Document Type : Original Article

Authors

1 Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran

2 Departments of Health Education and Promotion and Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences

Abstract

INTRODUCTION: Diet adherence may cause diabetes complications to be diminished.
OBJECTIVES: This study aimed at identifying determinants of diet adherence among patients with
Type 2 diabetes based on the health action process approach (HAPA).
METHODS: In this cross-sectional study, 734 patients with Type 2 diabetes, attending to South Tehran
health centers, were recruited during June–December 2018. The dietary regimen scale (nine items)
and a researcher-designed questionnaire consisting of HAPA constructs were used to gather the
data. Data were analyzed using the Mann–Whitney test, Pearson Chi-squared test, Fisher’s exact
test, and linear regression test. All statistical tests were assessed using SPSS (IBM Corp. Released
2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp.).
RESULTS: The level of nonadherence to diet was 91.1%. Diet adherence was significantly associated
with family income (P = 0.005), level of education (P < 0.001), and age (P = 0.009). The linear
regression showed that 55% of the variance of diet adherence was determined by HAPA variables.
Diet adherence was associated with intention (P < 0.001), action planning (P = 0.005), and barriers
(P = 0.003).
CONCLUSION: Most of the patients did not adhere to their diet. Appropriate programs should be
designed to promote diet adherence among the patients, especially those with low literacy and
patients living in poor communities.

