Pre-diabetes and Diabetes Early Awareness Education and Its Effects on BMI

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Nancy L. Gee Comment by Pamela Love: Looks like an interesting project, Nancy.Very good start! Be sure whenever you submit your manuscript that you change wording from study to project and avoid referring to the project as research. Review carefully for grammar, punctuation, sentence structure, format, or APA errors. Pay close attention to the reviewers comments as you continue on this DNP journey. Stay focused &be sure to follow the DPI template as you prepare for IRB submission.For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future. Jeremiah 29:11 (NIV).Blessings, breathe, and believe,Dr. Love

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

58

EARLY AWARENESS

Figure 2: Graphics of Research Process Onion.59

Chapter 1: Introduction to the Project

In society today, obesity is a serious comorbidity with the prevalence in the United States (US) continuing to increase (Jarolimova,Tagoni, &Stern, T. A., 2013). Obesity is a leadingcause of increased risks for developing many health problems such as an excessive rise in bodyweight. Furthermore, it isone of the most essential and changeable risk factors within the pathogenesis of health are complications problems like type-1 diabetes (T1D) andtype-2 diabetes (T2D). These problems are well, thus, is documented in most biochemical studies as well as cross-sectional research (Piven, 2014). In current times, there are many all-important biochemical studies in the inter-relationship amid body mass index (BMI) and its connection with the advancement of diabetic issues (Innocent, Oweh, Sandra & Josiah, 2013). Comment by Thomas, Maria: Space Comment by Thomas, Maria: Remove and change all tracking changes before submission for AQR Clarify this. Check for sentence flow so it is easy for the reader to follow your logic

The Center for Disease Control (CDC) anticipates that nearly thirty-three percent of adults may have diabetes by the year 2050 (CDC, 2010; Robert Wood Johnson Foundation, 2016); as presently, more than twenty-nine million adults in America have been diagnosed with diabetic issues, and an additional eighty-six million have pre-diabetes (Statistics about Diabetes, n.d; Robert Wood Johnson Foundation, 2016).

Pre-diabetes is a diagnosis where blood sugar levels are elevated, however lesser than the established inception of diabetes (Kowall et al., 2012). Kowallet al. (2012) write pre-diabetes is a result of Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), or perhaps a mixture of IFG and IGT (p. 828). Moreover, diabetes has numerous effects which might consist of several health disorders and, in a few instances, failure of bodily organs (Tabk, Herder, Rathmann, Brunner, & Kivimki, 2012; Brown, 2017). Thus, T2D puts individuals at risk for a variety of ailments like cardiac conditions, amputations, renal malfunction, vision loss, as well as obesity. Weight reduction has been seen to stop the triggering of T2D and morbid obesity in individuals having pre-diabetes (Brown & Kuk, 2015). As a result, early diagnosis and management of pre-diabetes can avoid its crossover to complete onset diabetes and thus reduce the related problems (Brown & Kuk, 2015, p. 79).

Little is known about how patients respond to Diabetes Self-Management Education (DSME). Thus, the goal of this project study will be to measure the awareness and knowledge of pre-diabetes and diabetic risk factors among obese patients in a family practice clinic. The project study adopts a quantitative approach using a descriptive method and pre-post tests to determine subjects' understanding and knowledge of pre-diabetes and T2D. The pretests will establish current knowledge ,and gaps about diabetes awareness, and post-test will determine the knowledge the participants gained from the Diabetes Self-Management Education (DSME) intervention. The results will state the advancement of the pre-diabetes and diabetes informative and knowledge-based programs. Comment by Pamela Love: Project, not study. Correct throughout paper.

This chapter focuses on a particular target audience while describing the idiosyncrasies of this Direct Patient Improvement (DPI) project such as background of the study, problem statement, purpose of the study, clinical question(s), advancing scientific knowledge, significance of the study, rationale for methodology, nature of the study, definition of terms, assumptions, limitations and delimitations and lastly, summary and organization of the remaining chapters.

Background to the Project

The frequency of identified diabetic issues amid U.S. adults has gone up twofold within the past four decades and seventy-five percent in the past twenty-five years (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The lifetime danger of acquiring diabetes within the U.S. in 2000 had been 33% for males and 39% for females,and this had been even greater amid U.S. minority communities (Narayan et al., 2003).

BMI is a highly reliable, yet a controllable risk element for diabetes (American Diabetes Association, 2017; Ford, Williamson and Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes,and BMI has notbeen extensively examined (Arayan, James, Theodore,et al., 2007). Medical experts use BMI to determine whether a person is overweight, obese, normal or underweight. It is a determination of the ratio of a persons weight and their height (Lo, Wong, Khalechelvam and Tam, 2016).

The following are details of the findings from research, about the relationship between the BMI ratio, pre-diabetes, and diabetes. It was found by Narayanet al. (2007) that ones risk of developing diabetes in their lifetime is one in three, at the point of birth. He further noted that the risks of developing the condition across the categories of BMI over a lifetime are still unclear. The study sought to demonstrate the specific lifetime risks for the various BMIs for people in the US, based on sex, ethnicity, and age subgroups (Narayan et al., 2007).

The survey data from the National Health Interview n=780, 694, from 1997 to 2004 was the basis for indicating race, sex, age, ethnicity, and the prevalence of BMI-linked occurrence of diabetes in the US in 2004 (Narayan et al., 2007). The data from the US Census Bureau including age, sex-specific mortality, population rate projections, and race were used along with two earlier studies relating to mortality, to project the mortality rates related to BMI ratios (Narayan et al., 2007).

The findings and estimates informed the Markov Model projection of the lifetime risks of diabetes diagnosed by race, sex baseline age, and BMI. According to the results, the lifetime risk of developing diabetes at the age of eighteen for underweight people was 7.6,and those who were obese was 70.3%. The figures also increased from 12.2 to 74.4 for women in the same weight categories. The difference in lifetime risk was lower at advanced ages. For example, at age 65, healthynormal weight males had their lifetime risk difference rise from 3.7 to 23.9 points in percentages between overweight people and the ones regarded as very obese. The figure increased by 8.7 percentage points to 26.7 for women (Narayan et al., 2007a). It was also determined that the effect of BMI on the duration of diabetes compounded with an increase in ones age (Narayan et al., 2007b).

The risk of developingdiabetes was ivestigated in case-control research by Ganzet al. (2014) by studying its incidence versus BMI ratios. The rising effect of BMI, based on BMI categories was assessed. Those who recorded weights between 25 and 29.9 were considered overweight. Moreover, then there was the Obesity Class I who measured between 30 and 34.9. Class II Obesity group registered BMI index from 35 to 39.9. Obesity Class III on its part recorded figures equal to or over 40(Ganz et al., 2014).

Relative risks and ratios regarding the odds were calculated from a range of logistic regression outcomes. Age, cardiac history, sex, and hyper-inflammatory were used to select group subjects (Ganz et al., 2014). Measures of BMI were taken a year preceding the first diagnosis of T2D. BMI was obtained from dates that were randomly assigned for those that were in control group. The relationship between BMI and the incidence of diabetes is strong with the risk increasing with higher BMI (Ganz et al., 2014).

There is a significant correlation between diabetes and being overweight. Some studies have established a compelling link between the two factors. In one study, for instance, Akbari et al. (2017) found that patient education regarding T2D can help reduce barriers. The core aim of the study was to establish the impact of an education program intervention, using the beliefs, attitudes, subjective norms and enabling factorsmodel (BASNEF) on awareness barriers, adaptation, lifestyle and support for patients living with T2D (Akbari, 2017). Comment by Thomas, Maria: Spell out first time use

Removing the barriers associated with pre-diabetes and diabetes is a reasonable step towards empowering patients with diabetes to manage their lives with the condition and to recognize what affects the barriers (Akbari, 2017). The findings indicated that there was a clear difference between a score derived from living barriers such as lifestyle, awareness, protection and adaptation components, and the BASNEF model variable, i.e., enabling factors, attitude, subjective norm, knowledge, and behavioral intention (Akbari, 2017).

Problem Statement

T2D also referred to asnon-insulin-dependent diabetes (NIDDM), makes up most cases of diabetes mellitus globally. In 2000 there had been roughlyone hundred and fifty million people with the illness and that this quantity is most likely to increase twofold by the year 2025 (Kaveeshawar & Cornwall, 2014; King, Aubert, & Herman, 1998). T2D will be the fourth or perhaps the fifth prominent cause of demise in many developed nations and there's expanding proof that this has attained epidemic dimensions in quite a few developing and recently industrialized nations (Amos, McCarty, &Zimmet, 1997). All-time low levels of T2Dare found in places where individuals retain a traditional lifestyle (Gray, 2015; Bennett, 1999). Dramatic modifications in the frequency ofthe occurrence of T2D is found in places where there have already been significant changes in the kind of foods utilized. The food choices range from the conventional native diet plan to a standard western diet plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel and Michael, 1987). Changing illness levels are revealed by modifications in some dietary elements along with modifications in other lifestyle associated elements, notably a decrease in physical exercise (Sami, Ansari, Butt, Rashid, & Hamid, 2017; Steyn et al., 2004). Comment by Maria Thomas: Space

It is not known if and to what degree these facts are known to diabetes patients. Therefore, Because of these facts, the purpose of this project study is to assess the awareness and knowledge of diabetes amongst patients with prediabetes in a family practice clinic. After carrying out DSME pre-intervention assessments on patients with prediabetes, gaps will be recognized in awareness and understanding of prediabetes and diabetes amongst diabetes patientsthe subjects. Measurement of BMI will be completedpre-test and eight weeks after post-test to assess the effects of the DSME intervention related to weight loss. Comment by Thomas, Maria: Present a clear declarative statement that begins with It is not known if and to what degree/extent..., or It is not known how/why and. Comment by Thomas, Maria: Include the broad population affected by the problem

Absent from the literature is information on how patients respond to self-management methods that should be adopted to attain the preferred benefits, and precisely what they will do with the knowledge they gain from DSME educational interventions. There's an expanding demand for interventions that enhance patients understanding and knowledge of pre-diabetes and diabetes (Islam et al., 2014). The substantial population at an increased risk for or with diabetes is actually within the age bracket of 25 - 65 years. Insufficient steps to decrease theoccurrence of pre-diabetes might result in a considerable boost in health investment, morbidity, as well as other associated health circumstance (National Diabetes Statistics Report, 2014, para 8).

For healthcare providers managing an increased incidence of diabetes diagnoses, health interventions will be essential to avoid diabetic issues or postpone their development (Islam et al., 2014). Such endeavors can consist of acompletelifestyle change for all those at an increased risk for pre-diabetic issues and timely treatment for patients suffering from the disorder. An ambitious method focusing on individuals at an increased risk of diabetes is a significant public health strategy targeted at reducing the threat elements for pre-diabetes and diabetes (International Diabetes Federation, 2013).

