- Email: [email protected]
Relationship of Diet Quality to Food Security and Nutrition Knowledge in Low-Income, Community-Dwelling Elders with Type 2 Diabetes Mellitus: A Pilot Study
Can J Diabetes 36 (2012) 310e313
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Relationship of Diet Quality to Food Security and Nutrition Knowledge in Low-Income, Community-Dwelling Elders with Type 2 Diabetes Mellitus: A Pilot Study Ghada Asaad MSc a, *, Catherine B. Chan PhD, Professor a, b a b
Department of Agriculture, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 July 2012 Received in revised form 6 October 2012 Accepted 13 October 2012
Objective: To examine nutrient intake and diet quality in relation to current Canadian Diabetes Association recommendations related to food security status of low-income, community-dwelling elders with type 2 diabetes mellitus in Edmonton, Canada. Methods: A cross-sectional survey study obtained socio-demographic, perceived dietary adherence, repeated 24-hour dietary recall and food security information. Diet quality was assessed using the Healthy Eating Index-Canada (HEI-C) calculated from dietary recall data. Results: Sixteen of 17 participants completed all study requirements. Overall, diet quality and dietary adherence were poor. The mean total HEI-C score was 64.4 14.6, which was largely attributed to less than recommended servings of all food groups except meat and alternatives. One-third of participants were classified as food insecure-severe but food security status was not related to HEI-C score. Accessibility to current knowledge regarding an appropriate diet was suboptimal, with <50% reporting receiving advice to increase fibre or eat low glycemic index foods. Conclusion: Low-income, community-dwelling elders with type 2 diabetes in this study had diet quality in the “needs improvement” range independent of food security status. Increased knowledge of current clinical practice recommendations may help increase diet quality. Ó 2012 Canadian Diabetes Association
Keywords: community-dwelling diet quality elders food security type 2 diabetes
r é s u m é Mots clés: vivant dans la communauté qualité du régime alimentaire personnes âgées sécurité alimentaire diabète de type 2
Objectif : Examiner l’apport en nutriments et la qualité du régime alimentaire en lien avec les recommandations actuelles de l’Association canadienne du diabète sur le statut de la sécurité alimentaire des personnes âgées de faible revenu vivant dans la communauté et ayant le diabète sucré de type 2, à Edmonton, au Canada. Méthodes : Une enquête transversale a obtenu le profil sociodémographique, a perçu l’observance alimentaire, a répété la méthode de rappel de la consommation des dernières 24 heures, la sécurité alimentaire. La qualité du régime a été évaluée en utilisant le Canadian-Healthy Eating Index (C-HEI). Résultats : Seize (16) des 17 participants ont rempli toutes les exigences de l’étude. Dans l’ensemble, la qualité du régime et son observance ont été médiocres. Le score total moyen au C-HEI a été de 64,4 14,6, ce qui a été en grande partie attribué à des portions moindres que celles recommandées pour tous les groupes alimentaires, à l’exception de la viande et de ses substituts. Un tiers (1/3) des participants a été en situation d’insécurité alimentaire grave, mais le statut de sécurité alimentaire n’a pas été associé au score du C-HEI. L’accès aux connaissances actuelles en ce qui a trait à un régime approprié a été sousoptimal :< 50 % rapportent avoir reçu des conseils pour augmenter l’apport en fibres ou pour manger des aliments dont l’indice glycémique est faible. Conclusion : Les personnes âgées de faible revenu vivant dans la communauté et ayant le diabète de type 2 de cette étude ont montré une qualité du régime à un niveau « nécessitant une amélioration » indépendante du statut de la sécurité alimentaire. L’enrichissement des connaissances sur les recommandations actuelles de la pratique clinique peut aider à rehausser la qualité du régime. Ó 2012 Canadian Diabetes Association
* Address for correspondence: Ghada Asaad, Department of Agriculture, Food and Nutritional Science, 6-126 Li Ka Shing Centre, Edmonton, AB T6G 2R3, Canada. E-mail address: [email protected] (G. Asaad). 1499-2671/$ e see front matter Ó 2012 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2012.10.006
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Introduction
Results
Diabetes care can be optimized by following the Canadian Diabetes Association (CDA) 2008 nutrition therapy recommendations, including Eating Well with Canada’s Food Guide (Food Guide) (1). However, newly-diagnosed type 2 diabetes mellitus patients report that adopting a new dietary pattern is challenging (2), resulting in low adherence to dietary recommendations (3,4). In addition, elders generally have poor diet quality (5,6). Food insecurity is “the inability to acquire or consume an adequate quality diet or a sufficient quantity of food in socially acceptable ways or the uncertainty that one will be able to do so” (7). Food insecurity, pervasive in elder populations (8), is associated with increased type 2 diabetes prevalence (9). Trade-offs between the purchase of testing supplies and medication vs. food by foodinsecure participants with type 2 diabetes led to a high incidence of hypoglycemia (10). Conversely, food-insecure elders with type 2 diabetes were more conscious of the cost of food compared to foodsecure participants without affecting glycemic control (11). Few studies have examined factors affecting the diet quality of elders with type 2 diabetes. We hypothesized that diet quality would be related to food security status of low-income, community-dwelling elders with type 2 diabetes. We found that, independent of food security, overall diet quality was poor due to low servings of most food groups, perhaps related to weight loss advice, and that nutritional knowledge of healthy food choices and meal patterns could be improved.
