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2012 17: 32 originally published online 5 November 2010Journal of Research in Nursing Bashar A. Abujudeh, Raeda F. Abu Al Rub, Ibrahim G. Al-Faouri and Muntaha K. Gharaibeh

type 2 diabetes mellitus among high-risk people in JordanThe impact of lifestyle mod ification in preventing or delaying the progression of

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The impact of lifestylemodification in preventing or delaying the progression of type 2 diabetes mellitus amonghigh-risk people in Jordan

Bashar A. AbujudehHead Nurse of General Intermediate Care Unit, King Abdulla University Hospital, Irbid, Jordan

Raeda F. Abu Al RubAssociate Professor, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Ibrahim G. Al-FaouriCNO at King Abdulla Univesity Hospital, Irbid, Jordan

Muntaha K. GharaibehDean of Nursing, Jordan University of Science and Technology, Irbid, Jordan

AbstractPurpose: To investigate (1) the effectiveness of educational interventions in reducing the risk fordeveloping type 2 diabetes mellitus (DM) among Jordanian adults at high risk, and (2) whetherlevels of self-esteem and self-efficacy affect the responses of participants towards educationalinterventions in reducing risks for developing type 2 DM.Design: A comparative experimental pretestpost-test control group design was used. Onehundred and thirteen participants at high risk for developing type 2 DM were randomlyassigned to a study group ( n 57) and a control group ( n 56) based on the matchingtechnique according to the risk factors.Methods: The participants in the study group received 12 educational sessions about healthy dietguidelines and five educational sessions about guidelines for moderately intense physical activity.Participants in the control group received general written information about diet and exercises,but no specific individualised interventions were offered to them.Results: The risk of type 2 DM among the study group was reduced by 28%. The results alsoindicated that participants in the study group had significant reduction in their body weight,

Corresponding author:

Raeda F. Abu Al Rub, Associate Professor, College of Nursing, Jordan University of Science and Technology, P.O. Box 1894,Irbid, JordanEmail: [email protected]

Journal of Research in Nursing 17(1) 3244

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and body mass index, and fasting blood sugar level. Participants in the study group with higher self-esteem and self-efficacy levels before receiving interventions achieved lower weight losscomparing to those who had lower self-esteem and self-efficacy levels.Implications: The findings of the present study confirmed that lifestyle interventions concerned

with educational sessions about dietary behaviours and exercises illustrate promising results inpreventing or delaying the risk of developing type 2 DM by modifying its risk factors.

KeywordsControl group, diabetes mellitus, type 2 DM, educational interventions, Jordan, research group

IntroductionDiabetes mellitus (DM) is a major emerging health problem that has reached epidemicproportions worldwide; it has a huge impact on morbidity and mortality rates in all societiesat all stages of development. DM is dened as a group of chronic metabolic diseases marked byhigh levels of blood glucose resulting from defects in insulin production, insulin action, or both(CDC, 2007). It occurs when the amount of insulin that is produced by the pancreas isinsufficient to meet the bodys needs (Kuzuya et al., 2002). Types of DM include type 1diabetes, type 2 diabetes, gestational diabetes, and secondary diabetes. To date the directcause or causes of diabetes are unknown, but hereditary factors or genetics, obesity, race of ethnicity, physical inactivity, advanced age and unhealthy dietary habits are believed to play amajor role in its development (Chaturvedi, 2007; Hussain et al., 2007).

Globally, at least 171 million people have type 2 DM, and this number is expected to riseto at least 366 million by the year 2030 due to population growth, ageing, urbanisation, poordietary habits and increasing prevalence of obesity, and physical inactivity (InternationalDiabetes Federation, 2004). In Jordan, the prevalence of type 2 DM among adults increasedfrom 13.4% in 1998 (Ajlouni et al., 1998) to 17.1% in 2004 (Ajlouni et al., 2008);unfortunately this number is expected to rise in the future.

People who develop type 2 DM almost always have a pre-diabetes stage, a termpublished in 2002 which means having blood glucose levels that are higher than normalbut not yet high enough to be diagnosed as diabetes (American Diabetes Association,2009a). In other words; a person with pre-diabetes has a fasting blood glucose levelbetween 100 and 125mg/dl (impaired fasting glycaemia (IFG)) or has a blood glucoselevel between 140 and 199 mg/dl measured after a fast and 2 h after drinking a glucose-rich beverage (impaired glucose tolerance (IGT)) (American Diabetes Association, 2009b).