Purpose of the Project

The purpose of this Direct Practice Improvement (DPI) project is to evaluate awareness and understanding concerning pre-diabetes and diabetes in pre-diabetic individuals and the effects of the DSME on BMI. To determine if the patients qualify for the study and are pre-diabetic, the researcher will utilize patients healthcare records to choose individuals with increased fasting glucose (IFG), and hypertension in the family practice clinic. The potential study participant will be recognized as obese if they have aBMI of more than 30kg/m2. Obesity and hypertension are both related to diabetes and may be considered as inclusion criteria.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing the Diabetic Knowledge Test 2 (DKT2), a close-ended questionnaire. The DKT2 was designed and developed by the Michigan Diabetes Research Training Center (MDRTC). Its purpose is for testing common knowledge of diabetes in pre-diabetic and diabetic patients.Thuspatients. Thus, the study uses a quantitative descriptive research design. Another dependent variable will be BMI assessment. The BMI will be measured by weighing the patient before awareness education and eight weeks after receiving the DSME intervention. Additional independent variables are how awareness and understanding levels amongst individuals differ based on education level,andlastly, the health belief model will be the theoretical foundation for this study.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Theseinclusion criteria for this study will be adults of both sexes with a BMI of more than 30kg/m2. Moreover, the results might be helpful in the advancement of future interventions towards decreasing pre-diabetes and diabetes risk in communities with ahigherrisk of acquiring T2D.

Clinical Question:

The clinical question is: Among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improveent in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period?

When promoting interventions to assist with prevention and control of diabetes, awareness is an essential resource (Demaio et al., 2013). There's a connection amid individuals with reduced levels of health understanding and increased diabetic problems (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients understanding of their health could be helpful in the assessment of the risks associated with developing diabetes, DSME interventions to reduce the risk, and their control over lifestyle changes including weight reduction. Consequently, outcomes of this research will promote stakeholders, within the healthcare sector to plan, create, and implement complete health campaigns focused on pre-diabetes-related DSME interventions.

The project will analyze the understanding and awareness of diabetes amongst patients with prediabetes in a family practice clinic with a BMI >30kg/m2. The research project query is: among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.The independent variable will be the DSME intervention plan,and the dependent variable is patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing a quantitativedescriptive research design and the DKT2. The DKT2will be used to assess participants knowledge pre-DSME and post-DSME.

Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-diabetes awareness education and eight weeks after receiving the intervention. Additional dependent variables are how awareness and understanding levels amongst individuals differ based on education level,and lastly, the health belief model will be used as the theoretical foundation for the projectstudy.

Advancing Scientific Knowledge

There is a controversy inexistence, relating to the BMI mortality diabetes paradox in which the BMI optimal category is higher in patients that are non-diabetic.Bayset al. (2007) noted that not all obese or overweight cases develop diabetes and that not all with diabetic conditions were necessarily obese or overweight (Bays et al., 2007). A paradox regarding BMI ratios and diabetes still exists and needs a solution.

Controversy is still rife related to the relationship between BMI and the occurrence of pre-diabetes and diabetes. Physicians will be empowered to minimize the risk factors for diabetes sooner if there is afull understanding of the relationship between the two. Modern day is well known for the diabetes epidemic. Numerous pre-condition indicators have been identified for medics to use to reduce the risk factors. It is irresponsible to wait to treat pre-diabetes and/or diabetes when there are ways topreventitsoccurrence. These potential populations need education about the risks and how they can self-manage them to reduce symptoms and avoid its inception.

Tabak, Herder, Rathmann, Brunner & Kivimki et al. (2012) wrote one can find an increase in thefrequency of pre-diabetes as well as obesity within the U.S. Additionally; there happens to be a higher chance of further advancement to T2D for individuals with pre-diabetes (Tabak et al., 2012). T2D raises the danger of acquiring other problems like high blood pressure, kidney issues, and loss of sight along with growing the price of therapy, and loss of efficiency. Thus, undoubtedly there is a need for a DSME intervention method to improve the levels of understanding and knowledge concerning pre-diabetes, diabetes, and weight problems amongst patients and to assure higher levels of successful Self-Managed cases. Comment by Maria Thomas: APA format for 3-5 authors, first time in text

This project utilizes the Health Belief Model (HBM) that is undoubtedly one of the most frequently utilized theories in health learning and health intervention campaigns (Glanz, Rimer, & Lewis, 2002; National Cancer Institute, 2003). HBMwas designed during the 1950s to describe the reason why healthcare screening programs proposed by the U.S. Public Health Services, especially for tuberculosis, just were not successful (Hochbaum, 1958). The root notion of the initial HBM was that health conduct is independent of individual beliefs or views with regards to a disorder as well as the methods accessible to reduce its prevalence (Hochbaum, 1958). Individual insight is affected by the complete array of intrapersonal elements impacting health conduct (Jones and Bartlett, 2008).

The results from this study can assist in realizing public awareness gaps and practices concerning pre-diabetes, diabetes,and obesity, which may help in the creation of obesity and diabetes self-management campaigns. Medical care services and professionals will find the outcomes of this study essential forproviding assistance to obese prediabetic patients. It will also contribute to knowledge already existing in the literature by increasing health care providers awareness of the extent to which diabetic patients are aware of their condition.

Significance of the Project

The occurrence of clinically diagnosed diabetes amongst U.S. adults has increased twofold within the past four decades and 75% in the past twenty-five years (Gregget al., 2004; Centers for Illness Control and Prevention, 2007). The lifetime danger of diabetes within the U.S. in the year 2000 had been 33% males and 39% females and was even higher amongst U.S. minority communities (Narayan et al., 2003). BMI is known as reliable, yeta changeable risk element related to diabetes (Ford, Williamson, &Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes, and BMI has not been extensively examined (Arayan, James, Theodore,et al., 2007).

The growing urbanization, westernization, and mechanization happening practically in every area around the globe are associated with modifications in the eating routine to one of higher fat, higher energy-packed meals, and an inactive way of life resulting in increased degrees of BMI (World Health Organization, 2000; Popkin, 2001). This change is further linked to the present rapid modifications in childhood as well as adult weight problems. Even in several low-income nations around the world weight problems are now dramatically rising, and frequently coexists within the same populace with persistent under-nourishment (Popkin, 2001). Life-span has risen because of improvement in nourishment, cleanliness, and the control over thecontagious ailment. Transmittable illnesses and nutritional insufficiency diseases are, consequently, being substituted in developing nations by unique health risks similar to obesity, cardio disorder and diabetic issues (World Health Organization, 2000;2 Swinburn, Caterson, Seidell & James, 2004). Comment by Maria Thomas: The citation must match the reference and vice versa Comment by Maria Thomas: Follow APA citation and reference format. Review and change for all citations and references

Even though treatment of diabetic subjects is costly, medical care establishments face a far more complicated problem in dealing with issues because of T2D like heart disease, cardiac arrest, stroke, and kidney malfunction that also hinders economic efficiency and boosts the price of medical treatment (C3 Collaborating for Wellbeing, 2011). Awareness and knowledge are vital assetsin controlling and preventing pre-diabetes and diabetes (Demaio et al., 2013). Lack of understanding and awareness about diabetes increases the chances of acquiring this disease (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients awareness assists in risk assessment of developing diabetes. Therefore, DSME interventions can reduce the risk in conjunction withlifestyle changes including weight reduction.

Consequently, knowledge of pre-diabetes and diabetes along with effective DSME strategies amongst overweight pre-diabetic individuals are essential strategies for lessening the damaging influences of the disorder to both people and the community.Thus, this project will use a quantitative descriptive design to measure the knowledge andunderstanding concerning pre-diabetes and diabetes in pre-diabetic individuals and their response to DSME using a pre-posttest closed-ended questionnaire. Participants will be weighedeight weeks after completing the post-test to analyze the effects of DSME on BMI, i.e., weight reduction. The study results will be integrated into campaigns to assist in the management of obesity and diabetic issues for the exact purpose of developing a tradition of understanding/increasing awareness about pre-diabetes and diabetes amongst overweight people within society.

The effectiveness of such an educational intervention might lead to considerable self-control over morbid obesity, BMI, and diabetes that would improve the standard/quality of life for diabetic individuals. Additionally, it might decrease health treatment expenses. By creating knowledge and providing awareness, the study's results might affect the local community favorably. For example, the results might also be utilized to teach the neighborhood about the risks of weight problems and just how individuals can handle prediabetes as well as T2D. For the public, the details on understanding and knowledge about diabetic issues will be utilized to organize public health guidelines targeted at preventing and managing diabetes.

Rationale for Methodology

The purpose of this DPI project is to measure the effects ofknowledge and awareness related to pre-diabetes and diabetes amongst overweight people who are at risk or have diagnoses ofprediabetes who happen to be patients in a family practice clinic. The project makes use of a quantitative descriptive research method to determine subjects understanding and knowledge of prediabetes and T2D while measuring the effects on BMI.

A descriptive study offers information for analyzing and monitoring policies and plans. This type of study model focuses on the best way to respond to these kinds of queries as: How much? How many? How effective? How successful? How sufficient? (Indiana University, n.d.). Furthermore, descriptive study designs are an approach that offers a description of the subjects. The critical methods for conducting a study utilizing a descriptive investigation design and style are acCase study, sSurvey along with observational scientific studies (Shawyer et al., 2014).

This projectuses a descriptive design to focus on the effectiveness of DSME intervention programs. The study will monitor the efficiency of DSME plans and provide recommendations for improvement of future DSME programs. Hence this study adopts a quantitative approach using a descriptive method utilizingthe DKT2 for pre-post tests to determine subjects' understanding and knowledge of prediabetes and T2D and the effect of DSME on BMI. Comment by Thomas, Maria: Use citations from textbooks or literature on the research methodology to justify the use of the selected methodology

The pretests will establish current knowledge,and gaps about diabetes awareness and post-test will determine the information they gained from the intervention (DSME) and how they plan to use that information in their life, i.e., reduction of BMI. The results will assist in the advancement and improvement of the prediabetes self-management intervention programs.

The quantitative method is the best method for this project and set of data because it provides much needed statistical information that can help close the gaps on this specific subject (Knight, Hickman, Gibbons & McIntyre, 2016). Statistical evidence is missing relating to this precise population. The quantitative method provides the means for this gap to be filled.

Nature of the Research Design for Project

This project will use adopt a quantitative descriptive design and use the DKT2 closed-ended questionnaire to carry out DSME pre-assessment and post-assessment on patients suffering from prediabetes. This study uses a descriptive design to measure the effectiveness of the DSME intervention program. Moreover, the study will monitor DSMEs efficiency and provide recommendations for improvement of future DSME programs.

