Supportive-Educative Nutrition Increases Family Support, Adequate

Nutrition, and Decrease Diabetic Gastroparesis

Siti Nur Qomariah

, I Ketut Sudiana

, Harmayetty

and Abu Bakar

Faculty of Health Science, Gresik University, Gresik, Indonesia

Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Supportive-Educative, Nutrition, Diabetic Gastroparesis

Abstract: Chronic complications are common in the gastrointestinal tract of diabetes mellitus patients called diabetic

gastroparesis. Supportive-educative nutrition will help patients and families to achieve adaptive behavior

and nutrition self-sufficiency. The purpose of this study was to analyze the influence of supportive-

educative nutrition on family support, nutritional intake, and decreased gastroparesis of patients with

diabetes mellitus. This study used quasi experimental, with pre-posttest design. The sample of 24 patients

and the patient's family was taken by purposive sampling technique. Independent variable was supportive-

educative nutrition and dependent variables were family support, nutritional intake, clinical sign of

gastroparesis, and blood glucose levels. Family support data, nutritional intake, clinical sign of gastroparesis

were measured by questionnaire and blood glucose levels by intake of venous blood samples. The

inferential analysis used was Wilcoxon Signed Rank, Mann-Whitney U test, paired T-test, Independent T-

test with significant level α=0.05. The result showed that there were significant differences in family

support (p = 0.005), nutritional intake (p = 0.015), and clinical sign of gastroparesis (p = 0.000). There was

no difference in post-prandial blood glucose levels (p = 0.229). Supportive-educative nutrition of diabetic

gastroparesis can improve the knowledge and acceptance of patients and families about the patient's

condition so that family support will increase and achieve adequate nutritional intake and decreased clinical

sign of gastroparesis.

1 BACKGROUND

The number of Diabetes Mellitus sufferers

worldwide and in Indonesia is increasing year by

year, the incidence of complications of the disease

also increases. Complications of DM disease of all

organs of the body and cause various complaints

(Ernawati, Suharto and Dewi, 2015). Diabetic

patients have diabetic gastroparesis after > five years

of onset and prevalence of diabetic gastroparesis or

dyspepsia occurring around 33.7% in DM patients

(Sfarti et al., 2010). Symptoms of diabetic

gastroparesis include: full satiety, after eating full

stomach, nausea, vomiting, abdominal pain and

abdominal distension. Patients with diabetic

gastroparesis experience symptoms as they eat,

resulting in inadequate oral intake and patients

experiencing calorie deficiency, some vitamins and

minerals (Koch and Calles-Escandón, 2015).

Supportive-educative is a nursing assistance

system that is given to patients with chronic diseases

and families who need support and education in the

hope that patients and families are able to do the

treatment independently (Tomey and Alligood,

2014). Supportive-educative nutrition to patients and

families becomes very important in the management

of DM disease because it helps increase the

participation of families in an effort to improve the

management of DM disease. Management of

diabetic gastroparesis patients with pharmacological

therapy has not given optimal results. Supportive-

educative nursing actions in diabetic gastroparesis

patients and families on nutritional intake in diabetic

gastroparesis patients will help patients and families

achieve adaptive behavior and self-sufficiency in

nutrition fulfillment. Recommended diet

modification based on an understanding of the

physiology of gastric emptying of food according to

the physical state and nutritional classification.

200

Qomariah, S., Sudiana, I., Harmayetty, . and Bakar, A.

Supportive-Educative Nutrition Increases Family Support, Adequate Nutrition, and Decrease Diabetic Gastroparesis.

DOI: 10.5220/0008322702000205

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 200-205

ISBN: 978-989-758-336-0

Research purposes was to analyzed the effects of

supportive- educative nutritional support to family

support, nutritional intake, decreased gastroparesis,

and measure blood glucose level in patients with

diabetes mellitus.

2 METHODS

2.1 Study Design

Type and design of this research using Quasi

Experiment, with pre-posttest design. The study was

conducted at the Hospital in Gresik on April, 11st to

May, 30th 2014.

2.2 Study Population, Sampling,

Variables

The affordable populations in this study were all

patients with Type 1 and Type 2 DM who had

dyspepsia and came to internal medicine. The

sampling process using purposive sampling

technique. Samples were taken based on the patient's

inclusion criteria: age 30-60 years, DM 5 years or

more, received the same hypoglycemic treatment:

oral/ insulin/ combination or the same

gastrointestinal medication. Family inclusion

criteria: age 25-60 years old, living at home with

patients and more intensively caring for patients,

able to read and write. Sample size in each group

was 12 patients and family.

