nutrition knowledge of physicians
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ASSESSMENT OF NUTRITION KNOWLEDGE OF PALESTINIAN PHYSICIANS EMPLOYED IN SHIFA HOSPITAL - GAZA CITYTRANSCRIPT
ASSESSMENT OF NUTRITION KNOWLEDGE OF
PALESTINIAN PHYSICIANS EMPLOYED IN
SHIFA HOSPITAL - GAZA CITY
By: Mohammad Subhi El-Lulu
Al-Azhar University of Gaza
Deanship of Postgraduate Studies and Research Affairs
Faculty of Pharmacy
Master Program of Clinical Nutrition
Assessment of Nutrition Knowledge of Palestinian Physicians
Employed in Shifa Hospital - Gaza City
A small Project
for Fulfillment of the Degree of Master of Clinical Nutrition
By
Mohammad Subhi El-Lulu
Supervisor
Dr. Jehad H. Elhissi Ass. Prof. of Public Health
Health and Nutrition Consultant
July- 2011
Dedication
I would like to dedicate this work
to the memory of my father “Subhi Salem El-Lulu”;
to my mother; to my brothers and sisters particularly
“Fawzi and Dr. Fathia”; to my wife and my lovely
children “Omar, Lana, and Balsam”
Faithful Mohammad
3
Introduction
Research Problem and Significance
Objectives
Methods and Subjects
Results
Conclusion
Recommendations
Selective References
Contents 4
Introduction 5
Introduction 6
The World Health Organization (WHO) defines health as “a state of complete physical, mental, and social well-being, not merely the absence of disease and infirmity” (Blair, 2001).
“Nutrition is important for the maintenance of life, growth, reproduction, the functioning of organs and tissues, and the production of energy” (Webster-Gandy et al,
2008).
The role of nutrition in promotion, disease prevention and treatment of chronic disease is well recognized (Schaller & James, 2005).
7
Diet is now considered to play a substantial role in
the etiology of many chronic degenerative diseases
such as coronary heart disease, atherosclerosis,
type-2 diabetes mellitus, osteoporosis, and some
cancer types such as bowel, stomach, breast and
prostate cancers (Turrell, 1997).
Introduction
Knowledge Background 8
Most individuals generally regard their physicians
as the primary source of diet and nutritional
information (Hu et al, 1997).
Survey studies revealed that physicians are hesitant
to provide nutritional information to patients due to
low levels of confidence resulting from a lack of
education and knowledge in this field (National health
promotion and disease prevention objectives, 2000).
9
Physicians have the potential to decrease morbidity and mortality if they provide effective nutrition counseling and advice (Kushner, 1995).
Rogers (1983) identified three types of knowledge:
(1) awareness (such as diet- disease relationship),
(2) Knowledge of principles (e.g. cholesterol is found in animal foods only),
(3) how to knowledge (e.g. how to select foods with less fat or how to read a food label accurately).
Knowledge Background
Nutrition in medical education in Palestine
1) Al-Azhar University provide two credit hours for general principles of nutrition at college of medicine.
2) Islamic University doesn’t provide a course of nutrition within curriculum plan.
1) An-Najah National University provides a course of nutrition that discusses the relationship of diet and diseases.
2) Al-Quds University of Abu-Dis doesn’t mention the academic plan of curriculum.
10
Gaza Universities West Bank Universities
11
Islamic University of Gaza provides Professional
Diploma in Children Health and Nutrition “Just for
Doctors” at college of Continuing Education.
Al-Azhar University of Gaza since 2006 has been a
Master Degree of Clinical Nutrition (MDCN), and
some of students in the program are doctors as many
other medical fields.
That means: the nutrition become a new developing
branch within medical education, which reveal the
importance of nutrition to help and support medicine.
Nutrition in higher education in Palestine
Research Problem and Significance 12
Research Problem & Significance 13
Five of the 10 current leading causes of death in
United States (coronary artery disease, cancer,
stroke, diabetes and atherosclerosis) are strongly
linked with unhealthy dietary habits.
Also, diet contributes importantly to the risk for
osteoporosis, obesity, hypertension and neural tube
defects (Promoting health/ preventing disease, 1989).
