A STUDY TO ASSESS THE KNOWLEDGE AND

PRACTICES OF HOUSE WIVES REGARDING DIABETES

MELLITUS, WITH A VIEW TO DEVELOP HEALTH

EDUCATION MODULE IN A SELECTED RURAL AREA,

BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Ms. REETHA SEBASTIN

IST YEAR M.Sc. (N) NURSING

MEDICAL AND SURGICAL NURSING

2011-2013

HARSHA COLLEGE OF NURSING

HARSHA HOSPITAL CAMPUS

193/4, NELAMANGALA BYPASS,

BANGALORE-561223

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKAPROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

MS.REETHA SEBASTINHARSHA COLLEGE OF NURSING HARSHA HOSPITAL CAMPUS193/4, NELAMANGALA BYPASS,BANGALORE-561223

2. NAME OF INSTITUTION Harsha College Of Nursing

Bangalore

3. COURSE OF STUDY AND

SUBJECT

I year M.Sc. Nursing Medical and Surgical Nursing.

4. DATE OF ADMISSION TO

COURSE

06/05/2011

5. TITLE OF THE STUDY

To Assess The Knowledge And

Practices Of House Wives Regarding

Diabetes Mellitus, With A View To

Develop Health Education Module

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6. 0 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION:

“ Prevention is better than cure”

“It is not too late to prevent Diabetes, take your first step today”

Diabetes is a group of metabolic disease characterized by elevated levels of

glucose in the blood resulting from defects in insulin secretion, insulin action, or both.

Insulin is a hormone produced by the pancreas, controls the level of glucose in the body

by regulating the production and storage of glucose. In the diabetes state, the cells may

stop responding to the insulin or the pancreas may stop producing insulin entirely.

Diabetes is a unique condition for women. When compared with man, women

have a 50 percent greater risk of diabetes coma. Compared with women who don’t have

diabetes, women with diabetes are up to five times more likely to develop toxemia, a

disorder marked by hypertension, protein in urine, swelling, head ache, and visual

disturbances.1

Diabetes is Global public Health Problem and is now growing as an epidemic in

both developed and Developing countries. India is the “diabetic capital” of the world with

41million people affected with the disease. Around 150 Million people suffer from

Diabetes in the World, out of which, above 35 million are Indians. India leads the World

to day with the larger number of Diabetes in any given country followed by China and

U.S.A.2

On this year world health day, focused on addressing issue that can improve

health status of women. A wide range of socio economic, cultural and gender based

inequalities continue to aggravate the risk for women. There is a heavy burden of

multiple risk factors of metabolic syndrome leading to non-communicable disorders

amongst the middle aged and elderly women in the urban as well as rural areas.

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The high prevalence of diabetes, obesity, hypertension, and high cholesterol level

in theses women calls for sincere interventions. So, it became imperative that women be

specifically targeted with health education and be motivated to practice healthy dietary

and life style habits.

Types of diabetes mellitus:

Type 1- Referred to as insulin dependent diabetes mellitus.

Type 2- Referred to as non- insulin dependent diabetes mellitus.

Type 3- Diabetes associated with other conditions or syndrome.

Type 4- Gestational diabetes mellitus (diabetes in pregnancy).

The common risk factors for Diabetes Mellitus are family history of Diabetes,

obesity, sedentary life style (lack of exercise) unhealthy eating habits (too much fat,

carbohydrates, not enough fiber) increased age, high blood pressure. 3

Life style plays a crucial role in prevention of diabetes

The problem of diabetes in today’s scenario is enhanced when there is adaptation

of wrong lifestyle in day to day life. Life style is the way you live your life, what you eat,

how and when you eat, how much you exercise, how you cope with stress full situations.

It is the need of hour because the biggest killer in the world today accounting for almost

80% deaths worldwide is not war, disease, natural calamities or accidents. The biggest

killer is life style.

