*2.3.1 Medical nutrition therapy (MNT) for T2DM*

Type 2 diabetic patients should consult a registered dietician (RD) to know about nutrition therapy for managing DM. MNT for type 2 diabetic patients encourages meal choices based on the patient's own needs and preferences, while awareness of the importance of dietary control promotes planning of meals and adherence to dietary regimen. There are some of the general dietary guidelines to follow to help manage diabetes are not to skip meals, to evenly distribute the meals throughout the day in small portions and to have a diet low in saturated fat [42, 43].

The goals of MNT include improving control of blood glucose levels, lipid profiles, and blood pressure to reduce the risk of cardiovascular disease in patients with T2DM through implementing lifestyle changes which reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and increase physical activity. Achieving these goals requires the dietitian and other professionals to teach and otherwise assist type 2 diabetic patients to modify or manage their nutritional intake in the light of a variety of individual factors such as: medication, exercise. Plasma glucose monitoring can be used to determine whether adjustments to foods and meals will be sufficient to achieve glycemic control or if medication(s) needs to be combined with MNT. MNT has been shown to reduce glycosylated hemoglobin (HbA1c) by 1% to 2% in patients with T2DM [44].

*Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*

#### **2.4 Diet composition**

#### *2.4.1 Carbohydrates (CHO) in T2DM management*

Type 2 diabetic patients are persuaded to keep track of the amount of CHO they eat. The amount and the type of CHO ingested usually affects postprandial response. The recommended daily allowance (RDA) for CHO (130 g/day) is an average minimum requirement but less than 130 g/day of CHO is not recommended because the brain and central nervous system have an absolute requirement for glucose as an energy source. About 45-60 grams of carbohydrate can be consumed at a meal. Perhaps more or less CHO needed at meal depending on how diabetes is being managed [37].

Carbohydrate intake should be from sources like: fruits, vegetables, whole grains, lentils and legumes, and low-fat dairyproducts. However, carbohydrates should not be avoided completely as carbohydrate containing food is also a good source of fiber, vitamins and minerals which are extremely essential for the proper functioning of the body [45].

#### *2.4.2 Glycemic index(GI)*

Glycemic Index concept has best described the type of CHO. Researchers developed the GI of food to compare the physiologic or postprandial effects of carbohydrates (usually 50 g carbohydrate portion) on glucose. Glucose is given a value of 100; other CHOs are given a number relative to glucose. A ranking system indicates how quickly CHO food raises blood glucose15level. The higher the blood glucose responses, the higher the GI ranks carbohydrate foods according to their effect on blood glucose levels. GI ranges, in general: low GI foods < 55, intermediate GI foods 55 – 70, and high GI foods > 70. Foods with low glycemic indexes such as: oats, barely, lentils, beans, fiber… etc., Substituting high GI foods with lower GI foods at mealtime reduces postprandial blood glucose [46]. Detailed lists can be found in the International Tables of Glycemic Index and Glycemic Load Values [47].

#### *2.4.3 Dietary fiber*

It is scientifically well known that fibers are non-digestible carbohydrates. Soluble fibers help to slow down the digestion of starches and absorption of glucose. Example: fruit pectin (guava, apples, and plums), oats fiber, and legume fiber (beans & lentils). Some studies proved that consuming a high-fiber diet (50 g fiber/ day) improves the postprandial glycemic response, reduces hyperinsulinemia, and lipemia in type 2 diabetic patients. Dietary Reference Intakes (DRI) recommended consumption of 14 g dietary fiber per 1000 kcal (or 25 g for adult women and 38 g for adult men) based on epidemiologic studies but usual fiber intake (up to 24 g daily) not shown to have beneficial effects on glycaemia. Good sources of fibers are: whole grain cereals, fruits, vegetables, beans and peas. Whole grains (contains the entire grain seed, bran, germ & endosperm) are not associated with improved glycemic control but may reduce systemic inflammation. The diabetic patient should consume at least half of all grains as whole grains [48, 49].