Keywords

  1. Ministry of Health and Medical Education. Diabetes: Ministry
    of Health and Medical Education; 2019. Available from: http://
    salamat.gov.ir/index.jsp?siteid=326&fkeyid=&siteid=326&p
    ageid=53525. [Last updated on 2018 Nov 10; Last accessed on
    2019 Apr 13].
    2. Mirahmadizadeh A, Khorshidsavar H, Seif M, Sharifi MH.
    Adherence to medication, diet and physical activity and the
    associated factors amongst patients with type 2 diabetes. Diabetes
    Ther 2020;11:479-94.
    3. WHO. Diabetes: WHO Web Site; 2019. Available from: https://
    www.who.int/health-topics/diabetes. [Last accessed on
    2019 Jun 14].
    4. American Diabetes Association. Standards of medical care in
    diabetes--2014. Diabetes Care 2014;37 Suppl 1:S14-80.
    5. Albanese AM, Huffman JC, Celano CM, Malloy LM, Wexler DJ,
    Freedman ME, et al. The role of spousal support for dietary
    adherence among type 2 diabetes patients: A narrative review.
    Soc Work Health Care 2019;58:304-23.
    6. Qian F, Liu G, Hu FB, Bhupathiraju SN, Sun Q. Association
    between plant-based dietary patterns and risk of type 2 diabetes:
    A systematic review and meta-analysis. JAMA Intern Med 2019;
    doi: 10.1001/jamainternmed.2019.2195. [Epub].
    7. Dow C, Balkau B, Bonnet F, Mancini F, Rajaobelina K, Shaw J,
    et al. Strong adherence to dietary and lifestyle recommendations
    is associated with decreased type 2 diabetes risk in the AusDiab
    cohort study. Prev Med 2019;123:208-16.
    8. Aflakseir A, Zarrinpour R. Predicting adherence to diet regimen
    based on health locus of control: A cross sectional study. IJDO
    2013;5:71-6.
    9. Mohammed MA, Sharew NT. Adherence to dietary
    recommendation and associated factors among diabetic patients
    in Ethiopian teaching hospitals. Pan Afr Med J 2019;33:260.
    10. Musee C, Omondi D, Odiwuor W. Dietary Adherence pattern in
    the context of type 2 diabetic management within clinical setting,
    Kenya. Int J Diabetes Res 2016;5:26-34.
    11. 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 Botswan. Afr J Prim Health Care Fam Med 2013;5:457.
    12. 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.
    13. Cheng LJ, Wu VX, Dawkes S, Lim ST, Wang W. Factors influencing
    diet barriers among outpatients with poorly-controlled type 2
    diabetes: A descriptive correlational study. Nurs Health Sci
    2019;21:102-11.
    14. Pereira MG, Pedras S, Ferreira G, Machado JC. Family and couple
    variables regarding adherence in type 2 diabetes patients in the
    initial stages of the disease. J Marital Fam Ther 2019;45:134-48.
    15. Jaworski M, Panczyk M, Cedro M, Kucharska A. Adherence to
    dietary recommendations in diabetes mellitus: Disease acceptance
    as a potential mediator. Patient Prefer Adherence 2018;12:163-74.
    16. McNabb WL. Adherence in diabetes: Can we define it and can
    we measure it? Diabetes Care 1997;20:215-8.
    17. Gholami M, Lange D, Luszczynska A, Knoll N, Schwarzer R.
    A dietary planning intervention increases fruit consumption in
    Iranian women. Appetite 2013;63:1-6.
    18. Schwarzer R, Sniehotta FF, Lippke S, Luszczynska A, Scholz U,
    Schüz B, et al. On the Assessment and Analysis of Variables in the
    Health Action Process Approach: Conducting an Investigation.
    Berlin: Freie Universeitat Berlin; 2003.
    19. Rohani H, Eslami AA, Ghaderi A, Bidkhori M, Raei M.
    Development and psychometric evaluation of a health action
    process approach inventory for healthful diet among type 2
    diabetes patients. Int J Prev Med 2016;7:69.
    20. MacPhail M, Mullan B, Sharpe L, MacCann C, Todd J. Using the
    health action process approach to predict and improve health
    outcomes in individuals with type 2 diabetes mellitus. Diabetes
    Metab Syndr Obes 2014;7:469-79.
    21. Renner B, Schwarzer R. In: Risk and Health Behaviors.
  2. Documentation of the Scales of the Research Project: “Risk
    Appraisal Consequences In Korea” (rack). International
    University Bremen & Freie Universität Berlin. 2005. p. 2.
    22. Joveini H. The effects of empoverment program based on the
    theory of planned behaviour and the Health Action Process
    Approach for hookah cessation among college students [Phd].
    Tehran: Tehran University of Medical Sciences; 2016.
    23. Renner B, Kwon S, Yang BH, Paik KC, Kim SH, Roh S, et al.
    Social-cognitive predictors of dietary behaviors in South Korean
    men and women. Int J Behav Med 2008;15:4-13.
    24. Schwarzer R, Renner B. Social-cognitive predictors of health
    behavior: Action self-efficacy and coping self-efficacy. Health
    Psychol 2000;19:487-95.
    25. Sniehotta FF, Scholz U, Schwarzer R. Bridging the
    intention–behaviour gap: Planning, self-efficacy, and action
    control in the adoption and maintenance of physical exercise.
    Psychol and Health 2005;20:143-60.
    26. Lawshe CH. A quantitative approach to content validity 1. Pers
    Psychol 1975;28:563-75.
    27. Baumgartner TA, Chung H. Confidence limits for intraclass
    reliability coefficients. Measurement Phys Educ Exercise Sci
    2001;5:179-88.
    28. Negarandeh R, Mahmoodi H, Noktehdan H, Heshmat R,
    Shakibazadeh E. Teach back and pictorial image educational
    strategies on knowledge about diabetes and medication/dietary
    adherence among low health literate patients with type 2 diabetes.
    Prim Care Diabetes 2013;7:111-8.
    29. Ayele AA, Emiru YK, Tiruneh SA, Ayele BA, Gebremariam AD,
    Tegegn HG. Level of adherence to dietary recommendations and
    barriers among type 2 diabetic patients: A cross-sectional study
    in an Ethiopian hospital. Clin Diabetes Endocrinol 2018;4:21.
    30. 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.
    31. Ewers B, Trolle E, Jacobsen SS, Vististen D, Almdal TP, Vilsbøll T,
    et al. Dietary habits and adherence to dietary recommendations
    in patients with type 1 and type 2 diabetes compared with the
    general population in Denmark. Nutrition 2019;61:49-55.
    32. Yeh JZ, Wei CJ, Weng SF, Tsai CY, Shih JH, Shih CL, et al.
    Disease-specific health literacy, disease knowledge, and
    adherence behavior among patients with type 2 diabetes in
    Taiwan. BMC Public Health 2018;18:1062.
    33. Renner B, Knoll N, Schwarzer R. Age and body make a difference
    in optimistic health beliefs and nutrition behaviors. Int J Behav
    Med 2000;7:143.
    34. Gollwitzer PM, Sheeran P. Implementation intentions and goal
    achievement: A meta-analysis of effects and processes. Adv Exp
    Soc Psychol 2006;38:69-119.
    35. Abraham C, Sheeran P, Johnston M. From health beliefs to selfregulation: Theoretical advances in the psychology of action
    control. Psychol Health 1998;13:569-91.
    36. Chester B, Babu JR, Greene MW, Geetha T. The effects of popular
    diets on type 2 diabetes management. Diabetes Metab Res Rev
    2019;35:e3188.
    37. Mason AE, Jhaveri K, Cohn M, Brewer JA. Testing a mobile
    mindful eating intervention targeting craving-related eating:
    Feasibility and proof of concept. J Behav Med 2018;41:160-73.
    38. Mason AE, Saslow L, Moran PJ, Kim S, Wali PK, Abousleiman H,
    et al. Examining the effects of mindful eating training on adherence
    to a carbohydrate-restricted diet in patients with type 2 diabetes
    (the DELISH study): Protocol for a randomized controlled trial.
    JMIR Res Protocols 2019;8:e11002.
    39. Jazayeri S, Pipelzadeh MH. Barriers to diet self-care in outpatients
    with type 2 diabetes in Iran. Pak J Med Sci 2006;22:412-5.
    40. Dalton M, Finlayson G, Walsh B, Halseth AE, Duarte C,
    Blundell JE. Early improvement in food cravings are associated
    with long-term weight loss success in a large clinical sample. Int
    J Obes (Lond) 2017;41:1232-6.
    41. Cradock KA, ÓLaighin G, Finucane FM, McKay R, Quinlan LR,
    Martin Ginis KA, et al. Diet behavior change techniques in type 2
    diabetes: A systematic review and meta-analysis. Diabetes Care
    2017;40:1800-10.