**Abstract**

Type 2 Diabetes mellitus, as one of the major universal public health disorders wide spread, requires patients' lifestyle modulation which would be conducive in dominating blood glucose. The aim of the study was to evaluate the effect of lifestyle modification on glycemic control of type 2 diabetic patients at Suez Canal University Hospitals at Ismailia city. A quasi-experimental design made up of a control group and a study group with pre- and post-test administration was applied. This study was carried out at the Family Medicine Outpatient Clinic and the Diabetic Outpatient Clinic of Suez Canal University Hospitals at Ismailia city in Egypt. 92 type 2 diabetic patients were included in this study. The Diabetes Knowledge Questionnaire; Health promoting lifestyle profile II Scale; and Physical assessment sheet were used for data collection in the two groups. After implementing of the program, those patients who received lifestyle modification intervention achieved better total score of knowledge & knowledge related practice about DM, health promoting lifestyle domains values and glycated hemoglobin, compared with the control group. Factors related to lower glycated hemoglobin in the present study were lower fasting blood sugar level and increasing physical activity. Overall, lifestyle modification program has a positive influence on blood glucose control of patients with type 2 diabetes mellitus. Therefore, it is recommended to that lifestyle modification interventions should be integral part of the curative management of type 2 diabetic patients, and further study in other places to investigate the effect of lifestyle modification on glycemic control of those patients.

**Keywords:** "lifestyle modification", "type 2 diabetes mellitus", and "glycemic control"

### **1. Introduction**

Diabetes Mellitus (DM) is one of the widespread and universal health problems that affect many people worldwide. It is defined as a metabolic disorder caused by different factors, which is characterized by hyperglycemia (elevated blood glucose level) and is usually associated with carbohydrate, fat and protein metabolism

abnormalities [1]. There are two main types of DM: Type 1diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM). T2DM is the commonest form of diabetes, constituting nearly 90% of the diabetic patients in any country [2].

Type 2 diabetes mellitus is a heterogeneous and progressive illness, with an underlying mechanism ranging from predominantly insulin resistance with relative insulin deficiency, to predominantly an insulin secretory defect with lesser degrees of insulin resistance. The spread of T2DM is increasing all over the world, probably due to the expectations of population's long life, a sedentary lifestyle and above all, the increasing rates of obesity. There are two sub-divisions of T2DM. The "Not Insulin Requiring" diabetes, managed by lifestyle measures alone and sometimes oral drugs, and the "Insulin requiring for diabetes control", where insulin is required to control, rather than survival [3].

A recent study proved that the uncontrolled diabetes, particularly elevated blood sugar over a prolonged period of time could lead to a number of short and long-term health complications. Such complications were divided traditionally into two main subtypes: the diabetes specific micro-vascular complications of retinopathy, nephropathy, and neuropathy which were caused by injuries to the small blood vessels; and the thrombotic macro-vascular complications of myocardial infraction, hypertension, and peripheral arterial disease which were presented due to arterial damage [4].

Many chronic diseases, as proved by recent studies, are associated with poor lifestyle and unwise human conduct. Lifestyle is an individual's typical way of life which includes activities and attitudes that influence man's health, whether healthy or unhealthy. A healthy lifestyle often results in better health and happiness. In contrast, an unhealthy lifestyle may cause illness and morbidity. Lifestyle related risk factors are associated with the development and progression of T2DM. These risk factors such as sedentary lifestyle, smoking, alcohol consumption, dietary choices and overweight are modifiable. The cornerstone of DM management includes appropriate lifestyle choices supported by regular medication and blood glucose self-monitoring, where necessary [5, 6].

The core of Type 2 diabetes mellitus treatment depends mainly on physical activity and nutrition therapy. The recent studies have proved the benefits of physical activity on individuals who maintain a physically active lifestyle and therefore, they are less likely to develop insulin resistance, impaired glucose tolerance, or T2DM. The effects of exercise training on glycemic control and related physiological parameters have also been extensively studied in type 2 diabetic patients. On the same line, healthy nutrition is the basis for the treatment of T2DM. It positively maintains blood glucose to be within normal limits and effectively minimizes the complications of the T2DM and weight loss is also an important goal because it improves glycemic control [7, 8].

The community health nurse had an effective role in patient education about all newly lifestyle modification for T2DM. No matter that encouraging and supporting lifestyle modifications could help in enabling type 2 diabetic patients to feel more satisfied in controlling of their disease. Pender's health promotion model (HPM) is one of the widely used models to plan for changing unhealthy behaviors and promote general hygiene. Pender's model was developed after the health belief model, to assist nurses in understanding the major determinants of health behaviors as a basis for behavioral counseling to promote healthy lifestyles. According to Pender's model, health promotion is a dynamic and positive process that encompasses conducts supporting a healthy lifestyle, including physical activity, dieting, spiritual growth, interpersonal relationships, health responsibility, and stress management. In nutshell, a health-promoting lifestyle is a multi-dimensional pattern of voluntary behaviors needed for promoting one's health conditions, self- growth, and perfection [9].

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

Moreover, a great importance should be paid for the patients' regular follow-up with the health care provider so as to avert any long-term complications. In diabetes Mellitus care, lifestyle modification can prevent or delay the complications and also decrease the need for medication. Because of the alarming and danger threaten DM statistics, the sacred role of nurses in assisting patients to control associated morbidity and mortality is becoming increasingly significant. Nurses, who are always on the front line, can screen patients for early diabetes identification, recognize and initiate corrective measures for inadequate treatment regimens, help patients set and achieve therapeutic goals and assess diabetes-related complications as soon as they arise [10]. DM, as a chronic disease, often has a relapsing and remitting course with substantial impact on function and quality of life (QOL). For chronic illnesses where there is no cure, it is important to establish that therapy which really makes people feel better.

