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i
Dietary Pattern Related To Diabetes Management
Among Self-Reported Diabetic Patients In
Malappuram, Kerala, India
Kamaruddeen M
Dissertation submitted in partial fulfilment of the
requirement for the award of the degree of
Master of Public Health
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum, Kerala
October 2013
ii
Certificate
I hereby certify that the work embodied in this dissertation entitled “Dietary pattern
related to diabetes management among self-reported diabetic patients in
Malappuram, Kerala, India” is a bonafide record of original research work
undertaken by Mr. Kamaruddeen M, in partial fulfillment of the requirement for
the award of the “Master of Public Health” degree under my guidance and
supervision.
Dr. Ravi Prasad Varma P
Assistant Professor,
Achutha Menon Centre for Health Sciences Studies
Sree Chitra Tirunal Institute for Medical Science and Technology
Thiruvanathapuram , Kerala
October 2013
iii
Declaration
I declare that the work embodied in this dissertation entitled “Dietary pattern
related to diabetes management among self-reported diabetic patients in
Malappuram, Kerala, India” is the result of original research and has not been
submitted for any degree in any other University or Institution.
Kamaruddeen M
Master of Public Health scholar,
Achutha Menon Centre for Health Sciences Studies
Sree Chitra Tirunal Institute for Medical Science and Technology
Thiruvanathapuram , Kerala
October 2013
iv
Dedication
To My Mother and Father
v
Acknowledgement
I whole heartedly thank God almighty and my parents in supporting and providing the
mental and personal strength for this work. I would like to express my sincere gratitude to
my guide Dr. Ravi Prasad Varma, for the continuous support of my thesis, for his
patience, motivation, enthusiasm and immense knowledge.
I would like to acknowledge the Kerala State Council for Science, Technology and
Environment for the financial support as well as thank the council for recognizing a
young researcher’s work at an early stage.
I am grateful to Dr. Mala Ramanathan, for her constant encouragement and support.
I would like to thank Dr. Sundari Raveendran, Dr. K R Thankappan, Dr. Raman Kutty,
Dr. Sankara Sarma, Dr. Manju R Nair, Dr. Kannan Srinivasan, Dr.Biju Soman, Ms. Jissa
V.T for their valuable comments.
I would like to thank Ms.Uma V Sankar and Dr. Sathish for their valuable comments and
support. I am thankful to Ms. Elsa Mary and Mr. Abdul Latheef V M for their support
throughout my thesis work. Also I would like to thank all my seniors, Batch mates and
juniors for their valuable suggestion to my thesis work.
I would like to thank all the study participants, without whom my study could have never
been completed.
vi
TABLE OF CONTENTS
Topic Page
number
List of tables
List of figures
Abstract
Chapter 1.Introduction 1
Chapter 2.Literature Review
2.1.diabetes mellitus
2.1.1.Definition
2.1.2 Historical Aspects
2.1.3.Pathophysiology
2.1.4.Clinical Presentation and Diagnosis
2.1.5.Management of Diabetes Mellitus
2.1.6.Goals of Biomarker Level in the Control of Diabetes
2.2.Disease Burden
2.2.1.Global Burden
2.2.2.Indian Scenario
2.2.3.Kerala Scenario
2.3.Importance of Diet in Diabetes Management
2.4.Dietary Recommendations for Diabetic Patients
2.5.Adherence to Good Dietary Behavior
2.6.Physical Activity
2.7.Factors Affecting the Dietary Behavior
2.8.Rationale/ Justification of the Study
2.9.Objectives of the Study
2
2
2
4
4
5
6
7
8
8
10
11
12
12
13
14
15
vii
2.9.1.Major Objective
2.9.2.Minor Objective
15
15
Chapter 3.Methodology
3.1.Study Design
3.2.Study Setting
3.3.Study Population
3.4.Inclusion Criteria
3.5.Exclusion Criteria
3.6.Sample Size
3.7.Sample Selection Procedures
3.8.Data Collection Techniques
3.9.Dfenition of Outcome Variable
3.10.Ethical Consideration
3.11.Confidentiality
3.12.Privacy
3.13.Consent
16
16
16
16
16
16
17
17
18
21
21
22
22
22
Chapter 4.Results
4.1.Socio Demographic Factors
4.2.Patient Empowerment Factors
4.3.Barriers and Facilitators
4.4.Self-efficay and Diabetes Knowledge
4.5.Lifestyle Factors
4.6.Variables Related to Disease and Clinical Management
4.7.Risk Perception
23
23
24
25
26
26
27
27
viii
4.8.Dietary Practices
4.9.Bivariate Analysis: Good Dietary Practice with Specific Factors
4.9.1.Socio Demographic Factors Associated with Good Dietary Practice
4.9.2.Patient Empowerment Factors Associated with Good Dietary Practice
4.9.3.Barriers and Facilitators Associated with Good Dietary Practice
4.9.4.Self-efficacy,Diabetes Knowledge and Lifestyle Factors with Good Dietary
Practice
4.9.5. Disease related and Clinical Management Factors Associated with Good
Dietary Practice.
4.10.Predictors of Good Dietary Practice: Results of Multivariate Analysis
4.10.1.Procedure
4.11.Final Model
28
28
28
29
30
31
31
32
32
33
Chapter 5.Discussion
Strengths of the Study
Limitations of the Study
Conclusion of the Study
Implication for Future Research
35
40
40
41
41
References 42
Appendix-1 51
Appendix-2 55
Informed Consent 57
Interview Schedule 60
List of Abbreviations 73
Flash card
ix
LIST OF TABLES
1. Table 2.1.Results of literature review in PubMed by the key word „Diet
Diabetes‟
2. Table 2.2. Oral anti diabetic drugs
3. Table 2.3 .Recommended blood glucose level for diabetic patients
4. Table 2.4.Prevalence of diabetes in Kerala from different studies.
5. Table 3.1. List of study variables that were used to collect data.
6. Table 4.1.Distribution of socio demographic characteristics by sex
7. Table 4.2 .Distribution of patient empowerment factors
8. Table 4.3.Description of lifestyle factors
9. Table 4.4. Frequency and proportions dietary practices.
10. Table4.5. Association of demographic factors with good dietary practice.
11. Table 4.6. Association patient empowerment factors with good dietary
practice
12. Table 4.7. Association barriers and facilitators with good dietary practice.
13. Table 4.8 Association of clinical and management factors with good dietary
practice.
14. Table4.9. associated factors of good dietary practice: Results of Multivariate
analysis.
15. Table 4.10.List of variables that did NOT had association with good dietary
practice
x
LIST OF FIGURES
1. Figure.3.1.Sample selection procedure
2. Figure.3.2. Conceptual framework used for identifying and organizing study
variables
3. Figure.4.1. Distribution of educational status of the respondents.
4. Diagram 4.2. Medication pattern by the diabetes patients.
5. Figure.4.3.Factors promoting good dietary practice among diabetic patients/
Diagrammatic representation of the study results
xi
ABSTRACT
Background: Prevalence of type 2 diabetes is very high in Kerala when compared to
other states. Effective management of diabetes can prevent or delay the complication.