Demographics
Methodology Study design, setting and participants The University of Alberta Research Ethics Board approved this study. Participants provided written informed consent. The cohort was a convenience sample of elders with type 2 diabetes (n¼17) living independently in subsidized retirement homes in Edmonton, Canada. Additional inclusion criteria were 60 years old and English-speaking. Respondents with type 1 diabetes and those on dialysis were excluded. Eligible participants gave 3 face-to-face interviews to complete the questionnaires in a private setting in their home building. Interviews were conducted over 1 month, each 2 weeks apart, and lasted 45 to 60 minutes. Measures and data analysis Demographic information was obtained through a questionnaire based on the Canadian Community Health Survey (12). Dietary intake was reported through repeated 24-hour dietary recall obtained at each interview and analyzed using Food Processor version 10.5. Dietary adherence and self-care activities were assessed subjectively using questionnaires developed from the Summary of Diabetes Self-Care Activities (13) adapted to the CDA guidelines (3). The Healthy Eating Index-Canada (HEI-C) (14) was adapted to the CDA nutrition therapy guidelines (3). Household food security status was assessed using a validated questionnaire (15). Data were analyzed with SPSS version 19 (SPSS, Chicago, IL). Repeated-measures analysis of variance (ANOVA) was used to compare the dietary recall nutrient data. Descriptive statistics were used to analyze perceived dietary adherence responses, which were grouped into low (0 to 2 days per week), medium (3 to 5 days per week) and high (6 to 7 days per week) adherence categories, except for saturated fat and refined sugars data, which were inversely scored. The Mann-Whitney U-test was used to compare variables between food insecure-severe and food secure groups. The significance level was set at p0.05.
311
Sixteen of 17 participants completed all study requirements. Table 1 outlines their demographic characteristics. Dietary intake Table 2 compares the three 24-hour recalls. Timing of the pension cheque did not affect total calories (p¼0.075), fat (p¼0.057) or protein intakes. Carbohydrate intake was lowest at the end of the month (p¼0.049). Regarding perceived dietary adherence (Fig. 1), >60% of participants reported high adherence to Food Guide recommendations for fruits/vegetables, fibre and foods high in sugar and moderate adherence to intake of low glycemic index foods. Adherence to other recommendations was lower. The mean total HEI-C score was 64.4 14.6 (range 42.0e80.0). Most participants were classified as “needs improvement” (87.5%), whereas the rest had “poor” diet quality. The highest component scores were obtained for other, total fat, cholesterol and meat/ Table 1 Demographic characteristics of the participants Variable Age (yr) Female Male Duration of diabetes (yr) Gender Male Female Ethnicity White Aboriginal South Asian Arab Education Less than high school High school Some college or university College University Employment Retirement income No. in household 1 2 Household annual income $21,000 $21,000 to $39,999 $40,000 to $59,999 Concurrent illness* Arthritis High blood pressure High cholesterol Bladder control difficulties Back problem Foot problem Balance problem Allergies Other health problem Osteoporosis Trouble hearing Poor appetite Burning foot Heart problem Cancer Trouble seeing Chronic asthma, emphysema, or bronchitis SD, standard deviation. * More than one response was possible.
Number (n¼17)
Mean SD or proportion
11 6
71.5 74.5 67.8 17.6
6.3 6.2 2.7 12.6
6 11
35.3% 64.7%
13 2 1 1
76.5% 11.8% 5.8% 5.8%
3 3 3 4 4
17.6% 17.6% 17.6% 23.5% 23.5%
17
100%
16 1
94.1% 5.9%
12 3 2
64.7% 17.6% 11.8%
11 10 10 10 9 9 9 8 8 7 6 6 5 5 4 4 1
64.7% 58.8% 58.8% 58.8% 52.9% 52.9% 52.9% 47% 47% 41.1% 35.2% 35.2% 29.4% 29.4% 23.5% 23.5% 5.8%
312
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Table 2 Macronutrient intake estimated from repeated 24-hour recalls obtained at the beginning, middle and end of the month Beginning*
Variable Total calories % energy from Fibre (g) % energy from % energy from % energy from
1387 51.9 18.7 protein 19.9 fat 28.1 saturated fat 9.5 carbohydrate
Middle
End
405 1168 274 1463 323 11 51.7 8.4 44.9 11.6z 7.9 13.1 5.8 16.7 10.8 7.4 18.7 5.6 20 4.4 7.6 29.4 8.5 34.9 12.2 4.2 9.7 4 9.4 5.3
P valuey 0.075 0.049 0.114 0.695 0.057 0.962
* The beginning of the month immediately followed receipt of government pension cheques. y P<0.05 was considered significant comparing beginning, middle and end of the month, 1-way analysis of variance. z Statistically different from the beginning and middle of the month by post hoc analysis.
alternatives (Fig. 2). Participants scored <50% of the maximum for fruits/vegetables, whole grains and milk/alternatives. The average daily servings deficit was (men, women): grains 2.5, 2.3; fruits and vegetables 4.3, 2.8; milk/alternatives 1.8,1.5; meat/alternatives 0.5, 0.3. Food security and nutrition knowledge Regarding food security, 69% were categorized as food secure and 21% as food insecure-severe but did not differ in HEI-C score (Table 3). With n¼17, the power is 80% to detect an effect size (Cohen’s d) of 1.8 at an a-level of 0.05. Thus, the study lacked power to detect differences in HEI-C (d¼0.41). Caloric intake was marginally higher (p¼0.079) and iron intake and grain servings were significantly higher in the food insecure-severe group. Food choices are affected by access knowledge of an appropriate diet. Two-thirds of participants recalled receiving dietary advice from a doctor whereas only half received advice from a dietitian (Table 4). One-third and 78% of participants did not recall being advised about the Food Guide or low glycemic index foods, respectively. Discussion Diet quality of this cohort of low-income, community-dwelling elders with type 2 diabetes was classified as “needs improvement” but this outcome was not associated with food security status. Furthermore, participants’ perception of their adherence was optimistic, perhaps reflecting lack of knowledge of current nutritional recommendations such as consuming low glycemic index foods.
