Table 1 presented the demographic and clinical features of the interview participants. Their age ranged from 45 to 77 years old, with a mean of 61.52 (SD: 10.81). The sample included 11 males (52.4%) and 10 females (47.6%). The average years of suffering from T2DM was 10.27 (SD: 5.07). Hemoglobin A1c (HbA1c) was 9.02±4.42 % on average.
Table 1
Characteristics of the participants
Participant
|
Gender
|
Age
(Years)
|
BMI
(kg/m2)
|
Occupation
|
Religion
|
Years of T2DM
|
Living with
|
HbA1C
(%)
|
1
|
Female
|
73
|
29.86
|
Retired
|
No
|
10
|
Family
|
8.4
|
2
|
Male
|
67
|
23.51
|
Home
|
Islam
|
11
|
Family
|
5.8
|
3
|
Male
|
47
|
26.2
|
Staff
|
No
|
5
|
Wife
|
7.8
|
4
|
Male
|
79
|
24.22
|
Retired
|
No
|
8
|
Wife
|
6.3
|
5
|
Male
|
46
|
22.5
|
Freelance
|
No
|
9
|
Alone
|
6.5
|
6
|
Male
|
60
|
28.14
|
Resident
|
No
|
19
|
Alone
|
9.8
|
7
|
Female
|
77
|
21.36
|
Retired
|
No
|
20
|
Family
|
9.2
|
8
|
Female
|
55
|
17.9
|
Public officials
|
No
|
10
|
Husband
|
11.5
|
9
|
Female
|
71
|
29.07
|
Public officials
|
No
|
11
|
Family
|
8.1
|
10
|
Male
|
50
|
17.91
|
Resident
|
Christian
|
1.5
|
Wife
|
7
|
11
|
Female
|
72
|
34.85
|
Retired
|
No
|
7.2
|
Husband
|
6.7
|
12
|
Male
|
67
|
26.25
|
Retired
|
No
|
13
|
Alone
|
9.6
|
13
|
Male
|
52
|
24.5
|
Resident
|
Buddhism
|
10
|
Family
|
11.5
|
14
|
Female
|
73
|
21.36
|
Retired
|
No
|
20
|
Husband
|
9.3
|
15
|
Male
|
64
|
16.89
|
Farmer
|
Buddhism
|
13
|
Wife
|
8.7
|
16
|
Female
|
66
|
22.2
|
Retired
|
No
|
6
|
Alone
|
7.2
|
17
|
Male
|
67
|
24.64
|
Retired
|
Buddhism
|
10
|
Wife
|
8.1
|
18
|
Male
|
53
|
24.80
|
Public officials
|
No
|
6
|
Wife
|
5.3
|
19
|
Female
|
45
|
30.00
|
Public officials
|
Buddhism
|
2
|
Alone
|
14.1
|
20
|
Female
|
58
|
16.65
|
Home
|
No
|
6
|
Family
|
3.3
|
21
|
Female
|
50
|
23.24
|
Home
|
No
|
3
|
Husband
|
25.3
|
Five themes emerged from the analysis to represent the nutritional problems and negative impacts on quality of life among Chinese patients with type 2 diabetes: knowledge about nutrition, social aspects of nutrition, cultural aspects of nutrition, behaviors and nutrition management, and health outcomes of nutrition.
Theme 1: Knowledge About Nutrition
Almost a half of the respondents (number=10) complained of the insufficient knowledge of nutritional education. Some doctors and nurses may have been fully occupied with therapies and operations, they were too busy to provide nutrition knowledge.
“The healthcare workers only gave me insulin pump and said nothing more. There were no doctors or nurses telling me about how to control my diet, not mention to discussing with me about what to eat and what not to eat in details.”(P12)
Although they have been educated by healthcare workers, five patients considered that the nutritional knowledge they were given were too broad and too superficial. They still expressed difficulties with the application of these information into daily meals because they did not know how to accurately control diet and precisely calculate calories.