Diabetes can be prevented by good life style practices. Lifestyle practices are pro-

active approach towards optimum health and wellness by bringing about appropriate

changes in the way you live to live life more. Wrong diet, lack of physical activity and

exercise, obesity, mental stress and tensions of fast paced competitive life, alcohol and

smoking are the major culprits, which manifest themselves innocently as high blood

pressure, diabetes, heart attack etc. Hence, one has to realize that one’s life style plays a

crucial role in “remaining healthy”.4

4

The latest diabetes prevention tips include:

Get more physical activity

Get plenty of fiber

Go for whole grains

Lose extra weight.

Skip fad diets and make healthier choices

Based on Epidemiological data, it has been estimated that the risk of Diabetes

may be reduced by 50% when controlling Obesity and increasing physical activity. The

primary prevention of Diabetes is possible by non- pharmacological intervention. To

reduce the burden of Diabetes, such an intervention is necessary as part of routine

preventive care.5

The diabetes prevention programme found that intensive life style interventions can

reduce the development of diabetes mellitus. The life style practices do not follow any

strict rules and is better established by following these points.

Series of group education and motivation sessions supporting life style changes.

Make smart choices while cooking and eating out.

Make healthy decisions about their exercises.

So, a scientifically planned and logically guided healthy practices is the corner stone to

preventing Diabetes and attaining optimum health and well being.4

6.1 NEED FOR THE STUDY

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“An ounce of prevention is equal to an ocean of care”.

Women; the word sounds so powerful. Since eternity, women have played a role

more important than men and that is no exaggeration. The world would not have been the

same lovely adorable and livable place without wonderful contribution so selflessly made

by women. It has been said that, you teach a female and you build up a nation and truth

can’t be closer than that. Women have always carried the burden of being a wife, mother,

sister etc. Hence, the study is conducted on “assessing the knowledge and practices of

housewives and giving health education on prevention of Diabetes mellitus”.6

Diabetes is a serious health condition that affects women in all life stages. With

the increasing life span of women and the rapid growth of minority populations in the

United States, the number of women at high risk for diabetes and its complications will

continue to increase. A public health perspective examines the challenges and risks of

diabetes in each stage of a woman's life. Of the 15.7 million people with diabetes in the

United States, more than half (8.1 million) are women. Minority racial and ethnic groups

are the hardest hit by type 2 diabetes; the prevalence is at least 2-4 times higher among

black, Hispanic, American Indian, and Asian Pacific Islander women than among white

women. 7

The number of diabetic cases in the world is estimated to be around 150 millions.

This number is predicted to double by 2025 prevalence rate about 5.4% with the greatest

number of cases being expected in china and India. The number of diabetic persons in the

countries of the region is likely to triple by the year 2025 increasing from the present

estimates of about 30 million to 80 million.

India has dubious distinction of having the highest prevalence of

diabetes worldwide. Further, the number of individuals with diabetes will reach 79.4

million by 2030 with earlier age manifestations. The prevalence of diabetes mellitus in

our country is 1-2% comparing of urban population ranging from 0.95% to 3.8% while

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the rural population ranging from 0.60%to 3.93%. A recent diabetic survey in India

showed that the prevalence rate of diabetes in Bangalore and Hyderabad was 12.9% and

16% respectively.

The Indian council of medical research studies reported respectively the

prevalence of diabetes among the rural population from 0.4%in Himachal Pradesh, 1.3%

Kerala, 1.5%Delhi and 3.9% in Gujarat.