Figure 1. Perceived adherence to 2008 CDA Nutrition Therapy Guidelines (1). Participants reported the number of days in the past week to which they had met recommendations to following Eating Well with Canada’s Food Guide (EWCFG), servings of fruits/vegetables (F&V), low glycemic index foods (LGI), use monounsaturated oils and those containing omega-3 fatty acids, consumption of foods high in fiber, consume fish, and consumption of foods high in fat or sugar.
Figure 2. Diet quality status of participants derived from the Healthy Eating IndexCanada Survey. No participants had good diet quality (score >80).
Participants’ perceptions regarding adherence to specific recommendations did not match with consumption of foods documented in dietary recalls. The questions asked were very specific, e.g. “On how many of the last 7 days did you eat the number of fruit and vegetable servings based on Canada’s Food Guide (7 servings)?” Most respondents indicated high adherence but dietary recalls showed far less consumption. Differences between perceived and actual intakes may reflect inaccurately estimating serving sizes (16), cognitive impairment, deliberate misrepresentation or lack of knowledge. American studies showed only half of respondents >60 years old were aware of the Food Guide Pyramid, compared to w80% younger than 20 years and awareness was further lowered by poverty (17). Participants herein had been living with diabetes an average of 17 years and may not have received updates on nutritional recommendations and the Food Guide, as indicated by their recall of self-care advice. No participant had a diet quality score in the “good” range, indicating general lack of compliance with the Food Guide similar to other Canadian (18) and American data (5,6). The number of servings per food group rather than macronutrient distribution primarily influenced the score. Other elderly populations also failed to meet recommended servings of local food guides (4,18e22), particularly for milk/alternatives and fruit/vegetables (4), similar to current findings. Meat/alternatives intake was closest to the Food Guide servings but was associated with higher than recommended saturated fat intake (1). Low servings of fruit/vegetables and whole grains correlated with fibre intake only w65% of the recommended 25 to 50 g/day (1). More positively, participants scored highly for the “other” category in the HEI-C, with low intakes of empty calories. Table 3 Comparison of dietary intake between food secure and food insecure-severe participants Variables
Median of FS (n¼12)
Median of FIS (n¼5)
Manne Whitney U
P value*
HEI score Total calories Total fat % Saturated fat % Protein % Carbohydrate % Fibre (g) Cholesterol (mg) Calcium (mg) Iron (mg) Sodium (mg) B12 (mg) Vitamin D (mg) Grain servings Fruits and vegetables servings Milk and alternative servings Meat and alternative servings
63.0 1300 32.8 9.1 17.2 51.9 13.7 25 598 8.1 2189 2.5 131 3.3 3.2 1.5 1.7
68.9 1457 29.4 9.7 20.8 50.5 16.0 234 561 14.3 2389 3.7 101 4.7 3.3 1.8 2.5
19 12 27 20 20 22 27 24 26 4 20 14 25 6 26 24 15
0.377 0.079 0.955 0.396 0.396 0.533 0.955 0.692 0.865 0.008 0.441 0.145 0.827 0.013 0.913 0.743 0.180
FIS, food insecure-severe; FS, food secure; HEI, Healthy Eating Index. * P value <0.05 was considered significant by ManneWhitney U-test comparing FS to FIS.
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Author Disclosures
Table 4 Recommended self-care activities for diabetes treatment Self-care activity Diet Follow Eating Well with Canada’s Food Guide Avoid food high in fat Eat foods high in dietary fiber Reduce number of calories Eat lots of fruits and vegetables Eat fewer sweets Eat a low glycemic index diet Advised by Doctor Dietitian Nurse Diabetes educator
313
Number (n¼17)
Proportion (%)
11 9 8 7 6 6 2
64.7 52.9 47.0 41.1 35.3 35.2 11.7
11 6 9 3
64.7 52.9 35.2 17.6
GA received personal funding from the Ministry for Higher Education, Kingdom of Saudi Arabia. Research funding was from Alberta Health Services and the University of Alberta, Faculty of Medicine and Dentistry. Author Contributions GA and CC together designed the study, interpreted the results and wrote the manuscript. GA carried out the participant recruitment and interviews, and analyzed the data. CC wrote the grant that funded the study. References
Other studies have documented that adults with diabetes had high intakes of saturated fat (3,4) and <5 servings of fruits/vegetables (3), although fibre in one cohort (6) was within the range of current recommendations (1). Overall low intake and total calories could reflect advice to lose weight, reported by 41% of participants. Food security status was not a strong predictor of diet quality or nutrient intake in this small sample, even though 5 of 17 perceived themselves as food insecure-severe. Surprisingly, the group had a significantly higher number of servings of grains and meat/alternatives, which likely accounted for higher iron intake. These results suggest that food insecure people make more careful decisions about food purchases but further research is required to verify this finding. Macronutrient intake patterns relative to receipt of pension cheques suggested the participants made adjustments in their diet, with lower carbohydrate intake at the end of the month, compensated by increased fat, indicating reliance on energy-dense foods. In contrast, food insecurity or low income (10,23,24) was associated with poor diet quality in elders and economic indices were more important predictors than nutrition knowledge or education (25). This study demonstrates nutritional risks faced by low-income elders with diabetes living independently in an urban setting. Limitations include small sample size and lack of statistical power and recruitment of a predominantly female, highly-educated cohort. Although cognitive disabilities may have affected the results, faceto-face interviews allowed facilitation of recall through prompting. Body weight and glycated hemoglobin data would have facilitated comparisons of glycemic and weight control with diet quality. In addition, participants answered questions from their perspective, and embarrassment or forgetfulness may have produced inaccurate information. Food intake recalls may have been subject to underreporting or underestimating. We used the HEI-C scale modified to the Food Guide and CDA recommendations for elders with type 2 diabetes; however, it was not validated with these modifications. Summary Overall, the elders with type 2 diabetes in this study had diet quality that was similar to other elderly people in North America. It would be preferable to increase dietary quality in this group to reduce the risk of diabetes complications; therefore, advice to lose weight should be tempered by consideration of the impact on diet quality. Given that people typically live with type 2 diabetes for decades, diabetes education needs to be updated regularly so that new recommendations can be incorporated into self-care activities. Acknowledgments We acknowledge Norwood Seniors Housing Association and the Greater Edmonton Foundation for their collaboration.
1. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008; 32(suppl 1):S40e5. 2. Nagelkerk J, Reick K, Meengs L. Perceived barriers and effective strategies to diabetes self-management. J Adv Nurs 2006;54:151e8. 3. Nelson KM, Reiber G, Boyko EJ. Diet and exercise among adults with type 2 diabetes: Findings from the third National Health and Nutrition Examination Survey (NHANES III). Diabetes Care 2002;25:1722e8. 4. Barclay AW, Brand-Miller J, Mitchell P. Macronutrient intake, glycaemic index and glycaemic load of older Australian subjects with and without diabetes: baseline data from the Blue Mountains eye study. Br J Nutr 2006;96:117e23. 5. Finke MS, Huston SJ. Healthy eating index scores and the elderly. Fam Econ Nutr Rev 2003;15:67e73. 6. Savoca MR, Anderson A, Kohrman T, et al. The diet quality of rural older adults in the south as measured by Healthy Eating Index-2005 varies by ethnicity. J Am Diet Assoc 2009;109:2063e7. 7. Davis B, Tarasuk V. Hunger in Canada. Agriculture and human values 1994;11: 50e7. 8. Gucciardi E, Vogt JA, Demelo M, et al. Exploration of the relationship between household food insecurity and diabetes in Canada. Diabetes Care 2009;32: 2218e24. 9. Seligman HK, Bindman AB, Vittinghoff E, et al. Food insecurity is associated with diabetes mellitus: Results from the national health examination and nutrition examination survey (NHANES) 1999-2002. J Gen Intern Med 2007;22:1018e23. 10. Seligman HK, Davis TC, Schillinger D, et al. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved 2010;21:1227e33. 11. Homenko DR, Morin PC, Eimicke JP, et al. Food insecurity and food choices in rural older adults with diabetes receiving nutrition education via telemedicine. J Nutr Educ Behav 2010;42:404e9. 12. Canadian Community Health Survey. Population health surveys. Statistics Canada. (available online at http://www.statcan.gc.ca/concepts/hs-es/indexeng.htm). Accessed April 23, 2012. 13. Toobert D, Hampson S, Glasgow R. The summary of diabetes self-care activities measure: Results from 7 studies and a revised scale. Diabetes Care 2000;23:943e50. 14. Woodruff SJ, Hanning RM. Development and implications of a revised Canadian Healthy Eating Index (HEIC-2009). Public Health Nutr 2010;13:820e5. 15. Canadian Community Health Survey. Cycle 2.2, nutrition income-related household food security in Canada. Health Canada. (available online at http:// www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/surveill/income_food_secsec_alim-eng.pdf). Accessed April 23, 2012. 16. Godwin S, Chambers E. Estimation of portion sizes by elderly respondents. Fam Econ Nutr Rev 2003;15:58e66. 17. Wright JD, Wang C-Y. Awareness of federal dietary guidance in persons aged 16 years and older: results from the National Health and Nutrition Examination Survey 2005-2006. J Am Diet Assoc 2011;111:295e300. 18. Garriguet D. Diet quality in Canada. Health Reports 2009;3:41e52. 19. McBee S, Cotugna N, Vickery CE. Fruit and vegetable consumption in an elderly population. J Nutr Elderly 2001;21:59e67. 20. Ellis J, Johnson MA, Fischer JG, et al. Nutrition and health education intervention for whole grain foods in the Georgia older Americans nutrition program. J Nutr Elderly 2005;24:67e83. 21. Nesbitt A, Majowicz S, Finley R, et al. Food consumption patterns in the Waterloo Region, Ontario, Canada: a cross-sectional telephone survey. BMC Public Health 2008;8:370e81. 22. DeWolfe J, Millan K. Dietary intake of older adults in the Kingston area. Can J Diet Pract Res 2003;64:16e24. 23. Kirkpatrick SI, Tarasuk V. Adequacy of food spending is related to housing expenditures among lower-income Canadian households. Public Health Nutr 2007;10:1464e73. 24. Guthrie JF, Lin B. Overview of the diets of lower- and higher-income elderly and their food assistance options. JNEB 2002;34(supp1):S31e41. 25. Sharpe D, Huston S, Finke M. Factors affecting nutritional adequacy among single elderly women. Fam Econ Nutr Rev 2003;15:74e82.
