ASSESSMENT OF NUTRITION KNOWLEDGE OF PALESTINIAN PHYSICIANS EMPLOYED IN SHIFA HOSPITAL - GAZA CITY

1. ASSESSMENT OF NUTRITION KNOWLEDGE OF
PALESTINIAN PHYSICIANS EMPLOYED IN
SHIFA HOSPITAL - GAZA CITY
By: Mohammad Subhi El-Lulu

2. Al-Azhar University of Gaza
Deanship of Postgraduate Studies and Research Affairs
Faculty of Pharmacy
Master Program of Clinical Nutrition
Assessment of Nutrition Knowledge of Palestinian Physicians
Employed in Shifa Hospital - Gaza City
A small Project
for Fulfillment of the Degree of Master of Clinical Nutrition
By
Mohammad Subhi El-Lulu
Supervisor
Dr. Jehad H. Elhissi
Ass. Prof. of Public Health
Health and Nutrition Consultant
July- 2011

3. Dedication
3
I would like to dedicate this work
to the memory of my father “Subhi Salem El-Lulu”;
to my mother; to my brothers and sisters particularly
“Fawzi and Dr. Fathia”; to my wife and my lovely
children “Omar, Lana, and Balsam”
Faithful Mohammad

4. 4 Contents
 Introduction
 Research Problem and Significance
 Objectives
 Methods and Subjects
 Results
 Conclusion
 Recommendations
 Selective References

5. 5 Introduction

6. Introduction
6
 The World Health Organization (WHO) defines health
as “a state of complete physical, mental, and social
well-being, not merely the absence of disease and
infirmity” (Blair, 2001).
 “Nutrition is important for the maintenance of life,
growth, reproduction, the functioning of organs and
tissues, and the production of energy” (Webster-Gandy et al,
2008).
 The role of nutrition in promotion, disease prevention
and treatment of chronic disease is well recognized
(Schaller & James, 2005).

7. Introduction
7
 Diet is now considered to play a substantial role in
the etiology of many chronic degenerative diseases
such as coronary heart disease, atherosclerosis,
type-2 diabetes mellitus, osteoporosis, and some
cancer types such as bowel, stomach, breast and
prostate cancers (Turrell, 1997).

8. Knowledge Background
8
 Most individuals generally regard their physicians
as the primary source of diet and nutritional
information (Hu et al, 1997).
 Survey studies revealed that physicians are hesitant
to provide nutritional information to patients due to
low levels of confidence resulting from a lack of
education and knowledge in this field (National health
promotion and disease prevention objectives, 2000).

9. Knowledge Background
9
 Physicians have the potential to decrease morbidity
and mortality if they provide effective nutrition
counseling and advice (Kushner, 1995).
 Rogers (1983) identified three types of knowledge:
 (1) awareness (such as diet- disease relationship),
 (2) Knowledge of principles (e.g. cholesterol is
found in animal foods only),
 (3) how to knowledge (e.g. how to select foods
with less fat or how to read a food label
accurately).

10. Nutrition in medical education in Palestine
10
Gaza Universities West Bank Universities
1) Al-Azhar University 1) An-Najah National
provide two credit University provides a
hours for general course of nutrition that
principles of nutrition discusses the
at college of medicine. relationship of diet and
2) Islamic University diseases.
doesn’t provide a 2) Al-Quds University of
course of nutrition Abu-Dis doesn’t
within curriculum mention the academic
plan. plan of curriculum.

11. Nutrition in higher education in Palestine
11
 Islamic University of Gaza provides Professional
Diploma in Children Health and Nutrition “Just for
Doctors” at college of Continuing Education.
 Al-Azhar University of Gaza since 2006 has been a
Master Degree of Clinical Nutrition (MDCN), and
some of students in the program are doctors as many
other medical fields.
 That means: the nutrition become a new developing
branch within medical education, which reveal the
importance of nutrition to help and support medicine.

12. 12 Research Problem and Significance

13. Research Problem & Significance
13
 Five of the 10 current leading causes of death in
United States (coronary artery disease, cancer,
stroke, diabetes and atherosclerosis) are strongly
linked with unhealthy dietary habits.
 Also, diet contributes importantly to the risk for
osteoporosis, obesity, hypertension and neural tube
defects (Promoting health/ preventing disease, 1989).

