Effectiveness of health education program enhance ability of patients with type 2 diabetes 2

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH UNIVERSITY OF MEDICINE AND PHARMACY, HO CHI MINH CITY NGUYEN THI GAI EFFECTIVENESS OF HEALTH EDUCATION PROGRAM ENHANCE ABILITY OF PATIENTS WITH TYPE DIABETES MASTER'S THESIS OF NURSING HO CHI MINH CITY - 2017 MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH UNIVERSITY OF MEDICINE AND PHARMACY, HO CHI MINH CITY NGUYEN THI GAI EFFECTIVENESS OF HEALTH EDUCATION PROGRAM ENHANCE SELF – MANAGEMENT ABILITY OF PATIENTS WITH TYPE DIABETES MASTER'S THESIS OF NURSING Major: Nursing Code: 60.72.05.01 Supervisor : Associate Prof Nguyen Thi Bich Dao, MD, PhD Associate supervisor: Kathy A Fitzsimmons, RN, PhD HO CHI MINH CITY - 2017 i REASSURANCES I swear this is my research The data and results of this thesis are completely honest and has not been published in any other scientific research Author Nguyen Thi Gai ii CATEGORY REASSURANCES ……………………………………………………………………… i CATEGORY ii LIST OF TABLES iii LIST OF CHART .vi LIST OF ACRONYMS vii BACKGROUND OBJECTIVES OF THE STUDY Chapter 1: LITERATURE 1.1 General about diabetes type 1.2 Epidemiology of diabetes 11 1.3 Self-management education for type diabetes 13 1.4 Apply nursing theories 16 Chapter 2: SUBJECTS AND METHODS 20 2.1 Study design 20 2.2 Research area 20 2.3 Research duration 20 2.4 Study subjects 20 2.5 Sample size 20 2.6 Sampling Technique 22 2.7 Control deviation 22 2.8 Data collection 23 2.9 Definition and classification variables 27 2.10 Diabetes self-managent education program 30 2:10 Ethics in research 31 Chart Research 33 Chapter 3: RESULTS 34 3.1 Characteristics of patients with type diabetes 35 3.2 Describe research results before and after DSME 41 3.3 Effectiveness of DSME programs 57 iii 3.4 Blood sugar of patients with type diabetes before and after DSME 63 Chapter 4: DISCUSSION 65 4.1 The characteristics of the study sample 65 4.2 Description of knowledge and effective DSME programs to enhance selfmanagement of type diabetes 68 4.3 Description of self – efficacy and effectiveness of DSM programs to enhance selfmanagement of patients type diabetes 69 4.4 Describe the behavior and level of effectiveness of DSME programs to enhance self-management of patients type diabetes 70 4.5 Effectiveness of intervention programs with glycemic of patients with type diabetes 72 4.6 Strengths and weaknesses 73 4.7 Prospects of the thesis 75 CONCLUSION 76 Compare the median point of knowledge, self efficacy and self-management behavior of patients with type diabetes before and after DSME 76 Compare the median of the glycemi of patients with type diabetes before and after DSME 76 REQUEST 78 APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX iv LIST OF TABLES Table 1.1 Diagnosis guidelines of diabetes of the American Diabetes Association Table 3.1.Demographic characteristics of patients with type diabetes before the intervention 35 Table 3.2 Demographic characteristics of patients with type diabetes under treatment hospital 37 Table 3.3 Clinical characteristics of patients with type diabetes .39 Table 3.4.Clinical characteristics of study subjects under treatment hospital .40 Table 3.5 Knowledge about the causes and symptoms of diabetes 41 Table 3.6 Knowledge of how to monitor and treat diabetes .42 Table 3.7 Knowledge about diabetes complications of diabetes .43 Table 3.8 Knowledge about diabetes self-care of patients with type diabetes 44 Table 3.9 General knowledge of type diabetes 45 Table 3.10 Self – efficacy to perform diet 46 Table 3:11 Self – efficacy to exercise and maintain a healthy weigt 48 Table 3:12 Self – efficacy to self check glycemic and pedicure self - care .49 Table 3.13 Self – efficacy to use medication prescription 50 Table 3.14 Self – efficacy to self manage type diabetes 50 Table 3.15 Dietary level of patients with type diabetes 51 Table 3.16 Level of physical activity of patients with type diabetes .52 Table 3.17 Level of glycemic self-monitoring of patients with type diabetic patients 53 Table 3.18 Level of using of prescription medication of patients with type diabetes 54 Table 3.19 Self - care level of patients with type diabetes 55 Table 3.20 Behaviors of self-management of type diabetes patients' .56 Table 3.21 Compare knowledge between the intervention group and the control group .57 v Table 3.22 Compare knowledge between Bac lieu hospital group and Thanh Vu hospital group .58 Table 3.23.Compare self - efficacy between the intervention group and control groups 59 Table 3.24 Comparison self - efficacy between the group and the Bac lieu hospital group and Thanh Vu