“The doctor only said that ‘the diet should be light; the amount of rice and noodles should be reduced; and more vegetables should be eaten’. That’s all the doctor said. However, I am still confused about how much exactly I should reduce the amount of rice and noodles. Their nutritional advice is helpless, and I still have to learn by oneself through reading a guide book, or looking up on the Internet.”(P8)
“I have no idea of what high-quality protein is. Tofu? seafood? There are thousands of kinds of food. I am really confused of what we could eat and what we could not.”(P21)
One-third of the participants (number=7) mentioned about the over-theorized knowledge. According to the traditional algorithm and theory provided by health-care workers, the amount and frequency of food intake was complex and difficult to calculate.
“As the doctors and nurses said, according to guidelines and theories on diabetes, my meals were required to be carefully controlled through calculating the precise amount of overall food intake . That means, you need to understand the calories of each kind of food, and also you need to weigh the precise amount of the food, and then you need to make some calculations. These process are beyond my understanding as an old guy. I just quit.”(P04)
Moreover, inaccurate knowledge were mentioned by 11 participants. There were some misunderstandings and wrong perceptions on diabetic nutrition. For example, some diabetics even refused to eat any kind of fruit.
“Diabetic patients can not eat any fruit because all fruits contain sugar. One of my friends, who has had diabetes for over 10 years, told me to cut back on any sweet, especially fruit. We believe that blood sugar would rise immediately after eating fruits and vegetables.”(P01)
“I had an old friend who had retired and raised bees, and he brought me two big bottles of bee honey. He told me that honey was not high in sugar and was good for health with no side effects to diabetes. Therefore I ate rice gruel and steamed bread with a spoonful of honey everyday. But as a result, my blood sugar went up high immediately.”(P03)
Theme 2: Social Aspects of Nutrition
Most of patients with type 2 diabetes were living with family members; therefor it was generally recognized that family support was a key to successful diabetic self-care. Foods acted as an important bridge connecting family members; therefore, patients’ nutrition habits were greatly impacted by their family members. Six respondents (28.6%) discussed that they would like to sacrifice themselves for their family. In other words, they gave priority to the nutritional needs of children or other family members over their own. If there was a conflict of the therapeutic diet with the family's dietary preferences, the patients would go against the diabetic diet and consider their family's eating habits.
“I am a diabetic patient, but at the same time, I am also a mother. If I reduce the amount of the oil and sugar too much when cooking, my son won’t eat the food because it is not tasty. Besides, my son needs enough energy for growing up. I could not require him to eat diabetic diet along with me. That is not fair for him. Therefore I cook and eat normal foods with my son; I rely on medicine to help me control the glucose.”(P19)
Three patients (14.3%) recommended that their family members also need to command essential knowledge on diabetic nutrition. If the family members lack relevant knowledge, they may fail to support patient’s diet control.
“My son is very kind to me. He always bought me a full box of fruit. There was a time that he sent me a lot of mangoes by Federal Express. The mango was so big in size, I could only ate a half. But it is wasteful to throw away the rest of the mango. So I ate the whole mango. And I still have a full box of mangoes waiting for me to eat up. I told my son not to buy so many fruits because I have diabetes; but he still because he loves me.”(P11)
Over one third of the participants (number=8) discussed about the stress came from multiple social roles may affect diet management and blood sugar control. Patients often ignored their own diet needs because of their responsibilities to family and work. For example, female diabetics were busy with family care while working at the same time, so they had no time to take care of their own diet control. For male diabetic patients, they complained more pressure from work and social interactions, so they chose to give up diabetic diet.
“I knew I had diabetes, but I was too busy at work to prepare myself a diabetic meal. Moreover, my child was at a key time for the preparation of college entrance examination, I spent my rest of time to take care of him. I just ate whatever I could have.”(P19)
“Before when I was working as a manager, I did have diabetes. But at that time, I had lots of social interactions, with my colleagues, with my clients and with my working partners. We gathered together to eat and drink. Every time I drank a lot alcohol, at least five to six bottles.”(P03)
“I often discuss business and eat outside, and sometimes I even have to drink until the middle of the night. I know I can't control my diabetes if I eat like this, but I have to work to earn money”.(P05)
Theme 3: Cultural Aspects of Nutrition
Given that the Chinese culture generally associated with collectivism and hospitality, it was impolite to refuse drinking and eating during social gatherings with family and friends. Some patients even worried about stigmatization as a result of their conditions. This perception usually affected these patients’ adherence to the nutritional recommendations.
