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