Poor dietary practice and its associated factors among patients with type 2 diabetes mellitus on follow up in Nigist Elleni Mohammed Memorial Comprehensive Specialized Hospital, Ethiopia


 Background

Despite the importance of dietary practice on self care of patients with type 2 diabetes mellitus, poor dietary practice results in long term complications. Therefore this study was conducted to identify the level of poor dietary practice among type 2 diabetic patients on follow up in Nigist Elleni Mohammed Memorial comprehensive specialized Hospital, Southern Ethiopia.
Methods

Facility based cross-sectional study design was employed to assess the level of poor dietary practice among type II diabetes mellitus adult patients. The study was conducted from March to April 2020 G.C. Systematic random sampling method was used to select the study respondent. Both bivariate and multivariable logistic regressions were carried out to assess independent predictors of poor practice to diet. Odds ratios and their 95% confidence intervals together with value ≤ 0.05 were used to identify independent predictors of poor dietary practice.
Result

The overall proportion of poor dietary adherence among type diabetes patients was 53.7% (n = 168). Having large family size, occupations, being low wealth status, lack of family support and not being member of diabetic association were the factors associated with poor adherence of dietary practice among type 2 diabetes mellitus patients.
Conclusion

The overall magnitude of the poor adherence to dietary practice among type 2 diabetes mellitus adult patients was 53.7% which is not going in line with international recommendations of diabetic self care. Every concerned body should strive to address those factors associated with poor dietary practice among type 2 diabetes mellitus patients.


Abstract Background
Despite the importance of dietary practice on self care of patients with type 2 diabetes mellitus, poor dietary practice results in long term complications. Therefore this study was conducted to identify the level of poor dietary practice among type 2 diabetic patients on follow up in Nigist Elleni Mohammed Memorial comprehensive specialized Hospital, Southern Ethiopia.

Methods
Facility based cross-sectional study design was employed to assess the level of poor dietary practice among type II diabetes mellitus adult patients. The study was conducted from March to April 2020 G.C.
Systematic random sampling method was used to select the study respondent. Both bivariate and multivariable logistic regressions were carried out to assess independent predictors of poor practice to diet. Odds ratios and their 95% con dence intervals together with value ≤ 0.05 were used to identify independent predictors of poor dietary practice.

Result
The overall proportion of poor dietary adherence among type diabetes patients was 53.7% (n = 168).
Having large family size, occupations, being low wealth status, lack of family support and not being member of diabetic association were the factors associated with poor adherence of dietary practice among type 2 diabetes mellitus patients.

Conclusion
The overall magnitude of the poor adherence to dietary practice among type 2 diabetes mellitus adult patients was 53.7% which is not going in line with international recommendations of diabetic self care.
Every concerned body should strive to address those factors associated with poor dietary practice among type 2 diabetes mellitus patients.

Background
Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to absolute or relative de ciency of insulin. It is clinically categorized DM as Type I diabetes, Type II diabetes, Gestational diabetes mellitus and other speci c types of diabetes due to other causes such as genetic defects in bcell function, genetic defects in insulin action and diseases of the exocrine pancreas [1].
The international diabetes federation estimates that 463 million adults are living with diabetes worldwide with 1 in 11 people are living with diabetes. Worldwide Diabetes Mellitus (DM) is one of the most challenging health problems. Ongoing patient self-management, education, and support are critical to prevent acute complications and to reduce the risk of long-term complications from the disease. Also adherence to recommended meal plans/dietary schemes and being active can keep blood glucose level, blood pressure, and cholesterol levels within optimum ranges. It follows that non-adherence to recommended diet would lead to life-threatening complications in individuals with diabetes [2].
Recommended dietary practices or dietary adherence include consuming more fruits and vegetables, nuts and whole grains, and choosing unsaturated vegetable oil as opposed to saturated animal based fats. It also includes limiting consumption of snacks that are high in fat, sugar, or salt [3].
Patients need to achieve and maintain a healthy body weight, perform a regular physical activity for at least 30min and moderate-intensity activity on most days, eat a healthy diet, and avoid sugar and saturated fats intake and tobacco use in order to prevent type2 DM and its complication [2].
Even though dietary modi cation is one of the corner stone in T2 DM management and is usually recommended as the rst step, it is considered as one of the most challenging aspects of diabetes management. Implementation of recommended dietary practice for individual's with T2 DM requires collaboration between the patient and the healthcare provider [4].
Non adherence to dietary recommendation in people with T2 DM has been identi ed as high in both developed and developing countries [5]. None adherence to recommended dietary recommendation in diabetes mellitus patients may results in long term complications [6]. Some of the factors associated with poor adherence to dietary recommendations are socioeconomic status, duration of illness, duration of follow up, educational level, coo morbidity, family support, lack of diabetes knowledge, cost of healthy diet and poor communication with healthcare providers are among the most common factors [7]. But there is, limited information regarding the level of adherence and factors associated with poor dietary recommendations in individuals with T2DM in Africa including Ethiopia. A few reports in Ethiopia and other parts of Africa suggest that adherence to dietary recommendation in DM patients are generally low [8].
In Ethiopia, lack of information on adherence to dietary recommendation and absence of dietary practice guideline for people withT2DM is still challenging. Moreover, due to little evidence-based researches were done, the health policy of Ethiopia is still unable to give evidence based decision. Therefore conducting and documenting such research would have a positive impact on designing and implementation of dietary practice programs for people with T2DM in Ethiopia.
There is a limited literature regarding dietary adherence among type II diabetes patients who are on follow up in public health care in Ethiopia, particularly in the study area, therefore this study was conducted to identify the level of adherence to dietary recommendation among type 2 diabetic patients on follow up in The study was conducted Nigist Eleni Mohammed Memorial Referral and teaching Hospital which is located in Hadiya zone in South Nation's Nationalities and Peo ples Region found in 232 kms south of Addis Ababa, Ethiopia. Currently it provides preventive, curative and rehabilitative clinical services organized in four case teams as outpatient, inpatient, emergency and critical care, maternal, child health and obstetrics and operation theatre. The out patients services are given in OPD clinics (internal medicine, surgery, pediatrics and child health, Gynecologic), specialty clinics (psy chiatry, dermatology, ophthalmology, Dentistry and Orthopedic), referral and consultation clinics, Maternal and child health care follow up clinics.
The study was carried out in Nigest Eleni Mohammed Memorial Referral and Teaching Hospital, Southern Ethiopia, from March to April 2020 G.C [9].

