Assessment of barriers to the dietary adherence among type 2 diabetic patients in Pakistan: A cross-sectional study

Objective: TTo assess the common barriers responsible for non-adherence to dietary recommendations among type 2 diabetic patients. Method: The cross-sectional study was conducted from October 4, 2021, to March 6, 2022, at the National Institute of Diabetes and Endocrinology, Dow University of Health Sciences, Karachi, and comprised type 2 diabetes patients of either gender aged 18-80 years who had previously been given recommended dietary advice. Dietary barriers were assessed using a 27-item validated questionnaire, and the subjects were compared in terms of age and diabetes duration. Anthropometric measurements and laboratory parameters were also measured. Data were analysed using Stata 17. Results: Of the 312 subjects, 234(75%) were females. The overall mean age was 52.2±11.2 years, and mean body mass index was 27.2±5.5kg/m2. The reliability of the questionnaire was established with Cronbach’s alpha 0.89. Factor analysis yielded 8 common barriers; lack of knowledge about dietary recommendations (variance: 14.7%), situational barrier (variance: 10.7%), lack of family support (variance: 9.5%), stress-related eating problems (variance: 9.1%), boring and monotonous diet (variance: 8.0%), expensive and ineﬀective diet recommended (variance: 6.5%), work conditions/don’t like food in diet (variance: 5.5%), and feeling hungry and weak (variance: 5.4%). The total variation explained by all the 8 factors was 69.4%. Conclusion: Lack of knowledge regarding dietary recommendations was reported to be the most common barrier towards recommended dietary adherence.


Introduction
The World Health Organisation (WHO) has reported that 536.6 million people are suffering from diabetes mellitus (DM), and it is predicted that by 2045, this number will rise to 783 million. 1Globally, the most common form of DM is type 2 DM (T2DM).In 2021, the International Diabetes Federation Diabetes (IDF) Atlas reported T2DM as the most prevalent form of diabetes; similar projections are expected in 2045.Also, T2DM is undiagnosed in around 49.7% of the people. 2 Pakistan is ranked third in the list of top 10 countries, reporting 33 million DM cases aged 20-79 years. 1 The overall prevalence of T2DM is 11.77% in Pakistan, with 11.20% of males and 9.19% of females suffering from DM. 3 This increasing frequency was preceded by lifestyle changes and urbanisation.Lack of physically demanding work, and sedentary lifestyles led to transition in global nutrition patterns, marked by higher consumption of energy-dense but nutrient-poor foods. 4T2DM and its complications can be prevented by following WHO recommendations that patients should be physically active, perform at least 30 minutes of moderate-intensity activity on most weekdays, maintain healthy body weight, eat nutrient-dense food rather than energy-dense food by avoiding saturated fat and refined sugar, and by staying away from tobacco use. 5A healthy diet protects against malnutrition as well as other non-communicable diseases (NCDs), like stroke, heart disease, diabetes and cancer. 6The American Diabetes Association (ADA) has recommended that secondary prevention of T2DM can be achieved by consuming fibre-containing foods, whole grains, vegetables, fruits and legumes and by minimising the use of sucrose-rich foods. 7ilure to implement such approaches will lead to the intensification of pharmacological treatments, or result in sub-optimal hypoglycaemic control.Although dietary modification has been anticipated as the keystone of T2DM management and is usually recommended as the first step, it is considered one of the most challenging aspects of DM management.Collaboration between the healthcare provider and the T2DM patient is required for the regular implementation of recommended dietary practices.Both developing as well as developed countries face the problem of non-adherence to dietary modification by Assessment of barriers to the dietary adherence among type 2 diabetic patients in ….. people with T2DM. 8,9[12] To date, several quantitative studies have examined the knowledge level of patients and self-care practices among people with DM in Pakistan. 13Cultural and psychological factors are among the barriers often reported to DM selfcare in Pakistan. 14However, there is limited data regarding the barriers to dietary recommendations and the level of adherence in individuals with T2DM in Pakistan.A few studies in Ethiopia and other parts of the world have suggested that adherence to recommendations is generally low. 15In Pakistan, appropriate dietary practice guidelines are not evident in most primary and secondary healthcare services, and there is a lack of information on the proper dietary practice for people with T2DM.The current study was planned to assess the common barriers to dietary adherence among T2DM patients in Pakistan.