14. Research Problem & Significance
14
 In 1990, the US Congress passed the National
Nutrition Monitoring and Related Research Act,
which mandated “that students enrolled in United
States medical schools and physicians practicing in
the United States have access to adequate training
in the field of nutrition and its relationship to
human health” (National Nutrition Monitoring and Related
Research Act, 1990).

15. Objectives
15
To identify the general nutrition knowledge of
physicians working in Shifa hospital.
To evaluate the concepts of patient’s
nutritional assessment.
To identify the role of physicians in nutrition
education.
To identify the knowledge of physicians regarding
nutrition situation of hospitalized patients who are
taking “total parenteral nutrition or enteral feeding”.
To recommend the decision makers about the
importance of nutrition in treating and preventing
diseases.

16. 16 Methods and Subjects

17. Study design
17
 A descriptive cross-sectional design was used to
determine nutritional knowledge. The study depends on
reviewed questionnaire by associated professors
working in academic and medical fields.
 Dependent variable (knowledge of nutrition).
Discusses the general principles of nutrition
knowledge, as well as disease- nutrition relationship.
 Independent variable (physicians):
Age, Sex (male and female), Graduation (bachelor,
master and MD), and Department.

18. Sample and sampling
18
 Sample size:
Purposeful non probability sample was taken; the sample
consists of 36 physicians.
 Study setting and period
The study was conducted in Shifa hospital in Gaza city,
which is a large public hospital from March 2011 to July
2011.
 Target population
All physicians who are working at Shifa hospital
(Surgical and Obstetric) departments.

19. Ethical consideration
19
 Approval letters from Deanship of Pharmacy.
 Approval and permission letter from General
Administration of Human Resource Development
(the main department at Ministry of health for
scientific researches).
 Approval signature from the head of department.
 Informed consent from participated physicians.

20. Eligibility criteria
20
Inclusion criteria Exclusion criteria
 Male and female  Trainees and (Job
physicians currently Creation Program)
employed in the physicians
hospital.

21. Data collection
21
• 1st part composed of physician’s personal characteristics.
• 2nd part explains training and practice.
Questionnaire • 3rd ask about knowledge of principles of nutrition.
• 4th awareness of diet- disease relationship
4 Parts
• 12 completed questionnaires from obstetrics and
gynecology department.
Criterion of • 24 completed questionnaires from surgical department.
Distribution

22. Study analysis
22
SPSS
Coding Entry Cleaning Analysis

23. 23 Results

24. 1 st part: Age of participants
24
Less than 35 years
No. 6 16.7%
From 35 to 45 years
No. 20 55.5%
More than 45 years
No. 10 27.8%
Total
No. 36 100%

25. 1st part: Physicians sex distribution
25
Male
No. 29 80.6%
Female
No. 7 19.4%
Total
N0. 36 100%

26. 1st part: Graduation degree of physicians
26
Bachelor
No. 12 33.3%
Master
No. 19 52.8%
PhD
No. 5 13.9%
Total
No. 36 100%

27. 1st part: Departments of physicians
27
Surgery
No. 24 66.7%
Gynecology and Obstetrics
No. 12 33.3%
Total
N0. 36 100%

28. 2nd: Studying the nutritional therapy in
school of medicine
28
• 27 out of 36
Yes • 75%
• 9 out of 36
No • 25%
• Intensive Course
If Yes (7.4%)
• Just Required Course
(92.6%)

29. 2nd: Courses of nutritional therapy at hospital
29
Yes
12 24
33.3% 66.7%
NO

30. 2nd: Can nutrition knowledge help and
develop practical medicine
30
• 35 out of 36
Yes • 97.2%
• (suggest the place) at next slide
• 1 out of 36
No • Without reasons

31. 2nd: The best place for teaching the
nutrition therapy
31
At Continued
At Medicine
Medical
school
Education
10 25
28.6% 71.4%

32. 2nd: Importance to have nutrition
department at hospital
32
33
Yes (91.7%)
3
No (8.3%)

33. 33 Part 3 of Questionnaire
Knowledge of Principles
Knowledge of Nutrition Assessment

34. Nutrition Principles (Questions) No. (%)
Stearic acid is essential fatty acid as linoleic acid
Yes 15 (41.7%)
No* 6 (16.6%)
I don’t know 15 (41.7%)
Leptin hormone is important for
Hunger 11 (30.6%)
Satiety* 6 (16.6%)
I don’t know 19 (52.8%)
Peripheral Parenteral Nutrition can lead to thrombosis
Yes* 23 (63.9%)
No 10 (27.8%)
I don’t know 3 (8.3%)
Central Venous Feeding is safe from infections
Yes 9 (25%)
No* 24 (66.7%)
I don’t know 3 (8.3%)
34

