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Original Research (Original Article) 


Basmah Abdullah Alanazi et al, 2020;4(2):461–468.

International Journal of Medicine in Developing Countries

Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes

Basmah Abdullah Alanazi1*, Mashael Jaza Alshammari1, Fahad Ahmed Alhawas2, Isamme AlFayyad3, Abdulrahman AlMaghamsi4, Ali Khalaf Alrowaidan2, Sultan Mohammed Alabrah2, Hadeel Mahmoud Alomrani5, Bayan Ali Alatawi5

Correspondence to: Basmah Abdullah Alanazi

*Resident, Internal Medicine, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia.

Email: dr.bes1994 [at] outlook.sa

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

Received: 26 December 2019 | Accepted: 08 January 2020


ABSTRACT

Background:

Carbohydrate counting is a meal planning approach used in diabetic patients who focus on carbohydrates as the primary nutrient, affecting postprandial glycemic response. As diabetes mellitus affects the metabolism of carbohydrates, thus patients should monitor carbohydrate intake and eat a heart-healthy diet using nutrition labels. The study aims to test the reliability and validity of Health habits counseling questionnaire (HHCQ) in order to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills in adults with diabetes, attending the diabetic center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.


Methodology:

A cross-sectional study was carried out in the diabetic center, KFMC, from 1st May to 31st December 2016. A total of 178 participants were included in the study using the convenience sampling technique. After translating the questionnaire into Arabic, data were collected by means of a personal interview with the participants. Data were coded and analyzed using the Statistical Packages for the Social Sciences (version 16).


Results:

Ninety-four (52.8%) participants had type 1 diabetes and 84 (47.2%) had type 2; the average duration of diabetes was 12.6 ± 3.7 years. There was no significant relationship between patients’ level of education and the use of carbohydrate counting on a regular basis and diabetes education (p > 0.05).


Conclusion:

The use of carbohydrate counting on a regular basis was found in only 18% of diabetic patients attending the diabetic center, KFMC, Riyadh, Saudi Arabia. This study recommends that health policymakers must conduct more effective health education sessions to increase the knowledge of diabetic patients and their caregivers about HHCQ to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills.


Keywords:

Reliability and validity, carbohydrate counting skills, knowledge of heart-healthy foods, nutrition label reading, diabetics.


Introduction

Diabetes mellitus (DM) is considered as a disease that is rapidly grown all over the world. It is a leading cause of morbidity and mortality worldwide, with an estimated 80% of the affected population living in developing countries [1]. The metabolic control achieved through medical nutrition therapy, physical activity, and medications (when needed) improves the quality of life and treats and prevents diabetes complications [2]. Cardiovascular disease is considered as a major comorbidity that led to death in diabetes [3]. The knowledge of foods containing carbohydrates is important for persons with diabetes to optimize their glycemic control. However, in diet, the sugar is permitted, and it should be included in the total carbohydrate content [4]. The risk of macro- and microvascular complications would be decreased by controlling and maintaining tight glycemic control [5]. A comprehensive dietary assessment is essential for the design and implementation of individualized nutrition interventions and evaluation of progress over time [6]. Monitoring carbohydrate intake method was integrated in the first half of the 20th century but did not become widely accepted until its use in the Diabetes Control and Complications Trial in the early 1990s [4,7]. To maintain good glycemic control for diabetic patients, carbohydrate counting is very essential as one of the key strategies for assessing the intake of the nutrient [4]. A previous study conducted in Oman and the United Arab Emirates [7] attributing the little knowledge of food carbohydrate sources found that carbohydrate-food knowledge score was 6.3 ± 2. Among the participants, 93% believed that whole wheat bread does not increase their blood glucose levels and 88% of them did not think that unsweetened fruit juices can increase the blood glucose levels. Furthermore, scores for Omani citizens were significantly lower than those of Emirati counterparts, with a mean difference of 2.3 (95% confidence interval: 1.5–3.1). Significant (p < 0.05) differences in carbohydrate-food knowledge scores between the two groups were found for 5 of the 14 foods assessed. The study aims to test the reliability and validity of Health habits counseling questionnaire (HHCQ) to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills in adults with diabetes attending the diabetic center, King Fahad Medical City (KFMC).


Subjects and Methods

A cross-sectional study was carried out in the diabetic center, KFMC, from 1st May to 31st December 2016. The inclusion criteria included all diabetic individuals attending the center who were older than 18-year old and can read and write, whereas diabetic individuals attending the center who were diagnosed less than 6 months were excluded from the study. In the study, 178 participants were included using the convenience sampling technique.