National survey shown that 54.1% of diabetes developed it in the most productive

of their lives that is before the age of 50 years and they also had higher risk of developing

diabetic complications. 5

The diabetes spectrum From Research to Practice section shows the complexity of

a chronic illness such as diabetes and the widespread effect that it can have on women’s

lives. Coronary heart disease (CHD), bio-psychosocial factors (e.g., puberty, eating

disorders, and peer pressure), racism, and the historical meaning of food in one’s culture

can all affect women’s health and self-management practices. Intervening with women

who have diagnosed diabetes and those who are at risk for the disease requires health

care providers to take a multidisciplinary approach to address the multifaceted effects that

diabetes can have on these women’s lives. 2

Approximately 70% India’s population lives in rural areas in resource – poor

setting where the increase in prevalence and chronic nature of diabetes. Lack of

awareness towards early life style modifications and poor access to quality care increase

diabetes- related complications. The diabetes prevention programme research group study

found that the life style interventions under taken over 2-8 years can reduce the incidence

of type2 diabetes mellitus by about 58%. 1

The study was carried out on global prevalence of diabetes mellitus for all age-

groups worldwide were estimated to be 2.8% in 2000 and 4.4% in 2030. The total

number of people with diabetes is projected to rise from 171 million in 2000 to 366

million in 2030. The prevalence of diabetes is higher in men than women, but there are

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more women with diabetes than men. The findings of the studies indicate that the

“diabetes epidemic” will continue even if levels of obesity remain constant.8

A cross-sectional survey was carried out among the Indian housewives and their

family members (mean age 39.6 years, 6764 females) by using a stratified random

sampling technique. Information on behavioral, clinical and biochemical risk factors of

DM was obtained, through standardized instruments. DM was diagnosed when fasting

blood glucose was ≥ 7.0 mmol/l and/or individuals took drug treatment for DM. The

result of the study shown that in the 20 to 69-year-old age group, the crude prevalence of

DM and impaired fasting glucose was 10.1 and 5.3%, respectively. The study was

concluded that the individuals in the lower education group had a high prevalence of DM

(11.6%). In diabetic subjects, 38.4% were unaware that they had diabetes. 9

A research has been conducted by M V Hospital for Diabetes and Diabetes

Research Centre, an association of the World Health Organization Collaborating Centre

for Diabetes in India. It has been found that more than 35 million Indians suffer from

diabetes. Alarmingly, as much as 13 million cases (50% in rural India and 30% in urban

India) remains undiagnosed, leading to long-term complications. Various factors such as

widespread urbanization reduced physical activity, the consequent obesity, stress and

several other environmental factors have been accounted for the high incidence of

diabetes in India.

The investigator herself came across the problems of diabetes mellitus in rural

communities. It is identified that housewives do not have adequate knowledge and

practices to prevention of diabetes mellitus. Hence the investigator felt that there is a

strong need to educate women regarding preventive measures for prevention of diabetes

mellitus with maximum effectiveness.

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6.2 REVIEW OF LITERATURE

Review of literature is a key step in research process refers to the activities

involved in searching for information on a topic and developing a comprehensive picture

of the state of knowledge on that topic .This provides a background for understanding

what has already been learned on a topic and illuminates the significant of new study. The

review is divided into under following sections:

Section A: Studies related to knowledge and practices of housewives regarding

diabetes mellitus.

Section B: Studies related to role of diet in diabetes.

Section C: Studies related to role of physical activities in diabetes.

Section D: Studies related stress control in prevention of diabetes.

Section A: Studies related to knowledge and practices of housewives regarding

diabetes mellitus.

Qualitative survey was conducted on Knowledge, attitudes, and behavior relating

to diabetes and its main risk factors among women (30-50yrs) residents in Cameroon.

Data were collected through in-depth interviews by using a pre-tested, semi-structured

interview guide. It includes a awareness of diabetes and knowledge of its causes, clinical

course, and complications. Many participants believed diabetes was caused by excessive

sugar consumption rather than excessive energy intake, obesity, or physical inactivity.

