Can a program of food and diabetes education improve the quality of the lives of diabetic patients with a previous myocardial infarction?
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Ann Ig 2018; 30: 120-127 doi:10.7416/ai.2018.2203
Can a program of food and diabetes education improve
the quality of the lives of diabetic patients with a previous
myocardial infarction?
A.Tantucci1, C. Ripani1, C. Giannini1, M. Fregonese1, M. De Angelis1
Key words: Diabetes, cardiovascular diseases, diabetes education, food education
Parole chiave: Diabete, malattie cardiovascolari, educazione al diabete, educazione alimentare
Abstract
Background and objectives. People with diabetes and cardiovascular complications need to be educated
about the self-management of the disease at the time of diagnosis and during the follow-up to best benefit from
what they learn. Education is most effective when offered to small groups of patients led by a professional
team.
The aim of the study is the evaluation of diabetes and food education aimed at improving the self-awareness
of the disease, the management and the quality of the lives of diabetic patients with a previous myocardial
infarction.
Methods and results. The sample group consisted of 20 subjects suffering from diabetes mellitus type 2 with
a previous myocardial infarction.
First, subjects were administered a test to assess the degree of knowledge of diabetes and quality of life;
they also performed a walking test and a food interview. Anthropometric assessments and serum chemistry
parameters were taken into consideration. Subsequently, they attended 7 lessons on nutrition, diabetes and
cardiovascular complications; post intervention, the sample group demonstrated statistically significant
improvement in the knowledge of the disease, in anthropometric measurements and walking test.
Conclusion. Although we have not found an improvement of biochemical parameters, informing diabetic
subjects of their health conditions and complications is essential in order to achieve patient empowerment
and the compliance.
Introduction with the traditional relationship between
doctor and patient and the first to understand
The education of diabetic patients has a the importance of education of diabetic
crucial role in the success of the disease. subjects (1).
The concept of therapeutic education was In 1997, in the United States, the National
introduced in the 70s by Jean Philippe Assal, Diabetes Education Program (NDEP),
a young endocrinologist shortly after he sponsored by the National Institutes of
realized that he was suffering from diabetes; Health and the Center for Disease Control
he was the first to express dissatisfaction and Prevention, was launched with the
1
Department of Medicine, Section of Internal Medicine, Endocrinology and Metabolism, Perugia University School of
Medicine, University of Perugia, ItalyEducation and Prevention in Diabetic People 121
aim of reducing morbidity and mortality took place about the experiences of each
from diabetes and its complications (2). participant. In addition, these meetings were
To achieve this aim, Dr. Assal tried to raise not conducted using a scientific-medical
awareness of the seriousness of diabetes, its language, while concepts were represented
risk factors and prevention strategies, and to through metaphors and images.
promote self-management diabetes among The objective of the above study was
patients. the evaluation of improvements in terms of
In Italy, the Diabetes Education Study knowledge of the disease, quality of life,
Group (GISED) and the Italian Society of Body Mass Index and blood chemistry such
Diabetology (SID) have identified seven as glycosylated hemoglobin and the lipid
key educational objectives in a program of profile following an educational intervention.
therapeutic education for diabetic patients This study found that subjects of the
(3): intervention group had an improvement in
• appropriate diet adoption; biochemical parameters, Body Mass Index,
• correct application of therapy; knowledge of the disease and quality of life,
• physical activity; while there were no significant changes in
• glucose monitoring; the subjects of the control group.
