Utilization of low glycemic index foods and associated factors among diabetes mellitus patients in Debre Markos referral and Finote Selam hospitals, Northwest Ethiopia, 2019

doi:10.21203/rs.3.rs-2576191/v1

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Utilization of low glycemic index foods and associated factors among diabetes mellitus patients in Debre Markos referral and Finote Selam hospitals, Northwest Ethiopia, 2019

https://doi.org/10.21203/rs.3.rs-2576191/v1

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Background

Entire populations are at risk of diseases such as diabetes. There is also limiting resources in Ethiopia to control hyperglycemia because of limited catastrophic expenditure for chronic diseases. Due to the importance of balancing blood glucose level in diabetes, low/ few glycemic foods are important to moderate blood glucose in diabetes patients.

Objectives

To assess the utilization of low glycemic index foods and associated factors among diabetes mellitus patients at Debre Markos referral and Finote Selam hospitals, Northwest Ethiopia, 2019.

Methods

Institution based cross-sectional study design was conducted. A systematic random sampling technique was used to select study participants. The data was coded and entered to Epi Data version 3.1 and exported to statistical package for social science (SPSS) version 25 for analysis. Binary logistic regression model was used for analysis. The adequacy of the final model was checked using Hosmer and Lemeshow goodness of fit test and an assumption of Binary Logistic Regression such as no multi-co linearity was checked. Both bivariable and multivariable analysis were conducted. Those variables that showed significant association at P < 0.25 were included to multivariable analysis. Variables that showed significant association at P < 0.05 with 95% CI was declared statistically significant factors of utilization of low glycemic index foods.

Results

A total of 416 diabetic patients were participated in this study with response rate of 98.5%. Among the study participants, 8.9% (95%CI: 6.3, 11.5) of the participants had good utilization of low glycemic index foods. In this study ≤ 3 Km distance from market [AOR: 3.851(95%CI: 1.262, 11.745)], informal education [AOR: 2.509 (95%CI: 1.178, 5.344)], alcohol consumption [AOR, 3.911(1.599, 9.567)], and good knowledge on low glycemic index foods [AOR: 3.354(1.091, 10.309)] were factors associated with utilization of low glycemic index foods.

Conclusion and Recommendations:

The magnitude of utilization of low glycemic index foods among diabetes mellitus patients attending follow up care service at Debre Markos referral and Finote Selam hospitals was found to be low. Distance to the market, educational status, practice of alcohol consumption, and knowledge on low glycemic index foods were found to be statistically significant with utilization level of low glycemic index foods.

Glycemic Index

Utilization

Finote Selam hospital

Debre Markos referral hospital

Diabetes Mellitus

Dietary carbohydrate can modify the evolution and complications of postprandial hyperglycemia in a clinically significant long term fashion (1). This concept favors the use of low glycemic index (LGI) carbohydrates. Although focusing on the total amount of carbohydrate intake is important for diabetic patients, using LGI carbohydrates could lead to additional benefits without increasing the fat content of the diet and consequently increasing plasma free fatty acids (FFAs), with all their deleterious consequences (2). Diets with a low glycemic index (GI) have been shown to improve glucose tolerance in both healthy and diabetic subjects (3).

The glycemic index (GI) is a measure that ranks foods according to their effect on your blood sugar levels. The rates at which different foods raise blood sugar levels are ranked in comparison with the absorption of 50 grams of pure glucose, which is used as a reference food and has a GI value of 100. Foods with a low-GI value (55gm or less) are the preferred choice, as they are slowly digested and absorbed, causing a slower and smaller rise in blood sugar levels (4, 5). Glycemic index is also defined as the incremental area under the glucose response curve after a standard amount of carbohydrate from a test food relative to that of a control food (either white bread or glucose) is consumed (5, 6). The glycemic index of a specific food or meal is determined primarily by the nature of the carbohydrate consumed and by other dietary factors that affect nutrient digestibility or insulin secretion. Carbohydrates those are found in breads, cereals, fruits, vegetables and dairy products, and they are an essential part of a healthy diet (7, 8).

