Application of the transtheoretical model to predict self-care outcomes and serum irisin level in the patients with type 2 diabetes
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Introduction and Objective: Type 2 diabetes (T2DM) is one of the most costly endocrine disorders of the present age. One of the reasons for increasing diabetes is lifestyle. Life style (healthy diet and physical activity) can better control blood glucose levels and long-term complications of diabetes. A healthy lifestyle such as proper diet and physical activity through multiple mechanisms, including improved serum irisin, a myokin secreted from muscle cells and it has a role in reducing insulin resistance and blood glucose, which is effective in reducing the long-term complications of diabetes. Therefore, structured educational interventions of self- manangement (SM) by professionals in the control of complications of diabetes are cost effective. One of the educational interventions is a transtheoretical model model. That self-care is widely used to guide behavior change and motivation. This mixed method study is based on a transtheoretical model that qualitative phase with the aim of describing and explaining inhibitor and facilitator factors in SM patients with T2DM based on the application of the decisional balance structure. A quantitative phase was with the aim of applying the structure of the stages of change (SOC) based on transtheoretical model (TTM)-which designed and implemented as a randomized clinical trial (RCT) in predicting SM outcomes and serum levels of irisin in patients with T2DM. Materials and Methods: One hundred and twenty-eight patients with T2DM, ranging from 70 to 30 years old with inclusion criteria were selected referring to a private clinic in Ardabil. In phase I study, general information questionnaire, 24-hour diet recall and physical activity completed for all subjects as face-to-face and anthropometric and blood pressure tests. Researcher-made questionnaire based on SOC in SM was evaluated for content and face validity, factor analysis. The SOCSMDQ-I was completed as face-to-face by the performer to determine the position of the subjects in SOC structure. The subjects were matched for SOC and BMI and they were randomly assigned to two intervention groups (n= 67) and control (n = 61). In phase II study, which was a qualitative phase and included an examination of SM on inhibitor and facilitator factors, a objective based sampling method was used. The subjects studied of the intervention group were selected. According to the Likert scale, participants were classified to pre-action and action stage. Data was obtained from two focus group sessions, interviews were conducted in the form of semi-structured (60-90 minutes) and continued data saturation. The decisional balance structure was used to collect data. Qualitative analysis was accomplished by MAXQDA 12 software and manually. Educational protocol was designed and Dramatic Film - Educational was recorded using obtained qualitative information, motivational interview and educational protocol. In phase III of the study (quantitative, intervention), biochemical evaluation, anthropometry and blood pressure were taken from both groups before the intervention. In the intervention group has at least 5 sessions and a maximum of 7 sessions educational on SOC and the number of patients needs with the contents of SM education including proper use of medications, healthy diet and physical activity for 1-2 hours was taught as lectures in groups and by the project. The control group also received routine training for patients with diabetes. At the end of the intervention, all questionnaires and evaluations were completed again and again for both groups. In phase III of the study (follow up), subjects in both groups were followed up for six months in this time; the subjects did not receive any training. After completion of 6 months follow up, all the subjects completed the questionnaires and evaluations. Results: Results phase I, the total content validity index (CVI) and face validity was 0.60-0.91, 0.81-1 and 4.32-4.82, respectively. The number of questions increased up to 10. In addition, EFA results showed that Kaiser-Mayer-Olkin (KMO) was 0.69, and total variance extracted was 23.6. ICC was above 0.6. Results phase II, Participants in action stages in section differents of SM identified the main inhibitory themes as the socio-economic status, treatment team’s weak function and physical-intellectual factors. Action stages individuals referred to lack of planning and pre-action stages patients for arbitrary treatment. The main subjects of facilitating factors in the pre-action and action stages were: gaining information and knowledge about physical situation, socio-economic status, beliefs about diabetes, satisfaction of treatment, treatment team’s support, gaining nutritional knowledge. Results phase III, there was a significant difference in proper use of medications on SOC in the intervention group, the after the intervention (p <0.05). The healthy diet and physical activity on SOC in the intervention group, after intervention and follow up, were significantly higher than the beginning of the intervention (p <0.05). Weight and BMI of individuals in the intervention group, 7 weeks after training -1/1 kg (-1/6, -0/6) and -0/31 kg/m2 (-0/55, -0/05) was observed a decreasing significant (p <0.05). Systolic blood pressure in the intervention group, 7 weeks after training -11/4 mmHg (-18/5, -4/3) decreased significantly compared to the control group (p <0.05). In the intervention group, fasting blood glucose after intervention and follow up -50/4 mg/dL (-73/7, -27/1) and -28/2 mg/dL (-56/1, -0/4) and in the intervention group, blood glucose level two hours after meals after the intervention -60/1 mg/dL (-87/5, -32/7) decreased significantly compared to the control group (p <0.05). After intervention and follow up of HbA1c in the intervention group respectively% -0/73 (-1/2, -0/28) and% -0/78 (-1/3, -0/21) was indicated a significantly reduced compared with the control group (p <0.01). After intervention in total cholesterol and triglyceride serum levels a decreased was observed in intervention group -22/3 mg/dL (-38/4, -6/2) and -32/1 mg/dL (-62/1, -2/1) (p <0.05). Serum irsin level during follow-up in the intervention group a significantly decrease was reported -0/07ng/ml (-0/14, 0/001) compared to the control group (p <0.05). Conclusion: The design questionnaire in this study is an acceptable tool for determining the SM status of patients with T2DM. In this study, by identifying inhibiting and facilitating factors in self-care, a SM educational program was designed based on a SOC model that this intervention program resulted in change behavior and could improve SM outcomes in these patients.