Type 2 DM has long been linked with behavioural, environmental as well as societalfactors such as overweight, sedentary lifestyle and unhealthy dietary habits (Mozaffarianet al., 2007). People who are at risk of type 2 DM, because of physical inactivity andunhealthy dietary habits, just wait to have diabetes and its complications. The highprevalence of this disease, together with its complications, costs and treatment bills,makes it important to focus efforts to reduce or delay the occurrence of this epidemicdisease among Jordanians. In fact, many clinical trials, which were mainly conducted indeveloped countries, demonstrated the effectiveness of lifestyle modications or drugtherapy programmes in reducing or delaying the progression and development of type 2DM among people who are at risk (Oldroyd et al., 2006; Lauritzen et al., 2007). The primaryprevention of type 2 DM should be one of the highest priorities of the health care system in

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Jordan and such trials are needed to be carried out in here. Therefore, one of the purposes of the present study is to determine the effectiveness of educational interventions, concernedwith dietary behaviours and moderately intense exercises, in reducing the risk for developingtype 2 DM among adults who are at high risk.

On the other hand, self-esteem is dened as an individuals feeling of self-worth or self-acceptance (Wikipedia, 2008). Setiloane (2004) found that AfricanAmerican adolescentswith high body mass index (BMI) had signicantly lower self-esteem than adolescents withlow BMI using the Rosenberg Self Esteem Scale. Moreover, Kotler et al. (2006) concludedthat intensive interventions of exercises provided for overweight adolescents improved theirself-esteem signicantly even in the absence of weight loss. Self-efficacy relates to theindividuals perceptions of their readiness and their capabilities to reach designated levelsof performance in a certain manner or attaining certain goals. Martin et al. (2004) conducteda study to examine if self-efficacy for weight loss can be considered as a predictor of weightchange among AfricanAmerican women. The results indicated that those who receivedpersonalised interventions with higher levels of self-efficacy before treatment achieved lessweight loss compared to those who had lower self-efficacy levels before intervention andtheir self-efficacy improved with time during the intervention. No studies were found thatinvestigated whether the levels of self-esteem and self-efficacy affect the responses towardseducational interventions in reducing the risk for developing type 2 DM among adults whoare at risk. Therefore, the other purpose of the study was to determine if levels of self-esteemand self-efficacy affect the responses of participants towards educational interventions inreducing risks for developing type 2 DM.

Literature review There are several types of DM: (1) type 1 diabetes, also called insulin-dependent diabetes or juvenile onset diabetes, is an autoimmune disease in which the insulin-making beta cells of the pancreas are mistakenly destroyed by the immune system; (2) type 2 diabetes, also callednon-insulin-dependent diabetes or adult-onset diabetes, is a disorder of metabolism in whichthe pancreas produces insulin but the body develops resistance to the effects of insulin:obesity is the main risk factor for developing type 2 DM; (3) gestational diabetes, whichis a temporary metabolic disorder that any non-diabetic woman could develop duringpregnancy due to hormonal changes and weight excess along with family history; and(4) secondary diabetes, which is caused by another condition such as pancreatitis, cysticbrosis and Down syndrome (Riaz, 2009).

A number of recent studies offer scientic trials and new hope for reducing the epidemicof type 2 DM through support of lifestyle modications. Most of these studies as discussedbelow were done in developed countries, so the effectiveness and impact of those studies inJordan needs to be investigated. Examples of those trials which were conducted in theWestern culture are discussed below.

Shishko and Mokhort (2006) assessed the effectiveness of lifestyle modication, includingaltered diet composition and moderate physical activity, in preventing type 2 DM amongindividuals with IGT and IFG. The study group included 183 patients and the control groupincluded 144 patients. After a 1 year follow-up, the results of this study showed a signicantreduction in body weight, BMI, waist-to-hip ratio, fasting blood sugar (FBS) level( 0.4 0.6 mmol/l) and oral glucose tolerance test (OGTT) ( 0.9 0.7 mmol/l) among

34 Journal of Research in Nursing 17(1)



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the study group. On the other hand, the control group had signicant increases in weight,BMI and waist-to-hip ratio, FBS and OGTT.

Another study conducted by Hamman et al. (2006) explored the contribution of changes in weight, diet and physical activity on the risk for developing type 2 DM among

1,079 participants who were at risk of having type 2 DM. After 3 years of follow-up, theresults showed that weight loss was the dominant predictor of reduced type 2 DM incidence;for every kilogram of weight lost, there was a 16% reduction in risk. Participants who didnot achieve the weight loss goal at year 1 but achieved the physical activity goal reduced theirrisk of having type 2 DM by 44%.

