Socio-demographic characteristics , dietary habits and physical activity influence on nutritional status of the diabetics : a cross sectional study

Diabetes mellitus, a chronic, debilitating disease, is associated with a range of severe complications which include cardiovascular disease, renal disease and blindness. Demographic and epidemiological evidences suggest that the incidence of diabetes is increasing worldwide. Diabetes mellitus in people of all ages is reaching epidemic proportions in Bangladesh. The main objective of this cross sectional study was carried out to evaluate that nutritional status of the diabetic patients influence by socio-economic level, dietary habits and physical activity.A total of 282 diabetic outpatients were recruited using Simple Random Sampling technique from three referral diabetic centers namely-Kushtia Diabetic Shomity, Bheramara Diabetic Shomity and Diabetic Shomity Kumarkhali, Kushtia, Bangladesh. The nutritional status of each participant was screened. Direct method of nutritional assessment including anthropometric measurement, biochemical measurement, clinical assessment and dietary method was carried out. Socio economic data were also collected. Data were analyzed using the computer program Statistical Package for Social Sciences (SPSS) version 22.The result reveals that51.1% (n=144) of the total participants were male and 48.9% (n=138) were female. About 28.4% population studied were between 51-60 years, 94.7% married, 44.7% were unemployed and 50.4% were resided in urban area. Based on Body Mass Index (BMI), mean BMI of male was 23.32 ± 3.47 and that of female was 25.83 ± 4.46, half of the respondents (48.9%) had an acceptable nutritional status with a BMI between 18.5-24.9 (62.3% male; 37.7% female) whilst 4.6% of the respondents were underweight with BIMs below 18.5. The female who were observed were 22 (88.0%) and the male were 3 (12.0%) showing a very great prevalence of obesity (BMI more than 30.0). Study showed that 98 (34.7%) respondents bear diabetes from their family and 147 (52.1%) respondents have family history of hypertension The mean blood hemoglobin level was 12.49±1.47g/dl, in which male hemoglobin level was 12.85±1.48g/dl and of female was 12.11±1.36g/dl. The result shows that about 29.8% (n=84) patients had no formal education; among them more were female 65.5% (n=55). More of the patient (50.7%) had family member of 4-6. About 33.0% of the studied patients were low-income level (25.9% were from upper-lower and 7.1% were from lower socio-economic status). Among 37.6% (n=106) overweight (BMI 25.0-29.9) diabetic patients more were female 56.6% (n=60) and 55.7% (n=59) were unemployed. So, female sex, lower educational status, more family member, low monthly family income group and unemployment are associated with malnutrition. Unemployed housewives represented to have both extremes of nutritional statusunder nutrition and over nutrition. In the study, most of the patient 126 (44.7%) were unemployed, among them almost all the patient 124 (98.4%) were female. Diabetic care seeking by rural people and female appeared encouraging emphasizing the need of decentralization of diabetic care center to periphery.


Introduction
Diabetes is a chronic condition characterized by hyperglycemia.It is caused by deficient insulin production, resistance to insulin action or a combination of both (Alberti and Zimmet, 1998).It is accompanied in many cases by secondary alteration of fat and protein metabolism resulting in an array of physical disorder.Diabetes therefore, is a metabolic disease that can be well under control and reasonably managed with proper care, though it cannot be cured once it occurs (Thomas, 2005).Diabetes may present with characteristics symptoms such as polyuria, polydipsia, weight loss with sometimes polyphagia and blurred vision.Impairment of growth and susceptibility to certain infections may also accompany with chronic state of hyperglycemia.Acute lifethreating consequences of diabetes are hyperglycemia with ketoacidosis or non-ketotic hyperosmolar syndrome (JakJervell, 2000).Diabetes mellitus can lead to long term complications many of which can be fatal, if not prevented and all of which have the potential to reduce quality of life for people with diabetes (Journal of American Medical Association, JAMA, 2002).The underlying pathophysiology and management of both forms are different; a common feature is development of long-term micro and macro vascular complications such as retinopathy, nephropathy macro vascular disease peripheral and autonomic neuropathy.These complications are associated with increased morbidity and mortality (DCCT, 1993).Malnutrition is still a devastating problem in certain parts of the world although proportion and absolute number of chronically under-nourished people have declined.Under-nutrition remains as a serious problem among poor families and of under-developed nations, resulting from consumption of poor diet over a long period of time (Awan, 1997).Protein energy malnutrition has been a common health problem of the third world (Khan et al., 1990).Malnutrition has many adverse consequences.It is often argued that a malnourished is mentally and physically fatigued.He or she lacks in curiosity and is irresponsive to environmental situation.He is also frequently attacked by illness leading to higher absenteeism which is considered as another cause for poor performance (Berg, 1969).A proper diet is a fundamental element of therapy in all diabetic individuals.A diet recommended for a diabetic patient is, in fact a "balanced diet" for anyone.A balanced meal is a combination of carbohydrates, fats, proteins and fibers appropriate for the individual.A diet plan should be individualized according to his/her needs; it must be simple to understand and easy to follow.The primary goal of medical nutrition therapy of diabetics is to achieve metabolic control in order to prevent short-term and long-term complications of diabetes mellitus.Therefore the aims of nutritional intervention should include not only optimum control of blood glucose levels but also normalization of lipids and lipoprotein concentrations and blood pressure.The recent dietary recommendations of the American Diabetes Association for diabetics include an individualized approach based upon the diabetes management goals of each patient that takes into consideration preference of the patient and control of hyperglycemia and dyslipidemia.In consideration of the composition of the diet, besides a low saturated (high carbohydrate diet, a high monounsaturated fat diet may also be recommended (Grag, 1996).Intake of trans-fatty acids and cholesterol should be restricted and alcohol should be completely avoided in diabetic with dyslipidemia.Protein intakes should be between 15-20% of the total energy intake.Fiber rich sources of complex carbohydrates are preferred over refined sugars.The diet should be wholesome and provide the dietary allowances of all vitamins and minerals (www.bamboweb, 2005).A survey of nutritional status should show the relationship between food and nutrients, their use in the body and general health.It may be good, fair or poor, depending on the body ability to utilize these (Overt, 1980).Nutritional assessment is the process whereby the state of nutritional health of an individual or group of individuals is determined.Nutritional status is commonly assessed by anthropometric measurement, clinical examinations for ascertaining nutritional deficiencies and also biochemical assessment (J Am, 1969).In the present context, it is more important to assess the nutritional status of diabetes patients.As such the present study was undertaken to assess the nutritional status in relation to clinical presentations, anthropometrical measurements, hemoglobin level and dietary pattern of diabetes patients on three selected Diabetic centers in Kushtia district, Bangladesh.

