Electronic ISSN 2287-0237
Diabetes mellitus is a major global public health problem. The prevalence of type 2 diabetes mellitus in adult population worldwide has been rising from 4.7% in 1980 to 8.5% in 2014.1 In Thailand; the prevalence of diabetes has also increased over time. Data from the fourth national health examination survey indicated that the prevalence of diabetes in people aged 15 and over was 2.3% in 1991 to 4.6% in 1997, to 6.8% in 2004 and to 6.9 % in 2009. The diabetes prevalence was higher in urban areas compared to rural areas.2
Diabetes can cause several health complications leading to the loss of function in many important organs such as cardiovascular, cerebrovascular, kidney, eyes and nervous system.3,4 These complications can be prevented by maintaining optimal blood glucose levels.4 This can be achieved by lifestyle modification and adoption of appropriate health behaviors including diet control, physical activity and/or blood glucose monitoring. Studies showed that lifestyle interventions targeted at weight loss, diabetes nutrition, and physical activity recommendations have been shown to improve glycemic control.5-7
Dietary management is considered as a main aspect in controlling blood sugar level. It is widely accepted that healthy nutrition is the basis for the treatment of type 2 diabetes. It contributes positively to the maintenance of blood sugar within the normal range and minimizes the complications of the disease.7 However, an important problem of most diabetic patients is their inability to control their blood sugar level due to a lack of knowledge on diet control appropriate for consumption habits or contexts of the community, so they are unable to control their calorie intake from food consumption or choose the type of food appropriate for their disease.8
The concept of food exchange is known as the principle of food management that that can be interchangeable or replaceable as appropriate to the needs or contexts of individuals.9,10 This concept can enable patients choosing a variety of wholesome foods in accordance with nutrition principles suitable for their lifestyles and level of activity.9 Studies of a food exchange program both in Thailand11,12 and other countries13,14 showed positive outcomes. In order to enhance the capacity of patients to manage their dietary management using food exchange, education based on behavioral impact is important. A health belief model15 is recommended for educational programs to increase impact of the programs. This model suggests that a person needs to have perceived susceptibility, perceived severity, and perceived threats of possible complications that influence them to avoid such threats.
According to data of Samut Prakarn province from the Bureau of Policy and Strategy, the Ministry of Public Health16 indicates that the hospitalization rate for diabetes has increased from 665.72 per 100,000 in 2011, to 689.46 per 10,000 in 2012 and to 733.41 per 100,000 in 2013. This may indicate that the incidence of poor glycemic control has also increased. Bangpla district is the district in Samut Prakarn province with several suburban areas. A pilot study conducted by the researcher showed there was approximately a rate of 10% of poor glycemic control patients of all patients who attended a health promoting hospital. Therefore, this study aimed to examine the effects of a diet control program using food exchange whilst applying a Health Belief Model15 on knowledge, food consumption behaviors, glycemic control and nutrient intake of persons with type 2 diabetes mellitus in a suburban setting.
Population and sample
This quasi-experimental study with a pretest-posttest two group design was conducted for this study. The population of the study was persons with type 2 diabetes at the Bangpla community who attended treatment and received care at the Bangpla Mu 6 Sub-district health promoting hospital and the Bangpla Mu 14 Sub-district health promoting hospital, Samutprakarn Province between February and October 2014.
The study sample were recruited purposively with the following inclusion criteria:
The 2 sub-district health promoting hospitals in Bangpla district, Sumut Prakarn province were randomly selected as experimental and for comparison purposes. The Bangpla Mu 14 sub-district health promoting hospital was selected as an experimental setting and the Bangpla Mu 6 sub-district health promoting hospital was the controlled setting.
The sample size was calculated by power analysis 17. Power of test = 0.80, p-value = 0.05 and effect size calculated from previous studies was 11 = 1.27 (large effect size), 42 samples were calculated (21 samples for each group). In this study, a total of 44 diabetic patients (experimental group = 22 and comparison group = 22) attended the program.
The intervention
Participants in the comparison group received routine care practiced at their health promoting hospital, which may have also included a summary of basic dietary principles by nurses. Participants in the intervention group, in addition to receiving the usual care, received comprehensive education on the main topics of diabetes; explanation of diabetes, symptoms and management, diet and the role of food exchange in controlling diabetes. The participants in the intervention group were also provided home visit and/or telephone follow up (3 times). The program was conducted by researchers and nurses. Comprehensive education was conducted at the sub-district health promoting hospital. The participants leaned about diabetes, and the food exchange concept by video animation developed by Fuangfung et al.11 A demonstration and discussion was given on food exchange using a food plate model, a pamphlet on food exchange of the Potential Development of Thai People Project18 and a manual on ready-to-eat dishes developed by Peasua et al.19 After the educational program, patients received three home visits and/or telephone follow ups to give individualized advice based on the food record to modify and plan for dietary intake at breakfast, lunch, and dinner between the researcher, patients and family members focusing on behavior assessment, goal-setting, and problemsolving.