Study design
Facility based cross-sectional study was employed to assess the level of adherence to dietary recommendations among type II diabetes mellitus adult patients.

Source population
The study source population was all patients with type 2 diabetes aged 18 years and above who were on diabetic follow up at Nigist Elleni Mohammed Memorial Teaching and Referral Hospital.

Study Population
The study population was Type 2 diabetic patients aged18 years and above who were visiting Nigist Elleni Mohammed Memorial Teaching and Referral Hospital diabetes clinic and randomly selected for the study

Inclusion Criteria
Patients those who were diagnosed with type 2 diabetes and on clinical care for at least one year were included.

Exclusion Criteria
A patient who was critically ill and need immediate treatment during data collection period was excluded from the study

Sample size determination
The sample size for the study was determined using the single population proportion formula for sample size determination [10].
By considering non-response rate of 10 % the nal sample size was 322.

Sampling techniques
Nigist Eleni Referral Hospital is selected purposively since it is the only hospital in the town. Systematic random sampling method was used to select the study respondent. There were 862 type II diabetes mellitus patients on follow up age of 18 and greater at the time. Each patient visits the facility on monthly basis. To run systematic sampling the K-value (the interval) was calculated by dividing total number of type 2 DM patients (862) from diabetes referral clinic registration log book to the calculated sample size (322). Therefore K= N/nf, where nf = nal sample size = 322 and N = total Number of type 2 diabetes patients who are attending the hospital for follow up , which is equal to 862 patients. Accordingly, every 2 nd patients were selected until the sample size lls with the rst sample chosen randomly between 1 and k. Food related: cost of the food, availability of the food, type of food that should be consumed, frequency and meal timings, member of diabetic association.

Study
Knowledge about the recommended diet Data collection instrument and personnel Data was collected using a structured interviewer administered questionnaire. The questionnaire was initially prepared in English then translated in to local language (Amharic) by professionals who were uent two languages and then translated back to English to ensure consistency. In order to ensure reliability and consistency, enumerators were trained for 1 day. Pretest was undertaken by considering 5% of the sample size in Homacho hospital located outside the study area. Findings of the pretest were incorporated to modify and clarify the collection tool before the actual data collection. Data were collected by four trained nurses and two supervisors for ve consecutive weeks from March to April 2020 G.C. The data collection tool used in this study was adapted and modi ed from previous studies on similar topics.
To determine the dietary non-adherence of individuals with DM, we used a modi ed form of the eight items Morisky medication adherence scale (MMAS-8) which was modi ed by Worku et al. [7]. This scale has 11 components and was computed by taking the mean value to classify the respondents' poor dietary practice as "dietary non-adherence" and good practice as "dietary adherence". The Perceived Dietary Adherence Questionnaire (PDAQ) was used for dietary adherence measurement. Each of the items contain two response options (Yes = 1 and No= 0 , here yes was used for those responses which are negatively answered or far true answer from what science is talking about). The questionnaire was tested for internal consistency (reliability) with Cronbach's Alpha test (0.7). The completeness, consistency, and accuracy of the collected data were examined by principal investigators every day.

Data processing and analysis
Data coding was done at the end of each day of data collection and recoded later where necessary. Data were entered and analyzed by using SPSS version-20 statistical package. House hold wealth index was determined from asset data using principal component analysis (PCA). First, variables were coded between 0 and 1, and then the variables entered and analyzed using PCA and those variables which have commonality values greater than 0.5 were used to produce factor scores. Frequency distributions, percentages, tables and charts were used to show results of univariate analysis. Bivariate and multivariable logistic regressions were carried out to assess independent predictors of non adherence to diet. Bivariate logistic regression was performed to identify candidate variables for multivariable logistic regression. Variables with value ≤0.25 in bivariate regression were considered as candidates for multivariable regression. Odds ratios and their 95% con dence intervals together with value ≤0.05 were used to identify independent predictors of non adherence to diet. Goodness of tness of the nal model was checked using Hosmer and Lemeshow adequacy of model test.

