International Journal of Academic Medicine

: 2023  |  Volume : 9  |  Issue : 1  |  Page : 25--30

Diet adherence and factors associated with nonadherence among Type 2 diabetics at an urban health center in Tamil Nadu, India

Janani Selvam, Prabha Thangaraj, Kumarasamy Hemalatha, Pandi Subbian 
 Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Tiruchirappalli, Tamil Nadu, India

Correspondence Address:
Dr. Prabha Thangaraj
Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Tiruchirappalli - 621 105, Tamil Nadu


Introduction: Diabetes is a slow epidemic causing threat to public health worldwide. Several studies have been done to assess the medication adherence among patients with diabetes. The present study has focused on dietary adherence and attempted to identify factors associated with nonadherence to a diabetic diet. Materials and Methods: A cross-sectional study was conducted among 284 patients with type 2 diabetes visiting the outpatient department of an urban health-care center in Tamil Nadu, India. A semi-structured questionnaire was used for data collection. Summary of Diabetes Self-Care Activities tool was used to assess adherence for medication and physical activity while Perceived Dietary Adherence Questionnaire tool was used to assess the adherence to diabetic diet. Results: The dietary adherence was high in only 4.2% (95% confidence interval [CI]: 2.20–7.26) of the patients with diabetes while 73.2% (95% CI: 67.69–73.30) and 22.5% (95% CI: 17.81–27.84) had medium and low adherence to diabetic diet, respectively. Adherence to medication and exercise were 91.5% and 63.4%, respectively. The duration of diabetes, higher body mass index, presence of comorbidity, history of diabetic complication, and adherence to exercise were associated with better compliance to diet while socioeconomic status was not. Conclusion: The present study has identified poor adherence to diabetic diet in spite of good medication adherence. The practice of spacing of carbohydrate food and intake of Omega-3 fats needs to be improved while the consumption of food rich in other fats should be decreased. Dietary fiber intake can also be better. The findings can help plan future study to identify barriers to diet adherence and also effective methods to improve dietary practices among the patients with diabetes. The following core competencies are addressed in this article: Medical knowledge, Patient care, Systems-based practice, Practice-based learning and improvement.

How to cite this article:
Selvam J, Thangaraj P, Hemalatha K, Subbian P. Diet adherence and factors associated with nonadherence among Type 2 diabetics at an urban health center in Tamil Nadu, India.Int J Acad Med 2023;9:25-30

How to cite this URL:
Selvam J, Thangaraj P, Hemalatha K, Subbian P. Diet adherence and factors associated with nonadherence among Type 2 diabetics at an urban health center in Tamil Nadu, India. Int J Acad Med [serial online] 2023 [cited 2023 Jun 10 ];9:25-30
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Full Text


Diabetes mellitus (DM) is a slow epidemic causing threat to the public health worldwide. The International Diabetes Federation had estimated that 415 million people globally suffered with diabetes in 2015 and predicted that it would increase to 642 million by 2040.[1] The burden of diabetes in India, among adults has increased from 5.5% in 1990 to 7.7% in 2016. A nationwide study by the Indian Council of Medical Research (ICMR) from 1990 to 2016, stated that the prevalence of diabetes was highest in Tamil Nadu, Kerala and Delhi, followed by Punjab, Goa and Karnataka.[2]

A significant proportion of health-care budget globally is spent on diabetes medication.[3] However, this alone will not help control diabetes and its complications since nutrition therapy has always been an accepted cornerstone in the management of diabetes[4] which is often neglected in our society. Several studies have been done in India to assess the overall self-care practices of patients with diabetes[5],[6],[7],[8],[9] and adherence to diabetes medication[10],[11],[12],[13],[14] while only few studies[15] have focused specifically on the dietary adherence. This probably could be due to the absence of diabetes nutrition practice guidelines by the health-care providers in India[16] or the difficulty in obtaining dietary information from the patients. However, clinical evidence suggests that adherence to the recommended diet achieves 1%–2% decrease in HbA1c, which is similar to intake of antidiabetic medication, thus decreasing the health-care cost and contributing to the improvement of overall health and quality of life.[17],[18] The present study has been done with the objective to assess the dietary practice among the patients with type 2 diabetes visiting a health center in an urban area of Tamil Nadu and to identify factors associated with nonadherence. This study population is unique since most of them are daily wage workers with educational background of primary or middle school, who visit our center on regular basis for diabetes management. Understanding their dietary practice can assist to plan future nutritional intervention through diet counseling and education.

 Materials and Methods

A cross-sectional study was done among patients diagnosed of diabetes, visiting outpatient department between May and July 2021 of an Urban Health Center under the Department Community of a Medical College in Tamil Nadu, South India. The minimum required sample size was calculated as 272 by using the following formula n = z2pq/d2, where n = required sample size, p = prevalence of dietary compliance in a previous study[10] was 76.9%, q = 1 − p and d = absolute precision 5%, and z = level of confidence measured; for 95% confidence interval (CI) (α = 0.05), z = 1.96. Further assuming 10% nonresponse rate, the sample size was estimated to be 299.

