This was a cross-sectional study on 148 type 2 diabetic patients between 30 and 65 years old, who had a medical record at Eghlid county Health Center and whose HbA1c level were recorded during the last two weeks. Eghlid is a county in Fars Province in Southwest Iran. Patients were excluded if they any specific diseases (cardiovascular disease and stroke, cancer, acute kidney disease) were present, as well as pregnant and lactating women.
In the period of May to September of 2018, eligible patients were enrolled and the study procedure was explained for them on the phone. They were invited to three community health centers in Eghlid County to complete the questionnaires. Written consent was obtained and demographic questionnaire, food security questionnaire and self-care questionnaire were completed by patients with the supervision of nutritionists. The most recent HbA1and fasting blood sugar (FBS) abstracted from the medical record and HbA1c ≥ 8.5% was classified as undesirable glycemic control. Weight and height were measured and BMI was calculated.
A demographic questionnaire was used to collect general demographic information, including age, sex, ethnicity, education, and employment status. Household economic status was determined using a questionnaire including 9-item home appliances and was classified owning less than 3-item as poor economic level, 4 to 6-item as moderate economic level, and more than 7-item as wealthy economic level.
The 18-item USDA household food security questionnaire was used to assess food security over the past 12 months (35). This questionnaire has been validated during previous studies in Iran (36). Rating of 18-item USDA household food security status questionnaire was a below: positive rate to answers “often true”, “sometimes true”, “almost every month”, “some months”, and “yes” and zero score to responses “not true”, “does not know or refused”, “only 1 or 2 months”, and “no”. Finally, scores 0–2 were categorized as food secure, scores 3–7 as food insecure without hunger, scores 8–12 as food insecure with moderate hunger, and scores 13 and higher as food insecure with severe hunger.
Collecting self-care behaviors was assessed using the Summary of Diabetes Self Care Activities (SDSCA) with 14 questions that assesses patients' self-care quality in the last seven days (37). Questions include diet: 5 questions, exercise: 2 questions, blood sugar control: 2 questions, foot care: 5 questions, and regular medications: 1 question. To score the questionnaire, for each question of self-care behaviors, one point was considered per day if it was done and zero points were considered if it was not done. The highest score in this tool is 98, which indicates the highest quality of self-management. The validity and reliability of this questionnaire have been studied by Anbari et al (38).
Weight was measured using a Seca scale with an accuracy of 100 g with minimal coverage and no shoes, and height was measured by a tape without shoes with an accuracy of 0.1 cm by a nutritionist. BMI was calculated by dividing weight (in kilograms) by height squared (in square meters).
All analyzes were performed using SPSS version 20 and the significance level was considered to be 0.05. The relationship of food quality and self-care with food security was tested by linear regression analysis. Logistic regression was used to investigate the association between glycemic control and food security with a 95% confidence interval.