Socio-Demographic and Economic Characteristics
Out of the total 394 study participants planned, 387 were participated in the study yielding a response rate of 98.2%. Of all` respondents, 180 (46.5%) and 207(53.5%) were female and male, respectively. The majority of the study participants, 288 (74.4%) were in the age group of 35 to 60 years. The mean (+ SD) age of the respondents was 51.27 ± 12.03 with the minimum and maximum age of 18 and 90, respectively. Three hundred and seven (79.3%) of the respondents are married. As for religion of the participants, 197 (50.9%) belonged to Orthodox Christian, followed by Protestant Christian, 153(39.5%). Larger populations were Amhara 134(34.6%) followed by Sidama ethnic group, 105(27.1%). Concerning the educational status of study subjects, a significant number, 298 (77.0%) of the study population had attended formal education and 89 (23.0%) were not able to read and write. Two hundred and sixty four (68.2%) respondents were unemployed and majority of the study participants 250(64.6%) had very low monthly income (Table 1 of supplementary material).
Dietary practices
From the total 394 study participants, the proportion of poor dietary practice was 171(44.2%). Nearly half of the participants 48% were forgetting to plan the meals they eat ahead and 37% of the participants were missed their dietary plan a day before interview. One hundred ninety four (50%) of participant were experienced failing to keep dietary plan (Table 2 of supplementary material).
Food groups consumed by type 2 DM patients
The food groups consumed by adults with type 2 DM patients in the 24 hours preceding the survey are shown in Table 4.The proportion of DM patients who consumed foods from grains/starchy staple was found to be the highest (97.4 %) followed by foods from other vitamin A rich fruits and vegetables. Organ meat was consumed only by 1.6% of DM patients (Table 3 of supplementary material).
Characteristic of patients according to the groups of dietary practice
The proportions of participants with poor dietary practice were 78 (43.3%) among males and 93(44.9%) among females. The proportion with poor dietary practice was 129(44.8%) among the age group of 35-60, and 32(41.0%) among those who were 61 and above years old (Table 4 of supplementary material).
Health status and available health services
About half of the respondents 195(50.4%) had >3 years duration of diabetic disease. The median duration since the diagnosis of diabetes was reported to be 4 years. Two hundred forty-nine (64.3%) of respondents were on oral hypoglycemic regimen, 113 (29.2%) were on insulin and 2(0.5%) were on only following dietary plan as recommended. About 161(41.6%) of the respondents had chronic disease other than diabetics. The majority 291(75.2%) of the respondents reported that they did not receive nutrition education in hospital and a large number did not get nutrition leaflet. More than half of the respondents 211(54.5%) were with BMI of >=25kg/m2 and the majority of the respondents 314 (81.1%) had Fasting Blood Glucose of > 126 mg/dl (Table 5 of supplementary material).
Barriers to adherence to dietary regimen
Concerning barriers to adherence, 275(71.1%) of the respondents said that foods were not prepared based on their disease. Furthermore, 278(71.8%) of the respondents had difficulty of choosing foods and 231(59.7%) of the respondents reported non-availability of fruits and vegetables. Price of food items and lack of support from family and friends were the two most important barriers to adhere to dietary regimen for 260(67.2%) and 114(29.5%) of the respondent respectively (Figure 1 of supplementary material).
Behavioral and Social Conditions of Participants
The majority, 239(61.8%) of the responded said that they have not made food choice when eating out of their home. Most of the respondents, 284(99.2%), and 351(90.7%) replied that they have no smoking and drinking habits, respectively. Furthermore, 47(12.1%) of the participants replied that they have experience of despondency. More than half of the respondents 235(60.7%) did not participate in physical activity and 384(99.2%) did not check their FBG on daily basis (Figure 1).
Respondents’ knowledge about diabetes
Knowledge of the participant about diabetes was measured by using nine variables with 24 possible correct responses. The mean (+SD) knowledge score of study subjects was 11.05(6.20) with a maximum possible score of 24. Two hundred six (53.2%) participants had good knowledge and 181 (46.8%) participants had poor knowledge regarding diabetes. More than half (53.5%) of study subjects didn’t know the definition of diabetes. The correct responses on risk factor for diabetes like family history, eating too much fat and sugar, and lack of exercise were 59.9%, 49.1%, 0.3% respectively.