14
In 1990, the US Congress passed the National
Nutrition Monitoring and Related Research Act,
which mandated “that students enrolled in United
States medical schools and physicians practicing in
the United States have access to adequate training
in the field of nutrition and its relationship to
human health” (National Nutrition Monitoring and Related
Research Act, 1990).
Research Problem & Significance
15
To identify the general nutrition knowledge of physicians working in Shifa hospital.
To evaluate the concepts of patient’s nutritional assessment.
To identify the role of physicians in nutrition education.
To identify the knowledge of physicians regarding nutrition situation of hospitalized patients who are taking “total parenteral nutrition or enteral feeding”.
To recommend the decision makers about the importance of nutrition in treating and preventing diseases.
Objectives
Methods and Subjects 16
Study design 17
A descriptive cross-sectional design was used to determine nutritional knowledge. The study depends on reviewed questionnaire by associated professors working in academic and medical fields.
Dependent variable (knowledge of nutrition). Discusses the general principles of nutrition knowledge, as well as disease- nutrition relationship.
Independent variable (physicians):
Age, Sex (male and female), Graduation (bachelor,
master and MD), and Department.
Sample and sampling 18
Sample size:
Purposeful non probability sample was taken; the sample consists of 36 physicians.
Study setting and period
The study was conducted in Shifa hospital in Gaza city, which is a large public hospital from March 2011 to July 2011.
Target population
All physicians who are working at Shifa hospital (Surgical and Obstetric) departments.
Ethical consideration 19
Approval letters from Deanship of Pharmacy.
Approval and permission letter from General
Administration of Human Resource Development
(the main department at Ministry of health for
scientific researches).
Approval signature from the head of department.
Informed consent from participated physicians.
Eligibility criteria
Male and female
physicians currently
employed in the
hospital.
Trainees and (Job
Creation Program)
physicians
20
Inclusion criteria Exclusion criteria
Data collection 21
Questionnaire
4 Parts
• 1st part composed of physician’s personal characteristics.
• 2nd part explains training and practice.
• 3rd ask about knowledge of principles of nutrition.
• 4th awareness of diet- disease relationship
Criterion of Distribution
• 12 completed questionnaires from obstetrics and gynecology department.
• 24 completed questionnaires from surgical department.
Study analysis 22
SPSS
Coding Entry Cleaning Analysis
Results 23
1st part: Age of participants 24
Total
No. 36 100%
More than 45 years
No. 10 27.8%
From 35 to 45 years
No. 20 55.5%
Less than 35 years
No. 6 16.7%
1st part: Physicians sex distribution 25
Total
N0. 36 100%
Female
No. 7 19.4%
Male
No. 29 80.6%
1st part: Graduation degree of physicians
26
Total
No. 36 100%
PhD
No. 5 13.9%
Master
No. 19 52.8%
Bachelor
No. 12 33.3%
1st part: Departments of physicians 27
Total
N0. 36 100%
Gynecology and Obstetrics
No. 12 33.3%
Surgery
No. 24 66.7%
2nd: Studying the nutritional therapy in
school of medicine 28
Yes
No
If Yes
• 27 out of 36
• 75%
• 9 out of 36
• 25%
• Intensive Course (7.4%)
• Just Required Course (92.6%)
2nd: Courses of nutritional therapy at hospital
29
12
33.3%
24
66.7%
Yes
N
O
2nd: Can nutrition knowledge help and
develop practical medicine 30
• 35 out of 36
• 97.2% • (suggest the place) at next slide
Yes
• 1 out of 36
• Without reasons No
2nd: The best place for teaching the
nutrition therapy 31
At Medicine school
10
28.6%
At Continued Medical
Education
25
71.4%
2nd: Importance to have nutrition
department at hospital 32
Yes 33 (91.7%)
No 3 (8.3%)
Knowledge of Principles
Knowledge of Nutrition Assessment
Part 3 of Questionnaire 33
34
Nutrition Principles (Questions) No. (%)
Stearic acid is essential fatty acid as linoleic acid
Yes
No*
I don’t know
15 (41.7%)
6 (16.6%)
15 (41.7%)
Leptin hormone is important for
Hunger
Satiety*
I don’t know
11 (30.6%)
6 (16.6%)
19 (52.8%)
Peripheral Parenteral Nutrition can lead to thrombosis
Yes*
No
I don’t know
23 (63.9%)
10 (27.8%)
3 (8.3%)
Central Venous Feeding is safe from infections
Yes
No*
I don’t know
9 (25%)
24 (66.7%)
3 (8.3%)
35
Nutrition Principles (Questions) No. (%)
To avoid aspiration, Enteral tube should be inserted into
Stomach
Duodenum*
I don’t know
27 (75%)
5 (13.9%)
4 (11.1%)
Clear Liquid Diet such as Plain Gelatin can provide calories for
few days
Yes*
No
I don’t know
11 (30.6%)
6 (16.6%)
19 (52.8%)
Mechanical Soft Diet can’t be used for whom suffer from difficulty
of chewing or swallowing
Yes
No*
I don’t know
9 (25%)
9 (25%)
18 (50%)
36
Assessment (Questions) No. (%)
Body Mass Index (BMI) = Weight in (kg)/Height in (cm)²
Yes
No*
I don’t know
21 (58.4%)
7 (19.4%)
8 (22.2%)
An important parameter act with BMI to assess obesity for male
Waist/hip ratio*
Hip/waist ratio
I don’t know
4 (11.1%)
5 (13.9%)
27 (75%)
Do you know Subjective Global Assessment (SGA)?