A quantitative measurement of BMI will also be used to test the effectiveness of the DSME intervention. The patients will be weighedbefore the pre-test and eight weeks after awareness education.Initially, subjects will be requested to be weighed to determine if their BMI is >30 and then take part in the pre-assessment and post-assessment once they sign a consent form. The pre-assessment queries will use the DKT2 in such a manner that respondents can comprehend and fully grasp the questions (Shawyer et al., 2014; Indiana University, n.d.; Michigan Diabetes Research Center, n.d.). The DKT2 will be carried out to measure the degree of knowledge and understanding concerning diabetes from the subjects. Making use of outcomes from the pre-assessment, the researcher will customize the educational intervention program to meet the requirements of the subjects. After the participants' DSME educationintervention has been completed; a post-assessment is going to be carried out utilizing the easy to understand questionnaire to ascertain the efficiency of the educational intervention.

One of the most productive approaches supporting this type of research is the

survey approach. The survey method has, through the years, established itself to be possibly the most efficient way of measuring any social research. Survey methodsassist the researcher to come up with, distribute, and ask relevant queries from the targeted subjects or sample. It enables the researcher to select from two different and all-encompassing strategies: 1) interviews and 2) questionnaires (Trochim, Donnelly,and Arora (2015). Trochimet al., (2015) explains in his research that a survey has the versatility to vary from a short-scaled easily written response to an all-inclusiveface-to-face extensive interview that is the thing that makes the survey such an essential research fragment. The standardized and closed-ended structure of survey,the,i.e., thequantitative DKT2 closed-ended questionnaire will be most valuable for this form of study.

This study compares the strategies and theories that were developed and verified by previous studiesabout the research matter. In this study, the connectionis amid awareness concerning diabetic issues in pre-diabetic individuals and the way it impacts their willingness to self-manage diabetes, i. e. weight reduction. After awareness-level and knowledge-level assessment of pre-diabetes and diabetes amongst the subjects utilizing quantitative methods, the researcher will use an edcational intervention program for patients with prediabetes. These types of interventions can be carried out to enhance clinical results amongst individuals, as well as, theprogression of more efficient educational intervention models (Funnel et al., 2010).

Definition of Terms

Diabetes knowledge.: For this project, the researcher will use the definition employed by Fonseca et al. (2012) who state that diabetes knowledge represents having abilities, data, and details concerning diabetic issues learned via experience or education.

Diabetes self-management education (DSME): For this project, the researcher will assume the definition put forward by ADA (2010) which states that DSME is are the ongoing process for facilitating knowledge and skills focusing on goals and life experiences guided by evidence-based standards, which supports self-care behaviors, problem-solving and promotes collaboration with the healthcare team. Comment by Thomas, Maria: Term.Write the definition of the word. This is considered a Level 3 heading. Definitions are supported with citations from scholarly sources

Risk factors. For this project, the researcher will assume the definition put forward by the Diabetic Council (2017) who state that risk factors are anything that increases your riskyour chancesof developing a particular disorder such as diabetes.

Pre-diabetes: For this project, the researcher will assume the definition put forward by ADA, (2013) which classifies prediabetes as a medical problem in which the degree of blood sugar is higher than the normal degree, although not enough to be classified as T2D.

Type II diabetes: For this project, once again, the researcher will assume the definition put forward by the ADA, (2013) classifies T2D as a disorder in which the body does not take advantage of the insulin released through the pancreas, resulting in higher blood sugar levels.

Body mass index (BMI): For this project, the researcher will assume the definition put forward by the Centers for Disease Control (CDC) (2016) which adult over-weight and obesity as a persons weight in kilograms (kg) divided by his or her height in meters squared.

Obesity: The researcher will use the definition put forward by Haas and his colleagues (2013) who state that this is a health disorder where there's excessive unwanted fat that may be established when BMI, calculated by dividing a persons weight from the height, which is powered square, exceeds 30 kg/m2.

Diabetes knowledge test 2: The researcher will use the definition put forward by Fitzgerald et al.(2016) who represents the DKT2 test by stating it hastwenty-three knowledge test items and developed by the Michigan Diabetes Research Training Center (MDRC). These twenty-three items represent a test of general knowledge of diabetes.

Assumptions, Limitations, and Delimitations

This project will concentrate on the belief that individuals with prediabetes might have less understanding and knowledge of diabetes. Consequently, the DSME intervention program will undoubtedly enhance the patients understanding of diabetic issues. Additionally, there is a presumption that growing awareness concerning diabetic issues as well as its associated challenges might lead to enhanced benefits when managing the health disorder. The sample for this study will be patients inside a family practice clinic. Consequently, the opportunity to make use of the results to the general populace at an increased risk of acquiring T2D is restricted (Stommel&Wills, 2004).

Results generalization is reasonably limited because of the small volume of subjects and the absence of a control group. Because of the target populace, the obstacles to registering more subjects will include individuals traveling, working, or experiencing other scheduling restrictions, along with issues in reaching out to a few subjects. The limitations to acquiring all after-intervention information may include lapses in subject's insurance coverage, and absence of insurance coverage to get a two-month BMI measurement. However, this project still has a fair degree of generalizability as the information obtained from it may serve as a foundation for better understanding the awareness of diabetes patients with regard to their condition.

Project impact might be understated because of the timing involved in the awareness education intervention that will take place during the February-March after winter months sedentary activity related to determents of winter weather and participating in holiday season festivities and parties where people might be much more likely to drink alcoholic beverages and avoid eating healthy foods. The subjects may well improve their health indicators much more if this DSME intervention takes place at another time.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed using a quantitative descriptive research design and employing the DKT2 closed-ended questionnaire. Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-assessment and awareness education and eight weeks after receiving the intervention.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Dedication towards increasing their understanding and awareness of diabetes as well as their risk of acquiring T2D might encourage them to alter their lifestyle and embrace new treatments to decrease the threat of diabetes.

Summary and Organization of the Remainder of the Project

Increasingly, diabetes is becoming a health problem which could potentially overload the existing healthcare system. Additionally, diabetes can be the cause of various other health problems making it a verycomplicated disease. There is undoubtedly a need for effective initiatives such as early awareness to assist with prevention or slowing down the incidences of the disease focused on slowing the progression (Brown, 2017). The achievements of a health intervention programs are partially affected by the peoples degree of understanding concerning the health disorder. Understanding and knowledge lead to obesity and diabetes cognizance, and as a result,therapy and control of this disorder (ADA, 2017). This projectexamines knowledge of pre-diabetesand diabetes in pre-diabetic subjects. The results of this project could assistlawmakers and Healthcare providers in creating and applying obesity and diabetes programs (Brown, 2017).

The project isdividedintofour additional chapters. The review makes up chapter two and will consist of the theoretical fundamentals. The methodology will make up chapter three. The fourth chapter will highlight all of the outcomes. The fifth and final chapter will offer evaluation and dialogue of the results.

Chapter 2: Literature Review

Introduction to the Chapter and Background to the Problem

This chapter explores specific and general literature on the management of diabetes and how to control it. The body of information is arranged as (1) Background of the study; (2) Themes Relevant to the PICOT Question; (3) Theoretical Foundations and/or Conceptual Framework; (4) (4a) HBMs Seminal Source (4b) The foundational, historical, current and relevant literature in the field (5) Theme One: prediabetes and obesity (5a) Subtheme 1: Prediabetes, Obesity and Type II Diabetes (T2D) (5b) Subtheme 2: Insulin-Resistance and Obesity (5c) Subtheme 3: Weight-loss (6) Main theme 2: Diabetic Education (6a) Sbtheme 1: Evaluation of education (6b) Subtheme 2: Effectiveness of education (6c) Subtheme 3: Cost-Efficiency of Diabetic education (7) Summary of the literature review.

Consequently, to access the sources of literature review, PubMed, Medline, Embase, Cochran Central Register of controlled trials, also referred to as CCTR, Bioline International, Database of Abstracts of Reviews (DARE), The Cochran Database of Systematic Reviews (CDSR) and Google Scholar. Apart from making use of libraries online, journal articles from Grand Canyon University that contained related information were also explored. Comment by Thomas, Maria: Cochrane

The search terms below are used in the project: prediabetes, obesity, T1D, T2D. A hand/manual search of selected journals from cover to coveris conducted following successful identification of the relevant studies. The references contained in the eighteen research studies were re-examined to pick out relevant studies that may have been missedduring the electronic search effort. The process of inclusion was meticulous. The study only reviewed journals published between 2009 and 2018. English language articles, quantitative and qualitative studies, and the latest articles published between 2009 and 2018 were included. The criterion for exclusion was that any non-English language articles, thesis, published abstracts, dissertations and articles published after 2000.

A review of therecent literature revealed thatdiabetic issues have doubled in their frequency in the past four decades. In the past 25 years, the frequency has gone up by 75% (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The risk of acquiring a diabetic condition in the United States in the year 2000 was 39% for females and 33% for men. These figures increased minority communities in the US (Narayan et al., 2003).

While BMI is a valid risk index for diabetes (ADA, 2017; Ford, Williamson & Liu, 1997; Diabetes Prevention Program Research Group, 2002), there is a gap in the literature regarding knowledge of diabetes based on BMI has not been carefully studied (Arayan, James, Theodore et al, 2007). BMI is an indicator of the ratio between ones weight and height (Lo, Wong, Khalechelvam&Tam, 2016). It is used to indicate whether one is underweight, normal,overweight, or obese.

According to estimates, there were over one hundred and fifty million individuals suffering from T2D in 2000. The number is predicted to double by the year 2025 (Kaveeshawar& Cornwall, 2014; King, Aubert, & Herman, 1998). It is projected that the condition is slated to become the fourth or fifth most common cause of death in developed countries. Indeed, there isincreasing evidence that T2D has reached epidemic proportions in several developed countries (Amos, McCarty, &Zimmet, 1997). Low levels of T2D occurrences are noted in communities where traditional and simplelifestylesareis maintained (Gray, 2015; Bennett, 1999). The situation is the opposite in communities where there is extensivepansive food modification to a western type food plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel &Michael, 1987). Illness levels change, based on amodification of lifestyle-related activities and habits, including physical exercise (Ansari, Butt, Rashid, & Hamid, 2017; Steynet al., 2004). Comment by Maria Thomas: APA citation

A gap in the literature exists regarding patients response to DSME that ought to be applied to acquire the advantages; and, on what these patients plan to do with the newfound knowledge gained via DSME intervention(Brown, 2017; Islam et al., 2014). The demand for interventions aimed at enhancing patients understanding about diabetes is increasing (Islam et al., 2014). The population that stands the most significant risk of developing diabetes is between the ages of 25 to 65 years. If there are no proper interventions to reduce pre-diabetes occurrence,there is a possibility that the lack of educational interventions may lead to a more significant financial burden in the health sector including a rise in morbidity (National Diabetes Statistics Report, 2014, para 8).