Moreover, Kilkkinen et al. (2007) examined the efficacy and feasibility of primary healthcare setting-based diabetes prevention model. Dietary and physical activity interventionswere provided, over a 3 month period, to 248 subjects with at least a moderate risk fordeveloping type 2 DM. The study demonstrated that lifestyle interventions improved healthoutcomes especially obesity and blood lipids in a population at high risk for developingtype 2 DM. And the results showed signicant reduction in the total cholesterol and the lowdensity lipoprotein (LDL) cholesterol, BMI, weight, waist and hip circumferences.

A large randomised control study was conducted by Kosaka et al. (2005) in Japan toexamine the effectiveness of lifestyle interventions designed to control body weight amongpeople with IGT. The results of this study indicated that a 67% risk reduction among thoseat higher risk of developing type 2 DM can be achieved by maintaining their BMI at lessthan 22kg/m 2 through an intensive lifestyle modication programme includingindividualised instructions regarding diet and physical exercise.

Similar epidemiological evidence was reported by Bassuk and Manson (2005) in theirsystematic review in which they aimed to nd epidemiological evidence for the role of physical activity in reducing the risk for type 2 DM and cardiovascular diseases. Theirresults indicated that physically active individuals have a 3050% lower risk of developingtype 2 DM than do sedentary persons. Risk reductions were observed with as little as 30 minof moderate-intensity activity per day independent of BMI.

In Jordan, one study was conducted to reassess 68 subjects previously diagnosedwith impaired glucose tolerance for their probability to have type 2 diabetes 2 years later.The results showed that 14.7% of the sample progressed to having type 2 diabetes (Ammariet al., 2005).

The research studies that were conducted in the developed countries showed theeffectiveness of interventions concerned with lifestyle modication in lowering the risk of developing type 2 DM. The present study aimed to test such interventions among aJordanian sample of workers who are at risk for developing type 2 DM. The study alsoaimed to determine if levels of self-esteem and self-efficacy of participants affect theresponses toward educational interventions in reducing the risks for developing type 2DM among adults who are at risk.

MethodsDesignThe study design was a comparative experimental pretestpost-test control group design.When participants are chosen by convenience sampling and then randomly assigned tocontrol and study groups, the design is referred to as a comparative experimental designand not a true experimental design (Burns and Grove, 1997).

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Sample and setting Participants were employees in a teaching hospital that has 457 beds. Participants wererecruited based on the screening for one of the risk factors of type 2 DM such as persons

who (1) had rst-degree relatives with type 2 DM; (2) were overweight and obese (dened asthose with a BMI of 25 kg/m 2 or higher); (3) were 45 years old and above; and (4) hadhypertension. Recruitment for participants was done by one of the researchers who visitedthe setting and conveniently recruited the participants based on having one of the above-mentioned risk factors. At the beginning the plan was to recruit the high-risk groups based onthe elevated value of IGTT. However, due to nancial constraints, it was hard to do the IGTTtest for every potential participant to determine if he/she meets the inclusion criteria;therefore, the recruitment was done conveniently based on the above criteria. The inclusioncriteria were (a) age 25 years, (b) ability to speak Arabic, (c) having at least one risk factorfor type 2 DM; such as (1) having rst-degree relatives with type 2 DM, (2) being overweightand obese (dened as those with BMI of 25 kg/m 2 or higher), (3) having hypertension, (4)having hypercholesterolaemia, (5) having hyper-triglyceridaemia, or (6) being older than 45years. The exclusion criteria were (1) having DM, and (2) taking medications indicated forweight loss or known to have impact on body weight or reducing glucose level (i.e. metformin).

According to Cohen tables, having a power of 0.80 and a medium effect size wouldrequire 64 subjects in each group with a total of 128 participants for both the control andstudy groups. One hundred and fty participants who met the inclusion criteria agreedto participate in the present study. Twenty-six participants (17%) were excludedbecause they had FBS more than 110 mg/dl. Another 11 persons refused to enrol in theprogramme. The remaining participants ( n 113) were randomly assigned to the studygroup ( n 57) and to the control group ( n 56). The study was conducted between April2008 and April 2009.

