RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES.KARNATAKA, BANGALORE.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

J.ANITHA, 1st YEAR,M.SC NURSING, RATHNA COLLEGE OF NURSING, BM ROAD,HASSAN.

2 NAME OF THE INSTITUTION

RATHNA COLLEGE OF NURSING, BM ROAD,HASSAN.

3 COURSE OF STUDY AND SUBJECT

MASTER IN NURSINGOBSTETRICS AND GYNAECOLOGICAL NURSING

4 DATE OF ADMISSION

O1/12/2008

5 TITLE OF THE TOPIC

STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING DIET AND EXERCISE AMONG PRIMIGRAVID WOMEN WITH GESTATIONAL DIABETES.

5.1 STATEMENT OF THE PROBLEM

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING DIET AND EXERCISE AMONG PRIMIGRAVID WOMEN WITH GESTATIONAL DIABETES OF SELECTED HOSPITALS AT HASSAN DISTRICT.

6. BRIEF RESUME OF THE INTENDED STUDY

6.1.INTRODUCTION.

“Pregnancy is special , Lets us make its safe”

Diabetes mellitus is a common disease in the united states.It is estimated that over

sixteen million caught with diabetes and 5.4 million diabetes are not aware of the existing

disease.

Diabetes prevalence has steadily in the last half of this century and will continue

rising among U.S population.It is a common medical disorder encountered in pregnancy.In

certain populations such as Asians,particularly Indians the prevalence of diabetes is high it is

about 10% of pregnancy. Obesity and advanced maternal age are other risk factors for

diabetes.1

Diabetes is a chronic systematic disease characterized by either deficiency of insulin

or a decrease ability of the body to use insulin. Some time it refers as “High sugar’’

There are three main types of diabetes ;

1. Type 1 diabetes(IDDM)

2. Type 2 diabetes(NIDDM)

3. Gestational diabetes 2

Gestational[jes- ta-shun –ull] is a type of diabetes that starts during pregnancy.our

body is not able to use the sugar(glucose)in our blood as well as level of sugar our blood

becomes higher than normal 3

It develops in women with poor pancreative reserve and insulin resistance such as

those with polycystic ovary syndrome or a family history of diabetes.

It is a disease characterised by glucose intolerance and occurring in about 1 % of all

pregnancy and making it is the most common metabolic disorder complicating pregnancy.It

usually develops in the second trimester (Between 18 – 20th weak of pregnancy).4

According to the National center for Health statistics (2004) ,diabetes now occur in

approximately 4to 14% of pregnant women.GDM represents almost 90% of this group

(ACOG,2005) .5

Gestational diabetes appears to result from the same broad physiological and genetic

abnormalities that characterize diabetes outside of pregnancy women with Gestational

diabetes are at high risk for having or developing diabetes.It has no effect on organogenesis

and does not cause congenital defects.6

Gestational diabetes mellitus is a form of hyperglycemia.Hyperglycemia resuls from

inadequate to meet tissue demands for normal blood glucose regulation.fetal

hyperinsulinemia occurring as a result of maternal hyperglycemia is responsible for all

perinatal complications.

Gestational diabetes is defined as carbohydrate intolerance of variable severity,with

onset or first identified during the present pregnancy.7

Perinatal mortality and morbidity are high in untreated diabetes pregnancies.

According to WHO estimated that 2.9million mothers died in 2000 as a result

diabetes, equivalent to 5.2% of global Mortality.

Mortality due to Gestational diabetes mellitus is not comparable in size to the day

today effect on the disease tends to occur in epidemics and affect the pregnant women. The

rising incidence of diabetes and its complication are going to pose a grave health care burden

of our country. Timely effective interventions / measures and screening test for complications

at the time of diagnosis becomes imperative not for early detection, but also prevent

progression to end stage of diseases. Life style changes and implementing the MCH

programmes mainly during the pregnancy that can prevent or delay the onset of diabetes in

India. Simple intervention strategies like “Eat less, Eat on time, and walk more” can go a

long way in preventing this chronic disorders among present as well as in the future

generations8

6.2 NEED FOR THE STUDY:-

Expecting a child is the most joyous moment of every woman.pregnancy comes with

a lot of responsibilities that are associated with the individual and child.In this Diet and

exercise plays an important role in antenatal mothers to avoid the high risk pregnancy such as

gestational diabetes.

