 sometimes,
4 often, 5 always.

L. Digkliou et al. / Obesity Medicine 1 (2016) 29e32


Table 2
Baseline characteristics and disease-specic knowledge according to DM type.

Age (years)
Duration of DM (years)
BMI (kg/m2)
Education
about DM (%)
about foot care (%)
about diet (%)
about exercise (%)
Knowledge
about DM (%)
about diet (%)
about exercise (%)
General score of knowledge (%)
Changes in lifestyle
related to diet
related to exercise

DM type 1
(n 45)

DM type 2
(n 31)

p value

37.2 13.0
20.1 13.5
25.9 5.1

65.3 8.0
13.4 7.7
31.3 4.2

<0.001
0.460
<0.001

91.1
93.3
97.8
75.6

42.0
71.0
87.1
71.0

<0.001
0.019
0.109
0.834

68
86
84
76

44
71
73
60

<0.001
<0.001
0.040
<0.001

3.6 0.2
3.2 0.2

3.3 0.1
2.7 0.3

0.276
0.172

Data are expressed as mean standard error of the mean (SEM) or as percentage (%) of correct answers. BMI: body mass index; DM: diabetes mellitus.
Application of the instructions is expressed on a 1e5 scale, where 1 never,
2 rarely 3 sometimes, 4 often, 5 always.

3.4. Knowledge according to the center of education


Knowledge about DM related issues seem to have statistically
signicant differences between public hospitals and private education centers, but do not have an impact on the changes in lifestyle
through application of the given instructions (Table 3).

4. Discussion
The aim of this study was to investigate whether people with
diabetes mellitus (DM) receive different education and have
different disease-specic knowledge according to gender, DM type
and centre of education and if DM-related knowledge plays a role in
adopting changes in their lifestyle.
For the needs of this study there has been made an extensive
search for questionnaires in the Greek and international literature, so as to nd a questionnaire that included all the relevant
questions but being also easy to comprehend and not requiring a
long completion time. Other questionnaires than the selected
Table 3
Baseline characteristics and disease-specic knowledge according to center of
origin.

Age (years)
Duration of DM (years)
BMI (kg/m2)
Education
about DM (%)
about foot care (%)
about diet (%)
about exercise (%)
Knowledge
about DM (%)
about diet (%)
about exercise (%)
General score of knowledge
Application of the instructions
for the diet
for the exercise

Public hospitals
(n 29)

Private centres
(n 47)

p value

60.0 2.6
15.4 1.9
31.5 0.8

41.7 2.4
18.6 1.9
26.0 0.7

<0.001
0.256
<0.001

51.7
72.4
89.7
72.4

83.0
91.5
95.7
74.5

0.031
0.020
0.305
0.995

49
73
76
62

64
83
82
73

0.001
0.017
0.372
0.003

3.3 0.2
2.9 0.3

3.6 0.2
3.0 0.2

0.264
0.836

Data are expressed as mean standard error of the mean (SEM) or as percentage (%)
of correct answers. BMI: body mass index; DM: diabetes mellitus. Application of the
instructions is expressed on a 1e5 scale, where 1 never, 2 rarely 3 sometimes,
4 often, 5 always.

