Non-adherence to diet and exercise recommendations amongst patients with type 2 diabetes mellitus attending Extension II Clinic in Botswana

Abstract Background Patients diagnosed with type 2 diabetes mellitus in Extension II Clinic in Botswana have difficulty in adhering to the lifestyle modifications recommended by health care practitioners. Poor adherence to lifestyle recommendations leads to poor control of the condition and consequently to complications. Objectives The aim of the study was to determine reasons for poor adherence to lifestyle recommendations amongst the patients. The objectives were to determine: reasons for poor adherence to dietary requirements, exercise recommendations, the support they had in adhering to the recommendations, and their understanding of the role of dietary and exercise requirements in the management of their condition. Method This was a cross-sectional descriptive study. The sample comprised of 105 participants. Data on participants’ baseline characteristics and adherence to dietary and exercise habits were analysed using the SPSS 14.0 version. Results The sample of 104 participants comprised of 61 (58.7%) women. The rates of non-adherence to diet and exercise were 37% and 52% respectively. The main reasons for non-adherence to diet were: poor self-discipline (63.4%); lack of information (33.3%) and the tendency to eat out (31.7%). The main reasons for non-adherence to exercise were: lack of information (65.7%); the perception that exercise exacerbated their illness (57.6%) and lack of an exercise partner (24.0%). Conclusion There was a relatively high rate of non-adherence to both diet and exercise recommendations by patients suffering from type 2 diabetes mellitus at Extension II Clinic, Botswana, with non-adherence to exercise recommendations more common.


Introduction
Several studies have shown the benefit of healthy dietary habits and regular exercise in the prevention and management of type 2 diabetes mellitus. 1,2,3,4 Adherence to prescribed lifestyle changes have also been shown to improve glucose levels, to lead to decreased blood pressure and to correct lipid abnormalities which are factors associated with the micro and macro-vascular complications of diabetes. 5,6 Therefore primary prevention based on strict adherence to healthy lifestyle habits must be advocated in health policies worldwide to control diabetes mellitus, particularly in developing countries like Botswana where access to and quality of health care is still under development. 7 Adherence has been defined as 'the extent to which a person's behaviour -taking medication, following a diet, and/or executing lifestyle changes -corresponds with agreed recommendations from a health care provider. 8 Though not perfect, the term 'adherence' is preferable to 'compliance', since the latter implies patient submission to the health care professional's orders without mutual negotiation. 9 Studies have been conducted worldwide and in Africa to establish factors associated with non-adherence to treatment amongst patients with type 2 diabetes mellitus. 10,11 Nevertheless, there is paucity of studies on compliance to lifestyle recommendations. Amongst factors identified as responsible for poor adherence to the treatment of diabetes mellitus is a poor relationship between the healthcare provider and patient. 12 Poor adherence to healthy lifestyle recommendations amongst type 2 diabetes mellitus patients has been found to be associated with the global urbanisation of communities (especially developing countries) with an increasing number of fast-food outlets serving unhealthy food. 13 In these patients, rates of non-adherence to diet and exercise recommendations were estimated to range from 35% -75% and 35% -81% respectively in studies conducted outside Africa. 14,15,16,17,18,19,20 Poor adherence to diet and exercise recommendations in people with type 2 diabetes mellitus is known to manifest itself through frequent hospitalisations leading to increased health care costs. 21,22 Some patients justify their non-adherence to dietary recommendations on the basis of criticism by others, lack of information, unwillingness, lack of support from spouse and/ or family, negative health beliefs and perceptions, previous experience with chronic disease and financial problems. 10,13,15 Other common reported barriers for non-adherence to exercise were lack of will-power, poor health, associated comorbidities, lack of an exercise partner, poor weather (hot and cold conditions) and a busy schedule. 4,10,15,16,17,23 The aim of the study was to determine reasons for poor adherence to lifestyle recommendations in patients with type 2 diabetes mellitus attending the clinic. The objectives were to determine reasons for poor adherence to dietary requirements, reasons for poor adherence to exercise recommendations, who supported them in order to adhere to recommendations, and their understanding of the role of dietary and exercise requirements in the management of their condition.

Significance of the study
To our knowledge, at the time of the study in 2008, there was a paucity of studies conducted to investigate non-adherence to lifestyle modification recommendations (diet and exercise) amongst type 2 diabetes mellitus patients in Africa and in Botswana in particular. It is hoped that the study will address this gap by establishing the reasons given by the patients for non-adherence to diet and exercise recommendations.

Method Setting
From 01 July 2008 to 30 September 2008 a simple descriptive, cross-sectional study was conducted to determine the reasons for non-adherence to diet and exercise recommendations given by health care practitioners to patients with type 2 diabetes at Extension II Clinic, a public health facility in Gaborone, Botswana. This study also elicited patients' understanding of the role of diet and exercise recommendations in the management of their condition.