#### *2.4.4 Nutritive and non-nutritive (calorie-free) sweeteners*

Nutritive sweeteners contain sucrose and fructose. Sucrose (table sugar), a disaccharide-containing glucose and sucrose-containing foods have proven not to have a significant effect on glycemic levels of diabetic patients and therefore, do not need to be restricted but fat ingested with sucrose (ice cream) will increase calories. Fructose produces a lower postprandial glucose response when it replaces sucrose or starch in the diet; however, fructose may adversely affect plasma lipids. Therefore, the use of added fructose as a sweetener in the diabetic diet is not recommended. It is founded in fruits, honey and vegetables. The US Food and Drug Administration (FDA) approved non-nutritive sweeteners such as: aspartame and saccharin are safe for diabetic patients when consumed within the acceptable daily intake levels established by the FDA. Diabetic patients should limit/avoid intake of sugar sweetened beverages to reduce risk for weight gain and worsening of cardio metabolic risk profile [37].

#### *2.4.5 Protein in T2DM management*

No ideal amount of protein recommended for patients without evidence of diabetic kidney disease except (protein intake typically 1-1.5 g/kg body weight) so as to optimize glycemic control or to improve one or more CVD risk measures. In T2DM: ingested protein increases insulin response without increasing plasma glucose concentrations. Therefore: CHO sources high in protein should not be used to treat or prevent hypoglycemia. For those with albuminuria and reduced glomerular filtration rate, dietary protein should be maintained at 0.8g/kg body weight/day. Reducing the amount of dietary protein below the recommended daily allowance is not advocated because it does not alter glycemic measures, cardiovascular risk measures or the rate at which glomerular filtration rate declines. Meals with > 75 g protein can raise post prandial glucose at 3-5 hours following consumption. The effect of protein & fat is additive (high fat increases insulin resistance). Protein from fish and chicken may also be included in the diet, however consumption of red and processed meat should be avoided [50, 51].

#### *2.4.6 Dietary fat and cholesterol in T2DM management*

It is recommended for type 2 diabetic patients to follow the guidelines for the recommended intakes of saturated fat dietary cholesterol and trans-fat since the type of fatty acids consumed is more important than total amount offal when looking at metabolic goals and CVD risk. Monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in CHO. Eating foods rich in Omega-3 fatty acids (fatty fish, nuts and seeds) is recommended to prevent or treat CVD (not supplements though). Monounsaturated and polyunsaturated fats are recommended over saturated fat. In general, trans-fat should be avoided. In animal & observational studies, higher intakes of total dietary fat produce greater insulin resistance. In clinical trials saturated & trans-fats have been shown to cause insulin resistance whereas mono- & polyunsaturated and omega-3 fatty acids do not have an adverse effect. Polyunsaturated fats are as beneficial as monounsaturated fats. Individuals with diabetes and Dyslipidemia may be able to modestly reduce total and lowdensity lipoprotein (LDL) cholesterol by consuming 1.6-3 g/day of plant stanols or sterols typically found in enriched foods such as: corn and soy <300 mg dietary cholesterol/day is recommended [50, 51].

#### *2.4.7 Sodium*

Generally, diabetic patients are advised to limit their sodium consumption to < 2.300 mg/day. Lowering sodium intake (i.e., 1.500 mg/day) could improve blood pressure in certain circumstances. However, other studies suggested caution for universal sodium restriction to 1.500 mg in diabetic patients [8].

*Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*

#### *2.4.8 Micronutrients and herbal supplements in T2DM management*

There is no clear evidence that supplementation in diabetic patients without deficiencies with vitamins, minerals, herbs or spices can improve diabetes. There is insufficient evidence to support the routine use of chromium, magnesium and vitamin D to improve glycemic control in people with diabetes. There is insufficient evidence to support the use of cinnamon for diabetes treatment. May be safety concerns regarding long-term use of antioxidant supplements such as: vitamin E, vitamin C and carotene [51].

#### *2.4.9 Meal planning*

There is no ideal meal plan that works for everyone with diabetes. Regardless of which meal planning method is used, it should be individualized and modified to put into practice with less difficulty. Meals and snacks should be distributed that is consistent with each individual's way of life, activity patterns and diabetes medication at regular meal times. Spacing of meals: MNT as monotherapy: 3 moderate meals or 4 smaller meals, snacks based on pt's schedule and preferences; MNT with oral anti-diabetes agents: moderate to small in size, snacks not needed unless risk of low BG, and maintain the consistent timing of meals and carbohydrates; and MNT with insulin: keep meals moderate to small in size. Avoid skipping meals. Varieties of eating patterns (combinations of different foods or food groups) are acceptable. Meal planning method ranges from simple guidelines to more complex counting methods. A simple diabetes meal planning approach such as: portion control or healthful food choices may be better suited to individuals with T2DM identified with health and numeric literacy concerns [45, 52].