We aimed to test the reliability and validity of HHCQ in order to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills in adults with diabetes, attending the diabetic center. After translating the questionnaire into Arabic, data were collected by means of personal interviews with the participants. After training the medical students for weeks before starting the collection of data and research activities, the questionnaire was administered by the medical students for each participant (male or female).

The Data Management and Analysis Plan Filled questionnaires were reviewed for completeness and accuracy before data entry. The data were collected and coded and analyzed using the Statistical Package for the Social Sciences (version 16). The X2-test was used as a test of significance, and the differences were considered to be significant at p-value 0.05 or less.


Results

The data were analyzed for 178 diabetic subjects; the average age was 47.3 ± 19.7 years and 104 (58.4%) participants were women. Ninety-four (52.8%) participants had type 1 diabetes and 84 (47.2%) had type 2; the average duration of diabetes was 12.6 ± 3.7 years (Table 1).

Regarding the use of carbohydrate counting on a regular basis, 18% of participants said that they do it on a regular basis. Regarding the place to learn, 34.4% of participants said that they learned it through their physician, whereas self-education was reported in 28.1% of participants. The reason for using carbohydrate counting was to adjust the insulin dose in 50% of cases and for weight loss/weight stabilization in 25% of participants. Regarding methods to count carbohydrates, this study reported that 37.5% of participants do it by calculating the grams, whereas the exchange system was reported in 15.6% of participants, healthy dish (plate) in 40.6%, and count 15 g carbohydrate choices and count 10 g carbohydrate choices in 6.2% (Table 2).

Regarding diabetes education, this study reported that 57.9% of patients agreed that they had diabetic education (Table 3).

There were no significant relationships (p > 0.05) between the level of education and the use of carbohydrate counting on a regular basis and diabetes education (Table 4).


Discussion

Diabetes is a chronic debilitating condition worldwide that is associated with increased complications, mortality, health utilization, and cost [8]. Carbohydrate-containing foods have the greatest impact on postmeal blood glucose levels. The total amount of carbohydrates consumed strongly predicts glycemic response; therefore, monitoring total carbohydrates by either exchanges or carbohydrate counting to appropriately assess the dose of rapid-acting insulin is critical to lower the mean glycemia (HbA1c) and to reduce the glucose variability [5]. Carb Quiz is the only tool for carbohydrate counting assessment in an adult population as reported by Kern [9]. This is a cross-sectional study conducted among 178 diabetic patients in the diabetic center, KFMC, Riyadh, Saudi Arabia. The study aims to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills in adults with diabetes.

Table 1. Sociodemographic characters; type, duration, and treatment method of DM; and visits to a dietitian (No. =178).

Frequency (No.) Percentage (%)
Gender
  • Male
74 41.6
  • Female
104 58.4
Age
  • 18–35
69 38.8
  • 36–50
44 24.7
  • 51–65
49 27.5
  • >66
16 9.0
Mean age (±SD) 47.3 ± 19.7
Level of education
  • High school
44 24.7
  • Collage graduate
80 44.9
  • Postgraduate
14 7.9
  • None
40 22.5
Treatment method
  • Oral hypoglycemic
72 40.4
  • Insulin injection
55 30.9
  • Oral hypoglycemic + insulin injection
34 19.1
  • Only diet
17 9.6
Visitation to a dietitian
  • 1–2
57 32.0
  • 3–10
36 20.2
  • More than 10
31 17.4
  • Never
54 30.3
Type of DM
  • Type1
94 52.8
  • Type 2
84 47.2
Duration of DM
  • Less than 1 year
30 16.9
  • 2–5 years
54 30.3
  • 6–10 years
43 24.2
  • More than 10 years
51 28.7
Mean diabetes duration (±SD) 12.6 ± 3.7

This study found that the use of carbohydrate counting on a regular basis was 18%. Another study conducted among 81 diabetic patients by applying a questionnaire called the PedCarbQuiz (PCQ) to assess the carbohydrate knowledge of patients reported that PCQ scores were 68.7 ± 16.3% for carbohydrates, which refer to a low level of carbohydrate counting knowledge [10]. Another study carried out among 134 patients with type 1 diabetes using the Nutri-Learn buffet (NLB), which is a new computer-based tool for patient instruction in carbohydrate counting, found that patients with type 1 diabetes assigned to the NLB group showed a better ability to estimate the carbohydrate content of the selected food than patients instructed with conventional tools [11]. Another study conducted in Oman and the United Arab Emirates reported that carbohydrate-food knowledge score was 6.3 ± 2, reflecting a low knowledge of food sources of carbohydrate [7]. Using carbohydrate counting for medical nutrition therapy for persons with diabetes was found to be important [12]. Another study reported some levels of carbohydrate counting from an advanced training program that was designed to teach clients with type 1 diabetes, who are using multiple daily injections or insulin infusion pumps [12].