Diet control is an important component in diabetes management. Very few studies
have looked into the dietary pattern among diabetic patients which forms the rationale
for the present study. This study aimed to assess the dietary pattern and factors
associated with it among self-reported diabetic patients in Malappuram.
Methodology: A cross- sectional survey was done among diabetic patients in
Malappuram block Panchayath. Cluster sampling method was used where all eligible
diabetic patients were included from the randomly selected wards of the block
Panchayath. A structured interview schedule was used to assess the dietary pattern;
factors associated with it and risk perception of frequent consumption of food. A
single composite outcome – good dietary pattern was created out of five dependent
variables. Analysis was done in SPSS Version 17.
Results: The prevalence of self- reported diabetes and good dietary practice among
diabetic patients is 11.6% and 20.4 % respectively. Factors like self-reported
difficulty in consuming a healthy diet [AOR:0.19(0.09—0.41)], presence of family
support [AOR:2.89(1.24-6.75)], role for other persons in controlling dietary pattern
[AOR:2.23(1.07-4.66)] and frequent blood sugar monitoring practice
[AOR:2.74(1.27-5.94)] were significantly associated with good dietary pattern.
Conclusion: Good dietary pattern among the diabetes patients was found to be very
low. So improvement in the dietary pattern can be done only with strategies such as
diet counseling that may help persons overcome perceived difficulties and also to
obtain support from family members or others who may be willing to help control the
dietary pattern
1
1. INTRODUCTION
Burden of non-communicable diseases (NCD) especially diabetes is very high in Asian
countries particularly in India.1 Diabetes mellitus is a chronic disease condition resulting
from ineffective use of insulin or inadequate production of insulin in the body. ―Diabetes
is recognized as a group of heterogeneous disorders with the common elements of
hyperglycaemia and glucose intolerance, due to insulin deficiency, impaired effectiveness
of insulin action or both‖.2 Management of diabetes mainly focuses on medicines,
physical activity, diet and stress management. Diet control has a crucial role in
controlling the glycaemic level and thereby preventing the complication of diabetes.
2
2. REVIEW OF LITERATURE
2.1.Diabetes mellitus
2.1.1.Definition
Diabetes mellitus is a chronic disease characterized by an increased concentration of the
glucose in the blood as a result of insufficient production of insulin by the body or when
the body cannot effectively use the insulin.3 Insulin is a hormone produced by pancreas.
There are three major types of diabetes.
Type 1 diabetes :- This is used to be called juvenile-onset diabetes.
Type 2 diabetes :-This is used to be called non-insulin dependent diabetes or
adult-onset diabetes. Type 2 diabetes is the most common type of diabetes.
Gestational diabetes (GDM) :-This is a form of diabetes which occurs when the
blood glucose level is increased during pregnancy.
2.1.2.Historical aspects
This medical condition characterised by excessive thirst, continuous urination and severe
weight loss has received the attention of different medical authors over last 3000 years.4
Physicians of ancient India at the same time explained the disease as characterized by
passing sugar through urine and they named it as ―madhumeha‖ or ―honey urine‖.4 The
word diabetic was used first in 230 BC, the meaning being ―to pass through‖ and the first
complete clinical description appeared in between 30BC and 50AD.4 Susrutha and
Charaka, fifth century physicians from India, contributed detailed explanations about
different types of diabetes.2 Likewise, 7th century physicians in China explained that
3
diabetic patients are more prone to boils and lung infection.4 In the 11
th century Ibn-Sina
from Bagdad explained the clinical description of diabetes and management in detail.4
The origin of modern understanding about the diabetes, its complications and
management came from Europe between 16th
and 18th
century. There was no effective
treatment for diabetes un until in the 19th and 20th centuries, when there took place
several discoveries in relation to the diabetes and its management including the discovery
of insulin and oral hypoglycaemic agents.4 Results of literature search in PubMed using
the key word ‗Diet Diabetes‘ shows a rapid increase in the number of studies in relation
with diabetes and diet. ―Case of diabetes, showing the importance of bread as an article of
diet‖ by Charles Cowan in 1843 is the first available literature that explains the
importance of diet and diabetes. The paper argued that high diet with bread will increase
the urine sugar level.
Table 2.1-Results of literature review in PubMed by the key word ‘Diet Diabetes’.
Year Number of available articles in PubMed
1800-1850 1
1851-1900 1
1901-1950 59
1951-2000 14291
2001 -2013 21989
The release of first ‗Surgeon General‘s Report on Nutrition and Health‘ in 1988 was a
historical mile stone in the effort to control the chronic disease in modern era which
explains the role of dietary practice in different chronic diseases.5 The increasing the
4
number of diabetic patients indicates the burden and the diabetes epidemic is new
perhaps, but as a disease diabetes is not a new entity.
2.1.3.Pathophysiology
In diabetes mellitus there will be a rise in blood glucose level from the normal. Normal
level of the glucose in blood is maintained by the hormone insulin produced by beta cells
of pancreas. Any impairment in beta cell function may lead to an impaired insulin
production. Diabetes is caused due to inadequate production of insulin or the cells fail to
respond to insulin.6 Both genetic and environmental factors are affects insulin sensitivity.
7
The insulin resistance and beta cell dysfunction are the major processes that happen very
early in the development of type 2 diabetes.8 Thus the healthy glucose homeostasis
system gradually fails to maintain and elevation of glucose level will occur.
2.1.4.Clinical presentation and Diagnosis
Ancient physicians explained a disease characterized by excessive thirst, continuous
urination and severe weight loss.2
These are symptoms typical of diabetes.3:-
Polyuria or frequent urination
Polydipsia or excessive thirst
Polyphagia or extreme hunger
Unexplained weight loss
Extreme hunger
Sudden vision changes
Tingling or numbness in hands or feet
Feeling very tired much of the time
Very dry skin, sores that are slow to heal and more infections than usual.
5
According to WHO the criteria for diabetes is – fasting plasma glucose ≥ 7.0mmol/l
(126mg/dl) or 2–h plasma glucose ≥ 11.1mmol/l (200mg/dl).9
2.1.5.Management of diabetes mellitus
People with diabetes must take responsibility for their day-to-day care, and keep blood
glucose levels from going too low or too high. Healthy eating, physical activity, and
blood glucose testing are the basic therapies for type 2 diabetes.3 In addition, many people
with type 2 diabetes require oral medication, insulin, or both to control their blood
glucose levels.3
Pharmacological management of diabetes mainly include oral anti diabetic drugs and
insulin therapy. Oral anti diabetic drug includes drugs that act by modifying the factors
that helps in adjusting the increased level of blood sugar by different actions, which
includes sulphonyl ureas and non-sulphonyl urea agents.10
Table 2.2. Oral anti diabetic drugs
Types
Sulphonyl urea
First generation
eg:-Chlorpropamide, Tolbutamide
Second generation
eg:-Glibenclamide,Glipizide
Non-sulphonyl urea
Meglitinide analogues
eg:- repaglinide
Biguanides
eg:- metfromin
Alpha glucosidase inhibitors
eg:- acarbose
Thiazolidinediones
eg:- rosiglitazone
6
Insulin can be used either if there is no response to oral therapy and lifestyle changes or
as a combination with other therapies.8,11
Non pharmacological therapies also have a great importance in the management of
diabetes through the control of blood sugar. Lifestyle changes are the most important non
pharmacological management in case of the type 2 diabetes. Lifestyle modification
include changes in dietary behaviour from unhealthy to healthy pattern to maintain the
body weight, normal sugar level, desirable lipid profile, and prevent and postpone the
complications related to diabetes.24
Lifestyle modification also includes regular exercise,
stress management and tobacco cessation.24
Being diagnosed as a diabetic is a stressful
situation and so the management should include behavioural modification to lead a
healthy life and special counselling and support is necessary to develop and maintain a
positive attitude. 24
Diabetic patients are at high risk of stroke, eye disease, nephropathy, neuropathy, foot
complications, various skin problems, stress, hypertension and peripheral arterial
diseases.12
Also diabetic patients are at high risk for developing infections.13
Several
studies shows that patients with type 2 diabetes mellitus have a high risk for developing
infectious disease.14,15
2.1.6.Goals of biomarker levels in the control of diabetes
The blood sugar level should be controlled in diabetic patients. There are different
biomarkers to compare the blood glucose level. Most commonly using biochemical
measurements are HbA1C, fasting blood glucose level and post meal glucose level.