• ability to solve metabolic emergencies Another important study was done in
and critical situations; the United Kingdom through DESMOND
• surveillance of complications; (Diabetes Education and Self Management
• appropriate health behavior and search for Ongoing and Newly Diagnosed), the
for better quality of life. first national education program for people
Education can be conducted in various with diabetes mellitus type 2. This study,
ways, one of which is represented by the however, revealed that an educational
education group. This type of intervention program aiming to increase knowledge and
has several advantages, such as the possibility improve the lifestyle of patients did not have
to educate many people at the same time significant effects on the intervention group
and the opportunities of interaction among compared with the control group (6).
patients. Sharing experiences with other The study investigating the association
patients, in fact, can greatly help individuals between cardiovascular events and lifestyle
to cope with the disease. In group meetings, was the “Seven Country Study” conducted in
however, it is important to avoid the classic Minnesota by Ancel Keys and collaborators
distinction between teacher and student as between 1958 and 1970 in which men
this model would prove inefficacious; while between 40 and 59 years of age from
it is important that patients have an active 7 different countries (Yugoslavia, the
role and the teacher assumes the role of Netherlands, Japan, Italy, Greece, USA,
moderator of the group (4). Finland) were examined (7).
The ROMEO (Rethink Organization to This study cast light on the importance
Improve Education and Outcomes) Study (5) of nutrition and the role of individual
is a clinical trial conducted over a four-year nutrients and was subsequently amplified
period on 815 patients with type 2 diabetes, and confirmed by multiple studies that have
not given insulin, divided into a control group been conducted from the 1980s until today.
and an intervention group. The intervention The Mediterranean diet is associated, in
group participated in seven one-hour general, with an average reduction of 30%
sessions in which experiences of daily life, in cardiovascular risk. (8, 9). The primary
such as shopping and choosing a menu, were approach for achieving and maintaining
simulated. During the sessions a conversation weight loss is the change in lifestyle, which122 A. Tantucci et al.
includes a reduction in caloric intake and Health Organization Quality Of Life,
an increase of physical activity (10). People WHOQOL-BREF) to assess the quality of
with diabetes should receive nutritional life, consisting of 26 questions investigating
counseling: education in small groups and/ four aspects of the quality of life: physical
or a setting with an individualized education health, psychological state, social and
program has proven beneficial for those at environmental context, and relationships
risk of diabetes or those who are diabetic. (the range of the medium score goes from
At the moment there is no evidence to 0 to 4).
suggest the benefits of a low-carbohydrate They also performed the “Six-minute
diets (or with a restriction to below 130 g/ walking test”, or “walk test”, which is
day) (11). As mentioned previously, the the gold standard test to evaluate the
performance of an adequate level of physical functional capacity of the patient (13) and
activity, to promote weight loss and improved a food interview to calculate the Italian
glycemic control, is important. Mediterranean Index (IMI) (14); IMI score is
In type 2 diabetes, aerobic and anaerobic based on 10 items: high intakes of 6 typical
exercises, associated with moderate weight Mediterranean foods (pasta, vegetables,
loss, has proven effective in improving fruit, pulses, olive oil, fish), low intakes of 4
glycemic levels and some parameters of non-Mediterranean foods (sugar-sweetened
metabolic syndrome and in preventing the beverages, butter, red meat and potatoes). If
loss of muscle mass (12). consumption of typical Mediterranean foods
The present study was carried out was in the third tertile of the distribution, the
through a program with a therapeutic and subject received 1 point, for all other intakes
food education group, in which we tried received 0 points; if consumption of non-
to encourage discussion and interaction Mediterranean foods was in the first tertile of
among patients. The aim of this study the distribution, subject received 1 point.
was to evaluate the effectiveness of group Anthropometric variables considered
education in diabetic subjects with known were: weight, height and waist circumference
acute cardiovascular events. Considering (WC) and the Body Mass Index (BMI)
educational GISED outcomes as fundamental was calculated. In addition, several blood
in a program of therapeutic education of parameters to evaluate the glycometabolic
diabetic patients, changes of biochemical and cardiovascular state of patients were
parameters (HbA1c and lipid profile), taken into consideration: glycosylated
eating habits, knowledge about the disease, haemoglobin (HbA1c) total cholesterol,
quality of lifestyle and changes in weight triglycerides (TAG), LDL and HDL
and body composition which occurred cholesterol fractions.
