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Original Research (Original Article) 


Tahir Ansari et al, 2019;3(7):581–585.

International Journal of Medicine in Developing Countries

Assessment of knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study

Tahir Ansari1*, Waqas Sami2, Nawaf Razhan Alsubaie3, Abdullah Ali Althaqib3, Abdulrahman Atallah Alenezi3, Ahmad Nueva Almutairy3,Mohammad Abdulkhliq Alshamrani3, Mohammed Ayed Alanazi3, Meshari Abdulkarim Almutairi4

Correspondence to: Tahir Ansari

*Consultant Internal Medicine, Assistant Professor, Department of Clinical Science, College of Medicine, Majmaah University, Majmaah, Saudi Arabia.

Email: t.ansari [at] mu.edu.sa

Full list of author information is available at the end of the article.

Received: 17 January 2019 | Accepted: 30 January 2019


ABSTRACT

Background:

Diabetes mellitus (DM) is a lifelong metabolic disease, considered often as an epidemic problem that leads to a reduction in quality and expectancy of life. There is an increasing prevalence of DM throughout the world as a result of changing dietary patterns and decreased physical activity. Providing proper education and guidance toward diabetes care among patients could result in considerable development in their glycemic control and disease treatment. The objective of this study was to assess the knowledge, attitude, and practice of dietary pattern among DM patients visiting primary health care center (PHC) in Al Majmaah City, Saudi Arabia.


Methodology:

A cross-sectional study was conducted among 155 patients with type 2 diabetes that included 73 male and 82 females.


Results:

Mean knowledge score was 43.22 ± 14.85. The mean attitudes score was 2.33 ± 0.40, and regarding the practice, the majority of the patients did not follow special diet 87 (56.1%) and only 24 (15.5%) patients follow diabetic diet. The majority 37 (23.9%) of patients took only 1–2 serving of starch per day, 47 (30.3%) patients took less than one serving of fruits per day, and 64 (41.3%) patients only drank four cups of water per day.


Conclusion:

In general, poor knowledge, attitudes, and practices were observed toward healthy dietary habits among type 2 DM in patients attending PHC in Al Majmaah city. The present study found only 15.5% among the study subjects were following a strict diabetic diet which reflects the poor level of diabetic control followed in this part of the country.


Keywords:

Saudi Arabia, Al Majmaah, diabetes mellitus, dietary pattern, knowledge, attitude, and practice.


Introduction

Diabetes mellitus (DM) is a lifelong metabolic disease and probably remains still one of the most frequent causes of death from the past few decades. Statistical estimations revealed that the total number of diabetic individuals would be 65% in the world (380 million) by 2025 [1]. It is usually characterized by a chronic increase in blood glucose level and results in cardiovascular and renal complications. These complications lead to impaired quality of life and reduced life expectancy [2]. DM is also defined as a chronic disease caused by the inherited and acquired reduction of insulin production by the pancreas or by the ineffectiveness production of insulin. This kind of deficiency results in increased concentrations of glucose in the blood, which eventually lead to damage of many body systems, in particular, the blood vessels and nerves [3]. DM has an international health load affecting 285 million grown-ups around the world (6.4%) and costing the international health care framework of USD 367 billion. It is additionally viewed as a standout among the emerging public health problems in Middle Eastern countries. International estimates have shown that the Middle East, as a whole, is ranked second in the world, between WHO regions, for the prevalence of DM, with an average prevalence of 9.3%. Diabetes prevalence is expected to be doubled over the next two decades in Middle Eastern countries [4]. Non-communicable diseases have emerged in developing countries as a serious threat. In Saudi Arabia, DM, hypertension, and ischemic heart disease are considered among the top 10 causes of death. These lifestyle-related diseases are sometimes mentioned as “the diseases of affluence” and their rising prevalence is reported to be because of change in dietary patterns (such as a growing culture of fast foods) and a decrease in physical activity. This kind of rapid spread of non-communicable diseases in the health system of Saudi Arabia is the greatest challenge of the governmental bodies to deal with [5]. Food consumption patterns worldwide, including Saudi Arabia have changed markedly. There is a rise in the consumption of food rich in total and saturated fats, refined products, high protein, intense energy diets, highly processed foods, fast food, and sugary beverages [6]. Recently compiled statistics show that around 150 million people have DM worldwide and that this number will double over by the year 2025. A rapid increase in DM prevalence occurs in developing countries as a result of factors such as population growth, aging, unhealthy diets, obesity, and sedentary lifestyles [3].