Contents lists available at SciVerse ScienceDirect
Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com
Original Research
Relationship of Diet Quality to Food Security and Nutrition Knowledge in Low-Income, Community-Dwelling Elders with Type 2 Diabetes Mellitus: A Pilot Study Ghada Asaad MSc a, *, Catherine B. Chan PhD, Professor a, b a b
Department of Agriculture, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 July 2012 Received in revised form 6 October 2012 Accepted 13 October 2012
Objective: To examine nutrient intake and diet quality in relation to current Canadian Diabetes Association recommendations related to food security status of low-income, community-dwelling elders with type 2 diabetes mellitus in Edmonton, Canada. Methods: A cross-sectional survey study obtained socio-demographic, perceived dietary adherence, repeated 24-hour dietary recall and food security information. Diet quality was assessed using the Healthy Eating Index-Canada (HEI-C) calculated from dietary recall data. Results: Sixteen of 17 participants completed all study requirements. Overall, diet quality and dietary adherence were poor. The mean total HEI-C score was 64.4 14.6, which was largely attributed to less than recommended servings of all food groups except meat and alternatives. One-third of participants were classified as food insecure-severe but food security status was not related to HEI-C score. Accessibility to current knowledge regarding an appropriate diet was suboptimal, with <50% reporting receiving advice to increase fibre or eat low glycemic index foods. Conclusion: Low-income, community-dwelling elders with type 2 diabetes in this study had diet quality in the “needs improvement” range independent of food security status. Increased knowledge of current clinical practice recommendations may help increase diet quality. Ó 2012 Canadian Diabetes Association
Keywords: community-dwelling diet quality elders food security type 2 diabetes
r é s u m é Mots clés: vivant dans la communauté qualité du régime alimentaire personnes âgées sécurité alimentaire diabète de type 2
Objectif : Examiner l’apport en nutriments et la qualité du régime alimentaire en lien avec les recommandations actuelles de l’Association canadienne du diabète sur le statut de la sécurité alimentaire des personnes âgées de faible revenu vivant dans la communauté et ayant le diabète sucré de type 2, à Edmonton, au Canada. Méthodes : Une enquête transversale a obtenu le profil sociodémographique, a perçu l’observance alimentaire, a répété la méthode de rappel de la consommation des dernières 24 heures, la sécurité alimentaire. La qualité du régime a été évaluée en utilisant le Canadian-Healthy Eating Index (C-HEI). Résultats : Seize (16) des 17 participants ont rempli toutes les exigences de l’étude. Dans l’ensemble, la qualité du régime et son observance ont été médiocres. Le score total moyen au C-HEI a été de 64,4 14,6, ce qui a été en grande partie attribué à des portions moindres que celles recommandées pour tous les groupes alimentaires, à l’exception de la viande et de ses substituts. Un tiers (1/3) des participants a été en situation d’insécurité alimentaire grave, mais le statut de sécurité alimentaire n’a pas été associé au score du C-HEI. L’accès aux connaissances actuelles en ce qui a trait à un régime approprié a été sousoptimal :< 50 % rapportent avoir reçu des conseils pour augmenter l’apport en fibres ou pour manger des aliments dont l’indice glycémique est faible. Conclusion : Les personnes âgées de faible revenu vivant dans la communauté et ayant le diabète de type 2 de cette étude ont montré une qualité du régime à un niveau « nécessitant une amélioration » indépendante du statut de la sécurité alimentaire. L’enrichissement des connaissances sur les recommandations actuelles de la pratique clinique peut aider à rehausser la qualité du régime. Ó 2012 Canadian Diabetes Association
* Address for correspondence: Ghada Asaad, Department of Agriculture, Food and Nutritional Science, 6-126 Li Ka Shing Centre, Edmonton, AB T6G 2R3, Canada. E-mail address: [email protected] (G. Asaad). 1499-2671/$ e see front matter Ó 2012 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2012.10.006
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Introduction
Results
Diabetes care can be optimized by following the Canadian Diabetes Association (CDA) 2008 nutrition therapy recommendations, including Eating Well with Canada’s Food Guide (Food Guide) (1). However, newly-diagnosed type 2 diabetes mellitus patients report that adopting a new dietary pattern is challenging (2), resulting in low adherence to dietary recommendations (3,4). In addition, elders generally have poor diet quality (5,6). Food insecurity is “the inability to acquire or consume an adequate quality diet or a sufficient quantity of food in socially acceptable ways or the uncertainty that one will be able to do so” (7). Food insecurity, pervasive in elder populations (8), is associated with increased type 2 diabetes prevalence (9). Trade-offs between the purchase of testing supplies and medication vs. food by foodinsecure participants with type 2 diabetes led to a high incidence of hypoglycemia (10). Conversely, food-insecure elders with type 2 diabetes were more conscious of the cost of food compared to foodsecure participants without affecting glycemic control (11). Few studies have examined factors affecting the diet quality of elders with type 2 diabetes. We hypothesized that diet quality would be related to food security status of low-income, community-dwelling elders with type 2 diabetes. We found that, independent of food security, overall diet quality was poor due to low servings of most food groups, perhaps related to weight loss advice, and that nutritional knowledge of healthy food choices and meal patterns could be improved.
