Dietary Modification Guidelines for Diabetic Patients: Are Final Year Nursing Students Prepared to Offer this Health Service?

Introduction

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases in both Western and developing countries [1]. According to the World Health Organization(WHO), the global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 [2]. It has been asserted that developing countries will bear the greatest brunt of the diabetes epidemic in the 21st century, with 80% of all new cases expected to appear in the developing countries like Ghana by 2025 [3]. There are also anticipations that a higher proportion of the projected numerical increase in the global prevalence of DM is to occur in developing countries [1]. There are also reports that 80% of people with diabetes live in low and middle-income countries with an estimated 522, 600 people in Sub-Saharan Africa reported to have died as a result of diabetes-related causes in 2013 [4]. Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation [2]. In a review of previous studies which assessed the prevalence of diabetes in Ghana, it was indicated that the prevalence of diabetes has risen from 0.2% in the late 1950s (in a study conducted in the Volta Region) to 6.0% in 2009 (in a study undertaken in Kumasi, Ashanti Region). In Accra, a prevalence of 6.4% was recorded in a mixed community in the late 1990s and 9.1% among civil servants in 2006 [5]. Diabetes can be treated and its consequences can be prevented or delayed with diet, physical activity, medication and regular screening. Eating a healthy diet in addition to engaging in regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of type 2 diabetes [2]. A study which assessed the prevalence and determinants of diabetes among older adults in Ghana highlighted the need for physical activity and nutrition to be emphasized in any diabetic prevention strategy [6]. Although, the responsibility of educating diabetics on adopting and consuming healthy dietary meals lies primarily in the hands of registered dietitians (RDs) and certified diabetes educators (CDEs), these professionals may not be available to patients as often as nurses, who constitute the largest proportion of professional health worker [7]. Studies conducted in the United States and Australia revealed that 90% of nurses on a regular basis receive request for nutrition advice from patients [8]. To this end, there have been recommendations on the need for nurses to be adequately knowledgeable about nutrition therapy for diabetes patients in order to provide effective advice. However, it has been reported that, generally, nurses do not achieve appropriate nutritional education and because of insufficient knowledge and skills cannot play an effective role in patient’s nutrition management [9, 10, 11]. A review of the literature suggests that the current knowledge levels of nurses on nutritional management of diabetes may be low [9, 12, 13]. Findings from these studies reported that nurses had inadequate knowledge of several aspects of nutrition management for diabetes, and they generally did poorly in relation to meal planning for diabetic patients. In an integrative review based on 25 related studies, the authors concluded that, generally, findings from the studies indicated wide-spread serious deficiencies in nurses’ knowledge of diabetes and diabetes care [14]. Consequently, in studies that were conducted to assess the therapeutic nutritional knowledge of nurses it was concluded that there is an urgent need to improve the curricula of undergraduate nursing courses regarding nutrition issues and to promote postgraduate continuing educational programs concerning therapeutic nutrition [8, 15]. With regard to the knowledge levels of nursing students who are about completing their training, such studies is almost non-existent and no study has elaborately covered nursing students’ knowledge in the nutritional management of diabetes. The purpose of this study was to evaluate the knowledge level of final year nursing students’ with regard to the nutritional management of diabetes. In addition, factors associated with nursing students’ knowledge levels were also assessed. Findings from this study can provide the needed information for the revision of nutrition-related courses taught in Nursing Training Institutions.

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Results

The results of the study are summarized and presented in subsequent tables. The data collected covered the following: background information of respondents, basic knowledge on diabetes, classification of diabetes, signs and symptoms of diabetes, complications of diabetes, risk factors of diabetes, prevention of diabetes, management of diabetes, knowledge on nutritional management of diabetes and nutritional recommendations for persons with diabetes.