“When I went to a dinner party, all my friends were eating and drinking. I didn't want to look like antisocial to them. Besides, I didn't want them to know I had diabetes. I just ate as the same way as they did.”(P5)
In addition, religions were important factors that influencing nutritional habits. Two participants reported themselves as a Islam religion. They mentioned about the conflicts between their religion culture and diet habit.
“In our religion we have a whole month of Ramadan (a festival of Fast-Breaking). Even as a diabetic patient, we still follow our religion culture and abstain from food and drink during daylight hours in Ramadan. There were several times I got dehydration and hypoglycemia during Ramadan.”(P13)
“I only ate meals before sunrise and after sunset. I did not eat anything, and even medicine at daytime. After Ramadan, we have Corban Festival. We slaughter sheep and cattle, and eat our favorite traditional foods to celebrate. Although this will cause unstable blood sugar, but we still follow the traditional customs.”(P17)
Theme 4: Behaviors and Nutrition management
4.1 Hard to follow dietary recommendations
The patient's behaviors of diet control goes to two extremes, either excessive restriction of food, or no restraints.
“I knew diabetic diet was important and essential to glucose control. But I was born to love meat and desserts. I would not fell happy if I quit them. I could not completely change my diet habits. So I just ate whatever I wanted. If the blood glucose got fluctuated, I just ate one more pill.”(P4)
“It is heard that eating fish and meat is easy to raise blood sugar. So I do not eat any fresh meat, even eggs; I only eat vegetables. This time when I was resident in hospital, my doctors said that my protein index was low. I assumed that low protein index was related to my strict restriction on meat.”(P08)
4.2 Unfixed timetable of food intake
Three interviewees complained that they felt it difficult to strictly adhere to meal plans due to changes on life styles or work schedules. Moreover, they did not know how to adjust their diet according to the changes.
“I work in a police station. Sometimes I fail to eat my meals on time when there is an accident or an emergency. I have to deal with the case before I could eat my meal. The doctors’ dietary advice were only suitable for patients living in a regular schedule. It did not suit people like me whose work schedule was not fixed.”(P18)
Although some diabetic patients realized the importance and benefits of a balanced diet to glucose control, seven participants still found themselves hard to comply with a diabetic diet. Some type 2 diabetics refuse to have low fruit and vegetable intake simply because they don't like it. In addition, some patients do not like to eat vegetables because they feel that the taste is light and does not conform to their personal taste preference.
“My husband and I both have diabetes. I adhere to dietary requirements very well, but my husband is obstinate and self-willed. Sometimes he sneaked out to eat ice-cream and high-sugar foods. Then he got blood glucose fluctuations.”(P7)
4.3 Nutrition information seeking
Diabetics reported high demands of nutrition information since the information seeking behaviors was evident in most participants (15, 71.4%). Respondents discussed a variety of ways they looked for and accessed information related to nutrition, including surfing on internet, talking with other patients, attending health professional lectures, and reading newspaper and cookbook.
“The doctors are so busy that they only tell you briefly and roughly about how to eat. As a patient, we still need to search for and learn about nutrition knowledge on our own, such as reading, online surfing.”(P21)
However, none of the respondents reported an effective source that was convenient to seek information to control diabetic diet. One reason was that some nutrition information was too professional to understand for patients. Moreover, complaints about the quality of online information were also raised. For example, information on internet were over-loaded and contradictory, it was difficult for patients to distinguish between true and false.Third, they also worried about the leak of personal information while log into online education platforms.
“I attended a lot of lecturers on nutrition organized by hospitals and communities; and I did take notes carefully every time. But my memory was poor. I could not remember exactly how to eat. It was troublesome and inconvenient to glance over all my notes. So I just gave up the notes and simply ate as the same as before.”(P15)
"The online information and education was convenient, but we still doubted the reliability of these information. I heard that personal information was leaked and money were cheated on the internet. So I did not think the network was still not very safe.”(P20)
Theme 5: Health outcomes of Nutrition
5.1 Psychological stress
Eleven interviewees reported feelings of high alerts due to worries and fear of hypoglycemia. They chose to eat extra meals if they feel slightly uncomfortable in case of hypoglycemia. Sometimes they even completely ignored diet control to avoid hypoglycemia.