Table 2. The use of carbohydrate counting on a regular basis, a place to learn and reason for using carbohydrate counting, and methods to count carbohydrate.

Frequency (No.) Percentage (%)
Use of carbohydrate counting on a regular basis (No. = 178)
  • Yes
32 18.0
  • No
146 82.0
The place to learn carbohydrate counting (No. = 32)
  • Physician
11 34.4
  • Nutritionist
11 34.4
  • Family or friend
1 3.1
  • Self-education
9 28.1
Reason for using carbohydrate counting (No. = 32)
  • Weight loss/weight stabilization
8 25.0
  • Used to adjust the insulin dose
16 50.0
  • Carbohydrate diet
5 15.6
  • Prescribed by the doctor
3 9.4
Methods to count carbohydrate (No. = 32)
  • Calculate the grams
12 37.5
  • Exchange system
5 15.6
  • Healthy dish (plate)
13 40.6
  • Count 15 g carbohydrate choices and count 10 g carbohydrate choices
2 6.2

Table 3. Diabetes education, knowledge about an appropriate diet for diabetes, most appropriate food if the blood sugar is 45, foods that contain 15 and 10 g of carbohydrate, and foods that do not contain (No.=178).

Frequency (No.) Percentage (%)
Diabetes education (No. = 178)
Yes 103 57.9
No 75 42.1
Diabetes education on appropriate diet for diabetes (No = 103)
Does not contain sugar 22 21.4
Contains a low percentage of carbohydrates 27 26.2
Healthy food for most people 43 41.7
Contains high carbohydrate content 4 3.9
I do not know 7 6.8
Most appropriate food if the blood sugar is 45 (No. = 103)
Laban 4 3.9
Orange juice 49 47.6
Dates 36 35.0
I do not know 14 13.6
Foods that contain 15 g of carbohydrate (No. = 103)
Medium orange 15 14.6
Medium orange, medium banana 1 1.0
Medium orange, half a medium banana 3 2.9
Medium orange, I do not know 1 1.0
Medium orange. McDonald’s with cheese. Half a medium banana 1 1.0
Medium orange. Half a medium banana 1 1.0
McDonald’s with cheese 12 11.7
McDonald’s with cheese, I do not know 1 1.0
Medium banana 11 10.7
Medium banana, Half a medium banana 2 1.9
Medium banana, I do not know 1 1.0
Half a medium banana 16 15.5
I do not know 38 36.9
Foods that contain less than 10 g of carbohydrate (No. = 103)
Huge carrots 13 12.6
Huge carrots, cup of salad 2 1.9
Huge carrots, I do not know 1 1.0
Huge carrots, half a cup of green peas, cup of salad 1 1.0
Huge carrots, half a cup of green peas, half a cup of corn 1 1.0
Half a cup of green peas 6 5.8
Half a cup of green peas, half a cup of corn 1 1.0
Half a cup of green peas. Cup of salad 2 1.9
Cup of salad 26 25.2
A cup of salad. Half a cup of corn 1 1.0
Half a cup of corn 12 11.7
Half a cup of corn, I do not know 1 1.0
I do not know 36 35.0
Foods that do not contain carbohydrate (No. = 103)
Eggs 9 8.7
Eggs, peas 1 1.0
Eggs, peas, milk, chicken 1 1.0
Eggs, peas, chicken 2 1.9
Eggs, milk 1 1.0
Eggs, milk, chicken 1 1.0
Eggs, chicken 6 5.8
Eggs, I do not know 1 1.0
Eggs, peas, chicken 1 1.0
Eggs, milk 1 1.0
Eggs, chicken 2 1.9
Peas 18 17.5
Peas, chicken 1 1.0
Peas, milk 2 1.9
Milk 9 8.7
Milk, chicken 2 1.9
Chicken 15 14.6
I do not know 30 29.1
Starchy vegetables (No. = 103)
Green beans 2 1.9
Green beans, corn 1 1.0
Green beans, corn, potatoes 6 5.8
Green beans, corn 1 1.0
Green beans, corn, potatoes 1 1.0
Corn 6 5.8
Corn, potatoes 18 17.5
Corn, potatoes, I do not know 1 1.0
Corn, I do not know 1 1.0
Corn, potatoes 10 9.7
Potatoes 43 41.7
Potatoes, cucumber 1 1.0
Cucumber 3 2.9
I do not know 9 8.7

Table 4. The relationship between the level of education and visits to a dietitian, use of carbohydrate counting on a regular basis, a place to learn carbohydrate counting, and diabetes education.

