i
“EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE OF HYPERTENSIVE
PATIENTS REGARDING DASH DIET AT SELECTED
KUMBALAGUDU PHC AREA, BANGALORE.”
By
Mr. ARUN BABU
Dissertation Submitted to the Rajiv Gandhi University of Health
Sciences, Bangalore, Karnataka.
In partial fulfillment of requirement for the degree of
Master of Science in Nursing
In
Community Health Nursing
Under the Guidance of
Mrs. KATHYAYINI.N.B. M.Sc. (N),
Assistant Professor,
Department of Community Health Nursing.
Kempegowda College of Nursing
K.R.Road, V.V.Puram, Bangalore-560 004
2013
ii
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “Effectiveness of structured
teaching programme on knowledge of hypertensive patients regarding DASH
diet at selected Kumbalagudu PHC area, Bangalore.”is a bonafide and genuine
research carried out by me under the guidance of Mrs.Kathyayini.N.B, M.Sc.
Nursing, Asst Professor, Department of Community Health Nursing, Kempegowda
College of Nursing, Bangalore-560 004.
Place: Bangalore. Signature of the Candidate
Date: 11-2- 2013 (Mr. Arun Babu)
iii
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled is “Effectiveness of structured
teaching programme on knowledge of hypertensive patients regarding DASH
diet at selected Kumbalagudu PHC area, Bangalore.”is a bonafide research done
by Mr. Arun Babu in partial fulfillment of the requirement for the degree of
Master of Science in Community Health Nursing.
Place: Bangalore. Signature of the Guide
Date: 11-2-2013 Mrs.Kathyayini.N.B. M.Sc. (N).
Asst. Professor,
Deparment of Community Health Nursing,
Kempegowda College of Nursing,
Bangalore-560004.
iv
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF
THE INSTITUTION
This is to certify that the dissertation entitled “Effectiveness of structured
teaching programme on knowledge of hypertensive patients regarding DASH
diet at selected Kumbalagudu PHC area, Bangalore” is a bonafide research done
by Mr. Arun Babu under the guidance of Mrs.Kathyayini.N.B. M.Sc(N).
Asst Professor, Department of Community Health Nursing, Kempegowda College
of Nursing, Bangalore-560 004.
Seal & Signature of the HOD Seal & Signature of the Principal
Mrs.V.T.LAKSHMAMMA. M.Sc(N) Mrs.V.T. LAKSHMAMMA
Professor and HOD, Principal, Head of the department,
Department of Community Health Nursing, Community Health Nursing,
Kempegowda College of Nursing, Kempegowda College of Nursing,
Bangalore-560 004. Bangalore-560 004.
Place: Bangalore. Place: Bangalore.
Date: 11-2- 2013. Date: 11-2- 2013
v
COPYRIGHT
Declaration by the Candidate
I hereby declare that Rajiv Gandhi University of Health Sciences, Karnataka,
shall have the rights to preserve, use and disseminate this dissertation/thesis in print
or electronic format for academic/research purpose.
Place: Bangalore. Signature of the Candidate
Date: 11/2/2013 (Mr. Arun Babu)
© Rajiv Gandhi University of Health Sciences, Karnataka.
vi
ACKNOWLEDGEMENT
“Let us be grateful to the people who make us happy; they are the charming gardeners who make our souls blossom.” (Marcel Proust)
First, I praise and thank Lord Almighty for his abundant grace and blessings
throughout the study.
I owe a deep sense of gratitude to all those who have contributed for the
successful completion of the study. It gives an immense pleasure to acknowledge
individuals who had been a source of inspiration, guidance and support from the
conception of this dissertation till completion.
I convey my sincere indebtedness to the Kempegowda College of Nursing,
Bangalore-04, for providing me an opportunity to be a student of this esteemed
institution and to conduct this study.
I extend my sincere thanks to Mrs.Lakshmamma., M.Sc. N., Principal and
HOD, Community Health Nursing, Kempegowda College of Nursing, Bangalore-4,
who let me and my search move around freely. I owe a deep sense of gratitude and
indebtedness to her.
It is my privilege to express my sincere thanks and profound gratitude towards
my esteemed teacher and guide Mrs.Kathyayini.N.B,M.Sc (N), Assistant Professor,
Department of Community Health Nursing. She is a mentor who infused me in
confidence and encouragement in my endeavour, whenever needed. It has been my
good fortune to have her as my guide. I appreciate her to tolerate my confused looks
and her innate capacity to diffuse my anxiety with her caring words. It has been an
invaluable experience working under her. We fall short of words to “Thank you
Madam”
vii
I thank The Medical Officer of Kumbalagudu PHC , Bangalore, for his timely aid
and co-operation during the study.
I extend my profound sense of gratitude to Dr.Gangaboraiah, Ph.D (Statistics),
Department of Community Medicine, KIMS, for his valuable suggestions and
guidance in statistical analysis.
My sincere gratitude goes to Mr.Manjunatha.H.R, lecturer and Mrs.Sunitha
lecturer, Department of Community Health Nursing for their meticulous
corrections, valuable suggestions and expert guidance.
I would like to extend my deepest gratitude to all the Experts who have
contributed in the form of constructive criticism and suggestions to formulate the tool.
I wish to place my sincere thanks to Mrs.Suma ,HOD Department of English,
College of arts and commerce,V.V.Puram Bangalore for editing the manuscript
meticulously for editing the tool.
My heartfelt thanks and appreciation to R&R Canon who toiled for the
meticulous DTP work and providing the bound volumes of the work.
My healthy ovation of gratitude to my beloved parents Mr. K.M. Puttamadhe
Gowda, Mrs.Jayalakshmamma, and my brother Mr.Kiran Babu for their
encouragement and support. A Heartfelt thanks to classmates and all my friends for
grooming me into a postgraduate nurse.
Finally, I thank all those well-wishers of mine who have directly or indirectly
contributed to the success of this work.
Place: Bangalore Signature of the Student
Date: (Mr. Arun Babu)
viii
ABSTRACT
Background and Objectives
This study was under taken to evaluate the effectiveness of structured teaching
programme on the knowledge of hypertensive patients regarding DASH diet in
selected Kumbalagudu PHC area, Bangalore.
Objectives of Study
i. To assess the level of knowledge of hypertensive patients regarding
DASH diet.
ii. To assess the effectiveness of structured teaching programme on
knowledge of hypertensive patients regarding DASH diet.
iii. To find association between knowledge of hypertensive patients and
selected socio demographic variables.
Method:
The study involved one group pre-test and post-test using pre-experimental
design, with non-probability sampling technique in which convenient sampling
method was used. 60 hypertensive patients in Kumbalagudu PHC area were taken as
samples (N=60) and requested to mark the structured questionnaire followed by
implementation of structured teaching programme and post-test conducted after 8
days, using the same structured questionnaire to find out the effectiveness.
Results:
The overall pre test knowledge scores of hypertensive patients on DASH diet
was found to be 33.38% and the overall post test knowledge scores was found to
77.23% and enhancement in the mean percentage knowledge score(131.36 %) was
found to be significant at 5% level of all the aspects under study. There was no
ix
significant association between pre test knowledge scores and selected demographic
variables.
Interpretation and Conclusion:
The overall findings of the study clearly showed that the Structured Teaching
Program was significantly effective in improving the knowledge scores of
hypertensive patients regarding DASH diet.
x
LIST OF ABBREVIATIONS
1. STP Structured Teaching Programme
2. H Hypothesis
3. SD Standard deviation
4. P Probability
5. Df Degree of freedom
6. N Number of respondents
7. Α Alpha
8. FEP Fisher’s Exact Probability
9. S Significant
10. NS Not significant
11. DASH Dietary Approaches to Stop Hypertension
12. WHO World Health Organization
13. ISH International Society of Hypertension
14. CVD Cardio Vascular Disease
15. CUPS Chennai Urban Population Study
16. JNC Joint National Committee
17. NHLBI National Heart, Lung & Blood Institute
18. SLAN Survey of Lifestyle, Attitudes and Nutrition.
xi
TABLE OF CONTENTS
Sl. No.
Particulars
Page No.
1.
Introduction
1-6
2.
Objectives
7-12
3.
Review of Literature
13-32
4. Methodology
33-44
5. Results
45-66
6. Discussion
67-72
7. Conclusion
73-76
8. Summary
77-81
9. Bibliography
82-86
10. Annexure
87-175
xii
LIST OF TABLES
Sl. No.
Title of the Table Page No.
1 Description of the research design. 34
2 Distribution of Respondents by Age. 46
3 Distribution of Respondents by Sex. 48
4 Distribution of Respondents by Dietary pattern. 49
5 Distribution of Respondents by Educational status. 50
6 Distribution of Respondents by occupation. 52
7 Distribution of Respondents by Income. 54
8 Distribution of Respondents by Source of information. 55
9 Distribution of Respondents by Duration of hypertension. 56
10. Aspects wise pre - test mean knowledge scores. 57
11 Aspect wise post -test mean knowledge scores. 58
12 Aspect wise enhancement of knowledge score on DASH diet. 59
13 Distribution of respondents according to knowledge level on DASH diet.
61
14 Aspect wise analysis of pre-test and post test knowledge scores. 63
15 Association between selected demographic variables and over all pre test knowledge scores.
64-66
xiii
LIST OF FIGURES
Sl. No.
Title of the Figure Page No.
1 Conceptual Framework based on general system model by Ludwig von Bertalanffy.
12
2 Schematic Representation of the Research Design. 44
3 Distribution of Respondents by Age. 47
4 Distribution of Respondents by Sex. 48
5 Distribution of Respondents by Dietary pattern 49
6 Distribution of Respondents by Education. 51
7 Distribution of Respondents by Occupation. 53
8 Distribution of Respondents by Monthly income. 54
9 Distribution of Respondents by Source of information. 55
10. Distribution of Respondents by Duration of Hypertension 56
11 Aspect wise enhancement of knowledge scores on DASH diet. 60
12 Distribution of respondents according to knowledge level on DASH diet.
62
xiv
LIST OF ANNEXURE
SL. NO
ANNEXURE INDEX
CONTENTS
PAGE NO.
1. Annexure-A Copy of letter seeking permission to conduct the study 87
2. Annexure-B Copy of the letter seeking expert’s opinion for the content validity of the tool and Structured teaching Programme.
88-90
3. Annexure-C Content validity certificate 91
4. Annexure-C (1)
Criteria rating scale for validating structured knowledge questionnaire 92-95
5. Annexure- D List of experts consulted for content validity of the tool and Structured teaching programme. 96-97
6. Annexure-E Copy of consent form 98
7. Annexure-F Structured questionnaire (English) 99-106
8. Annexure-F(1) Key answers for the structured knowledge questionnaire 107
9. Annexure-F(2) Blue print for the structured knowledge questionnaire 108
11. Annexure-G Structured teaching programme (English) 109-135
12. Annexure-H Structured questionnaire (Kannada) 136-143
13. Annexure-I Structured teaching programme (Kannada) 144-175
1
1. INTRODUCTION
“Diet cures more than the Doctor.”
(Maxim)
Health is the level of functional or metabolic efficiency of a living being.
In general it is a condition of a person's mind and body, usually meaning to be free
from illness, injury or pain.1To maintain good health, health and nutrition are the two
things that go hand in hand. Nutrition is the basic requirement for all the organisms
and cells to stay alive and to support life. A healthy diet contains a balance of food
groups and all the nutrients necessary to promote good health. Hippocrates suggested,
“Let food be your medicine.” Proper nutrition leads to a healthier body. From the
conception, the construction of the body structure in the womb starts with the food
taken by the mother. On birth, breast feeding and then other forms of foods contribute
to the growth of the child. Healthy eating is the practice of making choices about what
and/or how much one eats with the intention of improving or maintaining good health.
Many common health problems can be prevented or alleviated with a diet. Common
health problems related to unhealthy diet are cardiovascular diseases, kidney related
diseases etc.2
Blood pressure is the pressure that the blood exerts against the blood vessel
walls as the heart pumps. Blood pressure rises with each heartbeat and falls when the
heart relaxes between beats but there is always a certain amount of pressure in the
arteries. That blood pressure comes from two physical forces. The heart creates one
force as it pumps blood into the arteries and through the circulatory system. The other
2
force comes from the arteries resisting the blood flow. A normal blood pressure
reading for an adult is: 120 / 80 mm of Hg.3
Hypertension is the condition of having high blood pressure, systolic pressure
above 140 mm Hg and diastolic above 90 mm Hg consistently for more than six
months. Blood pressure changes from minute to minute and is affected not only by
activity and rest, but also by temperature, diet, emotional state posture and
medications.2 High blood pressure adds to the workload of the heart and arteries. The
heart must pump harder and the arteries must carry blood that is moving under greater
pressure. If the blood pressure is too high, the heart has to work harder to pump which
would lead to organ damage and several illnesses such as heart attack, stroke, heart
failure, aneurysm, renal failure, vision loss.3
A critical step in preventing and treating high blood pressure is healthy
lifestyle. Lifestyle modification that effectively lower blood pressure are losing weight
if patients are over- weight or obese. Losing as few as 10 pounds( 4.5 kilograms) can
lower blood pressure.4
For people who are obese or high cholesterol levels, changes in diet (to a diet
rich in fruits, vegetables, and low- fat dairy products with reduced saturated and total
fat content) are important for reducing the risk of heart and blood pressure.5
The best and recommended hypertension diet plan is DASH. DASH is a
scientifically arrived high blood pressure diet which stands for Dietary Approaches to
Stop Hypertension (DASH). It is a diet that was developed by the United States
National Heart, Lung and Blood Institute (NHLBI). DASH is an effective health eating
plans which work to directly control hypertension; it also helps in weight loss. Obesity
can definitely lead someone to hypertension. Like sodium intake, obesity is directly
3
correlated with hypertension. Losing weight even in small measure can have dramatic
effects in lowering your blood pressure. Maintaining a healthy weight is an important
part of a healthy lifestyle. Foods that lower blood pressure are embedded in this eating
plan which is low in saturated fat, cholesterol and total fat. Fruits and vegetables that
lower blood pressure are included in DASH including fat-free or low-fat milk and milk
products. This diet for hypertension also includes fish, poultry and nuts as well as
whole grain products.6 Taking calcium, potassium, and magnesium supplements
instead of eating these foods does not have the same effect.7
A landmark study called DASH (Dietary Approaches to Stop Hypertension)
looked at the effects of an overall eating plan in adults with normal to high blood
pressure. Researchers found that in just eight weeks, people following the DASH diet
saw their blood pressure decrease. A subsequent study called DASH two looked at the
effect of following the DASH diet and restricting salt intake to 1500 mg per day.
Under the DASH two diet, people with hypertension had their blood pressure decrease
as much or more than any anti-hypertensive medication had been able to lower it.8
4
NEED FOR THE STUDY:
In present day scenario the magnitude of non communicable diseases (NCDs),
mainly cardiovascular diseases, cancers, diabetes and chronic respiratory diseases,
represents a leading threat to human health and development. These four diseases are
the world's biggest killers, causing an estimated 35 million deaths each year - 60% of
all deaths globally - with 80% in low- and middle income countries.9
Hypertension has become a major cause of morbidity and mortality worldwide
and it is now ranked third as a cause of disability-adjusted life years. The World Health
Report states that elevated blood pressure alone contributes to about 50% of
cardiovascular diseases (CVD) worldwide. Furthermore, the risk for CVD starts even
at upper limits of normal levels of blood pressure. Therefore it would be desirable to
achieve optimal or normal BP (below 130/80 mmHg) in the young and middle-aged.10
About 15 % - 37% of the adult population worldwide is affected with
hypertension. Pooling of epidemiological studies shows that hypertension is present in
25% urban and 10% rural subjects in India. On estimation, there are 31.5 million
hypertensive in the rural and 34 million in the urban population.11
According to the recent review on the global burden of hypertension, the
estimated prevalence of hypertension(in people aged 20 years and older) in India in
2000 was 20.6% among males and 20.9% among females and is projected to increase
to 22.9% and 23.6% respectively by 2025.12
Hypertension has both modifiable and non-modifiable risk factors, where in
diet is one among them through which hypertension can be effectively managed and
complications can be prevented.13
5
Complications of hypertension are vascular damage, coronary artery disease,
left ventricular hypertrophy; cerebral vascular involvement may produce stroke
Cerebral infarcts accounts for 80% of the strokes and transient ischemic attacks in
hypertensive persons.14
Life style modification strategies are recommended in the Joint National
Committee (JNC) 7 guidelines for the treatment and prevention of hypertension and
cardiovascular disease. The primary strategies discussed are proper nutrition through
the Dietary Approaches to Stop Hypertension (DASH) eating plan and sodium
restriction, weight reduction, increased physical activity and moderation of alcohol
consumption. Patients with hypertension have been shown to decrease their resting
blood pressure considerably by adopting one or more of these strategies.15
The DASH diet (Dietary Approaches to Stop Hypertension) is a diet promoted
by the National Heart, Lung, and Blood Institute (part of the National institute of
health (NIH), a United States government organization) to control hypertension. In
addition to its effect on blood pressure, it is considered a well-balanced approach to
eating for the general public. It is now recommended by the U.S. Department of
Agriculture (USDA) as an ideal eating plan for all Americans.16
The recent studies show that a diet rich in fruits, vegetables, whole grains, and
low fat dairy products and low in fat, refined carbohydrates, and sodium can lower
blood pressure either alone or in combination with other lifestyle changes. These
studies have greatly expanded our knowledge of non-pharmacologic interventions to
prevent and manage hypertension. They also underscore the need for diet and lifestyle
counseling in the primary care setting.17
6
Regarding optimal management of Indian hypertensive population according to
CUPS – Chennai Urban Population Study, prevalence of hypertension in men (22.8%)
and in women (19.7%) is still a dream by pharmacological measurement, because rule
of halves for hypertension states that half the people with high blood pressure are not
known, half of those known are not treated, and half of those treated are not controlled.
