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Pinto et al. Int J Diabetes Clin Res 2017, 4:079

Volume 4 | Issue 2
DOI: 10.23937/2377-3634/1410079

ISSN: 2377-3634

International Journal of

Diabetes and Clinical Research
Open Access

Citation: Pinto E, Braz N, Nascimento T, Gomes E (2017) Do Patients Value Nutritional Therapy? A
Quantitative Study in Type-2 Diabetes Patients. Int J Diabetes Clin Res 4:079. doi.org/10.23937/2377-
3634/1410079
Received: October 01, 2017: Accepted: December 26, 2017: Published: December 28, 2017
Copyright: © 2017 Pinto E, et al. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.

Pinto et al. Int J Diabetes Clin Res 2017, 4:079 • Page 1 of 6 •

Do Patients Value Nutritional Therapy? A Quantitative Study in Type-
2 Diabetes Patients
Ezequiel Pinto1*, Nídia Braz1, Tânia Nascimento1 and Eurico Gomes2

1Centre for Research and Development in Health, School of Health, University of Algarve, Faro, Portugal
2AEDMADA, Portugal

*

Corresponding author

: Ezequiel Pinto, Centre for Research and Development in Health, School of Health, University of
Algarve, Dr. Adelino da Palma Carlos, 8000-510 Faro, Portugal, Tel: +351-289-800-100, E-mail: epinto@ualg.pt

Abstract

Introduction

: Type 2 diabetes patients’ adherence to phar-
macotherapy is higher than adherence to nutritional therapy
or lifestyle change behaviours, and patients do not value
nutritional therapy in the same level as they value other
types of interventions. This study aimed to analyse the va-
lue that T2DM patients place on nutritional therapy and to
identify perceived barriers to nutritional therapy adherence.

Methods

: A non-random sample of 62 patients receiving he-
alth care in a Diabetes Clinic in the municipality of Faro, in
the Portuguese region of the Algarve, was interviewed with
a semi-structured protocol regarding sociodemographic
characteristics, lifestyle, physical activity, and dietary habi-
ts. Additional data were collected from the patient’s clinical
files and by conducting anthropometric assessment using
standard methods.

Results

: Patients show a poor dietary intake and we found
a prevalence of 36% (n = 22) of overweight patients and
53% (n = 33) of obese patients. Mean BMI was 30.1 kg/m2
(SD = 4.21). Physical activity is considered less important
than dietary intake and that pharmacologic treatment for the
management and control of T2DM (F = 19.6; p < 0.001). Va- lue placed in dietary intake as a treatment for the disease is high, but patients seem to have a trouble in complying with the recommendations and to sustain the compliance they achieved. Patients should be empowered to improve their self-care and to consider nutrition therapy as valuable as other treatments.

Keywords

Type 2 diabetes, Nutrition, Adherence to treatment

OriGiNal rEsEarch arTiclE

Check for
updates

control, and general management of diabetes consists
of patient education, medical nutrition therapy, physi-
cal activity, and pharmacological therapy combined
with oral hypoglycaemic agents or insulin [1]. The
chronic nature of diabetes and its associated complica-
tions, as well as their potential for impact on the over-
all quality of life, confirm the need for adequate treat-
ment and management of the disease, preferably from
a team that may include physicians, nurses, dietitians,
and pharmacists with expertise and a special interest in
diabetes. In order for the therapeutic plan to succeed,
individuals with diabetes should also assume an active
role in their self-care [2].

Several literature reviews suggest that a significant
proportion of T2DM patients exhibit poor adherence to
treatment and poor management of the disease. Some
of the factors that compromise adherence include com-
plex pharmacological treatment, clinical inertia, safety
concerns, socioeconomic issues, ethnicity, poor patient
education, beliefs, and social support [3-5].