Several constraints to the adoption of healthy behaviors were identified. For diet, these

included lack of knowledge of the composition of a healthy diet. Barriers to undertaking

more physical activity included lack of facilities and inadequate time available. The

results indicate the need for health education about diabetes and its main risk factors in

these communities Health education should be informed by lay perspectives to maximize

the appropriateness of the messages and their effect on knowledge, attitudes, and

behavior.10

9

A structured questionnaire on knowledge, beliefs and practices regarding diabetes

was administered to 199 persons with diabetes (92.5% type 2) attending the Aga Khan

University Hospital, Karachi. Mean age [standard deviation (SD)] was 53 (11) years.

Mean duration of diabetes (SD) was 8 (7) years in men and 9 (6) years in women. Men

had a significantly better knowledge score than women (P = 0.02); there was no

significant difference in the beliefs and practices scores. Scores were classed as good (>

60%) in only 13.6% of participants for knowledge, 17.6% for beliefs and 11.2% for

practices.11

A questionnaire-based cross-sectional study was carried out to assess the

knowledge on awareness of diabetes mellitus among rural and urban women. After

analyzing the awareness level of both populations, the urban women were found to be

more educated about diabetes. A 25-question survey was used to judge the awareness

level of diabetes mellitus. A total of 240 diabetics were surveyed, 120 each from rural

and urban areas. The mean awareness among the rural population was 13 (SD± 2) correct

answers out of a possible 25. Similarly, in the case of the urban women the mean

awareness was 18 (SD± 2) correct answers. The study was concluded that rural women

are far less knowledgeable about diabetes mellitus, its management and its preventive

measures. Thus, there is an urgent need to improve the awareness level of diabetes

mellitus in rural areas.12

A prospective cohort study was conducted to assess the knowledge of women

regarding risk of developing diabetes mellitus. The analysis included 50277 women who

had a body mass index less then 30 and was free from diagnosed diabetes mellitus.

During 6 years of follow up, 3757(7.5%) of 5077 and1515 new cases of type 2 diabetes

mellitus detected. In the multivariate analysis adjusting for age, exercise levels, dietary

factors was associated with increase in risk of diabetes mellitus. The study concluded that

increasing number of diabetic cases indicates that women are having lack of knowledge

regarding prevention of diabetes.13

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Section B: Studies related to role of diet in diabetes.

A prospective cohort study conducted on control of body weight by balancing

energy intake and energy expenditure by evaluating intake of whole grain, bran and germ

in relation to risk of type 2 diabetes mellitus.161, 737 housewives without history of

diabetes were participated in this study. The findings from prospective study consistently

support increasing whole grain consumption for the prevention of type 2 diabetes

mellitus.14

A study was conducted to assess the effects of exercise and diet for preventing type

2 diabetes mellitus. The study revealed that exercise plus diet interventions reduced the

risk of diabetes. This had also favorable effects on weight and body mass index

reduction, waist-to-hip ratio and waist circumference. Exercise and diet interventions had

a very modest effect on blood lipids. The study concluded that Interventions aimed at

increasing exercise combined with diet are able to decrease the incidence of type 2

diabetes mellitus in high risk groups (people with impaired glucose tolerance or the

metabolic syndrome).15

A prospective study was conducted to evaluate a structured and integrated

intervention programme on diabetes management in individual with type2 diabetes in

Shanghai, China among men and women with body mass index>23kg/m2. The Reference

Group (n=50) received diabetes education including diet and physical activity instruction

only; the Intervention Group (n=100) received more intensive intervention, including

diabetes education with frequent blood glucose monitoring, nutritional counseling, meal

plans with diabetes-specific nutritional meal replacement, and weekly progress updates

with study staff. Results found that Intervention Group improved fasting blood glucose,

insulin, systolic and diastolic blood pressures compared to Reference Group ( p <0.05).