Data collection
This study was approved by the Institutional Review Board (IRB), Faculty of Medicine Ramathibodi Hospital, Mahidol University (2554/514). The patients received written and verbal explanations about the program before giving informed consent. The researcher and assistant researchers collected data and blood tests; FBS and HbA1c before starting the intervention and after the intervention was complete.
Data were collected using data forms and questionnaires for the following information:
Data analysis
Data entry and analysis were performed using Statistical Program for the Social Sciences (SPSS) version 18.0 software. Descriptive statistics were analyzed for frequency, percentage, mean and standard deviation. Chi-square test and independent t-test was used for comparing the characteristics of patients between the experimental and comparison group. Mann- Whitney U test and Wilcoxon signed rank test were used to compare personal data, knowledge score, food consumption behavior score, FBS and HbA1c before and after between the experimental and comparison groups.
Figure1: Study diagram
Of a total of 44 type 2 diabetic patients, 70.46% were female and 29.54% were male with an average age of 63.6±9.9 years old (ranging from 43-85 years old). Sixty-eight percent of patients were married and most of them (97.73%) had primary school and lower education with an average monthly income of THB 7,733.33. There was no difference in background characteristics between the experimental and comparison groups (Table 1).
Mean and standard deviation (SD) score of the experimental group on knowledge before attending the intervention was 22.86±5.89 and it was 23.68±4.19 after the intervention. The Wilcoxon Signed Rank test showed no statistically significant difference (p=0.242). For food consumption behavior, mean and SD score of the experimental group before attending the intervention was 38.50±5.64 and it was 39.72±5.59 after the intervention, so that the Wilcoxon Signed Rank test showed statistically significant difference (p=0.005). The finding also showed the mean fasting blood glucose and HbA1c of the experimental group at before attending the intervention was 161.41±53.25 mg/dl and 8.84±2.39 mg% respectively and it reduced to 154.0±54.68 mg/dl and 8.15±1.82 mg% after the intervention but with no statistically significant difference (p=0.758 and 0.184 respectively).
When comparing the mean difference score before and after attending the intervention between the experimental and comparison groups, the results found that the experimental group had a significantly higher food consumption behavior score than the comparison group (p<0.001). HbA1c levels of the experimental group showed a significant reduction in more than the control group (p=0.002) whereas knowledge score and blood sugar (FBS) showed no statistically significant difference (Table 2). Average FBS and HbA1c of the experimental group was reduced and in the comparison group it increased (Figure 2).
Table 1: Patients’ characteristics (n=44).
a = Chi-square test
b = independent t-test
Table 2: Comparison of mean and mean difference of knowledge scores, food consumption behavior score and glycemic control between experiment and control groups (n=44).
* difference in scores between before and after attending the intervention
a = Wilcoxon Signed Rank test
b = Mann-Whitney U test
Figure 2: Comparison of mean fasting blood sugar and HbA1c between experiment and control group
The results of this study showed that the patients who joined the diet control program had an improvement in the food consumption behavior score. These results were similar to the results from several studies11-13 in which food consumption behavior score in the intervention group increased significantly. The result is congruent with the Health Belief Model15. This was due to the patients in the experimental group perceived susceptibility from the education and that they also perceived benefits and especially perceived barriers from home visits or telephone follow ups. Then they can modify dietary intake, setting their goal and problem-solving by themselves. Moreover, home visits gave an opportunity to meet and discuss with patients’ family members who may prepare food for the patients. This can help to reduce patients’ barriers to suitable food consumption. The experimental group in this study also showed an improvement in glycemic control shown by a statistical significant reduction of HbA1c. The trend of nutrition intakes in the experimental group improved. Intakes of carbohydrate and sugar decreased. Reduction in fasting blood sugar and HbA1c might be mainly as a result of food consumption behavior change in the experimental group.
However, it is noteworthy that the knowledge score was not statistically different from before starting the program, but the knowledge score tended to go up. This may due to the fact that patients in the experimental group were mostly elderly (mean age=63.60 and SD=9.90) and their education was primary school level and lower which may impact the participants’ learning. When comparing the mean difference knowledge score between the experimental group and the comparison group, it was found that the mean score of the experimental group was higher than that of the comparison group. This may have been because the participants in the experimental group received knowledge from the video animation which is easy to learn and remember.
In summary, in the experimental group, food consumption behavior significantly increased and HbA1c was also improved. Also, intakes of carbohydrate and sugar were more likely to decrease, while knowledge and FBS was not significantly decreased. This study indicates that diabetes education and individualized diet planning through a home visit is effective for dietary management.
This study was funded by the Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University.