Yes
No
If the answer is Yes
SGA could be adapted to predict postsurgical nutrition
associated morbidities:
Yes*
No
I don’t know
8 (22.2%)
28 (77.8%)
7 (87.5%)
0 (-%)
1 (12.5%)
37
Assessment (Questions) No. (%)
Do you know Instant Nutritional Assessment (INA)?
Yes
No
If the answer is Yes
INA adapted for nutritional assessment of preoperative
patients:
Yes*
No
I don’t know
8 (22.2%)
28 (77.8%)
4 (50%)
4 (50%)
0 (-%)
Do you know Nutrition Risk Index (NRI)?
Yes
No
If the answer is Yes
It can’t be used as an index of malnutrition in hospitalized
patients:
Yes
No*
I don’t know
10 (27.8%)
26 (72.2%)
3 (30%)
6 (60%)
1 (10%)
Awareness of diet- disease relationship
38 Part 4 of Questionnaire
39
Diet - disease relationship (Questions) No. (%)
Excessive homocysteine level in blood associated with
Cancer
Heart disease*
I don’t know
11 (30.6%)
5 (13.9%)
20 (55.5%)
Which of the following in excessive amount is Tertogenic?
Vitamin A*
Vitamin K
I don’t know
15 (41.7%)
5 (13.9%)
16 (44.4%)
In presence of renal stone of Calcium Oxalate, we have to reduce
the intake of
Sodium*
Calcium
I don’t know
5 (13.9%)
25 (69.4%)
6 (16.7%)
Extra-abdominal fat level can be associated with breast cancer in
female
Yes*
No
I don’t know
13 (36.1%)
12 (33.3%)
11 (30.6%)
40
Diet - disease relationship (Questions) No. (%)
Anti-thrombotic nutrient is
Vitamin E
Omega 3*
I don’t know
10 (27.7%)
15 (41.7%)
11 (30.6%)
A type of fibers help lowering cholesterol level in blood
Soluble*
In-Soluble
I don’t know
12 (33.3%)
14 (38.9%)
10 (27.8%)
Disadvantages of Total Parenteral Nutrition (TPN) are Gall Stones
and Cholestasis
Yes*
No
I don’t know
20 (55.6%)
8 (22.2%)
8 (22.2%)
A nutrient prevents Neural Tube Defect
Folate*
Cyanocoblamin
I don’t know
20 (55.6%)
5 (13.9%)
11 (30.5%)
41
Diet - disease relationship (Questions) No. (%)
Daily requirement of fluids for normal adult is 2.5 ml/kcal of body
weight
Yes
No*
I don’t know
9 (25%)
9 (25%)
18 (50%)
Healthy adults require at least 50 Kcal/kg of body weight
Yes
No*
I don’t know
13 (36.1%)
6 (16.7%)
17 (47.2%)
Basal Metabolic Rate is the minimum energy required to maintain
normal physiological function during exercise
Yes
No*
I don’t know
15 (41.7%)
10 (27.8%)
11 (30.5%)
Do you know Refeeding Syndrome?