Many low- and middle-income countries have more people under the age of 60 with diabetes matched up to the world average. At the same time, for high-income countries, the biggest proportion of diabetes prevalence in the growing population is over the age of 60 [7]. Gathering information about the level of perception is the first step to formulate a preventive program for this disease. Education to diabetic patients will be more effective and beneficial if we know the level of knowledge attitude and practice of our patients. Many studies have been conducted to evaluate the general characteristics of diabetic patients, including their baseline knowledge, attitude, and practice (KAP) toward diabetes [8]. Eating patterns also called dietary pattern is a term used to describe combinations of various foods or food groups that characterize relationships between nutrition and health promotion and disease prevention. An assortment of eating designs (combinations of various sustenance’s or nutrition classes) is reported to be worthy of management of diabetes [8,9]. Recommended diet, the current “standard” diet for a person with diabetes is a weight-reducing low fat, low-glycemic index diet with reduced sodium content. Most patients will have type 2 DM and are slightly overweight, so this diet needs to be modified to the individual [10]. A healthy diet is a method of eating that minimizes the risk for complications such as heart disease and stroke. Healthy eating methods include eating a variety of food, including whole grains, vegetables, fruits, lean meats, poultry, fish, and non-fat dairy products. There is no justification for perfect food, so including a variety of different foods and controlling portion sizes are the key to a healthy diet [11]. Current increase of unhealthy dietary habits, including consumption of sweetened soft drinks by young people and skipping breakfast, and the role of these habits has to lead to pathogenesis of childhood obesity. Data from a study conducted on American indicated that having breakfast during school years was connected with 30% lower likelihood of been later becoming overweight or obese.

Research studies and reviews indicate that breakfast skipping is very high among adolescents in the United States and Europe, as well as in many Arab countries [12]. Many KAP studies of patients with type 2 diabetes have been published but we have focused on the studies that concerned about the diet. Our study “Assessment of Knowledge, Attitude, and Practice of Dietary Pattern among Type 2 Diabetes Mellitus Patients” has not been presented or published yet, however, the results of “Food Selection and Eating Patterns” Themes Found among People with Type 2 Diabetes Mellitus” have shown that eating patterns of patient with type 2 diabetes were influenced by participants’ knowledge of diabetes management. Challenges that participants encountered when applying nutrition recommendations were linked to their prior eating practices. Dietary self-efficacy, social support, and time management were identified as mediating variables that can influence dietary behaviors [13].


Subjects and Methods

A descriptive cross-sectional study was done to assess KAP of dietary pattern among type 2 DM patients visiting PHC in Majmaah city, which is located to the north west of Riyadh, Saudi Arabia. Data collection had been done with a structured, pre-coded, pre-tested, and self-administered questionnaire. The questionnaire was translated into the local Arabic language. The questionnaire consisted of four parts: socio-demographic data, knowledge, attitude, and practice. Collected data were further analyzed by using the Statistical Package for the Social Sciences (SPSS) software version 23. Data validation was performed by using double-entry option offered by SPSS software. All the data were double checked to reduce error in statistical calculations.


Results

In this study conducted among type 2 DM patients assessed for their KAP of dietary pattern, the baseline characteristics of the respondents are depicted in Table 1.

The age ranged from 40 to 94 years in the sample. The mean age of patients was 54.46 + 12.000. The mean age of patients at the diagnosis of type 2 DM was 45.76 + 6.949. Socioeconomic status was assessed by categorizing the patient into <3,000 Saudi Riyal (SR), 3,000–5,000 SR, 5,000–10,000 SR, 10,000–15,000 SR, and >15,000 SR. The majority of the respondents 58 (37.4%) patients were found with less than 3,000 SR. Education status (of the participant) was assessed by categorizing the patient into primary, intermediate school, high school, university, diploma, and uneducated. The majority of the respondents 43 (27.7%) patients were found with university education. In the occupation status, the majority of the respondents 55 (35.5%) were housewives and government employee 50 (32.3%). In the marital status, the majority of the respondents were married 114 (73.5%). In case of the smoking status, the majority were non-smoker 141 (91.0%). The majority of the treating doctor for the type 2 DM were general practitioners 106 (68.4%).

Table 1. Baseline characteristics.

