EAL

MNT: Disorders of Lipid Metabolism (2015)

Citation:

Patel M, Patel IM, Patel YM, Rathi, SK. Factors associated with consumption of diabetic diet among type 2 diabetic subjects from Ahmedabad, Western India. Journal of Health, Population and Nutrition, 2012; 30 (4): 447-455.

PubMed ID: 23304911

Study Design:

Cross-Sectional Study

Class:

D - Click here for explanation of classification scheme.

Quality Rating:

POSITIVE: See Quality Criteria Checklist below.

Research Purpose:

The present study aimed at providing the profile of the factors associated with consumption of diabetic diet among type 2 diabetes mellitus (T2DM) subjects from western India as an impetus for further exploration of the socio-cultural and subject-related factors affecting the outcomes of T2DM care that, in turn, will lead to redefine the diabetes control and prevention strategies in this region.

Inclusion Criteria:

At least 40 years of age
Diagnosis of T2DM for at least one year before enrollment for the study
Attendance at the Department of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre during the study period
Informed consent provided.

Exclusion Criteria:

Less than 40 years of age
No T2DM diagnosis or diagnosis less than one year before study enrollment
No attendance at Department of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre during study period.

Description of Study Protocol:

Recruitment

Recruited from the Department of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre.

Design

After recruitment of subjects based on selection criteria, subjects completed an interview-administered questionnaire
A detailed history including data on age, sex, education, occupation, smoking status, alcohol consumption, diabetic diet, method of cooking and source of advice regarding diet were recorded on a close-ended proforma
Diabetic diet was defined as a dietary adjustment for patients with DM intended to decrease need for insulin or oral hypoglycemic agents to avoid wide fluctuations in plasma glucose levels and to control weight by adjusting caloric and carbohydrate intake
Diabetic diet was evaluated by last three days' dietary recall including timings, quantity of each meal and snack, frequency of extra meal and food consumed from outside home and the calculated average calorie consumed per day
All subjects were interviewed regarding history of hypertension and a general physical examination was performed.

Blinding Used

None.

Intervention

None: Aim was to provide a profile of factors associated with the consumption of a diabetic diet among T2DM subjects.

Statistical Analysis

Sample size of 405 subjects was obtained using parameter estimation method with 5% precision around the point estimate with 95% confidence interval (CI)
Calculated minimum sample size was inflated by 5% to account for anticipated non response from subjects
Means, standard deviations and percentages were used for descriptive analysis
Student's T-test used for testing significance of differences between mean values of two continuous variables
Univariate logistic regression analysis was conducted by comparing the outcome variable with each independent variable of interest using odds ratio or their 95% CI
Likelihood ratio test was used in estimating odds ratio and 95% CI for all associations of interest
Multivariate logistic regression analysis was performed
Logistic regression model was used because the dependent variable was dichotomous
Wald statistic was used to assess the importance of each variable included in the model
Adjusted odds ratio and 95% CI were computed using the estimates of parameters of final model
P<0.05 was considered significant.

Data Collection Summary:

Timing of Measurements

All measurements completed once.

Dependent Variables

Consumption of diabetic diet.

Key Variables

Age
Gender
Height
Weight
Level of education
Duration of diabetes since diagnosis
BMI
History of hypertension
Family history
Self-testing of blood sugars
Smoking status
Alcohol use
Dietary practices regarding diabetic diet
Source of diabetic diet information
Plasma glucose level
Hemoglobin A1C
Fasting lipid levels
Blood pressure
Cooking methods.

Description of Actual Data Sample:

Initial N: 399 subjects (65% males, 35% female)
Attrition (final N): 399 subjects (65% male, 35% female)
Age: 53.16±7.95 years
Ethnicity: Indian.

Other Relevant Demographics

96% of subjects were literate
91% of subjects followed Hinduism religion; 4% followed Islam religion; 5% followed Christian or other religion
96% of subjects had been married; 4% were never married
Education level
- No education: 4%
- Primary school: 21%
- Secondary school: 44%
- College level: 26%
- University level: 4%
- Professional degree: 1%.
Occupation
- Government service: 2%
- Professional: 3%
- Private service: 22%
- Business: 29%
- Household work or retired: 44%.

Anthropometrics

BMI; statistically significant difference between males and females (P<0.001)
- Underweight (less than 18.5kg/m²): 3%
- Normal (18.5kg/m² to 22.9kg/m²): 21%
- Overweight (23kg/m² to 24.9kg/m²): 24%
- Obese (at least 25 kg/m²): 52%
Mean weight: 69.04±10.5kg; statistically significant difference between males and females. P<0.001
Mean height: 164.51±9.75cm; statistically significant difference between males and females, P<0.001

Location

Ahmedabad district, Gujarat, India.