Thus, by this rule one out of eight patients is optimally treated by pharmacological
measurement. If lifestyle modifications are adopted as a primary prevention strategy in
Indian population, then many of the uncontrolled hypertension patients can be
optimally managed.18
From the above statistics it indicates that hypertension is a burning issue; need
to bring awareness among hypertensive patients. People even after diagnosed as
hypertensive, don’t pay attention upon their diet, which can result in more
complication and severity of disease. Hence, studies suggest that educating patients
regarding DASH diet is important and essential.
The investigator has come across with many cases of hypertension in rural
communities, Bangalore and observed lack of knowledge regarding DASH diet. The
various studies already conducted also suggest and support for further research on
DASH diet in prevention of hypertension. By keeping the above points in view, the
investigator rightly felt to impart knowledge on DASH diet for hypertensive patients
for effective management and prevention of complications of hypertension.
7
2. OBJECTIVES
This chapter deals with the statement of the problem, objectives of the study,
hypothesis, operational definitions and conceptual framework, which provide a frame
of reference.
STATEMENT OF THE PROBLEM
“Effectiveness of structured teaching programme on knowledge of hypertensive
patients regarding DASH diet at selected Kumbalagudu PHC area, Bangalore.”
OBJECTIVES OF THE STUDY
(i) To assess the level of knowledge of hypertensive patients regarding
DASH diet before the administration of structured teaching programme.
(ii) To assess the effectiveness of structured teaching programme on
knowledge of hypertensive patients regarding DASH diet.
(iii) To find the association between knowledge of hypertensive patients and
selected socio demographic variables.
HYPOTHESIS
H1: There is a significant difference between pre-test and post-test knowledge
scores of hypertensive patients regarding DASH diet.
H2: There is a significant association between knowledge scores of hypertensive
patients regarding DASH diet and selected ¸socio-demographic variables.
VARIABLES
Variable refers to a characteristic or attribute of a person or object that varies with in
the population understudy.
8
In this study two types of variables are considered, they are dependent variables and
independent variable.
Dependent variable:
The presumed effect is referred to as the dependent variable.
In this study, knowledge of hypertensive patients is the dependent variable.
Independent variable:
The presumed cause is referred to as the independent variable.
In this study structured teaching programme is the independent variable.
OPERATIONAL DEFINITIONS:
Effectiveness: It refers to gain in knowledge on DASH diet among hypertensive
patients determined by significant difference between pre-test and post-test knowledge
scores.
Structured teaching programme: It refers to systematically organized instructional
design developed to provide information for hypertensive patients regarding DASH
diet.
Knowledge: It refers to the response given by hypertensive patients regarding DASH
diet.
Hypertensive patients: It refers to people who have been diagnosed with high blood
pressure.
9
DASH diet: Dietary approaches to stop hypertension (DASH) diet refers to diet rich in
fruits, vegetables, whole grains and low-fat dairy foods which includes meat, fish, and
poultry and are limited in sugar-sweetened foods and beverages.
DELIMITATIONS OF STUDY: The study is delimited to hypertensive patients in
Kumbalagudu PHC area.
CONCEPTUAL FRAMEWORK
The conceptual framework plays several interrelated roles in the progress of
science. Their overall purpose is to make scientific findings meaningful and generalize
them. A conceptual framework deals with abstractions that are assembled by virtue of
relevance to a common phenomenon. This study is intended to assess the effectiveness
of structured teaching programme on knowledge regarding dietary approaches to stop
hypertension (DASH) among hypertensive patients in a selected Kumbalagudu PHC
area, Bangalore. The conceptual framework of the present study is based on General
System`s Theory which was introduced by Ludwig Von Bertalanffy (1968) with input,
process, output and feedback.
According to System`s Theory, a system is a group of elements that interact
with one another in order to achieve the goal. An individual is a system because he/she
receives input from the environment. This input when processed provides an output.
This system is cyclical in nature and continues to be so, as long as the input, process,
output and feedback keep interacting. If there are changes in any of the parts, there will
be changes in all the parts. Feedback from within the systems or from the environment
provides information, which helps the system to determine whether it meets its goal. In
the present study these concepts can be explained as follows.
10
Input:
The input consists of information, material or energy that enters the system.
Hypertensive patient is a system and has inputs within the system itself and acquired
from the environment. The inputs include learner’s background like age, sex, dietary
pattern, education, occupation, income, source of information and duration of
hypertension which may influence the knowledge of hypertensive patients regarding
DASH die. It refers to the action needed to accomplish the derived task to achieve the
desired output that is Effectiveness of structured teaching programme on knowledge
regarding dietary approaches to stop hypertension (DASH) among hypertensive
patients in a Kumbalgudu PHC area, Bangalore.
Process or through put:
1. Assessment of level of knowledge among hypertensive patients regarding dietary approaches to stop hypertension (DASH) using a structured questionnaires.
2. Administration of STP on knowledge regarding DASH diet.
3. Assessment of post-test level of knowledge by using same structured questionnaires.
Output:
Output is the behavioural response. Output response becomes feed back to the
system and environment. In the present study, output is the gain in knowledge scores.
This is achieved through a comparison between mean pre-test and post-test knowledge
scores of the subjects.
11
Feedback:
It is the process that provides information about the system’s output and its
redirection to input. Accordingly the higher knowledge score obtained by the
hypertensive patients indicates the effectiveness of structured teaching programme in
enhancing the knowledge of hypertensive patients regarding dietary approaches to stop
hypertension (DASH).
According to Ludwig Von Bertalanffy the system acts as a whole. Dysfunction
of a part causes system disturbances rather than loss of a single function. Whole
system can be resolved into an aggregation of feedback circuits such as input,
throughput and output. The feedback circuits help in the maintenance and
improvement of an intact system.
In this study, effectiveness of structured teaching programme is tested by inter
related elements such as input, throughput and output. From the feedback efficiency of
the input, such as structured teaching programme regarding DASH diet, will be
assessed. The process of teaching as throughput will be assessed in terms of its
effectiveness.
xii
(- - - - - - - Not included in the study)
Figure 1: Conceptual framework based on General System Theory by Von Bertalanffy (1968)
INPUT
Demographic and clinical variables such as,
• Age
• Sex
• Dietary pattern
• Education
• Occupation
• Income
• Source of information
• Duration of hypertension
THROUGH PUT
• Assessment of knowledge regarding DASH by using structured questionnaires.
• Administration of STP regarding DASH on the same day soon after the pre‐test and encouraging learning by samples. Post test using the same structured questionnaires on 8th day after the administration of STP.
OUT PUT
Analysis and interpretation of knowledge regarding DASH into 3 categories,
Adequate Moderately adequate Inadequate
Feed back
13
3. REVIEW OF LITERATURE
This chapter deals with the review of related literature.
The literature reviewed has been presented under the following categories:
1. Literature related to prevalence and risk factors of hypertension
2. Literature related to treatment and lifestyle modifications
3. Literature related to diet and blood pressure
4. Literature related to DASH diet
5. Literature related to knowledge and effectiveness of Structured Teaching
programme
1. Literature related to prevalence and risk factors of hypertension
A study was conducted on prevalence,awareness,control, and associations of
arterial hypertension in a Rural Central India Population with sample size of 4,711
subjects (ages 30+ years) undergoing an ophthalmic and medical examination. Results
shows that arterial hypertension was found in 1,041 (22.1%) subjects. Its prevalence was
associated with higher age (P < 0.001), higher body mass index (P < 0.001), body height
(P = 0.001), higher blood hemoglobin levels (P < 0.001), and elevated blood urea
concentration (P = 0.008). It was not significantly associated with gender, level of
education, family income, kind of daily physical activities, type of diet, and serum
concentrations of cholesterol and creatinine among the hypertensive study participants (n
= 1,041), 208 (20.0%) subjects were aware of their disease. A current antihypertensive
treatment was reported by 84 subjects of the 1,041 arterial hypertensive subjects (8.1 ±
0.9%). Out of the treated subjects, 24 (29%) had abnormally high diastolic blood pressure
14
measurements and 44 (52%) participants had abnormally high systolic blood pressure
measurements. It concludes that rural Central Indian population of ages 30+ years, the
prevalence of arterial hypertension was 22.1 ± 0.6% with an awareness rate of 20% and a
treatment rate of 8%. The low awareness and treatment rate may demand increasing public
health efforts.19
A study was conducted to detect prevalence of essential hypertension and to
identify various risk factors in Mysore, India. Blood pressure was recorded in 503
apparently normal students in group as per standard guidelines. Detailed clinical
examination was done in all cases. 6.16% of adolescents had high blood pressure at the
end of fourth screening. Both systolic and diastolic hypertensions were documented.
Increased body mass index and reduced consumption of vegetables and fruits were found
to be statistically significant risk factors for hypertension. The study concluded that there
is a high prevalence of essential hypertension amongst adolescents with modifiable risk
factors for hypertension.20
A Meta analysis study was conducted on hypertension epidemiology in, Jaipur,
India. The study reveals the following facts. Indian urban population studies in the mid-
1950s used older WHO guidelines for diagnosis (BP > or =160 and/or 95 mmHg) and
reported hypertension prevalence of 1.2-4.0%. Subsequent studies report steadily
increasing prevalence from 5% in 1960s to 12-15% in 1990s. Hypertension prevalence is
lower in the rural Indian population, although there has been a steady increase over time
here as well. Recent studies using revised criteria (BP > or =140 and/or 90 mmHg) have
shown a high prevalence of hypertension among urban adults: men 30%, women 33% in
Jaipur (1995), men 44%, women 45% in Mumbai (1999), men 31%, women 36% in
15
Thiruvananthapuram (2000), 14% in Chennai (2001), and men 36%, women 37% in
Jaipur (2002). Among the rural populations, hypertension prevalence is men 24%, women
17% in Rajasthan (1994). Hypertension diagnosed by multiple examinations has been
reported in 27% male and 28% female executives in Mumbai (2000) and 4.5% rural
subjects in Haryana (1999). There is a strong correlation between changing lifestyle
factors and increase in hypertension in India.21
A Prospective cohort study conducted to know the prevalence of masked
hypertension on 302 hypertensive patients was followed in 75 Hypertension Units at
Spain. Masked hypertension was defined when mean daytime BP ≥ 135/85 mmHg. Mean
age was 56.2 years and 56% were male. Prevalence of masked hypertension was 48%. The
most prevalent accompanying risk factors were abdominal obesity (39.7%), smoking
(24.2%), family with premature cardiovascular disease (22.5%), and diabetes (11.6%).
Prevalence of left ventricular hypertrophy was 23.8%, and 22.2% of patients had
established cardiovascular disease, and 6.3% had renal disease. Masked hypertension was
related to the absence of established cardiovascular disease and to the proximity of the
clinic BP levels to the control thresholds. The researcher concludes that, the prevalence of
masked hypertension was approximately 50% in treated hypertensive patients.22
A cross sectional survey was conducted on 979 study participants in Sidama Zone,
to assess the prevalence and determinants of hypertension in rural and urban areas. Out of
979 participating subjects 485 were from urban and 494 were from rural. The prevalence
of hypertension was 9.9% with 10.1% in urban and 9.7% in rural areas ranging from 4.2%
in those below 30 years to 29.4% in those above 60 years. Bivariate analysis showed
hypertension was highly occurring more in those above 30 years old, those with the family
16
history of hypertension, and a BMI > or =25 kg/m2. Multivariate analysis showed similar
correlation of increased possibility of hypertension with being over 30 years, having a
family history of hypertension, a BMI > or =25 kg/m2 and excess meat consumption. The
study concluded that hypertension has equal public health importance in urban and rural
settings of southern Ethiopia. Hypertension is common among those over the age of 30
years, overweight, those who consume excess meat and those with family history of
hypertension.23
A cross sectional epidemiological study was conducted on 1,806 hypertensive
patients, men (n=904) and women (n=902), age range 25-64 years in India to determine
age-specific prevalence of hypertension and blood pressure (BP) levels in relation to diet
and lifestyle factors among North Indians. Diagnosis of hypertension was based on new
World Health Organization/International Society of Hypertension (WHO/ISH) criteria.
The prevalence of hypertension according to WHO/ISH criteria was 23.7% and by old
WHO criteria 13.3%.In the WHO/ISH hypertensive group, isolated diastolic hypertension
was present in 47.3% males and 40.6% females. In both sexes, the prevalence rates and
BP level increased with older age. The study concluded that association of higher socio
economic status, higher body mass index and central obesity in North Indian adults with
higher fat intake, lower physical activity.Higher prevalence and level of hypertension
indicate that these populations may benefit by decreasing the dietary fat intake and
increasing physical activity.24
17
2. Literature related to treatment and lifestyle modifications
A Prospective cohort study was conducted on 83,882 adult women aged 27 to 44
years who did not have hypertension, cardiovascular disease, diabetes, or cancer, and who
had normal blood pressure (120 mm Hg / 80 mm Hg), with follow-up for incident
hypertension for 14 years through 2005 in USA to assess the Diet and lifestyle risk factors
associated with incident hypertension in women. Six modifiable lifestyle and dietary
factors for hypertension were identified. The six low-risk factors for hypertension were a
body mass index (BMI) of less than 25, vigorous exercise, Dietary Approaches to Stop
Hypertension (DASH), modest alcohol intake, use of non narcotic analgesics less than
once per week, and intake of supplemental folic acid. The association between
combinations of low-risk factors and the risk of developing hypertension was analyzed.
The study revealed that all six modifiable risk factors were independently associated with
the risk of developing hypertension. For women who had all six low-risk factors (0.3% ),
the hazard ratio for incident hypertension was 95% [CI], 0.10-0.51.For five low-risk
factors (0.8%), (95% CI) for four low-risk factors (1.6%), and (95% CI) for three low-risk
factors (3.1% of the population).Body mass index alone was the most powerful predictor
of hypertension,(95%CI) The researcher concludes that, low-risk dietary and lifestyle
factors were associated with a significantly lower incidence of self-reported hypertension.
Adopting low-risk dietary and lifestyle factors has the potential to prevent a large
proportion of new-onset hypertension occurring among young women.25
A cross-sectional analysis of the Survey of Lifestyle, Attitudes and Nutrition
(SLÁN) was conducted in Ireland. They investigated socio\demographic and lifestyle
predictors of poor-quality diet in a population. The SLÁN survey is a two-stage clustered
18
sample of 10,364 individuals aged 18 years. The study Results was Adjusting for age
and gender, a number of socio demographic, lifestyle and health-related variables were
associated with poor-quality diet: although the association with social support was
attenuated and that with food poverty was borderline significant (OR = 1·2, 95 % CI 1·03,
1·45).Concluded that Dietary quality was associated with social class, educational
attainment, food poverty and related core determinants of health.26
A cross-sectional and descriptive assessment was done on adherence of
hypertensive individuals to treatment and lifestyle change recommendations in Turkey.
