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 Table of Contents  
Year : 2022  |  Volume : 42  |  Issue : 3  |  Page : 109-114

Nonadherence to dietary activities and its associated factors among patients with type 2 diabetes mellitus in an urban area of South India: A cross-sectional study

1 Department of Community Medicine, Siddhartha Medical College, NTR University of Health Sciences, Vijayawada, Andhra Pradesh, India
2 Department of Community Medicine, M. S. Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Date of Submission28-Jan-2021
Date of Decision26-Jul-2021
Date of Acceptance28-Jul-2021
Date of Web Publication15-Oct-2021

Correspondence Address:
Dr. Priyadarshini Chidambaram
Department of Community Medicine, M. S. Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India. Tel: +919945048482; Fax: 080 - 2360 6213
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmedsci.jmedsci_27_21

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Background: Self-care activities related to diet, physical activity, foot care, and blood sugar monitoring in Type 2 diabetes mellitus (T2DM), besides traditional doctor-centered care is essential. Hence, the study was undertaken to find the prevalence of nonadherence to dietary practices among patients with T2DM, its associated factors and to study the association of nonadherence with body mass index (BMI). Methods: The community-based cross-sectional study was carried out among 400 participants with T2DM aged ≥ 18 years in urban Bangalore. Dietary adherence was assessed using The Summary of Diabetes Self-care Activities Questionnaire and anthropometric measurements were made to calculate BMI. Results: Of the total, 207 (51.8%) were ≥ 60 years, 211 (52.8%) were females and 377 (94.3%) were on oral hypoglycemic agents. Calories were unrestricted in 62.7%, fruits and vegetables were not consumed by 68.8%, and overall, 83.5% were nonadherent to diet. Conclusion: Education and marital status can affect a diabetic individual's diet adherence and hence it is necessary to focus on individuals who are likely to be nonadherent by giving them simple understandable instructions to follow and enabling them with wider variety of food and recipe options. Dislike to food in the diet plan contributed majorly to diet nonadherence and having individualized dietary options with the help of food exchange lists and involving nutritionists in diet planning may help overcome food aversions ensuring better adherence to diet. Creating awareness about self-care among people with T2DM, ensuring strict adherence to diet at every follow-up visit to the health-care professional is required to prevent complications of diabetes.

Keywords: Self-care, type 2 diabetes mellitus, diet, adherence, community, Summary of Diabetes Self-care Activities Questionnaire

How to cite this article:
Chappidi M, Chidambaram P, Shivananjiah S, Somanna SN. Nonadherence to dietary activities and its associated factors among patients with type 2 diabetes mellitus in an urban area of South India: A cross-sectional study. J Med Sci 2022;42:109-14

How to cite this URL:
Chappidi M, Chidambaram P, Shivananjiah S, Somanna SN. Nonadherence to dietary activities and its associated factors among patients with type 2 diabetes mellitus in an urban area of South India: A cross-sectional study. J Med Sci [serial online] 2022 [cited 2023 Mar 20];42:109-14. Available from: https://www.jmedscindmc.com/text.asp?2022/42/3/109/328364

  Introduction Top

Diabetes mellitus (DM) and its complications impose unacceptably high human, social, and economic costs on countries of all income levels. Diabetes is one of the largest global health emergencies of the 21st century and among the top 10 causes of death globally. Together with three other major noncommunicable diseases (NCDs), i.e. cardiovascular disease, cancer, and respiratory disease, Type 2 DM (T2DM) accounts for over 80% of all premature NCD deaths. According to the International Diabetic Federation in 2017, 8.8% (7.2%–11.3%) of the global population had T2DM and 4.0 (3.2–5.0) million deaths could be attributed to it.[1] In South East Asia, one adult in every five lives with diabetes. The estimated prevalence of T2DM in India in 2017 was 8.79%.[1]

T2DM can be effectively managed by reducing excess weight and adopting a healthy lifestyle of good diet and physical activity, combined with medication when required. Self-care in diabetes is defined as behaviors undertaken by people with or at risk of diabetes in order to successfully manage the disease by themselves is central to the treatment of DM.[2] Adherence to self-care activities, which is the active, voluntary involvement of the patient in the management of his or her disease, by following a mutually agreed course of treatment and sharing responsibility with the health-care professional, is an important step in the management of DM.[3]