7
Table 2.3 .Recommended blood glucose level for diabetic patients.16
Normal Target
HbA1c
8
2.2.2.Indian scenario
Different studies are available for the prevalence of diabetes in India over several
decades. From 1970 onwards the prevalence of diabetes increased drastically especially in
urban areas due to the lifestyle changes and now the prevalence is reaching very high
levels.18, 12
Presently, India has the largest number of people with diabetes in the
world, over 40 million and the prevalence of diabetes in India is 8.3%.7 In India 11% of
total health expenditure was for diabetes in the year 2010.19
The social and economic
burden of diabetes is very high in India compared to other countries in the world because
of the high number of diabetes patients.20
2.2.3Kerala scenario
In India, Kerala is an exceptionally well performing state in social and health sectors
compared to other states of the country. Kerala model of health is well discussed in the
country and throughout the world because of the good health indicators and a life
expectancy compared to developed nations.21,22,23
But when it comes to the non-
communicable disease especially diabetes the situation is entirely different.In India,
Kerala is the most advanced state in health transition, and a ―harbinger of what will
happen to the rest of India in future".24
Prevalence of diabetes is very high in both rural
and urban Kerala.12
As reported by department health and family welfare Kerala 27% of
adult males and 19 % of adult females are diabetic and Kerala can be considered as the
diabetic capital of India.25
The prevalence of diabetes from different studies is given
below.
9
Table 2.4.Prevalence of diabetes in Kerala from different studies.
Study title Area Year Definition of
diabetes Prevalence
Risk factor profile for chronic
non-communicable diseases:
results of a community-based
study in Kerala, India.21
Trivandrum district 2010
fasting plasma
glucose > or =
126 mg/dL or
on drugs for
diabetes
16.2%
High prevalence of type 2
diabetes mellitus and other
metabolic disorders in rural
Central Kerala.26
Chengannur Taluk,
Alappuzha district. 2009
fasting plasma
glucose > or =
126 mg/dL or
on drugs for
diabetes.
14.6%
Type 2 diabetes in southern
Kerala: Variation in
prevalence among geographic
divisions within a region.27
Trivandrum 2000
Either fasting
plasma
glucose> 139
mg/dl, or
postprandial
plasma glucose
> 199 mg/dl,
or both
5.9%
High prevalence of type
2 diabetes in an urban
settlement in Kerala, India.28
Trivandrum 1999
fasting plasma
glucose > or =
126 mg/dL or
on drugs for
diabetes
16.3%
Metabolic Syndrome and
Other Cardiovascular Risk
Factors among Police
Officers.29
North Kerala 2012
Fasting
glucose ≥ 110
mg/dl or
known diabetic
13.7%
Prevalence of known and unde
tected diabetes and associated
risk factors in central Kerala—
ADEPS.30
Central south
Kerala 2006
fasting
capillary
glucose
≥110 mg/dl
and or 2-h
capillary
glucose of
≥200 mg/dl or
9.0%
10
Study title Area Year Definition of
diabetes Prevalence
self-reported
or on anti-
hyperglycaemi
c drugs
Occupational Hazards Vs
Morbidity Profile Among
Police Force in Kerala.31
Kottayam 2012
Self- reported 12.5%
Socioeconomic position and pr
evalence of self-
reported diabetes in rural Keral
a, India: results from
the PROLIFE study.32
Trivandrum district 2012 Self-reported 11.1%
The prevalence, risk factors an
d awareness of hypertension in
an urban population of Kerala
(South India).33
Trivandrum city 2009 Self-reported 15.1%
Diabetic retinopathy among
self- reported diabetics in
southern India: a population
based assessment.34
Palakkad district 2002 Self-reported 5.1%
Prevalence of coronary heart
disease in the rural population
of Thiruvananthapuram
district, Kerala, India.35
Trivandrum (Rural) 1993 Self -reported 4.0%
2.3.Importance of diet in diabetic management
Diet control is the corner stone in the management of type 2 diabetes. Ancient Egyptian
physicians explained a disease with ―too great emptying of the urine‖ and they advocated
the use of wheat grains, fruits and sweet beer for the management of same.4 Along with
medication effective managements like healthy diet, physical activity, maintaining
appropriate weight and not smoking have major role in control of blood sugar and
11
preventing or delaying the complications of diabetes.36
Maintaining a normal glucose
level in the blood is a key factor for the management of diabetes. Diet containing low fat,
high protein and low carbohydrate play an important role in decreasing the glucose level
in the blood.37
Majority of type2 diabetes patients are overweight /obese which further
increase their risk of complication.12 Healthy diet is necessary to prevent the
complications in the diabetic patients.
