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  • Research note
  • Open Access

Dietary practice and associated factors among type 2 diabetic patients in Felege Hiwot Regional Referral Hospital, Bahir Dar, Ethiopia

  • 1Email author,
  • 2 and
  • 1
BMC Research Notes201811:434

https://doi.org/10.1186/s13104-018-3531-2

  • Received: 16 April 2018
  • Accepted: 23 June 2018
  • Published:

Abstract

Objective

Even if patient’s dietary practice is a gold standard measure to manage type 2 diabetes, there is a limited study in the area. Therefore, the objective of this study was to assess dietary practice and associated factors among type 2 diabetic patients.

Result

The study revealed that only 35.9% of the patients had good dietary practice. Attending above primary education [AOR = 1.9, 95% CI (1.1, 3.2)], having family support [AOR = 2.6, 95% CI (1.6, 4.2)], and receiving nutrition education [AOR = 2.5, 95% CI (1.5, 4.2)] were independent predictors for good dietary practice. Thus, the findings indicate the need to improve a method of nutrition education both for the patients and their families. Moreover, the government needs to improve literacy rate of citizens.

Keywords

  • Dietary practice
  • Type 2 diabetes
  • Patients
  • Ethiopia

Introduction

Diabetes mellitus (DM), a set of metabolic disorders, is characterized by persistent high blood glucose level because of errors in insulin secretion, its action, or both [1, 2]. Diabetes in the general population can be of two types, namely type 1, and type 2 DM [2]. Type 1 DM makes up 5–10% of subjects and is more common among children and adolescents. On the other hand, more than 90–95% of patients belong to type 2 diabetes, and most of them are adults [3].

Type 2 diabetes mellitus (DM) is among the leading causes of illness and death in the world. For example, in 2011 there were 366 million type 2 DM cases and the number is anticipated to rise above 552 million in 2030 [4]. In Ethiopia, the prevalence of DM was estimated to be 6.5% [5, 6].

Uncontrolled diabetes predisposes patients to develop complications such as stroke, cardiovascular diseases, nephropathy, neuropathy, and retinopathy. The situation in Ethiopia is not different from the rest of the world. Gebre, for instance, pointed out that the magnitude of DM related hypertension, retinopathy, neuropathy, and DM foot ulcer were rising in the country [7]. The same study also showed a higher rate of infectious diseases such as urinary tract infection, hepatitis, and tuberculosis among DM patients than the general population.

Many studies indicated the role of appropriate dietary intake to control type 2 DM. Consumption of adequate amount of energy and nutrients is important to decrease high blood glucose level and to slow progress of the disease [8, 9]. However, dietary practices of type 2 diabetes patients differ across and within countries. For example, good dietary practice ranges from 3.1% in Brazil to 56% in Oman [1015]. In Addis Ababa, Ethiopia 48.6% of type 2 diabetes patients had good dietary practice [16, 17]. Though the dietary practice is culture and context specific, there is limited study about the dietary practice of type 2 DM patients in the study area. Therefore, the present study was designed to assess the dietary practice and associated factors among type 2 DM patients who had follow up at Felege Hiwot Referral Hospital.

Main text

Methods

Study setting

The study was carried out in Felege Hiwot Referral Hospital. The hospital was found in Bahir Dar City, situated 565 km away from Addis Ababa, Ethiopia in the Northwest direction. During the time of data collection, there were 5629 type 2 DM patients who had follow-up in the hospital.

Study design and study population

Institution based cross-sectional study was conducted among type 2 DM patients. Type 2 DM patients who had follow-up visit in the diabetes referral clinic during the study period were the study population.

Sample size, sampling procedure and data collection

A sample size of 423 was calculated using single population proportion formula with assumption of: 95% confidence level, proportion of good dietary practice among type 2 DM patients 48.6% [18], 5% margin of error, and 10% non-response rate. Systematic sampling technique was used to select the study participants. The K-value (the interval) was calculated by dividing total number of type 2 DM patients (5629) from diabetes referral clinic registration log book to the calculated sample size. Accordingly, every 13 patients were selected, with the first sample chosen by lottery method. Interviewer-administered structured questionnaire, adapted from previous similar literature [1820], was used to collect the data.