Adherence to treatment is defined as the active, vol-
untary involvement of the patient in the management
of the disease, by following a mutually agreed course
of treatment and sharing responsibility with health
care providers [6]. In health studies, non-adherence to
treatment regimens has been described and measured
as complying in less than 80% of the prescribed treat-
ment [3], and it is believed that, as a group, diabetes
patients are especially prone to substantial adherence
problems [7-9]. A 2003 report from the WHO states that

Introduction

Treatment and prevention approaches for type 2
diabetes mellitus (T2DM) focus on achieving glycaemic

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non-adherence rates for chronic illness treatment regi-
mens and for lifestyle changes are approximately 50%
[10] and, in the case of diabetes, literature reviews re-
port general adherence to treatment ranging from 23%
to 77% [3,11,12]. Adherence to one component of the
treatment also seems independent of the adherence to
other components [11], as research suggests that ad-
herence to pharmacotherapy is higher than adherence
to nutritional therapy or lifestyle change behaviours,
and that patients do not value nutritional therapy in the
same level as they value other types of interventions
[5,10,12].

Based on the available evidence, the study aims to
analyse the value that T2DM patients place on nutri-
tional therapy and to identify perceived barriers to nu-
tritional therapy adherence.

Methods

We conducted a quantitative assessment of a non-
random sample of T2DM patients receiving health care
in a Diabetes Clinic in the municipality of Faro, in the
Portuguese region of the Algarve. Patients were invited
to be a part of this study during their medical consulta-
tions and a date was set up according to their availabil-
ity to proceed with data collection. The inclusion criteria
were age below 85 years, medical diagnosis of T2DM for
at least 12 complete weeks, and having been at least in
one individual consultation with a registered dietitian in
the past year. Patients were excluded if they a) Were
undergoing a pharmacotherapy regimen with insulin, as
this could imply a significantly different nutritional ther-
apy when compared with patients on oral antidiabetic
agents only; b) Had a diagnosis of degenerative disorder
of the central nervous system; and c) Were following
a lactose-free or gluten-free diet. During a two-month
period, all patients matching the inclusion criteria were
invited to be a part of this study. Out of the 66 patients
who were invited, 4 declined, citing having a limited
time to spare and being unavailable to book a specific
date to attend the data collection interview. Thus, the
final study sample was composed of 62 patients.

Patients were individually assessed by a trained di-
etitian, using a semi-structured, face-to-face interview
protocol, regarding sociodemographic characteristics,
lifestyle, physical activity, and dietary habits. The inter-
view included a 24 h dietary recall, three questions were
the patients were asked to rate, in a five-point Likert
scale, the importance (1-not important at all, 5-abso-
lutely essential) that food, physical activity, and drug
therapy have in disease control, and also two questions
in a five-point Likert scale were patients were asked to
rate the quality (1-very poor, 5-very good) of both their
overall eating habits and the overall eating habits of
other T2DM patients. The last section of the interview
was conducted in a flexible and unstructured way, and
patients were asked to talk about the importance of fol-
lowing an adequate diet and complying with nutritional

recommendations.

Upon completing the interview, we collected data on
waist circumference, height, and weight, using stand-
ardized methods. We computed body mass index (BMI)
for each patient and collected additional clinical data
(HbA1c and lipid profile at the time of the recruitment
medical consultation, age at diagnosis) from the pa-
tients’ clinical files. Each data collection interview lasted
between 75 and 120 minutes.

All stages of this study obeyed the ethical rules for
health sciences research as stated in the sixth revision
of the Declaration of Helsinki, including an informed
consent form which was signed by every patient during
the briefing recruitment.

Dietary data was computed into nutrients using na-
tional food composition tables.

Data were analysed with IBM-SPSS software version
20.0 (SPSS Inc., Chicago, IL, USA). Patient description
and characterization were presented as mean values
accompanied by standard deviations, and prevalence
calculated as the percent of the total number of valid
observations in each calculation.

The Kolmogorov-Smirnov test was used to assess
adherence to the Normal distribution and Student’s t-
test or Mann-Whitney’s U were computed for compari-
sons between two groups. One-way analysis of variance
(ANOVA) was used for multiple group comparisons and
correlations were analysed with Pearson’s correlation
coefficients. The chi-square test (X2) was used for group
comparisons of qualitative variables.