hospital group .60 Table 3.25 Compare self-management behaviors between the intervention and control groups .61 Table 3.26 Compare self-management behavior between Bac lieu hospital group and Thanh Vu hospital group .62 Table 3.27 Compare glycemic between the control group and the intervention group .63 Table 3.28 Compare glycemic between Bac lieu hospital group and Thanh Vu hospital group .64 vi LIST OF CHART Diagram 1: Apply the nursing theories in study 20 Diagram 2: Diagram research… 33 vii LIST OF ACRONYMS STT Acronym English Vietnamese BV Hospital Bệnh viện ĐTĐ Diabetes Đái Tháo Đường KTPV Quartile range Khoảng tứ phân vị SD Standard deviation Độ lệch chuẩn TB Mean Trung bình TV ADA BMI DSMQ 10 DCCT 12 FPG 13 IDF 14 NGSP 15 OGTT 16 OR Median American Diabetes Association Body Mass Index Diabetes self -management questionaires Diabetes Control and Complications Trial Fasting Plasma Glucose The International Diabetes Federation National Glycohemoglobin Standardization Program Oral Glucose Tolerance Test odds Ration Trung vị Hiệp hội đái tháo đường Mỹ Chỉ số khối thể Bộ câu hỏi đái tháo đường tự quản lý Thử nghiệm kiểm soát đường huyết biến chứng Đường huyết lúc đói Liên đồn đái tháo đường quốc tế Chương trình chuẩn hóa glycohemoglobin quốc gia Thử nghiệm dung nạp glucose đường uống Tỷ số chênh 17 PG SDSCA Plasma Glucose Summury of Diabetes self care activities from 19 WDF Word Diabetes Foundation 20 WHO Word Health Organization Đường huyết Tóm tắt hoạt động đái tháo đường tự chăm sóc Quỹ đái tháo đường giới Tổ chức Y tế giới 18 BACKGROUND Diabetes (diabetes mellitus) is a chronic disease, not contagious In 2011, the World Health Organization (WHO) estimates that more than 346 million people are diagnosed with diabetes By 2030 this figure will double if no intervention takes place [35] In Vietnam, the incidence of diabetes is increasing at an alarming rate and has nearly doubled in 10 years According to WHO (2016), estimated at present in our country will have a in 20 people who have diabetes In addition, the number of people in the prediabetes stage times more than those who are diagnosed with diabetes [99] Proportion of diabetes type diabetes in particular are increasingly complex and tends [1], [3], [4], [80] Special rate diabetes patients in the community undetected still is very high (> 60%)[4] Also due to late detection, complications of diabetes has a significant proportion of type diabetes in patients immediately at the time of diagnosis of diabetes This disease becomes a burden, both in terms of health and economy for many countries, especially the type diabetes The cost of care for diabetes is high and increasing worldwide [21], [34], [44], [46] Cost of treatment, travel and prolonged hospital stays may affect the economics of the family of patients According to the International Diabetes Federation (IDF), the average 2015 costs related to diabetes in Vietnam is over 162.7 USD per patient/year Too much compared to the average monthly income of the people of Vietnam is 150 USD [99] Self-management refers to the ability of an individual to manage the symptoms, treatment, physical, psychosocial and lifestyle changes inherent to adapt to a chronic condition [96] Self-management concept was understood as both process and self-management education It equips patients with the conditions and skills needed to reduce the negative impact of the disease, with or without the collaboration with the medical team [44], [88] Self-management behavior of an individual can affect diabetes care everyday and clinical results and metabolism Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM 94 Robbins JM, Thatcher GE, Webb DA, Valdmanis VG (2008) "Nutritionist visits, diabetes classes, and hospitalization rates and charges" Diabetes Care 31 655-60 95 Ryan P, Sawin KJ (2009) "The Individual and Family Self-management Theory: Background and Perspectives on Context, Process, and Outcomes" Nurs Outlook , 57 (4), 217 - 225 96 Sharon J (2008) "Literature Review on Chronic Disease Self-Management " (13/11/2016) 97 Sharoni SK, Wu S.F (2012) "Self - efficacy and self - care behavior of Malaysian patients with type diabetes: a cross sectional survey" Nurs Health Sci, 14 (1), pp 1305-12 98 Skelly AH, Marshall JR, Haughey BP, Davis PJ, Dunford RG (1995) "Selfefficacy and confidence in outcomes as determinants of self-care practices in inner-city, African-American women with non-insulin-dependent diabetes." Diabetes Educ Jan-Feb;21(1):38-46., 21 (1), pp 38 - 46 99 World Health Day 2016 Feature Story (2016) The growing burden of diabetes in Viet Nam, WHO, http://www.wpro.who.int/vietnam/mediacentre/features/feature_world_healt