Diabetic glycemic index alters risk for diabetes, independent of body weight change, via effects on hyperinsulinaemia, insulin resistance, beta cell demand, and ultimately beta cell function (7, 9). Choosing LGI foods in place of conventional or high-GI foods has a small but clinically useful effect on medium-term glycemic control in patients with diabetes. The incremental benefit is similar to that offered by pharmacological agents that also target postprandial hyperglycemia (10). Low GI foods could enhance weight control because they promote satiety, minimize postprandial insulin secretion, and increase fat oxidation. Studies have shown that low GI foods are more satiating, delay the return of hunger, or decrease subsequent food intake (11).

The national survey conducted by using stratified multi stage sampling technique magnitude of low glycemic index foods among Australian children and adolescents was 3% from 2011 to 2012 Australian Health Survey (12). Longitudinal trend analysis that study in German also indicates utilization level of low glycemic index foods in 2002 was 56.5% among children’s 7–8 years (13). According to 2016 WHO report Ethiopian people’s have died with the cause of diabetes 2%, cardiovascular diseases 16%, and cancer 7% due to lack of prevention of those chronic diseases by using low glycemic index foods (14). International Diabetes Federation (IDF) 2015 report indicates the lack of these low glycemic index foods will have a great contribution from people morbid with diabetes which are 2.3 Million in South Africa, 1.8 Million in Democratic Republic of Congo, 1.6 Million in Nigeria, and 1.3 Million in Ethiopia (15).

International evidence that was conducted in relation with diabetes and GI identified some dietary terms (low glycemic index foods), such as whole grain rich foods, cereal fiber, legumes, and green leafy vegetables that play a protective role against chronic conditions including diabetes mellitus (16, 17). The nutritional composition (i.e., fiber, vitamins and minerals) of protective foods may decrease the risk of diabetes by reducing inflammation, improving glucose metabolism, endothelial function and insulin sensitivity (18). ‘Slow release’ or low GI carbs have been shown to help stabilize blood glucose levels and this is particularly helpful in diabetes. The amount you eat is also important and all low GI foods aren’t necessarily good for you. In general, filing lower GI foods such as beans, peas, lentils, porridge, fruit and vegetables are good choices and can help you to manage your weight and keep to an overall healthy eating plan (1). The type of sugar found in the foods may affect the glycemic index of the edible foods. It’s a misconception that all sugars have a high Glycemic index. Therefore, the Glycemic index of a food partly depends on the type of sugar it contains. In other case the preparation and cooking techniques can also change the Glycemic index value of the foods. Generally, the longer a food is cooked, the faster its sugars will be digested and absorbed, raising the Glycemic index. In other case unripe fruit contains complex carbohydrates that break down into sugars as the fruit ripens. The riper the fruit has the higher its Glycemic index (4, 8).

Most foods are consumed as part of a larger mixed meal, making the GI difficult to predict in these circumstances (4). Knowledge of qualities of the food like fat content, type of fat, energy density, fiber content, food processing, starch structure, and appropriate serving size may also makes vary on the value of the glycemic index (16, 18). However, in Ethiopia incomplete routine health information and lack of data on low glycemic index of diabetic patients affect the long term management of diabetes. Therefore, this study assesses the utilization of low glycemic index foods and its associated factors among diabetic patients in Debre Markos and Finote Selam Hospitals.

Study Design and Setting

Institutional based cross-Sectional study was conducted in Debre Markos referral and Finote Selam hospitals from September 15, 2019 to October 15, 2019. Debre Markos referral hospital is situated at Debre Markos town found in East Gojjam zone in Amhara region. It serves for the total of 3.5 million populations. Debre Markos city is located in northwest Ethiopia (19). Finote Selam hospital is situated at Finote Selam Town in western Ethiopia. The hospital provides health service to more than 1.5 million populations in its catchments. The town is Located in the West Gojjam zone of the Amhara region (19).