Demographics
Methodology Study design, setting and participants The University of Alberta Research Ethics Board approved this study. Participants provided written informed consent. The cohort was a convenience sample of elders with type 2 diabetes (n¼17) living independently in subsidized retirement homes in Edmonton, Canada. Additional inclusion criteria were 60 years old and English-speaking. Respondents with type 1 diabetes and those on dialysis were excluded. Eligible participants gave 3 face-to-face interviews to complete the questionnaires in a private setting in their home building. Interviews were conducted over 1 month, each 2 weeks apart, and lasted 45 to 60 minutes. Measures and data analysis Demographic information was obtained through a questionnaire based on the Canadian Community Health Survey (12). Dietary intake was reported through repeated 24-hour dietary recall obtained at each interview and analyzed using Food Processor version 10.5. Dietary adherence and self-care activities were assessed subjectively using questionnaires developed from the Summary of Diabetes Self-Care Activities (13) adapted to the CDA guidelines (3). The Healthy Eating Index-Canada (HEI-C) (14) was adapted to the CDA nutrition therapy guidelines (3). Household food security status was assessed using a validated questionnaire (15). Data were analyzed with SPSS version 19 (SPSS, Chicago, IL). Repeated-measures analysis of variance (ANOVA) was used to compare the dietary recall nutrient data. Descriptive statistics were used to analyze perceived dietary adherence responses, which were grouped into low (0 to 2 days per week), medium (3 to 5 days per week) and high (6 to 7 days per week) adherence categories, except for saturated fat and refined sugars data, which were inversely scored. The Mann-Whitney U-test was used to compare variables between food insecure-severe and food secure groups. The significance level was set at p0.05.
311
Sixteen of 17 participants completed all study requirements. Table 1 outlines their demographic characteristics. Dietary intake Table 2 compares the three 24-hour recalls. Timing of the pension cheque did not affect total calories (p¼0.075), fat (p¼0.057) or protein intakes. Carbohydrate intake was lowest at the end of the month (p¼0.049). Regarding perceived dietary adherence (Fig. 1), >60% of participants reported high adherence to Food Guide recommendations for fruits/vegetables, fibre and foods high in sugar and moderate adherence to intake of low glycemic index foods. Adherence to other recommendations was lower. The mean total HEI-C score was 64.4 14.6 (range 42.0e80.0). Most participants were classified as “needs improvement” (87.5%), whereas the rest had “poor” diet quality. The highest component scores were obtained for other, total fat, cholesterol and meat/ Table 1 Demographic characteristics of the participants Variable Age (yr) Female Male Duration of diabetes (yr) Gender Male Female Ethnicity White Aboriginal South Asian Arab Education Less than high school High school Some college or university College University Employment Retirement income No. in household 1 2 Household annual income $21,000 $21,000 to $39,999 $40,000 to $59,999 Concurrent illness* Arthritis High blood pressure High cholesterol Bladder control difficulties Back problem Foot problem Balance problem Allergies Other health problem Osteoporosis Trouble hearing Poor appetite Burning foot Heart problem Cancer Trouble seeing Chronic asthma, emphysema, or bronchitis SD, standard deviation. * More than one response was possible.
Number (n¼17)
Mean SD or proportion
11 6
71.5 74.5 67.8 17.6
6.3 6.2 2.7 12.6
6 11
35.3% 64.7%
13 2 1 1
76.5% 11.8% 5.8% 5.8%
3 3 3 4 4
17.6% 17.6% 17.6% 23.5% 23.5%
17
100%
16 1
94.1% 5.9%
12 3 2
64.7% 17.6% 11.8%
11 10 10 10 9 9 9 8 8 7 6 6 5 5 4 4 1
64.7% 58.8% 58.8% 58.8% 52.9% 52.9% 52.9% 47% 47% 41.1% 35.2% 35.2% 29.4% 29.4% 23.5% 23.5% 5.8%
312
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Table 2 Macronutrient intake estimated from repeated 24-hour recalls obtained at the beginning, middle and end of the month Beginning*
Variable Total calories % energy from Fibre (g) % energy from % energy from % energy from
1387 51.9 18.7 protein 19.9 fat 28.1 saturated fat 9.5 carbohydrate
Middle
End
405 1168 274 1463 323 11 51.7 8.4 44.9 11.6z 7.9 13.1 5.8 16.7 10.8 7.4 18.7 5.6 20 4.4 7.6 29.4 8.5 34.9 12.2 4.2 9.7 4 9.4 5.3
P valuey 0.075 0.049 0.114 0.695 0.057 0.962
* The beginning of the month immediately followed receipt of government pension cheques. y P<0.05 was considered significant comparing beginning, middle and end of the month, 1-way analysis of variance. z Statistically different from the beginning and middle of the month by post hoc analysis.
alternatives (Fig. 2). Participants scored <50% of the maximum for fruits/vegetables, whole grains and milk/alternatives. The average daily servings deficit was (men, women): grains 2.5, 2.3; fruits and vegetables 4.3, 2.8; milk/alternatives 1.8,1.5; meat/alternatives 0.5, 0.3. Food security and nutrition knowledge Regarding food security, 69% were categorized as food secure and 21% as food insecure-severe but did not differ in HEI-C score (Table 3). With n¼17, the power is 80% to detect an effect size (Cohen’s d) of 1.8 at an a-level of 0.05. Thus, the study lacked power to detect differences in HEI-C (d¼0.41). Caloric intake was marginally higher (p¼0.079) and iron intake and grain servings were significantly higher in the food insecure-severe group. Food choices are affected by access knowledge of an appropriate diet. Two-thirds of participants recalled receiving dietary advice from a doctor whereas only half received advice from a dietitian (Table 4). One-third and 78% of participants did not recall being advised about the Food Guide or low glycemic index foods, respectively. Discussion Diet quality of this cohort of low-income, community-dwelling elders with type 2 diabetes was classified as “needs improvement” but this outcome was not associated with food security status. Furthermore, participants’ perception of their adherence was optimistic, perhaps reflecting lack of knowledge of current nutritional recommendations such as consuming low glycemic index foods.