Subjects and Methods
The cross-sectional study was conducted from October 4, 2021, to March 6, 2022, at the National Institute of Diabetes and Endocrinology (NIDE), Dow University of Health Sciences (DUHS), Karachi.NIDE was selected as a specialised diabetic centre that offers educational and clinical services for diabetes and other endocrine-related disorders.
After approval from the DUHS ethics review committee, the sample size was calculated using OpenEpi calculator.The percentage of one of the barriers for non-compliance to diet, lack of knowledge 79% 9 was used with 5% margin of error and 95% confidence level.The sample was inflated by >20%.The sample was raised using non-probability convenience sampling technique.
Those included were T2DM patients of either gender aged 18-80 years who had already received dietary advice for T2DM from their respective healthcare provider.
Pregnant women or patients with endocrine, thyroid and other severe systemic comorbidity that could limit or restrict their diet, exercise or activity options were excluded.After taking written informed consent from each subject, demographic and anthropometric data was collected using an interview-assisted questionnaire.Dietary obstacles were evaluated using a validated 27-item questionnaire after receiving permission from the corresponding author. 16Each item graded on a 5-point Likert scale, ranging from 1=strongly disagree to 5=strongly agree.
Pretesting was done on 20 patients who met the inclusion criteria.In the final analysis, pre-test responses were excluded.Data was self-reported on lifestyle and sociodemographic variables, including age, gender, residence, occupation, family history of DM, and DM complications.The patients were taking oral anti-diabetic agents and had previously received dietary recommendations.Anthropometric data including height, weight, body mass index (BMI) and waist circumference (WC), were documented by taking measurements according to standard protocols.
The patients were grouped into categories based on the WHO population cut-offs for the Asian population: BMI <18.5 kg/m 2 =underweight, BMI 18.5-22.9kg/m 2 =normal, BMI 23 to 27.4 kg/m 2 =overweight, and BMI ≥27.5 kg/m 2 = obese. 17Laboratory parameters, including fasting blood glucose (FBG) and glycated haemoglobin (HbA1C) were also documented.Socio-demographic characteristics were considered independent variables, whereas barriers and compliance to dietary modifications were considered dependent variables.Data was analysed using Stata 17. Descriptive statistics were presented as mean±standard deviation (SD) for quantitative variables, and as frequencies with percentages for qualitative variables.The internal consistency of the questionnaire was checked using Cronbach's alpha.Factor analysis was carried out using principal component analysis to assess the factors as common barriers to dietary adherence.Items of perceived barriers to dietary adherence were found to be correlated, as checked through poly-choric correlation because the responses were ordinal, with each other enough that could be reduced into some common factors using factor analysis as Bartlett's test of sphericity was significant (p<0.001).A factor was considered if its eigenvalue was >1.Varimax rotation was used and factor loadings >0.45 were considered to find the common barriers to dietary adherence.The method used to determine the factor scores involved taking the mean score of the items linked to each factor.On the 5-point Likert scale of each item (1-5), a higher score indicated strong presence of barrier.P≤0.05 was considered statistically significant.

Results
Of the 312 subjects, 234(75%) were females and 78(25%) were males.The overall mean age was 52.2±11.2years, and mean BMI was 27.2±5.5kg/m 2 .There were 204(65.4%)housewives.The mean duration of T2DM was 8.3±7.2 years.A history of diabetes in first-degree relatives was present in 218(69.9%)patients.Other complications included eye impairment 113(36.2%),foot impairment 69(22.1%)and nerve impairment 68(21.8%)(Table 1).Responses of the subjects to perceived barriers to dietary adherence questionnaire were noted (Table 2).Kaiser-Meyer-Olkin's value for sampling adequacy was 0.84.A total of eight factors were extracted using the principal component analysis.The weighted mean of factor loadings for items loaded on each factor was used to determine its score.The 1st, 2nd and 3rd common barrier factors were loaded significantly with 6 (range: 0.89-0.56), 3 (range: 0.87- 0.83) and 5 (range: 0.71-0.51)items, respectively.The 4th and 6th factors were loaded with 3 items each (range: 0.88-0.64 and 0.72-0.53,respectively).The 5th, 7th and 8th factors were loaded with two items each (range: 0.92-0.88,0.84-0.48,and 0.89-0.68,respectively).Item number 18 did not load on any of the extracted factors, and was removed from the analysis.Factor analysis was repeated without this item, and found no change in the rest of the results (Table 3).