Waist and hip circumferences and waist: hip ratio decreased in the Intervention compared

to the Reference Group (p <0.05).16

Section C: Studies related to role of physical activities in diabetes.11

A prospective cohort study was conducted on association between physical

activity of moderate intensity and risk of type2 diabetes. The study is specifically

investigated role of walking. The findings of study is indicate that adherence to

recommendations to participate in physical activities of moderate intensity such as brisk

walking can substantially reduce the risk of type 2 diabete.17

A prospective cohort study was conducted on physical activity and risk of type2

diabetes among 70,102females aged 35-48 years. The results of the study shown that

after adjusting for age, history of hypertension, history of high cholesterol level, and

other covariates, the relative risks (RRs) of developing type 2 diabetes across quintiles of

physical activity (least to most) were 1.0, 0.77, 0.75, 0.62, and 0.54 (P for trend <.001);

after adjusting for body mass index (BMI), RRs were 1.0, 0.84, 0.87, 0.77, and 0.74 (P

for trend = .002).The study suggest that greater physical activity level is associated with

substantial reduction in risk of type 2 diabetes, including physical activity of moderate

intensity and duration.18

Diabetes research institute in university of mimami school of medicine, USA

conducted a study on role of physical activity in therapy for prevention of type 2 diabetes.

The results of the study shown that Increased physical activity delays the onset of non

insulin-dependent diabetes mellitus (NIDDM) or even prevents the disease in about 50%

of susceptible individuals (positive family history of NIDDM, body-mass index > 25,

hypertension or gestational diabetes). Regular exercise has been shown to lower plasma

triglyceride and to increase high-density lipoprotein cholesterol levels. Exercise has also

beneficial effects on hypertension, body composition and fat distribution.19

Section D: Studies related stress control in prevention of diabetes.

A study was conducted on psychosocial stress and the use of psychosocial support with a

sample of 410 patients with diabetes mellitus (Type I: n 157, Type II: n = 253). Stress in

different facets of daily life was assessed by using the revised Questionnaire Self-

constructed items were used to assess the use of psychosocial support during the course

of the illness. Results were showed that Diabetics with extreme psychosocial stress

showed worse diabetic control compared to less stressed diabetics. Profiles of

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psychosocial stress showed maximal stress with regard to depression in both types of

diabetes. The study was concluded a considerable number of diabetic patients suffers

from extreme psychosocial stress often associated with poor diabetic control. These

patients need psychosocial care which should primarily be offered in diabetologic centers

incorporating both the patients' family and family background.20

A descriptive study was conducted on Role of stress in the etiology and treatment

of diabetes mellitus .The study was revealed that stress shows effects on metabolic

activity hormones that are released in response to stress and that result in elevated blood

glucose levels and decreased insulin action.21

6.3 STATEMENT OF THE PROBLEM

“A study to assess the knowledge and practices of house wives regarding diabetes

mellitus with a view to develop health education module in selected rural areas,

Bangalore”.

6.4 OBJECTIVES:

1. To assess the knowledge and practices of housewives regarding diabetes mellitus.

13

2. To assess the relation between knowledge and practices of housewives regarding

diabetes mellitus.

3. To associate the knowledge and practices of housewives regarding diabetes mellitus

with selected demographic variables.

4. To develop health education module regarding diabetes mellitus.

6.5 OPERATIONAL DEFINITIONS

Knowledge: It refers to the level of understanding of housewives regarding diabetes

mellitus.

Practices: It refers to the measures followed by the house wives such as dietary

practices, exercise performed, and regular annual checkups.

House wives: In this study housewives are referred to the non diabetic married women

in the age group of 25-45 years and not employed formally by any outside agency

Diabetes Mellitus: A disorder of carbohydrate metabolism due to lack of insulin.

Health education module : It refers to the self learning information prepared in Kannada

and English on diabetes mellitus.

6.6 HYPOTHESIS OF STUDY

H1 –There will be a significant relation between knowledge and practices of housewives

regarding diabetes mellitus.

H2- There will be a significant association between the knowledge and practices of

housewives regarding diabetes mellitus with selected demographic variables.

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6.7 ASSUMPTION

1. House wives may have inadequate knowledge regarding Diabetes mellitus.

2. House wives who are not practicing preventive measures may prone to get Diabetes

mellitus.