Poor dietary practices leading to inadequate glycemic control can lead to micro and macrovascular complication among patients with diabetes.[4] The presence of one or more micro or macrovascular complications and other comorbidities like hypertension among adults with T2DM account for most of the morbidity and mortality due to diabetes.[5] Adherence to simple self-care measures in diabetes helps individuals to successfully manage the disease on their own and prevent occurrence of these complications.[2] This study was undertaken to find the prevalence of nonadherence to dietary practices among patients with T2DM, its associated factors and to study the association of nonadherence with body mass index (BMI) of the study participants.

  Materials and Methods Top

The study was a community-based cross-sectional study conducted from March to October 2016 in the urban field practice area of a tertiary care hospital. Institution ethical clearance (ECR/215/Inst/Ker/2013) was obtained before the start of the study. Patients aged 18 years and above, diagnosed with T2DM before a minimum period of 1 year and who were residents of the study area for a minimum period of 6 months were included in the study. Patients with dementia, any other comorbid illness or those not on exclusive allopathic treatment were excluded from the study.

Sample size

Based on a study conducted at Vellore in 2009, which showed that 29% of the study population followed good dietary practices for diabetes, the sample size was calculated at 95% confidence levels, 5% alpha error, and 6.5% absolute precision.[6] The sample size was estimated to be 371 people with T2DM, but after making an allowance of 5% coverage error or nonresponse rate, the final sample size was estimated as 400 people with T2DM.

From a study conducted in urban slums of Bangalore in 2013, the prevalence of T2DM was 12.33%.[7] Therefore, to obtain 400 people with T2DM, the population that needed to be screened was 3244. To obtain this sample size, population probability proportional sampling was done as shown in [Figure 1].
Figure 1: Flowchart for the study sample

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From ward 17 and ward 36, five census enumeration blocks (CEBs) and three CEBs, respectively, were selected to cover an adult population of 3244. CEBs from each ward were selected using a number table, and complete enumeration of all households from these CEBs was done.

A pretested semi-structured questionnaire was used for obtaining sociodemographic details, details of T2DM, and nonadherence to dietary activities developed using “the Summary of Diabetes Self-care Activities” (SDSCA).[8] It measured four parameters under the dietary domain including number of days of successfully restricted calories, number of days where meals were with fresh fruits and vegetables, number of days where meals were without fat foods/fried items, and number of days where meals were without sweets/sugars. The SDSCA questionnaire measures the level of self-care by an individual and has high validity and reliability for self-reporting of adherence by individuals. House-to-house survey was made by the investigator to identify patients with T2DM. After obtaining written informed consent from the study participants, the questionnaire was filled. Height was measured to the nearest 0.1 cm using a stadiometer and weight was measured to the nearest 0.5 kg using a calibrated weighing machine for all study participants. BMI was calculated in kg/m2 and classified using the Asian-Pacific WHO Classification of BMI.[9]

People were considered to be adherent to dietary activities if they had calorie restriction in meals for up to 75%–100% of the times in the past 1 week (preferred brown rice over polished rice and preferred whole wheat rotis/chapathis/phulkas on 5–7 days in the last 7 days); if they had vegetables and fruits accounting for >50% of the diet (had at least two servings of fruits and vegetables on 4–7 days in the last 7 days), if they had fats and fried foods accounting for <25% (avoided high fat foods on 5–7 days in the last 7 days), and if they had totally avoided sweets (stopped taking sugar/any sweets/any artificial sweeteners on all the days in the last 7 days). The rest of the study participants were nonadherent.

Statistical analysis

Descriptive statistics such as mean and standard deviation were employed to summarize the quantitative data such as age and duration of T2DM. Qualitative variables were expressed as percentages with 95% confidence interval (CI). Chi-square test/Fisher's exact test was employed to study the association between nonadherence to diet and BMI by testing for differences in the two proportions. Odds ratios (ORs) along with 95% CI were estimated for various factors after dichotomizing the data into appropriate adherence and nonadherence to diabetic dietary self-care activities. Logistic regression analysis was employed to evaluate the independent determinants associated with nonadherence.