35. Nutrition Principles (Questions) No. (%)
To avoid aspiration, Enteral tube should be inserted into
Stomach 27 (75%)
Duodenum* 5 (13.9%)
I don’t know 4 (11.1%)
Clear Liquid Diet such as Plain Gelatin can provide calories for
few days
Yes* 11 (30.6%)
No 6 (16.6%)
I don’t know 19 (52.8%)
Mechanical Soft Diet can’t be used for whom suffer from difficulty
of chewing or swallowing
Yes 9 (25%)
No* 9 (25%)
I don’t know 18 (50%)
35

36. Assessment (Questions) No. (%)
Body Mass Index (BMI) = Weight in (kg)/Height in (cm)²
Yes 21 (58.4%)
No* 7 (19.4%)
I don’t know 8 (22.2%)
An important parameter act with BMI to assess obesity for male
Waist/hip ratio* 4 (11.1%)
Hip/waist ratio 5 (13.9%)
I don’t know 27 (75%)
Do you know Subjective Global Assessment (SGA)?
Yes 8 (22.2%)
No 28 (77.8%)
If the answer is Yes
SGA could be adapted to predict postsurgical nutrition
associated morbidities:
Yes* 7 (87.5%)
No 0 (-%)
I don’t know 1 (12.5%)
36

37. Assessment (Questions) No. (%)
Do you know Instant Nutritional Assessment (INA)?
Yes 8 (22.2%)
No 28 (77.8%)
If the answer is Yes
INA adapted for nutritional assessment of preoperative
patients: 4 (50%)
Yes* 4 (50%)
No 0 (-%)
I don’t know
Do you know Nutrition Risk Index (NRI)?
Yes 10 (27.8%)
No 26 (72.2%)
If the answer is Yes
It can’t be used as an index of malnutrition in hospitalized
patients:
Yes 3 (30%)
No* 6 (60%)
I don’t know 1 (10%)
37

38. 38 Part 4 of Questionnaire
Awareness of diet- disease relationship

39. Diet - disease relationship (Questions) No. (%)
Excessive homocysteine level in blood associated with
Cancer 11 (30.6%)
Heart disease* 5 (13.9%)
I don’t know 20 (55.5%)
Which of the following in excessive amount is Tertogenic?
Vitamin A* 15 (41.7%)
Vitamin K 5 (13.9%)
I don’t know 16 (44.4%)
In presence of renal stone of Calcium Oxalate, we have to reduce
the intake of
Sodium* 5 (13.9%)
Calcium 25 (69.4%)
I don’t know 6 (16.7%)
Extra-abdominal fat level can be associated with breast cancer in
female
Yes* 13 (36.1%)
No 12 (33.3%)
I don’t know 11 (30.6%)
39

40. Diet - disease relationship (Questions) No. (%)
Anti-thrombotic nutrient is
Vitamin E 10 (27.7%)
Omega 3* 15 (41.7%)
I don’t know 11 (30.6%)
A type of fibers help lowering cholesterol level in blood
Soluble* 12 (33.3%)
In-Soluble 14 (38.9%)
I don’t know 10 (27.8%)
Disadvantages of Total Parenteral Nutrition (TPN) are Gall Stones
and Cholestasis
Yes* 20 (55.6%)
No 8 (22.2%)
I don’t know 8 (22.2%)
A nutrient prevents Neural Tube Defect
Folate* 20 (55.6%)
Cyanocoblamin 5 (13.9%)
I don’t know 11 (30.5%)
40

41. Diet - disease relationship (Questions) No. (%)
Daily requirement of fluids for normal adult is 2.5 ml/kcal of body
weight
Yes 9 (25%)
No* 9 (25%)
I don’t know 18 (50%)
Healthy adults require at least 50 Kcal/kg of body weight
Yes 13 (36.1%)
No* 6 (16.7%)
I don’t know 17 (47.2%)
Basal Metabolic Rate is the minimum energy required to maintain
normal physiological function during exercise
Yes 15 (41.7%)
No* 10 (27.8%)
I don’t know 11 (30.5%)
Do you know Refeeding Syndrome?
Yes 7 (19.4%)
No 29 (80.6%)
41