Thus,this DPI project focuses on establishing the knowledge and awareness of pre-diabetes, diabetes,and obesity among patients that have pre-diabetes with a BMI >30 in a family clinic. This study will utilize the DKT2 quantitative closed-ended questionnaire for pre-post testing and DSME to achieve these goals.

Theoretical Foundationsand Conceptual Framework

The PICOT question is an essential component of the research process. It provides the basis for establishing the research topic and appropriate themes. For this literature review the PICOT of interest is as follows:among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.Further, the following will address the central problem, the intervention, the comparison, and the outcome. Thus:

Problem. The central problem is the need to establish the knowledge and awareness levels about the diabetic condition among those with pre-diabetes in a family practice clinic. The following will be used to answer the question:

Intervention: a quantitative survey to conduct pre-assessment and post-assessment on pre-diabetic obese patients. It will include a quantitative BMI measurement after eight weeks following awareness campaigns. The subjects will be asked to take a measure of their weight and proceed to participate in pre and post DSME after signing a consent form. The assessment questions are crafted to make sure that respondents can will easily follow the content (Shawyer et al., 2014; Indiana University, n.d.).

Comparison: The DKT2 will seek to establish the extent to which respondents understand pre-diabetes and diabetes issues related to DSME.After presenting participants with self-management education, a post-assessment will be completed by use of the DKT2. The outcomes of pre and post assessments will be examined to show how efficient the educational intervention is.The post-assessment will measure their DSME knowledge and also measure their willingness to apply the newfound information in their lives.

Outcome: the desired results relate to improving clinical outcomes among patients and continuation and development of better DSME intervention models of education. The PICOT question forms the basis of two important themes. These are examined later in this chapter. The theoretical foundationis as follows.

Conceptual framework. Attitudes, beliefs related to health and knowledge are essential concepts of health behavior practice models. In particular, effects and control are included in socio-cognitive models because they represent health behavior, respond to change, intervene in related risk factors, and are the objectives for intervention (Jones, Smith, & Llewellyn, 2014). The health belief model (HBM) shaped the project. HBM(Hochbaum, 1958; Rosenstock, 1974) is an intrapersonal model laced around ones knowledge theory and beliefs in the promotion of health (Jones, Smith, & Llewellyn, 2014). Applying HBM was meant to examine peoples behavior via observing their awareness responses, attitudes and perceptions one may hold towards given ailments and the effects of specified actions.

HBMs seminalsource. HBM is a significantly most commonly applied theory in health promotion and education (Glanz, Rimer, & Lewis, 2002; National Cancer Institute [NCI], 2003). This model was crafted in the 1950sby social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal at the U.S. Public Health Service. The model was developed to demonstrate why medical screening for tuberculosis in the US was notmostlargely successful (Hochbaum, 1958). The basic concept in the HBM model s that peoples health behavior is influenced by personal perceptions, attitudes,and perceptions regarding illness and the available strategies to reduce the occurrence of such illness (Hochbaum, 1958). Moreover, perception at the personal level is determined by a wide range of factors that have to do with a person at theindividual level and affecting their health behavior. The centralconstruct of the model is shaped by the following four factors, which include perceived susceptibility, perceived seriousness, perceived barriers and perceived benefits (Jones & Bartlett, 2008). Each of the perceptions can be applied singly or in combination to demonstrate health behavior. Using the model as a theoretical basis can assist to enhance public awareness and understanding regarding pre-diabetes, diabetes, and issues of weight. In turn, pre-diabetes, diabetes,and obesity awareness campaigns may be improved. The health fraternity will find thebroad application of the study in approaching obese and pre-diabetes cases (Jones and Bartlett, 2008).

Perceived seriousness. Perceived seriousness has to do with ones belief regarding how severe a disease is. Although such perceptions are widely and commonly influenced by medical information, it may be spurred by ones beliefs regarding disease difficulties in their life (Jones and Bartlett, 2008).

Perceived susceptibility.Perceived susceptibility is a substantial perception that commonly influences peoples health behaviors. The perceived risk tends to be directly proportional to behaviors that reduce such risk (Jones and Bartlett, 2008).

Perceived benefits. Perceived benefits relate to ones belief of the helpfulness of new behavior in reducing the risk of contracting a disease. When people believe that their new way of behaving will reduce the chance of developing a disease, behaviors such as quitting smoking, using sunscreen, adopting a diet filled with fruit servings and vegetables are results of perceived benefits (Jones and Bartlett, 2008).

Perceived barriers. Because change is often resisted, perceived barriers relate to ones evaluation of the barriers/ obstacles that prevent them from pursuing a new behavior (Orji, Vassileva, &Mandryk, 2012). Indeed, the perceived barriers are most responsible for thechange in behavior.

According to the HBM framework, perceived susceptibility relates to ones belief about the possibility of the disease developing as a result of the behavior they engage in, and how such behavior will lead to an adverse health outcome (Orji, Vassileva, &Mandryk, 2012). Perceived threat examines the possibility of a disease developing. Risk of thediseasecould be determined by environmental factors and demographics including race, ethnicity and ones status, socioeconomically (Jones and Bartlett, 2008).

HBM is a practicaln effective framework for shaping this project by examining knowledge and beliefs which is summarized in the Conceptual Model by Ganz et al., 2002(figure1).

FIGURE 1: Health Belief Model (Glanz et al., 2002, p. 52)

The foundational, historical, current, and relevant literature. As specified

above, three aspects influence the chance that a person will adopt a specific behavior in HBM. a. There is perceived severity and susceptibility where one realizes that there is enough reason to prioritize a health concern. b. The perceived threat in which someone understands that he or she might be at the risk of developing a disease. Alternatively,an adverse health effect and c. Perceived barriers and benefits where one realizes that change in behavior can be positive and that the gains related to the change override the costs of doing it (Bayat et al., 2013).

HBM shows that a cue or trigger is central to encourage engaging in behaviors that are positive to health. Befitting cues may be internal or external. Pain symptoms are some of the internal cues. External cues include information and events from the media, friends, healthcare practitioners participating in behaviors related to health and family (Zareban et al., 2013). Cues that signal action include reminders emanating from medical staff, family and friends experiences and health product labels. Speedy action depends on the strength of the cues. It varies from between person to person based on perceived susceptibility, benefits, significance, obstacles and benefits. The model also insists self-efficacy which refers to ones perception of their competence to engage in a particular behavior (Brown, 2017).

Knowing about thedisease and peoples attitude towards the disease influences the chance of the action happening. After being aware of the possibility of a disease occurring, if there is no behavior change, it is essential to examine both benefits and barriers of taking action and pointing out which affect someones life more (Julinawati, Cawley, Domegan, Brenner, & Rowan, 2013). The likelihood of actionis determined by perceived gains including the quality of life. All behavior changes initiatives encounter barriers, and they contribute towards the outcome.

The HBM model showed that it supports the basic understanding regarding the psychological and environmental mechanisms of patients for approval. It is used in diabetes to simplify the awareness and understanding of the health condition behavior. The knowledge may mitigate the short and long-term diabetic effects and give instructions for investigators to develop suitable training methods (Bayat et al., 2013, p.45). The education improves acceptance and patient adherence to behaviors that are applicable such as nutritional plans that lead to long-term management of blood sugar levels and weight reduction in people with pre-diabetes and diabetes.

Review of the Literature

Theme 1-prediabetes, diabetes, and obesity. Deepa et al. (2014) carried out cross-sectional research in rural and urban areas of India. The study involved subjects from four geographical regions in India. Deepa et al. (2014) used 6,607persons as a sample. The researcher sought to establish diabetes awareness and the level of knowledge regarding the factors that cause it, including accompanying complications of the condition. He used a questionnaire administered by an interviewer. Deepa et al. (2014) realized a response rate of 8 percent from the participants. The researcher discovered that diabetes awareness levels in India were notably low in the rural places compared to urban areas (Deepa et al., 2014). Only 43.2% of the subjects were aware of diabetes. Urban residents, on the other hand, were well aware of the diabetes condition. The rate of awareness among urbanites stood at 58.4 compared to a relatively lower 36.8% by the rural dwellers. The researchers underscored the need for enhancing awareness and knowledge about the disease. Such awareness and understanding will enhance control and prevention of the condition (Deepa et al., 2014).

Given the fast developments occurring in China, the incidence of pre-diabetes is on the rise. Zhuanget al. (2015)argue in the same way. Zhuang et al. (2015)say that missing out on awareness may have cost a chance to prevent T2D. The study sought to establish the prevalence ofthe diabetes condition, and the level of awareness among the Southern Chinese community of Suzhou between the years 2012 and 2013. The researchers collected self-reporting questionnaires which included disease awareness index, demographics and a willingness to change lifestyle for curing diabetes. The study results indicated that 1.8% of the subjects were pre-diabetic while 38.5 percent of

the group were aware hat they had the condition.

Factors including not smoking, a higher level of education, low levels of BMI, and access to advisingrelated to pre-diabetes, diabetes, and obesity from providers were pointed out as reasons for a lower chance of developing diabetes among adults in China. It was also noted that a small number (less than one third) of the reported cases knew that pre-diabetes are a precursor to developing T2D and cardiovascular complications (Zhuanget al. 2015). Further, less than one-third of the pre-diabetes reported cases were likely to take precautionary measures to stop developing diabetes. The need for enhancing awareness regarding diabetes and promoting healthy behavior cannot be overemphasized in the fight to prevent the occurrence of pre-diabetes among adult Chinese (Zhuang et al. 2015).

In a study completed by the Finnish Diabetes Prevention Group, it was concluded that patients with glucose tolerance impairment could forestall the occurrence of diabetes by readjusting the risk factors relating to sedentary ways of life and obesity (Woodbury, Botros, Kuhnke, & Greene, 2013). In the research, 522 patients with glucose intolerance were assigned to a control group or an intervention set, arbitrarily. The intervention sought to achieve a weight loss of at least 5%, and to attain physical exercise running for at least an hour each day (Woodbury et al., Botros, Kuhnke& Greene, 2013, p. 703). After the comparison between the intervention set and the control regarding the general incidence of diabetes, it was found that there was a reduced probability of 58 percent of developing the diabetes condition. The results based on gender varied significantly too. The reduction rate was noted as 54 percent among women while that of men stood at 63 percent (Woodbury et al., 2013). The study demonstrated how lifestyle changes have a significant role in reducing the incidence of T2D. Comment by Maria Thomas: For Work by Three to Five Authors. In subsequent citations, only use the first author's last name followed by "et al."