The face-to-face interview method was used to collect data among 150 patients who were
followed by the outpatient clinics for at least one year. 94 (63%) were female, mean
duration of drug use was 6.5+/- 6.5 years and the mean number of drugs used was 1.6+/-
0.8. The adherence to recommendations of medication, diet, exercise, home-blood
measurement and smoking were 72%, 65%, 31%, 63% and 83%, respectively. 11% of
patients were adherent to one recommendation, 23% - to two, 29% - to three, 24% - to
four and 13% - to five. According to the regression analysis, factors effective on each type
of adherence were found to be different from others. The presence of three or more types
of adherence was related to income level (OR= 0.297; <0.001) and presence of any other
chronic disease (OR=2.329; p=0.002). It shows that the rates of adherence to medicine and
life-style changes were generally found to be low in hypertension and concludes that there
is a need to create awareness about the effectiveness of medicine and lifestyle changes in
managing hypertensive clients.27
A study was done on Effects of comprehensive lifestyle modification on diet,
weight, physical fitness, and blood pressure control: 18-month results of a randomized
19
trial at multicentre in Portland,USA. Where 810 adult volunteers with prehypertension or
stage 1 hypertension was enrolled as multicomponent behavioral intervention that
implemented the established recommendations plus the Dietary Approaches to Stop
Hypertension (DASH) diet ("established plus DASH"); and advice only To compare the
18-month effects of 2 multicomponent behavioral interventions versus advice only on
hypertension status, lifestyle changes, and blood pressure..The main 6-month results from
the PREMIER trial showed that comprehensive behavioral intervention programs improve
lifestyle behaviours and lower blood pressure. Relative to the advice only group, the odds
ratios for hypertension at 18 months were 0.83 (95% CI, 0.67 to 1.04) for the established
group and 0.77 (CI, 0.62 to 0.97) for the established plus DASH group. Reductions in
absolute blood pressure at 18 months were greater for participants in the established and
the established plus DASH groups than for the advice only group.28
A study was conducted in Alta, Canada to provide updated, evidence based
recommendations for health care professionals on lifestyle changes to prevent and control
hypertension in otherwise healthy adults. For people who already have hypertension, the
options for controlling the condition are lifestyle modification, antihypertensive
medications or a combination of these options. The results were the health outcomes
considered were changes in blood pressure and in morbidity and mortality rates. It is
recommended that health care professionals must determine the body mass index and
alcohol consumption of all adult patients and assess sodium consumption and stress
level.29
The contemporary approach to the epidemic of elevated BP and its complications
involves pharmacologic treatment of hypertensive individuals and “lifestyle
20
modification,” which is beneficial for both nonhypertensive and hypertensive persons in
Maryland. A substantial body of evidence strongly supports the concept that lifestyle
modification can have powerful effects on BP. Increased physical activity, a reduced salt
intake, weight loss, moderation of alcohol intake, increased potassium intake, and an
overall healthy dietary pattern, termed the Dietary Approaches to Stop Hypertension
(DASH) diet, effectively lower BP. The DASH diet emphasizes fruits, vegetables, and
low-fat dairy products and is reduced in fat and cholesterol. Other dietary factors, such as
a greater intake of protein or monounsaturated fatty acids, may also reduce BP but
available evidence is inconsistent. The current challenge to health care providers,
researchers, government officials, and the general public is developing and implementing
effective clinical and public health strategies that lead to sustained lifestyle modification.30
A study conducted on 661 hypertensive patients to investigate relationship
between blood pressure control status and lifestyle in Japan. It reveals that average BP
was 129 ± 10/71 ± 11 mmHg and overall rate of achieving goal BP was 60.1%. Achieving
rate of each target BP category was 83.3% in the elderly patients (<140/90 mmHg), 56.7%
in the young/middle patients (<130/85 mmHg) and 45.5% in the patients with diabetes
mellitus/chronic kidney disease/myocardial infarction (<130/80 mmHg). Adherence to
each item of lifestyle modification was as follows: Patients who answered to be conscious
about salt restriction was 80.9%, those with increased intake of fruits/vegetables was
79.0%, reduced intake of cholesterol/saturated fatty acids was 67.9%, presence of obesity
was 37.7%, daily exercise for ≥30 min was 31.9%, habitual alcohol intake was 38.0%,
habitual smoking was 9.8%. Only 22.5% of the patients had no lifestyle items to be
21
modified. On the other hand, 19.6% of patients had more than 3 items to be modified.
Subjects with more than 3 lifestyle items to be modified are more frequently found in
young, male, and obese groups. In conclusion about 60% of the patients achieved goal BP
by the intensive combination therapy. It shows that the lifestyle modification seems to be
important especially for the young, male and obese patients.31
3. Literature related to diet and blood pressure
Randomized trials were done to investigate the long term effect of salt restriction
and blood pressure (BP) control status among Japanese hypertensive outpatients. Three
trials in normotensives (n=2,326), five in untreated hypertensives (n=387) and three in
treated hypertensive (n=801) were included, with follow up from six months to seven
years. Systolic and diastolic blood pressures were reduced at 13 to 60 months in those
given low sodium advice as compared with controls. (Systolic by 1.1 mm Hg, 95%,
diastolic by 0.6 mm hg, 95%) People on anti-hypertensive medications were able to stop
their medication more often on a reduced sodium diet as compared with controls, while
maintaining similar blood pressure control. Evidence from a large and small trial showed
that a low sodium diet helps in maintenance of lower blood pressure following withdrawal
of anti hypertensives.32
A Prospective cohort study was conducted on 5,532 hypertensive patients to
evaluate the association between diet and mortality in the Third National Health and
Nutrition Examination Survey in New York. Among these, 532 participants, 391 (7.1%)
consumed a DASH-like diet. During an average of 8.2 person-years of follow-up, there
were 1,537 all-cause deaths; this included 312 cancer deaths and 788 cardiovascular
22
deaths, of which 447 were due to ischemic heart disease and 142 were due to stroke. After
adjusting for multiple confounders while accounting for the complex survey design by
utilizing survey weights, strata, and clusters in Cox proportional hazards models, a
DASH-like diet was associated with lower mortality from all causes hazard ratio (HR)
95% and stroke HR 95% . Mortality risk from cerebrovascular accident (HR 95%),
ischemic heart disease (HR 95%) and cancer (HR 95%) did not reach statistical
significance. The study concluded that, though findings for specific causes of mortality are
mixed, consumption of a DASH-like diet is associated with lower all-cause mortality in
adults with hypertension.33
A four-year randomized controlled trial assessed whether less severe hypertensive
could discontinue antihypertensive drug therapy, using nutritional means to control blood
pressure. The study population randomly allotted to three groups: group one--discontinue
drug therapy and reduce overweight, excess salt, and alcohol; group two--discontinue drug
therapy, with no nutritional program; or group three--continue drug therapy, with no
nutritional program. In groups one and two patients resumed drug therapy if pressure rose
to hypertensive levels. Loss of at least 4.5 kg (10 + lb) was maintained by 30% of group
one, with a group mean loss of 1.8 kg (4 lb); sodium intake fell 36% and modest alcohol
intake reduction was reported. At four years, 39% in group one remained normotensive
without drug therapy, compared with 5% in group two. The study findings demonstrated
that nutritional therapy may substitute for drugs in a sizable proportion of hypertensive or,
if drugs are still needed, can lessen some unwanted biochemical effects of drug
treatment.34
23
A study conducted on 307 hypertensive patients to evaluate the effects on BP of a
return to the habitual diet following a dietary intervention period in Italy. The study
reveals that patients had reported having reverted to their habitual diet after a period of at
least 6 months on a prescribed low-energy and/or low-sodium diet. Nutritional habits were
investigated by a simple semi quantitative 24-item food-frequency
questionnaire. Patients were divided into tertiles according to their systolic BP. The
groups differed in regard to their body mass index (27.6+/-4, 28.7+/-4, and 30.4+/-6
kg/m(2), respectively, for the low- to high-systolic BP groups, but were similar in regard
to the number of antihypertensive pills taken (2.1+/-0.9, 2.2+/-1.2, 2.2+/-1.3) and
metabolic parameters. Patients in the lowest tertile consumed a diet significantly lower in
the percentage of energy from saturated fats and sodium content and significantly higher
in the percentage of energy from carbohydrate, and the fiber and potassium content in
comparison to the highest tertile. The number of servings of legumes, fish and cooked
vegetables was higher and that of salami and cheese lower in the 1st tertile. Definitively
changing a habitual diet to a healthier one is a difficult task for hypertensive patients. In
conclusion those who return to a diet richer in vegetables, legumes and fish and poorer in
saturated fat and salt achieve better control of their BP, without increasing the number of
antihypertensive pills.35
A study conducted on 436 patients to determine the effects of diet on plasma lipids,
focusing on subgroups by sex, race, and baseline lipid concentrations. The intervention
consisted of 8 wk of a control diet, a diet increased in fruit and vegetables, or a diet
increased in fruit, vegetables, and low-fat dairy products and reduced in saturated fat, total
fat, and cholesterol (DASH diet), during which time subjects remained weight stable. The
24
main outcome measures were fasting total cholesterol, LDL cholesterol, HDL cholesterol,
and triacylglycerol. The result shows that the control diet, the DASH diet resulted in lower
total (−0.35 mmol/L, or −13.7 mg/dL), LDL- (−0.28 mmol/L, or −10.7 mg/dL), and HDL-
(−0.09 mmol/L, or −3.7 mg/dL) cholesterol concentrations (all P < 0.0001), without
significant effects on triacylglycerol. The net reductions in total and LDL cholesterol in
men were greater than those in women by 0.27 mmol/L, or 10.3 mg/dL (P = 0.052), and
by 0.29 mmol/L, or 11.2 mg/dL (P < 0.02), respectively. Changes in lipids did not differ
significantly by race or baseline lipid concentrations, except for HDL, which decreased
more in participants with higher baseline HDL-cholesterol concentrations than in those
with lower baseline HDL-cholesterol concentrations. The fruit and vegetable diet
produced few significant lipid changes. The study researcher concludes that the DASH
diet is likely to reduce coronary heart disease risk. The possible opposing effect on
coronary heart disease risk of HDL reduction needs further study.36
4. Literature related to dietary approaches to stop hypertension
A study was done in USA on dietary approaches to stop hypertension (DASH)
clinical trial: implications for lifestyle modifications in the treatment of hypertensive
patients where 459 participants were included for an 11- week period. Those randomized
to the combination diet (n = 151) had a significant change in systolic (-5.5 mmHg; p <
0.001) and diastolic blood pressure (-3.0 mmHg; p < 0.001) after subtracting the response
to the control diet (n = 154). The fruits-and-vegetables diet (n = 154) produced a
significant but lesser decrease in blood pressure (systolic, -2.8 mmHg; p < 0.001 and
diastolic, -1.1 mmHg; p = 0.07). Hypertensive individuals and African Americans had
25
particularly favorable responses with blood pressure reductions, which were significantly
greater than other subgroups. The combination diet was well-accepted and adherence to
the diet was high (>90%) for all participants. The study shows that the DASH
combination diet is an effective lifestyle modification for lowering blood pressure in
patients with high-normal or Stage 1 hypertension. 37
A longitudinal observational study was conducted in Boston University Medical
Centre, for evaluating Weight, blood pressure, and dietary benefits after 12 months of a
Web-based Nutrition Education Program (DASH for health). After 12 months, 735(26%)
of 2,834 original enrolees were still actively using the program. For subjects who were
overweight/obese (body mass index > 25; n = 151), weight change at 12 months was 4.2
lbs. For subjects with hypertension or pre hypertension at baseline (n = 62), systolic blood
pressure fell 6.8 mmHg at 12 months. Diastolic pressure fell 2.1 mmHg. Based upon self-
entered food surveys, enrolees (n = 181) at 12 months were eating significantly more
fruits, more vegetables, and fewer grain products. They found that continuous use of a
nutrition education program delivered totally via the Internet, with no person-to-person
contact with health professionals, is associated with significant weight loss, blood pressure
lowering, and dietary improvements after 12 months.38
A longitudinal observational study was conducted on 112 participants for one year
in Durham, regarding the Dietary Approaches to Stop Hypertension (DASH)-Sodium trial.
The participants were divided equally into the control group and trial group. The trial
groups significantly increase in their intakes of fruits or juices and vegetables for 12
months. Control participants had no change in DASH food group intake. Both groups
increased sodium intake. Among control participants, systolic and diastolic blood pressure
26
increased 5.33 and 3.20 mm Hg, respectively. Among DASH participants, systolic and
diastolic blood pressure increased 3.12 and 0.79 mm Hg, respectively. There was a
significant effect of the final sodium level by diet on the change in systolic blood pressure
over time. The study concluded that, DASH diet participants ate more fruits/vegetables
and had sustained reductions in blood pressure despite increased sodium intake.39
A randomized study was conducted on 412 participants were randomly assigned to
eat either a control diet typical of intake in the United States or the DASH diet to assess
the effect of different levels of dietary sodium in conjunction with the Dietary Approaches
to Stop Hypertension (DASH) diet, in persons with and in those without hypertension.
The participants were within the assigned diet, participants ate foods with high,
intermediate, and low levels of sodium for 30 consecutive days each, in random order. The
study result shows that, reducing the sodium intake from the high to the intermediate level
reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet and
by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the
intermediate to the low level caused additional reductions of 4.6 mm Hg during the
control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The DASH diet
was associated with a significantly lower systolic blood pressure at each sodium level; and
the difference was greater with high sodium levels than with low ones. As compared with
the control diet with a high sodium level, the DASH diet with a low sodium level led to a
mean systolic blood pressure that was 7.1 mm Hg lower in participants without
hypertension, and 11.5 mm Hg lower in participants with hypertension. The researcher
concludes that ,the reduction of sodium intake to levels below the current recommendation
27
of 100 mmol per day and the DASH diet both lower blood pressure substantially, with
greater effects in combination than singly.40
A study was conducted on 412 participants to study the effects on Blood Pressure
of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH)
Diet in England. Participants were randomly assigned to eat control diet typical of intake
in the United States or the DASH diet. Within the assigned diet, participants ate foods
with high, intermediate, and low levels of sodium for 30 consecutive days each, in random
order. Study reveals that Reducing the sodium intake from the high to the intermediate
level reduced the systolic blood pressure by 2.1 mm Hg (P<0.001) during the control diet
and by 1.3 mm Hg (P=0.03) during the DASH diet. Reducing the sodium intake from the
intermediate to the low level caused additional reductions of 4.6 mm Hg during the
control diet (P<0.001) and 1.7 mm Hg during the DASH diet (P<0.01). The effects of
sodium were observed in participants with and in those without hypertension, blacks and
those of other races, and women and men. The DASH diet was associated with a
significantly lower systolic blood pressure at each sodium level; and the difference was
greater with high sodium levels than with low ones. As compared with the control diet
with a high sodium level, the DASH diet with a low sodium level led to a mean systolic
blood pressure that was 7.1 mm Hg lower in participants without hypertension, and 11.5
mm Hg lower in participants with hypertension. It concludes that reduction of sodium
intake to levels below the current recommendation of 100 mmol per day and the DASH
diet both lower blood pressure substantially, with greater effects in combination than
singly.41
28
The Dietary Approaches to Stop Hypertension (DASH) Trial was designed to
assess the relation between modification of dietary patterns and hypertension in Boston.