Debre Markos referral and Finote Selam hospitals are found in the area of same socio- demographic characteristics. Around those hospitals teff is the major food which consumed by the population. In addition to teff, wheat, maize, potatoes, lentils, beans, peas, honey, dairy products, fruits and vegetables are the major food those are common in the areas. Those hospitals were selected randomly to get adequate sample size regarding with this study. Add information. Quantitative data was collected from diabetic patients who are attends services in Debre Markos referral and Finote Selam hospitals.

The ethical clearance was obtained from Debre Markos University, Health science college ethical committee. Official letter was written along with the ethical clearance and was submitted to Debre Markos referral and Finote Selam hospital office. This study was not had any risk consequence for study participants. Participants were also informed that participation was voluntary and participants who refused the consent had respect. Written consent was taken from the study participants after briefing them the objective of the study. There was no age of less than 18 years diabetes patients in the sample included. The confidentiality of participant’s related data was maintained by avoiding possible identifiers such as name of study participants only identification number was used as a reference. The interviewer administered questionnaires was kept safe throughout the whole process of the research work. During data collection time any diabetic client with medical problem findings such as any Diabetic complication, education was provided and contacted with health professionals found in those hospitals for support and treatment.

Sample Size Determination And Sampling Procedure

Sample size was calculated by a single population proportion formula:

n= [(Zα/2)² *P (1-P)] /d²

Since there was no previous study the sample size was calculated by assuming a 50% proportion (P) of utilization of low glycemic index foods, a confidence level of 95% (1.96), and 5% margin of error (d). Based on this assumption the

n= (1.96)²\(\frac{0.5\left(1-0.5\right)}{0.05²}\) = 384

After substitution the estimated sample size yields 384. By considering a 10% of non-response rate, 422 diabetic patients were planned to be included in the study.

Systematic random sampling was used to select 422 study participants from the study population. First 422 samples were proportionally allocated to Debre Markos referral hospital (241) and Finote Selam hospital (181). This data were taken from SMART care of those hospitals by filtering out DM patients specifically. Since there was no well-ordered or separated registration for DM patients, the sample was taken from those hospitals patient flow. Then K value was calculated. Based on k value lottery method was used to select the first respondents. Finally, the study participants were selected every K value was 2.4. Then the respondents were selected every 2 individuals until the required samples was full filed or interviewed.

Data Collection Procedure And Measurements

Data was collected by using interviewer administered structured questionnaire developed from different literatures such as (8, 20–22). The tool contains socio- demographic characteristics (6 items), food preparation and feeding technique (3 items), market access characteristics (4 items), health status related questions (4 items), life style related questions (6 items), and knowledge based questions (9 items). There are twenty food types in English version questionnaire and this questionnaire was translated to Amharic language. The respondents were asked to recall all foods and drinks they have taken in the three consecutive day’s meal history prior to the survey (17, 23) to assess utilization of low glycemic index foods of the respondents. By using different literatures the local food items were collected and summarized in twenty items. Six Professional nurses (two supervisors and four data collectors) were recruited to collect data. The data collectors use the codes “1’ for respondents who says yes and “0” for respondents who says no for low glycemic based questionnaire. The supervisors were follow the data collection technique and all the data collectors and supervisor were have regular meeting with the principal investigator at the end of each week of data collection period.

Operational Definition

Glycemic Index: is a scientific ranking of how the foods we eat affect our blood sugar levels in the 2 or 3 hours after eating. Foods are measured against pure glucose, which has a value of 100 on the index (1, 4, 5).

Low glycemic index: It indicates that the carbohydrates in a given food have a lower affect on postprandial blood glucose and possibly insulin responses. It has a GI value of < 55 gm (e.g. dairy products, fruits, vegetables…) (1, 4, 5, 24).

Utilized: Diabetic patients who are consumed above 75% from the total listed low glycemic index foods (25).

Diabetes Mellitus: is defined as a case identified for having the disease diabetes by the clinician.

Good Knowledge: respondents who answer correctly to knowledge related question and those who scored equal and above 75% of the total value.

Market access: Access of market measured in time and distance to get low glycemic food groups for study participants.