Two experienced nurses and one laboratory technician were recruited for data collection. While the nurses were responsible for interviewing the patients, the role of the laboratory technician was for performing blood glucose level. In addition, a public health professional was assigned as their supervisor.

Height and weight of patients were measured. During weight measurement, each participant was subjected to wear light clothes. Their weight was measured to the nearest 0.1 kg using weighing scale (Sica Germany). Similarly, height was measured to the nearest 0.1 cm using stadiometer. During the measurement, each participant stood on the measuring board without shoes, considering the normal anatomical position, while heels, buttocks, shoulders, and back of the head of patients touching the board. For both height and weight two readings were recorded, and the computed average was used in the analysis. The ratio of weight in kilograms to the square of height in meters was used to determine body mass index.

The blood sample was collected from each participant. Trained laboratory technician collect the blood sample by finger puncture, following aseptic technique. The sample was collected in the morning before participants took their breakfast (after 8 h of fasting). The blood samples were immediately taken to the hospital laboratory for chemistry analyses. Fasting blood glucose test was carried out using 902 Automatic Analyzer with Roche/Hitachi kit.

The dietary practice was assessed using the modified form of the fourteen item scales taken from previous literature [18, 20]. The items were focusing on the short and long term dietary plan of patients; their attitude towards preparing diabetes diet; selection of foods items in their daily meal; and pattern of food intake within a day. The items had “Yes” or “No” response. Value 1 was given for the “Yes” response and 0 for the “No” response. First, the median value of the fourteen items for each patient was computed to classify the respondents’ dietary practice. Then, patients who scored above the median value for the response were classified as having good dietary practice and poor dietary practice otherwise.

Data quality control

Two days training was given for data collectors and supervisors. The pre-test was done on 5% of the sample size. The supervisor and investigators closely supervised data collection technique on daily basis. Weight measuring scale was adjusted by setting it to zero before weighing every participant.

Data processing and analysis

The data entry and analysis was done using SPSS version 20 for software. The dietary practice of each patient was computed from composite variables. Bivariate analysis was done and explanatory variables with P value ≤ 0.2 were taken to the multivariable logistic regression analysis to control confounders. P value < 0.05 at 95% confidence interval was taken as statistically significant in the final model.

Ethical consideration

Ethical Review Board of Bahir Dar University approved this research. The hospital administrator also gave letter of permission to undertake this study in the hospital. Then, study participants gave verbal consent to participate in the study. The research protocol approved by the IRB clearly defined the reasons for verbal consent. Informed Verbal consent was obtained because the study imposes minimal risk on study participants. Personal identifiers were excluded from the data collection form to maintain privacy and confidentiality throughout the study period.

Results

From the total of 423 type 2 diabetes mellitus patients enrolled in this study, 401 of them gave complete information, with a response rate of 94.8 percent. The mean (± SD) age of type 2 DM patients was 56.05 ± (9.18) years with age range of 40–80 years. Above half, (52.1%) of the respondents were females. Majority of patients were from Amhara ethnic group (95.3%) and Orthodox Christian followers (87.5%). Nearly three-fourth of the participants were urban residents (73.3%) and married (72.8%). More than three in ten (63.6%) of the respondents had no formal education (Table 1).
Table 1

Socio-demographic characteristics of type 2 diabetic patients at Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia, 2016, (n = 401)

Variable

Frequency

Percentage (%)

Sex

 Female

209

52.1

 Male

192

47.9

Age in year

 40–60

289

72.1

 > 60

112

27.9

Religion

 Orthodox

351

87.5

 Muslim

50

12.5

Ethnicity

 Amhara

382

95.3

 Agew

13

3.2

 Tigre

6

1.5

Educational status

 Have no formal education

255

63.6

 Primary education

48

12.0

 Secondary education

44

11.0

 Above secondary education

54

13.4

Occupational status

 Housewife

111

27.7

 Farmer

79

19.7

 Retired

73

18.2

 Government employee

67

16.7

 Merchant

44

11.0

 Daily laborer

27

6.7

Marital status

 Married

292

72.8

 Widowed

40

10.0

 Single

37

9.2

 Divorced

32

8.0

Residence

 Urban

294

73.3

 Rural

107

26.7

Health status and self-care practice of type 2 diabetes patients

Duration of the disease for 60.8% of the respondents was ≤ 5 years. More than one in three (37.4%) respondents had other chronic diseases co-morbidities, mainly hypertension (29.4%) and heart diseases (4.5%). More than one-third (34.9%) of the patients were overweight/obese. Only 7% of the participants were measuring their blood glucose level at their home, and 24.2% got nutrition education from health professionals.