during the course of the study were taken In the following months the subjects
into account. involved in the survey attended seven group
lessons, of about one hour each. During the
lessons our team tried to increase knowledge
Methods about the disease and understanding of the
importance of a healthy lifestyle to optimize
20 subjects recruited for the study took glycemic control and to reduce the risk of
two tests to assess their degree of knowledge developing complications. In these meetings
of diabetes: the GISED Questionnaire, we talked about:
that consists of 32 questions (1 point for • diabetes and classification;
each question) about diabetes and its • self monitoring of blood glucose
complications, and another test (World (SMBG) and acute complications;Education and Prevention in Diabetic People 123
• diabetes therapy; Based on IMI score, ranging from 0 to
• chronic complications and cardiovascular 10, adherence to Mediterranean Diet (MD)
disease; was classified as low (≤3), medium (4-5),
• importance of physical activity; high (≥6) (14).
• digestive system, nutrients and food
groups;
• mediterranean diet and guidelines for Results
a healthy diet.
Patients were very interested in all Table 1 shows weight, BMI and WC at the
the classes, but particularly in lessons on beginning (0) and at the end (1) of the study;
nutrition and good eating habits. Table 2 shows the results of the GISED test to
After completing all meetings, we assess diabetes knowledge and the functional
made initial assessments to evaluate any capacity measured using the “Six Minute
modifications and improvements resulting Walking Test” at the beginning (0) and at
from what was learned during the classes. the end of the study (1); Table 3 shows the
Comparisons between data collected haematobiochemical parameters (HbA1c, total
before and after the lessons were carried out cholesterol, LDL, HDL, TAG) at the beginning
with the Wilcoxon-Mann-Whitney method. (T=0) and at the end (T=1) of the study; Table
For statistical analysis SPSS 22.0 was used 4 shows mean, standard deviation, minimum,
and the threshold of significance was set at maximum and percentiles of weight, BMI,
p < 0.05. WC, GISED and SMWT.
Table 1 - Weight, body mass index (BMI) and waist circumference (WC) at the beginning (T=0) and at the end (T=1)
of the study
Code Age Sex Height Weight Weight BMI (Kg/ BMI (Kg/ WC WC
(cm) (Kg) 0 (Kg) 1 m2) T 0 m2) T T 1 (cm) 0 (cm) 1
1 68 M 175 75 74 25.06 24.72 95 93
2 41 M 172 116 114 39.21 38.53 127 126
3 72 M 164 135 133 50.19 49.45 155 155
4 50 F 165 80 76 29.38 27.91 105 86
5 57 M 163 60 59 22.58 22.21 87 85.5
6 69 M 168 87 87 30.82 30.82 109 110
7 67 M 173 104 104 34.75 34.75 120 120
8 65 M 170 93 92 32.18 31.83 112 112
9 72 M 170 77 75 26.64 25.95 101 101
10 54 M 177 77 76 24.58 24.26 95.5 95.5
11 72 M 173 92 92 30.74 30.74 88 90
12 68 M 165 88 88 32.32 32.32 111 109
13 70 M 170 79 79 27.33 27.33 99 100
14 76 M 168 83 82 29.41 29.05 105 105
15 77 M 168 77.6 78 27.49 27.64 107 107
16 62 M 162 83 80 31.62 30.48 115 108
17 69 M 170 77 75.5 26.64 26.12 102 102
18 58 F 165 61 60 22.4 22.04 92 90
19 70 M 172 94 94 31.77 31.77 119 119
20 61 M 168 104 103 36.85 36.5 127 122124 A. Tantucci et al.
