Lifestyle Management: Differences in Knowledge, Physical Activity

and Diet Compliance with Diabetes Self-management Education

(DSME) Principles

Gunarti Yahya, Raden Rizqia Khansa and Reksy R. Kharisma

Nutrition Program Study, Health Sciences Faculty, University of Prof Dr Hamka, Jakarta, Indonesia

Keywords: DSME, Knowledge, Physical Activity, Diet Compliance.

Abstract: Lifestyle Management is the foundation for diabetes care including DSME, Medical Nutrition Therapy

(MNT), physical activity, smoking cessation counseling, and psychosocial care. DSME facilitates increasing

the knowledge and skills of people with diabetes to be able to manage diabetes care independently. This study

is to analyze differences in knowledge, physical activity, and dietary compliance with the provision of

Diabetes Self-Management Education (DSME). A pre-experimental study with one group pretest-posttest

design was conducted on 23 patients with type 2 DM, was carried out at a special DM clinic at Fatmawati

Hospital, Jakarta. Subjects were selected by consecutive sampling and received an education with the DSME

method 6 times for 6 weeks. Data were analyzed by paired t-test to determine the difference between the mean

of variables. There were significant differences before and after the DSME intervention in knowledge (p

=0.000), physical activity (p= 0.001) , and diet compliance (0.000). This study showed that there was a

significant increase in outcome data of patients who have been given the intervention of the Diabetes Educator

team. To increase access to DSME for patients, family support and motivation from the Diabetes Educator

team are needed.

1 INTRODUCTION

In 2015, the American Diabetes Association

published a Diabetes Self-Management Education

and Support (DSMES) program that provides

guidance for diabetics in increasing abilities needed

to be able to implement supportive behaviors in

managing lifestyles according to their disease

conditions.

The DSMES program was adopted and developed

by Endocrinology Community Indonesia, involving

patients and all medical and health workers in an

effort to reduce the prevalence of diabetes mellitus in

Indonesia.

One of the DSMES programs is nutrition

education related to implementing diet therapy and

physical activity in order to prevent acute and chronic

complications and to improve the quality of life of

people with diabetes mellitus.

2 BACKGROUNDS

Diabetes mellitus (DM) is defined as a metabolic

disease characterized by high blood sugar levels due

to abnormalities in insulin secretion and/or action

(Perkeni, 2019). According to the International

Diabetes Federation (2019), 1 in 11 adults aged 20 –

79 years worldwide has diabetes (approximately 463

million people) but it turns out that 1 in 2 adults with

diabetes are not aware that they have diabetes 232

million people (Indonesian Ministry of Health)

The 2018 Basic Health Research Report by the

Ministry of Health showed an increase in the

prevalence of DM to 10.9%. The 2017 International

Diabetes (IDF) report placed Indonesia as the 6th

country in the number of DM sufferers which reached

10.3 million. Predictions from the IDF state that there

will be an increase in the number of DM patients from

10.3 million in 2017 to 16.7 million in 2030

(PERKENI, 2019)

Various efforts have been made to prevent the

increase in the prevalence of people with diabetes

mellitus, one of which is developing self-

120

Yahya, G., Khansa, R. and Kharisma, R.

Lifestyle Management: Differences in Knowledge, Physical Activity and Diet Compliance with Diabetes Self-Management Education (DSME) Principles.

DOI: 10.5220/0010760600003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 120-124

ISBN: 978-989-758-542-5

management for people with diabetes to be able to

control blood sugar conditions and prevent

complications in order to achieve a good quality of

life, through patient education with the Diabetes Self-

Management Education and Support (DSMES)

approach.

The purpose of DSMES is to improve the

knowledge, skills, and confidence of diabetic patients

to accept responsibility for their self-management.

This includes collaborating with their health care

team, making informed decisions, solving problems,

developing personal goals and action plans, and

coping with emotions and life stresses. DSME

facilitates increasing the knowledge and skills of

people with diabetes to be able to manage diabetes

care independently. This study is to analyze

differences in knowledge, physical activity, and

dietary compliance in diabetic patients with the

provision of DSMES.

3 METHODS

A quasi-experimental with one group pretest-posttest

approach was conducted in diabetic outpatient in

Fatmawati Hospital Jakarta in July-August 2019.

Subjects were selected with consecutive sampling.

Inclusion criteria were Diabetic outpatients in

Fatmawati Hospital, aged >25 years, willingly to

participate in this study and following all intervention

session. Exclusion criteria was absent minimum one

of session.

Intervention of education with DSME principles

was carried out for 6 weeks (1 week each), and the

material was given by the trained Diabetes Mellitus

educator team. Educator team consisted of doctors,

dietitians, nurses and pharmacists. Education was

given 100 - 120 minutes per session.

Topics of education were session about basic

knowledge of DM, session 2 was about Diabetes Diet

Therapy, session 3 was about physical activity and

exercise, session 4 was about Pharmacological

Therapy, session 5 was about evaluating care, session

6 was about monitoring blood sugar levels and

hypoglycemia.