DASH provides evidence that existing dietary recommendations can produce concrete
health results in a relatively healthy but sedentary population in which 50% of the
participants were women and 60% were African American. The results showed a 12.1%
decreased risk of CHD in the participants consuming the DASH diet compared with a
slightly increased risk in those consuming the control diet. The decrease was achieved in
the absence of changes in weight or physical activity. Reductions in blood lipids were
greater in men than in women, whereas the lipid response to diet did not differ
significantly between African Americans and non-African Americans.42
A study conducted on 810 participants in local community of Durham to examine
the influence of the PREMIER study lifestyle interventions on dietary intakes and
adherence to the Stop Hypertension (DASH) dietary pattern and the Dietary Reference
Intakes (DRI). An 18-month multicenter, randomized controlled trial comparing two
multicomponent lifestyle intervention programs to an advice only control group design
used. The two active intervention programs were a behavioral lifestyle intervention that
implements established recommendations, and an established intervention plus the DASH
dietary pattern. Both interventions consisted of intensive group and individual counseling
sessions. The control group received a brief advice session after randomization and again
after 6 months of data collection. Dietary intakes were collected by two random 24-hour
recalls at baseline, 6 months, and 18 months. The study results that participants in both the
established intervention and established intervention plus DASH dietary pattern groups
substantially reduced energy, total fat, saturated fat, and sodium intake and these
29
reductions persisted throughout the study. Established intervention plus DASH dietary
pattern group participants increased intakes of fruits, vegetables, dairy, and many vitamins
and minerals; these increases were significantly greater than that of the control and
established intervention groups. A majority of established intervention plus DASH dietary
pattern group participants achieved at least two thirds of the DRI recommendations for
most nutrients at 6 months, despite their reduction in total energy intake. Some but
relatively small recidivism occurred at 18 months. The study concludes that in both
intervention were effective in helping participants follow established recommendations to
control blood pressure. The advice-only control group also made some behavior changes,
mainly decreasing energy and sodium intake. But intervention plus DASH dietary pattern
group developed intake of specific DASH food items. Whereas the established
intervention plus DASH dietary pattern group intervention provides a useful platform to
achieve the DASH dietary pattern and current DRI recommendations.43
A study conducted on 55 hypertensive patients to assess the BP response to
the DASH diet with an antihypertensive medication, losartan, in participants with essential
hypertension. Patients were assigned to 8 weeks of controlled feeding with either a control
diet or the DASH diet in USA. The study result shows that there was no significant
change in ABP during the placebo period on the control diet (n = 28), but there was a
significant reduction in systolic ABP and no change in DBP on the DASH diet (n = 27).
Losartan significantly reduced ABP on the control diet and to a greater extent on
the DASH diet particularly in African Americans. On the DASH diet, Delta SBP on
losartan was inversely related to basal plasma renin activity. The researcher concludes that
the DASH diet enhances the ABP response to losartan in essential hypertension.44
30
5. Literature related to knowledge and effectiveness of structured teaching
programme
A study was conducted on 205 elderly patients to determine the prevalence,
awareness and control of hypertension among elderly community in Penang, Malaysia. In
this population there are 74 hypertensive patients resulting in an overall prevalence of
36%, with 81% of patients being initially aware of this diagnosis. This relatively low
hypertension prevalence rate may be because residents have a fairly sheltered lifestyle
with less social stress and a daily routine that incorporates adequate exercise. Similarly,
the high hypertension awareness rate compared to reported figures in the community may
be because residents are more regularly monitored by the attending medical care-givers.
At the beginning of the study, only 34% of hypertensive patients were well controlled
with a blood pressure less than 140/90 mm Hg. This proportion rose to 53% at the end of
study period showing that closer medical attention plays an important part in achieving
better outcomes. Compliance is better at a residential home because medication is served
by their care-givers and cost is absorbed in this charitable organization. This study
suggests that hypertension awareness and control can be reasonable for the elderly in a
residential home.45
A random household survey conducted on 482 individuals (212 males and 270
females) to determine the prevalence and possible risk factors for hypertension and
pre hypertensive state in Trivandrum City of Kerala (South India). Overall prevalence of
hypertension was 47% (n = 226) with equal sex ratio; 109 (21.6%) had stage-I
31
hypertension, 45 (9.34%) had stage-II hypertension and 72 were taking drug treatment.
Only 55 (11.4%) individuals had normal BP, while 201 (41.7%) were pre hypertensives.
Only 81 (16.8%) hypertensive patients were aware of their disease. Among the parameters
such as dietary habits, physical activity, educational standards, salt intake, and diabetes
mellitus,Only high salt diet (P= 0.03) and diabetes mellitus (P= 0.004) had a significant
association with hypertensive state. The study concludes that prevalence of hypertension
is high but the awareness is low in our community, and intervention is necessary to
impose control measures and to improve awareness.46
A study on knowledge and perceptions about hypertension was conducted among
neo- and settled-migrants in Delhi, India .Data pertaining to blood pressure, height,
weight; socio-demographic details and knowledge and perceptions on hypertension were
obtained from a total of 453 individuals (227 neo-migrants and 226 settled-migrants) aged
20 years and above study results reveals that around 62% of respondents had heard of
blood pressure. This awareness was comparatively more among women and settled-
migrants. Less than half of the respondents considered hypertension a serious condition,
and a considerable proportion did not perceive that hypertension leads to other diseases.
With regard to prevention and control, more than one third suggested lessening tension
and anger followed by reducing salt intake/dietary changes, and a very small proportion
mentioned that exercise would help. Regarding treatment, three fourths of the respondents
considered that hypertension can be treated, mostly by medicines and only 10%
considered lifestyle changes along with medicines. The study concluded that knowledge
about hypertension was only moderate and comprehensive knowledge was lacking, and
32
recommended for the awareness programme for preventing and controlling hypertension
along with the provision of primary health care services.47
A study findings congruent with the study to assess effectiveness of planned
teaching programme on healthy lifestyle modifications to prevent hypertension. The total
mean percentage of the pre-test knowledge score was 38.13% with mean and SD 15.25 ±
3.11 and the mean post-test knowledge score was 73.56% with mean and SD 29.41± 3.62.
Significance of difference between the pre-test and post-test knowledge scores was
statistically tested using paired ‘t’ test and it was found to be very highly significant
(t=31.505, P<0.005). The pre-test knowledge scores of the adolescents in relation to
selected demographic factors were compared and tested statistically using chi-square test.
Significant association (χ2=4.6952; P<0.05) was found between the pre-test knowledge
score of the adolescents and their exposure to previous information.48
33
4. METHODOLOGY
This chapter comprises of the research approach used, research design, setting of
the study used, population, sample selection, sampling technique, development and
description of the tool, pilot study, method of data collection and plan for data analysis.
The study conducted was to evaluate the effectiveness of STP on knowledge regarding
DASH diet among Hypertensive patients.
1. RESEARCH APPROACH
In the present study, quantitative approach was considered to be the most
appropriate and adopted to assess the effectiveness of structured teaching programme on
knowledge regarding DASH diet among Hypertensive patients.
2. RESEARCH DESIGN
The research design selected for the present study was Pre-experimental one group
pre test and post test design in which pre-test was conducted followed by structured
teaching programme (STP) and then conducing post-test for the same group after 8 days.
(Table 1)
34
Table 1: Description of the research design
Group Pre-test Intervention Post-test
Hypertensive patients
at Kumbalgudu PHC
area, Bangalore.
Day I
Assessment of
knowledge by
conducting structured
knowledge
questionnaires
regarding DASH diet
among Hypertensive
patients.
Day I
Structured teaching
programme on DASH
diet among
Hypertensive
patients.
After 8 days of
structured teaching
programme,
knowledge of
Hypertensive
patients is assessed
by conducting
same knowledge
questionnaires.
O1 X O2
Effectiveness of STP= O2 – O1
O1: Knowledge scores regarding DASH diet among Hypertensive patients before
intervention.
O2: Knowledge scores regarding DASH diet among Hypertensive patients after
intervention.
X: Structured teaching programme on DASH diet.
35
3. SETTING OF THE STUDY
The study subjects were selected from the Kumbalagudu PHC area Bangalore. The study
conducted in Kumbalagudu, Gerupalya, Hospalya and Kanminke Colony.
i. Population
Population in the study consists of Hypertensive patients at Kumbalagudu PHC area,
Bangalore.
ii. Sample Size and Sampling Technique
The sample size for the present study is 60 Hypertensive patients at Kumbalagudu
PHC area, Bangalore and samples were selected by convenient sampling technique.
iii. Criteria for Selection of Sample
a) Inclusion Criteria
• Hypertensive patients who are available and willing to participate in the study.
• Hypertensive patients who can communicate in Kannada or English.
b) Exclusion Criteria
• Hypertensive patients who are sick at the time of data collection.
• Who have attended previous educational programme on DASH diet.
• Hypertension with diabetes mellitus patients.
4. TOOL OF RESEARCH
Based on the objectives of the study, a structured questionnaire was prepared in
order to assess the knowledge of hypertensive patients on DASH diet.
36
a) Selection and Development of Instrument
A structured questionnaire was prepared to assess the knowledge of hypertensive
patients regarding DASH diet.
The tool was selected based on the research problem, review of related literature
and with suggestions and guidance of experts in the field of Community Health Nursing,
Medical Surgical Nursing, General Physician, Statistician, Dietician, English language
expert, Kannada Language expert, Psychologist and sociologist. The tool was prepared on
the basis of objectives of the study. The final tool was prepared with guidance and
suggestion of the guide. These steps were followed in preparing the tool:
• A thorough review of literature to provide adequate content and information.
• Consultation and discussion with experts from Community Health Nursing,
Medical Surgical Nursing, Statistician, Dietician, English language expert,
Kannada language expert, Psychologist and Sociologist.
• Reviewing of text books.
• Discussion and consultation with the statistician.
• The final tool was prepared and translated to Kannada with guidance and
suggestion of the guide.
b) Preparation of Blue Print
The blue print of the structured questionnaires was prepared according to the
demographic characteristics, knowledge of hypertensive patients regarding DASH diet.
The blue print consists of 34 items.
37
c) Description of the Tool
After a thorough review of literature related to the topic and considering the
suggestions of experts a structured questionnaire was developed.
The structured questionnaires are of two parts:
Part I: Consists of 9 demographic characteristics of respondents seeking information such
as age, gender, religion, dietary pattern, educational status, occupation, monthly family
income, source of information regarding DASH diet, duration of disease.
Part II: Consists of 34 items pertaining to knowledge regarding DASH diet.
Scoring of the Items
There were 34 items. Each item has four options with one accurate answer. The
score for correct response to each item was “one” and incorrect response was “zero”. Thus
for 34 items maximum obtainable score was 34 and minimum score was zero.
Obtained Score
Percentage = -------------------------------× 100
Total Score
To find out the association with the selected demographic variables and knowledge
scores, respondents were categorize into three groups.
Below 50% - Inadequate knowledge
51-75% - Moderate knowledge
38
Above 75% - Adequate knowledge
5. TESTING OF THE TOOL
• Content Validity
Content validity of the tool was established by obtaining the suggestions from
experts. The tool was validated by 10 experts in the field of Community Health
Nursing, Medical Surgical Nursing, General Physician, Statistician, Dietician, English
language expert, Kannada Language expert, Psychologist and sociologist.
Modifications were made on the basis of recommendations and suggestion of the
experts. After consulting guide and statistician, the final tool was reframed. Tool was
found to be valid and suitable for hypertensive patients.
• Reliability
The tool after the validation was subjected to test for its reliability. The reliability
of the tool was computed by split half Karl Pearson’s correlation formula (raw score
method). The reliability co-efficient of knowledge found to be 0.93 revealing the tool is
feasible for administration for the main study. Since the reliability co-efficient for scale
r > 0.70, the tool was found to be reliable and feasible. (r=2r / 1+r) Brown�s prophecy
formula was used.
6. DEVELOPMENT OF THE STRUCTURED TEACHING PROGRAMME
The structured teaching programme was developed based on the review of the
related research, journals, books and the objectives of the study.
39
The following steps were adopted to develop the structured teaching programme.
• Development of content blue print.
• Development of structured teaching programme.
• Establishment of content validity of structured teaching programme.
• Pre-testing of structured teaching programme. Content blue print
A blue print of objectives and content items pertaining to knowledge of hypertensive
patients regarding DASH diet was prepared for the construction of structured teaching
program.
Preparation of structured teaching programme
(i) Preparation of first draft of structured teaching programme:
The first draft of structured teaching programme was developed based on the
objectives, criteria checklist, literature reviewed and the opinion of experts. The main
factors that were kept in mind while preparing structured teaching programme were:
literacy level of the sample, method of teaching to be adopted, simplicity of language,
relevance of teaching aids and attention span of hypertensive patients.
(ii) Content validity of the teaching plan The initial draft of structured teaching
programme was given to experts in the field along with the tool. The suggestions were
incorporated in the structured teaching programme and tool.
40
(iii) Preparation of final draft of structured teaching programme
The final draft of structured teaching programme was prepared after incorporating
suggestions of the experts; the final teaching plan was finalized after the modifications
based on the suggestions of guide.
(iv) Selecting the method of teaching
Lecture cum discussion was selected as an appropriate method of teaching for
hypertensive patients.
(v)Selection and preparation of appropriate audio-visual aids
Chalk board and the charts were considered as visual aids to increase the impact of
teaching.
(vi)Planning to implement the structured teaching programme
The time and date to implement the structured teaching programme was planned and
decided in co-ordination with the hypertensive patients.
(vii) Determining the method of evaluating the structured teaching programme
The evaluation of structured teaching programme was planned through conducting
post-test after eight days of implementation of structured teaching programme.
(viii) Description of structured teaching programme
The STP was titled Dietary Approaches to Stop Hypertension. The structured
teaching plan was structured for one session, which was prepared to enhance knowledge
of hypertensive patients on DASH diet. It consisted of the following content area:
1. Defines hypertension
2. Lists out the causes for hypertension
3. Enumerates the risk factors for hypertension
41
4. Explains the signs and symptoms of hypertension
5. Describes the complications of hypertension
6. Explains the importance of lifestyle modifications for control of hypertension
7. Discuss about dietary approaches to stop hypertension(DASH) diet
8. Define DASH diet
9. Explains the principles of DASH diet
10. Explains the importance of DASH diet
11. Discuss about components of DASH diet
7. PILOT STUDY
After having obtained formal administrative approval from the medical officer in
the Kumbalagud PHC, Bangalore, participants were informed about the purpose of the
study and consent was taken from them. The pilot study was conducted from the 7-09-
2012 to 14-9-2012. Data was collected from ten samples with the help of the structured
questionnaire schedule.
The subjects selected for pilot study were excluded in the actual study. The pre-
testing of the structured questionnaire was done to check the clarity of the items, their
feasibility, reliability and practicability. It was administered to ten hypertensive patients.
The samples chosen were similar in characteristics to the population under study. It was
found that each respondent took 35-40 minutes to complete the structured questionnaire
and it was found that the items were simple and comprehend.
42
The mean percentage knowledge score in post-test (73.23%) was higher than the
mean percentage knowledge score in pre-test (41.47%). The percentage enhancement
(48.98%) was found to be significant at 5 % (p<0.05) level. The findings of the pilot study
revealed that the study is feasible.
8. PROCEDURE FOR DATA COLLECTION
(a) Permission from the concerned authority
Formal permission was obtained from the medical officer in Kumbalagudu PHC
Bangalore.
(b) Period of data collection
The data was collected from 2/11/2012 to 30/11/2012 for a period of 4 weeks at
Kumbalagudu PHC area (Kumbalagudu, Gerupalya, Kanminke) Bangalore.
(c) Pre-test (O1)
The structured questionnaire was used to collect the data by conducting structured
interview schedule from the hypertensive patients at Kumbalagudu PHC area, Bangalore.
After obtaining permission from the authority and consent from the subjects, the
investigator collected data from 60 hypertensive patients at their houses that took 35-40
minutes for each patient to complete the structured questionnaires.
(d)Implementation of Structured Teaching Programme (X)
Followed by pre-test, on same day structure teaching program was conducted in
Kannada by the investigator for a period of 50 minutes by using appropriate visual aids.
(e) Post-test (O2)
The same structured interview schedule was used to collect the post test data. Post
test data was collected on 8th day after Structured Teaching Programme.
43
9. PLAN OF DATA ANALYSIS
The data obtained was analyzed based on the objectives of the study using
descriptive and inferential statistics.
Statistical analysis of data includes;
• Organization of data in master sheet.
• Frequencies and percentages to be used for analysis of demographic
characteristics.
• Calculation of mean, standard deviation of pre-test and post-test scores.
• Application of paired t” test to ascertain whether there is significant difference in
the mean knowledge score of pre-test and post-test.
• Application of Chi-square to find the association between demographic variables
with knowledge scores.
SUMMARY
This chapter dealt with research methodology which included the research
approach using one group pre-test post-test design, the setting and population, the
development of the instrument/tool, structured teaching programme, the description of
data collection, data collection procedure and plan for data analysis.