Nonprobability purposive sampling was done with inclusion criteria of all registered patients with type 2 diabetes attending the urban health center attached to community medicine department of a medical college during the research period, patients aged ≥18 years and under DM treatment for at least 1 year duration. Patients with gestational diabetes, severe comorbidity, severe mental illness, and not willing to participate were excluded. Consecutive sampling of patients with diabetes who satisfied the selection criteria was done on all days of the week during the study period till the required sample size was obtained.

Data collection tool

Based on review of literature a semi-structured questionnaire with both open- and closed-ended questions was prepared to collect the necessary data. The questionnaire has three sections:

Section 1: Sociodemographic information of such as age, sex, occupation, education, income.

Section 2: Diabetic profile of the study participants such as age of onset, duration, co-morbid condition, adherence to diet, and medication. Summary of Diabetes Self-Care Activities Measure (SDSCA)[19] was used to assess patient adherence to medication and physical activity.

Section 3: Adherence to diabetic diet was assessed using a validated tool i.e., Perceived Dietary Adherence Questionnaire (PDAQ).[20] The maximum score that can be obtained from questionnaire is 63. Based on previous study[21] a score of >46 (i.e. 75%) was considered adherent to diabetic diet.

A pilot study was done among 20 patients with Type 2 diabetes to check the feasibility and adequacy of the data collection tool. Data collection was done by principal investigator followed by the distribution of health education pamphlet and counselling to adhere to diabetic diet.

Operational definition

Dependent variable

Adherence to diabetic diet.

PDAQ was used to assess the adherence to diabetic diet. A score of more than 46 out of 63 was considered adherent and those scoring ≤45 was categorized as nonadherent.

Independent variable

Based on the review of literature,[22],[23] biological (age, sex, family history, etc.), socioeconomic (education, occupation, etc.), and behavioral (adherence to medication and exercise, etc.) factors that may have a role in determining the adherence to diabetic diet.

Statistical analysis

Data entry was be done in MS Excel software in codes and analysis in SPSS software version 21 (IBM Corp., Armonk, NY, USA). Baseline characteristics were expressed in frequency and percentage. Each item of the PDAQ questionnaire was expressed in mean and standard deviation, whereas the overall adherence to diabetic diet in percentage and 95% CI. Chi-square test was used to identify the factors associated with adherence to diabetic diet and P < 0.05 was considered to be statistically significant.

 Observation and Results

Of the total 295 patients with diabetes were surveyed, of which 284 satisfying the inclusion criteria and were included for the final analysis. The mean age of study participants was 56.87 ± 11.7 years. The socioeconomic and diabetic profile of the study participants is given in [Table 1] and [Table 2], respectively.{Table 1}{Table 2}

Response to the individual 9 items of PDAQ scale is represented in [Table 3]. Overall dietary adherence was found to be high only in 4.2% (95% CI: 2.20–7.26) of the study population while medium and low dietary adherence was seen among 73.2% (95% CI: 67.69–73.30) and 22.5% (95% CI: 17.81–27.84), respectively [Figure 1].{Figure 1}{Table 3}

In the present study, 162 (57%) patients with diabetes agreed that their physician had advised them on diabetic diet. Of these, 118 (72.8%) responded that their treating physician regularly enquired about their dietary practice during their follow-up visit. Regarding the family support received by patient with diabetes in adhering to diabetic diet was always present in 90 (55.6%) and sometimes in 40 (24.7%). The remaining 32 (19.7%) reported no family support in dietary adherence.

It was seen that greater the duration of diabetes (>5 years), presence of comorbid conditions, presence of obesity, and history of diabetic complication were found to be statistically significant at P < 0.05. None of the socioeconomic factors was found to be associated with dietary adherence. Among the behavioral factors, those with adherence to exercise based on SDSCA were better adherent to diabetic diet which was statistically significant (P < 0.05).


The present study was done in the Urban Health Training Center attached to Department of Community Medicine of a Private Medical College in Trichy. Most of them are daily wage worker belonging to the lower socio-economic class (65.5%), residing within 3 km radius of the center on regularly follow-up.

Greater proportion of patients with diabetes in our study had regular physician visits, blood sugar testing, and medication adherence. This could be because the center provides free blood test and medication for 20 days. The free medication is not given over the counter by the pharmacist but only on the doctor's prescription. Similarly, a study done in government hospital also reported high adherence to medication due to drugs given free of cost.[23] Similar results were obtained by studies in Karnataka[8] and Tamil Nadu.[9] All these studies have been conducted among patients attending a health-care setting, which is visited by patients who are more health conscious. There is a need to conduct these survey in urban community setting to identify any discrepancy in diet adherence rate among those regularly visiting the health center versus those not under regular checkup.