Statistical significance in all procedures was deter-
mined by two-tailed analysis and set at 0.05.

Results

The final sample was composed of 62 patients, 53%
males (n = 33) and 47% females (n = 29), with ages rang-
ing between 47 and 74-years-old (M = 60.2; SD = 7.68).
Women had a higher mean age (M = 61.1; SD = 7.90)
than men (M = 59.5; SD = 7.53) but differences were not
statistically significant (t = -0.79; p = 0.431). Regarding
educational level, 45% (n = 28) of patients completed
only up to 4 years of schooling and 10% (n = 6) have a
higher education degree. We did not find gender differ-
ences in educational levels (X2 = 5.29; p = 0.259).

The anthropometric, dietary and clinical characteris-
tics of the sample are presented in

Table 1

.

Of the anthropometric, dietary and clinical charac-
teristics of the sample, only two variables showed gen-
der differences: Male patients showed a significantly
higher (t = 2.8; p = 0.006) mean energy intake (M =
2499 kcal; SD = 793.19) than women (M = 2018.1; SD =
469.56), and also a significantly higher intake (t = 2.0; p
= 0.04) of total carbohydrates (M = 293.8 g; SD = 123.88)
than women (M = 241.3; SD = 73.22).

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patients is poorer (M = 2.5; SD = 0.82) than their own.
According to Mann-Whitney’s test, differences in scores
for diet intake quality are statistically significant (U =
473.5; p < 0.001). We did not find statistically significant correlations in the perceptions for the quality of own dietary intake or for the dietary intakes for other pa- tients, according to gender, age, or time (years) since the diagnosis (p > 0.05).

According to ANOVA analyses (F = 19.6; p < 0.001), physical activity is considered less important than di- etary intake and that pharmacologic treatment for the management and control of T2DM (

Table 2

).

Additional analyses with Student’s t-test, comput-
ed with Bonferroni’s correction, show that there are
statistically significant differences in all paired group
comparisons between treatments (p < 0.05), and that dietary intake (M = 3.9; SD = 0.93) is considered less im- portant than the pharmacological treatment (M = 4.3; SD = 0.73).

We did not find any gender differences in the per-
ceptions of the importance of dietary intake, pharmaco-

When considering BMI according to the categories
proposed by the WHO [13], we found that 22 patients
(36%) were overweight and that 33 patients (53%) were
obese. The remaining 7 patients (11%) were classified as
having normal weight.

BMI was positively correlated with total carbohy-
drate intake (r = 0.283; p = 0.029) and total energy in-
take (r = 0.274; p = 0.031), but not correlated with any
other nutrient intake that was computed using the 24 h
recall (p > 0.05). According to ANOVA analyses, we also
did not find any statistically significant differences (p >
0.05) in any of the dietary intake variables according to
BMI classification, which suggests that normal weight,
excess weight, and obese patients have similar dietary
intakes.

When asked to rate the quality of their overall diet
intake in a Likert scale (Table 2), patients scored a mean
value of 3.9 points (SD = 0.79). Patients rated their over-
all diet as “acceptable” (n = 24; 39%), “good” (n = 23;
37%) or “very good” (n = 15; 24%). On the overall, par-
ticipants consider that the dietary intake of other T2DM

Table 1: Anthropometric, dietary and clinical characteristics of the sample (n = 66).
Md M SD Min Max

HbA1c (%) 7 7.4 1.64 5 12
Age at diagnosis 55 54.0 7.49 37 69
Years with the disease 5 6.2 4.46 0 19
Weight (kg) 79 78.8 14.79 52 111
Height (cm) 159 161.4 8.95 149 181
BMI (kg/m2) 30 30.1 4.21 21 41
Dietary intake assessed by 24 h recall
Energy (kcal)* 2028 2274.2 699.90 1516 4519
Protein (g) 82 88.9 28.14 40 156
Protein (% of energy intake) 15.9 16.0 3.9 6.5 24.8
Total carbohydrates (g)* 254 269.3 105.87 107 565
Total carbohydrates (% of energy intake) 47.7 47.3 10.9 25.6 64.0
Sugars (g) 91 109.4 69.25 7 343
Sugars (% of energy intake) 18.7 19.0 9.6 1.8 46.3
Dietary fibre (g) 16 18.0 8.58 6 53
Lipids (g) 86 89.8 34.97 28 193
Lipids (% of energy intake) 37.2 35.6 9.7 15.7 59.8
Cholesterol (mg) 292 377.6 243.53 19 1045