42. 42 Conclusion

43. Mean of grades of physicians knowledge
(general principles and nutrition assessment)
43
Mean 3.11
SD: ±2.05
Minimum Maximum
score: 0/12 score: 9/12

44. Mean of grades of physicians knowledge
about awareness of diet- disease relationship
44
Mean 3.66
SD: ±2.04
Minimum Maximum
score: 0/12 score: 9/12

45. Mean of Total Score No (%)
45
6.77
Mean (28.23%)
SD: ±3.22
Minimum Maximum
Score Score
1/24 (4.16%) 13/24 (54.16%)

46. Relationship between age of participant physicians
and their percentage of nutrition knowledge
46
Percentage of knowledge
Age Less than 20% 20% - 40% More than 40%
No. (%) No. (%) No. (%)
Less than 35 2 (33.3%) 2 (33.3%) 2 (33.3%)
35 – 45 5 (25%) 11 (55%) 4 (20%)
More than 45 1 (10%) 8 (80%) 1 (10%)
The result shows that:
less age / more knowledge

47. Relationship between age of participant physicians
and their percentage of nutrition knowledge
47
(0.460)
Pearson Chi-
Square Value
Not Statistically
Significant

48. Relationship between percentage of
knowledge and participants department
48
Percentage of knowledge
Departments
Less than 20% 20% - 40% More than 40%
No. (%) No. (%) No. (%)
Surgery 5 (20.8%) 17 (70.8%) 2 (8.3%)
Obstetrics 3 (25%) 4 (33.3%) 5 (41.7%)
The result shows that: Physicians of obstetric department have higher
and more knowledge than physicians of surgery department

49. Relationship between percentage of
knowledge and participants department
49
Statistically
Significant
Pearson
Chi-
Square
Value
(0.038)

50. 50 Recommendations

51. Nutrition department at hospital is important request, because it
helps in clinical assessment, diet management, & status follow-up.
Physicians should take courses about basic and essentials of
nutrition, to get a proper understanding of nutrition.
School of medicines should have adequate course about nutrition.
Good training and practice at hospital through continued medical
education.
Physicians should take intensive course of nutrition therapy
according to their specialty.
51

52. Selective References
52
 Blair S., (2001). Clinical exercise physiology for cancer,
cardiovascular and pulmonary rehabilitation. Exercise Physiology.
(Eds. McArdle W.D., Katch F.I., Katch V.L.). Fifth Edition.
Lippinocott Williams and Wilkins. Philadelphia. PP: 912- 965.
 Hu S.P., Wu M.Y. and Liu J.F., (1997). Nutrition knowledge,
attitude and practice among primary care physicians in Taiwan. J.
Am. College Nutr. 16: 439- 442.
 Kushner R.F., (1995). Barriers to providing nutrition counseling by
physicians: a survey of primary care practitioners. Preventive
Medicine. 24: 546- 552.
 National health promotion and disease prevention objectives,
(2000).US Department of Health and Human Services. Office of
disease prevention and health promotion, healthy people 2010. US
Public Health Service. Washington, DC. Government Printing
Office.

53. Selective References
53
 National Nutrition Monitoring and Related Research Act of 1990,
(1990). Public Law. 101- 445.
 Promoting health/ preventing disease: year 2000 objectives for the
nation, (1989). US Department of Health and Human Services.
Washington, DC: US Government Printing Office.
 Rogers E.M., (1983). Diffusion of Innovations. New York: Free
Press.
 Schaller C. and James E., (2005). The nutritional knowledge of
Australian nurses. Nurse education today. Australia. 25: 405- 412.
 Turrell G., (1997). Department of gender differences in dietary
behavior. Nutr. Res. 17: 1105- 1120.
 Webster-Gandy J., Madden A. and Holdsworth M., (2008). Oxford
Handbook of Nutrition and Dietetics. Oxford. Oxford Medical
Publications.

54. Al-Azhar University of Gaza
Deanship of Postgraduate Studies and Research Affairs
Faculty of Pharmacy
Master Program of Clinical Nutrition
Assessment of Nutrition Knowledge of Palestinian Physicians
Employed in Shifa Hospital - Gaza City
A small Project
for Fulfillment of the Degree of Master of Clinical Nutrition
By
Mohammad Subhi El-Lulu
Supervisor
Dr. Jehad H. Elhissi
Ass. Prof. of Public Health
Health and Nutrition Consultant
July- 2011