INTRODUCTION
Dietary adjustments are an integral part of the management of diabetes
(Nathan et al., 2006). As per current recommendations of relevant
authorities none of the foods are to be excluded and instead, controlled
intake of foods from various food groups is suggested. Variety in food
intake is encouraged to ensure adequate and balanced dietary intake (Irwin,
2002; Lauber and Sheard, 2000). Persons having diabetes often need personal
guidance so as to enrich their knowledge and thus aid suitable selection
of foods and intake of balanced diet (Rafique and Shaikh, 2006). Awareness
and guidance provided by dieticians is aimed toward empowerment of patients
and facilitation of adequate and appropriate dietary intake (Lorenz et
al., 2000). The goal of MNT for diabetes management is to guide the
patient to consume a balanced diet providing adequate energy and nutrition
to maintain good glycemic control (Lauber and Sheard, 2000). In most cases
due to high prevalence of obesity among people with type 2 diabetes restrictions
in energy intake is often recommended by Daly et al. (2003), Franz
(2004), Basit et al. (2004) and Habib and Aslam (2003). Monitoring
of the quantity and quality of fat intake and that of high glycemic index
foods is also needed for prevention of complications and good glycemic
control (Irwin, 2002). Thus there are possibilities that in an attempt
to comply with these restrictions people with diabetes may either make
imbalanced and undue food restrictions or may choose not to follow the
guidance (Rafique and Shaikh, 2006; Serour et al., 2007; Vijan
et al., 2005). Low literacy level and lack of availability of information
about food contents further aggravates the problem of appropriate food
choice and may lead to inadequate intake of nutrients. Dietary guidance
provided by dieticians is found to be helpful in improving the diets however
most of these studies are done in affluent countries having high rates
of literacy, easily available information about food compositions and
a wide range of foodchoices. The impact of such guidance needs to be evaluated
in a variety of settings differing in terms recipients of guidance e.g.,
in areas having low literacy and relatively limited food choices, low
level of general knowledge about composition of foods and in terms of
resources and constraint to provision of guidance. Such assessments could
help in determining the areas needing focus during dietary guidance. This
study was planned to assess the dietary intake of diabetic subjects and
kind of dietary modification they have made after individualised dietary
guidance.
Assessment of impact of efforts made by dieticians to educate the patients
is needed for maintaining and enhancing the output of these efforts.
MATERIALS AND METHODS
Setting: In Pakistan professional dietary guidance is not available to a
vast majority of people with diabetes. Individual dietetic guidance is
not provided in most public and private diabetes clinics. In a few private
hospitals, where it is provided, the costs are high and only very affluent
people use these services. Baqai Institute of Diabetology and Endocrinology
(BIDE) is one of the rare institutes where professional and individual
dietary guidance is provided without extra costs to all the patients consulting
the physicians. The Socioeconomic Status (SES) of patient coming to BIDE
OPD is varied because a certain proportion of patients can get services
at subsidised cost also. Thus for the purpose of this study subjects were
recruited in such a fashion that the data could be collected from a mix
of high, middle and low income groups. Overall, the sample selected for
this study represents the middle income group of people with diabetes
living in Karachi.
Subjects for this study were recruited from the OPD of BIDE. Starting
from May 2004, a total of 200 patients were recruited. For the assessment
of impact data was collected from a random sub-sample of 73 patients.
Data collection: Information about clinical profile including height and weight;
and about dietary habits was recorded at first visit to BIDE. Dietary
guidance was provided as usual by qualified and experienced dietician.
The subjects were contacted again after 3 months during usual follow up
or through phone to collect information about diet and weight status.
Interviews were conducted to estimate dietary patterns and to record
usual daily diet. Food consumption was recorded in measures or numbers
of servings or exchanges as considered appropriate according to type of
food.
Data entry and analysis: Data was entered on SPSS 10 for analysis. Calculations were done
to assess the total servings of food consumed from various food groups.
Quality of diet was assessed by comparing the number of servings of foods
consumed from various groups to that recommended for healthy eating by
USDA. For each food group if the subject consumed the appropriate number
of recommended servings (cereals: 5-11; meat: 2-3; milk: 2-3; fruit: 2-3;
vegetable: 3-4; fat: 2-3 and sweets: 1-2) one point was awarded. The scores
for food groups were added to get Diet Adequacy Score. Paired sample T
test was done to compare differences in adequacy of diet before and after
dietary receiving guidance. Chi-Square test was done to compare differences
between groups.