Diet management alone may help the diabetic patient to maintain the glycemic level
normal. Different studies showed that a diet with high protein and low carbohydrate will
help to decrease the blood sugar level in people with untreated diabetes.38,39
A study at
Ernakulam (2005)showed that 66% of diet alone management patients had a good
diabetes control.40
There are different studies which showed a positive effect on the
control of diabetes with good dietary behavior. A study among Japanese elderly diabetic
patients (2008) showed that diet rich in vegetables and fish improves life prognosis and
the overall mortality and death due to diabetes related causes are less in patients who
following a healthy diet.41
Lifestyle modification has a significant role in the control of
blood glucose level. A study published from Korea (2013) showed that there significant
improvement in the HbA1C level of diabetic patients after regulating the diet and
physical exercise without changing the medication pattern.42
A study published from
Karnataka(2013) shows dietary intervention with low calorie fruits resulted in significant
reduction of blood glucose level among type 2 diabetic patients.43
2.4.Dietary recommendations for diabetic patients
As per WHO guidelines low glycemic index foods should be preferred as the source of
carbohydrate in the diet in type 2 diabetic patients.37
WHO also recommends a daily
intake of five serving of fruits and vegetables.44
The recommendations aim to control the
12
blood sugar level and to prevent different complications of diabetes. A diabetic patient
should avoid honey, sugar, sweets, artificial sweeteners, restrict processed foods like
Maida based food, controlled use of roots and tubers, restrict hydrogenated oils(use more
than one edible oil), use fibre rich food, restrict salt-pickles, pappad, salty processed
foods, avoid use of tobacco, smoking and alcohol.45
As the diabetic patients are more
prone to cardiac diseases excess use of salt, sugar, fried food items, oils, coconut,
cholesterol rich food items and refined food items should be avoid to protect the heart.46
2.5.Adherence to good dietary behaviour
Adherence is defined as the ―extent to which a person's behaviour - taking medication,
following a diet, and/or executing lifestyle changes, corresponds with agreed
recommendations from a health care provider‖.47
Adherence to a good dietary pattern will
help to regulate the blood sugar level in optimum level. From different studies it is very
clear that the adherence to healthy diet is very poor among the diabetic patients. Studies
done among diabetic patients in India and US shows that more than 60% in type 2
diabetes mellitus patients are not following the dietary guidelines.48,49
A study from
Tamilnadu in 2012 showed that the prevalence of good dietary practice was only 29 %.48
The healthy dietary pattern among diabetic patients is significantly associated with lower
HbA1C level.50,51
2.6.Physical activity
Physical activity has an important role in the maintenance of optimal glucose level of the
body along with the dietary modification. Physical activity is one of the basic therapies
for type 2 diabetes mellitus recommended by the Centre for Disease Control, Atlanta.52
Exercise has positive benefit on patients who have diabetes by lowering the blood glucose
level, improving the insulin sensitivity and strengthening the heart.53
According to ICMR
13
regular physical activity will help in improving insulin sensitivity, reduction in
hypertension, decrease in weight, improvement in lipid profile(reduces serum
triglycerides and increases HDL), improvement in cardiovascular function, increase in
bone density, improvement in the sense of physical and mental wellbeing and
improvement in quality of life.24
The overall benefits of physical activity is well studied
and it can control the blood sugar level and prevent further complications like
cardiovascular disease in type 2 diabetic patients.54
2.7.Factors affecting the dietary behavior
Different factor are influencing the diet of a diabetic patient. Cherrington A et al have
grouped the major factors that are associated with self-management of the diabetes,
including diet grouped under patient empowerment, self- efficacy, structural barriers,
facilitator or social support, and the knowledge of diabetes.55
Different factors like age,
duration of diabetes, socioeconomic status, family support and information regarding diet
may affect the dietary pattern of the patient. A study among low income minority diabetic
patients in 2008 shows that lack of proper information and confusing information are the
major barriers to self-management of diabetes.56
Among gestational diabetes patients of
Australia the family preference on food is a major barrier for following a diabetic dietary
pattern.57
The effective management of diabetes is determined greatly by the
socioeconomic status and the quality of diet is different in different SES.58,59
A study
from south India shows that older age, shorter duration of diabetes, family support,
nuclear family, less busy work life, advice from dietician and proper information on diet
has an influence on change in dietary behavior.60
Amount of staple starch food and use of
carbonated water usage have a positive relation with blood sugar level in type 2
patients.61
Due to industrialization and globalization the food habits among all class of
people in Kerala changed in to unhealthier pattern. The packed food items and soft drinks
14
usage has increased among the people of Kerala in last 30 years which lead to
consumption of more energy than required and energy spending through physical activity
reduced by a sedentary lifestyle approach.62
Food is considered as central attraction to
social events and the number of such social events is increased a lot in recent years.36
The
particularity of Indian states is that the people will consume large amount of energy rich
and unhealthy foods during religious and communal functions.63
Even though Kerala is a
highly literate state in India and people are more aware of relation between diet and
diabetes control, their fear is overcoming by the sociality of foods.36
2.8.Rationale /justification of the study
The prevalence of diabetes is very high in Kerala. Effective management of diabetes can
prevent or delay the complication. There are only few studies in Kerala that assessed the
dietary pattern among diabetic patients. One study from south Kerala reported that there
is increase in awareness regarding the dietary modification.64
The study did not look in to
the dietary pattern among diabetic patients. Dietary practices may vary between different
places even district to district and so there is a need to context specific studies.
Currently the health system of Kerala is planning to do different activities to improve the
quality of health, by restricting the incidence, prevention of complications and reduction
in mortality through educating and encouraging hotel and bakery group for promoting
NCD food and banning of junk foods in schools and government run canteens.22
The
health system of Kerala is planning specialized diabetes and hypertensive clinics in
general hospitals, District hospitals and Taluk hospitals on a step by step manner. Also
the programme is trying to post diet counselors and different supportive staff to these
centers.22
So the understanding of the dietary pattern and associated factors will help in
15
planning the effective management of diabetes. Also it will be helpful to the health
system in setting a good NCD control programme.
2.9.Objectives of the study
2.9.1.Major objective:-
1. To assess the dietary pattern in relation to the management of diabetes among type 2
diabetes patients in Malappuram district.
2.9.2.Minor objective:-
1. To assess the factors associated with dietary pattern among type2 diabetic patients.
2. To assess the risk perception of frequent foods in relation to diabetic management
16
3. METHODOLOGY
This chapter will explain the methodology part of the study.
3.1.Study design
Study design was a cross sectional survey
3.2.Study setting
The study conducted in Malappuram block panchayath in Malappuram district. This
consists of a predominantly rural area. Kerala have high prevalence of diabetes when
compared to other states in the country. The situation in Malappuram district is not
different from other part of the state. The public health system is not in a position to
address the burden of diabetes management.
3.3.Study population
My study population included all the diabetic patients in Malappuram block panchayath.
3.4.Inclusion criteria
Self-reported male and female diabetic patients aged 25 years and more and who were
living in the study area for more than or equal to one year, and who are willing to give the
consent to the study was included in the study. The subjects were diabetic for at least one
year at the date of data collection.
3.5.Exclusion criteria
Those who were unable to give answers to the interview like cognitively impaired
patients will be excluded from the study. Also bedridden patients, pregnant women, and
subjects with medical conditions that have a bearing on diet (eg:-chronic kidney disease)
were excluded from the study.
17
3.6.Sample size.
Sample size was calculated based on a study done in Tamilnadu in 2012 reported a good
dietary practice of 29% among diabetic patients.48
The sample selection procedure was
cluster sampling and so a design effect of 2 (arbitrarily) was considered. Sample size was
calculated by N = 4PxQ/ D2
( P=0.29 Q=0.71) and D was arbitrarily taken as 8% or
0.08.By considering the design effect the sample size was 257.38. By considering a non-
response rate of 20% the sample size was 308.85 and it was rounded to 310. There were 6
gramapanchayaths in Malappuram block panchayath. It included a total of 117 electoral
wards. From these wards I randomly selected 20 wards. From each of these 20 wards a
cluster of 16 diabetic were selected for the study.Estimated sample size was 310 from 20
wards of the Malappuram block panchayath. Each ward was considered as a cluster and
thus from a cluster 16 diabetic patients were interviewed.