Long distance: If the distance between market and study participants is greater than 3 Km (26).

Adherence to Exercise: If the patient follow recommended level of exercise for more than 3 days in the last seven days (27).

Alcohol Consumption: If reported consumption of alcohol twelve month prior to the survey (28).

Statistical analysis

The collected data were coded and entered into Epi Data Version 3.1 and cleaned. The cleaned data set was exported to Statistical package for social sciences (SPSS) Version 25 software for analysis. Study participants utilization on low glycemic index food groups (utilized, none utilized), and socio-demographic characteristics and other independent variables those affect utilization of low glycemic index foods were presented using relevant descriptive statistics. Binary Logistic Regression was performed to see the association between the dependent variable and independent variables. The adequacy of the final model was checked by using Hosmer and Lemeshow goodness of fit test and which had value of significance was 0.740. An assumption of Binary Logistic Regression such as no multi-co linearity was checked and the Variance Inflation Factor (VIF) of all variables was less than 5 and all included in multivariable analysis. Both bivariable and multivariable analysis were conducted. Those variables that showed significant association at p less than 0.25 were included to multivariable analysis. Finally those variables that showed significant association at p less than 0.05 with 95% CI was declared statistically significant factors of utilization of low glycemic index foods.

Socio-demographic Characteristics Of The Respondents

A total of 416 study participants were participated with response rate of 98.5%. The median age of respondents was 46.50 years (IQR 37–56 years). Among the study participants, 283(68%) were males. Regarding place of residence and their educational status, 272(65.4%) and 131(31.5%) of them were urban residents and have diploma and above respectively (Table 1).

Table 1

Socio-demographic characteristics of Utilization of low glycemic index foods among DM patients in FSH and DMR hospitals, Northwest Ethiopia, 2019(N = 416).
Variables	Categories	Frequency	Percent
Age of respondents	21–39	140	33.65%
	40–64	222	53.37%
	65–89	54	12.98%
Sex of respondents	Male	283	68.0%
	Female	133	32.0%
Educational status	Cannot read and write	118	27.9%
	Can read and write	137	32.4%
	Grade 1to8	28	6.6%
	Grade 9to12	65	15.4%
	Diploma and above	68	16.1%
Occupation	Merchant	119	28.1%
	Daily laborer	6	1.4%
	Government employee	93	22.0%
	NGO worker	40	9.5%
	Farmer	142	33.6%
	Nonemployee	16	3.8%
Marital status	Single	296	71.2%
	Married	71	17.1%
	Divorced	23	5.5%
	Widowed	26	6.3%
Husband educational status	Cannot read and write	43	35.6%
	Can read and write	12	10%
	Grade 1to8	18	15%
	Grade 9to12	10	8%
	Diploma and above	38	31.4%
Wife educational status	Cannot read and write	57	25.9%
	can read and write	98	44.5%
	Grade 1to8	16	7.3%
	Grade 9to12	17	7.7%
	Diploma and above	32	14.5%
Place of residence	Urban	297	71.4%
	Rural	119	28.6%

Food Preparation And Feeding Technique Of Respondents

In this study 307(73.8%) of study participants had practice of feeding processed foods. On the other hand 64(15.4%) feeding sweet fruits instead of unripe fruits (Table 2).

Table 2

Food preparation and feeding technique of low glycemic food utilization among diabetes patients in FS and DMR hospitals, Northwest Ethiopia, 2019 (N = 416)
Variables	Categories	Frequency	Percent
Feeding processed foods	Yes	307	73.8%
	No	109	26.2%
Feed foods prepared with malt sugar	Yes	64	15.4%
	No	352	84.6%
Feed sweet fruits instead of un riper fruits	Yes	198	47.6%
	No	218	52.4%

Market Access Related Characteristics Of Respondents

From here 263(63.2%) of diabetic patients were found less than or equals to three Km distance to the local market. Regarding with other characteristics 230(55.3%) of respondents were going on foot to the local market for food exchange and sale purpose (Table 3).