31

one, had only questions only general questions about DM or its


complications and no questions about knowledge on nutrition
and exercise. Others were very large, thus required a long
completion time.
The average score of the correct answers (knowledge) in the
whole sample was 69%. Gender did not seem to present signicant
differences in the characteristics of the individuals (mean age,
mean duration of the disease, BMI), education and knowledge (in
diabetes, nutrition and exercise). In contrast, there were signicant
differences between the two types of DM in the total scores of
knowledge and education about the disease and foot care, with DM
type 1 to prevail in all areas. Also, it seems that people with DM
type 1 are more educated about consuming snacks, weighing the
food and using their equivalents.
As shown by the statistical analysis between the two types of
DM, there were differences both in educational scores and the
scores of total knowledge. Mean age probably plays an important
role in this, as the mean age of the average with type 1 DM was
37.2 13.0 years, while the average age of the sample with DM type
2 was 65.3 8.0 years old.
The multiple linear regression test showed that the center of
education explains some percentage of the correct answers, while
the training that is being done in it, plays an important role.
The general level of education and the overall educational scores
(for DM, diet, exercise, snacks, weighing of food and food equivalents) were positively correlated with the total score of correct answers. Information on exercise had a positive correlation with the
correct answers in this eld but also with the frequency that someone exercised. The given information about weighing of food had also
a positive correlation with the frequency that the individuals
weighed their food. In contrast, education in diabetes was negatively
correlated with the total correct answers and the correct answers
about DM issues, information about nutrition negatively correlated
with correct answers in this subject, but also the frequency someone
applies a nutritional program and the information about the consumption of snacks and food equivalents negatively correlated with
the frequency that the individuals followed these instructions.
Based on the characteristics of the people, all the correct answers were positively correlated with gender, disease duration, the
center of origin and profession and negatively with age, DM type,
medication type and the occurrence of complications. Education in
DM issues had a negative correlation with the correct answers to
the total and the correct answers in the individual sections of DM,
diet and exercise. The general education was positively correlated
with the total correct answers and the correct answers in the diet
section. The type of DM had a negative correlation with the correct
answers to the DM subjects while the total score of education (for
diabetes, diet, exercise, snacks, weighing of food and food equivalents) had a positive one.
DM is a disease with severe complications, presents an
increasing prevalence worldwide and has high treatment costs for
both types of DM. Thus, people with type 2 DM should receive
education about the disease, as well as people with type 1 DM.
Furthermore, public hospitals should aim in structured educational
programs which help people with DM not to get afraid of their
disease and care more for its daily management. Mobilized and
sensitized health professionals could also play a key role in that.
In conclusion, people with DM type 1 have more knowledge
about the disease and are more up-to-date on practical aspects of
its management in comparison with people with DM type 2. The
given information on food weighing and exercise issues plays an
important role in making changes in lifestyle. However, information about nutrition (including information about the consumption
of snacks and the use of food equivalents) has no effect on making
changes in lifestyle.

32

L. Digkliou et al. / Obesity Medicine 1 (2016) 29e32

Skip to question 19, if you don't take insulin

Ethical rights of the participants


This study used no intervention methods, however, the individuals were informed about its purpose and were asked to ll a
consent form, which was given separately from the questionnaires,
so as to keep anonymity.
Disclosure
Data in this paper were presented as part of a MSc. in Diabetes
Care thesis, Faculty of Nursing, Alexander Technological Educational Institute of Thessaloniki, Greece.
Conict of interest
We wish to conrm that there are no conicts of interest associated with this publication and there has been no nancial support
for this work that could have inuenced its outcome.
Appendix

TRUE/FALSE/DON'T KNOW

TRUE/FALSE/DON'T KNOW

TRUE/FALSE/DON'T KNOW

TRUE/FALSE/DON'T KNOW

Source: Collins GS, Mughal S, Barnett AH, Fitzgerald J, Lloyd CE. Diabet
Med 2011; 28:306e10.

References

Revised Michigan Diabetes Knowledge Scale


True/False Version.
Here are 20 statements about diabetes: some are true and some are
false. Please, read each statement and then indicate whether you think
it is true or false by putting a circle round either TRUE or FALSE. If you
do not know the answer, please, put a circle around DON'T KNOW.
1. The diabetes diet is a healthy
diet for most people
2. Glycosylated haemoglobin (HbA1c)
is a test that measures your average
glucose level in the past week
3. A pound of chicken has more
carbohydrate in it than a pound of potatoes
4. Orange juice has more fat in it
than low fat milk
5. Urine testing and blood testing are both
equally as good for testing the
level of blood glucose
6. Unsweetened fruit juices raises
blood glucose levels
7. A can of diet soft drink can be used for
treating low blood glucose levels
8. Using olive oil in cooking can help
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9. Exercising regularly can help reduce
high blood pressure
10. For a person in good control exercising
has no effect on blood sugar levels
11. Infection is likely to cause an increase
in blood sugar levels
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14. Numbness and tingling may be
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15. Lung problems are usually associated
with having diabetes
16. When you are sick with the u, you
should test for glucose more often

17. High blood glucose levels


may be caused by too
much insulin
18. If you take your morning
insulin but skip breakfast
your blood glucose level
will usually decrease
19. Having regular check-ups
with your doctor can help
spot the early signs of
diabetes complications
20. Attending your diabetes
appointments stops you
getting diabetes complications

TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW

TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW

TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW
TRUE/FALSE/DON'T KNOW

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