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\title{Assessment of Knowledge, Attitude and Practices Regarding Life Style Modification among Type 2diabetic Mellitus Patients Attending Adama Hospital Medical College, Oromia Region, Ethiopia}
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             \author[1]{Abate  Wondesen}

             \author[2]{Belayneh Kefale  Gelaw}

             \author[3]{Esayas  Tadesse}

             \affil[1]{  Ambo University, college of medicine and health science, department of parmacy}

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\date{\small \em Received: 15 December 2013 Accepted: 5 January 2014 Published: 15 January 2014}

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\begin{abstract}
        


Background: The person with diabetes mellitus has a chronic lifelong disease, the person must be knowledgeable to coordinate life style modification in to a daily routine of work to achieve and maintain normal physiological blood glucose level. The objective of this study was to determine the knowledge, attitude and practices of LSM management of type 2 diabetic patients in Adama Medical college Hospital.Methodology: Across-sectional study was conducted to assess knowledge, attitude and practice of type 2 diabetic patients towards LSM management of DM in Adama Medical College Hospital. Data was cleaned and analysed by using SPSS version 16.0 and presented descriptively and analytically.

\end{abstract}


\keywords{type 2 diabetes mellitus, life style modification, knowledge, attitude, practice}

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\section[{Introduction a) Background}]{Introduction a) Background}\par
iabetes mellitus is a syndrome characterized by chronic hyperglycaemia, due to absolute or relative deficiency or diminished effectiveness of circulating insulin. It is the most common serious metabolic disease. Diabetes mellitus has been recognized as a clinical syndrome since ancient times and remains a crippling global health problem today \hyperref[b0]{[1]}. Its clinical diagnosis indicated by presence of symptoms such as polyurea, polydipsia and unexplained weight loss; and confirmed when one of the following abnormal glucose measured: fasting plasma glucose (FPG) value of >= 7.0 mmol l-1 (126 mg dl-1), or the casual plasma glucose value >= 11.1 mmol l-1 (200 mg dl-1), or if the plasma glucose value 2 hours after a 75g oral load of glucose is>= 11.1 mmol l-1 (200 mg dl-1). However, in asymptomatic subjects, the test should be performed more than one occasion to confirm the diagnosis and treat the subject  {\ref [2]}.\par
There are different categories of DM; but the two broad categories are type1 and type2.Both types of diabetes are preceded by a period of abnormal glucose classified as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Type 1 DM is the result of complete or near-total insulin deficiency. Type 2 DM is a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production \hyperref[b1]{[3]}.\par
The prevalence of type 2 diabetes is increasing in the world at high rate. For example according to the study of Diabetes Screening in Canada (DIASCAN) in the year 2000; the prevalence of Type 2 diabetes in individuals 40 years of age and older who see a general practitioner was 16.4\% in Canada and nearly 20\% in Québec. It was predicted that the number of Canadian diabetics will double within the next 15 years. The impact of diabetes on the health of populations and individuals afflicted with the disease is primarily related to late-stage complications. Diabetes is the primary cause of terminal kidney failure, blindness before the age of 65 and amputations \hyperref[b2]{[4]}.\par
The burden of diabetes is increasing in the worldwide including developing countries like Ethiopia. International diabetic federation association reported Ethiopia to be ranked 3rd in Africa with 1.4 million DM and prevalence of 3.32 by year 2012.The study done to determine prevalence of un diagnosized DM \& its risk factor in institution of Bishoftu town, East Shoa at 95\% confidence interval with (p=0.05 and margin of error 5\%) in the year 2012/2013 reported the prevalence of undiagnosed DM to be 5\% \hyperref[b3]{[5]}.\par
Ancient civilizations in Egypt, Greece, Rome and India recognized diabetes mellitus and recommended dietary modifications. During previous century's recommendation about dietary carbohydrates from diabetic individuals were based on theory rather than scientific facts. Prior to discovery of insulin, diabetes was treated with low carbohydrate, semi starvation diet. Even after insulin was discovered in 1921, most eastern diabetes specialists used low carbohydrates, high fat diets to treat diabetic individuals \hyperref[b4]{[6]}.\par