Yes
No
7 (19.4%)
29 (80.6%)
Conclusion 42
Mean of grades of physicians knowledge
(general principles and nutrition assessment) 43
Mean
Minimum score: 0/12
3.11 SD: ±2.05
Maximum score: 9/12
Mean of grades of physicians knowledge
about awareness of diet- disease relationship 44
Mean
Minimum score: 0/12
3.66 SD: ±2.04
Maximum score: 9/12
45
Mean
Minimum Score
1/24 (4.16%)
6.77
(28.23%)
SD: ±3.22
Maximum Score
13/24 (54.16%)
Mean of Total Score No (%)
Relationship between age of participant physicians
and their percentage of nutrition knowledge 46
Age Percentage of knowledge
Less than 20%
No. (%)
20% - 40%
No. (%)
More than 40%
No. (%)
Less than 35 2 (33.3%) 2 (33.3%) 2 (33.3%)
35 – 45 5 (25%) 11 (55%) 4 (20%)
More than 45 1 (10%) 8 (80%) 1 (10%)
The result shows that:
less age / more knowledge
Relationship between age of participant physicians
and their percentage of nutrition knowledge 47
Pearson Chi- Square Value
Not Statistically Significant
(0.460)
Relationship between percentage of
knowledge and participants department 48
Departments
Percentage of knowledge
Less than 20%
No. (%)
20% - 40%
No. (%)
More than 40%
No. (%)
Surgery 5 (20.8%) 17 (70.8%) 2 (8.3%)
Obstetrics 3 (25%) 4 (33.3%) 5 (41.7%)
The result shows that: Physicians of obstetric department have higher
and more knowledge than physicians of surgery department
49
(0.038)
Pearson Chi-
Square Value
Statistically Significant
Relationship between percentage of
knowledge and participants department
Recommendations 50
51
Nutrition department at hospital is important request, because it
helps in clinical assessment, diet management, & status follow-up.
Physicians should take courses about basic and essentials of
nutrition, to get a proper understanding of nutrition.
School of medicines should have adequate course about nutrition.
Good training and practice at hospital through continued medical
education.
Physicians should take intensive course of nutrition therapy
according to their specialty.
Selective References 52
Blair S., (2001). Clinical exercise physiology for cancer, cardiovascular and pulmonary rehabilitation. Exercise Physiology. (Eds. McArdle W.D., Katch F.I., Katch V.L.). Fifth Edition. Lippinocott Williams and Wilkins. Philadelphia. PP: 912- 965.
Hu S.P., Wu M.Y. and Liu J.F., (1997). Nutrition knowledge, attitude and practice among primary care physicians in Taiwan. J. Am. College Nutr. 16: 439- 442.
Kushner R.F., (1995). Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Preventive Medicine. 24: 546- 552.
National health promotion and disease prevention objectives, (2000).US Department of Health and Human Services. Office of disease prevention and health promotion, healthy people 2010. US Public Health Service. Washington, DC. Government Printing Office.
53
National Nutrition Monitoring and Related Research Act of 1990, (1990). Public Law. 101- 445.
Promoting health/ preventing disease: year 2000 objectives for the nation, (1989). US Department of Health and Human Services. Washington, DC: US Government Printing Office.
Rogers E.M., (1983). Diffusion of Innovations. New York: Free Press.
Schaller C. and James E., (2005). The nutritional knowledge of Australian nurses. Nurse education today. Australia. 25: 405- 412.
Turrell G., (1997). Department of gender differences in dietary behavior. Nutr. Res. 17: 1105- 1120.
Webster-Gandy J., Madden A. and Holdsworth M., (2008). Oxford Handbook of Nutrition and Dietetics. Oxford. Oxford Medical Publications.
Selective References
Al-Azhar University of Gaza
Deanship of Postgraduate Studies and Research Affairs
Faculty of Pharmacy
Master Program of Clinical Nutrition
Assessment of Nutrition Knowledge of Palestinian Physicians
Employed in Shifa Hospital - Gaza City
A small Project
for Fulfillment of the Degree of Master of Clinical Nutrition
By
Mohammad Subhi El-Lulu
Supervisor
Dr. Jehad H. Elhissi Ass. Prof. of Public Health
Health and Nutrition Consultant
July- 2011