  Results Top

Among the study participants, 207 (51.8%) were ≥60 years with mean age 57.39 ± 13.67 years. Of the total study participants, 211 (52.8%) were females, 117 (29.3%) were illiterate, and 275 (68.8%) were currently not employed. The mean age at diagnosis was 49.28 ± 11.785 years. The treatment was oral hypoglycemic agents (OHA) in 377 (94.3%), insulin in 11 (2.8%), and insulin + OHA in 12 (3.0%) people with T2DM, respectively [Table 1].
Table 1: Baseline characteristics of study participants

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Diet was assessed in the present study by four parameters (restricting calories, consuming fresh fruits and vegetables, restricting fat foods/fried items, and avoiding sweets/sugars). Nonadherence to each of the parameters was individually calculated and then nonadherence to entire diet was computed. Vegetables and fruits accounting for >50% of diet was not followed by 68.8% of the study participants. Among all, 12.2% of the study participants did not follow total avoidance of sweets. Among the study participants, 334 (83.5%) were found to be nonadherent to all parameters in the dietary domain [Table 2].
Table 2: Nonadherence to diet among study participants (n=400) (Summary of Diabetes Self-care Activities Questionnaire)

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There was a statistically significant association of education (P = 0.017) and marital status (P = 0.005) with nonadherence to dietary activities. In univariate analysis, the participants who had education of below high school (2.04 [95% CI: 1.21–4.70]) and those who were other than married (3.59 [1.39–9.26]) showed a statistically significant association with nonadherence to dietary activities. Variables in univariate analysis with P < 0.2 (age, gender, education, and marital status) were included in the multivariate analysis and only marital status (2.78 [1.02–7.61]) showed a statistically significant association with nonadherence to diet [Table 3].
Table 3: Factors associated with nonadherence to diet among the study participants (n=400)

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Majority of study participants were found nonadherent to dietary restrictions and the reasons perceived by the study participants for their nonadherence included dislike toward food items that were included in their dietary plan (n = 174, 52.1%), difficulty in making meals different from that of the other family members (n = 159, 47.6%), and financial constraints (n = 95, 28.4%). All the other reasons perceived by the study participants for being nonadherent to the dietary activities are stated in [Figure 2].
Figure 2: Reasons for nonadherence to dietary activities as perceived by the study participants

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Among those participants who were nonadherent, only 43 (12.8%) study participants were found to have normal range of BMI. The rest of the distribution of study participants with nonadherence to dietary activities according to their BMI are depicted in [Table 4]. Majority of the nonadherent participants were found to have BMI above 23.0 kg/m2 and this association between nonadherence to dietary activities and BMI was found to be statistically significant (χ2 = 65.952, P < 0.001).
Table 4: Association between nonadherence to diet and body mass index values among study participants

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  Discussion Top

T2DM is a diet-dependent morbidity requiring multidirectional and multidisciplinary management. Pharmacotherapy is not the sole method of treating T2DM; significant changes to the patient's lifestyle with respect to dietary habits and regular physical activity are also required. Lifestyle change is one of the most difficult and problematic part of treatment. Efficient treatment of the disease with optimal adherence to medications and self-care activities is vital to delay the occurrence of all micro and macrovascular complications.

This study revealed 83.5% of the study participants were nonadherent to dietary recommendations. The present study results are consistent with a similar community-based study done by Gopichandran et al.[6] in 2009 using the same study tool. It revealed that 29% of the study participants showed good dietary behavior and the rest 71% of participants were nonadherent to dietary activities.[6]

A study by Santhanakrishnan et al.[11] in 2011 observed that only 18.6% of participants were noncompliant to dietary activities. Another study by Rajasekharan et al.[12] during September–October 2012 showed 54.1% of participants were nonadherent to dietary activities. On contrary to the present study results, lower nonadherence rates are noticed in these two studies as these were hospital-based studies, one at taluk hospital tertiary care hospital and the other at the urban health center of a tertiary care hospital, and so majority of the patients who attend these settings would be more conscious about their health and would probably follow the self-care activities as instructed by the health-care professional.