It is widely acceptable that the healthy nutrition is a basis for T2DM treatment. It contributes positively to the maintenance of blood glucose within normal range and minimizes the disease complications. A balanced diet consisting of 45–60% energy from carbohydrate, 15–20% energy from protein and 20–35% energy from fats is encouraged. There is no ideal eating pattern that is expected to benefit all diabetic patients, but the total energy intake (and thus portion size) is an important factor no matter which eating pattern is chosen [8].

#### **2.5 Physical activity for T2DM**

Physical activity and exercise are just as important as nutrition for type 2 diabetic patients. Physical activity includes any movement that increases energy use; whereas exercise is considered a more specific form of physical activity designed to improve physical fitness. Exercise has been shown to have several benefits including: improved blood glucose control, reduced cardiovascular risk, increased energy as well as burning extra calories and fat to help manage weight and improve wellbeing. Exercise interventions of at least8 weeks also have shown to lower HbA1c in those with T2DM [42].

#### **2.6 The basic principles of an effective exercise program**

The basic principles of an effective exercise program are its intensity, its duration, and its exercise frequency. The intensity of exercise should be sufficient to cause changes in the cardiorespiratory system and is determined either by the physical condition of each patient or by the heart rate. In non-fit patients, the intensity can be set to 50-60% of maximum heart rate or to the intensity that increases the resting heart rate by 20 pulses per minute. The duration of the exercise should

be 30 minutes in the beginning, starting with 5-10 minutes of warm-up and finish always with recovery exercises. The lower frequency recommended is 3 times/week. Usually, low intensity and long-duration exercise programs are considered the most appropriate and safe for diabetic patients. Finally, the subjective perception of fatigue should be continuously assessed throughout the whole exercise session [53].

There are other important parameters that need to be estimated during exercise sessions are the levels of blood glucose before and during the exercise, the type of food and the time prior to exercise that it was consumed, the time and point of administration of medication. An appropriate environment during exercise is also required. Excessive heat leads to intense sweating and dehydration. Another factor that should not be underestimated during exercise is the use of proper footwear and maintenance of foot cleanness so as to prevent infection [53].

#### **2.7 Weight reduction for T2DM**

There is solid proof to help lifestyle alterations for those patients with DM who are overweight or obese to enhance glycemic control and lessen the requirement for medications with T2DM. A few examinations have demonstrated a decrease in HbA1c esteems and in addition fasting glucose with low-calorie eats fewer carbohydrates in stout patients with T2DM. Overweight and obese people with DM who are prepared to accomplish weight reduction ought to have an objective of somewhere around 5%weight misfortune through way of life changes [42].

Weight loss is also an important goal because it improves insulin resistance, glycemic control, blood pressure, and lipid profiles. Modest weight loss is defined as a sustained reduction of 5% of initial body weight and has been shown to improve glycemic control & reduce the need for glucose-lowering medications. 5% loss shows benefits but sustained loss of > 7% is optimal. A structured lifestyle plan that combines dietary modification, activity, and behavioral modification, along with ongoing support, is necessary for weight reduction. Lifestyle programs: reduce calories by 500-750/day or provide: For women 1.200-1.500 calories/day, adjusted for baseline weight. For men 1,500-1.800 calories/day adjusted for baseline weight. A reduction in the total calorie intake should allow gradual but systematic body weight reduction (by about 0.5–1 kg/week). The diet choice should be based on health status & preferences [8].

#### **2.8 Diabetes self-management education and support for T2DM**

Self-management is defined as a set of skilled behaviors engaged in to manage one's own illness. This emphasizes the responsibility and role of the diabetic patients in managing the disease. Self-management of DM can be achieved by self-management education. As part of this education, people with diabetes should receive instruction on how and when to perform self-monitoring; how to record the results in an organized fashion; the meaning of various blood glucose (BG) levels and how behavior and actions affect BG results [38].