Data collection and ethical proceduresAfter obtaining formal approval from the human rights committee from the affiliateduniversity and the targeted hospital, participants were recruited from the targeted hospitalbased on the criteria of inclusion. All participants provided written informed consent; andthen they completed a questionnaire that contained background data; the Rosenberg Self Esteem Scale (Rosenberg, 1965) and the General Perceived Self-Efficacy Scale (Schwarzerand Jerusalem, 1993). Moreover, clinical measurements were done for each participant,which included height, weight, BMI, waist and hip circumference, blood pressure, FBSand OGTT. All the measurements were taken at baseline and after 6 months.

Intervention protocol The subjects in the control group were given general written information about diet andexercise at baseline; but no specic individualised programmes or interventions were offeredto them. For subjects in the study group, written information about the nature of pre-diabetes and the purpose of the research was provided prior to the interventions. Thesubjects in the study group had educational sessions about healthy diet guidelines andguidance on increasing their level of physical activity for a period of 6 months. Theeducational sessions were provided at their workplace during their break time.




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Healthy diet. Individuals in the study group received dietary guidance based on dietaryguidelines called the food guide pyramid. They received a food plan that included dailyamounts of each food group and a limit for intake of discretionary calories: added fat andadded sugar. Each participant in the study group had eight educational sessions provided by

a nutritionist during the rst 2 months then one session every month thereafter. There was atotal of 12 sessions. However, there were some participants who called the nutritionist andasked for individual counselling, which was provided to them during a specic time that wasscheduled for them.

Physical activity. Participants in the study group also received guidance aimed at increasingtheir level of physical activity. Goals were to achieve and/or maintain at least 150 min perweek of moderately intense physical activity. Each subject in the study group received foursessions by a physiotherapist during the rst 4 months of the study and one sessionthereafter. In total there were ve physical activity sessions.

InstrumentsSelf-esteem scale. The Rosenberg Self Esteem Scale was developed by Rosenberg in 1965to measure global self-esteem. This scale consists of ten items. It is rated on a Likert scaleranging from 1 strongly disagree to 4 strongly agree. The alpha coefficient wasreported as 0.78 (CHIPTS, 2009). In the present study, the alpha coefficient was 0.72.

Self-efficacy scale. The General Perceived Self Efficacy Scale (GSE) consists of 10psychometric items and is used to assess the level of self-efficacy. The responses are ratedon four choices ranging from 1 not at all true to 4 exactly true. The scale has beenused in numerous research projects, where it typically yielded internal consistencies (alpha)between 0.75 and 0.90 (Schwarzer and Jerusalem, 1993). In the present study, the alphacoefficient was 0.74.

Laboratory tests. Tests to determine impaired fasting glycaemia and impaired glucosetolerance were carried out in the targeted hospital laboratory using venous blood.

Anthropometric measurements. These measurements were made according to thestandard procedures reported in the literature.

ResultsCharacteristics of the study groupsThe mean age of participants in the study group was 33.9 (SD 7.6) years, ranged from22 to 53 years of age. Above half of them were females (52.6%) and married (75.4%). Themost frequent academic qualication level was secondary school (36.8%) followed bydiploma (31.6%). The majority of them (87.7%) were not smokers. Only four participants(7%) complained from hypertension and half of them (49.2%) had rst relative familyhistory of type 2 DM. Moreover, only four participants (7%) practised exercises whilenine participants (15.8%) ate a healthy diet.

The mean age of the participants in the control group was 33.6 years (SD 7.59) rangedfrom 22 to 58 years old. Above half of them (53.6%) were males and married (64.3%).

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The most frequent academic qualication level among participants was secondary school(46.4%). One third of the participants (30.4%) were smokers. Four participants (7%)complained of hypertension, and half of them (48.2%) had rst relative family history of type 2 DM. Only three participants (5.4%) practised exercise regularly and three participants

(19.6%) ate a healthy diet. The control group was statistically similar to the study groupaccording to all background variables except for the prevalence of smoking. The controlgroup had a higher prevalence of smoking than the study group ( 2 5.518; p < 0.016).Concerning the anthropometric measurements (weight, BMI, SBP, DBP, waist-to-hipcircumference, FBS and OGTT), the participants in both the control and study groupswere also statistically similar at the baseline readings.