Summary of Results:

Key Findings

Risk and behavior profile
- 35% of subjects had good glycemic control (HgbA1C under 7%)
- Mean BMI was 25.57±4.05 kg/m²
- 198 out of 399 subjects had positive family history of hypertension and 300 out of the 399 subjects had a positive family history of diabetes
- 37% of subjects were performing self-testing for blood sugar
- 24% of subjects were smokers and 8% were consuming alcohol.
Dietary practices
- 73% of subjects consuming diabetic diets were recommended by family physicians or dietitians
- Doctors and family physicians were reported to be good source of dietary advice by 77% of study population
- 39% of subjects reported that they had visited a dietitian since their diagnosis of diabetes
- 2% of subjects reported counting calorie intake
- Main cooking methods was boiling and roasting (36%)
- Univariate analysis showed that visiting a dietitian (OR, 9.7; 95% CI, 4.898 to 19.465), secondary level of education (OR, 2.6; 95% CI, 1.611 to 4.128) and low intake of fat (OR, 2.6; 95% CI, 1.385 to 4.760) are significantly associated with consumption of diabetic diet among T2DM subjects
- In univariate analysis, not a single factor was significantly associated with glycemic status
- Final multivariate logistic regression model revealed that compared to the subjects not consuming diabetic diet, those who consumed a diabetic diet were more likely to visit dietitian (adjusted OR, 10.6; 95% CI, 5.124 to 21.816), consume low fat (adjusted OR, 2.2; 95% CI, 1.078 to 4.291), had higher level of education (adjusted OR, 3.5; 95% CI, 2.02 to 5.948) and have positive family history of diabetes (adjusted OR, 1.8; 95% CI, 0.996 to 3.094).

Univariate Logistic Analysis of the Factors Among Hospital-Based T2DM Subjects

Variables	Number of Subjects Consuming Diabetic Diet	Number of Subjects Not Consuming Diabetic Diet	Odds Ratio	95% CI	P-Value
Visit to Dietitian	144	10	9.7	4.898-19.465	<0.001
No Visit to Dietitian	146	99	1
No Education	6	8	0.48	0.158-1.479	0.203
Up to Secondary Education	208	52	2.58	1.611-4.128	<0.001
Above Secondary Education	76	49	1	-
Occupation: Housewifery/Retired	133	43	1.32	0.771-2.260	0.312
Occupation: Business	82	34	1.03	0.579-1.829	0.922
Occupation: Service	75	32	1	-
Positive Family History of DM	224	76	1.47	0.901-2.411	0.123
Negative Family History of DM	66	33	1	-
Consuming Low-Fat/Skim Milk	264	87	2.56	1.385-4.760	0.003
Not Consuming Low-Fat/Skim Milk	26	22	1	-
HgbA1C <7%	99	41	1	-
HgbA1C >7%	191	68	1.16	0.736-1.838	0.517

Multivariate Logistic Regression Analysis of Factors of Consuming Diabetic Diet Among Hospital-Based T2DM Subjects

Variable	Adjusted OR	95% CI	P-Value
Visit to Dietitian	10.6	5.124-21.816	<0.001
No Visit to Dietitian	1	-
No Education	0.7	0.215-2.453	0.606
Up to Secondary Education	3.5	2.02-5.948	<0.001
Above Secondary Education	1	-
Positive Family History of DM	1.8	0.996-3.094	0.051
Negative Family History of DM	1	-
Consuming Low-Fat/Skim Milk	2.2	1.078-4.291	0.03
Not Consuming Low-Fat/Skim Milk	1	-

Author Conclusion:

The study revealed that majority (73%) of the subjects were consuming diabetic diet
The study also showed that visit to dietitians, level of education, consumption of low-fat or skim milk and presence of family history of diabetes were the main factors associated with consumption of diabetic diet
Visits with a dietitian must be emphasized
Self-monitoring of blood sugar is done by few subjects (37%).

Funding Source:

Not-for-profit

All India Institute of Diabetes and Research

Reviewer Comments:

The authors mention lipid profile in the abstract
Abnormal lipids were reported at baseline, however no pre-post test changes were reported in those consuming or not consuming a diabetic diet or following guidance by a RD.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		N/A
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	Yes
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	Yes
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	N/A
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	No
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes