Dietary Knowledge Among Female Diabetic Patients in Amman , Jordan

The aim of this study was to assess dietary knowledge among females with diabetes in Amman, Jordan. We performed a cross-sectional study of diabetic patients attending outpatient diabetes clinics, at several hospitals in Amman . A questionnaires and 24-hour dietary recall were completed by the participants. The study used a face to face interview during which a questionnaire was filled by the investigator about knowledge and attitudes of diabetic patients. The study sample was composed of 180 females. Most of the patients have diabetes for more than two years (78.3%) and had a positive family history of diabetes as a first degree relative. About 50% suffered from diabetes related health disease and about half of the patients were overweight and 32.2% were obese. More than half of patients (56.1%) gave wrong answers for meals recommended for diabetes/day and that should be used with hypoglycemia (44.5%), food rich in protein (47.6%), number of snacks (50.6%) and their role (43.1%), drinks permitted with unlimited amounts (61.4%) and suitable time to drink juice (78.1%). Most of the patients gave correct answers for food rich in fats (48.4%), cholesterol (47.8%), and controlling blood sugar (51.7%), right and number of snacks recommended (68.7%) and food which raises blood sugar (49.1%). According to the results, the dietary knowledge of diabetic patients is inadequate and need improvement. The study recommends that there is a need to set up a health education programme on diabetes mellitus which would also include a self-monitoring programme.

Diabetes mellitus (DM) is a major health problem worldwide, that requires continuing medical care and ongoing patient self-management, education and support 1 .According to WHO , the global average prevalence is around 10% 2 .However the Arab countries have a higher prevalence of diabetes than the global average.Based on a study in 2010, in Jordan the prevalence of type 2 DM was 17.1% 3 .The prevalence rates of DM in the United Arab Emirates, Bahrain, Saudi Arabia and Kuwait were 20.1%, 20.1%, 30%, and 14.8% respectively 4,5 .
Suitable dietary practices are basic and integral part treating DM and may reduce the development of disease complications 6 .In Jordan, around 45% of 195 diabetic patients previously diagnosed, had unsatisfactory glycemic control 3 .It is documented that poorly controlled diabetes leads to serious complication [7][8][9][10][11] .
It was documented that diet control can improve glycemic control [12][13][14][15] .Adherence of diabetic patients to diabetic medications, to dietary advice and to physical exercise has been found to have a large effect on the degree of diabetic control 3,16,17 .The aim of this study was to assess dietary knowledge among female diabetic patients in Amman, Jordan.

METhODS
A convenience sampling technique was used to approach adult patients with DM , attending outpatient clinics from different hospitals in Amman, Jordan.One hundred and eighty diagnosed female diabetics were randomly selected with the help of the chief dietician at each hospital.Dietary knowledge was assessed by 14 multiple choice questions including food that raises and control blood sugar, food sources of nutrients, meals and snacks recommended.The response to each dietary knowledge question was scored from 0-2.With 2 for correct answer, 1 for incorrect and incomplete answer and 0 for wrong and don't answer.Total dietary score was ranged from 0 -28 and was leveled as good when score is 20-28, fair 10-19 and poor 0-9.Perceived benefits items were measured as questions formatted as 3 points likert scale with 3 for high perceived benefit.Total perceived benefits score was 12 -36, which leveled into: 30 -36 high perceived benefit, 21 -29 moderate perceived benefit and 12-20 low perceived benefits.Patients' files were reviewed to collect data on weight and height.The 24 hour recall was used to evaluate the food consumption pattern.The evaluation of the daily food intake was made by using ESHA Food Processor 18 , as well as Food Composition Tables for use in the Middle East 19 and Food Composition Tables for Kingdom of Bahrain 20 . .