Study area and period
The out-patient department based study was carried out at Kushtia Diabetic Shomity, Bheramara Diabetic Shomity and Diabetic Shomity Kumarkhali, Kushtia, Bangladesh.This descriptive cross-sectional study was carried out to evaluate that nutritional status of the diabetic patients influence by socio-economic level, dietary habits and physical activity from three diabetic centers, Kushtia during the period from August 2016 to July 2017.Total 282diabetes patients from both sexes (n = 282; 144 men and 138 women) were selected for the study by using Simple Random Sampling Technique.

Collection of data
All participants were informed of the purpose of the study and each patient signed a consent form.Data regarding anthropometric information and socioeconomic status like occupation, marital status, education, family size and monthly family income was collected by interviewing the subjects.All diabetic patients from out-patient departments of the three diabetic centers with the following criteria participated in the study: 1).having fasting blood sugar of (7.0 mml/L) 126 mg/dl and above.2).require insulin or oral hypoglycemic agents or both for the control of blood sugar.Patient's weight and height measurements were taken by the following anthropometric procedures (WHO, 1995).Body weight was measured with a digital weighting scale in kilogram.Height was taken with a measuring scale in centimeters.BMI was calculated by using the formula: Wt (in kg) / Ht (in m 2 ) = BMI (in kg/m 2 ).Assessment of nutritional status was done by Body Mass Index method (WHO, 1995).Respondents having BMI ˂ 18.5 were considered as underweight, having BMI 18.5-24.9as normal weight, having BMI 25.0-29.9as over-weight and having BMI ˃30 as obese.Blood samples were taken from each patient for the estimation of blood glucose, hemoglobin, serum creatinine and lipid profile.The estimation was performed following the new WHO diagnostic criteria (Diabetes care, 1997).Dietary intakes of the participants were collected by an interviewer administered 24-hour recall in the past 24 hours.It was done face to face early in the morning before the patients eat any food.Just like the name implies, the patients were asked to recall all they ate the previous day.The parameters in the food recall table were as follow: food and drink consumed, time the food eaten and description of the food.

Statistical analysis
Data were checked, entered and analyzed using the computer program Statistical Package for Social Sciences (SPSS) version 22.The statistical analyses include frequencies and mean ± SD.For all analyses, p value <0.05 was considered statistically significant.

Socio-demographic data
A descriptive cross-sectional study was carried out among 282 diabetic patients selected randomly from three diabetic centers in Kushtia district.Socio-demographic profiles of diabetic patients are shown in Table 1.  1 has shown that a total of 51.1% of the subjects were males and 48.9% were females.Only 8.2% of the subjects (4.2% were male and 12.3% were female) were within the age range of 30 years and below.Another 28.4% were within the age range of 51 to 60 years.About 32.6% were male and 23.9% were female subjects were within the age range of 51 to 60 years.About 50.4% of the diabetic patients were resided in urban area and 49.6% were resided in rural area.A total of 28.0% of the subjects (male were 24.3% and female were 31.9%)had primary education and about 95% of the subjects (94.7%) were married.About 44.7% of subjects were unemployed and 19.9% were traders.About half of the patient (50.7%) had 4 to 6 family members.About 23.8% families' monthly income were more than 19000 BDT.About 44.3% of the subjects were high income level (24.1% were upper and 20.2% were upper-middle socio-economic status), 22.7% were middle income level and 33.0% were low income level (25.9% were upper-lower and 7.1% were lower socio-economic status).