In yet another study conducted by Evert et al. (2013), it was demonstrated that changes in lifestyle could significantly reduce the possibility of developing diabetes type 2. In the study, a sample of 84,941 female nurses was tracked for 16 years. 3, 300 new diabetes cases were reported during the study. The study revealed that being overweight and obese, as measured using BMI was a clear indicator of developing diabetes down the course of time (Evert et al., 2013). When the BMI was adjusted, though, other precipitating factors including smoking, alcohol intake and a sedentary lifestyleare associated with a higher chance of developing diabetes. Conversely, it was noted that limiting alcohol intake, a healthy diet,regularexercising, and maintaining a recommended weightarereasonable steps to decrease the chance of developing T2D (Evert et al., 2013).

In another study, 19 participants were engaged from three practices of general nature. It was an assessment of a self-management intervention based on an internet site calledHeLP Diabetes) by Hoffmanet al. (2016). Collection of data was done at the onset and followed in six weeks interval. Accessing the online service showed a linkto reduced diabetes associated distress. As far as emotional distress and self-efficacy are concerned, there was no notable difference. According to the qualitative data, those that participated reported better self-efficacy, support, higher levels of awareness of diabetes and improved mood management (Hoffman, 2016).

Nevertheless, there were also some negative experiences linked to the use of the intervention. They included feeling guilty for not making use of the intervention as proposed or not successfully changing behavior. There were navigational,and other technical frustrations reported. It was determined that Internet-based diabetes interventions have the potential to reduce the incidence of the condition of T2D. Indeed, the qualitative study points to the possibility of internet interventions positively influencing behavioral and psychological outcomes of adult patients with T2D (Hoffman, 2016).

Further research also links lifestyle change to better chances of preventing the occurrence of T2D. The Diabetes Prevention Research Group compared diabetes incidence in people that changed their ways of life and patients who were on metformin as their primary remedy (Knauper et al., 2014). Metformin augments cell sensitivity to insulin effect and thus reducing resistance to insulin (Knauper et al., 2014). Three clusters with a total of 3234 patients with diabetes were studied. They included control group, the intensive lifestyle change group and the metformin group. The lifestyle change group aimed at achieving a weight loss of at least 7% and complete a minimum of150 minutes of physical exercise every week. The group that was on metformin took the medication twice every day. They also got lifestyle commendations. The control group on its part tool placebos twice every day and received a standard lifestyle commendation. The results of the research indicated that lifestyle change and the metformin reduced ones chances of developingT2D. Nevertheless, the lifestyle change cluster indicated a 58% reduction, compared to 31 percent elicited by metformin (Knauper et al., 2014).

Moreover, to manage diabetes efficiently, there is a level of awareness, understanding,and knowledge through education that must be taught to patients and their families. It is imperative, therefore, if success is to be achieved in prevention, management,and control…

Pre-diabetes and Diabetes Early Awareness Education and Its Effects on BMI

Submitted by:

Nancy L. Gee Comment by Pamela Love: Looks like an interesting project, Nancy.Very good start! Be sure whenever you submit your manuscript that you change wording from study to project and avoid referring to the project as research. Review carefully for grammar, punctuation, sentence structure, format, or APA errors. Pay close attention to the reviewers comments as you continue on this DNP journey. Stay focused &be sure to follow the DPI template as you prepare for IRB submission.For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future. Jeremiah 29:11 (NIV).Blessings, breathe, and believe,Dr. Love

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

58

EARLY AWARENESS

Figure 2: Graphics of Research Process Onion.59

Chapter 1: Introduction to the Project

In society today, obesity is a serious comorbidity with the prevalence in the United States (US) continuing to increase (Jarolimova,Tagoni, &Stern, T. A., 2013). Obesity is a leadingcause of increased risks for developing many health problems such as an excessive rise in bodyweight. Furthermore, it isone of the most essential and changeable risk factors within the pathogenesis of health are complications problems like type-1 diabetes (T1D) andtype-2 diabetes (T2D). These problems are well, thus, is documented in most biochemical studies as well as cross-sectional research (Piven, 2014). In current times, there are many all-important biochemical studies in the inter-relationship amid body mass index (BMI) and its connection with the advancement of diabetic issues (Innocent, Oweh, Sandra & Josiah, 2013). Comment by Thomas, Maria: Space Comment by Thomas, Maria: Remove and change all tracking changes before submission for AQR Clarify this. Check for sentence flow so it is easy for the reader to follow your logic

The Center for Disease Control (CDC) anticipates that nearly thirty-three percent of adults may have diabetes by the year 2050 (CDC, 2010; Robert Wood Johnson Foundation, 2016); as presntly, more than twenty-nine million adults in America have been diagnosed with diabetic issues, and an additional eighty-six million have pre-diabetes (Statistics about Diabetes, n.d; Robert Wood Johnson Foundation, 2016).

Pre-diabetes is a diagnosis where blood sugar levels are elevated, however lesser than the established inception of diabetes (Kowall et al., 2012). Kowallet al. (2012) write pre-diabetes is a result of Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), or perhaps a mixture of IFG and IGT (p. 828). Moreover, diabetes has numerous effects which might consist of several health disorders and, in a few instances, failure of bodily organs (Tabk, Herder, Rathmann, Brunner, & Kivimki, 2012; Brown, 2017). Thus, T2D puts individuals at risk for a variety of ailments like cardiac conditions, amputations, renal malfunction, vision loss, as well as obesity. Weight reduction has been seen to stop the triggering of T2D and morbid obesity in individuals having pre-diabetes (Brown & Kuk, 2015). As a result, early diagnosis and management of pre-diabetes can avoid its crossover to complete onset diabetes and thus reduce the related problems (Brown & Kuk, 2015, p. 79).

Little is known about how patients respond to Diabetes Self-Management Education (DSME). Thus, the goal of this project study will be to measure the awareness and knowledge of pre-diabetes and diabetic risk factors among obese patients in a family practice clinic. The project study adopts a quantitative approach using a descriptive method and pre-post tests to determine subjects' understanding and knowledge of pre-diabetes and T2D. The pretests will establish current knowledge ,and gaps about diabetes awareness, and post-test will determine the knowledge the participants gained from the Diabetes Self-Management Education (DSME) intervention. The results will state the advancement of the pre-diabetes and diabetes informative and knowledge-based programs. Comment by Pamela Love: Project, not study. Correct throughout paper.

This chapter focuses on a particular target audience while describing the idiosyncrasies of this Direct Patient Improvement (DPI) project such as background of the study, problem statement, purpose of the study, clinical question(s), advancing scientific knowledge, significance of the study, rationale for methodology, nature of the study, definition of terms, assumptions, limitations and delimitations and lastly, summary and organization of the remaining chapters.

Background to the Project

The frequency of identified diabetic issues amid U.S. adults has gone up twofold within the past four decades and seventy-five percent in the past twenty-five years (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The lifetime danger of acquiring diabetes within the U.S. in 2000 had been 33% for males and 39% for females,and this had been even greater amid U.S. minority communities (Narayan et al., 2003).

BMI is a highly reliable, yet a controllable risk element for diabetes (American Diabetes Association, 2017; Ford, Williamson and Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes,and BMI has notbeen extensively examined (Arayan, James, Theodore,et al., 2007). Medical experts use BMI to determine whether a person is overweight, obese, normal or underweight. It is a determination of the ratio of a persons weight and their height (Lo, Wong, Khalechelvam and Tam, 2016).

The following are details of the findings from research, about the relationship between the BMI ratio, pre-diabetes, and diabetes. It was found by Narayanet al. (2007) that ones risk of developing diabetes in their lifetime is one in three, at the point of birth. He further noted that the risks of developing the condition across the categories of BMI over a lifetime are still unclear. The study sought to demonstrate the specific lifetime risks for the various BMIs for people in the US, based on sex, ethnicity, and age subgroups (Narayan et al., 2007).

The survey data from the National Health Interview n=780, 694, from 1997 to 2004 was the basis for indicating race, sex, age, ethnicity, and the prevalence of BMI-linked occurrence of diabetes in the US in 2004 (Narayan et al., 2007). The data from the US Census Bureau including age, sex-specific mortality, population rate projections, and race were used along with two earlier studies relating to mortality, to project the mortality rates related to BMI ratios (Narayan et al., 2007).

The findings and estimates informed the Markov Model projection of the lifetime risks of diabetes diagnosed by race, sex baseline age, and BMI. According to the results, the lifetime risk of developing diabetes at the age of eighteen for underweight people was 7.6,and those who were obese was 70.3%. The figures also increased from 12.2 to 74.4 for women in the same weight categories. The difference in lifetime risk was lower at advanced ages. For example, at age 65, healthynormal weight males had their lifetime risk difference rise from 3.7 to 23.9 points in percentages between overweight people and the ones regarded as very obese. The figure increased by 8.7 percentage points to 26.7 for women (Narayan et al., 2007a). It was also determined that the effect of BMI on the duration of diabetes compounded with an increase in ones age (Narayan et al., 2007b).

The risk of developingdiabetes was investigated in case-control research by Ganzet al. (2014) by studying its incidence versus BMI ratios. The rising effect of BMI, based on BMI categories was assessed. Those who recorded weights between 25 and 29.9 were considered overweight. Moreover, then there was the Obesity Class I who measured between 30 and 34.9. Class II Obesity group registered BMI index from 35 to 39.9. Obesity Class III on its part recorded figures equal to or over 40(Ganz et al., 2014).

Relative risks and ratios regarding the odds were calculated from a range of logistic regression outcomes. Age, cardiac history, sex, and hyper-inflammatory were used to select group subjects (Ganz et al., 2014). Measures of BMI were taken a year preceding the first diagnosis of T2D. BMI was obtained from dates that were randomly assigned for those that were in control group. The relationship between BMI and the incidence of diabetes is strong with the risk increasing with higher BMI (Ganz et al., 2014).

There is a significant correlation between diabetes and being overweight. Some studies have established a compelling link between the two factors. In one study, for instance, Akbari et al. (2017) found that patient education regarding T2D can help reduce barriers. The core aim of the study was to establish the impact of an education program intervention, using the beliefs, attitudes, subjective norms and enabling factorsmodel (BASNEF) on awareness barriers, adaptation, lifestyle and support for patients living with T2D (Akbari, 2017). Comment by Thomas, Maria: Spell out first time use

Removing the barriers associated with pre-diabetes and diabetes is a reasonable step towards empowering patients with diabetes to manage their lives with the condition and to recognize what affects the barriers (Akbari, 2017). The findings indicated that there was a clear difference between a score derived from living barriers such as lifestyle, awareness, protection and adaptation components, and the BASNEF model variable, i.e., enabling factors, attitude, subjective norm, knowledge, and behavioral intention (Akbari, 2017).