With respect to diet, unlike married participants, others (OR: 3.59, 95% CI: 1.39–9.26) were found to be more nonadherent to dietary restrictions. The spouse could have probably helped and facilitated the participant to be more motivated toward following the dietary activities among married as suggested by their health-care professional.

The study by Rajasekharan et al.[12] showed that participants with T2DM for a duration <10 years were more nonadherent to an eating plan (P < 0.01) and consumption of low-fat diet (P = 0.04). The present study results however did not show any significant difference in dietary adherence between those participants who had DM for a duration ≥10 years and those with DM <10 years.

A major proportion of the study participants (83.5%) were nonadherent to the dietary activities. Since self-care in diabetes, including diet is an important part of management, establishing reasons for poor adherence is key. Majority of the participants neglected dietary activities as they disliked the food items that were included in their eating plan. Providing knowledge and awareness about diabetic exchange lists where a variety of foods can be offered or traded in place of the disliked foods can encourage persons to adhere to their diet.[13]

Another major barrier noted was the lack of knowledge regarding each of the parameters in the dietary domain. Additional education and motivation definitely improve knowledge of lifestyle modifications, thus resulting in a reduction of complications.[14] It has been noted in previous studies that this additional education should be customized and tailored to individual needs and beliefs of the person with T2DM, as cultural and social barriers were one of the main obstacles in introducing a suitable diet.[15],[16] The above barriers also highlight the need to involve medical nutritionists in designing suitable individualized diets for those with diabetes.

The effect of several confounding factors was controlled to an extent in the present study due to a larger sample size and also to make more precise estimates by efficiently distributing data in the categories of the adjustment variables. Misclassification and measurement biases in the present study were reduced by setting and adhering to operational definitions and criteria from standard validated questionnaire (SDSCA). The findings of the present study can be extrapolated to the entire population because appropriate sampling methods and techniques were employed while conducting the study. The present study holds a major strength than when compared to any other hospital-based study in assessing the actual adherence among patients with T2DM, as this was a community-based study design. This is because all the patients who do not visit the hospital were also included and addressed in the present study and these are the ones who would contribute to majority of nonadherence to the self-care activities. Thus, the values of nonadherence assessed out of the present study would be precise estimates.

It is likely that some of the patients with T2DM did not report their diabetes status. Participants with T2DM were identified based on self-reporting of the illness. Such people might have poor adherence to self-care activities. If they have not been included in the study, it is likely that the prevalence of nonadherence to self-care activities could be an underestimate and may reduce the generalizability of the study results. The SDSCA questionnaire also may have introduced some social desirability bias were the participants may have answered knowing desirable practices and some participants may have not recalled accurately resulting in recall bias. However, the questionnaire remains a valuable tool for shedding light on the patient's knowledge of self-care goals. While interpreting factors associated with adherence to self-care activities, it should be borne in mind that the ORs calculated are prevalence ORs. They are subject to the “prevalence effect,” i.e. it is difficult to establish a temporal sequence.

  Conclusion Top

Certain measures should be implemented to improve patient adherence to a diabetic diet. Addressing the most common concern of diet nonadherence by offering a wider array of foods to choose from may enable the person with diabetes to follow the recommendations of a diabetic diet. Repeated reminders of all the domains included in self-care will be useful to improve motivation. Having support schemes, health education, and financial assistance is also necessary. Psychological assistance, involvement of family members, and care givers in the execution of these self-care activities will be helpful. Future research on developing a standardized dietary program and its inclusion in the public distribution system across multiple populations will help achieve reduction of complications associated with T2DM. This potential intervention will have the ability to expand its scope to not only include diet, but also other components of self-care to combat or halt the complications associated with T2DM.

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Conflicts of interest

There are no conflicts of interest.

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IDF Diabetes Atlas Ninth Edition [Internet]. Vol. 9, International Diabetes Federation. 2019. Available from: https://diabetesatlas.org/upload/resources/material/20200302_133351_IDFATLAS9e-final-web.pdf [Last accesses 2021 July 26].  Back to cited text no. 1
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Sami W, Ansari T, Butt NS, Hamid MR. Effect of diet on type 2 diabetes mellitus: A review. Int J Health Sci (Qassim) 2017;11:65-71.  Back to cited text no. 4
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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