Variables n = 155 Percent
Age (Mean ± SD) 54.46 ± 12.000
Gender
Male
Female

73
82

47.1
52.9
Marital status
Married
Single
Divorced
Widow
Separate

114
13
11
14
3

73.5
8.4
7.1
9.0
1.9
Educational status
Primary
Intermediate school
High school
University
Deplume
Uneducated

19
24
36
43
9
24

12.3
15.5
23.2
27.7
5.8
15.5
Annual income (SAR)
<3,000 SR
3,000–5,000 SR
5,000–10,000 SR
10,000–15,000 SR
>15,000 SR

58
30
27
24
16

37.4
19.4
17.4
15.5
10.3
Occupation
Businessman
Government employee
Student
Housewife
Retired

9
50
15
55
26

5.8
32.3
9.7
35.5
16.8
Smoking
No
Yes

141
14

91.0
9.0
Treating doctor
Physician
General practitioner
Endocrinologist

16
106
33

10.3
68.4
21.3

The mean knowledge score was 43.22 + 14.85, which fall within the definition of “Poor Knowledge.” Assessment of attitudes showed the mean score of 2.33 + 0.40, which indicated that the majority were with neutral attitudes. When the assessment of practices was done in the present which have 155 diabetic patients, the majority 87 (56.1%) patients of them were found not following any special diet. Diabetic diet was followed only by 24 (15.5%) of 186 the patients (Table 2).

Table 2. Patient’s diets.

Variables n = 155 Percent
Type of diet
No
Low fat
Low sodium
Diabetic
Vegetarian
Other

87
15
8
24
3
18

56.1
9.7
5.2
15.5
1.9
11.6

On the other hand, the breakfast was the most regularly eaten meal by 60 (38.7%) patients among patients along with few subjects who had the Brunch meal 60 (38.7%), and a minority of them regularly ate dinner 6 (3.9%). The time of taking snack was in the afternoon in 51 (32.9%) patients, while just three (1.9%) patients preferred to take it in the morning. One hundred and nineteen (76.8%) patients were eating outside the house or order food compared with only 36 (23.2%) patients who did not do it at all. Among 119 patients, only 63 (40.6%) ate outside or order the food in the weekly pattern, and only 12 (7.7%) did in a daily pattern, the majority of the food ordered was from fast food 21 (13.5%). Their meals were mostly prepared “grilled” 43 (27.7%) patients, and only 6 (3.9%) patients had poached food. The daily taking of the basic food group and its amount starting with the starch: the majority 37 (23.9%) of patients took 1–2 serving per day, a minority 8 (5.2%) of patients took 9–11 serving per day, and 33 (21.3%) took 6–8 serving per day. These results were compared to the food pyramid published by the World Health Organization (WHO) and found that there was a poor intake of starch in these patients. When daily intake of fruits was considered, a majority 47 (30.3%) of patients only took less than 1 serving per day, while the minority 6 (3.9%) patients took 9–11 serving per day and three to five times were reported in 31 (20%) of patients. Comparing these results to the food pyramid, they should at least take 2–4 serving per day, so there was a poor intake of fruits in the majority of patients studied. Considering daily intake of dairy products, the majority 55 (35.5%) of patients were taking only 1–2 serving per day, while the minority 9 (5.8%) patients were taking 9–11 serving per day. Comparing these results to the food pyramid, they should take at least 2–3 serving per day, so there is an almost adequate intake of dairy in the majority of patients. In case of intake of meat-fish-poultry-eggs, the majority 37 (23.9%) of patients had only 3–5 serving per day, while the minority of the 6 (3.9%) patients took 9–11 serving per day. According to the food pyramid, they should take at least 2–3 serving per day, so there is an almost adequate intake of dairy in the majority of patients. For the daily intake of fat, the majority 51 (32.9%) of patients do not take any serving at all, while the minority 1 (0.6%) of patients took 9–11 serving per day. In sweets, 68 (43.9%) patients do not take any serving at all, comparing these results to the food pyramid they should take the fat and sweets sparingly per day, so there is inadequacy intake of these basic food group in the majority of the patients (Table 3). When daily intake of water was considered, the majority 64 (41.3%) of patients only had four cups per day, while the minority 1(0.6%) patients drank 15 cups per day. Comparing these results to the food pyramid, they should drink at least six cups per day, so there is poor intake of water in the majority of the patients. While in case of the daily intake of coffee, the majority 34 (21.9%) of patients do not drink any cup at all, while the minority 5 (3.2%) patients drink seven cups per day. In case of tea, the majority 53 (34.2%) of patients do not drink any cup at all, while the minority 1 (0.6%) patients drink five cups per day and in case of soda, which the majority 107 (69.0%) of the patients do not drink any cup at all, while the minority 4 (2.6%) patients drink three cups per day.