Knowledge, physical activity and dietary

compliance of diabetes mellitus diet were measure by

structured questionnaire. Questionnaires were given

before and after the nutrition intervention. Data on

the level of knowledge, level of physical activity and

level of dietary compliance are presented using the

good/adherent category if the respondent's score is

more than the average, and vice versa with the

poor/adherent category. Bivariate data were analyzed

using paired T-test and independent T-test with 95%

confidence level.

4 RESULTS

Characteristics subject of this study were average age

of 23 respondents is 61 years with the lowest age

being 35 years and the highest being 80 years. The

results also showed that the number of respondents

with diabetes 10 years was 56.5% while those who

were more than 10 years old were 43.5%.

According to Hariani et al, there is a relationship

between the length of suffering from type 2 DM and

the patient's quality of life, namely the longer the

patient suffers, the worse the patient's quality of life.

Consensus The Dieabetes Educators, 2015 there

are 4 critical times to implement and modify DSMES,

namely first times diabetes is diagnosed, annually or

when not meet treatment targets, when complications

factor developed and transitions in life occur

(advanced age).

Physiological changes that occur with age in DM

patients, result in a decrease in physiological function

in the endocrine system, in addition to an unhealthy

lifestyle and non-optimal DM management has the

potential to cause various complications, including

retinopathy, heart disease and kidney failure.

Therefore, it is important for patients and care

providers to manage a diabetes lifestyle through the

DSMES program, so that the quality of life of DM

patients gets better with increasing age and increasing

the length of time being a type 2 DM patient.

Lifestyle Management is the foundation for

diabetes care including education with DSMES

principles, Medical Nutrition Therapy (MNT),

physical activity, smoking cessation counseling, and

psychosocial care.

Table 1: Distribution of Respondents by Level of

Knowledge in Type II Diabetes Patients

Level of Nutrition

Knowledge

Pre test Post Test

Freq % Freq %

Low 11 47,8 0 0

Goo

12 52,2 23 100

Sum 23 100 23 100

The results showed that after receiving DSME-

based education, all respondents (100%) had a good

level of knowledge. Most of the respondents are

motivated to apply knowledge from the DSME

program to improve their own nutritional and health

status

Lifestyle Management: Differences in Knowledge, Physical Activity and Diet Compliance with Diabetes Self-Management Education

(DSME) Principles

121

Table 2: Results of Statistical Tests before and after the

intervention on increasing knowledge of Type II Diabetes

Patients

Nutrition

Knowledge

Mean

Min -

Max

PValue

Before the

DSMES-based

education

75,5

53,13-

90,63

6,7 0,000

after the

DSMES-based

education

89,9 78,13-

100

The average pretest score for knowledge was 75.5

(standard deviation 10.3). After DSMES-based

education was conducted, the posttest score increased

to 89.9 (standard deviation 7.04). The results of the

study, there was a significant difference between

education and DSME principles on the level of

knowledge before and after education, with a P value

< 0.05 (p = 0.000).

According to MA Simbolon et al, 2015 and CM

Yuni et al, 2019, DSME can increase knowledge of

self-management of Type 2 DM patients to prevent

disease complications.

The DSME learning process aims to provide

knowledge to patients so that there is a process of

changing information, emotions and decision making

that have an impact on the occurrence of the cognator

control process in the brain in order to carry out

learning and adaptation mechanisms.

The educational process in this study was carried

out in groups using the DSME curriculum, the

material provided was in the form of material related

to general DM knowledge, Diet Management,

Physical Activity, knowledge related to drugs, foot

care, and monitoring blood sugar levels, with lecture

method using props, emo demo and mind maps.

Changes in respondent's knowledge are felt to

increase, because of the interest and awareness to be

able to control blood sugar levels. Education is given

in stages with the lecture method, sharing between

sufferers, as well as activities that involve the family.

The existence of a booklet provided by the Educator

team also makes it easier for respondents to apply it

independently at home

Based on the respondents' confessions,

participating in DSMES-based DM education was

very fun, with an interesting method, being able to

gather and play with other diabetic patients. However,

the schedule is very long (2 hours per session and

takes approximately 1.5 – 2 months), they say it can

be done because of the support from the family.

Meanwhile, according to the Educator team's

admission, quite a lot of diabetes patients cannot

complete the entire education curriculum based on

this DSMES, and only 23 people could be

respondents in this study.

Family members and peers are an underutilized

resource for ongoing support and often struggle with

how to best provide help.

Including family members

in the DSMES process can help facilitate their

involvement. Such support people can be especially

helpful and serve as cultural navigators in health care

systems and as liaisons to the community.

Community programs such as healthy cooking

classes, walking groups, peer support communities,

and faith-based groups may lend support for

implementing healthy behavior changes, promoting

emotional health, and meeting personal health goals

(Diabetes Educator, 2019).

Z Zhouzi et al, 2019, The electronic nutrition

education resource (internet based) was found to be

an effective means for delivering education. It has

potential to bridge the gap between the limited supply

of healthcare resources and the increasing demand for

diabetes nutrition education. Most participants

expressed intentions to make positive dietary and

lifestyle choices.