Today ;essential components of the treatment for diabetes include diabetes self management education, lifestyle interventions, and goal setting glucose management and pharmacologic management of hypertension and hyperlipidemia \hyperref[b5]{[7]}. Life style modifications are considered the corner stone of management of diabetes mellitus and include the prescription of healthy diet, regular exercise, and avoidance of tobacco \hyperref[b6]{[8]} .\par
Education regarding diabetes is very important to improve the life style of the patients which would be helpful in maintaining (controlling) blood glucose. Observation has been reported that improper guidance and communication can lead to poor compliance to both medication and life style \hyperref[b7]{[9]}.\par
Dietary recommendations for DM patients focus on the reduction of fat intake and increase of vegetable consumption with moderate calorie restriction and it should be individualized according to the patients' physical activity, co morbid condition and personal preferences. Da Qing study in China showed diet intervention alone associated with 31\% reduction in the risk of developing type2 DM \hyperref[b8]{[10]}.\par
In the other way alcohol intake exacerbate neuropathy, dyslipidemia and obesity. Therefore it should be prohibited, if used it must be in moderation .Similarly smoking should be prohibited as it increases risk of complication \hyperref[b5]{[7]}.\par
Physical activity (exercise) also reduces the risk of developing DM type2 by 30-50\%.Physical activity improves insulin sensitivity .eg It can reduces free fatty acid load to the liver; there by reduces hepatic insulin resistance .Moderate exercise as little up to 30min/day or 150min/week can show the differences \hyperref[b9]{[11]}. 
\section[{b) Statement of the problem}]{b) Statement of the problem}\par
Despite the availability of different treatment modalities, diabetes has remained a major cause of death. Now a day's 3.8 million deaths are attributable to the diabetes in each year worldwide. It is the 4th leading cause of global death. In 2005 there were 246 million people worldwide were affected with diabetes and are expected to affect 380 million by 2025, over a seven fold increase just over 20 years \hyperref[b10]{[12]}. This indicates high burden of DM in today world and developing countries account for a substantially high proportion \hyperref[b11]{[13]}.\par
In Ethiopia; from hospital based studies; it was observed that the prevalence of diabetes admission had increased from 1.9\% in 1970 to 9.5\% in 1999 of all medical admissions \hyperref[b12]{[14]}. World Health Organization (WHO) also estimated the number of diabetics in Ethiopia to be about 800,000 cases by the year 2000, and the number is expected to increase to 1.8 million by 2030 \hyperref[b13]{[15]}.\par
In another way, according to the 2011 report of the International Diabetes Federation (IDF), the number of adults living with diabetes in Ethiopia was 3.5\%. A study done on urban Commercial Bank employees in Ethiopia showed a 6.5\% prevalence of DM \hyperref[b14]{[16]} which indicated the significance of lifestyle for DM aetiology and its burden to our country too.\par
Although, the diabetes is causing high wastage of life and resources the management is still low .Its management include pharmacologic and life style modification. However, LSM is ignored by many of the patients and care givers. For example Study done in Omani on type 2 DM patients in the year 2013 reported only less than 40\% of the patients participate on regular exercise \hyperref[b15]{[17]}. The other study done at USA in the year 2008 showed among 69 patients classified as elevated risk of diabetes only 17\%,32\% and 30\% had received advice for weight loss ,exercise \& diet modification \hyperref[b16]{[18]}.\par
Another similar cross sectional study done in four provinces of Kenya in the year 2010 found that; of the people participated in the study 75\% had poor dietary practices, while 72\%didn't participate in regular exercise \& about 80\% didn't monitor their body weight \hyperref[b17]{[19]}.\par
In another way, study done at Jimma University Specialised Hospital in the year 2011to assess quality of care given to diabetic patients showed that there was no attention given to diabetic education in Ethiopia. There were no diabetes nurse educators and diabetes dietician in the country and those who provide health services for diabetes had no special training for diabetes care \hyperref[b18]{[20]}.\par
