|Year : 2018 | Volume
| Issue : 3 | Page : 139-144
Dietary practices and barriers to dietary modification among diabetics and hypertensives in a rural health service area of Puducherry: A qualitative study
Mamta Gehlawat1, Bijaya Nanda Naik2, Subitha Lakshminarayanan1, Sitanshu Sekhar Kar1
1 Department of Community Medicine, JIPMER, Puducherry, India
2 Department of Community Medicine, SVMCH and RC, Puducherry, India
|Date of Web Publication||20-Jul-2018|
Dr. Subitha Lakshminarayanan
Department of Community Medicine, JIPMER, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
BACKGROUND: Healthy dietary practice is an important lifestyle modification and one of the key adjuncts to pharmacotherapy in the management of diabetes and hypertension.
AIM AND OBJECTIVE: This study aims to describe the awareness regarding healthy dietary practices among diabetic and hypertensive patients in a rural health center, and to identify the barriers to dietary modifications and compliance among them.
MATERIALS AND METHODS: Eight focus group discussions (FGDs) were conducted in this qualitative study among diabetic and/or hypertensive patients (homogenous groups, with 6–10 members) both in the special clinic as well as in the community setting of Ramanathapuram, in rural Puducherry. Verbatim group transcriptions were analyzed by systematic text condensation.
RESULTS: Four themes – “awareness toward dietary modification,” “compliance to dietary modification,” “family support in following dietary modification,” and “barriers faced in following dietary modification” emerged after the analysis of all FGDs. Most of the patients were aware regarding the dietary modifications, but few comply with the modifications due to the barriers such as lack of time, financial constraints, and inadequate family support. Other barriers in following the dietary changes include fear of taboo in social gatherings and inability to deviate from traditional food habits.
CONCLUSION: Despite good awareness, compliance to healthy dietary practices was poor owing to several barriers. Nutrition education sessions need to be conducted considering locally available resources and addressing the commonly encountered barriers in a simple and comprehensible manner involving family members/caregivers in addition to the patients.
Keywords: Awareness, barriers for dietary practices, compliance, dietary self-management
|How to cite this article:|
Gehlawat M, Naik BN, Lakshminarayanan S, Kar SS. Dietary practices and barriers to dietary modification among diabetics and hypertensives in a rural health service area of Puducherry: A qualitative study. Int J Health Allied Sci 2018;7:139-44
|How to cite this URL:|
Gehlawat M, Naik BN, Lakshminarayanan S, Kar SS. Dietary practices and barriers to dietary modification among diabetics and hypertensives in a rural health service area of Puducherry: A qualitative study. Int J Health Allied Sci [serial online] 2018 [cited 2023 Jun 6];7:139-44. Available from: https://www.ijhas.in/text.asp?2018/7/3/139/237259
| Introduction|| |
Noncommunicable diseases (NCDs) account for >50% of deaths globally as well as in India. Cardiovascular disease (CVDs) [for which hypertension is a major risk factor] and diabetes are two of the major NCDs. The mortality due to CVDs and prevalence of diabetes are projected to double by the year 2020 and 2030 respectively in India.,
Being chronic conditions, both diabetes and hypertension require lifelong management. The aim of diabetes and hypertension management is not only limited to adequate glycemic or blood pressure control but also to prevent complications and support appropriate rehabilitation. Adequate management of diabetes and hypertension includes behavioral modification along with pharmacotherapy., Being chronic conditions, onus of management of diabetes and hypertension lies on the patient more than the health personnel. Lifestyle modification is an important adjunct to the pharmacotherapy in the long-term management of chronic diseases such as diabetes mellitus and hypertension. The recent concept of self-management in chronic diseases such as diabetes and hypertension involves cognition, assessment of health belief, and behavioral modification strategies. Adherence to medication and therapeutic lifestyle modifications are important to achieve adequate glycemic control  and have been poor in Indian setting.
Participating in self-care, especially lifestyle modifications among chronic disease patients has profound impact on the progression and development of disease complications. Practicing diet-related self-care is a special challenge in the management of diabetes and other chronic diseases. Change in dietary habits, a component of therapeutic lifestyle modifications, needs special attention as it is extremely difficult to forego the old habits and get acquainted to new dietary habits.