Table 3. The poor daily taking of the basic food group.

Variables n = 155 Percent
Starch serving
Never
Less than 1
1–2 times
3–5 times
6–8 times
9–11 times

34
24
37
19
33
8

21.9
15.5
23.9
12.3
21.3
5.2
Fruits serving
Never
Less than 1
1–2 times
3–5 times
6–8 times
9–11 times

8
47
43
31
20
6

5.2
30.3
27.7
20.0
12.9
3.9
Fat serving
Never
Less than 1
1–2 times
3–5 times
6–8 times
9–11 times

51
50
15
31
7
1

32.9
32.3
9.7
20.0
4.5
0.6

Discussion

The management of DM not only requires the prescription of appropriate nutritional and pharmacological regimen by the physician but also intensive education and counseling of the patient [8]. Establishing that patient education and patient involvement can lead to better control over this disease [12], American Diabetes Association (ADA) has also stressed the importance of clinical care, self-care practices, patient education in the management and prevention of chronic complications of such a community health problem [13]. Our study reveals the poor level of overall knowledge and practice and neutral attitudes of the dietary pattern among type 2 diabetic patients. Studies from both developed and developing countries have reported that diabetes knowledge is generally poor among diabetic patients. While a study conducted in Oman shows that the majority of type 2 DM Omani patients displayed an optimal level of diabetes knowledge. They also follow good health practices, but these patients need to be encouraged to stick to regular exercise and dietary advice since they showed relatively poor adherence in these two domains [14]. Similar studies conducted in the past to assess the KAP of DM patients in Kuwait, Nepal, and Saudi Arabia have reported poor KAP scores [8,15,16]. Another study in Malaysia observed the good KAP scores among type 2 DM patients, they said that their study has two important findings that diabetic patients should possess; adequate knowledge and have a positive attitude toward their condition and there is no relation between the KAP and actual control of DM [16]. A diabetic diet is usually considered as a part of the management plan in controlling DM type 2, in our study, we found only 15.5% who followed the diabetic diet. Unfortunately, the majority of patients do not follow a special diet; 56.1% which has reflected in a negative manner in their diabetic control. However, there is a marked increase in fast food consumption, especially if we correlate it to our study that shows 76.8% eat outside the house or order food. In the daily taking of the basic food group, one study conducted in the US describing the diet, almost two-thirds of the respondents consumed >30% of their daily calories from fat and >10% of total calories from saturated fat. Mexican Americans and individuals over the age of 65 years ate a higher number of fruits and vegetables and a lower percentage of total calories from fat [17]. But in our study, the consumption of fat, 32.9% of them do not include fat it in their diet and 32.3% use just 1 or less serving. In the case of starch, only 26.5% of patients followed WHO recommendations. In the fruits, 63.2% had a poor intake. In the water intake, we were amazed and surprised to see that only 7% take the recommended amount which is at least six cups, and 93% have an inadequacy of it that could reflect in their physiological function. It is difficult to compare our results with others, as most of the studies used different instruments and are carried out among different ethnic or age groups. But we found that in the Middle East, there is a similar result of having poor knowledge due to lack of clarification from the doctor or from lack of spreading the awareness about diabetes and what should be done after diagnosis and the steps that he/she should do, including the dietary pattern. Our limitation was in the collecting of the data from the community as there was lack of cooperation from many of the patients as they think it is a waste of time or will not help them or make a change in their life.


Conclusion

In conclusion, there is generally poor knowledge, attitudes, and practices of participants toward healthy dietary habits among type 2 DM patients attending PHC in Al Majmaah city. This poor level of overall KAP of the dietary pattern among type 2 diabetic patients calls for urgent diabetes education programs and especially dietary style from the stakeholder to improve overall wellbeing and prolong the life span of people suffering from DM. Implementation of dietary intervention program will help to improve the KAP of type 2 DM patients to a greater level.


Acknowledgments

Thanks to all the staff, doctors, and nurses working in the PHC, Al Majmaah who helped in carrying out this research.


List of abbreviations

ADA American Diabetes Association
DM Diabetes mellitus
KAP Knowledge, attitude and practice
SPSS Statistical Package for the Social Sciences

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

This study was approved by Research Ethics Committee, Majmaah University, Al-Majmaah via Approval No: MUREC-Jan. 08/COM-2016. Date: January 24, 2016.