44
Figure 2: Schematic Representation of Research Design
PURPOSE
To evaluate the effectiveness of structured teaching programme on DASH diet among hypertensive patients
TARGET POPULATION: Hypertensive patients
Convenient Sampling Technique
SAMPLE
60 Hypertensive patients in Kumbalagudu PHC area, Bangalore
TOOL
Structured questionnaire to assess the knowledge regarding DASH diet among hypertensive patients
PRE‐TEST
STRUCTURED TEACHING PROGRAMME
POST‐TEST
ANALYSIS
Descriptive and Inferential ststistics
INTERPRETATION OF STUDY FINDINGS
ACCESSIBLE POPULATION: Hypertensive patients residing at Kumbalagudu PHC area, Bangalore
REPORT
45
5. RESULTS
Analysis and interpretation of data
Analysis is the categorizing, ordering, manipulating and summarization of the
data to obtain the answers to the research questions. The interpretation of tabulated data
can bring light to the real meaning and effectiveness of the findings.
This chapter presents the analysis and interpretation of the data collected from 60
hypertensive patients at Kumbalagudu PHC area, Bangalore.
A quantitative approach was adopted to assess the effectiveness of structured
teaching programme on Dietary Approaches to Stop Hypertension among hypertensive
patients.
The data was collected using structured questionnaires. The data collected from the
respondents were organized, tabulated, analyzed and interpreted by applying descriptive
and inferential statistics, based on the objectives of the study.
OBJECTIVES OF THE STUDY
1. To assess the level of knowledge of hypertensive patients regarding DASH
diet.
2. To assess the effectiveness of structured teaching programme on
knowledge of hypertensive patients regarding DASH diet.
3. To find association between knowledge of hypertensive patients and
selected socio demographic variables.
46
PRESENTATION OF DATA
The data were entered into the master sheet, for tabulation and statistical processing.
The findings were classified and presented under the following headings.
1. Distribution of samples according to demographic variables.
2. Aspect wise & overall distribution of pre and post test knowledge scores.
3. Comparison between pre-test and post-test knowledge scores.
4. Association between pre-test knowledge scores and selected demographic variables.
SECTION-I
DISTRIBUTION OF PARTICIPANTS BASED ON DEMOGRAPHIC VARIABLES:
Table 2: Classification of respondents by age (years)
Demographic characteristics of sample Frequency (f) Percentage (%) Age (in years) 35-45 10 16.70
45-55 32 53.30
55 & above 18 30.00
Above table depicts that majority (53.30%) of the respondents belongs to the age group of
45-55 years, 30% of respondents were in the age group of 50 & above and 16.70% of
respondents were in the age group of 35-45years.
47
Figure 3: Distribution of respondents by Age (years)
48
Table 3 : Classification of respondants by gender
Demographic characteristics of sample Frequency (f) Percentage (%)
Gender Male 47 78.30
Female 13 21.70
The above table depicts that majority of the respondents (78.30%) were males and
remaining 21.70% were females.
Figure 4: Distribution of respondents by gender
49
Table 4: Classification of the respondents by dietary pattern
Demographic characteristics of sample Frequency (f) Percentage (%)
Dietary pattern Vegetarian 02 3.30
Mixed 58 96.70
From the above table it is observed that the majority (96.70%) of respondents were
following mixed type of dietary pattern and remaining 3.30% were vegetarian.
Figure 5: Distribution of respondents by dietary pattern
50
Table 5: classification of the respondents by education
Demographic characteristics of sample Frequency (f) Percentage (%)
Education No formal education 8 13.33
Primary education 7 11.68
Secondary education 20 33.33
Higher secondary
education
20 33.33
Graduation & above 5 8.33
The above table depicts that 33% of respondents had secondary education, 33% had
higher secondary education, 13.33% had no formal education, 11.68% had primary
education and remaining 8.33% were graduated.
51
Figure 6: Distribution of respondents by education.
52
Table 6: classification of the respondents by occupation
Demographic characteristics of sample Frequency (f) Percentage (%)
Occupation
Coolie 2 3.30
House wife 6 10.00
Agriculture 24 40.00
Private employee 27 45.00
Govt.employee 1 1.70
Above table depicts that 45% of respondents were private employees, 40% were
agriculturist, 10% were housewives, 3.30% were coolie and remaining 1.70% were Govt.
employees.
53
Figure 7: Distribution of respondents by occupation.
54
Table 7: classification of the respondents by monthly income
Demographic characteristics of sample Frequency (f) Percentage (%)
Monthly income
(Rs)
1,000-5,000 31 51.70
5,001-10,000 17 28.30
10,001-15,000 10 16.70
15,001 & above 2 3.30
Above table depicts that majority (51.70%) of respondents had income between1000-
5000, 28.30% of respondents had income between5,001-10,000, 16.70% of respondents
had income between 10,001-15,000 and remaining 3.30% had income between 15,0001
and above.
Figure 8: Distribution of respondents by monthly income
55
Table 8: Classification of the respondents by source of information regarding
importance of diet in hypertension.
Demographic characteristics of sample Frequency (f) Percentage (%)
Source of information
Health personnel 29 48.30
Friends & Relatives
0 0
Mass media 0 0
No information 31 51.70
Above table depicts that majority (51.70%) of respondents had no information and
48.30% of respondents were aware of importance of diet in hypertension by health
personnel.
Figure 9: Distribution of respondents by source of information regarding importance
of diet in hypertension.
56
Table 9: Classification of the respondents by duration of hypertension
Demographic characteristics of sample Frequency (f) Percentage (%)
Duration of
hypertension
(years)
< 1 19 31.70
1-3 21 35.00
4-6 17 28.30
>6 3 5.00
The above table depicts that 35% of the respondents had duration of hypertension for 1-3
years, 31.70% of the respondents duration of hypertension was <1 year, 28.30% of the
respondents have history of hypertension for 4-6 years and remaining 5% of the
respondents duration of hypertension was >6 years.
Figure 10: Distribution of respondents by duration of hypertension.
57
2. Overall and aspect wise distribution of scores during the pre-test and post-test
Table 10: Overall and aspect wise pre-test mean knowledge scores.
Sl. No.
Aspect wise
No of items
Range Median Mean SD Mean %
1 Knowledge regarding Hypertension and its complications
10 0-8 4 3.83 1.48 38.30
2 DASH diet
24 2-18 7 7.51 2.87 31.30
Overall 34 6-26 11 11.35 3.6 33.40
Table 10: shows the mean knowledge score obtained by the patients in the aspect of
knowledge regarding hypertension and its complications for maximum score of 10 was
3.83(SD-1.48) and mean score percentage was 38.3, in the aspect of DASH diet mean
knowledge score obtained by patients for maximum score of 24 was 7.51(SD- 2.87) and
mean score percentage was 31.29. The overall knowledge score obtained by the patients
with hypertension in the pre test was 11.35 with standard deviation of 3.6 and mean score
percentage was 33.38.
58
Table 11: Overall and aspect wise post-test mean knowledge scores.
From the above table it is observed that the mean knowledge score obtained by the
patients in the aspect of knowledge regarding hypertension and its complications for
maximum score of 10 was 7.51(SD-1.12) and mean score percentage was 75.1, in the
aspect of DASH diet mean knowledge score obtained by patients for maximum score of
24 was 18.75(SD- 1.72) and mean score percentage was 78.12. The overall knowledge
score obtained by the patients with hypertension in the post test was 26.26 with standard
deviation of 2.30 and mean score percentage was 77.23.
SI NO
Area wise No of items
Range
Median Mean S.D Mean %
1 Knowledge regarding Hypertension and its complications
10 4-10 7.5 7.51 1.12 75.1
2 DASH diet
24 14-23 19 18.75 1.72 78.12
Combined
34 21-30 26 26.26 2.30 77.23
59
3. Comparison between pre test and post test knowledge scores
Table 12: Aspect wise enhancement of knowledge scores on Dietary approaches to
stop hypertension.
Knowledge
aspect
Pre –test
Post –test
Percentage
of
enhancement Mean
S.D
Mean S.D
Hypertension
3.83 1.48 7.51 1.12 96.08
DASH diet 7.51 2.87 18.75 1.72 149.66
Overall 11.35 3.6 26.26 2.30 131.36
It was found from the present study (table 12) that the mean knowledge score of 3.83 and
7.51 in the pre-test and post-test respectively was found in the aspect of hypertension, with
an enhancement of 96.08 percentages. The highest enhancement of knowledge (149.66%)
was observed in the aspect of DASH diet with pre and post-test mean of 7.51 and 18.75
respectively. The overall pre and post-test mean scores were 11.35 and 26.26 which gives
an enhancement of 131.36 percent.
60
Figure 11: Distribution of aspectwise enhancement of knowledge scores on DASH.
61
Table 13: Distribution of samples according to knowledge level on Dietary
approaches to stop hypertension.
Knowledge level
Classification of samples
Pre- test Post-test
Frequency (f) Percent (%) Frequency (f) Percent (%)
Inadequate (<50%) 39 65 0 0
Moderate (51-75%) 20 33.33 13 21.66
Adequate (>75%) 1 1.66 47 78.33
Total 60 100 60 100
Table 13: reveals that majority (65 %) of samples had inadequate knowledge, 33.33% had
moderate knowledge and 1.66% had adequate knowledge regarding dietary approaches to
stop hypertension in the pre-test. In the post-test, majority (78.33%) of the respondents
had adequate knowledge and 21.66% of the samples had moderate knowledge about the
topic.
62
Figure 12: Distribution of respondents according to knowledge level on DASH.
63
Table – 14: Aspect wise analysis of pre-test and post-test knowledge scores.
Aspect wise Pre –test Knowledge scores
Post –test Knowledge scores
t value (paired)
DF P value inference
Mean
S.D
Mean S.D
Hypertension
3.83 1.48 7.51 1.12 15.53 59 Significant <0.001
DASH diet 7.51 2.87 18.75 1.72 24.96 59 Significant <0.001
Overall 11.35 3.6 26.26 2.30 26.58 59 Significant <0.001
Note: *: Significant (P≤ 0.05); ** Highly significant (P≤ 0.001)
NS: Not significant (P>0.05)
The above table summarizes that the difference between the pre-test and post-test
mean knowledge score in the aspect of Hypertension is t=15.53 followed by DASH diet
t=24.96, were found to be highly significant. The calculated "t" value26.58 is greater than
the table value 2.106 at 0.05 level of significance. As there is increase in knowledge
scores among hypertensive patients in all the aspects of Dietary approaches to stop
hypertension after administering the structured teaching programme, the teaching
programme on Dietary approaches to stop hypertension was effective in terms of gain in
knowledge among Hypertensive patients.
64
4. Association between pre test knowledge scores and selected demographic
variables.
Table – 15: Findings related to association between pre-test knowledge scores with
selected demographic variables.
Association between Age, Sex, Dietary pattern, and Education with level of knowledge
Category of response
Pre-test knowledge score Chi-square value
Df Critical value
Statistical Inference ≤ Median > Median Total
Age (yrs)
≤ 55 25 17 42
1.845 1 3.841 Not significant
> 55 14 4 18
Total 39 21 60
Sex
Male 30 17 47 Fisher's exact probability = 0.495
Not significant
Female 9 4 13
Total 39 21 60
Dietary pattern
Vegetarian 1 1 2 Fisher's exact probability = 0.581
Not significant
Mixed 38 20 58
Total 39 21 60
Education No formal/ Primary
9 6 15
1.790 2 5.99 Not significant
Secondary 16 5 21 Higher secondary/ Graduates
14 10 24
Total 39 21 60
65
Association between Occupation, Income, Source of information and
Duration of HTN with level of knowledge
Category of response
Pre-test knowledge score Chi-square value
df Critical value
Statistical Inference ≤
Median > Median
Total
Occupation
Agriculturist 14 10 24
0.781 1 3.841 Not significant
Others (Private employee/ Housewife/ Coolie/ Govt. employee)
25 11 36
Total 39 21 60
Income
1001-5000 20 11 31
0.007 1 3.841
Not significant
> 5000 19 10 29
Total 39 21 60
Source of information Health personnel
18 13 31
1.356 1 3.841 Not significant
No information
21 8 29
Total 39 21 60
Duration of HTN (yrs)
< 1 15 4 19
2.592 2 5.99 Not significant
1- 3 13 8 21
> 3 11 9 20
Total 39 21 60
66
Note: 1. The responses of some of the demographic variables have been merged as
the expected frequencies was less than or equal to 5.
2. Fisher’s exact probabilities are computed in a 2 x 2 contingency
tables where ever the expected cell frequencies are less than or equal to 5.
3. Not significant (P>0.05); Significant (P≤ 0.05)
The analysis of association between the selected demographic variables and the
overall knowledge score of hypertensive patients during pre-test reveals the following
information. The χ2 value was computed to find association between the pre-test knowledge
level of hypertensive patients on Dietary approaches to stop hypertension and selected
demographic variables. The calculated χ2 value is less than the critical value for all
demographic variables such as age, gender, religion, dietary pattern, educational status,
occupation, income, duration of hypertension and source of information were not
significant at 0.05 level. Thus research hypothesis (H2) was rejected for all the
demographic variables. Thus there is no significant association between pre-test knowledge
scores of hypertensive patients regarding DASH diet and selected socio-demographic
variables.
67
6. DISCUSSION
Present study is to evaluate the “Effectiveness of a structured teaching programme on
knowledge of hypertensive patients on dietary approaches to stop hypertension in
Kumbalagud PHC area, Bangalore”.
A structured interview schedule was used to collect the data. A pre-experimental one-
group pre-test post-test design was used to evaluate the knowledge of 60 samples
(hypertensive patients) on dietary approaches to stop hypertension. The pre-test was
followed by implementation of structured teaching programme and post- test was
conducted after 7 days to evaluate the effectiveness of teaching programme.
The findings of the study are discussed under the following headings:
Section 1: Demographic characteristics
Section 2: Assessment of knowledge of hypertensive patients on dietary approaches to
stop hypertension .
Section 3: Evaluating the effectiveness of structured teaching programme on dietary
approaches to stop hypertension.
Section 4: Association between demographic variables and knowledge scores.
Section 5: Testing of the hypothesis.
Section 1
Demographic characteristics
In the present study, the findings reveal that majority (53.30%) of the respondents
belongs to the age group of 45-55 years, 30% of respondents were in the age group of 50
& above years and 16.70% of respondents were in the age group of 35-45years; regarding
68
gender majority of the respondents (78.30%) were males and remaining 21.70% were
females; with regard to religion 100% of the respondents were Hindus.
In contrary to the findings of the present study a cross sectional study was conducted
to determine the age specific prevalence of hypertension and blood pressure levels in
relation to diet and lifestyle factors among North Indians, age range 25-64 years. The
study results that in both the sex, the prevalence rates and BP level increased with older
age.24
In relation to dietary pattern dietary pattern majority (96.70%) of respondents were
mixed type of dietary pattern and remaining 3.30% were vegetarian.
A study congruent with the present study findings a cross sectional survey was
conducted on 979 study participants in Sidama Zone, to assess the Prevalence and
determinants of hypertension in rural and urban areas. The Bivariate analysis shows that
hypertension was highly occurring more in those above 30 years old, those with the family
history of hypertension, and a BMI > or =25 kg/m2. Multivariate analysis showed similar
correlation of increased possibility of hypertension with being over 30 years, having a
family history of hypertension, a BMI > or =25 kg/m2 and excess meat consumption.23
With regard to education 33% of respondents had secondary education, 33% had
higher secondary education, 13.33% had no formal education, 11.68% had primary
education and remaining 8.33% were graduated; regarding occupation majority 45% of
respondents were private employees, 40% of respondent’s occupation was agriculture,
10% were housewives, 3.30% were coolies and remaining 1.70% were Govt. Employees;
69
regarding monthly family income majority (51.70%) of respondents had income
between1000-5000, 28.30% of respondents had income between5,001-10,000, 16.70% of
respondents had income between 10,001-15,000 and remaining 3.30% had income
between 15,0001 and above.
A similar study supported by a cross-sectional analysis of the Survey of Lifestyle,
Attitudes and Nutrition (SLÁN). On 10364 individual to assess Sociodemographic, health
and lifestyle predictors of poor diets. The result shows that adjusting for age and gender, a
number of sociodemographic, lifestyle and health-related variables were associated with
poor-quality diet: social class, education, marital status, social support, food poverty (FP),
smoking status, alcohol consumption, underweight and self-perceived general health.