Md: Median; M: Mean; SD: Standard Deviation; Min: Minimum; Max: Maximum; *Statistically significant gender differences (p < 0.05), with higher mean intakes in male patients.

Table 2: Perceptions on the quality of dietary intake and importance for diabetes control and management, assessed in 5-point
Likert scales.

Quality of dietary intake
Likert-type score*; n (%)
1 2 3 4 5 M SD

Quality of own dietary intake 24 (39%) 23 (37%) 15 (24%) 3.9 0.79
Quality of the dietary intake of other patients 8 (13%) 22 (35%) 29 (47%) 2 (3%) 1 (2%) 2.5 0.82

Importance for diabetes control
Likert-type score**; n (%)
1 2 3 4 5 M SD

Dietary intake 1 (2%) 3 (5%) 19 (31%) 24 (39%) 15 (24%) 3.8 0.93
Pharmacologic treatment 1 (2%) 7 (11%) 27 (44%) 27 (44%) 4.3 0.73
Physical activity 1 (2%) 8 (13%) 27 (44%) 21 (34%) 5 (8%) 3.3 0.87

M: Mean; SD: Standard Deviation; *Likert scale anchors defined as: 1-very poor, 2-poor, 3-acceptable, 4-good, 5-very good; **Lik-
ert scale anchors defined as: 1-not important at all, 2-of little importance, 3-of average importance, 4-very important, 5-absolutely
essential.

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trends in T2DM patients. A systematic review of obser-
vational studies [14] reports that obesity rates exceed-
ed 30% in 38 of the 44 studies analysed for this variable
and 50% in 14 of the 44 studies. Additional data from
3637 UK patients in secondary care [15] showed that
86% of patients with T2DM were overweight or obese
and, in Spain, a nationwide population-based cross-sec-
tional survey with 12,077 individuals, reports that only
11.4% had BMI below 25 kg/m2 [16].

The results from the dietary assessment show high
intake of sugars, when assessed according to the dietary
references for adults [17] and also when considering the
nutritional guidelines for T2DM patients [2,18]. Total
carbohydrate intake is within acceptable macronutrient
range (carbohydrate should account for 45-65% of daily
energy intake) proposed for T2DM patients [18,19], but
patients’ intake of sugars, with a mean of 109.4 g (SD =
69.3 g) and accounting for 19% (SD = 9.6%) of daily en-
ergy intake, is significantly higher than recommended,
as guidelines state that adults should aim for a maxim
of 50 g of sugars or less than 10% of total energy intake,
per day [2,20]. The same guidelines suggest that a fur-
ther reduction of the intake of free sugars to below 5%
of total energy intake should be considered.

Our data suggest that patients should adjust their
intake to benefit from the advantages that proper nu-
trition provides to T2DM control and weight reduction,
and it is recommended that sucrose-containing foods
should be substituted for other carbohydrates, in order
to avoid excess intake in energy, and excess intake of
simple, fast-absorbing carbohydrates [2].

Patients showed an optimistic bias in their percep-
tion of the quality of dietary intake. This is in accordance
with the literature, which states that when asked to

logic treatment, or physical activity in diabetes control
(p > 0.05), but we found a positive correlation between
importance placed on pharmacologic treatment and
time since the diagnosis (r = 0.273; p = 0.032), suggest-
ing that patients that have a longer progression of the
disease place higher importance in the pharmacologic
treatment.

Table 3

shows the results of patients recalling advice
given by health professionals in the last year, and their
perception of compliance.