Experience from other countries showed difficulty in adherence to dietary modification among patients with chronic diseases.,, Diet-related self-care practices have been found to be unsatisfactory in Indian settings as well.,, Various factors at individual level, community level, or health system level play a role in diet-related self-care practices. Individual preferences, availability of food substitute at affordable level, knowledge about right diet, availability of time, and feasibility of individualized cooking practices, etc., play an important role in self-care dietary practice. Diet-related self-care practices must be individualized to have a greater impact on adherence to dietary advice.
Although information on quantitative assessment of dietary practices is widely available, literature on qualitative assessment of diet-related self-care practices is limited.,,, It is very much important to understand the culture-specific facilitating and hindering factors that influence the adoption of healthy dietary practices among patients with diabetes and hypertension. Hence, the current qualitative study was conducted to assess the current dietary practices in diabetic and hypertensive patients and to study the barriers to dietary modifications and compliance in the service area of a rural health center in Puducherry.
| Materials and Methods|| |
Study design and setting
This focus group discussion (FGD)-based qualitative study was conducted during September 2015 in the rural field practice areas of a tertiary care health institution in Puducherry. The rural field practice area (with a population of nearly 9000) is spread over four villages and catered by a rural health training center (RHTC) attached to the Department of Preventive and Social Medicine of the parent tertiary care institution. Comprehensive primary health care is delivered to the beneficiaries which include both hospital-based care and outreach activities. It also serves as a residential training center for interns and postgraduates on primary health care. A chronic disease clinic is being conducted every Wednesday in the RHTC for management of chronic diseases. The RHTC has around 500 people with diabetes and/or hypertension registered who avail health services.
Out of the total eight FGD sessions, five were conducted in the chronic disease clinic and three in the community. The FGD sessions were conducted by resident doctors (postgraduate in community medicine) trained in FGD. The FGD sessions were conducted as open discussion with the help of a study tool in local language (Tamil). The FGD groups were homogeneous with respect to age and gender. All the FGDs were gender specific to avoid dominant expression of a specific gender. A total of 58 diabetes and/or hypertensive patients with about 6–10 participants in each of the FGD were included for the study [Table 1]. The participants aged from 40 to 70 years and having type 2 diabetes mellitus and/or hypertension for at least 1 year were included for the study. The participants who were not fluent in Tamil were excluded from the study.
|Table 1: Details of focus group discussion conducted as a part of the study|
Click here to view
The participants for the FGD were recruited based on convenient sampling. During the chronic diseases clinic, 8–10 consecutive participants belonging to same gender and satisfying the inclusion criteria were invited for the FGD. The participants were included in the FGD after taking verbal informed consent. The FGD in the community was conducted in the Anganwadi center. The participants for the FGD in the community were contacted with the help of Anganwadi teachers and health workers.
A guide was developed to conduct the FGD based on ecological behavioral model and appropriate probes were constructed. The tool developed in English language was reviewed by two independent experts in the field of behavioral change for dietary modifications and having knowledge of sociocultural influence on dietary behavior in the study region. The tool was translated into local Tamil language. The study tool was finalized after two pilot FGD sessions.
One moderator and one notetaker trained in qualitative research conducted the FGD sessions. The participants were seated in semicircular fashion facing the moderator [Figure 1]. The moderator explained the purpose and process of the FGD to all the participants before proceeding further. Using the FGD guide, the moderator initiated the discussion in the local Tamil language. Each FGD session lasted for about 45–60 min. Discussion revolved around awareness on dietary practices, source of information, diet-related self-care practices, and various barriers to practice dietary modifications. The discussion was recorded in a voice recording device as well as by note taker in local language. These verbatim were transcribed in English and content analysis was done.
|Figure 1: Sociogram depicting interaction process in a focus group discussion lasting for 40 min (numbers indicate participant number; arrowhead indicates direction and frequency of interaction)|
Click here to view
Transcripts were independently reviewed by the authors by iterative process. Manual content analysis was done through intuitive coding process. All the information obtained was analyzed using systematic text condensation method. Transcripts were reviewed twice to identify emergence of codes. The codes were again categorized into different themes. Patient responses are also substantiated as quotes. The original transcripts and verbatim were revisited to ensure that meaning of themes is not diluted.
| Results|| |
A total of eight FGDs were conducted; four each among men and women [Table 1]. The mean (standard deviation) age of the study population from all FGDs was 59.9 ± 9 years. Majority (63.8%) of the study participants were female. About three-fourth of the participants belong to Below Poverty Line (BPL) category. Out of total participants, 19 each had either diabetes or hypertension and 20 had both diabetes and hypertension. The median (interquartile range) duration of having disease was 3 (2–5) years. All the participants reported having received health education on dietary modification in the past from the health centers/health personnel from other hospitals.