h_day_2016_vietnam/en/#.WEO3mMCcwpU, 12/12/2016 100 Nursing Theories (2012) Dorothea Orem's Self-Care Theory, http://currentnursing.com/nursing_theory/self_care_deficit_theory.html, Accessed 26/5/2016 101 Utz SW, Williams IC, Jones R, Hinton I, Alexander G, Yan G, Moore C, Blankenship C, Steeves R, Oliver MN (2008) "Culturally Tailored Intervention for Rural African Americans With Type Diabetes" Diabetes Educ , 34 (5), pp 854 - 865 102 Vischer UM, et all (2010) "The burden of hospital manutition in Spain: methods and development of the Prdyces study" Nutr Hosp, 25 (6), pp 1020-1025 Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM 103 WHO (2016) GLOBAL REPORT ON DIABETES, 24-25 104 Williams KE, Bond MJ (2002) "The roles of self-efficacy, outcome expectancies and social support in the self-care behaviours of diabetics" Psychology, Health & Medicine, (2) 105 Williams LF (2015) Diabetes Self-Management Education Program, Doctoral Studies, Walden University, pp 44 - 46 106 Wu S.F.V , Courtney M, Edwards H, McDowell J, Shortridge-Baggett L.M, Chang P.J (2008) "Development and validation of the Chinese version of the Diabetes Management Self-efficacy Scale" International Journal of Nursing Studies 45 (4), 534-542 107 Wu SF, (2007) Effectiveness of self - management for persons with type diabetes following the implementation of a self - efficacy enhancing intervention program in Taiwan, Queensland University of Technology pp 227 108 Wu SFV, Courtney M, Ewards H, McDowell J, Shortridge-Baggett L.M, Chang PJ (2007) "Self - efficacy, outcome expectation and self - care behaviour in people with type diabetes in Taiwan" Journal of clinical Nursing, 16 (11c), pp 250 - 257 Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM APPENDIX QUESTIONNAIRE EFFECTIVENESS OF HEALTH EDUCATION PROGRAM ENHANCE SELF-MANAGEMENT ABILITY OF PATIENTS WITH TYPE DIABETES Partly because investigators recorded Medical codes: Full name of the disease: FPG: HbA1C: Investigators (who asked): Date of interview: Sign: Date collected: The following questions exploit the personal information of participants in the study, he (she) respondents according to his/her personal opinion This information is only intended to serving for scientific research, not for other purposes Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM A BACKGROUND INFORMATION You read the questions below and circle the number next to the most appropriate answer to you ID Content A1 When were you born ? A2 Which is your gender? A3 A4 A5 A6 A7 A8 Answer Code answer Nam Nữ ≤ Primary Which grade school were Secondary you completed? High school ≥ College -Bachelor Farmer The officer Worker What are your job? Housewife Business Aging, retirement 1 Kinh Chinese Which is your ethnicity ? Khơmer Other:………………… How are your current Single marital status? Marriage Alone Who you live with ? Your family How long is your diabetes 10 years …………… years 2 Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM A BACKGROUND INFORMATION (continued) You read the questions below and circle the number next to the most appropriate answer to you ID Content A9 Except for type diabetes, you have any comorbidities? (See also follow-up book and opinion of treatment doctor) A10 Since you have diabetes, have you had health care workers consult your selfcare? A11 Does your family have any patients type of diabetes? (You can select multiple choices) Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Answer No Yes (1) Eyes (2) Kidney (3) Neurology (4) Foot Diabetes (5) High blood pressure (6) Heart (7) dyslipidemia (8) Other: (You can select multiple choices) No Yes (1) Individual counseling (2) Group (3) Telephone (4) Other (You can select multiple choices) No Yes (1) Father/mother (2) Brother/sister (3) Aunt / uncle (4)Grandfarher/ grandmother Code answer 2 Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM B DIABETES KNOWLEDGE QUESTIONNAIRES (DKQ) ID Content B1 Eating too much sugar and other sweet foods is a cause of diabetes B2 The usual cause of diabetes is lack of effective insulin in the body B3 Diabetes can be cured B4 A fasting blood sugar level of 210 is too high B5 The best way to check my diabetes is by testing my urine B6 There are two main types of diabetes: Type (insulin-dependent) and Type (non-insulindependent) B7 Diabetes often causes poor circulation B8 Cuts and abrasions on diabetics heal more slowly B9 Diabetics should take extra care when cutting their toenails B10 A person with diabetes should cleanse a cut with iodine and alcohol B11 The way I prepare my food is as important as the foods I eat B12 Diabetes can damage my kidneys B13 Diabetes