In AMCH the diabetes patients appointed to follow up clinic according their disease status. Most patients come to the Hospital every month or every two month and refill their medication. They check up their blood glucose only when they come according to their follow up appointment and contact the physician for less than five minutes for refill. Most of the time they asked only for adherence to medication and do not checked awareness for life style intervention. In certain circumstances both health care giver and patients do not raise all about non pharmacologic management of diabetes including new diagnosed type2 DM patients. These observations raised the researcher' concern about the knowledge, attitude and practice of lifestyle modifications among diabetic patients at AMCH, which this study seeks to explore and document. Since there was no similar study in the area, this information gap about of LSM among AMCH type 2 DM patients could be answered by this study. c) Significance of the study It is obvious that there is no adequate information on knowledge, attitude and practice of non pharmacologic management of diabetes in our country; Ethiopia. Most of literatures are drafted from developed countries like USA, Russia and European countries. Majority of the studies were done to evaluate the knowledge, attitudes and practices about diabetes mellitus among diabetics rather than on lifestyle modifications.\par
The result of this current study could be useful as a base line in implementing a community based awareness programme which will promote the importance of lifestyle modifications in the prevention and control of non-communicable diseases, particularly diabetes mellitus. Therefore it is helpful for all stake holders that involves in this areas i.e patients, caregivers, health care providers, health institution and policy makers (MOH, NGO, diabetic DM association)\par
The other benefit of this study is that the result of this study helps health care provider to give education and awareness on LSM management of DM. In addition DM patients' and family members realize the benefit of non pharmacologic management hand by hand with pharmacologic management for the success control of the disease and its complication. Thus the patients' care will improve and the patients' will be benefited.\par
Finally, Adama Medical College Hospital also uses this result for improving its services for DM patients and other chronic disease patients. It also helps to encourage good services of the clinics and modify the possible problems of between hospital mission and actual services given by diabetic follow up clinic .The hospital management can use this result to expand its services especially, this can help AMCH and diabetic association as feedback for the services they are giving for the patients II. III. 
\section[{Method and Materials a) Study area and period}]{Method and Materials a) Study area and period}\par
The study was conducted in Adama Medical College Hospital (AMCH) located 99 km south east of Addis Ababa, Ethiopia, Oromiya region, East Shoa zone. It was established in 1946 by Italian Missionaries and named as HailemariamMammo memorial hospital little bit after establishment but its name was changed to Adama Referral Hospital in mean time and now it renamed AMC H by Oromiya regional state health bureau after it start to teach accelerated medicine, emergency surgery and anaesthesia nurses. The hospital gives services for about 5 million people east and southern parts of Oromia, Afar, Somali and Southern Nation Nationalities and People (SNNP).\par
Now the hospital has 465 different workers to give different services, of which 194 are administration workers. The other 271 workers are health professionals. There are specialist in different field \hyperref[b21]{(23)},general practitioners(GP)36,Nurses(116),laboratory workers(20),x-ray(5), physiotherapy(2), sanitarians(2), Biomedical(1), Midwifery \hyperref[b14]{(16)}, Anaesthesia(9), Health officers(9),psychiatry nurses(3) and masters in different fields.\par
AMCH has different departments in it: Outpatient department (OPD) team case, internal medicine, dermatology, paediatrics, gynaecology/obstetric, surgery, dentistry, psychiatry, physiotherapy, ophthalmology, hospital pharmacy, anti retroviral therapy (ART) and tuberculoses (TB) Clinic. The study was conducted in OPD case team from April The study population consisted of all type 2 diabetes mellitus patients, aged 30 years and above, attending Adama Hospital for regular follow-ups from the 1 st April 2014to the 1 st May 2014. Age of 30 years was chosen as the cut-off age. One hundred sixteen (116) type 2 diabetes mellitus patients attended the diabetic clinic of AMCH during this period.\par
All diabetic patients who visited the follow up clinic within the limit of study period were included in the study. 
\section[{c) Sample size and Sampling technique}]{c) Sample size and Sampling technique}\par
The size of study population was limited by the number of diabetic patients visiting the clinic during the study. All diabetic patients those visited the hospital during study period were included depending on their consent. 