They were not significantly altered in the multivariate analysis, although the association
with social support was attenuated and that with food poverty was borderline significant
(OR = 1·2, 95 % CI 1·03, 1·45).26
With regard to source of information majority (51.70%) of respondents had no
information and 48.30% of respondents knew regarding importance of diet in
hypertension by health person; regarding duration of hypertension 35% of the respondents
gave history of 1-3 years, 31.70% of the respondent’s duration of hypertension was <1
year, 28.30% of the respondent’s duration of illness was 4-6 years and remaining 5% of
the respondents duration of hypertension was >6 years.
70
Section 2
Assessment of knowledge of hypertensive patients on dietary approaches to stop
hypertension.
In the present study the pre test knowledge score of hypertensive patients on DASH
diet, majority (65 %) of samples had inadequate knowledge, 33.33% had moderate
knowledge and 1.66% had adequate knowledge.
Similar to the findings of present study a population-based survey of adults in
Northern Ireland was conducted on the awareness of hypertension or high blood pressure,
and of measures of prevention. Almost all subjects (92 per cent) had their blood pressure
checked, most within the last five years. The majority were aware that high blood pressure
is detrimental to health, but there was a low awareness of measures of prevention.49
Section 3
Effectiveness of structured teaching program on knowledge regarding Dietary
Approaches to Stop Hypertension among hypertensive patients.
The mean post-test knowledge score was 26.26 which is higher than mean pre-test
score of 11.35. The scores denoted that the structured teaching program was effective.
Thus, the research hypothesis, H1 was accepted by the researcher. Mean difference of pre
test and post test was 14.91. The significant difference between the pre-test and post-test
was tested by using paired ‘t’ test and level of significance was set at 0.05. The
computed‘t’ value of 26.58 is more than the table value of 2.1065 indicating that there is
significant difference between pre-test and post-test knowledge score. Thus, it clearly says
that the STP was effective in increasing the knowledge of subjects.
71
Therefore, it was concluded that structured teaching programme was effective in
improving the knowledge of samples under study.
A study findings congruent with the study to assess effectiveness of planned
teaching programme on healthy lifestyle modifications to prevent cardiovascular diseases.
The total mean percentage of the pre-test knowledge score was 38.13% with mean and SD
15.25 ± 3.11 and the mean post-test knowledge score was 73.56% with mean and SD
29.41± 3.62. Significance of difference between the pre-test and post-test knowledge
scores was statistically tested using paired ‘t’ test and it was found to be very highly
significant (t=31.505, P<0.005).48
Section 4
Association between pre-test knowledge regarding DASH diet and selected variables.
There is no significant association found between knowledge scores with selected
sociodemographic variables like age, gender, religion, dietary pattern, education status,
occupation, income, source of information and duration of hypertension.
In contrary to the findings of the present study a cross-sectional analysis to investigate
sociodemographic and lifestyle predictors of poor-quality diet in a population was
conducted in Ireland. The study Results was Adjusting for age and gender, a number of
socio demographic, lifestyle and health-related variables were associated with poor-
quality diet: although the association with social support was attenuated and that with food
poverty was borderline significant (OR = 1·2, 95 % CI 1·03, 1·45).50
72
Section 5
Testing of the hypothesis.
H1: There is significant difference between pre test & post test knowledge scores
regarding DASH diet among hypertensive patients.
The research hypothesis H1 stated in the study is accepted since there was significant
change found between the pre-test (38.3%) and post-test (75.1%) knowledge scores of
hypertensive patients regarding DASH diet as obtained paired t value(26.58 ) is greater
than table value(2.009575) at P < 0.05 level. Hence the stated research hypothesis H1 is
accepted.
H2: There is significant association between pre test knowledge scores with selected
demographic variables.
The computed χ2 values for selected demographic variables are less than the table
value at 0.05 level of significance. Hence the investigator reject the stated research
hypothesis because there is a no significant association between pre-test knowledge scores
and demographic variables like age, gender, religion, dietary pattern, education,
occupation, income, source of information and duration of hypertension.
73
7. CONCLUSION
This chapter presents the conclusions drawn, implications, limitations, suggestions and
recommendations.
The focus of this study was to evaluate the Effectiveness of structured teaching
programme on the knowledge of hypertensive patients regarding DASH diet at
Kumbalagud PHC area, Bangalore. 60 samples were drawn from population using simple
random sampling technique. The data was collected by the structured interview schedule.
Data was analyzed and interpreted by applying statistical methods. The hypertensive
patients willingly participated in the study.
Further, the conclusion drawn on the basis of the findings of the study includes:
The overall mean and mean percentage of pre-test knowledge scores on DASH diet was
found to be 11.35 and 33.38% respectively. It indicates that the majority of the
respondents had inadequate knowledge on DASH diet.
The overall post test mean and mean percentage of knowledge score found to be
26.26 and 77.23% respectively. It indicates that STP was effective in enhancing the
knowledge of hypertensive patients regarding DASH diet.
On the other hand it was observed that sorce of information has significant association
with the respondent�s knowledge on DASH diet. But there is no significant association
found with other demographic variables such as age, gender, religion, dietary pattern,
education, occupation, income, and duration of hypertension.
74
IMPLICATIONS
From the findings of the study, the following implications are stated. The
implications of this study are important in the areas of nursing education, practice,
administration and research.
Nursing education
Nursing education plays an important role in preparing the nurses for wellbeing of
the people in various areas. The present study has implication on nursing education. The
findings of the study in terms of its effectiveness may encourage the teachers and nursing
staff to impart education in an effective way. Nursing education should prepare nurses
with the potential for imparting health information effectively and assisting people in
developing their self-care potential. The nursing curriculum is a means through which
future nurses are prepared. The concept of health has been changing from time to time.
Traditionally, health has disease prevention as its central focus, which has emerged into
complex multidimensional models towards the phenomenon of health. In the present era,
more emphasis is given on preventive and promotive health aspects than curative.
Teachers need to be aware of their role in DASH diet. Nurse educators conduct health
education programme on DASH diet for hypertensive patients.
Nursing practice
The obligation of the nursing profession is the provision of care and service to the
human beings. Several implications may be drawn from the present study for nursing
practice. Health professionals, especially community health nurses should be motivated to
75
give health teaching aspects of hypertension. They should regularly conduct health
education programmes and health camps in order to appraise the health status of each
hypertensive patient. These programmes should also help the student nurses to identify the
health problems of the hypertensive patients in their earlier stages and control them easily.
Thus, nurse plays an important role in early detection and treatment of hypertensive
diseases in community it directly helps for the effective implementation of health
education programme.
Nursing administration
Nursing administration is very important in the supervision and management of
nursing profession. The nurse administrators need to organize continuing nursing
programmes for nursing personnel and motivate them to conduct health education
programmes which are beneficial to the community. The nursing administrators should
see that adequate teaching time is allowed for the personnel for self-mastery during the
course so that they can apply their knowledge to different clients.
Nursing research
Nursing practice need to be based on scientific knowledge. Research should be
focused on health promotion programmes using various methods and techniques in
evaluating their effectiveness. Nurses can contribute to the profession to accumulate new
knowledge regarding different aspects of health education programme and can educate
and motivate the community towards health promoting activities.
76
Limitations of the study
• The study is limited to Kumbalagudu PHC area, Bangalore.
• The study did not use any control group.
• The study assessed only knowledge component of hypertensive patients regarding DASH diet.
• Small number of respondents (60) limits the generalization of the study.
• Long-term follow-up could not be carried out due to time constraints. Recommendations
On the basis of the findings of the study following recommendations have been made:
• The study can be replicated in a larger sample in different settings.
• Follow up studies can be conducted to evaluate the effectiveness of the STP on
knowledge regarding complications of hypertension.
• A similar kind of study can be done among patients with cardiovascular diseases
for whom antihypertensive medication can be prescribed.
• A video assisted teaching can be done for a larger group.
• A similar study may be conducted in other back ward districts, taluks, villages etc.,
• Manuals, information booklets and self-instruction module may be developed.
• A long term study can be done to assess the impact of DASH diet.
• A study can be conducted using two groups, one as a control group and the other
as experimental group.
• A comparative study can be undertaken to compare the findings of the rural and
urban community.
77
8. SUMMARY
Hypertension is the medical term for high blood pressure. It is defined as a
condition in which the patient repeatedly has high blood pressure readings. A high blood
pressure reading is 140/90 millimeters of mercury (mmHg) or higher. Hypertension is a
dangerous health condition that can be managed through personal behaviors such as eating
a healthy diet and engaging in regular physical activity, as well as taking medications that
lower blood pressure. Over a period of years, hypertension that is not controlled can cause
severe health complications such as neurological problems, metabolic diseases and organ
failure. The present study was to evaluate the effectiveness of STP on knowledge
regarding DASH diet among hypertensive patients at Kumbalagudu PHC area, Bangalore.
Objectives of the study
1. To assess the level of knowledge of hypertensive patients regarding DASH diet.
2. To assess the effectiveness of structured teaching programme on knowledge of
hypertensive patients regarding DASH diet.
3. To find the association between knowledge of hypertensive patients and selected socio
demographic variables.
Hypotheses:
H1: There is a significant difference between pre-test and post-test knowledge scores of
hypertensive patients regarding DASH diet.
H2: There is a significant association between knowledge scores of hypertensive
patients regarding DASH diet and selected socio-demographic variables.
78
Limitations of the study
• The study is limited to Kumbalagudu PHC area, Bangalore.
• The study did not use any control group.
• The study assessed only knowledge component of hypertensive patients regarding
DASH diet.
• Small number of respondents (60) limits the generalization of the study.
• Long-term follow-up could not be carried out due to time constraints.
The present study aims at developing and evaluating structured teaching programme
regarding DASH diet.
The conceptual framework used in the study was based on the general system
theory by Ludwig Von Bertanlanffy (1969), the main focus is on the discrete parts and
their interrelationship, which consist of input, throughput and output.
In this study various literature were reviewed which includes, literature related to
prevalence and risk factors of hypertension, treatment and lifestyle modifications, DASH
diet, blood pressure and diet and effectiveness of training/teaching programme on
hypertensive patients.
The research design selected for the study was one group pre-test post-test design.
The independent variable was STP and dependent variable was knowledge of hypertensive
patients regarding DASH diet.
79
The target population was hypertensive patients at Kumbalagudu PHC area,
Bangalore. Convenient sampling technique was used to select 60 hypertensive patients.
The tool developed and used for the data collection was structured questionnaire and
method of data collection was structured interview schedule.
The tool developed and used for the data collection was structured interview
schedule. 12 experts validated the content validity of the tool and the tool was found to be
reliable and feasible. The reliability of the tool was established by Spearman’s Brown
Prophecy formula where r = 0.93. The structured teaching programme consisted of various
aspects on DASH diet. The teaching plan was organized in sequence and in continuity.
Teaching plan was prepared with a view to enhance the knowledge of hypertensive
patients regarding DASH diet.
Pilot study was conducted on 7-09-2012 to 14-09-2012 as a part of the major
study, tool proved to be comprehensible, feasible and acceptable. The permission was
obtained from authorities of Kumbalagudu PHC area and hypertensive patients.
Data collection procedure for main study began from 1/11/2012 to 30/11/2012.
The investigator personally explained the need and assured them of the confidentiality of
their responses.
The pre-test was administered followed by a teaching programme; post-test was
administered 8 days after the teaching plan by using the same structured questionnaire
which used for pre-test.
The Data gathered were analyzed and interpreted according to objectives.
Descriptive statistics like mean, median and standard deviation, and inferential statistics
80
like paired ‘t’ test was included to test the hypothesis and Chi-square test was included to
test the association of knowledge scores with demographic variables and the data obtained
are presented in the graphical form.
Major Findings of the Study
The major findings of the study were as follows:
A. Findings related to demographic characteristics of the subjects.
• Majority (53.30%) of the respondents were belonged to the age group of 45-55
years.
• Majority (78.30%) of the respondents were males.
• 100% of the respondents were Hindus.
• Majority (96.70%) of respondents consume mixed type of diet.
• Majority (33.33%) of respondents had secondary education and higher secondary
education, followed by no formal education (13.33%), primary education (11.68%)
and remaining (8.33%) were graduated.
• Majority (45%) of respondents were private employees.
• Majority (51.70%) of respondents had income between Rs.1000-5000/month.
• Majority (51.70%) of respondents had no information regarding DASH diet.
• 35% of the respondents had duration of hypertension for 1-3 years.
81
B. Findings related to the pre-test and post-test mean percentage knowledge scores
of Hypertensive patients.
The mean knowledge scores of pre-test and post test are 11.35(SD-3.6) and
26.26(SD-2.30) respectively.
Highest pre test knowledge score obtained in the aspect of hypertension was
38.3%.
Highest post test knowledge score obtained in the aspect of DASH diet was
78.12%.
The overall post-test mean percentage knowledge score was found higher
(77.23%) when compared with pre-test mean percentage knowledge score
(33.38%).
Aspect wise enhancement of mean percentage knowledge scores in the aspect of
DASH diet was found higher (149.66%).
The statistical paired‘t’ test indicates that enhancement in the mean percentage
knowledge scores found to be significant at 5 percent level for all the aspects under
study.
C. Findings related to association between demographic variables and pre-test and
post-test mean percentage knowledge scores.
The Association between mean percentage knowledge score and demographic
variables were computed by using Chi-square test.
There was no significant association found between knowledge scores and selected
demographic variables such as age, gender, religion, dietary pattern, education,
occupation, income, source of information and duration of hypertension.
82
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Moore TJ. The DASH diet enhances the blood pressure response to losartan in
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87
ANNEXURE-A
88
ANNEXURE-B
LETTER SEEKING EXPERT’S OPINION FOR THE CONTENT
Validity of the tool and Structured Teaching Programme
From,
Mr. Arun Babu
II year M.Sc Nursing,
Kempegowda College of Nursing,
Bangalore-560004.
To,
Forwarded through,
The Principal,
Kempegowda College of Nursing,
Bangalore- 560004.
Respected Sir/ Madam,
Sub: Requisition for expert opinion on content validity of the research tool.
I, Arun Babu, a post graduate student of Kempegowda College of Nursing, Bangalore, as
a partial fulfillment of the master degree in Community Health nursing of Rajiv Gandhi
university of medical sciences, Bangalore, have selected the below mentioned topic for the
dissertation.
89
Title of the project: “Effectiveness of Structured Teaching Programme on knowledge
regarding DASH diet among hypertensive patients at a selected Kumbalagudu PHC
area, Bangalore.”
Objectives:
(i) To assess the level of knowledge of hypertensive patients regarding DASH
diet before the administration of structured teaching programme.
(ii) To assess the effectiveness of structured teaching programme on
knowledge of hypertensive patients regarding DASH diet.
(iii) To find the association between knowledge of hypertensive patients and
selected socio demographic variables.
I kindly request you to validate my structured questionnaire for its appropriateness and
relevancy.
I am here with enclosing the copies of
a) Structured Questionnaire.
b) Criteria rating scale/ check list.
c) Blue print for reference.
d) Content validity certificate.
I kindly request you to go through the content and give your expert and valuable
suggestions in the columns given and mark ( ) if you agree.
90
Your expert opinion and kind cooperation will be highly appreciated and gratefully
acknowledged.
Thanking you in anticipation,
Yours faithfully,
Place: Bangalore
Date: (Mr. Arun Babu)
Signature of guide: Signature of principal:
91
ANNEXURE –C
CONTENT VALIDITY CERTIFICATE
This is to certify that the tool and Structured Questionnaire developed by Mr. Arun Babu
II year M.Sc Nursing student of Kempegowda College of Nursing, Bangalore (Affiliated
to Rajiv Gandhi University of Health Sciences) is validated by the undersigned and can
proceed to conduct the main study for dissertation entitled as “Effectiveness of
Structured Teaching Programme on knowledge regarding DASH diet among
hypertensive patients at a selected Kumbalagudu PHC area, Bangalore.”
Place:
Date:
(Name and Signature of the
expert with designation and
with seal of the institution)
92
ANNEXURE-C (1)
CRITERIA RATING SCALE FOR VALIDATING THE STRUCTURED
KNOWLEDGE QUESTIONNAIRE ON DASH DIET.