Table 3

Market access measuring characteristics of Low glycemic index food utilization among diabetic patients in FS and DMR hospitals, Northwest Ethiopia, 2019 (N = 416)
Variables	Categories	Frequency	Percent
How far home to market	≤ 3 Km	263	63.2%
	> 3 Km	153	36.8%
Have employee at off farm activity?	Yes	242	58.2%
	No	174	41.8%
Do you have food exchange and sale practices in the market	Yes	389	93.5%
	No	27	6.5%
Way of transport	On foot	230	55.3%
	Horse and cart	33	7.9%
	Vehicles	153	36.8%

Health Status Related Characteristics Of Respondents

The median age of study participants with diabetes were 4 years (IQR 2–7 years). Regardless of health status related characteristics 123(29.6%) of study participants had developed chronic disease other than diabetes (Table 4).

Table 4

Health status related characteristics of utilization of low glycemic index foods among diabetic patients in FS and DMR hospitals, Northwest Ethiopia, 2019(N = 416)
Variables	Categories	Frequency	Percent
Years of patients live with diabetes after diagnosis by physicians	< 5 years	201	48.3%
	≥ 5 years	215	51.7%
chronic disease other than diabetes	Yes	123	29.6%
	No	293	70.4%
Hypertension	Yes	113	27.2%
	No	303	72.8%
Renal disease	Yes	11	2.6%
	No	405	97.4%
Cancer	Yes	4	1.0%
	No	412	99.0%
Cardiovascular disease	Yes	16	3.8%
	No	400	96.2%
Epilepsy	Yes	2	0.5%
	No	414	99.5%
Losses of appetite after diabetes	Yes	148	35.6%
	No	268	64.4%

Life Style Related Characteristics Of Respondents

A total of three hundred and ninety (93.8%) respondents consumed alcohol in their life time. From here 178(42.8%) of study participants were consume alcohol in the past twelve months. The study also indicates 193(46.%) of study participants were have greater than or equals to three days of practice in a week of physical activity in a specific exercise session (Table 5).

Table 5

Life style related characteristics of low glycemic index food utilizations among diabetic patients in FS and DMR hospitals, Northwest Ethiopia, 2019 (N = 416)
Variables	Categories	Frequency	Percent
Consumed alcohol in life time	Yes	390	93.8%
	No	26	6.3%
Consumed alcohol in past 12 months	Yes	178	42.8%
	No	238	57.2%
Cigarette smoking in the past seven days	Yes	23	5.5%
	No	393	94.5%
Number of cigarette in average over a day	Nothing	394	94.7%
	Even one puff	22	5.3%
Physical activity over seven days	≥ 3 days/week	361	86.8%
	< 3 days/ week	55	13.2%
Physical activity over seven days in a specific exercise session	≥ 3 days/ week	193	46.4%
	< 3 days/ week	223	53.6%

Knowledge Related Characteristics Of Respondents

In this study there were nine questions to measure knowledge about utilization of low glycemic index foods. Based on this, each question has many alternatives and were summed and coded to one. After that, all questions were also summed and coded as ≥ 75% for good and < 75% poor knowledge about utilization of low glycemic index foods.

From a total of 416 study participants included in the study 273(65.6%) of respondents had good knowledge on low glycemic index foods. From the study participants 73(17.5%), 116(27.9%), and 181(43.5%) were know the importance of low glycemic index foods as they use to prevent hypoglycemia, hyperinsulinaemia and their ability to delay return of hunger respectively. In addition to the above ideas 279(67.1%) and 197(47.4%) of respondents have good knowledge on feeding of the small portion of carbohydrate foods and the effect of feeding processed foods on blood glucose level among diabetic patients (Table 6).