Statistical Methods
Data analysis was carried out by using the SPSS software package version 16.Absolute and relative frequencies and means were used as descriptive statistics.Multiple regression was used to identify the variables related to knowledge.The internal consistency of the questionnaire was checked by Cronbach's alpha and it was considered good (0.87 for total knowledge ).

rESulTS
The study sample was composed of 180 females.As shown in Table (1), the majority of the patients were married (82.7%) in the age group 41-50 years (49.2%) and were housewives (62.9%).The patients were uniformly distributed across different education levels and the majority with monthly family income between 300 and less than 800 Jordanian Dinar (JD) (1 US$ = 0.71 JD).Most of the patients have diabetes for more than two years (78.3%) and had a positive family history of diabetes as a first degree relative.About 50% suffered from diabetes related health disease and about half of the patients were overweight and about 32% were obese.Table (2) shows dietary knowledge of diabetic patients.More than half of patients gave wrong answers for meals recommended for diabetes/day (56.1%) and that should be used with hypoglycemia (44.5%), food rich in protein (47.6%), number of snacks (50.6%) and their role (43.1%), drinks permitted with unlimited amounts (61.4%) and suitable time to drink juice (78.1%).Most of the patients gave correct answers for food rich in fats (48.4%), cholesterol (47.8%), and controlling blood sugar (51.7%), right and number of snacks recommended(68.7%)and food which raises blood sugar (49.1%).
Table 3 shows the perceived benefits of diabetic patients.Most of the patients perceived benefits of adherence of dieting regime (93.5%), regulating time and quantities of meals(65%), exercising (97.2%) and maintain or reducing weight (96.2%).A considerable percentage believed they should avoid starches food (51.3%) and honey will not affect blood sugar (57.4%).The benefit of herbal and traditional description in the management of diabetes is strong (48.9%).The assessment of daily nutrient intake of diabetic patients (Table 4) showed that the mean total energy intake was 1781.2 ± 671kcal, the percentage of total calories from carbohydrate 56%, protein 14% and fat 30%.The mean dietary fiber intake was 24.3 ± 10.4 (gm).The percentage of total calories from carbohydrate was more than the American Diabetic Association guidelines (ADA 2007), (48 % of energy) , while the percentage of total calories from protein and fat was within the ADA recommendations ( 10-20% and < 35 % of energy, respectively ).
The result of the multiple regression analysis (

DISCuSSION
In the past years many countries, have been experiencing a nutritional transition in food choices from the typical Mediterranean diet to the fast food pattern 21 .The rapid change in physical activity and food habits has led to the coexistence of many nutritional problems that underlies many chronic diseases.As populations become more urbanized, and as lifestyles shift towards reduced physical activity and increased food consumption, the prevalence of obesity is expected to rise.
We found in this study (Table 2) that more than half of patients gave wrong answers for meals recommended for diabetes/day (56.1%) and that should be used with hypoglycemia (44.5%), food rich in protein (47.6%), number of snacks (50.6%) and their role (43.1%), drinks permitted with unlimited amounts (61.4%) and suitable time to drink juice (78.1%).This is comparable to the results of a study conducted in Saudi Arabia by Z. Saadia, et al. 22 who reported 90% of patients answered 50% of the knowledge questions correctly Still a large proportion of population that is almost 40.3% were not able to score above 10.In another study , it was reported that only 40% of diabetic patients had good compliance with their diet 23 .Improving the Knowledge of the diabetics in our society will not be an easy task.Great efforts would be needed by health teams to enhance education of the diabetic patient in order to promote compliance.
It is reported that patients had low level of knowledge in Iran 24 , United Arab Emirates 25 , Kuwait 26 and in Nigeria 27 .On the other hand, a good level of knowledge was found among patients in Pakistan 28 , Malaysia 29 and in Qatar 30 .It was found that a good level of knowledge regarding DM, affect patients' adherence to pharmacological therapy 31,32 ,self-care activities 33 and good glycemic control 11,34,35 .
Diet which contains high fat may cause a problem for people with diabetes 36 .The more fat there is in the diet, the more difficult it is going to be for insulin to get the glucose into the cells 36 .Our results showed that the mean dietary fiber intake  4) .Dietary fiber helps to slow the release of sugar into the bloodstream, thus helping to keep the blood sugar levels normal 36 .
Diet is an important part in the treatment of a diabetic patient.Following a healthy lifestyle , managing the weight and eating a balanced diet, will improve the patient's health enormously.

CONCluSION
The dietary knowledge of diabetic patients among female Jordanians is inadequate and need improvement.Education and counseling about all the aspects of diabetes are needed.Studies with wider scope and much large sample size are recommended to confirm findings and explore relevant features .