Sampling
The target population were individuals of 30 years and above who had been diagnosed with type 2 diabetes mellitus more than two years previously and had been on treatment at the clinic during these years. This age group was targeted because, according to the clinic records, most of the type 2 diabetes mellitus patients were aged 30 years and above. 19 Individuals with type 1 diabetes mellitus, those aged less than 30 years and those who had been diagnosed less than two years before the study commenced were excluded from the study.

Design and procedure
The clinic for diabetic patients was on Wednesdays and Fridays. Patients seen per month ranged between 38 and 46, accounting for an average of 128 patients per month. Using a confidence level of 95% and 5% confidence interval, the sample size was calculated as 96 participants. For ease of calculation, the sample size was rounded off to 105, that is, 35 participants per month over three consecutive months.
Systematic sampling was done with every second patient seen at the diabetic clinic. A total of 105 participants were recruited, comprising of 44 men and 61 women. Informed written consent was obtained from each participant after the objectives of the study had been explained. None of the patients recruited declined to be part of the study. Anonymity and confidentiality of data were assured by non-inclusion of patient identifiers in the questionnaires. The research team was guided by a literature search in the formulation of the questions relevant for the study. 11,21 Each consenting patient was requested to fill in the structured questionnaire with the help of the research team members who were on hand to offer clarity where necessary. In our study, a respondent was regarded adherent to exercise if she or he reported exercising for a duration of ≥ 30 minutes per session, most days of the week. 24 We defined non-adherence to exercise as a self-reported default for more than three days per week. 25 Dietary recommendations comprised of a recommendation by a health care professional of a Dietary Approach to Stop Hypertension (DASH) diet comprising of whole grains and fibre (more than 5 portions), fruits and vegetables (at least 2 servings of each), lean meats, poultry and fish (at most 3 servings), low-fat milk and dairy products (at most 3 servings) and small amounts of fats, oils, refined sugars and salt. 26,27,28 We defined non-adherence to dietary recommendations as self-reported adherence of less than three days a week (seldom). 29 However, the researchers noted that the World Health Organization (WHO) Adherence Project indicates that regarding adherence measurement, 'no single measurement strategy has been deemed optimal. A multi-method approach that combines feasible self-reporting and reasonable objective measures is the current state-of-theart in measurement of adherence behaviour. 30 Data was collected from 01 July 2008 to 30 September 2008 using a questionnaire in English and Setswana (local language) and using the Microsoft Excel® software programme and subsequently exported to the SPSS 14.0 version for analysis.

Results
One hundred and five questionnaires were distributed to consenting participants; one had missing data on most sections and was discarded. A response rate of 100% was obtained.

Reasons for non-adherence to exercise recommendations
Fifty-two percent did not exercise regularly, because of a lack of information about the benefit of exercise and how it should

Prevalence of non-adherence to lifestyle recommendations
This study showed that more than one-third (37.2%) and nearly half (52.0%) of the participants did not adhere to diet and exercise recommendations respectively, but nonadherence to exercise was commoner than non-adherence to diet. We hypothesise that reasons for the difference in the rates might be related to differences in patients' understanding and perceptions of the role of diet and exercise in the control of diabetes mellitus. More than half (57.6%) of non-adherent patients thought that exercise would exacerbate their illness, one of the reasons being that they experienced body pains during and after exercising.
The rates of non-adherence to diet and exercise in this study compared well with those reported in previous studies. 17,18,19,20,21 However, non-adherence to diet and exercise from this study (37.4% and 52%, respectively) appeared to be slightly lower than those reported in other countries where similar studies were conducted (> 40% and > 55% for nonadherence to diet and exercise, respectively). 15,19,20,22,23 This may be ascribed to the smaller sample size used in this study compared to those studies that reported higher rates of non-adherence.

Reasons for non-adherence to both diet and exercise recommendations
Despite the fact that most participants understood that diet and exercise were important to achieve and maintain good glycaemic control, the majority still gave various reasons for their non-adherence to these recommendations. The most frequently reported reasons for non-adherence to dietary recommendations were poor self-discipline, lack of information, eating out (especially at fast-food outlets, social gatherings, and the homes of extended families and friends) and financial constraints.
On the other hand, the reasons given for non-adherence to exercise recommendations were lack of information on the benefits of exercise, the view that exercise worsened their condition, lack of an exercise partner, being away from home (e.g. at social gatherings, on official trips and at cattle posts), and extreme weather conditions (very cold winters and very hot summers). These findings are consistent with the observations noted in previous studies on nutrition and adherence to an exercise regimen conducted in the first world (USA) as well as in developing countries. The populations studied consisted of patients with type 2 diabetes mellitus who were discovered not to engage in recommended levels of physical activity and dietary guidelines for inter alia fruit and vegetable consumption. 15,20,23 Support from spouse or partner Support by family members Support by friends  Lack of emotional support from the spouse and friends was claimed to have contributed to non-adherence to diet and exercise recommendations. Other studies found that good support from spouse, family members and friends were good predictors to adherence to diet and exercise recommendations. 19,20,21,31 Our study demonstrated that, although there was a lack of support from friends and the spouse/partner of a patient with type 2 diabetes mellitus, there was reasonable support from other family members (55.2%). This finding is supported by the fact that there is strong family cohesion and support amongst traditional societies such as those found in Botswana. 21 Adherence to diet does require strong support from the patient's family, as meals are usually shared by all members in a family. In the study setting, this finding should be factored in during diabetes education.

