Adherence to dietary recommendation and associated factors among diabetic patients in Ethiopian teaching hospitals

Introduction Dietary management is considered to be one of the cornerstones of diabetes care. Improvement of dietary practice alone can reduce glycosylated hemoglobin (HbA1c) by an absolute 1 to 2% with the greatest impact at the initial stages of diabetes. Methods Data from Hospital based cross sectional study were used to assess the level of dietary adherence and its determinants among diabetic patients. The morisky 8 item medication adherence scale was used to develop 10 item tool for evaluation of dietary adherence. Multiple logistic regression was conducted to identify factors which affect dietary adherence and variables with P vale < 0.05 were considered statistically significant. Results More than half of 303 participants (55.7%) were found to be non-adherent to the recommended dietary approach. Gathering with family and friends and eating out were the major reasons for not being compliant with the recommended regimen. Attending diabetic nutrition education (AOR=2.8 95% C 1.97, 5.61) and having the disease for more than 10 years (AOR 2.9 95% CI 1.32, 5.84) were statistically significant with adherence to dietary recommendation. Conclusion Non-adherence to recommended dietary practice was observed in more than fifty percent of patients; it is therefore a major public health problem. Attending diabetic nutrition education and length of diabetes greater than 10 years were the factors associated with adherence to dietary recommendation. This findings indicate that it is important to design strategies to help patients understand their dietary regimens and improve their adherence.


Introduction
Diabetes is one of the most rapidly increasing noncommunicable diseases and an important public health problem all over the world [1]. The global burden of diabetes is rising dramatically worldwide and an estimated 422 million adults are currently living with diabetes mellitus [2,3]. As such, a previous estimate that the diabetes prevalence would increase from 171 to 276 million between 2000 and 2030 has already been exceeded. A more recent estimate suggests that the prevalence will reach 642 million people in 2040 [4]. Diabetes is unevenly distributed with over 70% of people with diabetes reside in low-and middle-income countries particularly sub-Saharan Africa, a region already heavily burdened by communicable disease [5]. Similarly diabetes has been a major public health concern in Ethiopia as the number of deaths attributed to diabetes reached over 21,000 in 2007 and this estimate has increased to about 25,000 and 34262 in 2011 and 2013 respectively [6,7].
Management of the disorder creates a great physical, psychological and socioeconomic burden on families and society, thus, prevention with diet and lifestyle modifications should be prioritized [8]. Glycemic control is achieved by undertaking and sustaining a complex array of self-care behaviors, including four main domains: taking medications, sustaining appropriate dietary practice, engaging in regular exercise and self-monitoring of blood glucose levels [9,10]. Of the preferred life style modifications for diabetes management, dietary modification is considered to be one of the cornerstones of diabetes care.
Appropriate dietary practices emphasizes the intake of less fat, more fiber, less sodium and more foods that have health-promoting properties such as fish, soy products, fruits and vegetable [11,12]. Improvement of dietary practice alone can reduce glycosylated hemoglobin (HbA1c) by an absolute 1 to 2% with the greatest impact at the initial stages of diabetes; and its effects are apparent after 6 to 12 weeks of initiation [13]. Various studies have been conducted to assess adherence to an appropriate dietary regimen as part of diabetes self-management. Unfortunately, most of these studies indicate a low level of adherence to the recommended dietary regimen [14]. For example, a study in India showed that dietary prescriptions were followed regularly only by 37% of patients [15].
Similarly, studies conducted in Jimma and Addis Ababa, Ethiopia has also revealed that the level of diabetic self-care practice was insufficient among study participants [16,17]. In Ethiopia, the paucity of health information and standard guideline related to diet has been posing crises on long-term glycemic control in diabetes patients. At the same time, care givers often give less attention to describe dietary recommendation and their appropriate preparation. Therefore, this study assesses the level of adherence to the recommended dietary practices and its associated factors among diabetic patients in selected Ethiopian Teaching Hospitals located in-Addis Ababa, Ethiopia. Study design and population: data for this analysis are from a Hospital based cross sectional study. These date are used to assess the rate of adherence to dietary recommendations and its predictors among diabetic patients. All registered Diabetic patients who have been attending a diabetic clinic for follow-up were included with the exception of patients who are under age 18, pregnant, or critically ill and patients whose diagnosis occurred less than 6 months prior.

Methods
Sample size and sampling procedure: the sample size (326) was calculated using a single population proportion formula; given the prevalence diabetic treatment adherence was 67% [18], Confidence Interval of 95%, 5% Marginal error and 10% non-respondent rate.
Systematic random sampling with kth value of 4 was used to select the study subjects.
Data collection and quality control: data were collected using a structured questionnaire administered via face to face interview.

Results
Socio-demographic characteristics: a total of 303 patients agreed to participate in the study, reflecting a response rate of 93%.
Health-related characteristics: more than two-thirds (71.3%) of study participants were diagnosed with type 2 diabetes mellitus. The mean number of years since diagnosis was 5.09 (SD = 4.18) years, ranging from less than five years (58.8%) to more than ten years (11.5%). In 27.4% of patients, some other comorbid disease was identified from their medical record. About two in ten (22.8%) patients were found be obese. The majority of patients (62.3%) stated that they have received a well-organized diabetes nutritional education ( Table 2). among patients whose diagnosis was received more than ten years ago (Table 5).

Discussion
This hospital-based cross-sectional study measured the proportion of adherence to dietary practice among diabetes patients. Findings indicate that more than half of participants were not adhering to the recommended dietary practices. Adherence to recommended dietary practices for diabetic patients is very critical to achieve optimal metabolic control, as non-adherence is associated with higher glucose level and cholesterol levels, which eventually lead to major complications [19]. It is widely accepted that diabetes and its complications pose a major burden worldwide and present significant challenges to patients, health care systems and national economies [20].  [29][30][31][32][33][34]. The possible explanation is that patients with longer duration of diabetes will have more frequent contacts with health professionals and are more likely to be given repetitive instruction on treatment adherence, thus, become aware of the acute and chronic complications of uncontrolled blood glucose that eventually leads to adoption of healthy behaviors'.
Limitations: despite extensive efforts have been made to minimize possible shortcoming of this study, the finding of this survey will be interpreted in the presence of the following inevitable limitations. The cross-sectional nature of this study makes it unreliable to form a causal relationship between the exposure and the outcome variable.
Response biases, mainly the intention of the participants not to respond the actual adherence questions is likely (social desirability bias).

Conclusion
The prevalence of non-adherence to dietary practice was observed in more than fifty percent of patients, which indicates a major public health problem. Attending diabetic nutrition education and being diagnosed more than 10 years ago were associated with greater adherence to dietary recommendation. All stakeholders including  There was a statistically significant association between duration of diabetes and adherence to dietary regimen.

Competing interests
The authors declare no competing interests.

Authors' contributions
Mohammed Akibu Mohammed and Nigussie Tadesse Sharew conceived and designed the study, supervised the data collection, performed analysis and organized the manuscript. All authors read and approved the final manuscript.

Acknowledgments
Authors would like to express their heartfelt gratitude to Stephanie Grutzmacher, (PHD, Assistant professor) for her amazing contribution on the edition of this manuscript. The authors would also like to express their appreciation to the University of Debre Berhan for the approval of ethical clearance. They also want to show their appreciation to the individuals who participated in this study.