Statistical Analysis
SPSS (Statistical Package for Social Sciences) statistical package program version 18 was used to evaluate the data obtained from the study. Continuous variables (quantitative variables) obtained by measurement are presented with mean, standard deviation, minimum and maximum values, and categorical variables (qualitative variables) with frequency and percentage values. Categorical variables were evaluated using the Chi-Square (X2) test. The compliance of the quantitative variables dealt with in the study to normal distribution was examined using the Kolmogorov-Smirnov test. Independent samples t-test was used for the comparison of two independent groups for the variables for which parametric test conditions were met, and the Mann-Whitney U-test was used for the comparison of two independent groups in cases where parametric test conditions were not met. Correlations between variables were analyzed using Spearman correlation coefficient. In all statistical analyzes, p<0.05 value was accepted as the statistical significance level.
RESULTS
This study was conducted on a total of 145 individuals with type 2 diabetes between the ages of 20-65, 73 males and 72 females, 93.8% of the individuals were between the ages of 46-65. 66.7% of women and 39.7% of men were primary and secondary education graduates and the difference according to gender was found to be statistically significant (p<0.001). 71.2% of men were retired and 76.4% of women were housewives (p<0.001). 9.0% of the participants were single, 91.0% were married (p<0.001) and 97.9% lived with their families (Table 1).
More than half of the individuals (58.6%) had diet quality required to be improved. Males (41.1%, 57.5% and 1.4%, respectively) and females (34.7%, 59.7% and 5.6%, respectively) had similar poor, need-to-improve, and good diet quality. 77.8% of individuals between the ages of 20-45 had bad diet quality, 61.0% of those between the ages of 46-65 had diet quality required to be improved (p<0.05). Most of the illiterate individuals (66.6%) had poor diet quality, while most of the primary and secondary, high school and university graduates (58.4%, 63.9% and 61.6%, respectively) had diet quality required to be improved. It was found that singles have more good diet quality (p<0.05) (Table 2).
The average score of the individuals in AIS was 30.2±5.62. Emotional distress of men (24.2±14.80) was found lower compared to women (32.4±16.83) (p<0.05). The BDS mean score of individuals was 10.1±6.94, 8.7±7.14 for men and 11.6±6.44 for women. The depression level of men was found lower than women (p<0.001). The HEI-2010 mean score of the individuals was 54.8±12.85, 53.1±12.99 points in men and 56.6±12.57 points in women. Physical and mental quality of life of men was found higher than women (p<0.001) (Table 3).
Also, a negative correlation was found between AIS-PAID Scale and between AIS-BDS, a positive correlation was found between SF-36 MCS-AIS and between SF-36 PCS-AIS (p<0.001). While there was a positive correlation between PAID Scale-BDS, a negative correlation was found between SF-36 MCS-PAID Scale and between SF-36 PCS-PAID Scale (p<0.001). A negative correlation was found between SF-36 MCS-BDS, and between SF-36 PCS-BDS (p<0.001) (Table 4).
The model that emotional distress and SF-36 MCS with acceptance of illness was found to be statistically significant as a result of multiple linear regression analysis (F(2, 142)=58.404, p=0.000). It has been observed that the effect of PAID Scale on the AIS is greater than that of SF-36 MCS. In type 2 DM individuals, it was found that, the acceptance of illness increased as SF-36 MCS score increased, and the acceptance of illness decreased as the emotional distress increased. The model that the independent variables of AIS, BDS and age (years) with emotional distress was found to be statistically significant (F(3, 141)=53.174, p=0.000). It was found that emotional distress decreased as the acceptance of illness and age increased, and emotional distress increased with increasing depression in type 2 DM individuals. The model that emotional distress and SF-36 MCS with the depression state was found to be statistically significant (F(2, 142)=82.029, p=0.000). SF-36 MCS effect on BDS was greater. It was found that as the SF-36 MCS score increased, the depression status decreased, and as emotional distress increased, the depression status increased. The model that the acceptance of illness and depression state with SF-36 MCS was found to be statistically significant (F(2, 142)=70.937, p=0.000). It has been determined that SF-36 MCS had a greater effect on the BDS. SF-36 MCS score increased as the acceptance of illness status increased, and SF-36 MCS score decreased as depression status increased. The model that emotional distress and depression state with the SF-36 PCS was found to be statistically significant (F(2, 142)=42.926, p=0.000). It was found that BDS had a greater effect on the SF-36 PCS. It was found that as the emotional distress and depression level increased, the SF-36 PCS score decreased in type 2 DM individuals (Table 5).
DISCUSSION
In conducted studies have found that type 2 DM is more common in less educated individuals compared to more educated individuals [27], and it has been observed that approximately half of the individuals are unemployed/retired/housewives [28, 29]. In this study, the results are similar. An appropriate diet in the treatment of DM can be effective in the success of the treatment [30]. Also, adherence to high-quality diets are associated with a lower risk of type 2 DM [31]. However, in a study, it was observed that only 21.0% of individuals with type 2 DM were compatible with their diet [32]. In this study, the HEI-2010 mean score of the individuals was 54.8±12.85, the males 53.1±12.99 and the females 56.6±12.57 points. Although the difference between the genders is not significant, the mean scores of women are higher than the mean scores of men. In another study, the HEI-2010 scores of individuals with type 2 DM were found as 63.9 points in men and 67.3 points in women [33]. As in this study, the HEI-2010 mean scores are higher for females than males. In this case, it suggests that women are more careful and attentive about nutrition than men.