Self-management education (SME) is the process of providing the person with diabetes the knowledge and skills needed to perform self-care, manage crisis and make lifestyle changes required to manage the disease. The goal of the process is to enable the patient to become the most knowledgeable and hopefully the most active participant in his or her diabetes care. It provides the information regarding various treatment options and the benefits and costs of each of these strategies, how to make changes in their behaviors and to solve problems [54]. Several meta-analyses have demonstrated that SME is associated with clinically important benefits in

*Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*

people with diabetes, such as reductions in glycated hemoglobin and improvements in cardiovascular risk factors and reductions in foot ulcerations, infections, and amputations [55].

People with diabetes should know how to prevent potential foot problems, recognize early presentation without losing time before referral to doctors. Some tips for preventing problems such as inspecting feet daily and washing for changes in color, texture, odor and firm or hardened areas which may indicate infection and potential ulcers. When washing the feet, the water should be warm (not hot), feet and areas between toes should be thoroughly dried afterward, applying moisturizers, but not between the toes, trimming toenails short and file the edges to avoid cutting adjacent toes and Well-fitting footwear is very important. Be sure the shoe is wide enough [56].

Self-management support (SMS) includes activities that support the implementation and maintenance of behaviors for ongoing diabetes self-management, including education, behavior modification, and psychosocial and/or clinical support. The objective of SME and SMS is to cultivate open doors for individuals with diabetes to end up educated and inspired to take part in viable diabetes selfadministration practices and practices ceaselessly. To date, a developing assemblage of research proof shows that the blend of both SME and SMS is most profitable for enhancing glycemic control, self-viability, self-care practices (i.e., observing of blood glucose and good dieting) and decreasing diabetes distress and foot complications [55].

## **3. Conceptual framework**

Health promotion theories and models can encourage building up, keeping up, and enhancing solid practices by anticipating factors affecting unsafe practices. The theoretical framework for this study is Pender's health Promotion model (HPM). This model is ideally suited to this study since health-promoting behaviors, especially when coordinated into a healthy lifestyle, result improved health, enhanced functional ability, and better quality of life. Healthy lifestyle behaviors are: health responsibility (one's paying attention to and accepting responsibility for one's own health, being educated about health, and seeking professional assistance when necessary), physical activity, nutrition, spiritual growth (one's sense of self-actualization and purpose), interpersonal relations (one's ability to develop intimacy and closeness), and stress management One's ability to identify and mobilize psychological and physical resources to control (including sleep) or reduce anxiety [57].

Pender et al. [58] believed that, health behavior might be persuaded by a desire to protect one's health by avoiding illness or a desire to increase one's level of health in either the presence or absence of illness. Understanding the mechanisms or the mediators for behavior change and sustainability of these changes is necessary to develop effective health promotion and prevention interventions. Health promotion is the art and science of enabling people to move toward a state of optimal health through lifestyle change and is considered a combination of educational and ecological supports for actions and conditions of living conducive to health. A combination of health promotion strategies is needed to address the multiple determinants of health. Ecological strategies address the social, economic, and physical environments that influence health.

Health promotion has moved from being viewed as an objective or wanted endpoint to a process or tool to facilitate movement toward accomplishment of goals. It balances individual health behavior choices with creating environments where

healthier choices become easier choices. The nurse's role is to advance a positive atmosphere for change, fill in as an impetus for change, assist with various steps of the change process, and increase the individual's capacity to maintain change [59].

### **3.1 Pender's health promotion model (HPM)**

Pender et al. [60] proposed a framework for coordinating nursing and behavioral science points of view with elements affecting health behaviors. This model offered a guide to investigate the complex biopsychosocial processes that motivate individuals to take part in practices coordinated toward improving health. This model aimed to help nursing professionals comprehend the major determinants of health behaviors as a reason for behavioral counseling to advance sound ways of life. The HPM integrated constructs from expectancy-value theory and social cognitive theory, within a nursing perspective of holistic human functioning. The expectancy-value theory is based on the idea that the course of action will likely lead to the desired outcome, and that this outcome will be of positive personal value. The social cognitive theory describes the concept of perceived self-efficacy which is a judgment of one's ability to carry out a particular course of action. The domains of this model include (a) individual characteristics and experiences (previous behaviors and personal factors); (b) behavior specific cognitions and affects (perception of benefits, barriers, self-efficacy, activity related affect, interpersonal influences, and situational influences); and (c) behavioral outcomes (commitment to the plan of action, and demands and preferences).