Respected Madam/Sir,
Kindly go through the content and place the tick mark (√) against the questionnaire
in the following columns ranging from very relevant to not relevant. When the question is
found to be not relevant and needs modification kindly give your valid opinion in the
remarks column. The structured questionnaire is presented in 2 parts.
Part I: Consists of 9 items related to the Demographic variable under the study.
Part II: It is designed to elicit information regarding DASH diet.
93
Part-I
Sl.No. Very
Relevant
Relevant Needs
Modification
Not
relevant
Remarks
1.
2.
3.
4.
5.
6
7.
8.
9.
Part-II
Structured knowledge questionnaire on Hypertension and DASH diet
Sl No
Very Relevant
Relevant Needs modification
Not relevant
Remarks
1.
2.
94
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
95
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
Suggestions if any:
Over all opinion of the validator:
Signature of the validator
Name and address of the validator
96
ANNEXURE D
LIST OF EXPERTS WHO VALIDATED THE TOOL AND STRUCTURED
TEACHING PROGRAMME
1. Mr. Sridhar M.Sc. (N)
Principal, HOD Medical surgical nursing
Fortis college of nursing
Bangalore.
7. Mr.Sibi Alexander
Head of the department
Medical Surgical Nursing
B.M.S Hospital Nursing college
Bangalore
2. Mr.Dinesh.S
Principal, Head of the department
Community Health Nursing
PadmashreeInstitute of Nursing
Bangalore
8. Mr. Gangaboraiah
Professor of Statistics
Kempegowda Institute of Medical
Science.
Bangalore-04
3. Mr.Prakash.H.D
Head of the department
Community Health Nursing
Governament college of Nursing
Bangalore
9. Dr.S.T.Yavagal.M.D,DM(Cardiology)
Professor& Head of the department
KIMS Bangalore
4. Mr.Prasanna Kumar.O
Lecturer & P.G.Guide
Department Community Health Nursing
Governament college of Nursing
Bangalore.
10. Dr.Keshav.H.K. M.B.B.S, M.D
Asst Professor Department of Medicine.
KIMS, Bangalore
97
5. Dr.Threessiamma.P.M. MSc(N),PhD
Associate Professor
Head of the department
Community Health Nursing
Fortis Institute of Nursing
Bangalore
11. Dr.Kavitha.D.S
Dietician
M.Sc Food & Nutrition
KIMS Bangalore
6. Mrs.Shani.E.Mathew
Head of the department
Community Health Nursing
Vydehi Institute of Nursing
Bangalore
12. P.M.Arulmozhi Baskaran
Head of the department
Community Health Nursing
Narayana Hrudayalaya college of Nursing
Bangalore
98
ANNEXURE – E
COPY OF THE CONSENT FORM
I am voluntarily willing to participate in the study conducted by Mr. Arun Babu on
“Effectiveness of Structured Teaching Programme on knowledge regarding DASH
diet among hypertensive patients at selected Kumbalagudu PHC area, Bangalore”. I
will also co-operate with the researcher in providing necessary information. I was
explained that the information provided would be kept confidential and used only for
above mentioned study purpose.
Signature of the Investigator Signature of the Participant
Date:
Place:
99
ANNEXURE – F
STRUCTURED KNOWLEDGE QUESTIONNAIRE
QUESTIONNARE:
A structured knowledge questionnaire to assess the knowledge of hypertensive
patients regarding DASH diet.
In the present study, questionnaire is designed to elicit the knowledge of
hypertensive patients regarding DASH diet. The participants are requested to respond
accurately to the questions. The information provided by the participant will be
exclusively utilized for the partial fulfillment of P.G. programme and the information will
be kept confidential.
The questionnaire is presented in two parts:
• Part I: Consists of 9 items related to the demographic variables under the study.
• Part II: It is designed to elicit the knowledge of hypertensive patients regarding
DASH diet. It consists of 34 items.
Part-I
SOCIO DEMOGRAPHIC DATA
Sample code ________________ Dear participant,
I would like you to answer following questions related to your socio- demographic data. Kindly respond as accurately as possible.
100
1. Age in years................................. 2. Gender a. Male [ ]
b. Female [ ] 3. Religion a. Hindu [ ]
b. Muslim [ ]
c. Christian [ ]
d. Any other specify……………. 4. Dietary pattern: a. Vegetarian diet [ ]
b. Mixed diet [ ] 5. Educational status ..................... 6. Occupation of the participant ................. 7. Family income per month (Rs).................. 8. Do you have source of information regarding importance of diet in hypertension: a. Yes/No......................
b. If Yes specify-----------
9. How long have you been diagnosed with hypertension? a. < 1 year [ ]
b. 1 - 3 years [ ]
c. 4 - 6 years [ ]
d. 6 years and above [ ]
101
Part-II INSTRUCTIONS: I Mr. Arun Babu, student of MSc nursing, would like to ask some information about Dietary Approaches to Stop Hypertension.each answer has four options (a,b,c,d) , I request you to answer all the questions .
Questions regarding hypertension 1. Hypertension means: a. Increased blood pressure [ ]
b. Decreased blood pressure [ ]
c. Increased cholesterol level [ ]
d. Increased blood sugar level [ ] 2.one among the following is the normal value of Blood in adults (25- 35years) is: a. 140/70 mm of hg [ ]
b. 160/90 mm of hg [ ]
c. 120/80 mm of hg [ ]
d. 90/60 mm of hg [ ] 3. In Elderly (60-75 years), the average level of normal Blood Pressure is: a. 180/100 mm of hg [ ]
b. 140/90 mm of hg [ ]
c. 190/110 mm of hg [ ]
d. 195/11 5mm of hg [ ] 4. Risk factors for Hypertension are a. Hereditary and life style patterns [ ]
b. Reaction during blood transfusions [ ]
c. Through physical contact among patients [ ]
d. Harmful radiation from the sun [ ] 5. Hypertension is found most commonly among: a. Men between 20 - 25 years [ ]
b. Females between 25 -30 years [ ]
c. Females between 30 -35 years [ ]
102
d. Men between 45 - 50 years [ ] 6. Hypertension can be most effectively controlled by: a. Exercise and Diet [ ]
b. Vaccination and First Aid [ ]
c. Accupuncture [ ]
d. Massage Therapy and Aromatherapy [ ] 7. One of the following drug which causes hypertension some times is: a. Pain Killers [ ]
b. Antibiotics [ ]
c. Birth Control Pills [ ]
d. Sleeping Pills [ ] 8.Regular exercise among hypertensive clients will help to: a. Increase the cholesterol levels in the body [ ] b. Increase the blood pressure [ ] c. Reduce the blood pressure in the long run [ ] d. Maintain the adequate minerals in the body [ ] Questions regarding complications of Hypertension 9. The body organs mainly affected by Hypertension are: a. Lungs, ears, stomach, spleen [ ] b. Heart, brain, kidneys & eyes [ ] c. Ear, nose & throat, stomach [ ] d. Muscle, rectum, colon & uterus [ ] 10. One of the following is not complication of hypertension: a. Heart attack [ ] b. ulcer [ ] c .Stroke [ ] d. Kidney failure [ ]
Questions regarding DASH diet 11. DASH stands for a.Dietary approaches to suppress hypertension [ ]
103
b. Dietary approaches to stimulate hypertension [ ] c.Dietary approaches to stop hypertension [ ] d.Dietary approaches to save hypertension [ ] 12. Dietary management of Hypertension includes: a. Liberal amount of fresh fruits and low fat foods [ ]
b. Oily and Fatty foods [ ]
c. Food rich in Iron and Calcium foods [ ]
d. Food rich in Sodium and Calcium [ ] 13. DASH diet helps to a. Increase blood pressure [ ] b.Control Hypertension [ ] c.Maintain normal body temperature [ ] d.Increase body weight [ ] 14. Rich source of sodium is: a. Fruits and dairy products [ ]
b. Canned food and bakery products [ ]
c. Green leafy vegetables [ ]
d. Grains and cereals [ ]
15. Sodium intake can be controlled by: a. Eating more meat and diary products [ ]
b. Adding canned foods in diet [ ]
c. Eating more fresh fruits and removing added salt from recipes [ ]
d. Increasing the intake of salads and ketchup [ ] 16. While buying frozen and canned foods one should observe for : a. Those rich in minerals and fat [ ]
b. Those labelled rich in sodium only [ ]
c. Those labelled rich in fat and sodium [ ]
d. Those labelled low in sodium or without added salt [ ] 17. While purchasing processed milk as a component of DASH diet one should opt for a. Rich in fat and protein [ ]
104
b. Low in fat or fat free [ ]
c. Rich in sodium and vitamin c [ ]
d. Rich in potassium and sodium [ ] 18. One among the following should be considered while selecting sweets: a. Fat-free or low-fat cookies [ ]
b. Coconut cookies [ ]
c. Butter cookies [ ]
d. chocolate cookies [ ] 19. Fast foods should be consumed in moderate quantity because they: a. Are poor sources of Sodium and fat [ ]
b. Are high source of minerals [ ]
c. Help to maintain the water levels in the body [ ]
d. Increase sodium and cholesterol levels in the body [ ] 20. In hypertensive patients fat intake must be restricted to: a. 60 gm/day [ ]
b. 35 gm/day [ ]
c. 50 gm/day [ ]
d. 100 gm/day [ ] 21. Rich sources of low fat food group are: a. Egg and meat [ ]
b. Canned food and bakery products [ ]
c. Milk and milk products [ ]
d. Green leafy vegetables [ ] 22. One among the following is appropriate while consuming fruits: a. A piece of fruit with meals and one as snacks [ ]
b. A piece of fruit on a weekly basis [ ]
c. Fruit juice on a monthly basis [ ]
d. A piece of fruit on a monthly basis [ ] 23. Frequency and amount of consuming Nuts should be:
105
a.1/2 cup 4-5 times a week [ ]
b.1 cup4-5 times a week [ ]
c.1/3 cup 4-5 times a week [ ]
d.2 cup 4-5 times a week [ ] 24. Assorted spices beneficial in hypertension include one among the following: a. Rose water and Indian Pickle [ ]
b. Turmeric and Cardamom Seeds [ ]
c. Clover and Black Salt [ ]
d. Black pepper and basil [ ] 25. Fruits and Vegetables rich in Potassium and magnesium are: a. Tomatoes and Banana [ ]
b. Cabbage and Watermelon [ ]
c. Cucumber and Strawberries [ ]
d. Apple and onions [ ] 26. The quantity of salt intake for normal person per day is: a. 5-6 Teaspoon [ ]
b. 7 -8Teaspoon [ ]
c. 1 -4Teaspoon [ ]
d. 9 -10Teaspoon [ ] 27. Recommended salt intake for hypertensive patients per day is: a. 3 Teaspoon [ ]
b. 1 Teaspoon [ ]
c. 2 Teaspoon [ ]
d. 2/3 Teaspoon [ ] 28. Meat, poultry and fish products should be cooked by: a. Boiling with skin and fat [ ]
b. Fry deeply in oil [ ]
c. Trimming skin and fat then boil [ ]
d. Deep fry in butter or ghee [ ]
106
29. Best alternative to meat would be: a. Fatty foods [ ]
b. Sodium rich foods [ ]
c. Canned foods rich in saturated fats [ ]
d. Egg white [ ] 30. Cooking oil which is recommended for healthy living is: a. Groundnut oil [ ]
b. Sun flower oil [ ]
c. Coconut oil [ ]
d. Palm oil [ ] 31. While buying rice it is advisable to select one of the following: a. Basmati rice [ ]
b. White rice [ ]
c. Brown rice [ ]
d. Steamed rice [ ] 32. For normal person, ideal frequency of tea/coffee to be consumed in a day is: a. once [ ] b. Thrice [ ] c. Four times [ ] d. More than four times [ ] 33. With regard to coffee/tea intake DASH recommends: a. Have coffee/ tea as part of the weekly diet [ ] b. strictly avoid use of coffee/tea [ ] c. Have coffee/tea if you have high blood pressure [ ] d. Have coffee/tea twice on a daily basis. [ ] 34. One among the following statements is true with regard to smoking: a. Completely disregarded as they have no effect [ ] b. Encouraged as they help reduce tension [ ] c. Recommended as they have a positive effect [ ] d. Should be avoided as they have adverse effects [ ]
107
ANNEXURE – F (1)
ANSWER KEY FOR STRUCTURED QUESTIONNAIRE
QUESTION
NUMBERS
KEY
ANSWERS
QUESTION
NUMBERS
KEY
ANSWERS
QUESTION
NUMBERS
KEY
ANSWERS
1 a 13 b 25 a
2 c 14 b 26 c
3 b 15 c 27 d
4 a 16 d 28 c
5 d 17 b 29 d
6 a 18 a 30 b
7 c 19 d 31 c
8 c 20 a 32 a
9 b 21 d 33 b
10 b 22 a 34 d
11 c 23 c
12 a 24 d
108
ANNEXURE – F (2)
BLUE PRINT OF STRUCTURED TEACHING PROGRAMME ON DASH DIET
Sl.No
Selected aspects on DASH diet
Knowledge Comprehension
Application Total no. of question
Percentage (%) Items No.
of qts.
Items No. of qts.
Items No. of qts.
1 Questions regarding hypertension
1,3
2 2,4,5 3 6,7,8 3
8 23.52
2 Questions regarding complications of hypertension
9 1 10 1 0 0
2
5.88
3 Questions regarding DASH diet
11, 14,23,24,25,26,27,3233.
9
12, 21, 22, 28, 29, 30, 34.
7
13, 15, 16, 17, 18, 19,20,31.
8
24
70.58
TOTAL 12 11 11 34 100
109
ANNEXURE – G
LESSON PLAN FOR STRUCTURED TEACHING PROGRAMME ON:
(Dietary Approaches to Stop hypertension)
Name of the investigator : Mr.Arun Babu
Group : Hypertensive Patients
Venue : Community area
Topic : DASH diet
Time : 45 Minutes
Size of the group : 5-10 members
Method of teaching : Lecture and Discussion
Language : Kannada and English
Audio Visual Aids : Flash Cards,charts
110
OBJECTIVES
GENERAL OBJECTIVES:
At the end of the teaching hypertensive patients will gain in depth knowledge on Dietary Approaches to Stop Hypertension and
applies the same knowledge in control of hypertension.
SPECIFIC OBJECTIVES:
Hypertensive patients will be able to,
1. defines hypertension
2. lists out the causes for hypertension
3. enumerates the risk factors for hypertension
4. explains the signs and symptoms of hypertension
5. describes the complications of hypertension
6. explains the importance of lifestyle modifications for control of hypertension
7. discuss about dietary approaches to stop hypertension(DASH) diet
8. define DASH diet
9. explains the principles of DASH diet
10. explains the importance of DASH diet
11. discuss about components of DASH die
111
TIME
EXPECTED
OUTCOME
CONTENT
TEACHER
ACTIVITY
LEARNER
ACTIVITY
A.V aids
REAL LEARNERS
OUTCOME
2mins
5mins
Defines
hypertension
Lists out the
causes for
hypertension
1.DEFINITION
Hypertension is a persistent elevation of the systolic blood pressure at a level of 140 mm Hg or higher and the diastolic blood pressure at a level of 90 mm Hg or higher.
2.CAUSES FOR HYPERTENSION
The etiology of hypertension can be classified as either primary or secondary.
Primary hypertension:
The exact cause of primary hypertension is unknown. Several contributing factors of hypertension are
Increased sodium intake Greater than ideal body weight Diabetes mellitus Excessive alcohol consumption Cigarette smoking
Teacher defines
hypertension and
explains the meaning
of hypertension.
Teacher discusses
causes by using flash
cards.
Learners
listen
Learners
listen and
clarify their
doubts
Flash
cards
Flash
cards
What is
hypertension?
What are the
causes of
hypertension?
112
2mins
Enumerates
the risk factors
for
hypertension
Stress Elevated levels of cholesterol &
triglycerides Secondary Hypertension
Secondary hypertension is elevated blood pressure with a specific cause and often can be identified and corrected.
Causes are:
Renal diseases Tumor of the adrenal gland Neurologic disorders such as Brain tumor, head injury Estrogen replacement therapy Oral contraceptive pills Cirrhosis Pregnancy induced hypertension Non steroidal anti-inflammatory drugs
3.RISK FACTORS FOR HYPERTENSION
Age Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids
Teacher explain the
risk factors
Learners
listen and
clarify the
doubts.