RESULTS
Food intake of people with diabetes: Data for the first visit was collected from 200 subjects. Characteristics
of the subjects are shown in Table 1.
Dietary data was transformed to calculate the number of servings of foods
usually taken per day form various food groups by the subjects. The number
of servings of fats indicates fat added during cooking or consumed as
spreads. The number of servings of sweets indicates foods or drinks with
added sugar.
Average numbers of servings of various foods consumed: For vegetables, fruits and milk the average intake was below the recommendation
among both males and females. For meat the average intake was below the
recommendations only among females. Intake of cereals was adequate among
both the groups mean energy intake was 2326 for males and 1870 for females
and was less than mean of estimated energy requirements (2498 for males
and 1834 for females). However, on individual basis, estimated energy
intake was more than the estimated requirements for 37.5% of males and
43% of females (Table 2).
About 60% of calories were being contributed by cereals in the diets
of both males and females (Fig. 1a, b).
A relatively lower proportion of calories were contributed by white meat
and higher by milk in the diets of females (3.2 and 12.9%) as compared
to males (4.0 and 10.6%).
Overall adequacy of diet was assessed on the basis of presence of minimum
required servings of foods in the diet. For individual food groups a much
higher proportion
| Table 1: |
Age and BMI of the subjects |
 |
 |
| Fig. 1a: |
Percentage of energy from various food groups in the
diets of male subjects having type 2 diabetes |
of subjects (38-68%) had adequate intakes as compared to proportion of
subjects having overall adequate diet. Percentage of male and females
having adequate intake of fruit and vegetable (>5 servings), milk (2
servings) and meat (2 servings) was 68, 38 and 63% for males and 52, 40
and 35% for female, respectively. Only 20.4% males and 5.9% females had
usual adequate consumption of the four food groups (Table
3).
Patterns of dietary inadequacy: Males and females differed in patterns of dietary inadequacy (Fig.
2). Among males the usual patterns were inadequate intake of milk
only (28.9%), milk and meat (21.1%) and milk and vegetable-fruits (18.4%).
Among females the common patterns of dietary inadequacy were insufficient
intake of meat and milk (22.3%), meat, milk and vegetable-fruits (19.1%)
and meat and vegetable-fruits (18.1%).
| Table 2: |
Average daily intake (in average servings) of food from
various food groups by male and female subjects |
 |
 |
| Fig. 1b: |
Percentage of energy from various food groups in the
diets of female subjects having type 2 diabetes |
 |
| Fig. 2: |
Patterns of dietary inadequacy: Percentage of subjects
having various combinations of inadequate intake of food groups) |
| Table 3: |
Adequacy of subjects` intake of foods from various food
groups |
 |
Changes in food intake of people with diabetes after receiving professional
dietary guidance: According to reported food intakes, at 3 months follow up visit several
statistically different changes were observed in the subjects` diets.
The changes were calculated in terms of absolute intake i.e., mean difference
in the intake of number of servings of foods from various food groups;
in terms of changes in diet pattern i.e., percentage of calories coming
from various foods in the subjects diets; and in terms of variations in
diet adequacy i.e., recommendation for intake of food from various groups
met or not.
In terms of absolute difference in intakes, intake of lentils was decreased
significantly both among men and women; intake of cereals was decreased
significantly among women only and intake of fat and red meat was decreased
significantly among men only (Table 4). On the other
hand in terms of changes in dietary patterns as represented by differences
in percentage of calories coming from various foods in the diet (Table
5), a relatively higher percentage of calories were contributed by
milk and lower by lentils after getting dietary guidance both among males
and females. Percentage of calories contributed by cereals and red meat
decreased significantly only among females.
| Table 4: |
Mean difference in number of servings of foods taken
after dietary guidance as compared to before dietary guidance |
 |
Differences in overall adequacy of diets and that intake of various food
groups before and after getting dietary guidance were bilateral. Overall
adequacy of diet remained the same for 47.2% of males and 35.1% of females;
improved for 11.1% of males and 27% of females; and worsened for 41.7%
of males 37.8% of females. In the case of milk the proportion of men and
women whose adequacy of milk intake was improved was higher than of those
whose adequacy of milk intake had worsened. In the case of vegetable and
meat the proportion of men and women whose adequacy of intake was improved
was lower than of those whose adequacy of milk intake had worsened Table
6.