Moral and emotional support
In this study, lack of information (including written instruction) from health care providers appeared to be the most frequently reported reason for non-adherence to diet and exercise recommendations. This barrier was more common in exercise non-adherence (65.7%); it was approximately double the finding for diet non-adherence (33.3%). This finding supports similar studies undertaken on the subject of lifestyle modification adherence. 20,31,33 It is the responsibility of the health care provider to provide adequate information on diet and exercise regimens to the patient as part of a holistic health care package. Patients with diabetes may not strictly adhere to lifestyle measures unless they are educated. Individualised lifestyle measures may be achieved through 'assessment of the patient's knowledge and needs, anticipation of the individual's future barriers' and identification of their support structures. 33 Our study demonstrated that eating away from home resulted in non-adherence to diet and exercise recommendations. This finding is consistent with cultural norms in the Republic of Botswana, where an individual has more than one home, such as a city home, a village home and a home at the cattle post. The individual's dietary and exercise habits differ in each location. Therefore it is important to assess and address the influence of alternative homes on adherence to diet and exercise regimens during diabetic education. A similar observation was made in a study that demonstrated that another person's home (14%) and specific locations away from home (20%) were associated with non-adherence to diet and exercise recommendations. 20

Patients' understanding of lifestyle modification recommendations
This study established that most of the participants' understanding of diet and exercise had a direct influence on their adherence to diet and exercise recommendations. One in two respondents had a general understanding that diet and exercise were important lifestyle measures by which to improve their diabetic control. This finding was consistent with studies done elsewhere that reported that individuals with type 2 diabetes felt that diet and exercise could have a positive effect on their glycaemic control. 15,23 In our study, one explanation for this understanding may be that most participants had a relatively high level of formal education (83.6%). Understanding cannot be equated to patient practice, however, a study in Uganda also found no significant association between the level of education and the management of diabetes mellitus. 11 This finding on patient understanding should be seen as an advantage by a health care provider and factored in when planning diet and exercise regimens for diabetes education amongst patients. Patient education on medication, diet and exercise were shown to significantly improve glycaemic control and health-related quality of life in a clinical trial conducted over a twelve-month period amongst type 2 diabetes patients attending a military hospital outpatient clinic in the United Arab Emirates. 34

Strengths and limitations of the study
This study investigated a subject not previously explored where there was a paucity of data. It reported reasons given by patients with type 2 diabetes mellitus in Gaborone, Botswana, for non-adherence to lifestyle modifications (diet and exercise). The study was conducted in a primary care setting, which makes it more relevant to the primary care practitioner. The study did not elicit whether there was prior instruction to the patients with type 2 diabetes mellitus on exercise and diet recommendations. It was based on the assumption that such instruction is given to patients during diabetes education. There was a limitation in the sampling method as the researchers excluded patients diagnosed less than two years before the study was conducted. The use of a structured questionnaire also limited the responses to the questions posed, as it excluded other possible reasons for non-adherence to lifestyle recommendations. The sample size was time-bound (over three months) due to financial constraints. The setting was limited to only one primary care centre out of 15 primary care centres in Gaborone, which may affect generalisability. A nationwide study covering all or most of the 15 primary care centres in Gaborone should shed more light in the subject.

Recommendations
There is a need for patient education and health promotion to address the lack of information on a healthy diet as well as the lack of information on the benefits of exercise and how exercise should be undertaken. There is also a need to investigate and address the notion by patients that exercise exacerbates diabetes mellitus.

Conclusion
There was a high rate of non-adherence to diet and exercise recommendations by patients suffering from type 2 diabetes mellitus seen at Extension II Clinic, Gaborone, Botswana. Non-adherence to exercise recommendations was more common than non-adherence to diet. The most common reasons for non-adherence to diet were poor self-discipline, lack of information, eating out and financial constraints. Lack of information, the perception that exercise exacerbates the illness, lack of an exercise partner, adverse weather and locations away from home were the most frequently reported reasons for not adhering to exercise recommendations. A lack of emotional support from the spouse, friends and to a lesser extent family members were the reported contributing factors for non-adherence to diet and exercise recommendations.