All the information related to change in dietary behavior were grouped into the following themes,
- Initiation of dietary modification
- Awareness on need for dietary modification
- Maintenance of dietary modification.
- Compliance to dietary modification
- Importance of family support
- Barriers in adopting behavioral changes.
Initiation of dietary modification
Awareness on need for dietary modification
Most of the participants were aware of the need for dietary modification to achieve glycemic control. The participants have received information about dietary modification during the chronic disease clinics. Some have received information from friends and relatives. The participants have been elaborated. They have received information on “what to eat and how to eat;” they have been told “to eat more of green leafy vegetables and locally available fruits.” Participants appreciated that change in dietary behavior is good for their health. Participants stressed on the fact that they should follow what is being advised to them for leading a healthy life.
“Dietary modification is good for health. If it does well, then we have to follow, no other alternative.” (50-year-old female with type 2 diabetes mellitus)
“If we follow what is told to us in dietary counseling, that itself is enough to be healthy.” (45-year-old female with type 2 diabetes mellitus and hypertension)
Maintenance of dietary modifications
Compliance to dietary modification
Participants felt that compliance to dietary modification is essential if it has to make an impact on sugar control. Most of the participants said that “sugar will be under control if diet is under control.” Some participants reported healthier feeling and happiness after adopting the changes in their dietary behavior.
“My sugar was 270 when I used to eat everything-without control; my feet used to burn and hurt. It became normal when I controlled my food habits.(Now) At night I have idli; afternoon I take pavaka (bitter gourd). Now my sugar is 120.” (55-year-old female with type 2 diabetes mellitus.
Importance of family support
Getting support from family members was one important determinant of change in dietary behavior and its compliance. Some participants were able to sustain the dietary changes because they decide the family menu and can insist on cooking specific items.
“My daughter-in-law will cook the food. Also, I have kept different maavu (flour) (to make my own dish).” (50-year-old female with type 2 diabetes mellitus)
However, majority of the participants had concern regarding sustaining the dietary modification. Most of the participants were unable to maintain the dietary changes because some other family member decides the menu (usually the daughter-in-law). Often, the menu is decided according to food preference of children. Many participants reported that they have been told to eat what is prepared for the family. Some reported reluctance among their family members to cook separately for a single person.
“If we say what doctors have advised about food practices, they ask us whether those who advise will cook for you.” (55-year-old female with type 2 diabetes mellitus)
“Food cannot be cooked separately for you alone. You have to eat from what is being prepared for the family!” (50-year-old female with hypertension)
Barriers in adopting behavioral changes
Lack of family support was one of the barriers and demotivating factors for adopting dietary change behavior. Financial constraint was a major limiting factor in dietary behaviors, especially in buying vegetables and fruits on a daily basis. Most of the participants belong to lower socioeconomic status. Hence, high price of fruits in the market was unaffordable for them.
“We can't get 1 fruit to eat per day. So we don't purchase. Papaya (though locally grown) is 30–40 rs/kilo. We can eat more if we have money.” (55-year-old male with hypertension)
Nature of work (most of them being daily wage laborer or farmer) makes small frequent meals impossible. They have three meals a day because of the cost associated with more frequent meals.
“We eat only 3 meals a day; not able to eat snacks. We don't eat snacks as it will incur more cost and moreover we are not hungry in between meals.” (55-year-old female with hypertension)
| Discussion|| |
The current study tried to assess the awareness about dietary modifications in control of diabetes or hypertension and how people are practicing dietary behavior change after being diagnosed to have diabetes or hypertension.
Awareness which influences the compliance on dietary modification is an important step toward control of blood sugar and high blood pressure. In this study, most of the participants were aware of the importance of dietary modifications. Rise et al. have reported improvement in lifestyle among participants with diabetes after an educational program which improved their knowledge. Being aware of the importance of dietary modification enables participants to understand what to eat and what to avoid considering their health problems, and this is associated with better adherence to dietary modification among T2 diabetes patients.