The impact of the health promotion programme on reducing the risk for developing diabetes mellitusThe t test was used to investigate the impact of the programme which included educationalsessions about healthy dietary behaviours and practising moderately intense exercises onreducing the risk for developing type 2 DM. The majority of anthropometric measurementswere decreased signicantly in the study group post-implementation of the programme. Theparticipants in the study group showed signicant reductions in (1) weight (the mean wasreduced by 1.8, SD 4.585; p 0.005); (2) BMI (the mean was reduced by 0.7, SD 1.724; p 0.003); (3) FBS level (the mean was reduced by 0.45, SD 0.447; p 0.000); and(4) blood sugar level 2 h after sugar consumption (the mean was reduced by 0.47,SD 0.174; p 0.01). Moreover, the participants in the study group showed signicantincreases in the levels of self-esteem (the mean increased by 2, SD 3.217; p 0.000).However, the study group showed no signicant changes in (1) waist ( p 0.148), hip( p 328), and waist-to-hip circumference ( p 0.127); (2) systolic blood pressure level( p 0.385) and diastolic blood pressure level ( p 0.666); and (3) self-efficacy ( p 0.12).The data regarding differences between pre- and post-readings of anthropometricmeasurements, sugar levels, self-esteem, and self-efficacy for the study group are presentedin Table 1.

For the control group, the analysis showed signicant increases in (1) weight (mean wasincreased by 2.2 kg, SD 3.472; p 0.000); (2) BMI (the mean was increased by 0.74,SD 1.171; p 0.000); (3) abdominal obesity reected by waist circumference (the meanwas increased by 0.56, SD 1.232; p 0.001). Moreover, the results surprisingly showed asignicant decrease in the FBS (the mean was reduced by 0.21, SD 0.45; p 0.001). On theother hand, no signicant changes were found regarding (1) hip circumference, (2) waist-to-hip circumference, (3) systolic blood pressure and diastolic blood pressure, (4) self-esteem,and (5) self-efficacy. The data about differences between pre- and post-readings of anthropometrics, sugar levels, self-esteem and self-efficacy for the control group ispresented in Table 2.

Furthermore, the t test was used to investigate if there was any difference in the levels of anthropometric measures, sugar levels, blood pressure, changes in the levels of self-esteemand self-efficacy between the study and control groups after implementing the programme.The analysis showed that the study group was statistically similar to the control group inregard to the measures of (1) hip circumference ( p 0.123), (2) waist-to-hip circumference( p 0.057), (3) systolic blood pressure ( p 0.992) and diastolic blood pressure ( p 0.896),(4) FBS level ( p 0.211), and (6) self-efficacy ( p 0.821).




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On the other hand, the study group showed a signicant increase in (1) level of self-esteem(the mean was increased by 1.4, SD 3.879; p 0.009). The study group also showedsignicant decreases in (1) weight (the mean was reduced by 3.96 kg, SD 5.614; p 0.000); (2) BMI (the mean was reduced by 1.45, SD 5.545; p 0.000); and waistcircumference (the mean was reduced by 0.92, SD 1.789; p 0.000). The dataconcerning differences between the study and control groups after the implementation of

Table 1. Data concerning differences between pre- and post-readings of anthropometric measurements,blood sugar levels, self-esteem, and self-efficacy for the study group

VariablePre-test,mean (SD)

Post-test,mean (SD)

Paired differences,mean (SD) t test p

Self-esteem 30.45 (3.79) 32.38 (3.03) 1.93 (3.22) 4.528 0.001 **Self-efficacy 30.32 (4.86) 31.18 (4.12) 0.86 (4.12) 1.577 0.12Weight (kg) 85.93 (14.14) 84.14 (14.83) 1.79 (4.59) 2.95 0.005 **BMI (kg/m2 ) 30.46 (4.18) 29.75 (3.98) 0.71 (1.72) 3.12 0.003 **Waist (cm) 38.64 (4.65) 38.30 (4.85) 0.34 (1.71) 1.47 0.148Hip (cm) 43.26 (3.21) 43.11 (3.01) 0.15 (1.21) 0.99 0.328Waist-to-hip circumference 0.90 (0.08) 0.89 (0.08) 0.01 (0.03) 1.55 0.127Systolic BP 118.95 (12.40) 117.84 (12.03) 1.11 (9.53) 0.88 0.385Diastolic BP 76.11 (8.31) 75.58 (10.71) 0.53 (9.17) 0.43 0.666Fasting blood sugar 5.48 (0.43) 5.18 (0.55) 0.30 (0.45) 5.08 0.001 **

First hour sugar level 7.01 (1.60) 6.60 (1.85) 0.41 (1.74) 1.77 0.82Second hour sugar level 5.58 (1.08) 5.16 (0.97) 0.42 (0.17) 2.69 0.010 *Third hour sugar level 4.65 (0.77) 4.45 (0.70) 0.20 (1.05) 1.36 0.181

Values in bold are significant.*p < 0.05; **p < 0.01.

Table 2. Data concerning differences between pre- and post-readings of anthropometric measurements,blood sugar levels, self-esteem and self-efficacy for the control group

Variable

Pre-test,

mean (SD)

Post-test,

mean (SD)

Paired differences,

mean (SD) t test pSelf-esteem 30.13 (2.86) 30.77 (2.87) 0.64 (2.53) 4.528 0.063Self-efficacy 30.86 (3.62) 31.59 (2.99) 0.73 (2.76) 1.985 0.052Weight (kg) 83.64 (13.26) 85.84 (15.07) 2.20 (3.47) 4.735 0.001 **BMI (kg/m2 ) 29.61 (3.66) 30.35 (4.13) 0.74 (1.17) 4.716 0.001 **Waist (cm) 38.12 (4.66) 38.68 (4.89) 0.56 (1.23) 3.416 0.001 **Hip (cm) 43.22 (3.59) 43.34 (3.64) 0.12 (0.58) 1.498 0.14Waist-to-hip circumference 0.88 (0.07) 0.89 (0.09) 0.01 (0.04) 1.023 0.311Systolic BP 119.42 (12.03) 118.37 (9.89) 1.05 (1.262) 1.04 0.305Diastolic BP 73.07 (8.44) 72.32 (8.29) 0.75 (9.17) 0.75 0.459

Fasting blood sugar 5.58 (0.35) 5.37 (0.49)

0.21 (0.45)

5.08 0.001 **First hour sugar level 6.78 (1.47) 6.61 (1.96) 0.17 (1.84) 0.71 0.48Second hour sugar level 5.16 (0.97) 4.86 (1.09) 0.30 (1.14) 1.97 0.54Third hour sugar level 4.50 (0.51) 4.44 (0.43) 0.06 (0.56) 0.83 0.408

Values in bold are significant.**p < 0.01.

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the programme regarding anthropometrics, sugar levels, blood pressure, levels of self-esteemand levels of self-efficacy are presented in Table 3.

The impact of self-esteem and self-efficacy on participants responses in the study groupThe results of the current study revealed that people with low self-esteem (below average)before implementing the programme had signicant reductions in (1) weight ( t test 2.819, p < 0.008), (2) BMI ( t test 2.933, p < 0.006), (3) waist-to-hip circumference(t test 2.045, p < 0.049), and (4) FBS level ( t test 4.790, p < 0.000). In contrast;people with high levels of self-esteem (above average) had only signicant reductions in(1) FBS level ( t test 2.676, p < 0.013); and (2) second blood sugar level after sugarconsumption ( t test 2.643, p < 0.015).

Regarding changes in self-esteem levels among participants, the data analysis revealedthat participants who improved their self-esteem during the implementation of theprogramme had signicant reductions in their (1) body weigh ( t test 3.134, p < 0.003),(2) BMI ( t test 3.259, p < 0.002), (3) waist circumference ( t test 2.613, p < 0.013),(4) waist-to-hip circumference ( t test 2.587, p < 0.014), (5) FBS level ( t test 3.617, p < 0.001), and (6) second blood sugar level after sugar consumption ( t test 2.532, p < 0.016). On the other hand, participants who had no change or a decrease in their self-esteem level showed only a decrease in FBS.

Concerning self-efficacy, the results of this study revealed that people with low levels of self-efficacy (below average) before implementing the programme had signicant reductionsin (1) weight ( t test 2.180, p < 0.036), (2) BMI ( t test 2.324, p < 0.026), and (3) FBSlevel (t test 3.210, p < 0.003). In contrast; people with high levels of self-efficacy (aboveaverage) had signicant reductions in (1) FBS level ( t test 4.088, p < 0.000), and(2) second blood sugar level after sugar consumption ( t test 4.564, p < 0.000).