can cause loss of feeling in my hands, fingers, and feet B14 Shaking and sweating are signs of high blood sugar B15 Frequent urination and thirst are signs of low blood Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Answer Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes No I don‘t know Yes Code answer 3 3 3 3 3 3 3 Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM sugar B16 Tight elastic hose or socks are not bad for diabetics No I don‘t know Yes No I don‘t know 3 C SELF CARE LEVEL diabetes (SDSCA) The following question was asked to take care of him (her) during week (7 days) have passed If he (she) pain (sick) in the last days, you can recall the previous days when he (she) is not sick Please circle the number (corresponding to the number of days) in each line below C1 C2 C3 C4 C5 C6 C7 Diet On how many of the last SEVEN DAYS have you followed a healthful eating plan? On how many of the last SEVEN DAYS did you eat food with vegetables and fruits every day? (About 400grams of fruit, for example slices of vegetables, plates of fruit per day, one fork, one quarter of papaya) On how many of the last SEVEN DAYS did you eat high fat foods such as red meat or fullfat dairy products? Physical activity On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity? (Total minutes of countinuos activity, including, walking) On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you around the house or as part of your work? Check blood sugar On how many of the last SEVEN DAYS did you test your blood sugar ? On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider? Use medicine Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn 01234567 01234567 01234567 01234567 01234567 01234567 01234567 Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM C8 C9 C10 C11 C12 On how many of the last SEVEN DAYS, did you take your recommended diabetes madication ? Foot care On how many of the last SEVEN DAYS did you check your feet? On how many of the last SEVEN DAYS did you dry between your tose after washing ? On how many of the last SEVEN DAYS did you inspect the inside of your shoes? On how many of the last SEVEN DAYS did you wear appropriate shoes to protect your feet when you go out ? 01234567 01234567 01234567 01234567 01234567 D POSSIBILITY BELIEVE IN OURSELVES IN ORDER MANAGEMENT diabetes Below is a list of activities he (she) should to manage diabetes (diabetes) his (her) Please read it once and then circle the number that best describes your level of confidence he (she) in the implementation of such activities For example, if he (she) completely confident that I can maintain the diet for people with diabetes during the festivals, banquets, circle number 10 If he (she) feels almost every time he (she) can not it, circle number or If he (she) said that he (she) is absolutely no time to it, circle the number D1 D2 D3 D4 D5 D6 I am able to follow a healthy eating plan during festive periods I am able to follow a healthy eating plan when I am away from home I am able to choose different foods and maintain a healthy eating plan when I am eating out or at a party I am able to choose different foods and maintain my eating plan when I am away from home I am able to choose different foods and maintain a healthy eating plan I am able to choose the foods that are best for my health Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn 10 10 10 10 10 10 Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 I am able to maintain my eating plan when I am feeling stressed or anxious I am able to maintain my eating plan when I am ill I am able to follow a healthy eating plan most of the time I am albe to control my weight and keep it at reasonable level I am able to enough physical activity (e.g walking the dog, yoga, gardening, stretching exercises) I am able to more physical activity if the doctor advises me to When doing more physical activity, I am able to adjust my eating plan I am able to adjusted my blood sugar when the sugar level is too low (e.g.eat different foods) I am able to examine both of my feet (e.g for cuts or blisters) I am able to take my medication as prescribed Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn 10 10 10 10 10 10 10 10 10 10 Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM APPENDIX THE INFORMATION FOR RESEARCH SUBJECTS AND CONSENT RESEARCH Dear You About me: CNDD Nguyen Thi Gai, of the Medical College of Health Bac Lieu I write this information sent to You wishing invited You to participate in a study called: "Effectiveness of health education program to enhance self-management of patients with type diabetes" Sample information below for you You consent