Discussion
Pakistan is facing an immense healthcare burden due to an alarming increase in the incidence of T2DM and its complications. 18Despite the great significance of dietary modification in the management of T2DM and its complications, like skin, nerve, kidney and eye issues, foot impairment, hearing impairment, and cardiovascular diseases, it is evident that there are various factors acting as barriers for noncompliance with dietary recommendations, 19 making it vital to identify the barriers leading to non-dietary adherence comprehensively.The identification of barriers to dietary recommendations in Pakistan will assist healthcare providers to tailor targeted interventions that address the specific needs of T2DM  -0.01 0.10 0.02 0.15 0.19 0.72 0.18 0.07 13 I feel hopeless with the continuation of the recommended diet since I don't see effective results on my disease.0.10 0.11 0.16 0.14 0.22 0.68 0.13 0.17 3 I think recommended diet is expensive.0.19 -0.01 0.20 0.02 -0.03 0.53 -0.14 0.12 20 I prefer to enjoy the food I eat than dieting.0.15 0.09 0.09 -0.02 0.00 0.11 0.84 0.00 19 Due to work conditions, I can't adhere to the recommended diet.0.20 0.14 0.19 0.43 0.19 0.00 0.48 0.06 1 I don't feel full with the dietary food recommended.
-0.00 0.04 0.06 0.05 0.08 0.01 0.10 0.89 2 Following the recommended diet, I usually feel hungry and weak.0.13 0.09 0.01 0.17 0.19 0.34 -0.16 0.68 18 I can't resist the temptation to eat unhealthy food and food that is not recommended to me.0.18 0.37 0.27 0. patients in Pakistan.This can include culturally appropriate dietary education, counselling and support services to help patients overcome these barriers.This can lead to improved patient outcomes and better management of DM.
In the current study, the most common barrier to dietary adherence was lack of knowledge regarding dietary recommendations, which showed that DM patients had inadequate information about the recommended food, alternative selection in food choices and portion size to be consumed at each meal.Similar findings were reported in earlier studies where insufficient understanding of the prescribed diet plan and uncertainty about the appropriate food choices to include in the daily regime were reported as the most common barrier to dietary adherence leading to disease progression and poor glycaemic control. 11,12To overcome this barrier, patients must be provided with recommendations that are simple, feasible and flexible with regular follow-ups. 16e second most common barrier identified in the current study was the situational barrier.In line with a study in Iran, 16 participants of the current study reported that special occasions and situations, such as holidays, weekends, going to restaurants, parties, visits or trips and gatherings, made it difficult for them to adhere to optimal dietary recommendations.
Likewise, a study among Nepali diabetics revealed that festivals and feasts were barriers that made it difficult to adhere to dietary advice.In South Asian traditions, food has pivotal significance, and during festivals, social pressure to eat everything provided on the table makes dietary adherence difficult to be followed. 20Similar results were reported by another study. 12e contribution of friends, family and community members can play both obstructive and supportive roles.An improved support group can not only help in better management of T2DM, but can also mediate in the reduction of DM-related complications. 12,21study in an Ethiopian hospital revealed that the attitudes, beliefs and knowledge of social support groups, like friends and family, were positively correlated with adherence to dietary and other lifestyle interventions.A remarkable impact was observed when the social support groups had prior higher knowledge regarding counselled diet, lifestyle modifications and interventions. 22A study in Botswana reported similar findings. 23Likewise, a qualitative evaluation in Nepal also reported that lifestyle changes and dietary modifications were difficult to be followed by the patients due to the people that surrounded them. 24To overcome this barrier in Pakistan and worldwide, meticulous attention is required to formulate programmes highlighting the importance of family support in the dietary adherence of T2DM patients.