3. Health education module may improve the knowledge and practices of housewives

regarding Diabetes mellitus.

6.8 DELIMITATION

The study was delimited to

1. Housewives who are residing at selected rural area, Bangalore.

2. 4-6 weeks of time period.

6.9 VARIABLES

Research variables on the concept at various levels of abstraction that are entered

manipulated & collected in a study.

1. Dependent variables: knowledge and practices of house wives regarding diabetes

mellitus

2. Demographic variables: It contains demographic variables of house wives such as

age, religion, education, type of family, income of the family, food habits of the

family physical activities, source of information regarding diabetes.

15

7. MATERIAL AND METHODS

The study is designed to assess the knowledge and practices of house wives

regarding diabetes mellitus in a selected rural area in Bangalore.

7.1. SOURCE OF DATA:

The data will be collected from house wives residing in selected rural area in

Bangalore.

7.1.1 RESEARCH DESIGN:

The present research is of Descriptive design.

7.1.2 RESEARCH APPROACH:

The present research adopts Survey approach

7.1.3 SETTING OF THE STUDY:

This study will be conducted in selected rural area in Bangalore.

7.2 METHODS OF COLLECTION OF DATA:

Structured self administered questionnaire will be used to assess the knowledge and

checklist to assess the practice of housewives regarding diabetes mellitus

.7.2.1 SAMPLING TECHNIQUE:

Probability sampling technique, for the present study simple random sampling

(Lottery method) will be used

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7.2.2 SAMPLE SIZE:

The sample of the study consists of 60 housewives.

Duration of study:

The study is planned to be conducted over a period of 4 weeks

7.2.3 SAMPLING CRITERIA:-

Inclusion criteria:

1. Residing at selected rural areas, Bangalore.

2. Age group between 25-45 years.

3. Non-diabetic house wives.

4. House wives those who can understand Kannada or English.

Exclusion criteria:

1. Not available at the time of data collection

2. Working women

7.2.4 TOOLS FOR DATA COLLECTION:

Structured self administered questionnaire will be used to assess the knowledge

and checklist to assess the practice of housewives regarding diabetes mellitus

Procedure for data collection:

Data collection is the gathering of information needed to address a research

problem. A validated structured questionnaire will be used to collect the data about

knowledge and practices of house wives regarding diabetic mellitus.

7.2.5 DATA ANALYSIS METHOD:

Descriptive statistics

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-Frequency and percentage distribution were used to study the demographic variables of

the house wives regarding diabetes mellitus.

-Mean and standard deviation were used to determine the level of knowledge and

practices regarding diabetes mellitus.

Inferential statistics

Pearson’s correlation: will be used to assess the relation between knowledge and

practices of housewives regarding prevention of diabetes mellitus.

Chi-square test: will be used to bring out the relation between the knowledge and

practices with selected demographic variables. Level of significance was fixed at 5%

level.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTION OR INVESTIGATION

TO BE CONDUCTED TO THE PATIENTS, OTHER HUMAN OR ANIMALS?

NO. The Study does not Require Any Intervention invasive or Investigation to

Be Conducted to the Patients, Other Human or Animals

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Permission will be obtained from:

1. The research committee of the college of Nursing.

2. Authorities of selected rural area, Bangalore.

3. Informed consent will taken from the Housewives who are willing to

Participate in the study.

4. The data obtained is meant and utilized only for present research purpose.

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8. LIST OF REFERENCE:

1. Francine kaufman, women and diabetes available from URL;

http://www.dlife.com/dlife/do/showcontent/policy/editorial.htm ;2008june25.

2. Park k. Park’s text book of preventive and social

medicine.19thed.Jabalpur: M/sBanarsidas Bhannot;2007Jan;327.

3. Brunner and Suddarth’s. Text book of medical and surgical

nursing.8th ed. Lippincoot Raven publishers pvt Ltd;973-1025.