\section[{d) Inclusion and Exclusion criteria}]{d) Inclusion and Exclusion criteria}\par
i. Inclusion criteria: Type 2 diabetes mellitus patients aged 30 and above attending the diabetic clinic at Adama Medical College Hospital for their regular follow up visits and had willing to participate in the study were included in the study.\par
ii. Exclusion criteria: Patients with type 1 diabetes mellitus, gestational diabetes, other specific types of diabetes mellitus and diabetes insipidus were excluded from the study. In addition, all type 2 diabetes mellitus patients with impaired memory or cognitive functions and those younger than 30 years were also excluded.\par
e) Variables i. Dependent variables: knowledge, attitude and practice ii. Independent variables: age, religion, Sex, educational status, marital status, ethnicity, monthly income, duration of disease.\par
V. 
\section[{Data Collection Process and Collection Technique}]{Data Collection Process and Collection Technique}\par
In this study a face-to-face interview using a structured questionnaire was carried out for data collection. The data was collected by the researcher and his assistant colleagues using a structured questionnaire. The researcher trained two qualified graduating students of clinical pharmacy, proficient in the local language (Amharic \&Afan Oromo) as research assistants. They assisted him throughout the data collection processes through a face-to-face interview. During and after data collection principal investigator checked the consistence and completeness of the data. 
\section[{a) Data Quality Assurance}]{a) Data Quality Assurance}\par
In order to assure the quality of the data the following measures was under taken: Data was collected by three of graduating class of clinical pharmacy students ? The data collectors were taken the training to check completeness of the data during the data collection and appropriate recording. ? The body mass index (BMI) of each participant was calculated by the researcher and his assistants using the formula BMI = Weight (kg)/Height (m2) after the weight and height were measured using a calibrated beam scale with height rod graduated in centimetres and participants were classified according to the WHO international classification of adult weight.\par
? The principal investigator supervised all field work, check for completeness and accuracy of data collection daily. 
\section[{b) Data processing and analyzing}]{b) Data processing and analyzing}\par
The collected data was coded and checked for completeness. Once data coded and checked for completeness, data processing was done by SPSS version 16.1 and, presentation of the data was done by using frequency distribution, percentage and rate. 
\section[{c) Ethical consideration}]{c) Ethical consideration}\par
Ethical clearance letter was written by Ambo University department of Pharmacy after approved the proposal of the study to request AMCH for the permission. AMCH management and research office approved the letter of study and requested different hospital departments and any help during the study. The purpose of the study was explained to the respondent and data was collected after ensuring their willingness to give their response. Confidentiality of participants maintained at all time .Participants were informed that the participation were voluntary.  
\section[{Results}]{Results} 
\section[{a) Demographic Characteristics of Respondents}]{a) Demographic Characteristics of Respondents}\par
From total number of 116 type2 DM patients participated in the study 44(37.9\%) male and 72(61.1\%) were female. Regarding marital status of the patients; 16(13.8\%) single, 80(69\%) married, 10(8.6\%) widow and 10(8.6\%) patients were divorced. Concerning age of the clients 14(12.1\%), and 52(44.83\%) were in age group of 30-40, and >=61 respectively. The other 50 were in 1:1 ratio of 41-50 and 51-60 ages. Ethnicity of the patients participated in the study include Oromo (33.6\%), Amhara (37.9\%), Tigre (5.2\%) and 27(23.3\%) were other ethnic groups.\par
On the other hand 38(32.8\%) patients do not read and write, and 24(20.7) patients read and write only. The other 28(24.1\%), 23(19.8\%), and 3 (2.6\%) patients attended grade 1-8, grade9-12 and college respectively. When we consider employment status of the study participants; 27(23.8\%) patients were unemployed (private employee) and other 11 (9.5\%) were unable to do because of old age. Furthermore, 3(2.6\%) were government employee, 17(14.7\%) farmers, 34(29.3\%) house wife and other 22(19\%) had different jobs. In another way, about 41(35.3\%) patients had monthly income less than 500 birr and 60(51.71\%) patients had monthly income of 501-1500 birr. Only 14(12.1\%) and 1(.9\%) patients had monthly income of 1500-2500 and 2500-3000 birr per month respectively.  Regarding diabetic education such as attending group classes or having meeting with health professional half of the patients didn't get the opportunities while the other half got the chance one or more till now.\par
On the other hand, majority of the patients 59(50.9\%) were 1-5 years with the disease followed by 6-10 years with the disease which were 42(36.2\%).only one patient with disease for 25 years.  