Author details

Tahir Ansari1, Waqas Sami2, Nawaf Razhan Alsubaie3, Abdullah Ali Althaqib3, Abdulrahman Atallah Alenezi3, Ahmad Nueva Almutairy3, Mohammad Abdulkhliq Alshamrani3, Mohammed Ayed Alanazi3, Meshari Abdulkarim Almutairi4

  1. Consultant Internal Medicine, Assistant Professor, Department of Clinical Science, College of Medicine, Majmaah University, Majmaah, Saudi Arabia
  2. Department of Public Health and Community Medicine, College of Medicine, Majmaah University, Majmaah, Saudi Arabia
  3. Medical Intern, College of Medicine, Majmaah University, Majmaah, Saudi Arabia
  4. Medical Student, College of Medicine, Majmaah University, Majmaah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Ansari T, Sami W, Alsubaie NR, Althaqib AA, Alenezi AA, Almutairy AN, Alshamrani MA, Alanazi MA, Almutairi MA. Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. IJMDC. 2019; 3(7): 581-585. doi:10.24911/IJMDC.51-1547743129


Web Style

Ansari T, Sami W, Alsubaie NR, Althaqib AA, Alenezi AA, Almutairy AN, Alshamrani MA, Alanazi MA, Almutairi MA. Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. http://www.ijmdc.com/?mno=26771 [Access: August 20, 2019]. doi:10.24911/IJMDC.51-1547743129


AMA (American Medical Association) Style

Ansari T, Sami W, Alsubaie NR, Althaqib AA, Alenezi AA, Almutairy AN, Alshamrani MA, Alanazi MA, Almutairi MA. Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. IJMDC. 2019; 3(7): 581-585. doi:10.24911/IJMDC.51-1547743129



Vancouver/ICMJE Style

Ansari T, Sami W, Alsubaie NR, Althaqib AA, Alenezi AA, Almutairy AN, Alshamrani MA, Alanazi MA, Almutairi MA. Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. IJMDC. (2019), [cited August 20, 2019]; 3(7): 581-585. doi:10.24911/IJMDC.51-1547743129



Harvard Style

Ansari, T., Sami, . W., Alsubaie, . N. R., Althaqib, . A. A., Alenezi, . A. A., Almutairy, . A. N., Alshamrani, . M. A., Alanazi, . M. A. & Almutairi, . M. A. (2019) Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. IJMDC, 3 (7), 581-585. doi:10.24911/IJMDC.51-1547743129



Turabian Style

Ansari, Tahir, Waqas Sami, Nawaf Razhan Alsubaie, Abdullah Ali Althaqib, Abdulrahman Atallah Alenezi, Ahmad Nueva Almutairy, Mohammad Abdulkhliq Alshamrani, Mohammed Ayed Alanazi, and Meshari Abdulkarim Almutairi. 2019. Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. International Journal of Medicine in Developing Countries, 3 (7), 581-585. doi:10.24911/IJMDC.51-1547743129



Chicago Style

Ansari, Tahir, Waqas Sami, Nawaf Razhan Alsubaie, Abdullah Ali Althaqib, Abdulrahman Atallah Alenezi, Ahmad Nueva Almutairy, Mohammad Abdulkhliq Alshamrani, Mohammed Ayed Alanazi, and Meshari Abdulkarim Almutairi. "Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study." International Journal of Medicine in Developing Countries 3 (2019), 581-585. doi:10.24911/IJMDC.51-1547743129



MLA (The Modern Language Association) Style

Ansari, Tahir, Waqas Sami, Nawaf Razhan Alsubaie, Abdullah Ali Althaqib, Abdulrahman Atallah Alenezi, Ahmad Nueva Almutairy, Mohammad Abdulkhliq Alshamrani, Mohammed Ayed Alanazi, and Meshari Abdulkarim Almutairi. "Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study." International Journal of Medicine in Developing Countries 3.7 (2019), 581-585. Print. doi:10.24911/IJMDC.51-1547743129



APA (American Psychological Association) Style

Ansari, T., Sami, . W., Alsubaie, . N. R., Althaqib, . A. A., Alenezi, . A. A., Almutairy, . A. N., Alshamrani, . M. A., Alanazi, . M. A. & Almutairi, . M. A. (2019) Assessment of Knowledge, attitude, and practice of dietary pattern in patients with type 2 diabetes mellitus: a locality-based perspective study. International Journal of Medicine in Developing Countries, 3 (7), 581-585. doi:10.24911/IJMDC.51-1547743129