Table 6

Knowledge based characteristics of utilization of low glycemic index foods among diabetic patients in FS and DMR hospitals, Northwest Ethiopia, 2019 (N = 416)
Variables	Categories	Frequency	Percent
What does mean term low glycemic index to you?	Correctly answered	210	50.5%
	Wrongly answered	157	37.7%
	Says I don’t know	49	11.8%
Which is the importance of low glycemic index foods for DM patients?	Correctly answered	132	31.7%
	Wrongly answered	284	68.3%
Which one is do you think have low GI value in related with fruit ripeness?	Correctly answered	187	45.0%
	Wrongly answered	141	33.9%
	Says I don’t know	88	21.2%
Which one do you think have low GI value in related with time of cooking?	Correctly answered	239	57.5%
	Wrongly answered	87	20.9%
	Says I don’t know	90	21.6%
Which types of sugar do you think have low GI value?	Correctly answered	143	34.4%
	Wrongly answered	273	65.6%
As a diabetic patient how you feed in day to day feeding system?	On my own prepared food	367	88.2%
	With my family	49	11.8%
Can you list any problems on persons those are decreased by due to low glycemic index foods consumption?	Correctly answered	262	63.0%
	Wrongly answered	154	37.0%
How you feed carbohydrate foods?	In small portion	137	32.9%
	In large portion	279	67.1%
Which of the following food groups have affect blood glucose by increasing blood glucose level quickly?	Correctly answered	219	52.6%
	Wrongly answered	197	47.4%

Magnitude Of Utilization Of Low Glycemic Index Food Groups

In this study there were twenty types of food groups those are adapted from different studies according to their availability in Ethiopia including the study area and these food groups were coded and summed. Among the respondents that had ≥ 75% were considered as good utilization of low glycemic index foods and < 75% were considered as poor utilization of low glycemic index foods. Finally, 37(8.9%) respondents had good utilization of low glycemic index foods (95%CI: 6.3, 11.5) (Table 7)

Table 7

Magnitude of low glycemic index foods among diabetic patients in FS and DMR hospitals, Northwest, Ethiopia, 2019(N = 416)
Variables	Categories	Frequency	Percent
Lamp	Yes	52	12.5%
Lamp	No	364	87.5%
Olive oil	Yes	111	26.7%
Olive oil	No	305	73.3%
Collard greens	Yes	280	67.3%
Collard greens	No	136	32.7%
Fish	Yes	18	4.3%
Fish	No	398	95.7%
Chicken	Yes	26	6.3%
Chicken	No	390	93.8%
Kitifo	Yes	56	13.5%
Kitifo	No	360	86.5%
Eggs	Yes	183	44.0%
Eggs	No	233	56.0%
Butter	Yes	296	71.2%
Butter	No	120	28.8%
Bell peppers	Yes	335	80.5%
Bell peppers	No	81	19.5%
Carrots	Yes	217	52.2%
Carrots	No	199	47.8%
Broccoli	Yes	56	13.5%
Broccoli	No	360	86.5%
Onion	Yes	393	94.5%
	No	23	5.5%
Whole grains (beans, peas, lentils)	Yes	358	86.1%
Whole grains (beans, peas, lentils)	No	58	13.9%
Tomatoes	Yes	253	60.8%
Tomatoes	No	163	39.2%
Cabbage	Yes	261	62.7%
Cabbage	No	155	37.3%
Mustard greens	Yes	65	15.6%
Mustard greens	No	351	84.4%
Kale	Yes	83	20.0%
Kale	No	333	80.0%
Lettuce	Yes	133	32.0%
Lettuce	No	283	68.0%
Water	Yes	100	100.0%
Spicy foods	Yes	397	95.4%
Spicy foods	No	19	4.6%

Factors Of Utilization Of Low Glycemic Index Foods

In this study the constants coded for 1 as they are protective based on literature. At Bivariable analysis, variables such as place of residence, educational status, distance to market, doing physical activity, alcohol consumption, employee at off farm activity, feeding processed foods, losses of appetite, developing chronic disease other than diabetes, and knowledge on low glycemic index foods were have P value less than 0.25 and included to multivariable analysis.