#### **1.1 Diabetes mellitus**

#### *1.1.1 Definition*

Diabetes Mellitus (DM) is a complex, chronic disease that caused by inherited and/or acquired deficiency in production of insulin by the pancreas or by the ineffectiveness of the insulin produced; both require continuous medical care with multifactor risk-reduction strategies beyond glycemic control. It is defined as a metabolic disorder caused by different factors and is characterized by hyperglycemia (elevated level of blood glucose) with disturbances in carbohydrate, fat and protein metabolism. The chronic hyperglycemia is associated with long-term damage, dysfunction and degeneration/deterioration of various organs, particularly eyes, kidney, nerves, heart and blood vessels [8, 11].

#### *1.1.2 Etiologic classification of DM*

This classification includes four types:(1) Type 1 diabetes mellitus (T1DM), (2) Type 2 diabetes mellitus (T2DM), (3) Other specific forms of diabetes: Genetic defects of beta cell function; Genetic defects of insulin function; exocrine pancreatic diseases; Endocrinopathies; drugs and chemicals; infections; rare immunologic forms of diabetes; other genetic syndromes associated with diabetes; Latent autoimmune diabetes in adults (LADA); Maturity-onset diabetes of the young (MODY) and (4) Gestational diabetes mellitus (GDM) [8].

The majority of cases of diabetes can be broadly classified into 2categories: T1DM– autoimmune which is primarily a result of pancreatic beta cell destruction with consequent insulin deficiency, which is prone to ketoacidos is. This form includes cases due to an autoimmune process and those for which the etiology of beta cell destruction is unknown; T2DM – may range from predominant insulin resistance with relative insulin deficiency to a predominant secretory defect with insulin resistance. Ketosis is not as common. GDM refers to glucose intolerance with onset or first recognition during pregnancy. Other specific types include a wide variety of relatively uncommon conditions, primarily specific genetically defined forms of diabetes or diabetes associated with other diseases or drug use [12].

#### *1.1.3 Latent autoimmune diabetes in adults*

Latent autoimmune diabetes in adults (LADA) is a late manifesting autoimmune form of diabetes in adults, most commonly diagnosed in patients above35years of age, characterized by clinical insulin independence in the first months after the

diagnosis, with the presence of serum antibodies against glutamic acid decarboxylase (anti-GAD65) and/or other anti-islet antibodies and a low serum peptide C level. LADA is a form of T1DM with slowly progressive autoimmune-mediated destruction of beta cells. This diabetes subtype is present in 5–10% of subjects with diabetes diagnosed after 35 years of age and categorized asT2DM. Clinical manifestations of LADA do not always allow a definite diagnosis, presenting diagnostic challenges when differentiating with T2DM. A definite diagnosis of LADA requires identification of auto-antibodies typical for T1DM, mostly antiGAD65, and/or a low serum peptide C level [13].

#### *1.1.4 Monogenic diabetes*

Monogenic diabetes amounts to 1–2% of all diabetes cases. It is caused by single gene mutations. Most forms are associated with a defect of insulin secretion, and the most common ones are maturity-onset diabetes of the young (MODY), mitochondrial diabetes, and neonatal diabetes. Considering the monogenic forms in the differential diagnosis of diabetes may contribute to treatment optimization and proper evaluation of prognosis in the patient and his family members. A definite diagnosis of monogenic diabetes is a result of genetic testing. The most common form of MODY is associated with HNF1A and glucokinase gene mutations [13].

Typical clinical presentation of MODY due to an HNF1Agene mutation includes: (1) Early onset of diabetes (typically before 25 years of age; (2) No insulin dependence and keto acidosis, low insulin requirement, detectable peptide C levels despite the disease being present for several years or even longer; (3) Diabetic family history over at least 2 generations, with early-onset diabetes in at least two family members. OGTT performed at an early stage of diabetes usually shows high postprandial glucose level elevation with often normal fasting blood glucose; (4) Absence of auto antibodies typical for T1DM; and (5) Glycosuria higher than expected based on blood glucose levels [13].

#### **1.2 Type 2 diabetes mellitus**

#### *1.2.1 Type 2 diabetes mellitus (T2DM)*

It is universally known that Type 2 diabetes mellitus is considered a modern-day epidemic of epic proportions, affecting all classes of the society. The prevalence is becoming alarmingly high among younger age groups. Global prevalence of diabetes mellitus is about 9%. The prevalence of diabetes is expected to double by 2030 from 8.3 to 17.6% globally, excluding the high numbers of undiagnosed cases estimated as 175 million. Approximately 1.9% of the global disability adjusted life years (DALY) is attributed to diabetes. The International Diabetes Federation (IDF) estimates that 450 million people are living with diabetes, with 5.1million dying from it annually worldwide. T2DM is the greatest contributor to the burden of diabetes globally accounting for up to 90% of people with diabetes worldwide [14].

T2DM is a chronic and progressive medical condition which results from two major metabolic dysfunctions: insulin resistance and a relative insulin deficiency. Insulin resistance in which clinical signs may include: acanthosisnigricans–characterized by hyper pigmentation (darkening of skin pigment) especially in the neck and axillae; skin tags – benign (non-cancerous) skin growths on the body or face; central obesity – defined by a high waist-to-hip ratio, waist-to-thigh ratio and waist circumference; menstrual irregularities; and hirsutism– excess facial and body hair, especially on women. A relative insulin deficiency in which chronic hyperglycemia

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

with multiple disturbances in carbohydrate, protein and fat metabolism develops when a person's beta cell function is no longer sufficient to meet his/her insulin requirement [15].