In this COVID-19 pandemic situation, it is worth

considering developing and modifying an educational

curriculum with this DSMES approach, by utilizing

resources such as making videos distributed through

social media (youtube, Instagram, Facebook) or

comprehensive web-based or digital health

educational programs.

Table 3: Distribution of Respondents by Level of Physical

Activity in Type II Diabetes Patients

Physical activity

level

Pre test Post Test

Fre

% Fre

Low 21 91,3 13 56,5

Goo

28,7 10 43,3

Sum 23 100 23 100

Most of the respondents (91.3%) had a low level

of physical activity. After receiving DSME-based

education, respondents were motivated to do various

activities such as jogging 1-2 times a week, walking

in the morning and evening for 15-30 minutes, doing

physical exercise using tools assisted by special

trainers at home, and some respondents actively

participates in gymnastics with the community 1 time

/ week

ICSDH 2021 - International Conference on Social Determinants of Health

122

Table 4: Results of Statistical Tests before and after the

intervention on increasing Physical activity of Type II

Diabetes Patients

Physical activity

Mean

Min -

Max

PValue

Before the

DSMES-based

education

1,42 0,56-97

0,23 0,003

after the

DSMES-based

education

1,59 0,92-2,1

The pretest score on physical activity averaged

1.42 (standard deviation 0.29), after the DSMES-

based education, there was an increase in the posttest

score to 1.59 (standard deviation 0.33). The results of

the Paired t-test showed that there was a significant

difference between nutrition education and DSME

principles on the level of physical activity, with a P

value < 0.05 (p = 0.003).

NR Zaky's research, 2018, showed a significant

difference between physical activity compliance in

patients with type 2 diabetes mellitus before and after

being given Diabetes Self-Management Education

(DSME) with a p value = 0.000

After every DSME education session, some

respondents try to be more active than before, starting

from walking in the morning and evening, after lunch,

and also starting to sit back and lie down.

Respondents are more understanding and motivated

about the importance of changing attitudes and

healthy living behavior, namely planning an

appropriate diet and carrying out regular physical

exercise.

Exercise has been shown to improve blood

glucose control, reduce cardiovascular risk factors,

contribute to weight loss, and improve well-being.

However, there are still 56.5% of respondents whose

level of physical activity is considered lacking,

therefore it is important for the management of the

diabetes care team to understand the difficulty that

many patients have reached definite treatment targets

and to define individual approaches to improving

goals achievement.

Physical exercise should be adjusted to age and

physical fitness status. The intensity of physical

exercise in relatively healthy diabetic patients can be

increased, while in diabetic patients with

complications, the intensity of exercise needs to be

reduced and adjusted to each individual.

Table 5: Distribution of Respondents by Level of Dietary

Adherence in Type II Diabetes Patients

Dietary adherence

level

Pre test Post Test

Freq % Freq %

Obey 10 43,5 23 100

Not Obe

13 56,5 0 0

Sum 23 100 23 100

All respondents (100%) adhered to dietary

recommendations after being given DSEM-based

education. Compliance behavior shown by some

respondents, such as, "always" considers the value of

energy (calories) in daily food, takes medication as

recommended, and "never" consumes high-fat foods

and high sugar beverages or soft drink

Table 6. Results of Statistical Tests before and after the

intervention on increasing Dietary Adherence of Type II

Diabetes Patient

Dietary

adherence

Mean

Min -

Max

PValue

Before

the

DSMES-

based

education

78,35

60-

8,6 0,000

after the

DSMES-

based

education

103,65 87-

114

The average pretest score on dietary compliance

was 78.35, after the DSMES-based education, there

was an increase to 103.65. The results of paired t-test

showed that there was a significant difference

between nutrition education and DSME principles on

the level of physical activity, with a P value < 0.05 (p

= 0.000)

Laili, et al., 2012’s study showed that there was

an effect of DSME approach on dietary compliance

practices with p=0.002 and p=0.564. Nutrition

therapy has an integral role in overall diabetes

management, and each person with diabetes should

be actively engaged in education, self-management,

and treatment planning with his or her health care

team, including the collaborative development of an

individualized eating plan.

A variety of eating patterns are acceptable for the

management of diabetes, and a referral to an

registered dietitian nutritionist (RDN) is essential to

assess the overall nutrition status of, and to work

collaboratively with, the patient to create a

personalized meal plan that considers the individual’s

health status, skills, resources, food preferences, and

health goals to coordinate and align with the overall

Lifestyle Management: Differences in Knowledge, Physical Activity and Diet Compliance with Diabetes Self-Management Education

(DSME) Principles

123

treatment plan including physical activity and

medication (Diabetes Educator, 2019)

5 CONCLUSIONS

There was a significant difference between before and

after DSME intervention of knowledge; level of

physical activity level and dietary compliance. This

study showed that there was a significant increase in

outcome data of patients who have been given the

intervention on the Diabetes Educator team. To

increase access to DSME for patients, family support

and motivation from Diabetes Educator team are

needed. In this COVID-19 pandemic situation, it is

worth considering developing and modifying an

educational curriculum with this DSMES approach,

by utilizing resources such as making videos

distributed through social media or comprehensive

web-based educational programs.

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