3.7.Sample selection procedures
Among the 15 block panchayath of Malappuram district I had arbitrarily selected
Malappuram block panchayath as the study area. In the next stage I selected 20 wards
from the total 117 electoral wards of Malappuram block panchayath. This was done by
lottery method. Out of 20 wards 16 diabetic patients from each ward will be selected by
cluster sampling. The central part of the ward was identified with the help of a local
person. Using a spin bottle method, direction of data collection was decided. The first
house was identified by selecting randomly a number between 1 and 10 and went to that
house. Starting from the first house consecutive houses was visited until I got 16 diabetic
patients. If more than one eligible member was present in household then subject for
interview was selected by lottery method. Interview was done at a convenient time in the
concerned household for the subject who reported inconvenience at the time of data
18
collection. Households with door was locked at the time of visit were excluded from the
survey.
Figure.3.1.Sample selection procedure
3.8.Data collection techniques
The tool used for the data collection was a structured interview schedule for identifying
the dietary pattern among the diabetic patients, the factors affecting the dietary pattern
and the risk perception of commonly consumed foods. The interview schedule contained
questions from standard tool like IPAQ (international physical activity questionnaire-
short form) to assess the physical activity and a general self-efficacy scale (GSE) by
Matthias Jerusalem and Ralf Schwarzer. The GSE was available in 31 languages
including English and Hindi. Written Informed consent was got signed before starting
Malappuram district
Malappuram block panchayath
6 panchayath=117wards
20 wards
16 household with diabetes from each ward
1 diabetic patient from each household (if more than 1,
selection by lottery method)
19
each interview. Both the interview schedule and the consent form was translated in to
local language (Malayalam)
Figure.3.2. Conceptual framework used for identifying and organizing study
variables
Associated variables
*CDC-2012
The data was analysed to get the proportion of diabetic patient with good dietary
behaviour. Univariate and bivariate was done to summarise and describe the findings and
observed differences. Statistical associations found out in bivariate analysis used to
inform modelling during multivariate analysis
Patient
Patient
empowerment
Self -efficacy
Facilitators( social
support)
Structural barriers/
impediments
Diabetes knowledge
Good dietary
behaviour
20
Table 3.1. List of study variables that were used to collect data.
Socio demographic
variables
Age
Sex
Marital status
Family type
SES
Patient empowerment
Responsible person in cooking
Decision making role
Education
Occupation
Self- efficacy& Diabetes
knowledge
General Self-Efficacy scale
Importance of diet
Knowledge of complications
Structural barriers
/impediments and
facilitators
Type of information
Source of information
Barriers due to
Cost
Availability
Taste
Barriers at work place
Family support
Other support
Life style factors
Physical activity by Using IPAQ-short form
questionnaire
Tobacco use
Alcohol consumption
Disease and clinical
management
System of medicine
Blood sugar level monitoring
Type of institute of health seeking
Perception of different
foods
Questions on perception
Intermediate outcome
variables
Low fruits and vegetable
serving
High fat diet
high salt diet
High sugar diet
Unhealthy snacking
behaviour
21
3.9.Definition of outcome variable
Good dietary practice was defined as the outcome variable. Good dietary practice was
defined by presence /absence of five dietary behaviours. That is low fruits and vegetable
servings, high fat diet, high salt diet, high sugar diet and unhealthy snacking behaviours.
For the analysis of this study, a diabetic patient with good dietary practice means he/she
should not have more than one of the unhealthy dietary behaviours.
1. Low fruits and vegetable serving:- Those who had less than or equal to three
servings of fruits and vegetables per week.(The WHO recommendation for fruits
and vegetable is five servings per week. In this study the number of servings taken
as 3 because number of respondents with the WHO criteria was very less.)
2. High fat diet:- Those who having high fat food more than one day per week or
who having fried foods with main meals ‗often‘/ ‗always‘.
3. High salt diet:- Those who having a high salt diet more than one day per week or
having salt at table ‗yes‘
4. High sugar diet:-Those who having high starchy food or sugar sweetened
beverage more than one day per week
5. Unhealthy snacking behaviour: - Those who having unhealthy snacks more than
one day.
3.10.Ethical considerations
The ethical clearance of the study was cleared by Institutional Ethics Committee of Sree
Chitra Tirunal Institute for Medical Science and Technology, Trivandrum on 12-06-
2013(reference number SCT/IEC-480/JUNE-2013)
22
3.11.Confidentiality
The identity of the participant kept anonymous from the stage of data collection as in the
entry form, where only the dummy ID number had shown. The separate list of name,
contact and telephone number with respondent‘s ID number with the signed consent was
separated and maintained strictly confidential under my care.
3.12.Privacy
The interview was conducted at respondent‘s home which was comfortable for them.
3.13.Consent
Purpose of the interview was explained and informed written consent was obtained from
the subject prior to the start of the interview .The subject had the freedom to refuse
participation in the study or even withdraw from the study at any stage.
The data was collected from June 15th
of 2013 onwards and complete on first week of
September of 2013.
23
4. RESULTS
The survey was completed for 304 respondents and the coverage was 95%. Data
collection was completed by two and half months. The study covered a total of 20
clusters. One electoral ward of grama panchayath was considered as one cluster. The
study covered 3272 adults from 979 households. The total number of diabetic patients
met during the survey was 380. One person disagreed to participate the study, 5 were not
living in the study area in the past year, 4 were with less than one year duration of
diabetes and the remaining 66 from households where there was more than one diabetic
person. The estimated prevalence of self-reported diabetes in the studied population was
11.6%.(95% C I: 8.9-14.3%)
4.1. Socio demographic factors
The study included both males and female of age from 28years to 86years. The mean
age of the study population was 55.64±11.07 years and the median age was 55 years.
The study population included 171(56.2%) females and 133(43.8%) males. Age was
grouped in to three categories and 45-64 year age group consists of 61.8% of the total
subjects. Socio Economic Status (SES) was defined to three groups based on the type of
floor of the household. More than half (56.3%) of the subjects belongs to poor SES
category.
24
Table 4.1.Distribution of socio demographic characteristics by sex
Variable Category Male
N (%)
Female
N (%)
Total
N (%)
Age group 25-44
45-64
65 and above
19(14.3%)
82(61.6%)
32(24.1%)
28(16.4%)
106(62.0%)
37(21.6%)
47(15.5%)
188(61.8%)
69(22.7%)
SES High
Middle
Low
38(28.6%)
32(24.1%)
63(47.3%)
45(26.3%)
33(19.3%)
93(54.4%)
83(27.3%)
65(21.4%)
156(51.3%)
Marital status Widowed/Separated
Married
2(1.5%)
131(98.5%)
55(32.2%)
116(67.8%)
57(18.8%)
247(81.2%)
Type of
family
Nuclear/Extended
Joint
123(92.5%)
10(7.5%)
163(95.3%)
8(4.7%)
286(94.1%)
18(5.9%)
4.2. Patient Empowerment factors
Patient empowerment factors were assessed by education, Job, Exposure to media, having
their own money to spend and weather they have any role in decision making in their
health care, making purchases to the family and family visits. The number of respondent
with more than 10 years of education was very less.
Figure.4.1. Distribution of educational status of the respondents.