Operational de nitions
Poor dietary adherence: respondents who answered incorrectly on 10 items of perceived dietary adherence questions and those who scored above the mean value were classi ed as poor adherence to dietary recommendation [10].
Good dietary adherence: respondents who answered correctly on 10 items of perceived dietary adherence questions and those who scored equal or below the mean value were classi ed as good adherence to dietary recommendation [10].
Good Dietary Knowledge: respondents who answered correctly to knowledge related questions and those who scored greater than the overall mean value.
Poor Dietary Knowledge: respondents who answered in-correctly to knowledge related questions and those who scored less than or equal to overall mean value.

Ethical consideration
Ethical clearance was obtained from ethical review board of wachemo university department of public health research ethical committee. O cial letter of permissions was obtained from Nigist Eleni Mohammed Memorial hospital medical director o ce and respondents were well informed about the purpose of the study, then data was collected after written consent from each participant obtained. Information was recorded anonymously and con dentiality and bene cence was assured throughout the study period.

Results
Socio demographic characteristics of the respondents A total of 313 respondents agreed to participate in the study and 97.2% of the participants gave complete response. More than half of the participants (56.9%) were males. The mean age (±S.D) of type 2 DM patients was 48.12 (±11.348) years with the age ranges between 20 -90 years. The majority of the participants 187 (59.7%) were between 41 and 60 years. Among the respondents, majority of them 214 and 240 (68.4% and 76.7%) were from protestant Christian followers and from Hadiya ethnic group respectively. Regarding to educational status, 51(16.3%) and 99(31.6%) of the patients attended higher education and had no formal education respectively. Of the total study participants, 116(37.1%) of the respondents were rural residents .Nearly half of respondents 148(47.3%) had 4-6 family size and 83(26.5%) of the respondents were government employees. More than one third (34.8%) of the study participants were from low or poor economic status (Table 1). ] .According to this study the proportion of poor dietary adherence practice among age groups of less than 40 years was 28.6% [95%CI, (22, 32.6)] and it was 10.7% [95%CI, (8.9, 16.3)]among the age groups of 60 years and above.
More than half of the respondents (57.8%) reported that they were an unable to follow dietary recommendation due to unavailability of food items, cost of foods, lack of supports from their families and friends and lack of information. A signi cant number of the study participants (45%) didn't continue with dietary plan when they felt that their DM is under control. A large number of the study participants (81.5%) forgot to consume fruits 3 times or more a day or 6 times or more a week. A large number of patients (80.5% & 78.3%) responded that they forgot to include fruits and vegetables in their daily foods respectively. More than 3 in 4 patients (76%) failed to cut down fat intake from their daily foods Factors associated with poor dietary adherence among type II diabetes mellitus adult patients Family size, residence, educational status, occupation, wealth status ,knowledge status of the respondents ,duration of follow up , co-morbidity, fasting blood sugar level, physical exercise ,being member of diabetic association, missed dietary planning, cost of foods, access to fruits and vegetables and family and friends support were selected as candidate for multivariable logistic regression. However in multivariable analysis family size, occupation, wealth status, family and friends support, not being member of diabetic association and missed dietary planning were independently associated with poor dietary adherence among type II DM adult patients (Table 2).  20] which showed there was a positive association between social support and adherence to lifestyle recommendations. This is due to the fact that when they couldn't get help from their nearby family they may feel despondent and then they might miss their dietary meal plan, including taking the excess sweetness and alcohol. Positive family support is the means of promoting preventive measures like good dietary practice and other diabetes self-care practices [17,18]. It is similar with studies done in Taiwan and Nekemte Referral Hospital, Ethiopia that family and social support was passively associated with good adherence of dietary practice among type II DM patients [21,22].
Being a member of the Diabetic association was also signi cantly associated with adherence to dietary recommendation which was in line with the study in Felegehiwot Hopital, North west Ethiopia [19]. This might be due to the association's regular support given to the patients including support on self care in addition to securing medicine to some of the lower income members and blood glucose testing with a relatively lower price.
Assessing the level of dietary practice using self-reported dietary practice was one of the limitations of the study. Besides, using self-reported dietary adherence as a measure of the level of adherence may introduce social desirability or recall bias.

Conclusion And Recommendation
The overall magnitude of the poor adherence to dietary practice among type II diabetes mellitus adult patients was 53.7% which is not going in line with international recommendations of diabetic self care.
Besides, having large family size, occupations, being low wealth status, lack of family support and not being member of diabetic association were the factors associated with poor adherence of dietary practice among type II DM patients. Ever concerned bodies should focus on addressing family planning issues, creating job opportunities and increasing household economic status of patients with type II DM. Lastly, support from the family members and expanding the diabetic association service are essential factors to promote dietary practice among type II DM adult patients.