Especially, patients with type 2 DM who are diagnosed later, experience difficulties both mentally and physically while trying to establish a new order for their lives. Anxiety, depression, stress and diabetes distress weaken the motivation of individuals with type 2 DM to cope with the disease [34]. After metabolic control is achieved, re-evaluation of depressive symptoms is important in order not to miss the diagnosis. It is beneficial to screen diabetic patients in terms of depression and anxiety, and to treat those with psychological problems. Also, the rejection of the disease in diabetic patients negatively affects the self-care and diet of the individual [35]. In studies, it shows that individuals with type 2 DM have a low degree of acceptance of the illness [36, 37]. In studies have also found that there is no significant difference between the AIS scores and gender [36, 38]. Similarly, in this study, there was no statistically significant difference between the genders in the acceptance of the illness (p>0.05). However, it is very important for individuals to accept their illnesses in order to show appropriate healthy behaviors.
Emotional distress is observed in most people with type 2 DM. In a study, the prevalence of diabetes distress in individuals with type 2 DM was found to be 49.2% [39]. In another study, in individuals with early onset (20-45 years old) type 2 DM, the mean PAID Scale score was found to be higher in women (31.5±21.4) compared to men (21.5±17.4) [40]. Similarly in this study, the PAID Scale mean scores of women were higher than men (p<0.05). It is thought that this case is resulted from that women are more sensitive about their own and their families’ health issues and have more emotional distress. Depressive symptoms are observed with a higher rate in individuals with type 2 DM compared to individuals without DM [41, 42, 43]. In conducted studies, depressive symptoms in diabetic patients were observed more frequently in women compared to men [41, 43]. Similarly in this study, the BDS mean scores were found to be significantly higher in women compared to men (p<0.05). It is known that there is a two-way causal relationship between depression and DM. The development of anxiety/depression negatively affects the patient’s compliance, response to treatment and the prognosis of the disease. It causes deterioration in self-care and quality of life, an increase in the risk of developing complications, morbidity, mortality and health expenditures, as well. It is thought that traditional gender roles and expectations reveal the psychological consequences like causing despair, so women are more prone to depressive reactions than men. It has been shown that depression is significantly associated with a high risk of mortality in patients with type 2 DM, and glycemic control increases significantly with the reduction of depressive symptoms in these patients, and the presence of depression negatively affects the compliance of these patients to treatment [44, 45]. Also, it was stated in a study that being a woman and poor sleep quality increase possiblity of occurrence of hypoglycemic/hyperglycemic acute events and anxiety/depression symptoms [46]. It has been reported that in the presence of depression, control due to diabetes becomes difficult [47], diet therapy, exercise and blood glucose control are affected [48], bad eating habits and the habit of disrupting their medication increase, depressive diabetic patients fail to comply with the diet 3 times more than non-depressive diabetic patients [49]. Also, the presence of type 2 DM and depression negatively affect the quality of life of individuals [36]. It is noteworthy that the quality of life of women is lower than that of men in studies [36, 44, 50]. In this study, SF-36 MCS and PCS scores of women were found to be lower than these scores of men, as well (p<0.001).
In the study of Jaworski et al. [9], only a small mediating effect of acceptance of illness was found on the relationship between regular blood glucose control and compliance with dietary recommendations. Johnson et al. [11] found that in adults with type 2 DM, those with more distress or depressive symptoms displayed less positive lifestyle behaviors. It has been reported that the decrease in the quality of life in individuals with type 2 DM may result from non-compliance with lifestyle changes [51]. In this study, correlations between AIS, PAID Scale, BDS and SF-36 were found to be significant (p<0.05), but there was no correlation between the HEI-2010 and these scales (p>0.05). As a result of the decrease in adherence to medical treatment that occured according to the deacrese in acceptance of illness, problems such as prolongation and delay in the healing process can be seen. It can be thought that the acceptance of the illness, emotional distress about DM, depression and quality of life of individuals with type 2 DM may affect each other, but the changes in these factors cannot affect the diet quality of the individual with type 2 DM. The reason for this may be that individuals with DM do not consider their diet as a part of the treatment, cannot understand the importance of nutrition in diabetes management, or have different treatment priorities.