135 152
17
0
50
100
150
200
0-4yrs 5-10yrs Morethan10yrs
EDUCATION
25
Table 4.2 .Distribution of patient empowerment factors
Variable Categories Frequency Percentage
Job Yes
No
117
187
38.5%
61.5%
Having own money to spend Yes
No
268
36
88.2%
11.8%
Role in health care Yes
No
253
51
83.2%
16.8%
Role in decision making /purchase by the
family
Yes
No
173
131
56.9%
43.1%
Media exposure Yes
No
262
42
86.2%
13.8%
Deciding the food items to family Respondent
Somebody
others
148
156
48.7%
51.3%
4.3.Barriers and facilitators
Thirty two (10.5%) reported that they did not get any form dietary advice. 264(86.8%)
got advise from doctor, 6(2.0%) from nurse and 2(0.8%) got advise from dietician.
140(46.1%) reported that they had a difficulty to consume a low salt, low sugar and low
fat diet. Difficulty in consuming high fruits and vegetables were reported by 40(13.2%) of
the respondents. The main barrier for low sugar, low salt and low fat food was taste and
for fruits and vegetables was cost. 33(10.9%) of the respondents reported that they were
frequently travelling for job and other purposes.
26
Somebody had to control their diet was reported by 143(47.0%). Good family support to a
good healthy diet was reported by 124(40.8%), 99(32.6%) reported that they are getting
support ‗sometimes‘ and 81(26.6%) reported no family support.
4.4.Self-efficacy and diabetes knowledge
Mean self-efficacy score of the study population was 28.84±8.67 and median 30 with a
cronbanch‘s alpha of 0.97. The minimum score was 10 and maximum score was 40.
36(11.8%) subjects reported that diet had no major role in the control of diabetes. Good
knowledge about complication of diabetes was reported by 204(67.1%).
4.5. Lifestyle factors
The main lifestyle factors assessed were tobacco use, alcohol use, physical activity and
sitting time
Table 4.3.Description of lifestyle factors
Variable Categories Frequency Percentage
Tobacco Non-user
Current user
Past user
229
45
30
75.3%
14.8%
9.9%
Alcohol User
Non-user
3
301
1.0%
99.0%
Physical activity Sedentary
Moderate
Vigorous
60
103
141
19.7%
33.9%
46.4%
Sitting time 6hours
186
118
61.8%
38.2%
27
4.6 Variables related to disease and clinical management.
Mean duration of diabetes was 7.44±5.84years and median 6 years with a range of 1-33
years. 293(96.4%) prefer Allopathy and 11 (3.6%) prefer other system of medicine as
their main system of medicine. 97(31.9%) reported using public sector and 207(68.1%)
reported using private sector for their treatment.
Diagram 4.2. Medication pattern by the diabetes patients.
Medication pattern ‗not as per advice‘ included ―take more when I feel necessary‖-24
(7.9%), ―take less tablets when asymptomatic‖-17(5.6%), ―taken medicines as per
convenience‖-17(5.6) and ―taken medicines when available‖-5(1.6%). Nine (3%) never
checked blood sugar, 146(48%) checked 1-5 times and 149(49%) checked more than 6
times in the last 6 months. Only 6(2%) of the study population checked HbA1C ever.
4.7. Risk perception
One of the objectives of the study was to assess the risk perception of frequently
consuming foods. Majority of patients mentioned sugar and beef as the foods that should
be avoided by a diabetic patient. 8.9% of the participants told that fruits should be
avoided by a diabetic patient. 91.8%participants do not check the labels on packed foods.
In the study population 143(47%) of the respondents reported that they had followed a
healthy diet in all the seven days of the week and 13.7% reported that they never followed
79%
21%
Medication pattern
As per advice
Not as per
advice
28
a healthy diet in any days of the week. Among the 143 only 49(34.3%) were followed a
healthy diet as per the definition.
4.8 Dietary practices
Each intermediate outcome variable and the composite outcome variable were analysed
separately to identify the proportions.
Table 4.4. Frequency and proportions dietary practices.
Dietary practices Frequency (N=304) Percentage CI (95%)
High fat diet 168 55.3% 49.7-60.9
High sugar diet 102 33.6% 28.3-38.9
High salt diet 170 55.9% 50.3-61.5
Low fruits and vegetable diet 229 75.3% 70.5-80.1
Unhealthy snacking behaviour 110 36.2% 30.8-41.6
Good dietary practices 62 20.4% 15.9-24.9
4.9 Bivariate analysis: good dietary practice with specific factors
Bivariate analysis was done for all the independent variable with good dietary practice as
outcome variable. Results of variables that were not significant in bivariate analysis are
given in Appendix 1.
4.9.1 Socio demographic factors associated with good dietary practice
Older age group have a higher proportion of good dietary practice and females having
higher odds of good dietary practice. Among different SES group the percentage of good
dietary practice is less in high SES and middle and low have similar percentages and it
was not significant. Type of family had no significant association with good dietary
practice.
29
Table4.5. Association of demographic factors with good dietary practice.
Variable
Categories N Good dietary
practice
n (%)
p-
value
Crude OR
(95% CI)
Age group 25-44 47 5(10.6%) *
45-64 188 36(19.1%) 0.176 1.99(0.74-5.4)
>=65 69 21(30.4%) 0.016 3.68 (1.27-
10.6)
Sex Female 171 41(24%) *
Male 133 21(15.8
%)
0.079 0.6(0.33-1.07)
Marital
status
Married 57 19(33.3%) *
Divorced/widowed 247 43(17.4%) 0.007 0.42(0.22-0.8)
*reference
4.9.2 Patient empowerment factors associated with good dietary practice
Those who had job and high educational years had significantly lower odds of good
dietary practice. Having own money to spend, role in decision making their health care,
making purchases, family visit, decision making in selection of food items to the family
had no significant association with good dietary practice. Exposure to different type of
media also had no significant association with good dietary practice.
30
Table 4.6. Association patient empowerment factors with good dietary practice
Variable Categories N Good dietary practice
n(%)
p-value Crude OR
Education 0-4yrs 135 35(25.9%) *
5-10yrs 152 25(16.4%) 0.05 0.56(0.32-1.0)
More than 10yrs 17 2(11.8%) 0.215 0.38(0.083-1.75)
Job No 187 46(24.6%) *
Yes 117 16(13.7%) 0.021 0.49(0.26-0.91)
*reference
4.9.3 Barriers and facilitators associated with good dietary practice
Advice on diet modification and perceived difficulty to have a high fruits, vegetable diet
had no significant association with good dietary practice. Some body having perceived
difficulty in having low salt, sugar, fat diet, frequently travelling for job and other
purposes, and having family support had a higher odds of good dietary practice.
Table 4.7. Association barriers and facilitators with good dietary practice.
Variable Categories N Good dietary
practice
n(%)
p-
value
Crude OR
Difficult to consume low
salt, sugar, fat food
No 164 49(29.9%) *
Yes 140 13(9.30%)
31
4.9.4 Self-efficacy, diabetes knowledge and lifestyle factors with good dietary
practice
Persons with a self-efficacy score of more than 30 had a lower odds of having good
dietary practice when compared to group with self-efficacy less than or equal to
30[OR:0.45(0.24-0.83)] with a p-value of 0.01. Physical activity and diabetes knowledge
had no significant association with good dietary practice. Group with sitting time more
than 6 hour had a higher odds of good dietary practice compared to others[OR:1.78(1.02-
3.13)] with a p-value of 0.043.