At multivariable analysis, variables such as distance less than three Km to market is 3.85 times more likely to utilize low glycemic index foods, AOR: 3.851(95%CI: 1.262, 11.745), formal education were 2.509 times more likely to utilize low glycemic index foods, AOR: 2.509(95%CI: 1.178, 5.344), no history of alcohol consumption in the past twelve months prior to the survey were 3.991 times more likely utilize low glycemic index foods, AOR, 3.911(1.599, 9.567), and good knowledge of respondents in related to low glycemic index foods were 3.354 times more likely to utilize low glycemic index foods, AOR, 3.354(1.091, 10.309) were significantly associated with utilization of low glycemic index foods at P < 0.05 with 95% CI (Table 8).

Table 8

Bivariable and Multivariable analysis of factors of utilization of low glycemic index foods among diabetic patients in FS and DMR hospitals, Northwest Ethiopia, 2019 (N = 416)
Variables	Categories	Utilization of low glycemic index foods		COR with 95% CI	AOR with 95% CI	P value
Variables	Categories	Yes	No	COR with 95% CI	AOR with 95% CI	P value
Place of residence	Urban	31	266	2.195(0.891–5.406)	0.915(0.310–2.700)	0.872
Place of residence	Rural	6	113	1	1
Distance to the market	≤ 3 Km	32	231	4.100(1.562–10.761)	3.851(1.262–11.745)	0.018*
Distance to the market	> 3 Km	5	148	1	1
feeding processed foods	Yes	31	276	1	1
feeding processed foods	No	6	103	1.928(0.782–4.757)	1.362(0.469–3.951)	0.570
Chronic disease other than diabetes	Yes	11	106	1	1
Chronic disease other than diabetes	No	26	273	1.090(0.520–2.283)	0.905(0.402–2.039)	0.810
Appetite losses after diabetes	Yes	9	139	1	1
Appetite losses after diabetes	No	28	240	0.555(0.255–1.210)	2.171(0.938–5.023)	0.070
Knowledge	Good	32	240	3.707(1.658–13.771)	3.354(1.091–10.309)	0.035*
Knowledge	Poor	5	139	1	1
Educational status	Formal education	21	140	2.241(1.132–4.436)	2.509(1.178–5.344)	0.017*
Educational status	Informal education	16	239	1	1
Physical activity	Good	26	190	2.351(1.129–4.894)	1.955(0.862–4.434)	0.109
Physical activity	Poor	11	189	1	1
Alcohol consumption	Not consumed	30	183	4.590(1.968–10.707)	3.911(1.599–9.567)	0.003*
Alcohol consumption	Consumed	7	196	1	1
Employee at off farm activity	Yes	32	240	3.707(1.412–9.733)	2.689(0.913–7.924)	0.073
Employee at off farm activity	No	5	139	1	1

Low glycemic index foods have a great public health importance in related to the prevention of chronic diseases like diabetes mellitus, hypertension, and cancer. This study finding showed that magnitude of utilization of low glycemic index foods were 8.9% (95%CI: 6.3–11.5).

This finding less than the research conducted in German, 56.5% (13, 17). The difference may be due to the difference of socio-demographic characteristics, way of life, countries growth and development difference, age difference of the respondents because they were study on school children’s. The difference also may be due to the way of research conducted that was done by longitudinal trend analysis.

In other ways this study magnitude higher than study conducted in Australia, 3% (12). This may also due to difference of age group that were children’s, difference of study subjects that was not specifically diabetic patients, time of research conducted that was conducted by using twelve years data and also conducted eight years ago, and method of research conducted that was trend analysis on the Australian health survey.

The diabetic patients with formal education were 2.509 times more likely to utilize low glycemic index foods than that of respondents who attained informal education. This was due to respondents who had informal education had incomplete interpretation of instructions, patients tend to forget the advices given by the health care providers, and unable to understand uses of low glycemic index foods. This study supported by the studies conducted in Southern Ethiopia, India, and USA (29–31).