\section[{d) Sources of life style modification}]{d) Sources of life style modification}\par
Majority of the patients 68(58.62\%) following the diabetic clinic get the information from health personnel followed by those who get information from more than one source 25(21.55\%).From the whole participants 12 patients reported that they have no information about LSM management of diabetes. See table 2 below   Regarding selected dietary practices of cigarette smoking, alcohol consumption, fruit and vegetable, sweet sugar, buttery and fatty meal; almost all patients do not smoke and consume alcohol always while 67(57.8\%) patients never take sweaty food, 71 patients never take buttery and fatty meal, while only 3(2.6) patients never take fruit and vegetable because of lack of resource. About 54(46.6\%) and 37(30.21\%) patients take eggs usually and never respectively. Surprisingly only one patients use herbal medicine to control her diabetic symptom with her medication.  No patient had negative attitude to LSM but, 21(18.1\%) patients had neutral attitude. Table7: shows the correlation of level of knowledge, attitude and practice towards LSM. It shows that there is positive Pearson correlation between level of knowledge and attitude(r=0.098, p=0.293), positive Pearson correlation of 0.184(p=0.048) between knowledge and practice, and positive Pearson correlation of 0.517(p=0.000) between level of attitude and practice level. 
\section[{VII.}]{VII.} 
\section[{Discussion a) Demographic Characteristics of Respondents}]{Discussion a) Demographic Characteristics of Respondents}\par
There were more females (62.1\%) than males (37.1\%) participated in this study, a reflection of the gender ratio attendance of patients in the diabetic clinic at AHMC hospital. More recent reports from developing countries have found that DM and its risk factors are more common in women This finding is in keeping with the results from a study conducted in South Africa at Mamelodi Hospital in which 81.1 \% were female and 18.9 \% were male \hyperref[b23]{[25 ]}.\par
Majority of respondents in this study came from the age groups 41-50 years, 51-60 years and >61 years with 21.55\%, 21.55\% and 44.83\% of respondents respectively, which add up to 87.93 \% of respondents.. This is reflective of the fact that the ethnology of type 2 diabetes mellitus usually at old age  {\ref [3, 17, and 25]}.\par
In this study respondents with no formal education consists (53.5\%) and only (2.6\%) respondents with higher education. This indicates that most respondents had little or no education. This result may be the direct consequence of scarcity of higher education system in Ethiopia in the past \hyperref[b24]{[26]}. Additionally the results of this study reported less than half (45.7\%) of the participants got diabetic education such as attending meeting with health professionals. This confirmed with the study conducted in 2011 at Jimma University Specialised Hospital which reported as there was no attention given to diabetic education in Ethiopia \hyperref[b18]{[20]}.\par
Majority of respondents in this study had income between 501 birr and 1500 birr (51.7\%) followed by respondents in the less than 500 birr income (35.3\%). This low income amongst majority of respondents could limit their accessibility and affordability of a wellbalanced diet and healthy food and it was considered as the main factors (barrier) to their practice of life style modification especially diet modification.\par
This finding was in keeping with the results from a cross sectional study of Adherence to Diabetes Self-Management Practices among Type Ii Diabetic Patients in Ethiopia; in which majority of the study participants 139 (43\%) had very low monthly income \hyperref[b25]{[27]}. 
\section[{Volume XIV Issue VII Version I}]{Volume XIV Issue VII Version I}\par
Year 2014 
\section[{( B )}]{( B )}\par
Majority of respondents (50.9\%) had normal weight, followed by 44.8\% with overweight and only 4.3\% had class I obesity. In the study class 2 obesity and class 3 (morbid obesity) were not found. This study had just demonstrated that lack of physical activities and poor dieting habit among respondents, seem to contribute to the development of type 2 DM rather than obesity. But about 45\% of the patients in the study were overweight which increases the risk of obesity.\par
This finding is in contrast with many studies done on this area in which obesity was common in the representative sample of type 2 diabetes patients attending a diabetes clinic \hyperref[b26]{[28]}. 