Energy intake and weight change: Energy intake was reduced by more than 10 for 55% of subjects. Weight
reduction was observed in 54.8% of females and 32.2 % of males. Mean percentage
of weight loss was 2.2% in males and 2.5% among females, range being 1-4%
in both. BMI was decreased among 27.7% of subject, increased in 21.5%
and remained the same others (50.8%). When viewed according to reported
reduction in caloric intake rate of BMI reduction was significantly higher
in the group who had reduced their caloric intake (Fig.
3).
| Table 5: |
Mean difference in percentage of calories from various
food groups in the diets of males and female subjects after receiving
dietary guidance as compared to before receiving dietary guidance |
 |
| Table 6: |
Changes in adequacy of food intake after receiving dietary
guidance among male and female subjects |
 |
 |
| Fig. 3: |
Rate of reduction in BMI within the two groups of subjects
whose caloric intake was decreased or not |
DISCUSSION
This study has given a comprehensive picture of the dietary habits
of type 2 diabetics living in Karachi. It is the first prospective study
from Pakistan reporting the impact of dietary interventions on energy
and food intake and BMI of subject with type 2 diabetes. The findings
demonstrate that the interventions were successful in bringing out certain
major desired dietary changes i.e. reduction in caloric intake in the
majority of patients and as a result significantly high rate of BMI reduction
amongst those who had reduced their every intake as compared to those
who had not. These observations support the suggestion that input in providing
service of trained dietician to people with diabetes is a very cost effective
investment even within a low resource community as has been observed in
affluent economies (Franz et al., 1995; Kaplan and Davis, 1986;
Sheils et al., 1999). Further research is needed to quantify the
contributions made by dietary interventions to the overall outcome of
treatment.
This study has also been successful in indicating the areas of dietary
guidance where further attention is to be given by dietician i.e., balanced
intake of foods form various food groups. The observation that people
with diabetes in an attempt to reduce energy intake may not be able to
retain adequate intake of certain foods, has implications not just for
dietetics but for other areas of food policies in developing countries
like Pakistan. Overall attention given to food supply and nutrition situation
is far from sufficient in Pakistan (Khalil, 2000). For example opportunities
for higher education and research in human nutrition and dietetics are
very limited, there is no legislation about minimum information to be
provided on food labels, no information about food and nutrition is compulsory
at school level etc. Consequently even for a well meaning and motivated
person it is not easy to make appropriate food choices and at times even
professionals are unable to find accurate information about composition
of foods. Though undoubtedly even within the existing circumstances dietary
intervention would contribute to better management of diabetes and prevention
or delay in onset of complications, improvement in education and research
opportunities and presence and implementation of legislation is definitely
needed. Besides, while assessing the impact of any dietary intervention
in Pakistan we should keep in mind the overall education level of the
concerned population.
In terms of cost effectiveness of dietary interventions, the impact is
underestimated by both policy makers and patients. Governments and NGOs
are always willing to invest in tertiary health centres but not in preventive
strategies like provision of professional dietary guidance. Even in big
cities of Pakistan only 39% of hospitals have any dietician (Afzal, 1999).
Usually General Physicians (Rani, 2000) and Consultants (Khan, 2000) provide
dietary guidance themselves and even in case of diabetes where dietary
guidance plays an important role only a printed leaflet is handed to patients
with diabetes (Khan, 2003). Most patients can neither afford nor consider
it important to consult private dieticians. The message for Policy makers,
health care providers and patients is:
Investing in dietetic centres and nutrition science to help and educate
people about making good food choices is one of the most cost effective
investments. Training a dietician is much less expensive than training
a physician and government must take at least the same if not more interest
in training dieticians and providing dietetic services to all the people
with diabetes free of cost. This would certainly reduce the burden of
diabetes and its complications in the community as well as could possibly
help in primary prevention of the diseases high risk groups.
ACKNOWLEDGMENTS
We acknowledge the cooperation of PharmEvo, Pakistan for providing
the support to the Research Department of Baqai Institute of Diabetology
and Endocrinology.
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