4.9.5 Disease related and clinical management factors associated with good dietary
practice
System of medicine for diabetic treatment and preference of public sector/ private sector
had no significant association with good dietary practice. Duration of diabetes and
frequent blood sugar monitoring had associated with good dietary practice. Last
monitoring day of blood sugar had no significant association with good dietary practice.
32
Table 4.8 Association of clinical and management factors with good dietary practice.
Variable Categories N Good dietary
practice
-n(%)
p-
value
Crude OR
Duration of
diabetes
6yrs or less 177 28(15.8%) *
More than 6 127 34(26.8%) 0.021 1.95
(1.11-3.42)
Medication pattern Not as per advise 63 8(12.7%) *
As per advise 241 54(22.4%) 0.089 1.99
(0.89-4.42)
Blood sugar
monitoring in last 6
months
Less than 5 times 131 16(12.2%) *
5 or more times 173 46(26.6%) 0.002 2.60
(1.40-4.85)
*reference
4.10. Predictors of good dietary practice: Results of Multivariate analysis
Multivariate analysis was done to find out the predictors of good dietary practice.
4.10.1.Procedure
Multivariate analysis was done for important demographic variable that may affect other
predictor variables and for the independent variables which are significant at 10% level in
bivariate analysis with good dietary practice. List of variables showing association with
intermediate outcome variable in bivariate and multivariate analysis are given in
appendix2.
33
4.11.Final model
Good dietary practice among studied population was associated with perceived difficulty
to consume low sugar, low salt and low fat diet. Good family support and another person
having a control of their diet also had significantly higher odds of good dietary practice.
Those who are frequently monitoring blood sugar also found to have higher odds.
Table4.9. associated factors of good dietary practice: Results of Multivariate
analysis.
Variable Categories N Good dietary
practice
-n(%)
Adjusted
OR(95%CI)
p-
value
Difficult to consume
low salt, sugar, fat
food
No 164 49(29.9%) *
Yes 140 13(9.3) 0.19
(0.09-0.41)
34
Figure.4.3.Factors promoting good dietary practice among diabetic patients/
Diagrammatic representation of the study results
*Frequent blood sugar monitoring group may have some other characteristics to follow
good dietary practice (eg:-complication, good nutritional knowledge etc.) that were not
captured in the study.
Table 4.10.List of variables that did NOT had association with good dietary practice.
Bivariate analysis Multivariate analysis
SES
Type of family
Knowledge about complication
Knowledge of importance of diet in diabetes management
Tobacco use
Physical activity
System of medicine
Preference of health care setting
Last blood sugar monitoring day
SES*
Age group
Sex
Marital status
Education
Job in last 12 months
Frequent travel for job/other purposes
Self-efficacy
Sitting time
Duration of diabetes
Medication pattern
*Important demographic variables included in multivariate analysis even though it was
not significant in bivariate analysis.
Diabetic patient
No perceived difficulty
to have healthy diet
Having another person
to control diet
Having Family
support
Frequent blood sugar
monitoring*
Good dietary
practice
35
5. DISCUSSION
The present study was done to assess the dietary pattern, associated factors and the risk
perception of frequent foods among the self-reported diabetic patients in Malappuram
district which is in the northern part of the Kerala. The study design was cross sectional
survey method and the sample size was 304. The prevalence of self- reported diabetes
was 11.6% and which is similar to the recent studies from different parts of the Kerala.
The prevalence of self-reported diabetes in various studies done in the years 1993 to 2012
in different parts of Kerala showed values from 4.0% to 12.5% (given in table 2.4).
The study hypothesized that the prevalence of good dietary practice would be very
low(about 29%) among diabetic patients and that good dietary practice will be associated
with patient empowerment factors , diabetes self-efficacy, facilitators/social support,
structural barriers/ impediments that can influence the dietary pattern and the knowledge
regarding the disease, complications and the goal .
The outcome variable of the study was defined as good dietary practice. The
measurement of diet is very difficult and it is difficult to work out whether one‘s dietary
pattern is good or not. As the diet include several component the study measured it in five
major categories, that is consumption of high fat diet, high salt diet, high sugar diet, low
fruits and vegetables servings and unhealthy snacks. Each of these categories was defined
by the number of days of consumption of specific foods in a usual week or by the
frequency of some unhealthy ‗behaviours‘ like using extra salt at table or frequent
consumption of soft drinks. The overall outcome was good dietary practice. Since the
number of subject without all the five unhealthy behaviours was very low to do analysis,
the definition used for good dietary practice in this study was that he/she should not have
more than one of the unhealthy dietary behaviours.
36
The prevalence of good dietary practice in the study population was only 20.4% (95%CI-
15.9%-24.9%) and it was lesser when compare with similar studies in the neighbouring
states and which was29.0% (with 95%CI- 20.8%-37.2%).48
The decrease in the
prevalence may suggest that the sample size calculated for this study is inadequate.
However, the present study used a more complex definition for good dietary practice and
this would be the reason for the lower prevalence that is observed. Some studies from
India and US showed a 40% prevalence of adherence to dietary guidelines which cannot
be compared to study group because of the lack of information regarding the dietary
advice to the study group. 48, 49
Diabetic patients with family support follow a healthy dietary pattern probably because
their family members take much care to prepare separate food for patient or they even
change the whole dietary pattern of the family accordingly with the patient needs. Such
diabetic patients were found to have more chance to follow a better diet in relation to their
diabetic self-care management activities. In addition to general family support, patients
with somebody to specifically control their diet have a good dietary practice. Persons like
spouse, family members, friends, peer groups and neighbours can have an influence in
dietary pattern and this type of facilitating factors seemed to be significantly associated
with a better diet management of the diabetic patients. Different studies from India and
outside countries showed the positive influence of family and other facilitators in
following a better diet.56, 60
Difficulty in consuming low salt, low sugar and high fat foods was found to be
significantly associated with good dietary practice. This indicates the difficulty to follow
a healthy diet even though it has a major role in the control of diabetes. The reason for
this may be the difficulty to compromise the taste of the food by decreasing the sugar and
37
salt from the food and avoiding fried or high fat food items. Taste will be the main criteria
for selecting a food. Similar studies in diabetic patients showed the influence of taste in
the selection of foods.65,
66,
67
The study suggested that the dietary pattern was good among the diabetic patients who
were frequently monitoring blood sugar which does not have a direct relationship with
good dietary practice. The probable reason may be these patients were more particular
about various aspects of diabetes management or they may have some complications of
diabetes mellitus or some other characteristics to modify their dietary pattern that were
not captured in the present study. Nevertheless, 97% of the diabetics found to be checked
their blood sugar at least once in last six months and among the total 49% checked blood
sugar more than 5 times in the last six months. This finding is important as it reflects
increased awareness level or higher accessibility of diabetic patients with respect to blood
sugar level monitoring. Reasons for the poor dietary management by diabetic patients
should study more in a setting where having high awareness regarding blood sugar level
management. The study also suggesting that increased knowledge regarding the disease
and its complication or understanding of importance of diet in controlling the diet did not
have any influence on good dietary practice. So just increasing the knowledge of
individual diabetic patients may not lead to improved dietary pattern. From the study it is
clear that interventions focussing on family members and other persons who can have a
control over the diet of the patient may benefit in a better dietary pattern. Educational
status did not show any relation with the good dietary practice. Studies from different
settings showed that higher education will result in a better diabetic management and
better glycaemic control.68
,69
But very few (5%) of the study subjects had education of
more than high school level and this may explain why the educational level did not
influence the dietary pattern of the studied group.