Independent variable in this research was

supportive-educative nutrition using booklet

combination with guidance and teaching. Dependent

variables include: family support, patient behavior in

nutritional intake, clinical symptoms and blood

glucose levels 2 hours pp series diabetic

gastroparesis patients.

2.3 Measure

The instrument of data collection using observation

sheet of Diabetes Social Support Questionnaire-

Family, Block Food Frequency Questionnaire,

Gastroparesis Cardinal Symptom Index, and

examination of blood glucose level 2 hours pp in

cooperation with the Laboratory Hospital in Gresik.

2.4 Intervention

The patient's initial procedure measured family

support, last week's nutritional intake, clinical sign

diabetic gastroparesis, and 1st blood glucose level.

Then, the patient treatment group was given

supportive-educative nutrition for 4 times (every

meeting 30-60 minutes) in 4 weeks, before starting

the patient's action checked blood glucose 2nd, 3rd,

4th. The control group performed conventional

intervention in accordance with the Standard

Operating Procedures (SPO) of the hospital. The

final stage of patient and family is reassessed family

support, last week's nutritional intake, clinical

picture, and 5th blood glucose level.

2.5 Data Analysis

The collected data were analyzed descriptively and

analytically by Wilcoxon Signed Rank Test, Mann-

Whitney U test, Paired T-Test, Independent T-Test,

ANOVA Same Subject and ANOVA Interaction 2

Factor with significance level α=0.05.

2.6 Ethical Clearance

Ethical permission was obtained from the Ethical

approval No: 75-KEPK, April 7th 2014 from the

Ethics Committee of the Faculty of Public Health

Universitas Airlangga. At the beginning of this

study, participants fulfilled informed consent and

demographic data. The researchers keep secret data

of each participants by using code.

3 RESULTS

Participants between treatment group and control

group had a similar characteristic in gender, age, and

length suffer of DM, which is most of the patients

Table 1: Characteristic of Patients Diabetic

Gastroparesis

Variable

Treatment Group

Control Group

Gender

Male

Female

16.6

83.4

Age (M ± SD)

51.58 ± 5.9

52.42 ± 3.6

Education

Elementary

Junior

Senior

Higher Ed.

8.3

91.7

Length of DM

5-10 years

11-15 years

16-20 years

16.7

8.3

91.7

8.3

Supportive-Educative Nutrition Increases Family Support, Adequate Nutrition, and Decrease Diabetic Gastroparesis

201

were female and length of DM 5-10 years. The

average age treatment group was 51.58 years old, as

much as 75% patients had a length of DM 5-10

years (Table 1). Characteristic of patients in control

group shows that the average age was 52.42 years

old, as much as 91.7% patients had a length of DM

5-10 years.

The results of data collection were obtained in

the treatment group from the total of 12 participants

before the supportive-educative action of low family

support nutrition as much as 9 people (75%) and

high family support of 3 people (25%). After high

family support action as many as 10 people

(83.33%) and low family support as much as 2

people (16.67%). In the control group of total

participants 12 people before the action of low

family support nutrition counseling as much as 9

people (75%) and high family support as much as 3

people (25%). After given supportive-educative

nutrition, high family support as much as 8 people

(66.67%) and low family support counted 4 person

(33.33%).

Wilcoxon Test Signed Rank Test got p value =

0.005. The p <0.05 results mean that there is a

supportive-educative effect of nutrition on family

support in DM patients with gastroparesis. While

Mann-Whitney test obtained p value = 0.106. The

p> 0.05 results mean that there is no difference in

family support between the treatment group and the

control group.

Data of nutrient intake in treatment group from

total of 12 participants before supportive-educative

action of nutrition of nutritional intake of patient

was nutritional deficiency as much as 5 people

(41.67%), nutrition more than 3 people (25%) and

nutrition fulfilled as many as 4 people (33.33%).

After given supportive-educative, nutrition intake of

patient is enough nutrition as many as 10 people

(83.33%) and nutrition more as much as 2 person

(16.67%). In the control group of total participants

12 people before nutritional counseling treatment of

nutritional intake of patients was nutritional

deficiency as much as 5 people (41.67%), more

nutrition as many as 3 people (25%), nutrient

fulfilled by 4 people (33.33%). After standard

procedure from hospital, nutrition intake of patient is

enough nutrition as many as 11 people (91.67%) and

more nutrition as much as 1 person (8.33%).