Epidemiological evidences suggest that an to describe the close relationship of GDM

to prediabetic states,in addition to the risk of future deterioration in insulin resistance and

development of overt Type 2 diabetes.women with an early diagnosis of GDM,in the first

half of pregnancy,represent a high-risk subgroup,with an increased incidence of obstetric

complications,recurrent GDM in subsequent pregnancies,and future development of Type 2

diabetes 9.

It is possible that improving insulin sensitivity with diet,exercise and insulin therapy

may reduce the risk of diabetes in individuals at high risk,such as impaired glucose tolerance

and a history of GDM

GDM consists of medical nutrition therapy with adjunctive exercise for atleast 30

minutes/day to reduce the complications.Nutritional therapy is an integral part of the

management of GDM.Most women with GDM are treated by nutritional management alone.9

A study was conducted to assess the effects of dietary advise in preventing GDM in

Australia.Quasi randomized& randomized studies of dietary intervention of preventing

glucose intolerance in pregnancy.Three trials were included in this study.one trial(25pregnant

women) analysed high fibre diet& two trials (82pregnant women) assessed low glycaemic

index vs high glycaemic index diet for pregnant women.Hence the study emphasized that the

women on the low glycaemic index(LGI)diet gave birth to lighter-babies.10

A pilot project was developed to document the effectiveness of a structured low-

intensity walking protocol on capillary glucose control in GDM women. Ten GDM women

followed conventional management of diet and insulin therapy, plus a low-intensity walking

program (W) from diagnosis to delivery. The results suggest an effective role in glucose

regulation for this structured walking.11

In Karnataka a population based studies was conducted that included atleast 500

pregnant women or hospital based studies that included 1000 pregnant women with atleast

70 % population screened for GDM

Maintaining a good diet is an essential part of antenatal mothers. pregnant mothers

need healthy food in their diet.Avoidance of potatoes,rice,sweet items in their diet to reduce

the diabetes during pregnancy.12

Regular exercise can helps to improve the strengthening of muscles and used to keep

blood sugar levels lower because it contracting muscles and stimulate glucose

transport.energy to the body..The most easiest exercise in pregnant period is Walking.Non

weight bearing exercises such as stationary cycling,swimming&arm exercises and other

exercise also very beneficial for the mothers. Regular exercise will help to sleep better at

night and also maintain glucose Homeostasis.Encourage the mothers to follow a nutritional

diet and exercise regularly to decrease the risk. 13

A Study was conducted to estimate the influence of knowledge of life style

modifications such as diet and exercise to the diabetes mothers.Restriction of carbohydrates

to 35-40% of calories,has been shown to decrease the maternal glucose levels and improve

maternal&fetal outcomes.

Providing health teaching to the antenatal mothers about diet and exercise will helps

to reduce the risk of diabetes during the pregnancy.

The more women know about the measures they should take during pregnancy to

safeguard their health,the more likely to concentrate their dietary pattern & exercise inorder

to avoid the Gestational diabetes mellitus.so it is essential for the investigator to enhance the

knowledge of Gestational mothers about the role of diet and exercise during their pregnancy

to achieve “safe motherhood”.

6.3 STATEMENT OF THE PROBLEM:-

“A s tu d y to a ss e s s the e f f ec t i ven es s o f s t ru c tu red t eac h i ng

p rogramme on th e k n owl ed ge regar d i ng diet and exercise among

primigravid women with gestational diabetes of selected hospitals at Hassan.”

6.4 OBJECTIVES:-

A. To assess the pre-test and post-test knowledge of experimental group.

B. To assess the pre-test and post-test knowledge of control group.

C. To compare the pre-test and post-test knowledge of experimental group.

D. To compare the pre-test and post-test knowledge of control group.

E. To corelate the pre-test and post-test knowledge score between experimental and

control group.

F. To associate the demographic variable with level of knowledge in experimental and

control group.

6.5 HYPOTHESES:-

H1 - There will be an significant difference in the knowledge level in experimental

group than control group

H2 - Significance association of demographic variables with knowledge level

regarding diet and exercise.

6.6 ASSUMPTION;-

The study assumes that:

1. Reinforcement concepts of diet and exercise enriches learning and leads to

modification of one’s behaviour.

2. Participatory care will improve self-esteem towards the promotion of health.

6.7 OPERATIONAL DEFINITION:-

A. Assess;

It refers to evaluation or estimation of knowledge level

B. Effectiveness:

In this study it refers to the extent to which the Structured Teaching Programme has

achieved the desired effect as measured by gain in knowledge level of gestational diabetic

mothers through questionnaire

C. Knowledge:

The ability of primi gravid women with gestational diabetes to respond towards the

questionnaire on the selected aspect of diet and exercise.