Dietary practice

In this study about 35.9% [95% CI (31.0, 41.0), P-value, 0.024] of type 2 diabetes patients had good dietary practice (Table 2). More males (40.1%) compared to females (32.1%) had good dietary practice. Besides, urban residents had better dietary practice than rural dwellers (39.5% vs 26.2%).
Table 2

Dietary practice of type 2 diabetic patients at Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia, 2016, (n = 401)

Variable

Frequency

Percentage (%)

Plan the meals she/he eat ahead

 Yes

331

82.5

 No

70

17.5

Took meal based on dietary plan yesterday

 Yes

264

65.8

 No

137

34.2

Took meal based on dietary plan over the past 2 weeks

 Yes

185

46.1

 No

216

53.9

Always eat based on dietary plan

 Yes

150

37.4

 No

251

62.6

Always eat based on dietary plan, even when she/he feels her/his blood glucose level is controlled

 Yes

163

40.6

 No

238

59.4

Never feel hassled to stick on dietary plan

 Yes

210

52.4

 No

191

47.6

Have no feelings of dietary deprivation

 Yes

225

56.1

 No

176

43.9

Follow flexible eating plan

 Yes

147

36.7

 No

254

63.3

Eat fruits daily

 Yes

37

9.2

 No

364

90.8

Eat vegetables daily

 Yes

45

11.2

 No

356

88.8

Cut down butter intake

 Yes

265

66.1

 No

136

33.9

Cut down fat intake

 Yes

318

79.3

 No

81

20.7

Cut down sweet and soft drink intake

 Yes

255

63.6

 No

146

36.4

Always follow regular meal time

 Yes

128

31.9

 No

273

68.1

Overall practice

 Good

144

35.9

 Poor

257

64.1

Factors affecting the dietary practice of type 2 diabetic patients

The bivariate logistic regression analysis showed that sex, educational status, nutrition education on diabetes diet, availability of fruits, availability of vegetables, family support and awareness on diabetes diet were statistically associated with the dietary practice of type 2 diabetic patients.

From the multivariable logistic regression analysis, type 2 diabetic patients who get counseling on diet were 2.5 times more likely to have better practice than their counterparts [AOR = 2.5, 95% CI (1.5, 4.2)]. Likewise, patients who attended secondary education and above were 1.9 times more likely to have good dietary practice than those who attend less than secondary education [AOR = 1.9, 95% CI (1.1, 3.2)]. The odds of having good dietary practice was 2.6 times higher among respondents who had awareness on diabetes diet than patients who had no awareness [AOR = 2.6, 95% CI (1.5, 4.6)]. Family support also showed association with dietary practice. In this aspect, Participants who had family support were 2.6 times more likely to have good dietary practice than patients who did not have family support [AOR = 2.6, 95% CI (1.6, 4.2)] (Table 3).
Table 3

Factors associated with dietary practice of type 2 diabetic patients at Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia, 2016

Variable

Dietary practice

COR (95% CI)

AOR (95% CI)

Good practice

Poor practice

Get nutrition education on diabetes diet at hospital

 Yes

48 (49.5)

49 (50.5)

2.1 (1.3, 3.3)

2.5 (1.5, 4.2)**

 No

96 (31.8)

206 (68.2)

1.00

1.00

Availability of fruits

 Yes

44 (46.3)

51 (54.7)

1.7 (1.1, 2.8)

 

 No

100 (32.7)

206 (67.3)

1.00

 

Availability of vegetables

 Yes

37 (46.8)

42 (53.2)

1.7 (1.1, 2.9)

 

 No

107 (33.2)

215 (66.8)

1.00

 

Have family support

 Yes

61 (51.3)

58 (48.7)

2.5 (1.6, 3.9)

2.6 (1.6, 4.2)**

 No

83 (29.4)

199 (70.6)