Wilcoxon Test Signed Rank Test got p value =

0.015. Result p count <0.05 meaning that there is

influence of supportive-educative nutrition to

nutrition intake of DM patient with gastroparesis.

While Mann-Whitney test obtained p value = 0.001

count. The p <0.05 results mean that there is a

significant difference in the patient's nutritional

intake between the treatment group and the control

group.

Clinical overview data on treatment group of

total participant 12 people before supportive-

educative nutrition of participant experience clinical

sign gastroparesis very severe as much as 1 person

(8.33%), severe clinical sign of gastroparesis

counted 4 person (33.33%), medium clinical sign as

many as 3 people (25%), mild clinical sign as much

as 1 person (8.33%), and very light clinical sign of 3

people (25%). After given supportive-educative

nutrition, most of participant feel clinical sign

gastroparesis very light as much as 7 people

(58.3%). In the control group of total participants 12

persons before the participant's nutritional

counseling experience clinical sign of gastroparesis

very severe as much as 2 people (16.7%), severe

clinical sign counted 6 people (50%), medium

clinical sign as many as 3 people (25%), and very

light clinical sign of 1 person (8.33%). After the

action, most of the clinical experience gastroparesis

very light as much as 7 people (58.3%).

Paired T-Test test obtained p value = 0,000.

Results p <0.05 which means that there is influence

support-educative nutrition to the clinical sign of

DM patients with gastroparesis. While the

independent test T-Test obtained p value = 0.994.

The p> 0.05 results mean that there is no difference

in the clinical sign of the patient between the

treatment group and the control group.

Most of the participants in the treatment group

showed an abnormal 2 hour pp blood glucose test of

200 mg / dL can be seen picture below.

Figure 1: Blood Glucose Test 2 hour pp series(1-5) on

intervention group.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

202

Figure 2: Blood Glucose Test 2 hour pp series on control

group.

ANOVA Same Subject test obtained p value =

0.229. Results p> 0.05 which means that there is no

influence supportive-educative nutrition to blood

glucose patient examination DM with gastroparesis.

While the test ANOVA Interaction Two Factors

obtained p value = 0.772. Results p> 0.05 which

means that there is no significant difference in blood

glucose levels of DM patients with gastroparesis

between the treatment group and the control group.

4 DISCUSSION

Family support is verbal information, real assistance

or behavior provided by the family with the subject

in his or her social environment or in the form of

attendance and things that can provide an emotional

advantage or influence on the behavior of the

recipient. People who get emotional support feel

relieved to be noticed, get advice or a pleasant

impression on him (Almutairi, 2015). Most

participants experienced increased family support

from low support to high support. There were 2

participants of the treatment group families who did

not experience a significant increase in family

support after the supportive-educative nutritional

action was performed because 2 intensive families

treated the patients to work in the civil service,

rarely at home and provide support and attention to

DM patients with gastroparesis. Factors that affect

family support one of them is intimacy. The more

intimate a person then the support obtained will be

greater. The family is the main group that has the

greatest emotional bond and the closest to the

sufferer, any grievances that are felt are usually

expressed on family members. Besides, families

relieve the burden of suffering during illness.

The results showed that most participants

experienced calorie deficiency before giving

supportive-educative nutrition. It says deficiency

when <60% of nutrient intake is needed (Keld and

Lal, 2014). The results of this study in line with

research in America showed that many patients with

DM gastroparesis deficiency energy, vitamins and

minerals by 194 patients from 305 patients. Caloric

deficiency of DM patients by <60% of estimated

total calorie requirement and deficiency of vitamin

C, D, E, K, folate, calcium, iron, magnesium and

potassium (Parkman, 2015). However, the study

participants showed no deficiency of certain

vitamins and minerals because most participants

received vitamin and mineral supplements to

provide less intake.

The results also showed 2 treatment group

participants with more nutritional intake. Patients

with chronic disease are sometimes saturated and

bored with existing dietary rules so that patients are

not adherent in the management of DM disease.

Giving supportive-educative nutrition in this study

not only touches the physical aspect but also the

psychological aspects so that patients are able to

adapt and independently in meeting and controlling

food intake.