When analysing patient perceptions and opinions
about the importance of food and nutritional recom-
mendations, recorded in the non-structured part of the
interview, we found that all of the patients stated that
“food is important” or that it plays “an important role”
in patients’ life. Most (53%; n = 32) patients expressed
the importance that food has in social gatherings and
67% (n = 40) of them stated that food is “something that
gives me pleasure”, with a smaller subset of these (n
= 8) expressing that “sometimes it’s the only pleasure”
they have. All patients, at some point in the interview,
considered dietary intake as an “important part of the
treatment for diabetes” and also declared that, on the
overall, they try to comply to all nutrition recommenda-
tions that they are given. Nevertheless, at some point
during the interview, 38 participants (63%) stated that
“sometimes, my diabetes doesn’t seem to be affected
by my diet, whatever I eat”.

Table 4

describes the difficulties that were most fre-
quently mentioned by patients when talking about nu-
trition recommendations.

Discussion

Our data reflect the general overweight and obesity

Table 3: Advice given by health professionals.
During the past year, did a health
professional told you to…

Remembers being told by
a health professional

Tried his/her best to
comply, after being told

Complies at the
moment

N % N % N %
Engage in physical activity 55 83% 22 40% 16 29%
Try to lose weight 41 62% 21 51% 18 44%
Follow a scheduled time for meals 62 94% 42 68% 42 68%
Weigh or measure foods 45 68% 30 67% 12 27%
Record/write a food diary 18 27% 10 56% 0 0%
Use food substitution list to plan meals 35 53% 5 14% 1 3%
Switch to foods with lower calories 18 27% 13 72% 7 39%
Eat less carbohydrates 29 44% 14 48% 14 48%
Eat less sugar, candy or sweets 19 29% 19 100% 12 63%
Share or engage in meal planning/preparing 33 50% 12 36% 12 36%

Table 4: Statements about barriers to comply with nutrition recommendations.
Statement N %
“A proper diet takes too much effort”. 32 52%
“Following dietary advice implies different meals from the rest of the family”. 26 42%
“My diabetes doesn’t seem to be affected by my diet, whatever I eat”. 38 61%
“When I go to [social gatherings] there are no adequate meal options”. 24 39%
“A proper diet is more expensive”. 30 48%
“I feel confused by the information I have about nutrition in diabetes”. 25 40%

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their daily life. Patients’ perception that their disease
does not seems to be affected, no matter what they eat,
should be addressed by proper nutrition education. Re-
garding the limitations of our study, we propose that the
small sample size does not allow us to extrapolate to a
wider group of patients. Although we invited patients to
this study during the course of a two-month period and
recruited a significant number of T2DM patients who
attend consultations at the clinic, the final sample size
can limit our ability for some statistical analyses and for
stratifying the data. Additionally, we did not conduct a
thorough dietary assessment, which must include other
data collection tools apart from a 24 h recall. This meth-
od provides an estimate of intake, but can misrepresent
usual dietary intake.

Our sample was also composed by patients with low
educational level, which can be associated with a low
adherence to treatment and is also identified in the lit-
erature as an important determinant of dietary habits
[31,32].

Conclusions

Our study allows us to conclude that T2DM patients
perceive dietary intake as an important part of their
treatment, but not as valuable as pharmacologic ther-
apy.

The purpose of this study was not to assess the qual-
ity of the nutritional or medical therapy, or the type of
patient education messages that were previously de-
livered to these patients, but our data suggest that pa-
tients believe that engaging in nutritional recommenda-
tions is hard or that patients are not provided with the
necessary tools to follow recommendations.

Patients should be empowered to improve their self-
care and to consider nutrition therapy as valuable as
other treatments, such as pharmacologic therapy.