Problem Statement

T2D also referred to asnon-insulin-dependent diabetes (NIDDM), makes up most cases of diabetes mellitus globally. In 2000 there had been roughlyone hundred and fifty million people with the illness and that this quantity is most likely to increase twofold by the year 2025 (Kaveeshawar & Cornwall, 2014; King, Aubert, & Herman, 1998). T2D will be the fourth or perhaps the fifth prominent cause of demise in many developed nations and there's expandig proof that this has attained epidemic dimensions in quite a few developing and recently industrialized nations (Amos, McCarty, &Zimmet, 1997). All-time low levels of T2Dare found in places where individuals retain a traditional lifestyle (Gray, 2015; Bennett, 1999). Dramatic modifications in the frequency ofthe occurrence of T2D is found in places where there have already been significant changes in the kind of foods utilized. The food choices range from the conventional native diet plan to a standard western diet plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel and Michael, 1987). Changing illness levels are revealed by modifications in some dietary elements along with modifications in other lifestyle associated elements, notably a decrease in physical exercise (Sami, Ansari, Butt, Rashid, & Hamid, 2017; Steyn et al., 2004). Comment by Maria Thomas: Space

It is not known if and to what degree these facts are known to diabetes patients. Therefore, Because of these facts, the purpose of this project study is to assess the awareness and knowledge of diabetes amongst patients with prediabetes in a family practice clinic. After carrying out DSME pre-intervention assessments on patients with prediabetes, gaps will be recognized in awareness and understanding of prediabetes and diabetes amongst diabetes patientsthe subjects. Measurement of BMI will be completedpre-test and eight weeks after post-test to assess the effects of the DSME intervention related to weight loss. Comment by Thomas, Maria: Present a clear declarative statement that begins with It is not known if and to what degree/extent..., or It is not known how/why and. Comment by Thomas, Maria: Include the broad population affected by the problem

Absent from the literature is information on how patients respond to self-management methods that should be adopted to attain the preferred benefits, and precisely what they will do with the knowledge they gain from DSME educational interventions. There's an expanding demand for interventions that enhance patients understanding and knowledge of pre-diabetes and diabetes (Islam et al., 2014). The substantial population at an increased risk for or with diabetes is actually within the age bracket of 25 - 65 years. Insufficient steps to decrease theoccurrence of pre-diabetes might result in a considerable boost in health investment, morbidity, as well as other associated health circumstance (National Diabetes Statistics Report, 2014, para 8).

For healthcare providers managing an increased incidence of diabetes diagnoses, health interventions will be essential to avoid diabetic issues or postpone their development (Islam et al., 2014). Such endeavors can consist of acompletelifestyle change for all those at an increased risk for pre-diabetic issues and timely treatment for patients suffering from the disorder. An ambitious method focusing on individuals at an increased risk of diabetes is a significant public health strategy targeted at reducing the threat elements for pre-diabetes and diabetes (International Diabetes Federation, 2013).

Purpose of the Project

The purpose of this Direct Practice Improvement (DPI) project is to evaluate awareness and understanding concerning pre-diabetes and diabetes in pre-diabetic individuals and the effects of the DSME on BMI. To determine if the patients qualify for the study and are pre-diabetic, the researcher will utilize patients healthcare records to choose individuals with increased fasting glucose (IFG), and hypertension in the family practice clinic. The potential study participant will be recognized as obese if they have aBMI of more than 30kg/m2. Obesity and hypertension are both related to diabetes and may be considered as inclusion criteria.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing the Diabetic Knowledge Test 2 (DKT2), a close-ended questionnaire. The DKT2 was designed and developed by the Michigan Diabetes Research Training Center (MDRTC). Its purpose is for testing common knowledge of diabetes in pre-diabetic and diabetic patients.Thuspatients. Thus, the study uses a quantitative descriptive research design. Another dependent variable will be BMI assessment. The BMI will be measured by weighing the patient before awareness education and eight weeks after receiving the DSME intervention. Additional independent variables are how awareness and understanding levels amongst individuals differ based on education level,andlastly, the health belief model will be the theoretical foundation for this study.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Theseinclusion criteria for this study will be adults of both sexes with a BMI of more than 30kg/m2. Moreover, the results might be helpful in the advancement of future interventions towards decreasing pre-diabetes and diabetes risk in communities with ahigherrisk of acquiring T2D.

Clinical Question:

The clinical question is: Among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period?

When promoting interventions to assist with prevention and control of diabetes, awareness is an essential resource (Demaio et al., 2013). There's a connection amid individuals with reduced levels of health understanding and increased diabetic problems (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients understanding of their health could be helpful in the assessment of the risks associated with developing diabetes, DSME interventions to reduce the risk, and their control over lifestyle changes including weight reduction. Consequently, outcomes of this research will promote stakeholders, within the healthcare sector to plan, create, and implement complete health campaigns focused on pre-diabetes-related DSME interventions.

The project will analyze the understanding and awareness of diabetes amongst patients with prediabetes in a family practice clinic with a BMI >30kg/m2. The research project query is: among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.The independent variable will be the DSME intervention plan,and the dependent variable is patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing a quantitativedescriptive research design and the DKT2. The DKT2will be used to assess participants knowledge pre-DSME and post-DSME.

Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-diabetes awareness education and eight weeks after receiving the intervention. Additional dependent variables are how awareness and understanding levels amongst individuals differ based on education level,and lastly, the health belief model will be used as the theoretical foundation for the projectstudy.

Advancing Scientific Knowledge

There is a controversy inexistence, relating to the BMI mortality diabetes paradox in which the BMI optimal category is higher in patients that are non-diabetic.Bayset al. (2007) noted that not all obese or overweight cases develop diabetes and that not all with diabetic conditions were necessarily obese or overweight (Bays et al., 2007). A paradox regarding BM ratios and diabetes still exists and needs a solution.

Controversy is still rife related to the relationship between BMI and the occurrence of pre-diabetes and diabetes. Physicians will be empowered to minimize the risk factors for diabetes sooner if there is afull understanding of the relationship between the two. Modern day is well known for the diabetes epidemic. Numerous pre-condition indicators have been identified for medics to use to reduce the risk factors. It is irresponsible to wait to treat pre-diabetes and/or diabetes when there are ways topreventitsoccurrence. These potential populations need education about the risks and how they can self-manage them to reduce symptoms and avoid its inception.

Tabak, Herder, Rathmann, Brunner & Kivimki et al. (2012) wrote one can find an increase in thefrequency of pre-diabetes as well as obesity within the U.S. Additionally; there happens to be a higher chance of further advancement to T2D for individuals with pre-diabetes (Tabak et al., 2012). T2D raises the danger of acquiring other problems like high blood pressure, kidney issues, and loss of sight along with growing the price of therapy, and loss of efficiency. Thus, undoubtedly there is a need for a DSME intervention method to improve the levels of understanding and knowledge concerning pre-diabetes, diabetes, and weight problems amongst patients and to assure higher levels of successful Self-Managed cases. Comment by Maria Thomas: APA format for 3-5 authors, first time in text

This project utilizes the Health Belief Model (HBM) that is undoubtedly one of the most frequently utilized theories in health learning and health intervention campaigns (Glanz, Rimer, & Lewis, 2002; National Cancer Institute, 2003). HBMwas designed during the 1950s to describe the reason why healthcare screening programs proposed by the U.S. Public Health Services, especially for tuberculosis, just were not successful (Hochbaum, 1958). The root notion of the initial HBM was that health conduct is independent of individual beliefs or views with regards to a disorder as well as the methods accessible to reduce its prevalence (Hochbaum, 1958). Individual insight is affected by the complete array of intrapersonal elements impacting health conduct (Jones and Bartlett, 2008).

The results from this study can assist in realizing public awareness gaps and practices concerning pre-diabetes, diabetes,and obesity, which may help in the creation of obesity and diabetes self-management campaigns. Medical care services and professionals will find the outcomes of this study essential forproviding assistance to obese prediabetic patients. It will also contribute to knowledge already existing in the literature by increasing health care providers awareness of the extent to which diabetic patients are aware of their condition.

Significance of the Project

The occurrence of clinically diagnosed diabetes amongst U.S. adults has increased twofold within the past four decades and 75% in the past twenty-five years (Gregget al., 2004; Centers for Illness Control and Prevention, 2007). The lifetime danger of diabetes within the U.S. in the year 2000 had been 33% males and 39% females and was even higher amongst U.S. minority communities (Narayan et al., 2003). BMI is known as reliable, yeta changeable risk element related to diabetes (Ford, Williamson, &Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes, and BMI has not been extensively examined (Arayan, James, Theodore,et al., 2007).

The growing urbanization, westernization, and mechanization happening practically in every area around the globe are associated with modifications in the eating routine to one of higher fat, higher energy-packed meals, and an inactive way of life resulting in increased degrees of BMI (World Health Organization, 2000; Popkin, 2001). This change is further linked to the present rapid modifications in childhood as well as adult weight problems. Even in several low-income nations around the world weight problems are now dramatically rising, and frequently coexists within the same populace with persistent under-nourishment (Popkin, 2001). Life-span has risen because of improvement in nourishment, cleanliness, and the control over thecontagious ailment. Transmittable illnesses and nutritional insufficiency diseases are, consequently, being substituted in developing nations by unique health risks similar to obesity, cardio disorder and diabetic issues (World Health Organization, 2000;2 Swinburn, Caterson, Seidell & James, 2004). Comment by Maria Thomas: The citation must match the reference and vice versa Comment by Maria Thomas: Follow APA citation and reference format. Review and change for all citations and references

Even though treatment of diabetic subjects is costly, medical care establishments face a far more complicated problem in dealing with issues because of T2D like heart disease, cardiac arrest, stroke, and kidney malfunction that also hinders economic efficiency and boosts the price of medical treatment (C3 Collaborating for Wellbeing, 2011). Awareness and knowledge are vital assetsin controlling and preventing pre-diabetes and diabetes (Demaio et al., 2013). Lack of understanding and awareness about diabetes increases the chances of acquiring this disease (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients awareness assists in risk assessment of developing diabetes. Therefore, DSME interventions can reduce the risk in conjunction withlifestyle changes including weight reduction.

Consequently, knowledge of pre-diabetes and diabetes along with effective DSME strategies amongst overweight pre-diabetic individuals are essential strategies for lessening the damaging influences of the disorder to both people and the community.Thus, this project will use a quantitative descriptive design to measure the knowledge andunderstanding concerning pre-diabetes and diabetes in pre-diabetic individuals and their response to DSME using a pre-posttest closed-ended questionnaire. Participants will be weighedeight weeks after completing the post-test to analyze the effects of DSME on BMI, i.e., weight reduction. The study results will be integrated into campaigns to assist in the management of obesity and diabetic issues for the exact purpose of developing a tradition of understanding/increasing awareness about pre-diabetes and diabetes amongst overweight people within society.