\section[{b) Knowledge Assessment of Respondents}]{b) Knowledge Assessment of Respondents}\par
In this study (77.59\%) of respondent had adequate knowledge, (11.21\%) of respondents had fair (average) knowledge and 11.21\% of respondents had poor knowledge of the benefits of exercise, and healthy diet. Large numbers of the participants (68\%) got information from health professionals may have contributed to this result. This relatively revealed similar result with study done in Nigeria at Kaduna in the year 2012 on 347 patients; 230 non diabetic and 117 diabetic patients' .The study recorded 56.4\% score of knowledge for diabetic participants \hyperref[b21]{[23]}.\par
In contrast to this finding, IKOMBELE found in his study that no respondent had good knowledge and 92.6\% of respondents had poor knowledge of the benefits of exercise, weight loss and healthy diet \hyperref[b23]{[25]}. 
\section[{c) Attitude Assessment of Respondents}]{c) Attitude Assessment of Respondents}\par
The majority of respondents (81.89\%) had positive attitude towards lifestyle modifications, followed by 18.1\% of respondents who had neutral attitude, and no respondents had a negative attitude. This revealed relatively similar results with study conducted on 100 patients attending diabetic clinic at kinikkashitan Seri Manjung which recorded 99\% of patients answered greater than or equal to 50\% of attitude question \hyperref[b27]{[29]}. This finding is similar to those of studies done in South Africa at Mamelodi Hospital in which the majority of respondents (92.7\% and 51.6\% respectively) had positive attitude towards lifestyle modifications \hyperref[b23]{[25]}. 
\section[{d) Practice Assessment of Respondents}]{d) Practice Assessment of Respondents}\par
The proportion of respondents with good practice (49.1\%) and those with average practice (17.24\%) and poor practice (33.62\%).About one third, patients had poor practice of LSM and the result was not satisfactory as that of knowledge and attitude. That could be due to majority of the patients had limited resources and low income which limit their affordability for a well balanced dieting and necessary equipment to exercise. This result was similar with study conducted in Qatar and Omani which reported 49.5\% of the respondents were not exercise regularly and 48\% of the participants were not practices recommended diet \hyperref[b19]{[21]} and less than 40\% exercise regularly and only 56\% of the patients were adhere to recommended diet respectively \hyperref[b17]{[19]}.\par
Regarding consumption of alcohol ,chat and smoking the results of this study is promising as 93.1\%,90.51\% and 80.2\% patients never smoke, chew chat and take any type of alcohol respectively. This result is similar with study conducted in Western Nigeria in 2012 which reported all study patients neither consume alcohol nor smoke cigarette \hyperref[b20]{[22]}. The other similar study conducted in Omani in the year 2013 also reported out of 106 study patients only 10.6\% were smoker.\par
Additionally the result of this study showed as only one patient use herbal medicine. Surprisingly study in Omani also reported only 2 patient use herbal medicine regularly \hyperref[b15]{[17]}. 
\section[{Correlation between Knowledge, Attitudes and Practices}]{Correlation between Knowledge, Attitudes and Practices}\par
There was a weak, non-significant positive correlation (r = 0.098, p = 0.293) between knowledge level and practice level of respondents. This means that being knowledgeable did not necessarily willingness to observe healthy lifestyle habits. In other way, there was a significant positive correlation (r = 0.184, p = 0.048) between the knowledge level and the practice level of respondents in this study. This means that the better respondents were knowledgeable, the better they were practice healthy lifestyle.\par
Finally, there was a very significant positive correlation (r = 0.517, p = 0.000) between attitude level and practice level. This means the better the patients had positive attitude toward LSM, the better they were practices healthy life style modification.\par
The result found in this study were opposite to the study conducted in South Africa at Mamelodi Hospital which reported significant positive correlation (r = 0.171, p = 0.012) between knowledge and attitude level, and weak positive non significant correlation (r = 0.037, p = 0.587) between attitude and practice level. In addition that study also reported weak positive non significant correlation(r = 0.102, p = 132) between attitude and practice level \hyperref[b23]{[25]}. 
\section[{VIII. ConclusionandRecommendation a) Conclusion}]{VIII. ConclusionandRecommendation a) Conclusion}\par
The discussion on the findings of this study shows that the knowledge and attitude levels of lifestyle modifications among type 2 diabetes mellitus patients attending Adama Medical College Hospital were generally high. However practice of the patients regarding LSM still not sufficient as more than half of the patients had no good practices. The study also found out that there was significant positive correlation (r = 0.0184, p = 0.048) between knowledge and practice, very significant positive correlation (r = 0.517, p = 0.000) between attitude and practice and a weak nonsignificant correlation(r = 0.098, p = 0.293) between knowledge and attitude. 