1.00

1.00

Awareness on diabetes diet

 Yes

120 (40.8)

174 (59.2)

2.3 (1.4, 3.9)

2.6 (1.5, 4.6)**

 No

24 (22.4)

83 (77.6)

1.00

1.00

Educational status

 Less than secondary

92 (30.4)

211 (69.6)

1.00

1.00

 Secondary and above

52 (53.1)

46 (46.9)

2.1 (1.3, 3.4)

1.9 (1.1, 3.2)**

Thinking of low cost of food

 Yes

109 (38.1)

177 (61.9)

1.4 (0.8, 2.2)

 

 No

35 (30.4)

80 (69.6)

1.00

 

Sex

 Male

77 (40.1)

115 (59.9)

1.4 (0.9, 2.1)

 

 Female

67 (32.1)

142 (67.9)

1.00

 

Residence

 Urban

116 (39.5)

178 (60.5)

1.8 (1.1, 3.0)

 

 Rural

28 (26.2)

79 (73.8)

1.00

 

Age (years)

 40–60 

107 (37.0)

182 (63.0)

1.1 (0.7, 1.8)

 

 > 60 

37 (33.0)

75 (67.0)

1.00

 

Marital status

 Married

101 (34.6)

191 (65.4)

0.8 (0.5, 1.2)

 

 Single/divorced/widowed

43 (39.4)

66 (60.6)

1.00

 

COR crude odds ratio, AOR adjusted odds ratio, C/I confidence interval

** P-value < 0.01

Discussion

In this study only 35.9% [95% CI (31.0, 41.0), P-value, 0.024] of the respondents had appropriate dietary practice. This practice is better than the study finding in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia (22.2%) [21]. The difference might be due to the time gap between studies; currently, more nutrition education is given on diabetes diet than do the earlier. Moreover, there is better internet access and media coverage now than in the past, which might contribute for improving knowledge on diabetes diet.

On the other hand, this practice is lower than study findings in Yekatit 12 Hospital, Addis Ababa, Ethiopia (48.6%) [22] and Botswana (62.8%) [23]. This discrepancy might be due to the difference in study settings and study subjects; this study was done among urban and rural residents with the low level of education whereas the former studies were done among urban residents with better educational status.

Patients who got nutrition education on diabetes diet were more likely to have good dietary practice than their counterparts. This finding is similar with the study findings in Ethiopia [24], Iran [25], and Nepal [26]. This may be due to the fact that nutrition education changes dietary behavior.

Educational status of respondents had an association with their dietary practice. This is in line with study findings in Addis Ababa, Ethiopia [21, 22], Iran [25] and Bahrain [27]. The correlation between higher educational attainment of respondents and appropriate dietary practice might be explained by the fact that patients with better education have better access to information from books, leaflets, newspaper and social media than uneducated patients. Additionally, educated participants could better understand nutrition education given by professionals or through mass media than uneducated people.

Having awareness of diabetes diet was an important predictor of good dietary practice. This is in agreement with the study finding in Nepal [26]. When people have awareness on the benefit of having diabetes diet plan they are more likely to adopt and maintain the newly adopted behavior [28, 29].

Family support was also another predictor of appropriate dietary practice. This is in agreement with the study finding in Bahrain [27]. Positive family support is the means of promoting preventive measures like good dietary practice and other diabetes self-care practices [30, 31].

Conclusion and recommendation

In this study, the dietary practice of type 2 diabetes patients was poor. Factors associated with good dietary practice were getting nutrition education on diabetes diet management, attending secondary school and above, and having awareness of diabetes diet and family support. Thus, findings recommend the need to give context based nutrition education to patients and families. Moreover, the government needs to work more in improving the literacy rate of citizens.

Limitation

Assessing the level of practice using self-reported dietary practice might introduce social desirability bias. However, to minimize this bias detail explanation was provided about the aim of the study.

The result need to be used with caution as some of the variables (such as availability of fruits and vegetables) did not show association in our final model which otherwise could have contribution to dietary practice of diabetes patients. Thus, we recommend future studies with large sample size.