The current study found that stressful families or work environment acted as a barrier to dietary adherence.In Pakistan, people usually have long, physically or mentally stressful work hours with little choice to concentrate on recommended diet at the workplace.Previous studies revealed that negative attitudes, like stress, depression, burnout, anxiety and other psychosocial problems, were factors that poorly affected dietary regimen adherence in T2DM patients. 16Furthermore, it has been reported that both the aetiology and management of DM are affected negatively by psychological stress. 10Health professionals should encourage patients to develop calculated eating habits.Providing psychosocial care by improving problemsolving skills related to management of DM needs to be focussed as recommended in the diabetes selfmanagement education and support (DSMES) programme. 25mans by nature cannot intake monotonous food all the time.The current participants did not enjoy their mealtimes due to the lack of food diversity.They found it monotonous and boring.The findings were in line with a previous study which reported a monotonous diet and fewer healthy food choices as barriers to dietary adherence, resulting in aggravated feelings of deprivation. 16For optimal health management, nutrition therapy in T2DM management should support diversified healthy food choices, especially focussing on appropriate quality and portion size of the dietary pattern. 26e current study's participants revealed that the diet recommended to them was quite expensive to follow as well as very much different from what they were previously consuming, which made dietary adherence difficult.Pakistan is a developing country in which most people are striving hard for their livelihood.Thus, patients' needs should be fulfilled with healthy, low-cost food choices and recipes that are socially and culturally acceptable.Similar findings were conveyed in a study conducted in Iran where DM patients considered the high cost of food as the main barrier to dietary adherence, and the annual increase in the cost of healthy food resulted in higher stress levels in patients from lower socioeconomic status. 16A study reported the cost of a diabetic diet as the main contributing barrier towards noncompliance to dietary recommendations, which resulted in the increased prevalence of diabetic complications as well as the prevalence of T2DM in lower socioeconomic groups. 12ieticians and healthcare providers need to address this barrier by formulating cost-effective recipes.The focus should not only be on managing a diet properly, but also on its sustainability.
The current study had its limitations.The cross-sectional design meant the study could not explore the improvement in barriers to dietary adherence in T2DM patients.Secondly, participants' self-reporting of barriers can be associated with potential bias.The findings cannot be generalised and may not represent the entire country's population as it was a single-centre study, and barriers to dietary adherence may vary in different geographical locations.
Despite the limitations, the findings suggest that dietary adherence can be achieved in Pakistan if dietary recommendations are individualised, based on the patient's psychological, sociocultural and socio-economic conditions, individual's level of understanding and dietary preferences with the inclusion of common food and appropriate alternatives, simplified cooking methods and specified portion sizes.Using techniques, like motivational enhancement therapy (MET), can be beneficial. 27Different counselling sessions can improve dietary adherence and mitigate any future complications of the disease.Policymakers and healthcare decision-makers in areas where they are not available should design effective and practical dietary guidelines for diabetic patients.

Conclusions
Lack of knowledge regarding dietary recommendations was reported to be the most common barrier towards recommended dietary adherence.

Table - 4
: Extracted factors for perceived barriers to dietary adherence.

Table - 3
: Factor loadings for each item of perceived barriers to dietary adherence.Stressful family environment makes it difficult for me to follow the recommended diet.0.07 0.18 0.03 0.87 0.08 0.04 -0.06 0.06 12 When anxious and angry (emotional stress), it is difficult for me to follow the recommended diet.0.06 0.10 0.04 0.64 0.07 0.21 0.19 0.12 4 I don't enjoy the diet that is recommended to me.0.08 0.11 0.08 0.11 0.92 0.07 0.02 0.05 5 I don't enjoy the diet recommended to me, I find it monotonous and boring.0.09 0.20 0.11 0.09 0.88 0.14 0.03 0.12 11 The diet recommended to me is very different from my previous diet.