Compliance to dietary modification is an important aspect of controlling the progression of chronic diseases such as diabetes and hypertension. Compliance to dietary modifications varies from 20% to 60% among diabetes patients., Compliance to dietary modification is best when health professionals consider the cultural aspect of eating habits and individual's taste. Some participants in our study shared their experience after being compliant to dietary modification. Awareness and attending the nutrition counseling session has enabled them to choose what to eat, which in turn was reflected in their glycemic status.
External support, especially from family members in Indian context, is important to initiate and adapt to the behavioral changes like dietary modification because decisions are taken at family level mostly.,, Initiation and compliance to dietary modifications become difficult at family level because of taboo attached to the new dietary habits, negotiating family for adapting to new dietary behaviors, especially among vulnerable people due to varied family preferences ,, and fear of social taboo and social responsibilities which render many chronic disease patients to carry on with traditional foods and eating habits., Although none of the participants expressed such stigma in our study, most of them did not receive adequate family support to follow the dietary behavior suggested by health professionals. Negotiation with family on different aspect of food habits starting from buying ration to food preparation was a challenge felt by many participants in our study.
Unavailability and high cost involved with healthy food have deterred execution of modified dietary behaviors among patients with chronic diseases despite having adequate knowledge about healthy eating options., Vijan et al. also have identified the cost of healthy food and lack of family support as important barriers to dietary modifications. Marcy et al. have identified high cost of healthy food and inability to resist the temptation to eat unhealthy as barriers in adopting new dietary habits among type 2 diabetes patients belonging to low-income group. Similar concern of high cost of healthy food items was expressed by participants in our study. Many participants in our study were daily wage laborer or farmers as in most of rural India. As stated in our study, it was not convenient for them to maintain a routine eating schedule of small frequent meals. Similar findings have been reported by Jolles et al.
This study was done to address the research gap in qualitative aspects of dietary behavior among diabetes and hypertensive patients. The results of the study have helped us in planning nutrition education sessions using specific examples of healthy practices. At the end of the study, counseling regarding dietary modifications was given to all the participants. Family members of patients with chronic diseases were invited during the health day observations at the clinic for nutrition education based on locally available items and recipes that are inexpensive and easy to prepare. Counseling of family members/caregivers has been planned in chronic disease clinic, especially for newly diagnosed patients. Commonly encountered barriers like family support wrong perceptions regarding availability and cost of healthy food should be addressed during these sessions.
| Conclusion|| |
This study found that the patients with chronic disease, such as diabetes and hypertension, were aware of importance and need of dietary self-management in controlling their disease status. However, barriers such as inadequate family support, work schedule, perceived unavailability of unhealthy foods, and high cost of healthy food have deterred them in initiating and complying with the dietary advices as per their health condition.
We thank all the interns posted in the RHTC during September 2015 and RHTC health staff for the help in conducting the FGDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J 2014;7:45-8.
Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord 2013;12:14.
Viswanathan V, Ranjan S. Diabetes – An ancient disease, epidemic & an economic burden for the present era. Indian J Med Res 2016;143:389-91.
] [Full text]
Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al.
Lifestyle interventions to reduce raised blood pressure: A systematic review of randomized controlled trials. J Hypertens 2006;24:215-33.
Price MJ. An experiential model of learning diabetes self-management. Qual Health Res 1993;3:29-54.
Mumu SJ, Saleh F, Ara F, Afnan F, Ali L. Non-adherence to life-style modification and its factors among type 2 diabetic patients. Indian J Public Health 2014;58:40-4.
] [Full text]
Arulmori S, Mahalakshmi T. Self care and medication adherence among type 2 diabetics in Puducherry, Southern India: A Hospital based study. J Clin Diagn Res 2014;8:UC01-3.
Willig AL, Richardson BS, Agne A, Cherrington A. Intuitive eating practices among African-American women living with type 2 diabetes: A qualitative study. J Acad Nutr Diet 2014;114:889-96.
Nthangeni G, Steyn NP, Alberts M, Steyn K, Levitt NS, Laubscher R, et al.
Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services. Public Health Nutr 2002;5:329-38.
Fort MP, Alvarado-Molina N, Peña L, Mendoza Montano C, Murrillo S, Martínez H, et al.