Majority of the study participants 327 (84.5%) and 324(83.7%) considered injection/insulin therapy and orally taken tablets as treatment options, respectively. Passing lots of urine, excessive thirsty, tiredness and weight loss were reported as symptom of poorly controlled DM by 213(55.05%), 167(43.2%), 292(75.5%) and 47(12.1%) respondents respectively. The correct responses on complication of DM like retinopathy, hypoglycemia, nephropathy, and neurologic were 57.9%, 14.5%, 52.5% and 38.2% respectively. Exercise and diet were reported as a life style modification for prevention of DM by 197(50.9 %) and 245(63.3%) respondents respectively. However, less than 25.0% of study participants knew weight reduction as life style modification for prevention of diabetes related complications.
Nearly three fourth (69.5%) of study participants knew about the importance of control of blood glucose to reduce complication of DM. Two hundred seventy eight (71.8%) knew the importance of control of blood pressure for prevention of DM complications. Less than one third (30.7%) of the participants did know about optimum blood sugar level they should be achieve to prevent DM (Table 1).
Table 1:Knowledge of participants regarding diabetes mellitus, Adare General Hospital Hawassa City, Ethiopia , Ethiopia, 2016 (n = 387)
Variable
|
Frequency
|
Percent
|
What is diabetes?
|
|
|
DM is a raised blood sugar only
|
50
|
12.9
|
DM is a disease which affects any part of the body
|
177
|
45.7
|
I don’t know
|
157
|
40.6
|
Identify risk factor for DM
|
|
|
Over eating
|
121
|
31.3
|
Family history
|
232
|
59.9
|
Eating too much fat and sugar
|
190
|
49.1
|
Alcohol
|
98
|
25.3
|
Cigarette smoking
|
61
|
15.8
|
Lack of exercise
|
1
|
0.3
|
No response
|
63
|
16.3
|
Knows treatment options of DM
|
|
|
Injection/Insulin therapy
|
327
|
84.5
|
Orally taken tablets
|
324
|
83.7
|
Dietary management
|
194
|
50.1
|
Exercise
|
120
|
31.0
|
Don’t know
|
47
|
12.1
|
Knows symptom of poorly controlled DM
|
|
|
Passing lots of urine
|
213
|
55.05
|
Loss of appetite
|
71
|
18.3
|
Excess thirst
|
167
|
43.2
|
Tiredness
|
292
|
75.5
|
Weight loss
|
47
|
12.1
|
Don’t know
|
64
|
16.5
|
Knows complications of DM, if not treated
|
|
|
Ophthalmologic
|
224
|
57.9
|
Hypoglycemic
|
56
|
14.5
|
Renal
|
203
|
52.5
|
Neurologic
|
148
|
38.2
|
Don’t know
|
121
|
31.3
|
Know regarding life style modification
|
|
|
Exercise
|
197
|
50.9
|
Dietary modification
|
245
|
63.3
|
Weight reduction
|
96
|
24.8
|
Don’t know
|
124
|
32.0
|
Control of your blood glucose levels is an important reducing Complication of DM?
|
|
|
Yes
|
269
|
69.5
|
No
|
118
|
30.5
|
What is optimum blood sugar level you should achieve to prevent DM?
|
|
|
<126mg/dl
|
119
|
30.7
|
>=126mg/dl
|
101
|
26.1
|
I don’t know
|
167
|
43.2
|
Diabetes patient should measure his or her Blood pressure?