There is sufficient evidence in the literature to sup-
port the effectiveness of nutritional therapy in T2DM
and there are clear guidelines for the construction of
meals plans for T2DM patients. Nevertheless, future re-
search must address the ways that educational, psycho-
social, cultural or economic characteristics may hinder
compliance of nutritional recommendations. Although
a stricter adherence to existing guidelines and a much
stronger attention to the desired therapeutic goals may
allow a decrease in diabetes costs, morbidity, and mor-
tality, there is still a significant problem in adherence to
therapy. Future research must also focus on developing
tailored strategies for patient education and for improv-
ing risk communication.

Acknowledgements

All authors contributed to the drafting and revising
of this manuscript. The authors wish to express their
gratitude to the AEDMADA Diabetes Clinic and its pro-
fessionals, without whom this work would not have

classify their agreement with the likelihood of an event,
individuals are more unjustifiably optimistic when they
perceive having some form of control over that event
[21]. This can explain the difference in the perception
of diet quality, as individuals, having more control over
their own diet, perceive its outcomes in a favourable
way. According to the literature, the tendency to be-
lieve that one’s own outcomes of an event are more
favourable than that of others, can partly explain why
health education messages can be ineffective [22].

Patients consider a proper diet a valuable treatment,
but pharmacotherapy is a more highly regarded ther-
apeutic tool. This is in accordance with the literature,
which suggests that adherence to pharmacotherapy
seems to be the behaviour with the highest prevalence
in T2DM patients, with reports of adherence to thera-
peutic regimens of oral antidiabetic agents ranging from
70% to 80% [5,12,23]. Regular physical activity also pre-
sents a low prevalence in diabetes patients, with a lit-
erature review reporting an adherence to a physical ac-
tivity plan of 26%, and stating that individuals with dia-
betes are considered among the least likely to engage in
regular physical activity [24]. This review also suggests
that only 25% of older adults with diabetes meet the
recommendations for physical activity proposed by the
ADA [2].

Our data suggest that patients consider nutrition
as an important part of their daily life, but do not en-
gage or maintain dietary recommendations for long.
The literature shows that nutrition counselling requires
a contextual understanding of the patient’s individual
situation, in order to support and promote health be-
haviour change [25], and that the difficulties and com-
plexities of the nutritional care process in T2DM suggest
that a single, uniform approach is not desirable, due
to the intricacies of diabetes aetiology, complications,
and glycaemia determinants [26-28]. Patient educa-
tion, which enables people with diabetes to improve
their knowledge, skills and confidence, allowing them
to self-manage their condition, must include interven-
tions that empower patients to incorporate nutritional
management and physical activity into his/her lifestyle
and to develop personal strategies to promote health
and behaviour change [29]. Changing food behaviour is
not an easy task because it requires alterations in habits
that have been built up over the course of an extended
period of time, but targeted interventions that include
behaviour and nutrition counselling have proven to be
successful in primary care and community settings, in-
cluding in T2DM patients [30]. Nevertheless, nutrition
counselling requires a contextual understanding of the
patient’s individual situation, in order to support and
promote health behaviour change [25].

Our study shows that even if patients place value
in nutritional therapy, they still experience significant
problems in translating dietary recommendations to

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17. Institute of Medicine (2005) Dietary Reference Intakes for
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18. Franz MJ, Bantle JP (2012) American Diabetes Association
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19. Franz MJ, Boucher JL, Green-Pastors J, Powers MA (2008)
Evidence-based nutrition practice guidelines for diabetes
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20. World Health Organization (2015) Guideline: Sugars intake
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21. Weinstein ND (1980) Unrealistic optimism about future life
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22. Weinstein ND, Klein WM (1995) Resistance of personal risk
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23. Ahmad NS, Ramli A, Islahudin F, Paraidathathu T (2013)
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been possible.

Ethical Statement

We declare that this study followed all necessary
ethical procedures and regulations.

Conflict of Interest Disclosure Statement

The authors did not receive any funding for this re-
search and confirm that the content of this article has
no conflict of interest.

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• Title

Corresponding author
Abstract
Keywords
Introduction
Methods
Results
Discussion
Conclusions
Acknowledgements

• Ethical Statement
• Conflict of Interest Disclosure Statement

Table 1
Table 2
Table 3
Table 4
References