It is known that the presence of DM in an individual does not increase compliance with nutritional recommendations [52]. Individuals with type 2 DM have low adaptation to diet and exercise, and this situation negatively affects the self-care activities of the individual [53]. Perceived competence to manage diabetes, diabetes assessment, and motivation are psychological factors that target three important areas of DM care (such as diet, exercise) [54]. In a conducted study, it was observed that individuals with DM evaluated drug treatment as more important than diet and exercise and, were more compatible with drug treatment [55]. In another study, almost one-third of diabetic patients did not perceive the given diet as a nutritional treatment, and dietary attitudes were strongly associated with individual characteristics of the patients [56]. In the study of Jalilian et al. [57], diet change was not perceived as a necessary part of the treatment process in most individuals with type 2 DM. In another study, although 78.0% of individuals with type 2 DM were aware of the importance of diet control and exercise, only 68.0% of them adhered to dietary control. Lack of information, difficulty in meeting treatment, and forgetfulness of the patients were the main reasons that made it difficult to adhere to diet control [58]. The lack of macro and micronutrient information in the diabetic person may also be another important limitation in the implementation of the diet [59]. Health literacy also affects diabetes self-care [60, 61]. Also, it may be useful to discuss diet-related difficulties not only with a specialist but also with family members, and adequate social support is also important in complying with dietary recommendations [62]. It is thought that improving the health literacy of individuals with type 2 DM together with social support from family and friends and professional support of dietitians will facilitate dietary behavioral change [63]. The results show that socio-cultural and individual factors can strongly affect the attitudes and preferences towards diet of individuals with type 2 DM.
It has been observed that as the acceptance of the disease of individuals with type 2 diabetes increases, their satisfaction with life also increases [38]. In this study, as a result of multiple linear regression analysis, a relationship between emotional distress and SF-36 MCS with acceptance of illness was found (p<0.001). Emotional distress may be experienced during the course of DM, which in return this negatively affects the quality of life [64]. Diabetes distress has a negative relationship with quality of life [65]. In studies have shown that there is a strong negative relationship between depression and quality of life in patients with type 2 DM [66, 67]. In this study, similar to the other studies, emotional distress was found to be associated with acceptance of illness, depression state and age; depression state with emotional distress and SF-36 MCS; SF-36 MCS with acceptance of illness and depression state; SF-36 PCS with emotional distress and depression. For this reason, the recommendation of the American Diabetes Association (ADA) is to provide psychosocial care to all diabetic individuals in order to improve the health outcomes and quality of life of the individual. It is recommended that all individuals with DM should be evaluated in terms of emotional/diabetes distress, depression and anxiety symptoms [4]. Lifestyle behavior change positively affects the general health perception and mental health of individuals. Depression of diabetic patients negatively affects the lifestyle change and this case negatively affects the treatment. Diabetic patients with depression have difficulty in complying with the diet, have fluctuations in glycemic levels, and often experience complications compared to those who do not have depression [68]. In conclusion, the main goal in the treatment of diabetes is to relieve complaints in patients, to reduce, prevent or delay the development of complications, to increase the quality of life, to ensure that the individual has a physically, emotionally, spiritually and mentally regular life in addition to metabolic control. Diabetes education given to individuals with type 2 DM positively affects the dietary control of individuals [69, 70]. Although nutrition in type 2 DM is at the key point for the treatment and management of the disease, in this study it is thought that individuals were not aware of its importance. Therefore, considering the obstacles to nutrition programs in individuals with DM, it should be ensured that nutritional treatments are personalized according to the socio-economic, socio-cultural and psychological conditions of the individual [54].
CONCLUSIONS AND SUGGESTIONS
The presence of diabetes does not require individuals without diabetes to have different eating habits. Diabetes does not affect the individual’s need for energy and nutrients. After the individual is diagnosed with diabetes, the desired changes in eating habits consist of the recommended dietary habits for a healthy life. However, it is beneficial to carry out the treatment in a multidisciplinary and holistic approach according to considering medical nutrition as a part of medical treatment, what are the priorities in the management of diabetes and the obstacles affecting the nutrition of individuals, in type 2 DM. Long-term studies with large samples are needed on this subject. Instead of a diet plan that individual with type 2 DM cannot make or adapt to a lifestyle, it will be beneficial to provide effective, continuous, periodically supervised training about diabetes and medical nutrition treatment by including the individual’s family members in necessary conditions in accordance with their individual preferences, cultural habits and needs.
Limitation
The limitation of this study was that it only evaluated food intake for one day. The diabetic individual’s dietary intake may vary from day to day during the period when he or she does not pay attention to his diet, and a 1-day evaluation may not reflect an individual’s usual food intake. Therefore, the results obtained cannot be generalized for the entire population with type 2 DM. However, they emphasize the importance of the topic and provide data for further research. Also, more research is needed to determine the relationship between acceptance of illness, emotional distress, depression status, quality of life, nutrition quality and health outcomes in different age groups with diabetes.
Credit authorship contribution statement
Busra Ozyalcin: Visualization, Investigation, Supervision, Writing - review & editing, data analysis.
Nevin Sanlier: Conceptualization, Methodology, Data curation, Writing - original draft.
Conflict of interest
No conflict of interest was declared by the authors.
Acknowledgments
The authors thank all the participate in this study. They are warmly acknowledged for their helpful and wholehearted cooperation.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
ORCID
BO= 0000-0001-5872-179X
NS= 0000-0001-5937-0485
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