D. Structured teaching programme;

It is a systematically prepared teaching programme which will be taken for 45

minutes to educate the gestational diabetes mothers regarding diet and exercise.

E. Primigravid women :

A women who has her first pregnancy.

F. Gestational diabetes:

Primi gravid women who is having carbohydrate intolerance of variables severity

with onset or first identified during the present pregnancy.

G. Diet:

It means the mothers who restricts the food for some medical reasons.

I. Exercise:

It is an activity requiring physical effort carried out for the sake of health and fitness.

6.8 CRITERIA FOR SAMPLE SELECTION:-

Inclusion Criteria

All the primi gravid women who :-

1. Attend antenatal clinics during second trimester

2. Are willing to participate in the study

3. Can understand Hindi / English/kannada

Exclusion Criteria:

All the Primi gravid women : who,

1. Are associated with other obstetric complications.

2. Have other chronic illness.

3. Cannot understand Hindi/English/kannada.

6.9 DELIMITATION:-

1. The study is limited to primi gravid women with gestational diabetes.

2. Sample size is limited to 60 gestational diabetes mothers.

3. Prescribed data collection is 4-6 weeks .

6.10 SIGNIFICANCE OF THE STUDY:-

The purpose of the study is to improve knowledge of primigravid women with

gestational diabetes who are attending selected antenatal clinics at Hassan.

6.11 CONCEPTUAL FRAMEWORK:-

This study is based on ‘ GENERAL SYSTEM THEORY’

6.12 REVIEW OF LITERATURE:-

Review of literature is key in research process. It is an Exclusive, Exhaustive and

systematic examination of earlier/ contemporary.

Publication relevant to research study. It is an essential for researcher to analysis the

existing knowledge before going into new area of study. This will help to make a stepping in

the progress of the study.14

This chapter attempts to present on overview of the literature reviewed under

following heading:-

1. Studies related to Prevalence/ Incidence of Gestational diabetes mellitus.

2. Studies related to Disease aspect of Gestational diabetes mellitus.

3. Studies related to Effect of Diet and exercise in Gestational diabetes mellitus.

1. Studies related to prevalence /incidence of Gestational diabetes mellitus.

A study was conducted to survey at New Delhi and gathered information on

asymptomatic age individual (>or=60) for the prevalence of major health problem like

gestational diabetes. A total number of 200 individuals(200pregnant woman with gestational

Diabetes) were studied over the period of three month GD was defined as 4.5% among

population.

A Study was conducted ,in which subjects underwent testing for GDM and then

testing for GDM and type2 diabetes after delivery. women 6 weeks postpartum to 28 years

postpartum.cumulative incidence of type 2 diabetes increased markedly in the first 5 years

after delivery and appeared to plateau after 10 years..The study reveals that rapid increases in

the cumulative incidence occurring in the first 5 years after delivery for different racial

groups.15

A prospective cohort study was analysed included 14613 women without previous

GDM or other diabetes reported a singleton pregnancy between 1990&1994.In analyses

including age,pregravid body mass index,(BMI)& other GDM risk factors,the risk for

GDM ,increased significantly with increasing maternal age(p for trend <.01)&family history

of diabetes mellitus(relative isk,1.68 ; 95% confidence interval 1.39-2.04.Risk for GDM

increased with greater weight gain in early adulthood and non white women.The study find

out that the women at particular risk for GDM& suggest potential strategies for reducing the

risk before a women becomes pregnancy,such as avoiding substantial weight.16

2. Studies related to Disease aspects of Gestational diabetes mellitus.

A study was conducted to assess the reccurence rate of gestational diabetes mellitus in

a subsequent pregnancy.It was conducted with 100 women.The recurrence rate of GDM was

35%.An increase in weight between the two pregnancies and a higher maternal age and parity

were risk associates for a recurrence.A recurrence of GDM was not associated with a higher

glucose level,insulin use,or fetal birth weight in the index pregnancy.17

A prospective cohort study of 187 patients with diabetes of pregnancy and 259

randomly selected negative control patients was conducted to assess the obstetric

significance of diabetes of pregnancy.The perinatal mortality rate was significantly higher in

the diabetic patients than its control.Maternal age had a significant effect on the outcome of

pregnancy in diabetics,with obesity leads to increase in perinatal losses.the study concluded

that pregnant diabetic women aged 25 years or more are at greatest risk18

3. Studies related to effect of diet and exercise in gestational diabetes mellitus

A study was conducted to examine forty-one patients with gestational diabetes

mellitus requiring insulin were enrolled in a randomised study to investigate the efficacy of

an exercise programme in normalizing glucose tolerance.seventeen of twenty one patients

completed the exercise programme while maintaining normoglycemia and obviating insulin

therapy.The type of programme described appears to be safe and can serve as a model for

exercise prescription for pregnant diabetic women to attain improved glucose tolerance.19