|
|
|
Yes
|
278
|
71.8
|
No
|
4
|
1
|
Don’t know
|
105
|
27.1
|
Knowledge overall score
|
|
|
Good knowledge
|
206
|
53.2
|
Poor knowledge
|
181
|
46.8
|
With mean knowledge of 11.05 and SD is 6.201 and maximum response is 21 and minimum response is 0 and with possible correct response is 24(9 tools)
|
|
|
|
|
Factors associated with the dietary practice of type 2 diabetic patients
An output from a bivariate analysis showed that there are significant associations between dietary practice and various attributes such as: monthly income, occupation, drug regimen, having chronic disease, DM education in hospital, and frequency of DM education. All characteristics with p-value of at most 0.25 in bivariate analysis, such as , knowledge of optimum FBG level, body mass Index (BMI), knowledge about-DM , despondency, lack of support from family and friends, poor understanding on diet disease association, difficulty on availability of fruits and vegetables and price of diet items were entered into the final multivariable logistic regression model to control for potential confounders and significant association at a 5% level of significance was reported.
The multivariable logistic regression analysis showed that those who had very low monthly income were 4.87 times more likely to have poor dietary practice than those who had average income (AOR= 4.87; 95% CI: (1.20 -19.81). Subjects who take insulin regimen were 2.36 times more likely to follow poor dietary practice than those who take only oral DM medication (AOR=2.36; 95%CI: 1.13 - 4.91) and those who took both insulin injection and oral medication were 11.26 time more likely to follow poor dietary practice than those who take only oral DM medication (AOR=11.26; 95% CI: (3.05 - 41.54). With regard to education, those who didn’t get DM education were 2.72 times more likely to have poor dietary practice than those who got (AOR=2.72; 95%CI: (1.08 - 6.85) and who did get DM education for less than 2 times were 5.88 times more likely to follow poor dietary practice compared to those who got dietary education twice or more (AOR=5.88; 95% CI: 1.88 -18.88). Respondents who had despondency were 3.71 times more likely to follow poor dietary practice than those who did not have despondency (AOR = 3.71; 95% CI: (1.39 - 9.89).
Respondents who had lack of support from family and friends were 5.64 time more likely to follow poor dietary practice than those who had support (AOR=5.64; 95% CI: 2.66 -11.92). Likewise, patients who had less access to fruits and vegetables were 3.04 times more likely to have poor dietary practice than those who did not (AOR = 3.04; 95% CI: 1.11-8.34)(Table 3).
Table 2:Bivariate and Multivariable Logistic Regression Analysis of Factors Associated With Dietary Practice of Type 2 Diabetic Patients in Adare General Hospital Hawassa City, Ethiopia, 2016 (N = 387)
Variables
|
Dietary practice
|
COR (95% CI)
|
AOR (95% CI)
|
Poor
|
Good
|
Monthly Income
|
|
|
|
|
Very low
Low
Average
Above Average
|
135(54.0%)
10(34.5%)
10(27.8%)
16(22.2%)
|
115(46.0%)
19(65.5%)
26(72.2%)
56(77.8%)
|
4.11(2.24-7.55)*
1.84(0.72-4.74)
