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Factors Influencing Adherence to Dietary Recommendations for the control of Diabetes Type ll
Geoffrey T Gibney, Medical Student, University of Connecticut School of Medicine
Assessment of knowledge about benefits of Exercise for the control of Diabetes Type ll
Christine Trapp, Medical Student, University of Connecticut School of Medicine
Grecia, Costa Rica, 2002
Background
Diabetes mellitus is a major cause of morbidity and mortality with 120 to 140 million people currently affected worldwide In the United States, diabetes has a prevalence rate of 4 and is the seventh leading cause of death Higher prevalence rates are observed in Latin America 8 in Costa Rica and Hispanic American populations in the US Over 90 of diabetics have type 2 diabetes Type 2 diabetes can largely be controlled through diet and exercise therapy However, diabetic morbidity and mortality remains high due to poor adherence Therefore, the aim of this investigation was to identify factors that influence exercise and dietary adherence
Setting
Grecia, Costa Rica an at risk population identified by IHCAI International Health Central
American Institute, a non-profit organization in Costa Rica IHCAI began an intervention program in the cantons of San Roque, Santa Gertrudis and Rincon de Salas, specifically designed to reduce cardiovascular complications associated with diabetes The intervention began in 2001, and consisted of weekly nutrition classes held at the local clinics 6 weeks and the establishment of walking groups Our work sought to evaluate the success of this program and to address barriers to exercise and diet adherence for future improvements to the program
Model
Social Economic Factors Knowledge Present Health Status
Family Characteristics
Food Consumption Factors
Adherence with Diabetic Exercise Recommendations
Participant Characteristics
Utilization of Health Care Services
Adherence with Diabetic Dietary Recommendations
Hypotheses
Dietary Adherence
1 Increased utilization of health care services yields greater adherence 2 Increased family support yields greater adherence 3 Greater outcome expectancy yields greater adherence 4 Greater knowledge of diabetes yields greater adherence 5 Greater self-confidence yields greater adherence
Exercise Adherence
1 Greater knowledge about benefits
of exercise yields greater adherence 2 Increased family support yields greater adherence 3 Poor health yields less adherence 4 Increased utilization of health care services yields greater adherence 5 Greater knowledge of diabetes yields greater adherence
Methods: General
Interviews with IHCAI staff about the intervention and the structure of the health care system in Costa Rica Interviews conducted with staff members at clinics in San Roque and Santa Gertrudis to gain understanding of the patient populations and challenges faced by diabetics Focus group with residents of Grecia to learn about local attitudes towards diet, exercise, and health care Assessment of local food availability in each canton Structured interviews with diabetics who participated in the intervention
Methods: Survey
92-item survey instrument constructed health status, dietary adherence to the recommendations given during the nutrition classes, adherence to an exercise regimen, socioeconomic status, as well as measures of social support, self-confidence, and barriers to adherence Survey translated into Spanish and back-translated for accuracy 24-item diabetic knowledge questionnaire utilized 1 hour
interviews conducted in Spanish at participants homes
Methods: Analysis
Data was coded and entered into Excel and subsequently analyzed in SPSS, using frequency tabulation, chi-squared tests, one-way ANOVA and Pearsons Correlations Statistical significance was reported at a p value of 05 Dietary adherence was calculated from the sum of responses for 12 questions 7 points each - days/wk recommendation followed The sum was converted to a percentage of total possible points 0-100, yielding the Dietary Adherence Score DAS High dietary adherence was considered to be a DAS of 65 or greater Exercise adherence was calculated as the number of days/wk a participant exercised High adherence considered to be 3 days/wk or more
Results: Demographics
48 participants interviewed; 45 questionnaires completed Area breakdown of participants: Ricon de Salas 23 from San Roque 13 from Santa Gertrudis San Roque 9 from Rincon de Salas Santa Gertrudis Average age 58 yrs Range 37 71 yrs 39 females/6 males Average time since diagnosis of diabetes 6 yrs Average education level 6th grade
Results: Demographics
37 participants taking diabetic medications 10 requiring insulin 14 participants
reported complications as a result of their diabetes 756 of participants utilized the loca 