A current evidence suggests that both diet and exercise can alter the usual increase in

insulin resistance during mid and late pregnancy.A low-glycemic diet combined with a low-

volume exercise regimen during pregnany decreases the glucose and insulin response to both

mixed caloric intake and exercise,and probably lowers both 24-h blood glucose

concentrations and the maternal substrate utilization ratio of carbohydrate and fat.The end

result is a marked decrease in both maternal weight gain and size at birth.changes in diet and

physical activity appear to prevent the onset of gestational diabetes mellitus in at-risk

women20.

A prospective cohort study stated that physical activity during pregnancy is

associated with a reduced risk of gestational diabetes mellitus.A study was conducted with

prepregnancy,earlypregnancy,and midpregnancy physical activity was assessed using the

Kaiser physical activity survey.A total of 33 women were diagnosed with GDM,119 women

were diagnosed with abnormal glucose tolerance.control of age and prepregnancy body mass

index, women in the highest quarantile of prepregnancy and midpregnancy.Household/

caregiving activities as well as midpregnancy sports/exercise had a reduced of GDM

compared with women in the lowest quartile.21

A study was conducted to compare low and high carbohydrate diets in their

effectiveness,safety and tolerability in women with GDM.The mothers were randomized into

two groups;those on a low and those on a high carbohydrate diet.Daily glucose profiles and

compliance were analysed.No changes in fasting glucose level were notified in the two

groups.The study concluded that both high and low carbohydrate diets are effective and

safe.22

A study was conducted with a serious complication of pregnancy associated with

increased risk of adverse outcomes for both mother& Infant.This study assessed the

association of maternal exercise during GDM pregnancy& selected maternal and infant

adverse GDM.participants in the exercise group were less likely than those in the non-

exercise group to have delivered a large for gestational age(LGA) infant.The result of this

study suggests that moderate maternal leisure time physical exercise during GDM Pregnancy

may reduce the risk of delivery of LGA Infant.23

7. MATERIALS AND METHODS OF STUDY

7.1 SOURCES OF DATA .

The data will be collected from 60 Primigravid women with GDM in antenatal clinics

of selected hospitals at Hassan i.e SC Hospital and Mangala Hospital.

7.2 RESEARCH DESIGN

A Quasi- experimental design which includes Manipulation, Control,and no

randomization.

Two group pre test-post test design

Group Pre-assessment Intervention Post assessment

Experimental 01 X 02

Control 01 -- 02

Key:-

01- Pre Assessment of knowledge level regarding diet and exercise

02- Post Assessment of knowledge level regarding diet and exercise

X-Structured teaching programme regarding diet and exercise.

7.3 METHOD OF DATA COLLECTION:-

Data will be collected by direct interview after obtaining consent from the subjects

and authority. The background information will be collected through socio demographic

schedule prepared by the investigator and level of knowledge will be assessed by semi

structured questionnaire for demographic variables regarding diet and exercise.

7.4 SAMPLING PROCEDURE:-

POPULATION.

All the primigravid women who are attending antenatal clinics.

SAMPLES

Primimothers who fulfilled the inclusive and exclusive criteria are the samples.

SAMPLE SIZE.

The sample size for the study is 60.A total of 60 primimothers equally divided into

two groups as experimental group with 30 gestational diabetes mothers and control group

with 30 gestational diabetes mothers.

SAMPLING TECHNIQUE.

Non-probability convenient sampling

SETTING

The setting selected is from antenatal clinic of selected hospital at Hassan i.e,

Mangala Hospital and S.C.Hospital.

PILOT STUDY

Pilot study is planned with 10% of population.

8. VARIABLE

8.1 Independent Variable: - Structured Teaching Programme.

8.2 Dependent Variable: - Knowledge Level regarding diet and exercise.

9.PLAN FOR DATA ANALYSIS

The plan for data analysis includes descriptive and inferential statistics.

DESCRIPTIVE STATISTICS

To describe the knowledge and demographic variables, number, frequency,

percentage, mean standard deviation.

INFERENTIAL STATISTICS

To compare the knowledge between the groups independent ‘t’ test within the group

paired ‘t’ test.