1.35(0.54-3.37)
1
|
4.87(1.20-19.81)**
1.32(0.27-6.43)
1.05(0.27-4.00)
1
|
Occupation
|
|
|
|
|
Employed
Unemployed
Merchant
|
34(33.3%)
132(50.0%)
5(23.8%)
|
68(66.7%)
132(50.0%)
16(76.2%)
|
1
2.00(1.24-3.22)*
0.63(0.21-1.85)
|
1
0.53(0.14-2.00)
0.39(0.07-2.14)
|
Drug regimen currently
|
|
|
|
|
Oral DM medication
Insulin
Insulin & Oral
Only Diet plan
|
92(36.9%)
58(51.3%)
19(82.6%)
2(100%)
|
157(63.1%)
55(48.7%)
4(17.4%)
0(0.0%)
|
1
1.80(1.14-2.82)*
8.12(2.67-24.5)*
0.00(0.00 - )
|
1
2.36(1.13-4.91)**
11.26(3.05-41.54)**
0.00(0.00 - )
|
Having Chronic Disease
|
|
|
|
|
Yes
No
|
82(50.9%)
89(39.4%)
|
79(49.1%)
137(60.6%)
|
1.60(1.06-2.40)*
1
|
1.79(0.92-3.50)
1
|
Ever attended DM Education in Hospital
|
|
|
|
|
Yes
No
|
29(15.6%)
142(70.6%)
|
157(84.4%)
59(29.4%)
|
1
13.03(7.91-21.46)*
|
1
2.72(1.08-6.85)**
|
Number of DM Education in one year
|
|
|
|
|
=<2 times
>2 times
|
159(93.0%)
12(7.0%)
|
91(42.1%)
125(57.9%)
|
18.20(9.54-34.72)*
1
|
5.88(1.83-18.88)**
1
|
Optimum FBG level should achieve to prevent DM related Complication
|
|
|
|
|
<126mg/dl
>= 126mg/dl
|
53(44.5%)
12(11.9%)
|
66(55.5%)
89(88.1%)
|
1
4.14(2.70-6.36)*
|
1
2.56(0.99-6.57)
|
Knowledge for DM
|
|
|
|
|
Good Knowledge
Poor Knowledge
|
68(31.5%)
113(66.1%)
|
148(68.5%)
58(33.9%)
|
1
4.24(2.76-6.50)*
|
1
1.65(0.64-4.25)
|
Despondency
|
|
|
|
|
Yes
No
|
37(78.7%)
134(39.45)
|
10(21.3%)
206(60.6%)
|
5.69(2.74-11.82)**
1
|
3.71(1.39-9.89)**
1
|
|
|
|
|
|
*Statistically associated Variable with; P= < 0.25; NB: P-Value is, Value of COR analysis result
** Statistically associated Variable with; P= <0.05; NB: P-Value is, Value of AOR analysis result
Table 3:Bivariate and Multivariable Logistic Regression Analysis of Barriers affecting dietary practice of type 2 diabetic patients in Adare General Hospital Hawassa City, Ethiopia, 2016 (n = 387)
Variables
|
Dietary practice
|
COR (95% CI)
|
AOR (95% CI)
|
Poor
|
Good
|
Challenge on food preparation based on DM status
|
|
|
|
|
Yes
No
|
117(42.5%)
54(48.2%)
|
158(57.5%)
58(51.8%)
|
0.79(0.51-1.24)
1
|
|
Difficulty on choosing foods
|
|
|
|
|
Yes
No
|
120(43.2%)
51(46.8%)
|
158(56.8%)
58(53.2%)
|
0.86(0.55-1.35)
1
|
|
Lack of support of family and friends
|
|
|
|
|
Yes
No
|
92(80.7%)
79(28.9%)
|
22(19.3%)
194(71.1%)
|
10.27(6.02-17.51)*
1
|
5.64(2.66-11.92)**
1
|
Poor understanding on food d/s association
|
|
|
|
|
Yes
No
|
79(66.4%)
92(34.3%)
|
40(33.6%)
176(65.7%)
|
3.78(2.39-5.96)*
1
|
1.15(0.55-2.40)
1
|
|
|
|
|
|
Do you control DM by food planning?
|
|
|
|
|
Yes
No
|
126(73.7%)
45(26.3%)
|
180(83.3%)
36(16.7%)
|
1
1.79((1.09-2.93)*
|
1
0.75(0.30-1.86)
|
Difficulty on availability of fruits and vegetables
|
|
|
|
|
|
|
|
|
|
Yes
No
|
141(61.0%)
30(19.2%)
|
90(39.0%)
126(80.8%)
|
6.58(4.08-10.61)*
1
|
3.04(1.11-8.34)**
1
|
High cost of foods
|
|
|
|
|
Yes
No
|
147(56.5%)
24(18.9%)
|
113(43.5%)
103(81.1%)
|
5.58(3.36-9.27)*
1
|
1.03(0.33-3.20)
|
|
|
|
|
|
|
*Statistically associated Variable with; P < 0.25 NB: P-Value is, Value of COR analysis result
** Statistically associated Variable with; P<0.05 NB: P-Value is, Value of AOR analysis result