The effectiveness of such an educational intervention might lead to considerable self-control over morbid obesity, BMI, and diabetes that would improve the standard/quality of life for diabetic individuals. Additionally, it might decrease health treatment expenses. By creating knowledge and providing awareness, the study's results might affect the local community favorably. For example, the results might also be utilized to teach the neighborhood about the risks of weight problems and just how individuals can handle prediabetes as well as T2D. For the public, the details on understanding and knowledge about diabetic issues will be utilized to organize public health guidelines targeted at preventing and managing diabetes.

Rationale for Methodology

The purpose of this DPI project is to measure the effects ofknowledge and awareness related to pre-diabetes and diabetes amongst overweight people who are at risk or have diagnoses ofprediabetes who happen to be patients in a family practice clinic. The project makes use of a quantitative descriptive research method to determine subjects understanding and knowledge of prediabetes and T2D while measuring the effects on BMI.

A descriptive study offers information for analyzing and monitoring policies and plans. This type of study model focuses on the best way to respond to these kinds of queries as: How much? How many? How effective? How successful? How sufficient? (Indiana University, n.d.). Furthermore, descriptive study designs are an approach that offers a description of the subjects. The critical methods for conducting a stuy utilizing a descriptive investigation design and style are acCase study, sSurvey along with observational scientific studies (Shawyer et al., 2014).

This projectuses a descriptive design to focus on the effectiveness of DSME intervention programs. The study will monitor the efficiency of DSME plans and provide recommendations for improvement of future DSME programs. Hence this study adopts a quantitative approach using a descriptive method utilizingthe DKT2 for pre-post tests to determine subjects' understanding and knowledge of prediabetes and T2D and the effect of DSME on BMI. Comment by Thomas, Maria: Use citations from textbooks or literature on the research methodology to justify the use of the selected methodology

The pretests will establish current knowledge,and gaps about diabetes awareness and post-test will determine the information they gained from the intervention (DSME) and how they plan to use that information in their life, i.e., reduction of BMI. The results will assist in the advancement and improvement of the prediabetes self-management intervention programs.

The quantitative method is the best method for this project and set of data because it provides much needed statistical information that can help close the gaps on this specific subject (Knight, Hickman, Gibbons & McIntyre, 2016). Statistical evidence is missing relating to this precise population. The quantitative method provides the means for this gap to be filled.

Nature of the Research Design for Project

This project will use adopt a quantitative descriptive design and use the DKT2 closed-ended questionnaire to carry out DSME pre-assessment and post-assessment on patients suffering from prediabetes. This study uses a descriptive design to measure the effectiveness of the DSME intervention program. Moreover, the study will monitor DSMEs efficiency and provide recommendations for improvement of future DSME programs.

A quantitative measurement of BMI will also be used to test the effectiveness of the DSME intervention. The patients will be weighedbefore the pre-test and eight weeks after awareness education.Initially, subjects will be requested to be weighed to determine if their BMI is >30 and then take part in the pre-assessment and post-assessment once they sign a consent form. The pre-assessment queries will use the DKT2 in such a manner that respondents can comprehend and fully grasp the questions (Shawyer et al., 2014; Indiana University, n.d.; Michigan Diabetes Research Center, n.d.). The DKT2 will be carried out to measure the degree of knowledge and understanding concerning diabetes from the subjects. Making use of outcomes from the pre-assessment, the researcher will customize the educational intervention program to meet the requirements of the subjects. After the participants' DSME educationintervention has been completed; a post-assessment is going to be carried out utilizing the easy to understand questionnaire to ascertain the efficiency of the educational intervention.

One of the most productive approaches supporting this type of research is the

survey approach. The survey method has, through the years, established itself to be possibly the most efficient way of measuring any social research. Survey methodsassist the researcher to come up with, distribute, and ask relevant queries from the targeted subjects or sample. It enables the researcher to select from two different and all-encompassing strategies: 1) interviews and 2) questionnaires (Trochim, Donnelly,and…

Pre-diabetes and Diabetes Early Awareness Education and Its Effects on BMI

Submitted by:

Nancy L. Gee Comment by Pamela Love: Looks like an interesting project, Nancy.Very good start! Be sure whenever you submit your manuscript that you change wording from study to project and avoid referring to the project as research. Review carefully for grammar, punctuation, sentence structure, format, or APA errors. Pay close attention to the reviewers comments as you continue on this DNP journey. Stay focused &be sure to follow the DPI template as you prepare for IRB submission.For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future. Jeremiah 29:11 (NIV).Blessings, breathe, and believe,Dr. Love

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

58

EARLY AWARENESS

Figure 2: Graphics of Research Process Onion.59

Chapter 1: Introduction to the Project

In society today, obesity is a serious comorbidity with the prevalence in the United States (US) continuing to increase (Jarolimova,Tagoni, &Stern, T. A., 2013). Obesity is a leadingcause of increased risks for developing many health problems such as an excessive rise in bodyweight. Furthermore, it isone of the most essential and changeable risk factors within the pathogenesis of health are complications problems like type-1 diabetes (T1D) andtype-2 diabetes (T2D). These problems are well, thus, is documented in most biochemical studies as well as cross-sectional research (Piven, 2014). In current times, there are many all-important biochemical studies in the inter-relationship amid body mass index (BMI) and its connection with the advancement of diabetic issues (Innocent, Oweh, Sandra & Josiah, 2013). Comment by Thomas, Maria: Space Comment by Thomas, Maria: Remove and change all tracking changes before submission for AQR Clarify this. Check for sentence flow so it is easy for the reader to follow your logic

The Center for Disease Control (CDC) anticipates that nearly thirty-three percent of adults may have diabetes by the year 2050 (CDC, 2010; Robert Wood Johnson Foundation, 2016); as presently, more than twenty-nine million adults in America have been diagnosed with diabetic issues, and an additional eighty-six million have pre-diabetes (Statistics about Diabetes, n.d; Robert Wood Johnson Foundation, 2016).

Pre-diabetes is a diagnosis where blood sugar levels are elevated, however lesser than the established inception of diabetes (Kowall et al., 2012). Kowallet al. (2012) write pre-diabetes is a result of Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), or perhaps a mixture of IFG and IGT (p. 828). Moreover, diabetes has numerous effects which might consist of several health disorders and, in a few instances, failure of bodily organs (Tabk, Herder, Rathmann, Brunner, & Kivimki, 2012; Brown, 2017). Thus, T2D puts individuals at risk for a variety of ailments like cardiac conditions, amputations, renal malfunction, vision loss, as well as obesity. Weight reduction has been seen to stop the triggering of T2D and morbid obesity in individuals having pre-diabetes (Brown & Kuk, 2015). As a result, early diagnosis and management of pre-diabetes can avoid its crossover to complete onset diabetes and thus reduce the related problems (Brown & Kuk, 2015, p. 79).

Little is known about how patients respond to Diabetes Self-Management Education (DSME). Thus, the goal of this project study will be to measure the awareness and knowledge of pre-diabetes and diabetic risk factors among obese patients in a family practice clinic. The project study adopts a quantitative approach using a descriptive method and pre-post tests to determine subjects' understanding and knowledge of pre-diabetes and T2D. The pretests will establish current knowledge ,and gaps about diabetes awareness, and post-test will determine the knowledge the participants gained from the Diabetes Self-Management Education (DSME) intervention. The results will state the advancement of the pre-diabetes and diabetes informative and knowledge-based programs. Comment by Pamela Love: Project, not study. Correct throughout paper.

This chapter focuses on a particular target audience while describing the idiosyncrasies of this Direct Patient Improvement (DPI) project such as background of the study, problem statement, purpose of the study, clinical quesion(s), advancing scientific knowledge, significance of the study, rationale for methodology, nature of the study, definition of terms, assumptions, limitations and delimitations and lastly, summary and organization of the remaining chapters.

Background to the Project

The frequency of identified diabetic issues amid U.S. adults has gone up twofold within the past four decades and seventy-five percent in the past twenty-five years (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The lifetime danger of acquiring diabetes within the U.S. in 2000 had been 33% for males and 39% for females,and this had been even greater amid U.S. minority communities (Narayan et al., 2003).

BMI is a highly reliable, yet a controllable risk element for diabetes (American Diabetes Association, 2017; Ford, Williamson and Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes,and BMI has notbeen extensively examined (Arayan, James, Theodore,et al., 2007). Medical experts use BMI to determine whether a person is overweight, obese, normal or underweight. It is a determination of the ratio of a persons weight and their height (Lo, Wong, Khalechelvam and Tam, 2016).

The following are details of the findings from research, about the relationship between the BMI ratio, pre-diabetes, and diabetes. It was found by Narayanet al. (2007) that ones risk of developing diabetes in their lifetime is one in three, at the point of birth. He further noted that the risks of developing the condition across the categories of BMI over a lifetime are still unclear. The study sought to demonstrate the specific lifetime risks for the various BMIs for people in the US, based on sex, ethnicity, and age subgroups (Narayan et al., 2007).

The survey data from the National Health Interview n=780, 694, from 1997 to 2004 was the basis for indicating race, sex, age, ethnicity, and the prevalence of BMI-linked occurrence of diabetes in the US in 2004 (Narayan et al., 2007). The data from the US Census Bureau including age, sex-specific mortality, population rate projections, and race were used along with two earlier studies relating to mortality, to project the mortality rates related to BMI ratios (Narayan et al., 2007).

The findings and estimates informed the Markov Model projection of the lifetime risks of diabetes diagnosed by race, sex baseline age, and BMI. According to the results, the lifetime risk of developing diabetes at the age of eighteen for underweight people was 7.6,and those who were obese was 70.3%. The figures also increased from 12.2 to 74.4 for women in the same weight categories. The difference in lifetime risk was lower at advanced ages. For example, at age 65, healthynormal weight males had their lifetime risk difference rise from 3.7 to 23.9 points in percentages between overweight people and the ones regarded as very obese. The figure increased by 8.7 percentage points to 26.7 for women (Narayan et al., 2007a). It was also determined that the effect of BMI on the duration of diabetes compounded with an increase in ones age (Naraya.......Ganzet al. (2014) by studying its incidence versus BMI ratios. The rising effect of BMI, based on BMI categories was assessed. Those who recorded weights between 25 and 29.9 were considered overweight. Moreover, then there was the Obesity Class I who measured between 30 and 34.9. Class II Obesity group registered BMI index from 35 to 39.9. Obesity Class III on its part recorded figures equal to or over 40(Ganz et al., 2014).

Relative risks and ratios regarding the odds were calculated from a range of logistic regression outcomes. Age, cardiac history, sex, and hyper-inflammatory were used to select group subjects (Ganz et al., 2014). Measures of BMI were taken a year preceding the first diagnosis of T2D. BMI was obtained from dates that were randomly assigned for those that were in control group. The relationship between BMI and the incidence of diabetes is strong with the risk increasing with higher BMI (Ganz et al., 2014).