This study found that diabetic patients who had no history of alcohol consumption in the past twelve months prior to the survey were 3.991 times more likely utilize low glycemic index foods than that of respondents who had practice of alcohol consumption. This was due to drinking alcohol leads to low intake of fiber, fruits (19), nutritional distortion due to infections caused by drinking alcohol (32). In this case drinking alcohol leads to poor appetite in users and secondary to infection causes poor food intake and adherence to foods like low glycemic index foods. This study supported by the study conducted in Addis Ababa, Finland, and USA (19, 28, 33).

This study also showed that diabetic patients who live in less than or equals to three Km to the local market were 3.851 times more likely utilize low glycemic index foods than who were live in greater than three Km among diabetic patients. This may be due to > 3 Km to the local market had inability to practice food exchange and sale foods especially low glycemic index food groups and also persons who were live in long distance to local market have not go to local market for only the purpose of exchange of fruits, vegetables, eggs and so on, since those food commodities are usually found in the market. This study similar with the study conducted in South Gondar zone (26).

In this study respondents who had good knowledge of respondents in related to low glycemic index foods were 3.354 times more likely utilize low glycemic index foods among diabetic patients. It has been observed that good knowledge among respondents may use to easily recognize the impact of unhealthy diet, use to differentiate low glycemic food groups easily, and can fill gaps which facing in use of low glycemic foods. This study supported by other studies conducted in Jimma University specialized hospital, Ethiopia, India, and Australia (17, 21, 31, 34).

GDP Gross Domestic Product, GI Glycemic Index, HGL High Glycemic Index, IDF International Diabetes Federation, LGI Low Glycemic Index, NCD Non Communicable Disease, NGO’s Non- Governmental Organizations, SMART Specific, Measurable, Achievable, Realistic, and Time bounded, SPSS Statistical Package for Social Sciences, T2DM Type 2 Diabetes Mellitus, WHO World Health Organization

Ethics approval

The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The ethical clearance was obtained from Debre Markos University, Health science college ethical committee. Official letter was written along with the ethical clearance and was submitted to Debre Markos referral and Finote Selam hospital office. This study was not had any risk consequence for study participants.

Consent to participate

Participants were also informed that participation was voluntary and participants who refused the consent had respect. Written consent was taken from the study participants after briefing them the objective of the study. There was no age of less than 18 years diabetes patients in the sample included. The confidentiality of participant’s related data was maintained by avoiding possible identifiers such as name of study participants only identification number was used as a reference. The interviewer administered questionnaires was kept safe throughout the whole process of the research work. During data collection time any diabetic client with medical problem findings such as any Diabetic complication, education was provided and contacted with health professionals found in those hospitals for support and treatment.

Consent for publication

Not applicable

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author. The data will not be shared in order to preserve participant anonymity.

Conflict of interests

The authors have declared that no competing interests exist.

Funding

No funding was obtained for this study.

Acknowledgments

We thank Debre Markos University college of Health science for providing ethical clearance, data collectors, supervisor and study participants for their willingness to participate in the study.

Author Contributions

Conceptualization: ZD. Formal analysis: ZD, HT, HZ, HA. Development or design of methodology: ZD, HT, HZ, HA. Entering data into computer software: ZD. Supervision: ZD, HT, HZ, HA. Validation: ZD, HT, HA. Writing original draft: ZD HT. Writing review and editing: ZD, HT, HA. All authors read and approved the final manuscript.

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No competing interests reported.

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Utilization of low glycemic index foods and associated factors among diabetes mellitus patients in Debre Markos referral and Finote Selam hospitals, Northwest Ethiopia, 2019

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Abstract

Background

Objectives

Methods

Results

Conclusion and Recommendations:

Background

Methods

Study Design and Setting

Sample Size Determination And Sampling Procedure

Data Collection Procedure And Measurements

Operational Definition

Statistical analysis

Results

Socio-demographic Characteristics Of The Respondents

Food Preparation And Feeding Technique Of Respondents

Market Access Related Characteristics Of Respondents

Health Status Related Characteristics Of Respondents

Life Style Related Characteristics Of Respondents

Knowledge Related Characteristics Of Respondents

Magnitude Of Utilization Of Low Glycemic Index Food Groups

Factors Of Utilization Of Low Glycemic Index Foods

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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