DM patients with gastroparesis obtained data

before the nutritional supportive-educative measures

mostly had clinical sign of severe gastroparesis and

after most of have clinical sign of gastroparesis were

very light. Provision of nutritional supportive-

educative approaches known as Guidance (Booklet)

and Teaching by discussion method, where

participants and families are given the freedom to

express experience during illness, if any gaps are

corrected and guided by researchers and discussions

with patients and families to make decisions. This

method provides an opportunity for patients and

families to receive and respond to received guidance

and instruction (Notoatmodjo, 2010). This method

becomes very important because it emphasizes the

involvement of patients and families directly and

will more easily accept the various input given.

There were 1 treatment group participants who

still experienced severe gastroparesis sign after

providing supportive-educative nutrition. This is

because the participant does not carry out any

activity. This situation is in accordance with

previous research which shows that patient

perception can influence the success of action

(Homko, Siraj and Parkman, 2016). Symptoms and

signs of gastroparesis in DM patients due to slowing

Supportive-Educative Nutrition Increases Family Support, Adequate Nutrition, and Decrease Diabetic Gastroparesis

203

of emptying of the stomach without any organic

obstruction either in the stomach or small intestine

proximal part (Camiller et al., 2013). Light activity

such as walking casually half an hour after eating

will help empty the food in the stomach because the

food is quickly digested (Hasler, 2011).

Treatment group and control group participants

used gastrointestinal drugs. Symptoms associated

with gastroparesis in DM patients can be treated

using prokinetic drugs such as: metoclopramide,

cisapride and domperidone. These drugs can

penetrate the blood brain barrier causing side effects

drowsiness, anxiety, anxiety and fatigue. There is an

effect of gastrointestinal drug use on the decrease in

clinical sign of gastroparesis in DM patients. The

use of prokinetic drugs is not recommended in the

long term because it will lead to Parkinson's

syndrome and can occur seizures (Camilleri,

Bharucha and Farrugia, 2011). Between treatment

and control group also used same medication for

hipoglikemik and gastrointestinal drug, however

intervention group have more decrease in clinical

sign of gastroparesis than control group.

Most of the participants in the treatment group

showed an abnormal 2 hour blood glucose level that

is ≥200 mg/ dL. Adaptive behavior of individuals

and families, can not change the condition of

recombinant organ or cell DM patients that have

been damaged. This is in accordance with previous

research which states that the effects of gastroparesis

can damage the absorption of drugs so that blood

glucose levels become difficult to control (Oh and

Pasricha, 2013).

This study used diabetic gastroparesis patients

with the use of DM drugs and varying doses; oral,

insulin or a combination of oral-insulin. Incoming

foods will be absorbed in the small intestine that

activates insulin and glucagon. Insulin will cause

increased glycogenesis and inhibit glycogenolysis

(Guyton and Hall, 2014). Glucagon increases

glycogenesis by activating adenyl cyclase and

increasing intracellular cyclic adenosine

monophosphate (cAMP) in the liver. This will

activate phosphorylase through protein kinase

resulting in the breakdown of glycogen. With

glucagon then gluconeogenesis will also increase so

that the patient's blood glucose level is controlled

(Guyton and Hall, 2014).

The study participants who showed normal blood

glucose levels were some of the treatment group

participants and the control group who used

combination therapy of oral hypoglycemic drugs and

insulin. But the control group, although most use

oral hypoglycemic drugs can normalize blood

glucose levels. This is because most of the control

group participants with less duration of DM sickness

than the treatment group. Long suffer of DM

demonstrates the longer duration of DM disease that

is felt, the patient will feel bored and bored to

control the disease and obey the rules of the existing

diet. In addition to long-term DM pain associated

with damage to organs that produce insulin or cell

receptors (Camiller et al., 2013).

5 CONCLUSIONS

Supportive-educative nutrition can improve

understanding and acceptance of the family about

the patient's condition, related to increase family

support for the patient and changes in adaptive

nutritional intake behavior and decreased clinical

picture of gastroparesis. However, there was no

effect of supportive-educative nutrition on blood

glucose levels of 2 hp pp series of DM patients with

gastroparesis. The patient's blood glucose levels still

show abnormal blood glucose levels. Subsequent

studies may use gastric or endoscopic scintigraphic

diagnostic tests to confirm diabetic gastroparesis.

ACKNOWLEDGEMENT

We would like to acknowledge all of the

participants, nurse, and other hospital staff who

cooperated in the present study.

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