Biophysical characteristics
Biophysical characteristics of male and female diabetic patients in Kushtia district are shown in Table 2. Table 2 has explained that, a total of 29.1% of the subjects had high systolic blood pressure and 35.5% of the subjects had high diastolic blood pressure.Again about 36.8% and 38.9% of the diabetic male had high systolic and diastolic blood pressure, whereas 21.0% and 31.9% of the diabetic female had high systolic and diastolic blood pressure.So the result shows that male diabetic patients were more prevalent for high systolic and diastolic blood pressure than that of female.About 73.8% of the total subjects were non-smoker.About 63.9% of the male subjects and 59.4% of the female subjects had experience of regular physical exercise.

Anthropometric indices
Anthropometric characteristics of the diabetic patients are shown in Table 3, Table 4 and Table 5.Table 3 has revealed that the mean BMI of the males was 23.32±3.47kg/m2and that of the females was 25.83±4.46kg/m2.The BMI value for the females was significantly (p‹0.05)higher than that of males.A total of 37.6% (n=106) of the patients were overweight, 8.9% (n=25) were obese, 4.6% (n=13) were underweight and 48.9% (n=138) were normal.Table 4 has shown the cross tabulation of BMI of subjects with sex, place of residence, educational level, occupation and socio-economic status.Among 13 diabetics who were underweight, 69.2% were males and 30.8% were females.Among those who were of normal weight 62.3% were males and 37.7% were females.Among the 25 diabetics who were obese 12.0% were males while 88.0% were females.As many as 56.6% of female were overweight, among the overweight category while 43.4% male were overweight.About 7.7% of the diabetics who lived in urban area were underweight while 92.3% who lived in rural were underweight.About 33.3% of diabetics who were normal weight live in the urban and 66.7% in the rural.Among the 106 subjects within the overweight category 71.7% of those that lived in urban area were overweight while 28.3% were from the rural area.Among the 25 subjects who were obese 76.0% were from the urban while 24.0% were from the rural area.Among 106 diabetics who were overweight 8.5% had secondary education while 33.0% had no formal education.In obese category, among 25 subjects 28.0% had no formal education, 16.0% had secondary education, while 20.0% of the subjects that had graduate and above.Unemployed respondents showed overweight 59 (55.7%) more and among 25 obese patients 72.0% were unemployed.On the other hand among 13 underweight respondents more (46.2%)were farmer.But no underweight with high family income could be detected.Among 25 obese patients more (40.0%)were from upper socio-economic status.
Table-5 shows relationship between the socioeconomic variables and BMI of diabetic patients.The BMI of patients was significant in different sex, resident and occupation.There were no significant differences (p > 0.05) in the BMI of patients in different educational attainments and age range.

Biochemical tests
Biochemical indices of the diabetic patients are shown in Table 6.The mean blood hemoglobin level was 12.49±1.47g/dl,in which male hemoglobin level was 12.85±1.48g/dland of female was 12.11±1.36g/dl.The mean fasting blood glucose level of the patients was 8.86±1.67mmol/Land blood glucose level two hours after breakfast was 13.94±2.88mmol/L.The mean serum creatinine level of the male patients were 1.17±1.05mg/dland female were 1.26±1.05mg/dl.The patients mean total cholesterol, low density lipoprotein; high density lipoprotein and triglyceride levels were 197.23±48.99mg/dl,117.21±44.65mg/dl,34.96±5.38mg/dland 225.30±74.08mg/dlrespectively.

Clinical findings
The distributions of family history of chronic diseases of the diabetics have shown in Table 7.About 39.0% of the diabetic patient had no family history of chronic diseases.Only 6.7% of the diabetic patient had family history of diabetes alone and 26.3% patients had family history of hypertension alone.About 13.5% and 2.5% patients had family history of hypertension and hypertension with CVD along with diabetes.About 2.1% patients had family history of renal disease and 3.5% had hypertension and renal disease along with diabetes.

Dietary results
The food consumption patterns of the respondents are shown in Table 8.Majority (99.2%) consumed rice once per day while few (34.0%) consumed milk and milk product once per day.Averagely (58.7%) of the respondents consumed egg while majority (98.8%) consumed green leafy vegetables once per day.Fried and dairy products were consumed by 19.3% once per day while fruits were consumed by 47.2% respondents once per day.Approximately 79.5% consumed pulses and nuts once daily while 30.0%consumed tae and biscuit once per day.Majority of the patients (66.5%) consumed fish once per