19

4. Life style modification. Available from URL;http//www.live

lifemore.com.

5. Perkins I. Diabetes mellitus epidemiology-classification,

determinants and public health impacts. Jemmisstate med Association.20004

Dec;45(12) 355-62.

6. Health and women. Available from URL; http://www.

Indianchild.com.

7. National Diabetes and womens health. Available from

URL;http;//www.alpha.org/programmes/diabetes women health.htp

8. Sarah wild, M B. Bchir, Gojkaroglic, et al. Global prevalence of

Diabetes estimates for the year 2000 and protection for 2030. Diabetes care 27:1047-

53,2004.

9. V.S.Ajay, D. Prabhakaran, P.Jeemon, et al. Prevalence and

determinants of Diabetes mellitus in the Indian housewives. Original article,

epidemiology July 4,2008.

10. Kiawi E , Edwards R, Shu J,et al. Knowledge, attitudes, and

behavior relating to diabetes and its main risk factors among urban residents in

Cameroon: a qualitative survey. Ethn Dis. 2006 Spring;16(2):503-9.

11. Rafigue G, Azamsi, White F. Diabetes knowledge, beliefs and

practices people with diabetes attending a university hospital in Karachi, Pakistan.

East mediter Health J2006 sep;12(5):598-9.

12. Ahamad Ayazsabri, Muhammad Ahad, Naif usman saigal, et al.

comparing knowledge of Diabetes mellitus among rural and urban women. Mcgilj

Med,2007July;10(2):87-89.

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13. Frank B.HU,tricia Y. Li, Graham A.colditz, et al, Television

watching and other sedentary behavior in relation to risk of type 2 diabetes mellitus

in women. J diabetes pre. 2003 April9; vol-289.

14. De munter JS, Spiegelman D, Franzm, et al. whole grain, bran and

germ intake and risk of type 2 Diabetes ;a prospective cohort study and systematis

review.PLOS Med.2007Aug;4(8):261.

15. Orozco LJ, Buchleitner AM,Gimene Z, et al. exercise and diet for

preventing type 2 Diabetes. Cochrane data base syst Rev.2008 Jul;16(3):3054.

16. Sun J, Wang Y, Chen X, et al. an integrated intervention

programme to control diabetes in over weight Chines women and men with type 2

Diabetes. Asia pac J clin Nutr.in Shangai, China, 2008;17(3):514-24.

17. Jeon CY, Lokken RP, HuFB, et al. physical cativity of moderate

intensity and risk of type 2 Diabetes:asystematic review. Diabetes care.2007

Mar;30(3):744-52.

18. Hu FB, Sigal RJ, Rich-edward JW, et al.Walking compared with

vigorous physical activity and risk of Diabetes in women. JAMA.2000

Oct;282(15):1433-9.

19. Lehmann R, Spinas GA. Role of physical activity in the therapy

and prevention of type 2 Diabetes mellitus. Therumsch. London 2000

Dec;53(12):925-33.

20. Herpertz S , Johann B, Lichtblau K, et al. Psychological stress and

use of psychological support:multicenter study Med klin, 2000 Jul15;95(7):369-77.

21. Zachary T. Bloomgarden. Diabetes and Stress. 2003 Jul; 33(3):180-

8.

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9. SIGNATURE OF STUDENT :

10. REMARKS OF THE GUIDE :

11. NAME & DESIGNATION OF :

11.1 GUIDE NAME & ADDRESS :

Head of the Department

Medical And Surgical Nursing

11.2 SIGNATURE OF GUIDE :

11.3 CO - GUIDE (IF ANY) :

11.4 SIGNATURE :

11.5 HEAD OF THE DEPARTMENT :

Head of the Department, Medical And surgical Nursing

11.6 SIGNATURE OF H.O.D :

12.1 REMARK OF PRINCIPAL :

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12.2 SIGNATURE OF PRINCIPAL :

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