\section[{b) Recommendation}]{b) Recommendation}\par
Lifestyle modification has important roles in prevention and management of chronic diseases like type 2 DM patients. But its prevalence is increasing worldwide at an alarming rate especially in developing countries due to different factors like sedentary life style (westernization), and deficits in the knowledge and practice of LSM.\par
Based on these facts and on our research findings, it was recommended that: ? Health education about life style modification (importance of exercise, physical exercise and weight loss) to the general society should be implemented by the responsible body. ? Medical nutrition intervention program should be implemented with a multidisciplinary team (Doctor, dietician, pharmacists?) and all stake holders (health institution, MOH, diabetic association other responsible nongovernmental organization) should work cooperatively on this issues ? Empower and train Adama hospital healthcare workers about this issue in order to promote behavioural change and adoption of healthy lifestyle practices by patients. ? Further research should be done on this area\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-3.png}
\caption{\label{fig_1}}\end{figure}
       \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.437189292543021\textwidth}P{0.07151051625239006\textwidth}P{0.29416826003824087\textwidth}P{0.04713193116634799\textwidth}}
Source of information\tabcellsep \multicolumn{3}{l}{Frequency Percent Valid Percent}\\
NO INFORMATION\tabcellsep 12\tabcellsep 10.3\tabcellsep 10.3\\
HEALTH PERSONNEL\tabcellsep 68\tabcellsep 58.6\tabcellsep 58.6\\
MEDIA\tabcellsep 4\tabcellsep 3.4\tabcellsep 3.4\\
RELATIVE\tabcellsep 2\tabcellsep 1.7\tabcellsep 1.7\\
FRIENDS\tabcellsep 3\tabcellsep 2.6\tabcellsep 2.6\\
MORE THAN 1 OPTION\tabcellsep 25\tabcellsep 21.6\tabcellsep 21.6\\
OTHER\tabcellsep 2\tabcellsep 1.7\tabcellsep 1.7\\
Total\tabcellsep 116\tabcellsep 100.0\tabcellsep 100.0\\
e) Types of treatment\tabcellsep \tabcellsep \multicolumn{2}{l}{on one type of pharmacologic treatment and in parallel}\\
\multicolumn{2}{l}{When this study conducted; almost all patients}\tabcellsep \multicolumn{2}{l}{practice LSM partially or completely. Only 2 patients}\\
\multicolumn{2}{l}{were taking more than one types of treatment}\tabcellsep \multicolumn{2}{l}{were taking one type of treatment modalities.}\\
\multicolumn{2}{l}{modalities. All patients attending the clinic were at least}\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.27021604938271604\textwidth}P{0.0026234567901234564\textwidth}P{0.10493827160493827\textwidth}P{0.1259259259259259\textwidth}P{0.026234567901234566\textwidth}P{0.2675925925925926\textwidth}P{0.05246913580246913\textwidth}}
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Year 2014\\
70\tabcellsep \tabcellsep \tabcellsep \tabcellsep 64\\
10 20 30 40 50 60 0\tabcellsep 2\tabcellsep 20\tabcellsep 30\tabcellsep \tabcellsep Volume XIV Issue VII Version I ( B )\\
\multicolumn{2}{l}{OHG ONLY}\tabcellsep LSM \& INSULIN INJECTION\tabcellsep LSM,OHG \&INSULIN INJECTION\tabcellsep LSM\&OHG\tabcellsep Medical Research\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Global Journal of\\
Type of diet\tabcellsep \tabcellsep Always\tabcellsep \multicolumn{2}{l}{Some time}\tabcellsep Occasionally\tabcellsep Never\\
Smoke\tabcellsep \tabcellsep 0\tabcellsep 2\tabcellsep \tabcellsep 6\tabcellsep 108\\
Alcohol\tabcellsep \tabcellsep 0\tabcellsep 6\tabcellsep \tabcellsep 17\tabcellsep 93\\