Level of education Total (n = 178) p-value
High school (n = 44) Collage graduate (n = 80) Postgraduate (n = 14) None (n = 40)
Visits to a dietitian
  • 1–2
18 25 3 11 57 0.473
40.9% 31.2% 21.4% 27.5% 32.0%
  • 3–10
7 21 3 5 36
15.9% 26.2% 21.4% 12.5% 20.2%
  • >10
5 13 4 9 31
11.4% 16.2% 28.6% 22.5% 17.4%
  • Never
14 21 4 15 54
31.8% 26.2% 28.6% 37.5% 30.3%
Use of carbohydrate counting on a regular basis
  • Yes
8 15 5 4 32 0.191
18.2% 18.8% 35.7% 10.0% 18.0%
  • No
36 65 9 36 146
81.8% 81.2% 64.3% 90.0% 82.0%
A place to learn carbohydrate counting
  • No learning
36 65 9 36 146 0.238
81.8% 81.2% 64.3% 90.0% 82.0%
  • Physician
5 4 1 1 11
11.4% 5.0% 7.1% 2.5% 6.2%
  • Nutritionist
2 5 2 2 11
4.5% 6.2% 14.3% 5.0% 6.2%
  • Family or friend
0 0 0 1 1
.0% .0% .0% 2.5% 0.6%
  • Self-education
1 6 2 0 9
2.3% 7.5% 14.3% .0% 5.1%
Diabetes education
  • Yes
24 52 8 19 103 0.304
54.5% 65.0% 57.1% 47.5% 57.9%
  • No
20 28 6 21 75
45.5% 35.0% 42.9% 52.5% 42.1%

Regarding the methods to count carbohydrates, this study reported that most of the participants calculate the grams (6.7%), whereas exchange system was reported in 2.8%, healthy dish (plate) in 7.3%, and count 15 g carbohydrate choices and count 10 g carbohydrate choices in 1.1%. Another study reported that different methods exist to quantify carbohydrate, including counting in 1 g increments, 10 g portions, or 15 g exchanges; carbohydrate estimations in portions or exchanges have been thought to be inadequate because they may result in less precise matching of insulin dose to carbohydrate amount [13]. To correctly count carbohydrates, it is necessary to know the exact food weight, but scales are rarely used in everyday life [11]. The total amount of carbohydrate consumed is a strong predictor of the postprandial glycemic response, and monitoring the total grams of carbohydrate remains a key strategy in achieving glycemic control [14]. The proficiency in carbohydrate counting allows an increased flexibility in meal planning and thus dietary freedom; this is an important consideration for the quality of life in diabetic patients [11]. In children, a study has reported that flexible insulin therapy with glargine insulin based on carbohydrate counting resulted in improved glycemic control and reduced hypoglycemia among preschool-aged children with type 1 diabetes [15]. Label reading skills are important in both carbohydrate counting and recognition of foods that are heart-healthy [16].

To enable consumers make healthy decisions based on the information presented on nutrition labels, they must be able to read and understand labels [16]. Persons with diabetes report usually reading food labels [16]. In a study by Miller [17], women with type 2 diabetes who were 65 years of age scored an average of 49% on a food label knowledge test.

Regarding diabetes education, this study reported that 57.9% of patients said that they had the basic diabetes education. Another study reported that 24.2% of patients had received diabetes education [18].


Conclusion

The use of carbohydrate counting on a regular basis was found in only 18% of diabetic patients attending the diabetic center, KFMC, Riyadh, Saudi Arabia. This study recommends that health policymakers must conduct more effective health education sessions to increase the knowledge of diabetic patients and their caregivers about HHCQ to assess the carbohydrate counting skills, knowledge of heart-healthy food, and nutrition label reading skills


List of Abbreviations

DM Diabetes mellitus
KFMC King Fahad Medical City
NLB Nutri-Learn buffet

Conflict of interest

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


Funding

None.


Consent for publication

An informed consent was obtained from all the participants.