l EBAIS only for health care needs; others utilized both their local EBAIS and area hospitals 16 subjects participated in walking group sessions 43 subjects participated in dietary classes Mean diabetic knowledge score 67 11
Results: Exercise
Adherence to an exercise program was not related to area, educational level, or number of years since diagnosis Knowledge and diet class attendance was unrelated to exercise adherence or physical activity levels Positive Correlations found between: 1 Exercise adherence and family support/encouragement R 0299, p0046 2 Exercise adherence and personal belief in the importance of exercise as a measure of diabetic control R 0521, p00001
Results: Exercise
Significant Relationships found between: 1 Exercise adherence and participation in walking group sessions x212740, p00001 2 Exercise adherence and availability of a walking companion x2 9054, p0003 3 Exercise adherence and difficulty walking, due to physical limitations x2 22922, p00001
Results: Diet
Dietary class attendance resulted in higher DAS ANOVA, F338 p0027 Greater self-confidence
correlated to higher DAS PC, R0347, p0021
80
80
70
70
60
Dietary Adherence Score
50
Dietary Adherence Score
No Y es Some Classes Private Instruction
60
40
30
50 Strongly Agree Agree Disagree
Dietary class attendance
Confidence in ones ability to follow dietary recommendations
Results: Diet
Diabetes knowledge had a positive association with DAS PC, R0313, p0039 Strong distaste for recommended foods correlated to low DAS PC, R0347, p002 Individuals who received family help or included themselves as a significant dietary support had higher DAS ANOVA, F270 p0035 No correlation between dietary adherence and type of health care utilization, duration of diabetic status, ease of following recommendations, or social economic factors
Discussion: Diet
Factors that are associated with adherence in Latin American populations include nutrition programs, diabetes knowledge, self-efficacy, family support, and desirability of food recommendations Higher dietary adherence could be achieved by expanding nutrition programs to include information about diabetes, structured family participation, better access to recommended foods, classroom exercises to improve selfconfidence, and
more satisfying and enjoyable recipes/food recommendations By addressing these factors, therapeutic programs may be able to largely improve adherence levels in Costa Rica as well as more generalized populations including Hispanic Americans in the US
Discussion: Exercise
Interventions must be tailored to accommodate those who work during the day or have difficulty leaving the home Greater focus must be placed on health status and the ability of individuals to physically participate in exercise programs Suitable exercises must be made available to those individuals with physical limitations Greater emphasis should be placed on family involvement in the management and care of a loved one with diabetes
Discussion: Limitations
The greatest limitations of this investigation were the small sample available to study, disproportional representation of female subjects, and lack of representation of employed population The design of the IHCAI program contributed to these limitation due to the daytime scheduling of classes Also, baseline DAS, baseline exercise routines or control subjects were not used for comparison to determine if the programs directly improved adherence This leaves
to question whether it was the information and confidence gained in the program that was responsible for greater adherence or simply an individuals motivation that yielded greater adherence Further study of these complex issues is required
Sources
wwwwhoint/ncd/dia/indexhtm Chipkin, S, Klugh, S, and Chasan-Taber, L Exercise in Secondary Prevention and Cardiac Rehabilitation Cardiology Clinics August 2000; 19 3: 489-505 Garcia,A, et al The Starr County Diabetes Education Study: development of the Spanish-language diabetes knowledge questionnaire Diabetes Care 2001; 241: 16-21 Hamdy, O, Goodyear, L, and Horton, E Diet and Exercise in Type 2 Diabetes Mellitus Endocrinology and Metabolism Clinics December 2001; 30 4: 883907 Toobert DJ, Hampson SE, Glasgow RE, The Summary of Diabetes Self-Care Activities Measure, Diabetes Care 23: 943-950, 2000 Tristán, M et al A description of Investigación e intervención para el mejoramiento de la dieta y aumento del ejercicio físico para pacientes diabeticos Tipo 2 unpublished abstract, 2001
diagnostico y manejo de la diabetes mellitus tipo 2 con medicina basada en evidencia, 2000 URL: http://wwwaladorg/guiasalad/guiacap1html Diabetes,
from the World Health Organization home page:
Asociacion Latinoamericana de Diabetes ALAD, Guias ALAD 2000: Para el
Source:ihcai.org