Table 3. Differences between the study group and control group after implementation of the programmeregarding anthropometric measures, blood sugar levels, blood pressure, level of self-esteem and level of self-efficacy

Variable

Study group (n 57),

mean (SD)

Control group ( n 56),

mean (SD) t test p

Self-efficacy 0.89 (4.15) 0.73 (2.76) 0.277 0.821Self-esteem 2.05 (3.11) 0.64 (2.53) 2.722 0.009 **Weight (kg) 1.77 (4.62) 2.20 (3.47) 5.61 0.001 **BMI (kg/m2 ) 0.71 (1.74) 0.74 (1.17) 5.55 0.001 **Waist (cm) 0.36 (1.72) 0.56 (1.23) 3.85 0.001 **Hip (cm) 0.16 (1.22) 0.12 (0.58) 1.57 0.123Waist-to-hip circumference 0.01 (0.04) 0.01 (0.04) 1.94 0.057Systolic BP 1.04 (9.60) 1.05 (7.61) 0.01 0.992Diastolic BP 0.54 (9.25) 0.75 (7.53) 0.131 0.896

Fasting blood sugar 0.31 (0.45) 0.21 (0.45) 1.27 0.211First hour sugar level 0.40 (1.75) 0.18 (1.84) 0.83 0.412Second hour sugar level 0.43 (1.30) 0.31 (1.16) 0.48 0.635Third hour sugar level 0.19 (1.04) 0.19 (0.54) 0.54 0.592

Values in bold are significant.**p < 0.01.




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Regarding changes in self-efficacy, the data analysis revealed that participants whoimproved their self-efficacy had signicant reductions in (1) body weight ( t test 2.617, p < 0.017), (2) BMI ( t test 2.775, p < 0.012), (3) FBS level ( t test 3.169, p < 0.005), and(4) second blood sugar level after sugar consumption ( t test 2.706, p < 0.014). While

participants who had a decrease in their self-efficacy level showed no signicant changesin their anthropometric measurements or blood sugar levels, participants with no change inself-efficacy level had only signicant reduction in FBS ( t test 3.367, p < 0.026).

DiscussionThe current study is the rst clinical trial performed in Jordan that investigated theeffectiveness of educational sessions about healthy dietary behaviours and exercises onreducing the risk for developing type 2 DM. The results showed that the educationalprogramme provided to the study group through educational sessions helps in reducingthe risk for developing type 2 DM by modifying its risk factors (weight, BMI and waistcircumference). Based on the formula that indicates for every kilogram of weight loss, thereis a 16% reduction in risk for developing type 2 DM (Hamman et al., 2006), the risk of type2 DM in the present study was reduced by 28% (changes in weight, 1.8 kg 16%).

The results pointed out that participants in the intervention group had signicantreduction in their body weight and BMI. Such results were consistent with the studies byShishko and Mokhort (2006), Fujimoto et al. (2007) and Kilkkinen et al. (2007). On theother hand, participants in the control group of the present study had signicant increase inweight, BMI and waist circumference. In the study by Shishko and Mokhort (2006),participants in the control group had also signicant increase in weight, BMI and waist-to-hip circumference.

The small proportion of weight loss in the present study (mean was reduced by 1.8 kg)may be due to the shorter time of follow-up (6 months). Such ndings complement theresults reported by Oldroyd et al. (2006). Those researchers provided similar interventionsfor 6 months and consisted of regular motivational counselling from the National HealthService dietician and physiotherapist. The results of the present study also showed that therewas a statistically signicant difference between the study group and control group withregard to the difference in means for body weight, BMI and waist circumference. Suchresults are consistent with the Finnish Diabetes Prevention Study by Tumileheo et al. (2001).

The impact of educational interventions on blood sugar levels after 6 months of startingthe programme showed a signicant reduction among the study group in their FBS level andsecond sugar level after load. However, surprisingly, the control group also showed asignicant decrease in the FBS as well. Even though participants in the study groupshowed more decrease in the level of FBS (reduced by 0.30) than participants in thecontrol group (reduced by 0.20); such a difference was not signicant. In fact, the effectsof lifestyle interventions on glucose levels are still controversial. It is also worth mentioningthat the period of time for providing educational programmes might have an effect on theoutcomes of the study such as reducing glucose levels. Most studies that indicated sucheffects on lowering glucose levels among intervention groups compared to control groupsprovided interventions for at least 1 year (Tumileheo et al., 2001; Watanabe et al., 2003;Shishko and Mokhort, 2006). The present study was conducted only for 6 months.