38
Previous studies showed that there is a difference in dietary pattern among different SES
group and the effective management of diabetes is determining by socioeconomic status
of the patient. 58, 59
But this study did not show any significant association of different
SES group with good dietary practice. The probable reason may be the globalisation and
industrialisation which lead to life style modification and transition of dietary behaviour
of Kerala people regardless of the socio economic strata, from a healthy diet to unhealthy
diet. 62
Study done in a diabetic group in south India who received advice on diet showed
that older age group less busy work life has an influence on the diet.60
Almost 85% of the
study subjects were above 45 years. There is no sex difference in the good dietary
practice among the studied population this may be because the number is inadequate in
both group to bring up significant differences. Job and frequent travelling for job and
other purposes also did not show any significant association, probably due to same
reason.
A high self-efficacy should improve the diet of a diabetic patient.55
But in present study
there is no significant difference among the high self-efficacy group. The tool used to
measure the self-efficacy was General self-efficacy scale and not a disease specific one.
Moreover subjects may be in an earlier stage of their behaviour change (Trans theoretical
model of behaviour change). The original recommendation for using the scale states that
each of the questions has to be incorporated among several similarly structured questions.
This was not done in this study as that would have made the questionnaire very long.
Hence all questions of the scale might have elicited similar responses. There is no
difference in dietary pattern among physically active and sedentary group and the
prevalence of sedentary group is less (19.7%) when compared to general population
(21.9%).21
It is important as physical activity is another major therapy for regulation of
glucose and preventing the complication.24, 52, 53, 54
39
The prevalence of other behaviours like tobacco use (14.8%) and alcohol (1%) use among
the diabetic patients was low when compared to the general population.21
The diabetic
status, non-existence of alcohol use in females of the study area and the study done in
Muslim dominated area might have resulted in the low prevalence of alcohol use.
Apart from the low prevalence of good dietary practice the diabetic patients have
perceived the risk of unhealthy foods like sugar and beef. This may be due to the
awareness of the diabetes patient about the maintenance of blood sugar and cholesterol
level. But this type of knowledge regarding unhealthy food items did not seems to be
reflected in the dietary pattern of the diabetic patients. Around ten percentage of the
subjects believed that fruits are unhealthy for diabetic patients and this along with barriers
to have fruits may lead to the low prevalence of five serving norm off fruits and vegetable
servings as per WHO guidelines. Around half of the diabetic patients believed that they
were following a healthy diet throughout the week. But the study results showed a
prevalence of around 20%. This gap shows the lack of proper nutritional knowledge and
lack of dietary counselling.
40
Strengths of the study
The study brings out some challenges in addressing a difficult component of
diabetes management, i.e. dietary practices, in a relatively backward district
Malappuram and the challenges may be similar in most of rural north Kerala
Along with the individual factors which affect the dietary pattern, the study has
also looked into the social factors, some health system related components and
health seeking behavior of the diabetic patients
To the best of my knowledge this is the first study that assessed dietary pattern
and its determinants among diabetic patients in Kerala.
All the surveys were taken by the principal investigator there by avoiding inter
observer bias
Limitations of the study
The study has not looked into the other co-morbidities like hypertension which
may influence the dietary pattern. Only persons with severe co-morbidities were
excluded
For the measurement of diabetes self-efficacy the study used General self-efficacy
scale due to non-availability of disease specific self-efficacy scale.
The study did not measure the exact nutritional knowledge of the subjects.
The study did not measure the frequency and quality of the dietary advice given
by the health care providers
41
Conclusion of the study
Dietary pattern among the studied population was very poor and the prevalence of good
dietary practice was only 20.4% (OR-15.9%-24.9%). Some of the important factors that
influence good dietary practice include family support, presence of another person to
control their diet and a low perceived difficulty in having a healthy diet. Many individual
level factors such as knowledge on diabetes and its complications did not have an
association with the outcome. Therefore, improvement in the dietary pattern can be done
only with strategies such as diet counseling that may help persons to overcome perceived
difficulties and also to obtain support from family members or others who may be willing
to help control the dietary pattern. The currently existing NCD control programme should
not focus only at individual level but also focus family and other persons who may be
available to support the diabetic person.
Implication for future research
These findings can be validated by food frequency questionnaire or 24 hour recall
method.
Adherence to good dietary practice can be studied in a diet advice given group
42
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Appendix 1
Cross tabulation of demographic variables with good dietary practice
Variables
Categories
N Good dietary
practice
n (%)
p-
value
Crude OR
(95% CI)
SES High 83 14(16.9%)
*
Middle 65 14(21.5%) 0.472 1.35(0.59-3.09)
Low 156 34(21.8%) 0.367 1.374(0.69-
2.74)
Type of
Family
Nuclear/Extended 286 59(20.6%) *
Joint 18 21(15.8%) 1 0.77(0.22-2.75)
*reference
Cross tabulation of barriers with good dietary practice
Variables Categories N Good dietary
practice
n(%)
p-
value
Crude OR
Advise on diet modification Yes 272 58(21.3%) *
No 32 4(12.5%) 0.241 0.53
(0.18-1.56)
Difficult to consume high
fruit ,veg foods
Yes 40 7(17.5%) *
No 264 55(20.8%) 0.626 1.24(0.52-
2.96)
*reference
52
Cross tabulation of patient empowerment factors with good dietary practice
Variables
Categories
N Good dietary
practice
n(%)
p-
value
Crude OR
Having own money to spent
No 36 7(19.4%) *
Yes 268 55(20.5%) 0.880 1.07(0.45-
2.57)
Role in health care
No 51 11(19.6%) *
yes 253 52(20.6%) 0.878 1.06(0.5-
2.26)
Role in decision making of
purchases/ visits by family
No 131 28(21.4%) *
Yes 173 34(19.7%) 0.712 0.9(0.51-
1.58)
Media exposure No 42 11(26.2%) *
Yes 262 51(19.5%) 0.315 0.68(0.32-
1.45)
Deciding the food items to
family
subject 148 29(19.6%) *
others 156 33(21.2%) 0.736 1.1(0.63-
1.93)
*reference
53
Cross tabulation of diabetes knowledge and other lifestyle factors with good dietary
practice.
Variable Categories N Good
dietary
practice
n(%)
p-
value
Crude
OR
Diabetes
knowledge
Major role for
diet in diabetes
control
No 36 9(25%)) *
Yes 268 53(19.8%) 0.465 0.74(0.33-
1.67)
Knowledge about
complication
Less 100 25(25%) *
Good 204 37(18.1%) 0.163 0.67(0.37-
1.18)
Other
lifestyle
factors Tobacco use
Non-user 229 51(22.3%) *
Current
user
45 7(15.1%) 0.316 0.64(0.27-
1.52)
Past user 30 4(13.3%) 0.267 0.54(0.18-
1.61)
Physical activity
Inactive 60 11(18.3%) *
M
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