Table 2 - GISED test and “Six minutes walking test” (SMWT) at the beginning (0) and at the end (1) of the study
Code GISED (32) 0 GISED (32) 1 SMWT (m) 0 SMWT (m) 1
1 19 27 521.3 527.4
2 16 30 533.4 548.7
3 20 28 288.6 302.1
4 16 27 459 490.5
5 22 31 294.3 297.1
6 20 30 479.7 489.3
7 21 29 273.9 395.1
8 22 31 383.4 503.1
9 24 29 375 450
10 19 29 325 311
11 28 30 390 360
12 28 30 270 310
13 10 29 475 510
14 20 30 435 450
15 17 23 347.16 389.04
16 19 23 436.53 430.34
17 21 25 466.03 530.92
18 21 26 431.81 498.47
19 23 26 229.47 319.14
20 21 28 499.06 536.52
Table 3 - Haematobiochemical parameters at the beginning (0) and at the end (1) of the study
Code HbA1c HbA1c Tot chol Tot chol LDL LDL HDL HDL TAG TAG
(0) (1) (0) (1) (0) (1) (0) (1) (0) (1)
1 5.9 6.2 409 216 316 156 39 34 269 128
2 8.1 8.0 230 227 68 64 53 52 168 163
3 8.6 8.4 280 258 201 179 48 42 222 183
4 5.7 5.7 123 101 33 31 71 68 92 93
5 4.9 5.7 136 146 69 71 50 56 84 94
6 8.3 8.3 161 171 83 81 46 48 159 258
7 7.8 6.3 141 121 61 59 32 34 238 142
8 7.2 6.5 180 118 58 50 30 35 137 164
9 6.3 6.2 210 197 83 68 41 40 233 198
10 5.9 7.0 197 124 115 63 35 43 231 90
11 7.2 8.2 145 154 84 87 42 49 95 90
12 6.2 6.2 115 137 58 74 43 45 70 91
13 5.6 5.6 115 83 51 44 41 32 72 33
14 7.2 7.4 212 183 111 86 70 56 153 205
15 5.8 5.8 102 81 52 46 60 58 137 139
16 7.4 6.4 80 80 37 34 25 26 101 101
17 6.8 6.8 184 184 109 102 63 63 61 61
18 5.9 5.9 135 129 69 68 40 40 125 122
19 7.4 8.1 127 136 70 69 33 35 116 162
20 8.8 8.8 159 140 72 49 33 32 270 294Education and Prevention in Diabetic People 125
Table 4 - Mean, Standard Deviation, Minimum, Maximum and Percentiles of weight, BMI, WC, GISED and
SMWT
N Weight Weight BMI BMI WC WC GISED GISED SMWT SMWT
0 1 0 1 0 1 0 1 0 1
Mean 20 20 20 20 20 20 20 20 20 20
St deviation 87.1 86.1 30.6 30.2 108.6 106.8 20.4 28.1 395.7 432.4
Minumum 17.6 17.6 6.4 6.3 16.0 16.5 4.0 2.4 91.8 89.5
Maximum 60.0 59.0 22.4 22.0 87.0 85.5 10.0 23.0 229.5 297.1
Percentile 135.0 133.0 50.2 49.4 155.0 155.0 28.0 31.0 533.4 548.7
25 77.0 75.6 26.6 26.0 96.4 93.6 19.0 26.3 302.0 329.4
50 83.0 81.0 30.1 29.8 106.0 106.0 20.5 29.0 410.9 450.0
75 93.8 93.5 32.3 32.2 118.0 117.3 22.0 30.0 472.8 508.3
Table 5 - Statistical analysis of weight, BMI, WC, GISED and SMWT
Test Statisticsa
Weight 1 (kg) - BMI 1 - WC 1 (cm) - GISED 1 (32) - SMWT 1 (M) -
Weight 0 (kg) BMI 0 WC 0 (cm) GISED 0 (32) MWT 0(M)
Z -3.282b -3.234b -2.014b -3.924c -3.248c
Asymp.
.001 .001 .044 .000 .001
Sig. (2-tailed)
a. Wilcoxon Signed Ranks Test
b. Based on positive ranks.
c. Based on negative ranks.