The first zone, as found in (**Figure 1**) is individual characteristics and experiences, which consists of two aspects that affect the willingness to take health actions. The first aspect is prior related behavior that is related to the health practices and behaviors in the past that influence the existing behavior. The second aspect: personal factors that are related to the biological, psychological, and sociocultural of the individual. These factors affect the individual's behavior. Examples such as age, gender, body mass index comprises biological factors. Psychological factor variables such as; self- esteem, motivation, personal competence, and perceived health status are also represented along with race, ethnicity, education and socioeconomic status [61].

The second zone, behavior-specific cognitions and affect consist of six other aspects: perceived benefits of action, perceived barriers to action, perceived

**Figure 1.** *Diagram of Pender's health promotion model. Source: [61].*

#### *Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*

self-efficacy, activity-related affect, interpersonal influences, and situational influences. Perceived benefits are perceptions of the positive or reinforcing benefits of practicing healthy behaviors. Perceived barriers to action suggest that hindrances or obstacles may occur on the process of undertaking healthy behavior. Perceived self-efficacy is the personal capability and self-confidence of performing the health behavior successfully and believing that change is possible. Being self-efficient decreases the perception of barriers to achieving a positive outcome [61].

Activity- related affect is defined as the person's subjective feeling states or emotions before, during and after associated to a specific behavior. A person with positive subjective feeling tends to be self-efficient leading to a positive effect. Interpersonal influences are behaviors, beliefs and attitudes of family, peers, and relevant others in relation to norms, social support and modeling greatly influence undertaking such health behaviors. Lastly, situational influences include options available, demand characteristics and aesthetic features of the behavior environment that influence the action [61].

The third zone, behavioral outcome, has three aspects: immediate competing demands and preferences, commitment to a plan of action and health promoting behavior. The first aspect, immediate competing demands and preferences are behaviors that an individual has low or high control of. Individuals have low control with regards to competing demands such as work and family responsibilities and high control on the competing preferences such as selection of food or diet. These factors infringe the course of action prior to the planned healthy behavior. Second, commitment to a plan of action is the intention to implement health behavior including recognition of strategies to achieve a positive outcome. Lastly, healthpromoting behavior is the final, desired, and positive outcome [61].

The HPM recommended that people have one of a kind individual quality and encounters that influence resulting subsequent behavior. The set of variables related to behavior specific cognitions and affect are highly motivational to the individual. Health promoting behavior is the desired outcome although it can be hindered by immediate competing demands and preferences [58]. Individual characteristics are generally viewed as indirect influencers of health promoting behaviors while behavior-specific cognitions and affect are viewed as direct influencers of behavior. Personal factors can be altered by intervention; however, they are generally viewed as fixed factors of HPBs. Behavior-specific cognition variables of the HPM, such as perceived benefits and barriers, are considered to have major motivational significance because they can be altered by nurse intervention [62].

This study concentrated on individual characteristics which are subdivided into prior related behavior and personal factors– demographic, socio-economic, clinical variables and type 2 diabetic patients' knowledge regarding diabetes are considered to be a personal factor; Regarding to the behavior specific cognitions of perceived benefits, the awareness of the lifestyle modification and its positive effect on glycemic control are believed to influence the need to undertake a health behavior, Perceived self-efficacy, social support, and situational influences.; and the behavioral outcomes of health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management.

#### **3.2 The role of family and community health nursing**

The community health nurses play a pivotal role in the detection, monitoring, treatment and prevention of diseases and in health promotion in the whole community. They help patients to learn or relearn lifestyle practices, as concentrating on the patient's reaction to health and illnesses rather than on the disease itself [63, 64]. The focus of community health nursing includes not only the individual, but

also the family and the community, meeting these multiple needs requires multiple roles. The seven major roles of a community health nurse are: Care provider, educator, advocate, manager, collaborator, leader and researcher.

The community health nurse as a care provider assists the patient in implementing nursing care plan for disease management. The patient should take an active role in disease management, it is the responsibility of the community health nurse to promote this self-management and to instill the confidence in the patient that they can manage their disease process to remain healthy and decrease the risk of potentially deadly complications [17].