The present study did not aim to improve self-esteem and self-efficacy levels; it onlyconsidered the inuence of these variables on participants responses to the intervention

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provided. The results demonstrated that participants in the study group had signicantimprovement in their self-esteem; however, the results indicated no signicantimprovement in the self-efficacy. On the other hand, participants in the control group hadno signicant changes in the levels of self-esteem or self-efficacy. Our ndings are congruent

with ndings by Kotler et al. (2006), who found that intensive interventions of exercisesprovided for overweight adolescents improved their self-esteem signicantly even in theabsence of weight loss. With regard to self-esteem, this study revealed that participantswho received a lifestyle modication programme and had higher self-esteem and self-efficacy levels before the implementation of the programme achieved lower weight losscompared to those who had lower levels of self-esteem and self-efficacy. Such ndings areconsistent with those of Martin et al. (2004) who concluded that people who receivedpersonalised interventions and had higher levels of self-efficacy before treatment achievedless weight loss compared to those who had lower self-efficacy levels before intervention.Further research studies are needed to investigate the effects of the levels of self-esteem andself-efficacy in modifying lifestyle.

ImplicationsImplications from the study provide empirical evidence that lifestyle modication concernedwith changes in dietary behaviours and practising exercises can reduce the risk of developingtype 2 DM. Such results should be utilised by health care professionals, nutritionists,physiotherapists and other health care providers while providing education or care topatients or clients who are at risk for developing type 2 DM. Nurses understanding of lifestyle modication strategies is essential and central to any successful diabetesprevention effort. The current study demonstrated that lifestyle interventions can besuccessfully implemented in worksites and provided empirical evidence of the impact of atype 2 DM prevention programme; these results may be utilised by health care professionalsto gain the support of stakeholders and decision makers, and to create a partnership withthem to effectively deliver type 2 DM prevention programmes

Moreover, the ndings of the current study may be utilised by health policy makers toemphasise the importance of healthy lifestyle; such results could be employed to supportpolicies that enhance healthy lifestyles among the public, such as making healthy foodmore appealing and facilitating exercise by, for example, making walking paths availablethroughout the country. The interventions provided in the current study demonstrated theeffectiveness of teaching as a tool or strategy to reduce the risk factors for developing type 2DM. Nurse educators should emphasise to nursing students the importance of patienteducation as a vital part of nursing interventions. Moreover, nurse educators could play animportant role in designing educational campaigns that aim to teach the public the importanceof adopting healthy lifestyles such as eating a healthy diet and undertaking regular exercise.

ConclusionStudies that have used lifestyle interventions provided consistent evidence of the potential of lifestyle changes to diminish the risk of type 2 DM in various populations. The ndings of thepresent study conrmed that lifestyle interventions concerned with educational sessions aboutdietary behaviours and exercises help in preventing or delaying the risk of type 2 DM bymodifying its risk factors. Furthermore, other variables such as self-esteem and self-efficacy




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should be considered if effective strategies are to be developed to delay the progression of type 2 DM. In this study, participants with higher levels of self-esteem and self-efficacy beforetreatment achieved less weight loss compared to those who had lower levels before theimplementation of the programme. Further research studies are needed to build scientic

evidence that determines the mechanism by which self-esteem and self-efficacy affect theresponse of participants towards lifestyle modication programmes.

Key points

. Lifestyle modications in terms of dietary changes and exercises modify the risk factors of type 2 DM.

. Adoption of healthy lifestyle could play a major role in delaying or preventing theprogression of type 2 DM.

. Self esteem and self efficacy should be considered when health promotion programs areplanned for delaying or preventing the progression of type 2 DM.

Funding

This study was supported by Jordan University of Science and Technology [grant number 122/2008].

Acknowledgement

The authors thank all participants for agreeing to take part in the study.

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Bashar A. Abujudeh (MSN, RN) is the head nurse of the intermediate intensive care unit atKing Abdullah University Hospital, Jordan. His research interest areas are in improvingpatient outcomes.

Raeda F. Abu Al Rub (PhD, RN) is the Vice Dean of the College of Nursing at JordanUniversity of Science and Technology and the director assistant of the World HealthOrganization Collaborating Center. She is also involved in teaching graduate studentswho seek a masters degree in nursing service administration and community healthnursing. Her research interest areas are job stress, social support, job performance andsatisfaction among hospital nurses and patient outcomes.

Ibrahim G. Al-Faouri (PhD, RN) is the CNO as well as Head of the Quality ImprovementDepartment, King Abdullah University Hospital, Jordan. He is also an assistant professor atthe College of Nursing, Jordan University of Science and Technology. He is now involved inteaching graduate students who seek a masters degree in nursing service administration. Hisresearch interests are social support, burnout, job satisfaction and quality care.

Muntaha K. Gharaibeh (PhD) is Dean of Faculty of Nursing at Jordan University of Scienceand Technology and the director of the World Health Organization Collaborating Center.She is involved in teaching graduate and undergraduate students. Her research interests arewomens health, and violence against children and women.

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