Discussion

The results of this study showed that more than half of the respondents had information on diabetes from lesson taught in school and therefore suggests that most nursing students are likely to never hear of diabetes until they gain admission into the Nursing Training College and also implies that training received by students from Health Training Institutions plays a key role in introducing them to chronic health conditions and preparing them to support patients afflicted by these conditions. More than 50% of the respondents knew that engaging in regular exercise, weight reduction, moderate alcohol consumption and not smoking are all other preventive measures of diabetes. These findings suggest that most of the students have an idea about strategies that can be Nursing & Healthcare International Journal

adopted to prevent diabetes or lower its likelihood of occurring. However some (20%) of the respondents indicated that diabetes can be prevented by taking in herbs such as garlic. This finding call for some needed attention at correcting these wrong notions that some students have on the use of herbs to prevent or treat diabetes. The most recent American Diabetic Association position statement concludes that after a review of the evidence available on the role that herbs play in the prevention, treatment or management of diabetes, there is not enough clear data to substantiate recommending the use of herbs. The paper goes on to say that the use of any herbal supplements, which are not regulated and vary in content, may provide more risk than benefit, in that, herbs may interact with other medications that are taken to control diabetes [10]. With regard to the ultimate goal of any diabetes management programme, less than 50% of the respondents indicated that it is to ensure that blood glucose levels falls within the normal range. However, as indicated in literature, the major goal of diabetes treatment and management is to maintain normal or near normal blood glucose levels in affected individuals [10, 16]. The findings of this study suggest that most of the students do not know the ultimate goal of diabetes treatment and management plan and this may negatively influence their nursing care practices. With regard to whether the total amount of carbohydrates is more important than the type of carbohydrate for diabetics, less than half (45.7%) were able to provide the right answer. In a related study which was conducted among professional practicing nurses in a Ghana, over 50% of the nurses did not know that the total amount of carbohydrates consumed per meal is generally more important than the type of carbohydrate consumed [9]. The finding that more than 70% of the respondents did not know that diabetics should be advised to increase their intake of long-chain omega-3 fatty acids, such as EPA and DHA, mainly from fatty fish is of great concern and worrying and suggests that nursing trainees lack some knowledge about appropriate dietary practices that must be recommended to diabetics to help them manage their health condition. Perhaps, these students might not have received adequate education on the role of fatty acids in preventing and managing diabetic conditions.

Only 51.3% of the respondents agreed that diabetics should reduce or avoid the intake of red and processed meat products and this finding deserves much concern as the current knowledge of these final year nursing students may inform the kind of nutritional advice given to diabetic clients who access health facilities to manage their health condition. There is ample evidence in literature that highlights that a high total intake of animal protein but not vegetable protein intake is associated with diabetes risk [17, 18]. This study revealed that more than 50% of the nursing students did not know that diabetics should be encouraged to consume meals that are rich in monounsaturated and polyunsaturated fatty acids. This warrants great concern regarding the knowledge levels of these final year nursing trainees regarding the different types of fatty acids and how they either positively or negatively influence the management of diabetic conditions. It has been shown that diets rich in monounsaturated fatty acids (MUFA) may benefit glycemic control and cardiovascular risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern among diabetics [10]. There is some evidence that replacing saturated fatty acids (SFA) with MUFA improves insulin responsiveness in insulin-resistant and type 2 diabetic subjects [19]. Although majority of the study participants knew that intake of animal fat and saturated fat should be restricted in diabetics, just approximately one fourth (25.1%) of the respondents were able to indicate that <7% of the total caloric intake of diabetics can come from saturated fat. Indeed, the 2013 Standards of Medical Care for Diabetes from the American Diabetes Association recommends that saturated fat intake should be less than or equal to 7% of total calories and encourages replacing high trans-fat partially hydrogenated vegetable oils and animal fats with healthier oils and foods higher in unsaturated fats such as monounsaturated and polyunsaturated [10]. It is worrying that findings of this study suggest that almost all the nursing students are not well- informed about the need to caution alcoholics who are also diabetics that apart from reducing their alcohol intakes, they should always ensure that whenever they have the urge to drink, they should drink the alcoholic beverage with a meal and not take the drink alone on an empty stomach. It has been recommended that diabetics who want to take in alcoholic beverages should drink in moderation and consume alcohol with meals in order to Nursing & Healthcare International Journal