Barriers and facilitating factors for disease self-management: A qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico. BMC Fam Pract 2013;14:131.
Rajasekharan D, Kulkarni V, Unnikrishnan B, Kumar N, Holla R, Thapar R, et al.
Self-care activities among patients with diabetes attending a tertiary care hospital in Mangalore Karnataka, India. Ann Med Health Sci Res 2015;5:59-64.
] [Full text]
Shah VN, Kamdar PK, Shah N. Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Int J Diabetes Dev Ctries 2009;29:118-22.
Gopichandran V, Lyndon S, Angel MK, Manayalil BP, Blessy KR, Alex RG, et al.
Diabetes self-care activities: A community-based survey in urban Southern India. Natl Med J India 2012;25:14-7.
Doherty ML, Owusu-Dabo E, Kantanka OS, Brawer RO, Plumb JD. Type 2 diabetes in a rapidly urbanizing region of Ghana, West Africa: A qualitative study of dietary preferences, knowledge and practices. BMC Public Health 2014;14:1069.
Foley E, BeLue R. Identifying barriers and enablers in the dietary management of type 2 diabetes in M'bour, Senegal. J Transcult Nurs 2017;28:348-52.
Sohal T, Sohal P, King-Shier KM, Khan NA. Barriers and facilitators for type-2 diabetes management in South Asians: A Systematic review. PLoS One 2015;10:e0136202.
Kapur K, Kapur A, Ramachandran S, Mohan V, Aravind SR, Badgandi M, et al.
Barriers to changing dietary behavior. J Assoc Physicians India 2008;56:27-32.
Saleh F, Mumu SJ, Ara F, Hafez MA, Ali L. Non-adherence to self-care practices & medication and health related quality of life among patients with type 2 diabetes: A cross-sectional study. BMC Public Health 2014;14:431.
Ganiyu AB, Mabuza LH, Malete NH, Govender I, Ogunbanjo GA. Non-adherence to diet and exercise recommendations amongst patients with type 2 diabetes mellitus attending extension II clinic in Botswana. Afr J Prim Health Care Fam Med 2013;5:6m. Available from: http://www.phcfm.org/index.php/phcfm/article/view/457
. [Last accessed on 2016 Sep 11].
Hempler NF, Nicic S, Ewers B, Willaing I. Dietary education must fit into everyday life: A qualitative study of people with a Pakistani background and type 2 diabetes. Patient Prefer Adherence 2015;9:347-54.
Moser A, van der Bruggen H, Widdershoven G, Spreeuwenberg C. Self-management of type 2 diabetes mellitus: A qualitative investigation from the perspective of participants in a nurse-led, shared-care programme in the Netherlands. BMC Public Health 2008;8:91.
Rise MB, Pellerud A, Rygg LØ, Steinsbekk A. Making and maintaining lifestyle changes after participating in group based type 2 diabetes self-management educations: A qualitative study. PLoS One 2013;8:e64009.
Vanstone M, Giacomini M, Smith A, Brundisini F, DeJean D, Winsor S, et al.
How diet modification challenges are magnified in vulnerable or marginalized people with diabetes and heart disease: A systematic review and qualitative meta-synthesis. Ont Health Technol Assess Ser 2013;13:1-40.
Johnson AE, Boulware LE, Anderson CA, Chit-ua-aree T, Kahan K, Boyér LL, et al.
Perceived barriers and facilitators of using dietary modification for CKD prevention among African Americans of low socioeconomic status: A qualitative study. BMC Nephrol 2014;15:194.
Cross-Bardell L, George T, Bhoday M, Tuomainen H, Qureshi N, Kai J, et al.
Perspectives on enhancing physical activity and diet for health promotion among at-risk urban UK South Asian communities: A qualitative study. BMJ Open 2015;5:e007317.
Singh H, Cinnirella M, Bradley C. Support systems for and barriers to diabetes management in South Asians and whites in the UK: qualitative study of patients' perspectives. BMJ Open 2012;2:e001459.
Vijan S, Stuart NS, Fitzgerald JT, Ronis DL, Hayward RA, Slater S, et al.
Barriers to following dietary recommendations in type 2 diabetes. Diabet Med 2005;22:32-8.
Marcy TR, Britton ML, Harrison D. Identification of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus. Diabetes Ther 2011;2:9-19.