Chat\tabcellsep \tabcellsep 4\tabcellsep 4\tabcellsep \tabcellsep 3\tabcellsep 105\\
Fruit \&vegetable\tabcellsep \tabcellsep 30\tabcellsep 52\tabcellsep \tabcellsep 31\tabcellsep 3\\
Sugar\tabcellsep \tabcellsep 2\tabcellsep 13\tabcellsep \tabcellsep 34\tabcellsep 67\\
Egg\tabcellsep \tabcellsep 0\tabcellsep 27\tabcellsep \tabcellsep 54\tabcellsep 35\\
\multicolumn{2}{l}{Buttery and fatty}\tabcellsep 0\tabcellsep 4\tabcellsep \tabcellsep 41\tabcellsep 71\\
meal\tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.3633419689119171\textwidth}P{0.40518134715025905\textwidth}P{0.08147668393782383\textwidth}}
Variable\tabcellsep Number\tabcellsep Frequency (\%)\\
Exercising regularly\tabcellsep \tabcellsep \\
Yes\tabcellsep 77\tabcellsep 66.4\\
No\tabcellsep 39\tabcellsep 33.6\\
Total\tabcellsep 116\tabcellsep 100\\
If yes, how often\tabcellsep \tabcellsep \\
Less than 15 min/day\tabcellsep 21\tabcellsep 18.1\\
Less than 30 min/day or less than\tabcellsep 40\tabcellsep 34.5\\
150 min/week\tabcellsep \tabcellsep \\
More than 30 min/day or more than\tabcellsep 21\tabcellsep 18.1\\
150 min/week\tabcellsep \tabcellsep \\
\tabcellsep \multicolumn{2}{l}{left 26 patients, 13(11.21\%) fairly knowledgeable and the}\\
\tabcellsep \multicolumn{2}{l}{other 13(11.21\%) were poorly knowledgeable. Figure1}\\
\tabcellsep \multicolumn{2}{l}{below summarize status of the knowledge of the}\\
\tabcellsep patients.\tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.6175213675213674\textwidth}P{0.03632478632478633\textwidth}P{0.19615384615384615\textwidth}}
h) Knowledge Assessment of Respondents\tabcellsep \tabcellsep \\
\multicolumn{2}{l}{Concerning knowledge of the patients towards}\tabcellsep \\
\multicolumn{2}{l}{LSM management of diabetic; majority of the patients}\tabcellsep \\
\multicolumn{2}{l}{were knowledgeable which accounts 90(77.59\%). Of the}\tabcellsep \\
\multicolumn{2}{l}{frequency}\tabcellsep \\
\tabcellsep 0\tabcellsep \\
13(11.21\%)\tabcellsep 0\%\tabcellsep \\
13(11.21\%)\tabcellsep \tabcellsep knowlegeable\\
\tabcellsep \tabcellsep fairly knowledgable\\
\tabcellsep \tabcellsep poorly knowledgeable\\
\tabcellsep \tabcellsep 90(77.58\%)\\
Attitude level\tabcellsep Number\tabcellsep Percent \%\\
Positive\tabcellsep 95\tabcellsep 81.9\\
Neutral\tabcellsep 21\tabcellsep 18.1\\
Negative\tabcellsep 0\tabcellsep 0\end{longtable} \par
 
\caption{\label{tab_4}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.85\textwidth}}
2014.\end{longtable} \par
 
\caption{\label{tab_5}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7} \par 
\begin{longtable}{P{0.25660377358490566\textwidth}P{0.5933962264150943\textwidth}}
knowledge\tabcellsep of\\
clients\tabcellsep level of attitude level of practice\end{longtable} \par
  {\small\itshape [Note: **. Correlation is significant at the 0.01 level (2-tailed).]} 
\caption{\label{tab_6}Table 7 :}\end{figure}
 			\footnote{© 2014 Global Journals Inc. (US)} 		 		\backmatter   			 
\subsection[{IX. Acknowledgements}]{IX. Acknowledgements}\par
We are very grateful to our college staff members for unreserved guidance and constructive suggestions and comments from the stage of proposal development to this end. We would like to thank Ambo University for supporting the budget which required for this research. Finally our deepest gratitude goes to Adama Hospital Medical College staff workers who help and allow us in conducting this research. 			  			  				\begin{bibitemlist}{1}
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