decrease the risk of hypoglycemia, which can particularly occur in the fasting state [10]. In addition, high alcohol consumption reduces insulin sensitivity and decreases pancreatic β-cells survival, thereby significantly reducing insulin secretion [20]. Majority of the respondents indicated that they will not recommend a reduction of the intake of trans fats among diabetics. The findings suggest that maybe nursing students do not have adequate knowledge on what trans fatty acids are and its negative health effects on the general population including diabetics. The American Heart Association, and American Diabetes Association currently recommends limiting the amount of dietary saturated and trans fat intake. This is because reducing the intake of trans fat also lowers Low Density Lipoproteins cholesterol and increases High Density Lipoprotein cholesterol, therefore intake of trans fat should be minimized by diabetics [10]. More than 70% of the nursing students did not know that when diabetic patients are on a premixed or fixed insulin plan, meals have to be consumed at similar times every day as highlighted in literature [21]. This finding warrants immediate attention since nurses are expected to be knowledgeable about how and when medications should be taken in relation to the intake of food in order to appropriately advise and caution patients. The fact that just a little over half (53.3%) of the respondents indicated that they will advise diabetics to consume more high fibre foods raises concerns particularly because of the significant role played by dietary fibre foods in diabetics. People with diabetes are advised to consume at least the amount of fibre and whole grains recommended for the general public [11]. A higher proportion of the respondents (72.4%) did not agree that it is recommended to advise diabetics to consume more of low-glycemic index (GI) diets. Based on some studies, it has specifically been recommended to use low–glycemic index diets to improve glycemic control [11, 22]. A higher proportion of the respondents (55.3%) indicated that they will not caution diabetics to reduce or avoid the intake of refined carbohydrates food items such as white bread and white rice. This finding is worrying because of the ample evidence summarized in two meta- analysis, all of which eventually concluded that a high consumption of white rice is associated with a significantly increased risk of Type 2 diabetes Mellitus [18, 23].

Conclusion

Although this study showed that final year nursing students were knowledgeable in the risk factors and signs and symptoms of T2DM, their knowledge in the aspects of nutritional therapy for the prevention and management of T2DM was sub-optimal. Findings from this study demonstrate and reiterate the urgent need to promote continuing education programmes in the area of therapeutic nutrition/dietary modification for diabetic patients. With regard to possible methods of further education, a recommendation is the need to update and strengthen the content of the nutrition curriculum of diploma and degree-awarding nursing programmes in collaboration with experts in nutrition such as dieticians. It is also worth considering conducting regular refresher workshops for nurse tutors/educators who teach nutrition-related courses to help them update their knowledge in current trends of managing health conditions like T2DM. In addition, it is worthwhile to advocate for the development of a dietary modification resource toolkit for chronic conditions like T2DM which can be adopted for use by all nursing training institutions. Another helpful suggestion will be the need to consider giving nursing students the opportunity to apply their theoretical knowledge during practical clinical field experience in hospital settings while being mentored by dieticians as part of their training.

Conflict of Interests

The authors declare that there is no conflict of interest regarding the publication of this paper.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions

Christiana Nsiah- Asamoah conceived the idea of the study, contributed to the study design, assisted with developing the survey instruments, wrote the draft manuscript and contributed to final version of manuscript. Christiana Okantey contributed to the study design, assisted with developing the survey instruments, and contributed to final version of manuscript. Guido Nyellayeng Bamere contributed to the study design, assisted with developing the survey instruments, Nursing & Healthcare International Journal

collected and analyzed the data and contributed to the final version of the manuscript. All the authors read and approved the final manuscript.

Acknowledgements

The authors would like to acknowledge the effort of all the final year nursing students for their participation in the survey and tutors for their great help and support with the data collection.