Abbreviations

AOR: 

adjusted odds ratio

CI: 

confidence interval

COR: 

crude odds ratio

DM: 

diabetes mellitus

Declarations

Authors’ contributions

YMD: conceived and designed the study, conducted statistical analysis and result interpretation, prepared manuscript. AAE: assisted the study design, conducted statistical analysis and result interpretation, prepared manuscript. ATA: assisted the study design, data analysis and result interpretation, prepared manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to express our gratitude to the study participants who participated in this study and provided valuable information with their full cooperation. We also acknowledge the data collectors and supervisor for their time and full commitment.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All the data related to this research are available in text, figures or tables.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethical Review Board of Bahir Dar University approved this research. The hospital administrator also gave letter of permission to undertake this study in the hospital. Then, the study participants gave verbal consent to participate in the study. The research protocol approved by the IRB clearly defined the reasons for verbal consent. Informed Verbal consent was obtained because the study imposes minimal risk on study participants. Personal identifiers were excluded from the data collection form to maintain privacy and confidentiality throughout the study period.

Funding

This research was funded by Bahir Dar University.

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Authors’ Affiliations

(1)
School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, P.O.Box 79, Bahir Dar, Ethiopia
(2)
School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, P.O.Box 79, Bahir Dar, Ethiopia

References

  1. Alberti KG, Zimmet PF. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus. Provisional report of a WHO consultation. Diab Med. 1998;15(7):539–53.View ArticleGoogle Scholar
  2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diab Care. 2015;38(Supplement 1):S8–16.View ArticleGoogle Scholar
  3. Kharroubi AT, Darwish HM. Diabetes mellitus: the epidemic of the century. World J Diab. 2015;6(6):850.View ArticleGoogle Scholar
  4. Sami W, Ansari T, Butt NS, Hamid MRA. Effect of diet on type 2 diabetes mellitus: a review. Int J Health Sci. 2017;11(2):65–71.Google Scholar
  5. Yeman T, Belachew T, Asaminew B, Befekadu O. The prevalence of type 2 diabetes mellitus in Jimma town. Ethiop J Health Dev. 2007;17(2):107–14.Google Scholar
  6. Nshisso L, Reese A, Gelaye B, Lemma S, Berhane Y, Williams MA. Prevalence of hypertension and diabetes among Ethiopian adults. Diab Metab Syndr. 2012;6(1):36–41. https://doi.org/10.1016/j.dsx.2012.05.005.View ArticleGoogle Scholar
  7. Gebre MW. Diabetes mellitus and associated diseases from Ethiopian perspective: systematic review. Ethiop J Health Dev. 2013;27(3):249–53.Google Scholar
  8. Mann J, DeLeeuw I, Hermansen K, Karamanos B, Karlström B, Katsilambros N, et al. Evidence based nutritional approaches to the treatment and prevention of diabetes mellitus. Nutr Metab Cardiovasc Dis. 2004;14:373–94.View ArticlePubMedGoogle Scholar
  9. Broadbent E, Donkin L, Stroh J, Psych D. Illness and treatment perceptions are associated with adherence to medications, diet, and exercise in diabetic patients. Diab Care. 2011;34:338–40.View ArticleGoogle Scholar
  10. Faria HT, Rodrigues FF, Zanetti ML, Araújo MF, Damasceno MM. Factors associated with adherence to treatment of patients with diabetes mellitus. Acta Paul Enferm. 2013;26(3):231–7.View ArticleGoogle Scholar
  11. Taruna S, Juhi K, Dhasmana D, Harish B. Poor adherence to treatment: a major challenge in diabetes. J Indian Acad Clin Med. 2014;15(1):40.Google Scholar
  12. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, Nagelkerke N. Assessment of dietary practice among diabetic patients in the united arab emirates. Rev Diab Stud. 2008;5(2):110.View ArticleGoogle Scholar
  13. Zeyana S, Shah A, Pratap D. Evaluation of T2DM related knowledge and practices of Omani patients. Saudi Pharm J. 2015;23:22–7.View ArticleGoogle Scholar