During the treatment process, they follow the progress of the patient and act accordingly with the patient's best interests in mind and therefore leading to improve diabetes coping skills of those patients. They help their patients adjust treatment regimens to ease the burden of diabetes management and to maintain good glycemic control and good health. They are responsible for the holistic care of patients, which includes a wide range of approaches, including medication, education, communication, self-help, and complementary treatment. Holistic care increases self-awareness and self-confidence in patients and causes nurses to better understand the effects of an illness on a person's entire life and his/her true needs. It also improves harmony between mind, body, emotions and spirit in an everchanging environment [65, 66].

The community health nurse ought to guarantee that the patient is on a strict dietary regimen and that they are checking blood glucose levels regularly. The nurse should also ensure that the patient is complying with medication regimen, checking their feet and getting standard eye examinations, not smoking, and practicing routinely. The community health nurse should monitor the patient's health status and motivate them to be compliant with the prescribed treatment regimen. The nurse should encourage and motivate the patient to take active role in avoiding further complications and to remain compliant with the prescribed treatment regimen and follow up arrangements [17].

The community health nurse as an educator provides health teaching and education through health promotion programs and services. Diabetic health teaching in regard to health promotion and prevention is an ideal role of them because of the overwhelming rate of diabetes and knowledge deficit of the individuals. Concerning diabetes, an individual must be committed to self-health promoting behaviors and to adopting a lifestyle change or else non-compliance will result and complications of the disease process could follow [17].

The community health nurse educates about health and wellness activities such as healthy diet, regular exercise, smoking cessation. The patient should be encouraged and expected to take active role in creating and maintain healthy behaviors. Concerning individualized characteristics and experiences, the patient must examine his or her own behaviors including diet, and level of physical activity, body fat and weight, and settle on a decision to change unhealthy behaviors to health promoting behaviors. The patient will be instructed to be proactive in their own health. The patient will be made to understand that maintain a healthy lifestyle will decrease the chances of getting diabetes. Personal responsibility is the key to diabetes prevention and treatment [17].

The community health nurse assists the patient in early recognition of the signs and symptoms of diabetes and to take control of the disease before potential complications emerge. For those who are prediabetic, it is imperative for community health nurse to clarify the signs and symptoms of hyperglycemia besides what to report to the physician. It is critical to screen those at risk for diabetes. The early diagnosis is similarly as vital. If diabetes is caught prior to the point where complications arise then it will be easier for the patient to be proactive in health

#### *Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*

promotion. Besides, as blood glucose levels are controlled, the risk of complications diminishes. During educational treatment they are responsible for ensuring that patients are able to understand their health, illnesses, medications, and treatments to the best of their ability. It is fundamental to assess whether the individual with diabetes or a close relative has comprehended the messages and has adequate self-care abilities or skills [17].

The community health nurse as advocator advocates for the patients' rights and maintains the patient's dignity. Every patient has the right to receive, just, equal, and human treatment. This is particularly important for patients who are the poor, the disadvantaged, those without health insurance because they become frustrated, confused, degraded, and unable to cope with the system on their own. The community health nurse often acts as an advocate for patients, pleading their cause or acting on their behalf, Clients may need some one: To explain which services to expect, which services they ought to receive; to make referrals as needed; to write letters to agencies or health care providers for them; and to assure the satisfaction of their needs. The advocate role incorporates four characteristics actions: Being assertive; taking risks; communicating & negating well; and identifying recourses and obtaining results. The community health nurse support the patient and represent the patients best interests at all times, especially when treatment decisions are being made [67].

The community health nurse as a manger exercises administrative direction toward the accomplishment of specified goals by: Assessing patients' needs; planning and organizing to meet those needs; controlling; and evaluating the progress to ensure that goals are met. These activities are sequential and yet also occur simultaneously for managing service objectives. As other health professionals are usually responsible for making the final treatment decisions, nurses should be able to communicate information regarding patient health effectively. In this, the community health nurse facilitates collaboration, coordination, and cooperation among caregivers for continuity of care for the patient and promoting the best patient health outcomes [67].