“If I have a feeling of empty in my stomach, I will have some food as soon as possible. I am not sure whether it is hypoglycemia or not. But I still have something to eat in order to prevent it (hypoglycemia).” (P15)
“When my blood sugar is low, I feel weak and uncomfortable. On the contrary, when my blood sugar is high, I don't feel anything. Therefore I don't pay much attention to my diet when my blood sugar is high.” (P20)
Diabetes was a chronic and lifelong disease. Long-term self-management and worries about complications caused huge psychological pressure and mental burden to patients. Five participants expressed their lack of confidence and low self-efficacy on lifelong blood glucose control. This may first because they do not command enough and correct knowledge on nutritional diet, so they have no idea of how to correctly control blood glucose; and another reason may lie in that the fluctuations of blood sugar do not bring them positive feedback and sense of benefits.
“Through diet control, I could never command the change patterns of blood sugar, which is always high or always low. I am too tired and bored to monitor the diet and the glucose . I want to give up.”(P21)
“I have been too anxious to sit down since the diagnosis of diabetes. I am angry with myself because my parents and sisters do not have diabetes. I do not know how I can get this disease. I feel overwhelmed, and I even doubted that it was a punishment from Gods.”(P10)
“When my blood sugar is unstable, I often feel upset and particularly sad. Why it was me who got the disease, and why I could not eat sweet food and eat whatever I want, just like my other friends have done.”(P06)
5.2 Poor glucose control
One of the evident impacts of diet is the fluctuant blood sugar. Failing to follow strict diet management may result in poor glucose control.
“When my blood sugar went up a little high, my daughter asked me to control my diet first, saying that ‘if I didn't control my diet well, I would soon get diabetes’. I didn't believe it at all, and I still ate dates all day long. As a result, after half a year, my fasting blood sugar reached more than 10.”(P14)
5.3 Diabetic complications
The fluctuant blood sugar caused by uncontrolled diet management may also lead to a variety of diabetes-related complications, such as diabetic nephropathy, diabetic retinopathy, cardiovascular and cerebrovascular diseases and so on. The complications increased the physical and economic burdens to patients, which were closely associated with the decrease of health quality of life.
“Actually I knew my blood sugar was high five years ago, but I didn't take it seriously. I still ate whatever I wanted. Anyway, it didn't hurt or itch, until I got some problems on my eyes. I regretted that I did not listen to the doctor’s advice on diet control at the beginning.”(P06)
5.4 Reduced quality of life
The experience of daily insulin injection and the fear of hypoglycemia and diabetic complications placed a negative impact on daily activities and social interactions, eventually resulting in a decrease on quality of life. Most of the respondents suffered reduced life quality when they were too cautious about low blood glucose. They have had to prepare candy and nuts in case of hypoglycemia everywhere they went, including at home, at workplace and during traveling.
“I can not accept that I have to get insulin injection before eating every day; and also I can not bear that I have to take my insulin pen when going out for a long distance. All of these are inconvenient.”(P12)
“There is a joke saying that ‘it is all right to go out without taking money, but it is bad to go out without candy’. I know the bad feeling of hypoglycemia, so now I have sugar all over my house. If I don't have a few sweets handy, I'm in a panic.”(P09)
Moreover, some participants even mentioned behaviors of avoidance and restrictions on physical exercises and social interactions. The interviewees were overly cautious about hypoglycemia so that they decreased the number of going out and reduced the length of social gathering. One respondent even gave up driving due to the potential risks of hypoglycemia.
“I do not dare to go far. I only take a walk around my house; therefore I could go back to home in a short time if I feel uncomfortable.”(P04)
“Generally, I seldom go out and travel around, because it is very inconvenient that I have to prepare medicine and insulin. Besides, I keep worrying about emergency situations such as hypoglycemia.”(P07)
“I quit driving a car on my own. When I have a hypoglycemia attack, I shiver and can not move my body. I am afraid this will cause me into danger if I am driving. (P08)