Figure 1. Perceived adherence to 2008 CDA Nutrition Therapy Guidelines (1). Participants reported the number of days in the past week to which they had met recommendations to following Eating Well with Canada’s Food Guide (EWCFG), servings of fruits/vegetables (F&V), low glycemic index foods (LGI), use monounsaturated oils and those containing omega-3 fatty acids, consumption of foods high in fiber, consume fish, and consumption of foods high in fat or sugar.
Figure 2. Diet quality status of participants derived from the Healthy Eating IndexCanada Survey. No participants had good diet quality (score >80).
Participants’ perceptions regarding adherence to specific recommendations did not match with consumption of foods documented in dietary recalls. The questions asked were very specific, e.g. “On how many of the last 7 days did you eat the number of fruit and vegetable servings based on Canada’s Food Guide (7 servings)?” Most respondents indicated high adherence but dietary recalls showed far less consumption. Differences between perceived and actual intakes may reflect inaccurately estimating serving sizes (16), cognitive impairment, deliberate misrepresentation or lack of knowledge. American studies showed only half of respondents >60 years old were aware of the Food Guide Pyramid, compared to w80% younger than 20 years and awareness was further lowered by poverty (17). Participants herein had been living with diabetes an average of 17 years and may not have received updates on nutritional recommendations and the Food Guide, as indicated by their recall of self-care advice. No participant had a diet quality score in the “good” range, indicating general lack of compliance with the Food Guide similar to other Canadian (18) and American data (5,6). The number of servings per food group rather than macronutrient distribution primarily influenced the score. Other elderly populations also failed to meet recommended servings of local food guides (4,18e22), particularly for milk/alternatives and fruit/vegetables (4), similar to current findings. Meat/alternatives intake was closest to the Food Guide servings but was associated with higher than recommended saturated fat intake (1). Low servings of fruit/vegetables and whole grains correlated with fibre intake only w65% of the recommended 25 to 50 g/day (1). More positively, participants scored highly for the “other” category in the HEI-C, with low intakes of empty calories. Table 3 Comparison of dietary intake between food secure and food insecure-severe participants Variables
Median of FS (n¼12)
Median of FIS (n¼5)
Manne Whitney U
P value*
HEI score Total calories Total fat % Saturated fat % Protein % Carbohydrate % Fibre (g) Cholesterol (mg) Calcium (mg) Iron (mg) Sodium (mg) B12 (mg) Vitamin D (mg) Grain servings Fruits and vegetables servings Milk and alternative servings Meat and alternative servings
63.0 1300 32.8 9.1 17.2 51.9 13.7 25 598 8.1 2189 2.5 131 3.3 3.2 1.5 1.7
68.9 1457 29.4 9.7 20.8 50.5 16.0 234 561 14.3 2389 3.7 101 4.7 3.3 1.8 2.5
19 12 27 20 20 22 27 24 26 4 20 14 25 6 26 24 15
0.377 0.079 0.955 0.396 0.396 0.533 0.955 0.692 0.865 0.008 0.441 0.145 0.827 0.013 0.913 0.743 0.180
FIS, food insecure-severe; FS, food secure; HEI, Healthy Eating Index. * P value <0.05 was considered significant by ManneWhitney U-test comparing FS to FIS.
G. Asaad, C.B. Chan / Can J Diabetes 36 (2012) 310e313
Author Disclosures
Table 4 Recommended self-care activities for diabetes treatment Self-care activity Diet Follow Eating Well with Canada’s Food Guide Avoid food high in fat Eat foods high in dietary fiber Reduce number of calories Eat lots of fruits and vegetables Eat fewer sweets Eat a low glycemic index diet Advised by Doctor Dietitian Nurse Diabetes educator
313
Number (n¼17)
Proportion (%)
11 9 8 7 6 6 2
64.7 52.9 47.0 41.1 35.3 35.2 11.7
11 6 9 3
64.7 52.9 35.2 17.6
GA received personal funding from the Ministry for Higher Education, Kingdom of Saudi Arabia. Research funding was from Alberta Health Services and the University of Alberta, Faculty of Medicine and Dentistry. Author Contributions GA and CC together designed the study, interpreted the results and wrote the manuscript. GA carried out the participant recruitment and interviews, and analyzed the data. CC wrote the grant that funded the study. References
Other studies have documented that adults with diabetes had high intakes of saturated fat (3,4) and <5 servings of fruits/vegetables (3), although fibre in one cohort (6) was within the range of current recommendations (1). Overall low intake and total calories could reflect advice to lose weight, reported by 41% of participants. Food security status was not a strong predictor of diet quality or nutrient intake in this small sample, even though 5 of 17 perceived themselves as food insecure-severe. Surprisingly, the group had a significantly higher number of servings of grains and meat/alternatives, which likely accounted for higher iron intake. These results suggest that food insecure people make more careful decisions about food purchases but further research is required to verify this finding. Macronutrient intake patterns relative to receipt of pension cheques suggested the participants made adjustments in their diet, with lower carbohydrate intake at the end of the month, compensated by increased fat, indicating reliance on energy-dense foods. In contrast, food insecurity or low income (10,23,24) was associated with poor diet quality in elders and economic indices were more important predictors than nutrition knowledge or education (25). This study demonstrates nutritional risks faced by low-income elders with diabetes living independently in an urban setting. Limitations include small sample size and lack of statistical power and recruitment of a predominantly female, highly-educated cohort. Although cognitive disabilities may have affected the results, faceto-face interviews allowed facilitation of recall through prompting. Body weight and glycated hemoglobin data would have facilitated comparisons of glycemic and weight control with diet quality. In addition, participants answered questions from their perspective, and embarrassment or forgetfulness may have produced inaccurate information. Food intake recalls may have been subject to underreporting or underestimating. We used the HEI-C scale modified to the Food Guide and CDA recommendations for elders with type 2 diabetes; however, it was not validated with these modifications. Summary Overall, the elders with type 2 diabetes in this study had diet quality that was similar to other elderly people in North America. It would be preferable to increase dietary quality in this group to reduce the risk of diabetes complications; therefore, advice to lose weight should be tempered by consideration of the impact on diet quality. Given that people typically live with type 2 diabetes for decades, diabetes education needs to be updated regularly so that new recommendations can be incorporated into self-care activities. Acknowledgments We acknowledge Norwood Seniors Housing Association and the Greater Edmonton Foundation for their collaboration.
1. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2008; 32(suppl 1):S40e5. 2. Nagelkerk J, Reick K, Meengs L. Perceived barriers and effective strategies to diabetes self-management. J Adv Nurs 2006;54:151e8. 3. Nelson KM, Reiber G, Boyko EJ. Diet and exercise among adults with type 2 diabetes: Findings from the third National Health and Nutrition Examination Survey (NHANES III). Diabetes Care 2002;25:1722e8. 4. Barclay AW, Brand-Miller J, Mitchell P. Macronutrient intake, glycaemic index and glycaemic load of older Australian subjects with and without diabetes: baseline data from the Blue Mountains eye study. Br J Nutr 2006;96:117e23. 5. Finke MS, Huston SJ. Healthy eating index scores and the elderly. Fam Econ Nutr Rev 2003;15:67e73. 6. Savoca MR, Anderson A, Kohrman T, et al. The diet quality of rural older adults in the south as measured by Healthy Eating Index-2005 varies by ethnicity. J Am Diet Assoc 2009;109:2063e7. 7. Davis B, Tarasuk V. Hunger in Canada. Agriculture and human values 1994;11: 50e7. 8. Gucciardi E, Vogt JA, Demelo M, et al. Exploration of the relationship between household food insecurity and diabetes in Canada. Diabetes Care 2009;32: 2218e24. 9. Seligman HK, Bindman AB, Vittinghoff E, et al. Food insecurity is associated with diabetes mellitus: Results from the national health examination and nutrition examination survey (NHANES) 1999-2002. J Gen Intern Med 2007;22:1018e23. 10. Seligman HK, Davis TC, Schillinger D, et al. Food insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes. J Health Care Poor Underserved 2010;21:1227e33. 11. Homenko DR, Morin PC, Eimicke JP, et al. Food insecurity and food choices in rural older adults with diabetes receiving nutrition education via telemedicine. J Nutr Educ Behav 2010;42:404e9. 12. Canadian Community Health Survey. Population health surveys. Statistics Canada. (available online at http://www.statcan.gc.ca/concepts/hs-es/indexeng.htm). Accessed April 23, 2012. 13. Toobert D, Hampson S, Glasgow R. The summary of diabetes self-care activities measure: Results from 7 studies and a revised scale. Diabetes Care 2000;23:943e50. 14. Woodruff SJ, Hanning RM. Development and implications of a revised Canadian Healthy Eating Index (HEIC-2009). Public Health Nutr 2010;13:820e5. 15. Canadian Community Health Survey. Cycle 2.2, nutrition income-related household food security in Canada. Health Canada. (available online at http:// www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/surveill/income_food_secsec_alim-eng.pdf). Accessed April 23, 2012. 16. Godwin S, Chambers E. Estimation of portion sizes by elderly respondents. Fam Econ Nutr Rev 2003;15:58e66. 17. Wright JD, Wang C-Y. Awareness of federal dietary guidance in persons aged 16 years and older: results from the National Health and Nutrition Examination Survey 2005-2006. J Am Diet Assoc 2011;111:295e300. 18. Garriguet D. Diet quality in Canada. Health Reports 2009;3:41e52. 19. McBee S, Cotugna N, Vickery CE. Fruit and vegetable consumption in an elderly population. J Nutr Elderly 2001;21:59e67. 20. Ellis J, Johnson MA, Fischer JG, et al. Nutrition and health education intervention for whole grain foods in the Georgia older Americans nutrition program. J Nutr Elderly 2005;24:67e83. 21. Nesbitt A, Majowicz S, Finley R, et al. Food consumption patterns in the Waterloo Region, Ontario, Canada: a cross-sectional telephone survey. BMC Public Health 2008;8:370e81. 22. DeWolfe J, Millan K. Dietary intake of older adults in the Kingston area. Can J Diet Pract Res 2003;64:16e24. 23. Kirkpatrick SI, Tarasuk V. Adequacy of food spending is related to housing expenditures among lower-income Canadian households. Public Health Nutr 2007;10:1464e73. 24. Guthrie JF, Lin B. Overview of the diets of lower- and higher-income elderly and their food assistance options. JNEB 2002;34(supp1):S31e41. 25. Sharpe D, Huston S, Finke M. Factors affecting nutritional adequacy among single elderly women. Fam Econ Nutr Rev 2003;15:74e82.