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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