BMI: body mass index; WC: waist circumference; SMWT: six minutes walking test; HbA1c: glycated haemoglobin;
Tot chol: total cholesterol; TAG: triglycerides
There is statistically significant mg/dL and 150 mg/dL respectively; slight
improvement in weight, BMI and WC (p≤ reduction for total cholesterol (167.05 ±
.001; p≤ 0.001; p= 0.044 respectively), 77.81 vs 149.3 ± 37.88), too. No important
functional capacity measured using the “Six variations regarding HDL (44.75 ± 12.58
Minute Walking Test” (p=0.001) and in vs 44.4 ± 1103) and HbA1c (6.85 ± 1.09 vs
knowledge about diabetes using the GISED 6.87 ± 1.03), remaining below 7%.
questionnaire (p=0.000) (Tab. 5). No improvement in the perception of
No significant differences in quality of life and physical health measured
haematobiochemical parameters, probably using the WHOQOL-BREF, whereas a slight
due to the limited time span from the improvement regarding medium values
beginning and the end of the study (two of IMI, that shifts from 2.35 ± 1.7 (low
months) to check an improvement in this adherence) to 3.25 ± 1.6 (medium adherence)
sense; however, we can see a slight lipid (Tab. 6), although diets remain imbalanced
improvement and medium values of LDL from the qualitative point of view, for the
(90 ± 68.44 vs 74.05 ± 30.31) and TAG excessive intake of soluble (simple) sugars,
(151.65 ± 75.61 vs 140.55 ± 74.27), that fall animal proteins and saturated lipids (data
within recommended limits, less than 100 not reported).126 A. Tantucci et al.
Discussion di un programma di educazione alimentare, al diabete e
alle sue complicanze cardiovascolari sulla diminuzione
dei fattori di rischio cardiovascolari e sul miglioramento
The data we obtained allow us to make a dell’autogestione della malattia.
number of considerations. At the first sight, Metodi e risultati. Il gruppo campione consiste di
it is possible to conclude that the subjects are 20 pazienti di ambo i sessi, con età compresa tra i 50 e
highly satisfied with the intervention program 70 anni, affetti da diabete mellito tipo 2 con pregresso
with 100% agreeing that participation have infarto del miocardio.
increased the knowledge and self-awareness All’inizio ai soggetti è stato somministrato un test per
valutare il grado di conoscenza del diabete e la qualità
of the disease; one of the strongest indicators della vita; hanno inoltre eseguito un “test del cammino”
of satisfaction was the 33% of the sample e un’intervista alimentare.
indicating they would repeat the course Sono stati presi in considerazione i parametri antro-
regularly, so that the basics are not forgotten, pometrici ed ematobiochimici. Successivamente, hanno
and would recommend the program to the partecipato a 7 incontri teorici riguardanti l’educazione
many more people who have the same alimentare, il diabete e le complicanze cardiovascolari;
infine, sono state ricontrollate le valutazioni iniziali per
problems.
verificare eventuali modifiche e miglioramenti.
This project has established a preliminary Non ci sono state differenze statisticamente signifi-
study of diabetes and food education and it cative per quanto riguarda i parametri ematobiochimici
is useful in order to verify the importance e la qualità della vita, mentre miglioramenti statistica-
of this type of intervention, with the aim of mente significativi sono stati rilevati nella conoscenza
improving the living conditions of patients circa la malattia, le misure antropometriche e il “test
suffering from this pathology. Although we del cammino”.
L’intero campione risulta essere soddisfatto della
have not found significant improvement tipologia dell’intervento.
of biochemical parameters (probably the Conclusione. Anche se non abbiamo riscontrato un
time elapsed between the start and the miglioramento statisticamente significativo dei parametri
conclusion of the project is too short to ematobiochimici e la loro funzionalità, informare i sog-
obtain a significant change in this sense) getti diabetici delle loro condizioni di salute e complican-
informing diabetic subjects about their ze è essenziale per ottenere una maggiore compliance, in
modo che essi possano prendere possesso della malattia
condition is essential in order to achieve e diventarne parte attiva.
patient empowerment and compliance; these
are the basics of therapeutic education.
References
Acknowledgements: We are extremely grateful to all
the participants and their families.