The community health nurse as a collaborator enables and promotes the interprofessional teamwork and comprehensive care provided by healthcare professionals, paraprofessionals, and volunteers. The collaborator role also may involve functioning as a consultant with other healthcare colleagues to inform decisionmaking and planning to meet healthcare consumer needs therefore, provide proper care and improve patient outcomes. This role requires communication skills, skill in interpreting the nurse's unique contribution to the team and acting assertively as an equal partner [67, 68].

The community health nurse as a leader focuses on affecting change, thus the nurse becomes an agent of change. The community health nurse seeks to initiate changers that positively affect people's health. They also seek to influence people to think and behave differently about their health and the factors contributing to it. The care for diabetic patients includes adopting a healthy lifestyle where the diet plan represents an important support of care so they can meet their goals. At the community level, the leadership role may involve working with a team of professionals to direct and coordinate such as a campaign to eliminate smoking in public areas [67, 69].

The community health nurse as a researcher engages in systematic investigation, collection, and analysis of data for solving problems and enhancing community health practice. The community health nurse often participates in agency and organizational studies to determine such matters as risks associated with home visiting. The researcher role helps to determine needs, evaluate effectiveness of care, and develop theoretic bases for community health nursing practice. Nurses

must become responsible users of research, keeping up-to-date of new knowledge and applying it in practice. Nurses must learn to evaluate nursing research articles critically, assessing their validity and applicability to their own practice. A commitment to use and conduct of research will move the nursing profession forward and enhance its influence on the health of at-risk populations [67].

The main results of the present study could be outlined in the following points: Results revealed that 68.5% of the studied sample groups were females and 64.1% of them aged from 45-64 years with mean 49.76 ± 9.19 years.

Regarding educational level, 42.4% of the studied sample groups were illiterate. Whereas, 63.0% were unemployed, 68.5% of them came from urban areas, and 76.2% of them had low social class level.

Regarding diabetes history, 43.5% of the studied sample had rare attacks, 96.7% of them have taken oral hypoglycemic agents, 94.6% of them were not following planned diet regimen and 76.1% of them did not do physical activities.

Independent t-test demonstrated high significant difference (P-value < 0.005) between pre-test study and control groups' total score of knowledge & knowledge related practice about DM. Though, this result was of unnecessary inconsistency between the two groups, both levels of their pre-test knowledge and practices about diabetes mellitus were still inadequate. Independent t-test demonstrated also that there was only statistical significant difference (P-value < 0.023) between the two groups regarding pre-test health responsibility domain. It can be concluded from outputs that the mean scores between control and study were successful in achieving homogeneity of most sub-class groups.

However, differences regarding clinical data between pre-test study and control groups were statistically insignificant. Generally, the mean scores of groups between control and study were homogeneous for all sub-class groups.

Results of Paired t-test between total score of knowledge & knowledge related practice about DM, health promoting lifestyle domains values and clinical data, before and after the program intervention in the study group revealed high significant differences represented in (P-value < 0.009 or P-value < 0.001 or P-value < 0.0001). Patients who received lifestyle modification intervention program achieved better total score of knowledge & knowledge related practice about DM, health promoting lifestyle domains values and clinical data.

Statistical results of Paired t-test that was computed between total score of knowledge & knowledge related practice about DM pre- and post-tests in the control group, have illustrated high significant differences (P-value < 0.0001). Those patients were still having inadequate and insufficient total score of knowledge & knowledge related practice about DM.

Statistical results of Paired t-test that were computed between health promoting lifestyle domains pre- and post-tests pre- and post-tests in the control group, have illustrated statistical significant differences of all domains except that for the physical activity and interpersonal relations domains. Patients though didn't receive a lifestyle modification intervention, have had slight increases (with no trend change) in their total scores of overall health promoting lifestyle score, health responsibility, nutrition, spiritual growth, stress management domains.

Statistical results of Paired t-test that were computed between clinical data pre- and post-tests in the control group have not revealed any statistical significance regarding clinical data.

Glycated Hemoglobin multiple linear regressions demonstrated a statistical significant positive independent predictor (fasting plasma glucose; P-value < 0.0001), whereas the Physical Activity Domain was the only statistical significant negative independent predictor (P-value < 0.015) after employing the program in the study group.

*Effect of Lifestyle Modification on Glycemic Control of Type 2 Diabetic Patients at Suez Canal… DOI: http://dx.doi.org/10.5772/intechopen.97738*