Author details

Basmah Abdullah Alanazi1, Mashael Jaza Alshammari1, Fahad Ahmed Alhawas2, Isamme AlFayyad3, Abdulrahman AlMaghamsi4, Ali Khalaf Alrowaidan2, Sultan Mohammed Alabrah2, Hadeel Mahmoud Alomrani5, Bayan Ali Alatawi5

  1. Resident, Internal Medicine, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
  2. Resident, Internal Medicine, Faculty of Medicine, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
  3. Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
  4. Endocrine Consultant, Obesity, Endocrine, and Metabolic Center, King Fahad Medical City, Riyadh, Saudi Arabia
  5. Intern, Faculty of Medicine, Tabuk University, Tabuk, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alanazi BA, Alshammari MJ, Alhawas FA, AlFayyad I, AlMaghamsi A, Alrowaidan AK, Alabrah SM, Alomrani HM, Alatawi BA. Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. IJMDC. 2020; 4(2): 461-468. doi:10.24911/IJMDC.51-1577364150


Web Style

Alanazi BA, Alshammari MJ, Alhawas FA, AlFayyad I, AlMaghamsi A, Alrowaidan AK, Alabrah SM, Alomrani HM, Alatawi BA. Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. https://www.ijmdc.com/?mno=79481 [Access: January 28, 2022]. doi:10.24911/IJMDC.51-1577364150


AMA (American Medical Association) Style

Alanazi BA, Alshammari MJ, Alhawas FA, AlFayyad I, AlMaghamsi A, Alrowaidan AK, Alabrah SM, Alomrani HM, Alatawi BA. Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. IJMDC. 2020; 4(2): 461-468. doi:10.24911/IJMDC.51-1577364150



Vancouver/ICMJE Style

Alanazi BA, Alshammari MJ, Alhawas FA, AlFayyad I, AlMaghamsi A, Alrowaidan AK, Alabrah SM, Alomrani HM, Alatawi BA. Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. IJMDC. (2020), [cited January 28, 2022]; 4(2): 461-468. doi:10.24911/IJMDC.51-1577364150



Harvard Style

Alanazi, B. A., Alshammari, . M. J., Alhawas, . F. A., AlFayyad, . I., AlMaghamsi, . A., Alrowaidan, . A. K., Alabrah, . S. M., Alomrani, . H. M. & Alatawi, . B. A. (2020) Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. IJMDC, 4 (2), 461-468. doi:10.24911/IJMDC.51-1577364150



Turabian Style

Alanazi, Basmah Abdullah, Mashael Jaza Alshammari, Fahad Ahmed Alhawas, Isamme AlFayyad, Abdulrahman AlMaghamsi, Ali Khalaf Alrowaidan, Sultan Mohammed Alabrah, Hadeel Mahmoud Alomrani, and Bayan Ali Alatawi. 2020. Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. International Journal of Medicine in Developing Countries, 4 (2), 461-468. doi:10.24911/IJMDC.51-1577364150



Chicago Style

Alanazi, Basmah Abdullah, Mashael Jaza Alshammari, Fahad Ahmed Alhawas, Isamme AlFayyad, Abdulrahman AlMaghamsi, Ali Khalaf Alrowaidan, Sultan Mohammed Alabrah, Hadeel Mahmoud Alomrani, and Bayan Ali Alatawi. "Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes." International Journal of Medicine in Developing Countries 4 (2020), 461-468. doi:10.24911/IJMDC.51-1577364150



MLA (The Modern Language Association) Style

Alanazi, Basmah Abdullah, Mashael Jaza Alshammari, Fahad Ahmed Alhawas, Isamme AlFayyad, Abdulrahman AlMaghamsi, Ali Khalaf Alrowaidan, Sultan Mohammed Alabrah, Hadeel Mahmoud Alomrani, and Bayan Ali Alatawi. "Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes." International Journal of Medicine in Developing Countries 4.2 (2020), 461-468. Print. doi:10.24911/IJMDC.51-1577364150



APA (American Psychological Association) Style

Alanazi, B. A., Alshammari, . M. J., Alhawas, . F. A., AlFayyad, . I., AlMaghamsi, . A., Alrowaidan, . A. K., Alabrah, . S. M., Alomrani, . H. M. & Alatawi, . B. A. (2020) Reliability and validity of an Arabic version of a questionnaire to assess carbohydrate counting skills, knowledge of heart-healthy foods, and nutrition label-reading skills in adults with diabetes. International Journal of Medicine in Developing Countries, 4 (2), 461-468. doi:10.24911/IJMDC.51-1577364150