to participate in research ABOUT THE STUDY I.THONG I would like to provide some information and invite You to join and become part of the research Purpose and conduct research The study was conducted aimed at determining the effectiveness of health education programs can improve self-management of type diabetes or not? The results of this study as a basis for adjusting model appropriate health education to enhance self-care and self-management of diabetes subtype TheYou enthusiastically participated in the study will help provide evidence to standardize the assistance programs, health education thereby helping to improve the quality of life of him, She, She, Uncle, Brother, Sister, as well as the type diabetes else Processes conducted When you agree to participate in the you will spend extra 20 minutes to: Answer some information about diabetes, how you self-care at home, according to the questionnaires that we'll give You look at the interview We will record the number of tests available only of you as you see doctor These tests include fasting plasma glucose, HbA1C and conducted strictly in accordance with medical treatment for uou So you will not have to pay any additional expense compared to the time of medical examination other diabetes This information will we collect again (after the first months) for comparison with the first The process of working with You will be made by me (RN Nguyen Thi Gai) or my collaborators performed Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM Participants You invited to participate in the study because of you ≥ 18 years old, had been diagnosed with type diabetes, is being monitored at the General Hospital in Bac Lieu The voluntary participation You was right to decide, without being forced to participate You can withdraw at any time without prejudice to the treatment /care that you are enjoying The risks and disadvantages We only ask about the disease, how you self-care at home and recorded the results of your tests available So there is no risk for you when you join in this study Participating interests Since this is not the funded research, we sincerely apologize for not supporting you any other costs Security • The questionnaire that participants answer the research does not require recording full name and personal information secret We expected to post reports and published research results, but the information will be provided in the form can not identify him / her Contact If You have any questions can ask now or later If you wish to ask questions later, please contact us via: - Telephone: 0939696390 Ms Gai - Or email: nguyenthigai02021989@gmail.com Ms Gai II RESEARCH CONSENT I have read and understand the information panel for research participants and the purpose of this study and understand that:  I participated in this study was due to my voluntary  I can refuse to answer questions if I want  I understand that all the answer I give is confidential and used only for research purposes I agree to participate in this study Signature of the participant: _ _ Signature Full name Day month Year _ Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM Signature of the witness or the legal representative (if applicable): _ _ Signature Full name Day month Year _ Signature of Researcher / people get approved: I, the undersigned, certify that the patient / volunteer study participants sign a consent form was read in full the above information, this information was explained in detail to you have to understand the nature, risks and benefits you participate in this study _ _ Signature Full name Day month Year Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM APPENDIX PLEASE ALLOW THE USE OF HEALTH EDUCATION TOOLS Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM APPENDIX CONTENT OF DIABETES SELF-MANAGEMENT EDUCATION Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn Bản quyền tài liệu thuộc Thư viện Đại học Y Dược TP.HCM APPENDIX LIST PATIENTS PARTICIPATE IN RESEARCH Tuân thủ Luật Sở hữu trí tuệ Quy định truy cập tài liệu điện tử Ghi rõ nguồn tài liệu trích dẫn ... 32. 1 25 29 .8 20 35.7 Officials 5.0 6.0 3.6 Worker 2. 1 1 .2 3.6 Housewife 31 22 .1 19 22 .6 12 21.4 Trade 15 10.7 8.3 14.3 Old, retired 39 27 .9 27 32. 1 12 21.4 6.4 6.0 7.1 131 93.6 79 94.0 52 92. 9... level of effectiveness of DSME programs to enhance self-management of patients type diabetes 70 4.5 Effectiveness of intervention programs with glycemic of patients with type diabetes. .. self manage type diabetes 50 Table 3.15 Dietary level of patients with type diabetes 51 Table 3.16 Level of physical activity of patients with type diabetes . 52 Table 3.17 Level of glycemic