1. Assal JP. A global integrated approach to diabe-
Conflict of interest: None tes: A challenge for more efficient therapy. In:
Davidson JD, ed. Clinical Diabetes Mellitus. A
Problem-Oriented Approach. 2nd ed. Stuttgart,
Riassunto Germany: Thieme, 1991: 703-7.16.
2. Gallivan J, Greenberg R, Brown C. The Na-
Un programma di educazione alimentare ed al dia-
tional Diabetes Education Program Evaluation
bete può migliorare la qualità della vita dei pazienti
Framework: How to Design an Evaluation of a
diabetici con pregresso infarto del miocardio?
Multifaceted Public Health Education Program.
Prev Chronic Dis 2008; 5(4): A134.
Introduzione e scopo. Le persone con diabete e 3. Miselli V. La valutazione degli interventi edu-
complicanze cardiovascolari dovrebbero essere educate
cativi nel diabete. GIDM 2000; 20: 37-40.
a gestire la propria malattia al momento della diagnosi
4. Assal JP, Mühlhauser I, Pernet A, et al. Patient
e durante il follow-up per ricavare il massimo beneficio
da ciò che hanno imparato. L’educazione è più efficiente
education as the basis for diabetes care in clinical
se condotta in piccoli gruppi di pazienti da un team pro- practice and research. Diabetologia 1985; 28(8):
fessionale. Lo scopo dello studio è valutare l’efficacia 602-13.Education and Prevention in Diabetic People 127
5. Trento M, Gamba S, Gentile L, et al. For The cietà Italiana di Diabetologia (SID) - Standard
Romeo Investigators. Rethink Organization to italiani per la cura del diabete mellito 2014.
Improve Education and Outcomes (ROMEO). Available from: http://www.standarditaliani.it/skin/
Diab Care 2010; 33(4): 745-7. www.standarditaliani.it/pdf/STANDARD_2014_
6. Davies MJ, Heller S, Skinner TC, et al. Ef- May28.pdf [Last accessed: 2017, Apr 21].
fectiveness of the diabetes education and self 11. Dyson P. Low Carbohydrate Diets and Type 2
management for ongoing and newly diagnosed Diabetes: What is the Latest Evidence? Diabetes
(DESMOND) programme for people with newly Ther 2015; 6(4): 411-24.
diagnosed type 2 diabetes: cluster randomised 12. Thent ZC, Das S, Henry LJ. Role of exercise in
controlled trial. BMJ 2008 Mar 1; 336(7642): the management of Diabetes Mellitus: The Global
Scenario. PLoS One. 2013; 8(11): e80436.
491–95.
13. Solway S, Brooks D, Lacasse Y, Thomas S. A
7. Keys A, Mienotti A, Karvonen MJ, et al. The
qualitative systematic overview of the measurement
diet and 15-year death rate in the seven countries
properties of functional walk test used in the car-
study. Am J Epidemiol 1986; 124(6): 903-15. diorespiratory domain. Chest 2001; 119: 256-70.
8. Trichopoulou A, Kouris-Blazos A, Wahlqvist 14. Agnoli C, Krogh V, Grioni S, et al. A prioridefined
ML, et al. Diet and overall survival in elderly dietary patters are associated with reduced risk of
people. BMJ 1995; 311: 1457-60. stroke in a large Italian cohort. J Nutr 2011; 141:
9. Trichopoulou A, Orfanos P, Norat T, et al. 1552-8.
Modified Mediterranean diet and survival: EPIC- 15. Bonaccio M, Di Castelnuovo A, Bonanni A, et al.
elderly prospective cohort study. BMJ 2005; Decline of the Mediterranean diet at the time of
330: 991. economic crisis. Results from the Moli-sani study.
10. Associazione Medici Diabetologi (AMD) - So- Nutr Metab Cardiovasc Dis 2014; 24:8 53-60.
Corresponding author: Dr Alice Tantucci, Department of Medicine, Section of Internal Medicine, Endocrinology and
Metabolism, Perugia University School of Medicine, University of Perugia, Via del Giochetto, 06123 Perugia, Italy
e-mail: alice.tantucci@alice.itYou can also read