Dietary adherence based on the PDAQ in the present study was high among 4.2% of patients with diabetes, while medium and low adherence was seen in 73.2% and 22.5%, respectively. Similar findings were obtained in Nepal[21] and Ethiopia.[24] However, a study done in Western India in a similar setting found a very high dietary adherence of 76%.[15] Other studies done worldwide show a varying proportion of adherence ranging from 2.2% in Egypt,[25] 38% in Mexico,[26] and 63% in South Africa.[27] However, these studies have used different tools to assess the dietary adherence thus making comparison and interpretation difficult.

Among the expected diabetic dietary practices using the PDAQ tool, it was found that higher mean score was obtained on adequate intake of fruits and vegetables and overall adherence to healthy meal plan. Faulty dietary practices seen were poor spacing of carbohydrate food, decreased intake of Omega-3 fats, and high consumption food rich in other fats. Similar findings were reported in a study done in Nepal.[21] However, a study done in India found better adherence toward spacing of carbohydrates and overall healthy meal plan but poor intake of fruits and vegetables.[23]

Our study found good dietary adherence among those with more than 5 years of diabetes, body mass index (BMI) of more than 24.9, presence of comorbidity, and diabetic complication. Similar finding has also been documented in other studies.[23],[28] A study done in Surat[15] found duration of diabetes to be associated with good dietary adherence but not the presence of comorbidity. The factors such as age and education were not significantly associated with dietary adherence, but other studies have found age <40 years were 2.8 times more adherent[22] and literate more adherent than illiterate.[15],[21] Except for one study[15] in which females were more adherent none other studies found sex to influence dietary practices. Interestingly, none of these studies found socioeconomic status to be associated with better dietary adherence similar to our study. Thus, there is a scope to improve dietary practices among these urban residency from the lower economic background.

Those with better exercise adherence were also adherent to their diet but not those with medication adherence. Physician advice on dietary practice and also regular dietary follow-up among those patients was not associated with better dietary adherence. However, others studies[22],[24],[29] have reported patients with diabetes receiving health education on diabetic diet were better adherent. This suggests a need for further research to identify the quality of dietary advice given by the health-care provider and whether patients understood the same. A study from Ethiopia has highlighted the fact that even though numerous efforts have been taken by the stake holders, there exist a significant proportion of nonadherence to dietary recommendation.[24] Health-care providers typically blame patients for being noncompliant to dietary adherence while on the other side patients feel health care professionals do not provide a realistic and practical solution to their problem thus leading to lack of mutual trust. Noncompliance should be viewed as feedback indicating that the current approach is not working and a need for alternative approach.[29]

Those diagnosed of prediabetes or diabetes need medical nutritional therapy (MNT) which comprises the use of nutritional and behavioral science along with the physical activity. ICMR has given guidelines for MNT needing four prolonged approach. First, nutritional assessment of the patients includes lifestyle parameter. Second, setting goal that are patient centered, practical, and achievable. Third, nutritional intervention of providing nutritional education and individualized meal plans based on their family eating habits. Finally, evaluation to assess if the patient is able to achieve the set goal and make necessary changes accordingly.[30] Global evidence suggests that MNT is as advantageous as pharmacologic intervention and should be implemented with equal importance. Its effective implementation can enhance better control of diabetes but demands alterations in established eating patterns and habits.

We have used the PDAQ tool, which reflects the dietary practice over the past 1 week. Certain issues such as religious festivals, fasting, family functions, and other occasions can temporarily affect their dietary practices. Some individuals might not want to reveal their negligence towards self-care and dietary practice making them report falsely. Finally, this study was conducted during the COVID-19 pandemic lockdown which might also influence the study findings. Apart from these limitations the study provides an insight into the current dietary practices of patients with diabetes in our urban field practice area.


The present study found a poor dietary adherence among patients with type 2 diabetes attending a primary health in spite of good medication adherence and regular testing of blood sugar level. The practice of spacing of carbohydrate food and intake of omega-3 fats needs to improve while intake of food rich in other fats should be decrease. Dietary fibre intake can also be better. Duration of diabetes, higher BMI, presence of co-morbidity, and diabetic complication were associated with better compliance to diet while socioeconomic status was not. Thus, highlights the scope to improve diet adherence among the lower economic group in our setting. This study provides the baseline data on which we can plan further interventional studies to improve dietary practices.


The author's thank the patients for their participation in the study. We also thank the staffs of Urban Health Centre, Samayapuram for their support in conducting this research.

Financial support and sponsorship

This study was financially supported by ICMR STS 2020 (Indian Council of Medical Research, Short term student funding).

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

Institutional IRB and IEC clearance was obtained prior to the study (Ref.No. 14/TSRMMCH&RC/ME-1/2020-IEC No: 007 dated January 31, 2020). Clinical registration was not done since it was an observational study. The authors declare that the research writing of this study was done according to the EQUATOR Network reporting guidelines.


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