To associate the demographic variables with knowledge ‘ Chi square (X2) or

ANOVA (F)

10. ETHICAL CONSIDERATION

Does study require any investigation or intervention to be conducted on ?

Yes. Informed consent will be taken from the respondents

Has ethical clearance been obtained from Hospital authorities in case study requires

investigation?

Yes. Permission obtained from the medical officers of selected Hospitals at hassan

and also copy of the same letter will be sent to Nursing Superindent and ward incharge

Sister.

11. LIST OF REFERENCES(Vancouver style)

1. Sheila Balakrishnan .Text book of Obstetrics.Paras medical publisher.287-295.

2. D.C Dutta .Text book of Obstetrics,5th ed,New central book agency(p) Ltd 2001:284-

285.

3. file://G:/diabetes mellitus/Gestational Diabetes Diet plan.htm

4. file://F:New Folder/. What is Gestational Diabetes on Right Health.htm

5. Elizabeth Stepp Gilbert. Manual of High Risk Pregnancy Delivery .4 th ed,Mosby

publisher.216-220

6. Sabaratnam Arul Kumaran,PratapKumar.Essentials of Obstetrics 2nd ed.Jaypee

brothers.147-149.

7. Shirish N Daftary,Sudip Chakravarti.Manual of Obstetrics.2nd ed.Updated colour

edition of the classic HOLLAND & BREWS Manual.139-141

8. Lt Gen SR Mehta., VSM . Diabetes mellitus in India : The Modern Scourge. MJAFI

2009 ; 65 : 50 - 54

9. A.Ben-Haroush,Y.Yogev and M.Hod. Epidemiology of gestational diabetes mellitus

and its association with Type 2 diabetes.Department of obstetrics and

Gynaecology.mhod@clalit.org.il

10. file://F:/New Folder/Exercise and Pregnancy,Healthy Recipes,

exercise,pregnancy,.htm

11. Tieu J, Crowther CA, Middleton P. Dietary advice in pregnancy for preventing

Gestatinal Diabetes mellitus .Discipline of Obstetrics&Gynaecology

j.tieu@ugrad.unimelb.edu.au.

12. Davenport MH,Mottola MF,Mc Manus R.A Walking intervention improves capillary

glucose control in women with GDM:Pilot study,Foundation,Exercise&Pregnancy

labaratory ,university of Canada.

13. Diet&Exercise:Gestational Diabetes:Indian Food Diet(www.pubmed.com)

14. Mottola MF. The role of exercise in the Prevention &Treatment of Gestational

Diabetes Foundation,Exercise,and pregnancy Labaratory Mellitus.mmottola@uwo.ca.

15. BT Basavanthappa .Nursing Research.2nd ed.Jaypee brothers.177-178.

16. Catherine kim,Robert,H.Gestational Diabetes& the incidence of type 2

diabetes.American Diabetes Association 2002,25:1862-1868

17. C.G Solomon.A Prospective study of pregravid determinants of Gestational

Diabetes Mellitus.Journal of American Medical Association.vol.278 No:13,oct

1,1997.

18. RG Moses.The Recurrence rate of Gestational Diabetes in subsequent pregnancies

19(12):1348

19. O’Sullivan JB,Mohan CM. Gestational Diabetes and Perinatal mortality

rate.American Journal of Obstetrics&Gynaecology.Aug 1,1973;116(7);901-904

20. Bung,P:Artal,R,kjos,S.Exercise in gestational diabetes.An optimal therapeutic

approach.Diabetes 1991 Dec:40 suppl 2182-5

21. Clapp JF.Effects of Diet &Exercise on Insulin Resistance during

pregnancy,Department of Obstetrics&Gynaecology, Vermont.

22. Chasan-TaberL,Manson JE.Physical activity& Gestational Diabetes Mellitus.Division

of Biostatistics& Epidemiology.LCT@schoolph.umass.edu

23. Cypryk k,Kosinski M. A comparison of the effectiveness,tolerability&safety of high

& low carbohydrate diets in women with Gestational Diabetes.Department of

Diabetology&Metabolic diseases.Kcypryk@mp.pl

24. Snapp CA.Donldson SK . Gestatational diabetes mellitus:Physical exercise& Health

outcomes.Department of Obstetrics, Gynaecology, & Reproductive

sciences.csnapp@upiumaryland.edu.(pubmed indexed for MEDLINE)

12. Signature of the candidate

13. Remarks of the guide

14. Name and designation of guide

15.1 Signature

15.2 Head of the Department

15.3 Signature

15.4 Remarks of the Principal

15.5 Signature