Flash
card
What are the risk
factors for
hypertension?
113
2mins
Explains the
signs and
symptoms of
hypertension.
Excess sedentary sodium Gender Obesity Family history Ethnicity Sedentary lifestyle Socioeconomic lifestyle Stress
4. SIGNS AND SYMPTOMS • Referred as the “ silent killer” • Frequently asymptomatic until target
organ disease occurs or recognized on routine screening
• Symptoms often secondary to target organ disease.
• Can include: Fatigue, reduced activity
tolerance Dizziness Palpitations Dyspnea Headache Blurred vision Nausea and vomiting Chest pain and shortness of
breath.
Teacher explains the
signs and symptoms
of hypertension
Listeners
clarify
doubts
Flash
card
What are the
signs and
symptoms of
hypertension?
114
2mins
Discribes the
complications
of
hypertension.
5.COMPLICATIONS OF HYPERTENSION
• Target organ diseases occur most frequently in:
Heart Brain Peripheral vasculature Kidney eyes
• hypertensive heart disease coronary artery disease left ventricular hypertrophy heart failure
• cerebrovascular disease stroke
• peripheral vascular disease • nephrosclerosis • retinal damage • atherosclerosis • end stage renal disease • hemorrhage, blindness
6. LIFESTYLE MODIFICATIONS
The first line of treatment for hypertension is lifestyle change which includes: dietary
Teacher explains the
complications of
hypertension
Listener
listen
Flash
card
What are the
complications of
hypertension?
115
6mins
Explain the
importance of
lifestyle
modifications
for control of
hypertension
changes ,physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension. If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication.
a) EXERCISE:
• maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)
• engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)
• exercising regularly
b) HABITS:
• limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women.
• Smoking should be avoided as they have adverse effects.
Discuss the lifestyle
modifications
Listener
listen
Flash
card
How lifestyle
modifications
are important in
Controlling
hypertension?
116
c) MEDICATIONS
Diuretics
Adrenergic inhibitors
Direct vasodilators
Angiotensin inhibitors
Calcium channel blockers
d) DIET
consume a diet rich in fruit and vegetables (e.g. at least five portions per day)
eating a nutritious, low-fat diet
decreasing salt (sodium) intake
e) FOLLOW-UP CARE The most important element in the management of high blood pressure is follow-up care.
117
2mins
Discuss the
dietary
approaches to
stop
hypertension
• Routine blood pressure check-up are important to monitor readings and decide upon a treatment plan.
• Routine physical examinations and screening blood tests may be suggested to help monitor the success of blood pressure management.
• Follow-up visits are a great opportunity for monitoring for other associated risk factors, such as high cholesterol, smoking cessation, and obesity.
7. DIETARY APPROACHES TO STOP HYPERTENSION(DASH) DIET
Introduction
DASH stands for Dietary Approaches to Stop Hypertension. The DASH diet is a lifelong approach to healthy eating that's designed to help treat or prevent high blood pressure (hypertension).
The DASH diet may offer protection against
Teaches about
dietary approaches to
stop hypertension
Listeners
listen and
clarify
doubt
Flash
cards
and
charts
What are the
dietary
approaches to
stop
hypertension?
118
2mins
Define DASH
diet.
osteoporosis, cancer, heart disease, stroke and diabetes.
a) Meaning
The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium.
8.Definition: DASH is an eating plan that,
• Is low in saturated fat, cholesterol, and total fat
• Focuses on fruits, vegetables, and fat-free or low-fat dairy products
• Is rich in whole grains, fish, poultry, beans, seeds, and nuts
• Contains fewer sweets, added sugars and sugary beverages, and red meats.
e.g. vitamins, garlic, fish oil, L-arginine, soy, herbs, phytosterols, and chelation therapy.
9.PRINCIPLES OF DASH DIET • Lowering blood pressure
Teacher defines
DASH diet
Learners
listen
Flash
card
What is dash
diet?
119
2mins
2mins
Explain
principles of
DASH diet
Explain
importance of
DASH diet in
hypertension.
• Lower the risk of heart disease, stroke and cancer.
• Support reaching and maintaining a healthy weight.
10.IMPORTANCE OF DASH DIET IN HYPERTENSION A Diet is not just a plan for losing weight; a diet refers to the way we eat. Dietetic management includes:
• Set up a healthy eating plan with foods low in saturated fat, total fat, and cholesterol, and high in fruits, vegetables, and low fat dairy foods such as the DASH eating plan.
• Write down everything that you eat and drink in a food diary. Note areas that are successful or need improvement.
• If you are trying to lose weight, choose an eating plan that is lower in calories.
Teacher explains
principles of DASH
diet
Teacher explains the
importance of DASH
diet in hypertension.
Learners
listen
Listeners
listen
Flash
cards
Chart
What are the
principles of
DASH diet?
What are the
importance of
DASH diet in
hypertension?
120
10mins
Discuss about
components of
hypertension.
11.Components of DASH diet
i. Protein In severe hypertension the protein has to be restricted to 20 gm/day where as the mild and moderate hypertensive can have 1 gm/kg body weight. For example if the person is 60kg then he can have 60 gms of protein / day. ii. Fats It is better to avoid high intake of animal fat which contain saturated fatty acids. The cholesterol rich foods such as liver, meat, egg yolk, crab and prawns should be minimised in the diet. The dietary fats should consist of vegetable oil like, olive oil and sunflower oil. The recommended fat for hypertensive patient is 60gms. iii.Minerals and Vitamins
• Low sodium and high potassium diet will help to lower high blood pressure. Moderate sodium restriction 2- 3 gm per day decreases diastolic blood pressure 6- 10 mm of Hg.
• Potassium intake should be increased.
Teacher discuss
about components of
hypertension
Learners
listen
Flash
cards
What are the
components of
DASH diet?
121
Food sources of potassium should be increased to patients. For example apricots, tomato, chickoo, watermelon, banana, leafy vegetables, bitter gaurd, brinjal and potato should be included in the daily diet since they contain low sodium and high potassium. Hypertensive patients with kidney disease should avoid a high intake of potassium as it puts an excessive load on the kidney.
• Vitamins should be adequate to the recommended allowances that can be achieved by consuming fruits and vegetables.
Effect of sodium on Blood pressure Sodium: Essential in small amounts, Your body needs some sodium to function properly. Benefits of sodium � Helps maintain the right balance of fluids in your body
� Helps transmit nerve impulses
122
� Influences the contraction and relaxation of muscles Hazards of sodium People who are sodium sensitive retain sodium more easily, leading to excess fluid retention and increased blood pressure. If you're in that group, extra sodium in your diet increases your chance of developing high blood pressure, a condition that can lead to cardiovascular and kidney diseases. Identification of food stuffs rich in sodium
• The best way to determine sodium content is to read food labels. The Nutrition Facts label tells you how much sodium is in each serving. It also lists whether salt or sodium-containing compounds are ingredients.
• Examples of these compounds include: Monosodium glutamate (MSG) ,Baking soda ,Baking powder ,Disodium phosphate ,Sodium nitrate or nitrite
123
Main sources of sodium
� Processed and prepared foods, such as canned vegetables, soups, luncheon meats and frozen foods. .
� Sodium-containing condiments. One teaspoon of table salt has 2,325 mg of sodium, and 1 tablespoon of soy sauce has 1,005 mg of sodium. � Natural sources of sodium. Sodium naturally occurs in some foods, such as meat, poultry, dairy products and vegetables. For example, 1 cup of low-fat milk has about 110 mg of sodium. cut your sodium intake
• Eat more fresh foods and fewer processed foods.
• Eats lots of fresh fruits and vegetables. They need no added salt. They also increase potassium stores, which helps lower blood pressure.
124
• Opt for low-sodium products. Look for unsalted snacks (if you need them) and foods that have reduced sodium.
• Limit the use of Salad dressings, sauces, ketchup and mustard all contain sodium.
• Use herbs, spices and other flavourings to enhance foods. Learn to flavor foods with lemon juice, parsley, garlic, or onions, instead of salt.
• Not adding salt when cooking rice or hot cereal.
• Buying foods labeled "no salt added," "sodium-free," "low sodium" or "very low sodium"
Lower sodium DASH diet: You can consume up to 1,500 mg (2/3 teaspoon of table salt) of sodium a day.
iv. Fluids
Fluid restriction is not necessary for
125
hypertension unless the patient is having oedema and heart failure where the fluid restriction is regulated according to the urine output.
v. Grains (6 to 8 servings a day) Grains include bread, cereal, rice and pasta. Examples of one serving of grains include 1 slice whole-wheat bread, 1 ounce (oz.) dry cereal, or 1/2 cup cooked cereal or rice. Focus on whole grains because they have more fiber and nutrients than do refined grains. For instance, use brown rice instead of white rice and whole-grain bread instead of white bread. Look for products labeled "100 percent whole grain" or "100 percent whole wheat."Grains are naturally low in fat, so avoid spreading on butter or adding cream and cheese sauces. Some examples of whole grain food choices include: Brown rice, oatmeal, popcorn, whole wheat bread, noodles, corn flakes, white bread white rice.
126
vi. Vegetables (4 to 5 servings a day)
Tomatoes, carrots, broccoli, sweet potatoes, greens and other vegetables are full of fiber, vitamins, and such minerals as potassium and magnesium. Examples of one serving include 1 cup raw leafy green vegetables or ½ cup cut-up raw or cooked vegetables.
Fresh or frozen vegetables are both good choices. When buying frozen and canned vegetables, choose those labelled as low sodium or without added salt.
Beneficial vegetables and spices for hypertension
A number of common vegetables and spices have beneficial effects in controlling hypertension. Incorporate these into your cooking. Alternately, you can make a tea or a vegetable soup.
Garlic: Garlic is a wonder drug for
127
heart. It has beneficial effects in all cardiovascular system including blood pressure. In a study, when people with high blood pressure were given one clove of garlic a day for 12 weeks, their diastolic blood pressure and cholesterol levels were significantly reduced. Eating quantities as small as one clove of garlic a day was found to have beneficial effects on managing hypertension. Use garlic in your cooking, salad, soup, pickles, etc. It is very versatile.
Onion: Onions are useful in hypertension. What is best is the onion essential oil. Two to three tablespoons of onion essential oil a day was found to lower the hypertension. This should not be surprising because onion is a cousin of garlic.
Tomato: Tomatoes are high in gamma-amino butyric acid (GABA), a compound that can help bring down blood pressure.
Broccoli: This vegetable contains several active ingredients that reduce
128
blood pressure. Carrot: Carrots also contain several
compounds that lower blood pressure. Saffron: It contains a chemical called
crocetin that lowers the blood pressure. You can use saffron in your cooking. You can also make a tea with it. Unfortunately, it is very expensive.
Assorted spices: spices such as fennel, oregano, black pepper, basil and tarragon have active ingredients that are beneficial in hypertension. Use them in your cooking.
vii.Fruits (4 to 5 servings a day) Many fruits need little preparation to become a healthy part of a meal or snack. Like vegetables, they're packed with fiber, potassium and magnesium and are typically low in fat. � Have a piece of fruit with meals and one as a snack, then round out your day with a dessert of fresh fruits topped with a splash of low-fat .
129
viii. Dairy (2 to 3 servings a day) Milk, cheese and other dairy products are major sources of calcium, vitamin D and protein. But the key is to make sure that you choose dairy products that are low-fat or fat-free because otherwise they can be a major source of fat. Examples of one serving include 1 cup skim or 1% milk, 1 1/2 oz. cheese. Go easy on regular and even fat-free cheeses because they are typically high in sodium. ix.Lean meat, poultry and fish (6 or fewer servings a day) Meat can be a rich source of protein, vitamins, iron and zinc. But because even lean varieties contain fat and cholesterol, don't make them a mainstay of your diet — cut back typical meat portions by one-third or one-half and pile on the vegetables instead. Examples of one serving include 1 oz. cooked skinless poultry, seafood or lean meat, 1 egg. � Trim away skin and fat from meat and then broil, grill, roast or poach instead of frying.
� Fish: has always been considered health
130
food. Fish oils are known to maintain blood pressure. Eat heart-healthy fish, such as salmon and tuna. These types of fish are high in omega-3 fatty acids, which can help lower your total cholesterol Consuming fish like Mackerel (Bangada), Tuna and Surmai at least thrice a week will help you reduce your daily dose of medicines.
x.Nuts, seeds and legumes (4 to 5 servings a week) Almonds, sunflower seeds, kidney beans, peas and other foods in this family are good sources of magnesium, potassium and protein. They're also full of fiber which are plant compounds that may protect against some cancers and cardiovascular disease. Serving sizes are small and are intended to be consumed weekly because these foods are high in calories. Examples of one serving include 1/3 cup (1 1/2 oz.) nuts, 2 tablespoons seeds or 1/2 cup cooked beans or peas. Soybean-based products, can be a good alternative to meat because they contain all of the amino acids your body needs to make a complete protein, just like meat.
131
xi. Sweets (5 or fewer a week) You don’t have to banish sweets entirely while following the DASH diet – just go easy on them. Examples of one serving include 1 tablespoon sugar, jelly or jam. Whenever you eat sweets, choose those that are fat-free or low-fat, such as sorbets, fruit ices, jelly beans, hard candy, and low-fat cookies. xii. Alcohol and caffeine Drinking too much alcohol can increase blood pressure. The DASH diet recommends that men limit alcohol to two or fewer drinks a day and women one or less. The DASH diet doesn’t address caffeine consumption. The influence of caffeine on blood pressure remains unclear. But caffeine can cause your blood pressure to rise at least temporarily. If you already have high blood pressure or if you think caffeine is affecting your blood pressure. 12.DASH DIET CHART
132
Food group Daily servings Serving sizes
Grains 6-8 1 slice bread
1 oz dry cereal
½ cup cooked rice, pasta or
cereal
Vegetables 4-5 1 cup raw leafy vegetable
1/2 cup cut-up raw or
cooked vegetable
1/2 cup vegetable juice
Fruits 4-5 1 medium fruit
1/4 cup dried fruit
1/2 cup fresh, frozen, or
canned fruit
1/2 cup fruit juice
133
Fat – free or
Low- fat milk and milk
products
2-3 1 cup milk or yogurt
11/2 oz cheese
Lean meats, poultry and
fish
6or less 1 oz cooked meats, poultry,
or fish
1 egg+
Nuts, seeds and legumes 4-5 week 1/3 cup or 11/2 oz nuts
2 Tbsp peanut butter
2 Tbsp or 1/2 oz seeds
1/2 cup cooked legumes
(dry beans
and peas)
Fats and oils 2-3 1 tsp soft margarine
1 tsp vegetable oil
1 Tbsp mayonnaise
2 Tbsp salad dressing
134
Sweets and added sugars 5 or less/week 1 Tbsp sugar
1 Tbsp jelly or jam
1/2 cup sorbet, gelatin
1 cup lemonadeB O X 3
Sodium 1,500 to 2,400
mg a day
1,500 mg of sodium equals
about 4 grams, or 2/3
teaspoon of table salt
CONCLUSION:
The patient with hypertension will achieve and maintain goal BP as defined for the
individual, understand, accept and implement the therapeutic plan.
Summary:
Hypertension is a silent killer disease which needs to be identify as early as possible and
manage with lifestyle modifications, especially dietary approaches are most important to
stop hypertension.
135
Bibliography:
1.Lewis, Heitkemper, O’Brien. Medical-Surgical Nursing.7th edition. pp 761- 783.
2.Joyce. M. Black. Medical- Surgical Nursing. 7th edition.
3.Take a healthy diet to prevent hypertension:htt://www.blood.pressure.updates.com.
136
ANNEXURE – H
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2) ���� a) ����� b) ������
3) ����
a) ����� b) ������� c) ����������� d) ���� (��������� )
4) ���� ����
a) ��������� b) �������
5) ������������ ����_____________________________
6) ������______________________________
7) ������� ���� (��������)___________________________ 8) ���� ���������� ������� ���� ��������������
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9) ����� ���� ���������� ���������� ����� �����
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137
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���� ��������������� ����������� ��������� ����� ����� ������������ ���� ����� �������������. ������ ���������� ������������ ������ ������������ ������� ������� ����� �������. �������� ���� ����� ����� ������������ ������������� ������.
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