There is a significant correlation between diabetes and being overweight. Some studies have established a compelling link between the two factors. In one study, for instance, Akbari et al. (2017) found that patient education regarding T2D can help reduce barriers. The core aim of the study was to establish the impact of an education program intervention, using the beliefs, attitudes, subjective norms and enabling factorsmodel (BASNEF) on awareness barriers, adaptation, lifestyle and support for patients living with T2D (Akbari, 2017). Comment by Thomas, Maria: Spell out first time use

Removing the barriers associated with pre-diabetes and diabetes is a reasonable step towards empowering patients with diabetes to manage their lives with the condition and to recognize what affects the barriers (Akbari, 2017). The findings indicated that there was a clear difference between a score derived from living barriers such as lifestyle, awareness, protection and adaptation components, and the BASNEF model variable, i.e., enabling factors, attitude, subjective norm, knowledge, and behavioral intention (Akbari, 2017).

Problem Statement

T2D also referred to asnon-insulin-dependent diabetes (NIDDM), makes up most cases of diabetes mellitus globally. In 2000 there had been roughlyone hundred and fifty million people with the illness and that this quantity is most likely to increase twofold by the year 2025 (Kaveeshawar & Cornwall, 2014; King, Aubert, & Herman, 1998). T2D will be the fourth or perhaps the fifth prominent cause of demise in many developed nations and there's expanding proof that this has attained epidemic dimensions in quite a few developing and recently industrialized nations (Amos, McCarty, &Zimmet, 1997). All-time low levels of T2Dare found in places where individuals retain a traditional lifestyle (Gray, 2015; Bennett, 1999). Dramatic modifications in the frequency ofthe occurrence of T2D is found in places where there have already been significant changes in the kind of foods utilized. The food choices range from the conventional native diet plan to a standard western diet plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel and Michael, 1987). Changing illness levels are revealed by modifications in some dietary elements along with modifications in other lifestyle associated elements, notably a decrease in physical exercise (Sami, Ansari, Butt, Rashid, & Hamid, 2017; Steyn et al., 2004). Comment by Maria Thomas: Space

It is not known if and to what degree these facts are known to diabetes patients. Therefore, Because of these facts, the purpose of this project study is to assess the awareness and knowledge of diabetes amongst patients with prediabetes in a family practice clinic. After carrying out DSME pre-intervention assessments on patients with prediabetes, gaps will be recognized in awareness and understanding of prediabetes and diabetes amongst diabetes patientsthe subjects. Measurement of BMI will be completedpre-test and eight weeks after post-test to assess the effects of the DSME intervention related to weight loss. Comment by Thomas, Maria: Present a clear declarative statement that begins with It is not known if and to what degree/extent..., or It is not known how/why and. Comment by Thomas, Maria: Include the broad population affected by the problem

Absent from the literature is information on how patients respond to self-management methods that should be adopted to attain the preferred benefits, and precisely what they will do with the knowledge they gain from DSME educational interventions. There's an expanding demand for interventions that enhance patients understanding and knowledge of pre-diabetes and diabetes (Islam et al., 2014). The substantial population at an increased risk for or with diabetes is actually within the age bracket of 25 - 65 years. Insufficient steps to decrease theoccurrence of pre-diabetes might reslt in a considerable boost in health investment, morbidity, as well as other associated health circumstance (National Diabetes Statistics Report, 2014, para 8).

For healthcare providers managing an increased incidence of diabetes diagnoses, health interventions will be essential to avoid diabetic issues or postpone their development (Islam et al., 2014). Such endeavors can consist of acompletelifestyle change for all those at an increased risk for pre-diabetic issues and timely treatment for patients suffering from the disorder. An ambitious method focusing on individuals at an increased risk of diabetes is a significant public health strategy targeted at reducing the threat elements for pre-diabetes and diabetes (International Diabetes Federation, 2013).

Purpose of the Project

The purpose of this Direct Practice Improvement (DPI) project is to evaluate awareness and understanding concerning pre-diabetes and diabetes in pre-diabetic individuals and the effects of the DSME on BMI. To determine if the patients qualify for the study and are pre-diabetic, the researcher will utilize patients healthcare records to choose individuals with increased fasting glucose (IFG), and hypertension in the family practice clinic. The potential study participant will be recognized as obese if they have aBMI of more than 30kg/m2. Obesity and hypertension are both related to diabetes and may be considered as inclusion criteria.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing the Diabetic Knowledge Test 2 (DKT2), a close-ended questionnaire. The DKT2 was designed and developed by the Michigan Diabetes Research Training Center (MDRTC). Its purpose is for testing common knowledge of diabetes in pre-diabetic and diabetic patients.Thuspatients. Thus, the study uses a quantitative descriptive research design. Another dependent variable will be BMI assessment. The BMI will be measured by weighing the patient before awareness education and eight weeks after receiving the DSME intervention. Additional independent variables are how awareness and understanding levels amongst individuals differ based on education level,andlastly, the health belief model will be the theoretical foundation for this study.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Theseinclusion criteria for this study will be adults of both sexes with a BMI of more than 30kg/m2. Moreover, the results might be helpful in the advancement of future interventions towards decreasing pre-diabetes and diabetes risk in communities with ahigherrisk of acquiring T2D.

Clinical Question:

The clinical question is: Among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period?

When promoting interventions to assist with prevention and control of diabetes, awareness is an essential resource (Demaio et al., 2013). There's a connection amid individuals with reduced levels of health understanding and increased diabetic problems (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients understanding of their health could be helpful in the assessment of the risks associated with developing diabetes, DSME interventions to reduce the risk, and their control over lifestyle changes including weight reduction. Consequently, outcomes of this research will promote stakeholders, within the healthcare sector to plan, create, and implement complete health campaigns focused on pre-diabetes-related DSME interventions.

The project will analyze the understanding and awareness of diabetes amongst patients with prediabetes in a family practice clinic with a BMI >30kg/m2. The research project query is: among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.The independent variable will be the DSME intervention plan,and the dependent variable is patients awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing a quantitativedescriptive research design and the DKT2. The DKT2will be used to assess participants knowledge pre-DSME and post-DSME.

Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-diabetes awareness education and eight weeks after receiving the intervention. Additional dependent variables are how awareness and understanding levels amongst individuals differ based on education level,and lastly, the health belief model will be used as the theoretical foundation for the projectstudy.

Advancing Scientific Knowledge

There is a controversy inexistence, relating to the BMI mortality diabetes paradox in which the BMI optimal category is higher in patients that are non-diabetic.Bayset al. (2007) noted that not all obese or overweight cases develop diabetes and that not all with diabetic conditions were necessarily obese or overweight (Bays et al., 2007). A paradox regarding BMI ratios and diabetes still exists and needs a solution.

Controversy is still rife related to the relationship between BMI and the occurrence of pre-diabetes and diabetes. Physicians will be empowered to minimize the risk factors for diabetes sooner if there is afull understanding of the relationship between the two. Modern day is well known for the diabetes epidemic. Numerous pre-condition indicators have been identified for medics to use to reduce the risk factors. It is irresponsible to wait to treat pre-diabetes and/or diabetes when there are ways topreventitsoccurrence. These potential populations need education about the risks and how they can self-manage them to reduce symptoms and avoid its inception.

Tabak, Herder, Rathmann, Brunner & Kivimki et al. (2012) wrote one can find an increase in thefrequency of pre-diabetes as well as obesity within the U.S. Additionally; there happens to be a higher chance of further advancement to T2D for individuals with pre-diabetes (Tabak et al., 2012). T2D raises the danger of acquiring other problems like high blood pressure, kidney issues, and loss of sight along with growing the price of therapy, and loss of efficiency. Thus, undoubtedly there is a need for a DSME intervention method to improve the levels of understanding and knowledge concerning pre-diabetes, diabetes, and weight problems amongst patients and to assure higher levels of successful Self-Managed cases. Comment by Maria Thomas: APA format for 3-5 authors, first time in text

This project utilizes the Health Belief Model (HBM) that is undoubtedly one of the most frequently utilized theories in health learning and health intervention campaigns (Glanz, Rimer, & Lewis, 2002; National Cancer Institute, 2003). HBMwas designed during the 1950s to describe the reason why healthcare screening programs proposed by the U.S. Public Health Services, especially for tuberculosis, just were not successful (Hochbaum, 1958). The root notion of the initial HBM was that health conduct is independent of individual beliefs or views with regards to a disorder as well as the methods accessible to reduce its prevalence (Hochbaum, 1958). Individual insight is affected by the complete array of intrapersonal elements impacting health conduct (Jones and Bartlett, 2008).

The results from this study can assistin realizing public awareness gaps and practices concerning pre-diabetes, diabetes,and obesity, which may help in the creation of obesity and diabetes self-management campaigns. Medical care services and professionals will find the outcomes of this study essential forproviding assistance to obese prediabetic patients. It will also contribute to knowledge already existing in the literature by increasing health care providers awareness of the extent to which diabetic patients are aware of their condition.

Significance of the Project

The occurrence of clinically diagnosed diabetes amongst U.S. adults has increased twofold within the past four decades and 75% in the past twenty-five years (Gregget al., 2004; Centers for Illness Control and Prevention, 2007). The lifetime danger of diabetes within the U.S. in the year 2000 had been 33% males and 39% females and was even higher amongst U.S. minority communities (Narayan et al., 2003). BMI is known as reliable, yeta changeable risk element related to diabetes (Ford, Williamson, &Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes, and BMI has not been extensively examined (Arayan, James, Theodore,et al., 2007).

The growing urbanization, westernization, and mechanization happening practically in every area around the globe are associated with modifications in the eating routine to one of higher fat, higher energy-packed meals, and an inactive way of life resulting in increased degrees of BMI (World Health Organization, 2000; Popkin, 2001). This change is further linked to the present rapid modifications in childhood as well as adult weight problems. Even in several low-income nations around the world weight problems are now dramatically rising, and frequently coexists within the same populace with persistent under-nourishment (Popkin, 2001). Life-span has risen because of improvement in nourishment, cleanliness, and the control over thecontagious ailment. Transmittable illnesses and nutritional insufficiency diseases are, consequently, being substituted in developing nations by unique health risks similar to obesity, cardio disorder and diabetic issues (World Health Organization, 2000;2 Swinburn, Caterson, Seidell & James, 2004). Comment by Maria Thomas: The citation must match the reference and vice versa Comment by Maria Thomas: Follow APA citation and reference format. Review and change for all citations and references

Even though treatment of diabetic subjects is costly, medical care establishments face a far more complicated problem in dealin