  14. Eman MM, Hala IA. Compliance to diabetes self-management in rural El-MinIa, Egypt. Central Eur J Public Health. 2011;19(1):35–41.View ArticleGoogle Scholar
  15. Ganiyu AB, Mabuza LH, Malete NH, Govender I, Ogunbanjo GA. Nonadherence 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(1):6. https://doi.org/10.4102/phcfm.v5i1.457.View ArticleGoogle Scholar
  16. Kalayou KB, Alemayehu BK, Haftu BG. Adherence to diabetes self-management practices among type 2 diabetic patients in Ethiopia; a cross sectional study. Greener J Med Sci. 2013;3(6):211–21.View ArticleGoogle Scholar
  17. Yohannes A, Akine E, Endalew H. Assessment of diabetic patient perception on diabetic disease and self-care practice in Dilla University Referral Hospital, South Ethiopia. J Metab Syndr. 2013;3(4):2167-0943.Google Scholar
  18. Amelmal W, Solomon MA, Molla MW. Dietary practice and associated factors among type 2 diabetic patients: a cross sectional hospital based study, Addis Ababa. Ethiopia SpringerPlus. 2015. https://doi.org/10.1186/s40064-015-0785-1.View ArticleGoogle Scholar
  19. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin Epidemiol. 2011;64(3):255–7.View ArticlePubMedGoogle Scholar
  20. Plakas S, Mastrogiannis D, Mantzorou M, Adamakidou T, Fouka G, Bouziou A, et al. Validation of the 8-item morisky medication adherence scale in chronically ill ambulatory patients in rural greece. Open J Nurs. 2016;6:158–69. https://doi.org/10.4236/ojn.2016.63017.View ArticleGoogle Scholar
  21. Berhe KK, Demissie A, Kahsay AB, Gebru HB. Diabetes self care practices and associated factors among type 2 diabetic patients in Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia—a cross sectional study. Int J Pharm Sci Res. 2012;3(11):4219–29.Google Scholar
  22. Amelmal W, Solomon MA, Molla MW. Dietary practice and associated factors among type 2 diabetic patients: a cross sectional hospital based study, Addis Ababa. Ethiopia SpringerPlus. 2015;4:15. https://doi.org/10.1186/s40064-015-0785-1.View ArticleGoogle Scholar
  23. 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 Prm Health Care Fam Med. 2013;5(1):1–6. https://doi.org/10.4102/phcfm.v5i1.457.View ArticleGoogle Scholar
  24. Addisu Y, Eshete A, Hailu E. Assessment of diabetic patient perception on diabetic disease and self-care practice in Dilla University Referral Hospital, South Ethiopia. J Metab Synd. 2014;3(4):166. https://doi.org/10.4172/2167-0943.1000166.View ArticleGoogle Scholar
  25. Tol A, Mohebbi B, Sadeghi R. Evaluation of dietary habits and related factors among type 2 diabetic patients: an innovative study in Iran. J Educ Health Prom. 2014;3:4.View ArticleGoogle Scholar
  26. Parajuli J, Saleh F, Thapa N, Ali L. Factors associated with nonadherence to diet and physical activity among nepalese type 2 diabetes patients; a cross sectional study. BMC Res Notes 2014;7(758):758. http://0-www.biomedcentral.com.brum.beds.ac.uk/1756-0500/7/758.
  27. Shamsi N, Shehab Z, AlNahash Z, AlMuhanadi S, Al-Nasir F. Factors influencing dietary practice among type 2 diabetics. Bahrain Med Bull. 2013;35:3.View ArticleGoogle Scholar
  28. Foma MA, Saidu Y, Omoleke SA, Jafali J. Awareness of diabetes mellitus among diabetic patients in the Gambia: a strong case for health education and promotion. BMC Public Health. 2013;13(1):1124.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Nazar CMJ, Bojerenu MM, Safdar M, Marwat J. Effectiveness of diabetes education and awareness of diabetes mellitus in combating diabetes in the United Kigdom; a literature review. J Nephropharmacol. 2016;5(2):110.PubMedGoogle Scholar
  30. Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve diabetes outcomes for adults. Ann NY Acad Sci. 2015;1353(1):89–112.View ArticlePubMedGoogle Scholar
  31. Pamungkas RA, Chamroonsawasdi K, Vatanasomboon P. A systematic review: family support integrated with diabetes self-management among uncontrolled type II diabetes mellitus patients. Behav Sci. 2017;7(3):62.View ArticleGoogle Scholar

Copyright

© The Author(s) 2018

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