Year : 2022 | Volume
: 4 | Issue : 2 | Page : 91--96
I must eat what I want: A roadblock to type 2 diabetes management
Oluwaseyi Abiodun Akpor1, Samuel Segun Abegunde1, Olaolorunpo Olorunfemi2, Oluwaseun Oluwafunmilayo Abiodun3,
1 Department of Nursing Science, College of Medicine and Health Sciences, Afe Babalola University, Ado Ekiti, Nigeria
2 Department of Medical Surgical/Adult Health Nursing, Federal University, Oye-Ekiti, Ekiti State, Nigeria
3 Department of Nursing Science, College of Basic Health Science, Achievers University, Owo, Ondo State, Nigeria
Mr. Olaolorunpo Olorunfemi
Department of Medical Surgical Nursing, Federal University, Oye Ekiti, Ekiti State
Globally, type 2 diabetes mellitus (T2DM) is considered as one of the most common diseases, which is associated with irreversible risk factors such as age, gene, race, ethnicity, and reversible factors such as diet, physical activity, and smoking. Noncompliance to dietary regimen is the major factors for rapidly rising incidence of T2DM among developing countries. Recently, elevated HbA1c level has also been considered as one of the leading risk factors for developing microvascular and macrovascular complications. Improvement in the elevated HbA1c level can be achieved through diet management; thus, this study found that improvement in patients' dietary knowledge, attitude toward, and compliance to diet regimen will promote a better control of the disease. In conclusion, the stakeholders (health-care providers, health facilities, agencies involved in T2DM care) should educate the patients on the importance of dietary modification in the disease management. Similarly, there is a need for nurses and other health care professionals to advocate and promote a better holistic management that will encourage patients participation and family involvement in the care.
|How to cite this article:|
Akpor OA, Abegunde SS, Olorunfemi O, Abiodun OO. I must eat what I want: A roadblock to type 2 diabetes management.J Integr Nurs 2022;4:91-96
|How to cite this URL:|
Akpor OA, Abegunde SS, Olorunfemi O, Abiodun OO. I must eat what I want: A roadblock to type 2 diabetes management. J Integr Nurs [serial online] 2022 [cited 2022 Oct 4 ];4:91-96
Available from: https://www.journalin.org/text.asp?2022/4/2/91/348375
The increase in this endemic disease, type 2 diabetes mellitus (T2DM), is partly due to urbanization, noncompliance to diet prescription, cultural challenges, societal obstacles such as poor education and illiteracy, lower socioeconomic status, and lack of well-equipped health-care facilities. T2DM is a group of metabolic diseases in which a person has high blood sugar because body cells do not respond to the insulin that is produced. Globally, an estimated record of 422 million adults in 2014 was diagnosed with diabetes mellitus and was ranked among the first eight causes of death worldwide among both sexes, and it has been considered as a risk factor of cardiovascular fatalities and chronic kidney diseases. Moreover, 43% of those deaths happened before the individual reaches 70 years of age. In Africa, the occurrence rate of T2DM may almost have been doubled in numbers from 3.1% in 1980 to 7.5% in 2019, which corresponds to the 4 million persons from 1980 to the 27 million persons in year 2019.
Nigeria is a large densely populated West African country with a population of over 200 million inhabitants, 50% of Nigerians live in the urban area with cultural diversity and a record of 398 ethnic groups. The provision of health care in Nigeria is currently under the responsibility of the government and private health-care providers. Both play a vital role in delivering an excellent health-care service. A study conducted by Iloh and ANk in 2018 showed an increasing rate of diabetes prevalence in Nigeria from 0.8% in 1960 up to 2.8% in 2000. In a similar study carried out in 2018 found T2DM prevalence in Nigeria to be between 2% and 12% across the country. Diabetes mellitus affects almost every system of the body including eyes (diabetic retinopathy), cardiovascular system (increased risk of thromboembolism), renal system (diabetic nephropathy), and extremities (diabetic neuropathy). There is a bigger risk of earlier problems in developing countries, and the use of early interventions and educational strategies can significantly reduce the morbidity and improves the overall healthy life period. Major death or complications arising from diabetes in Nigeria are cerebrovascular accident, diabetic foot ulcer, myocardial infarction, and diabetic nephropathy. The burden of the disease as well as its complications is increasing every day in Nigeria and this is associated with the cultural belief about what they eat and the situation that patients are not ready to comply with dietary management. Self-care and self-management strategies minimize the risk and other morbidities and mortality associated with T2DM. Therefore, this review aims to examine patients' dietary knowledge and attitude toward dietary regimen of T2DM, dietary routines, dietary compliance, and its influencing factors as well as roles of families in enhancing management of the disease.
Dietary Knowledge on Type 2 Diabetes Mellitus
Dietary knowledge on T2DM is crucial to facilitate normalization of blood glucose and lipids; adequate nutrition knowledge has been described as having an awareness of practices and concepts related to nutrition including adequate food intake and well-being. American Diabetes Association opined that dietary management is a key step in providing the T2DM patients with the knowledge and skill in relation with treatment, nutritional aspects, medications, and complications. A study on how informed are the general public about T2DM in London found that the dietary knowledge of the targeted group who were at high risk of developing T2DM was poor.
Attitude of Type 2 Diabetes Patients Toward Dietary Regimen
Type 2 diabetes mellitus can be controlled through improvement in patient's dietary knowledge, attitudes, and regimen and these factors are considered as an integral part of comprehensive diabetes care. The prevalence of T2DM is higher in most countries where patients are still deficient in understanding the importance of diet habits in the management of diabetes. Studies have shown that assessing patients' dietary attitude may have a considerable benefit toward treatment compliance and decrease of diabetes complications.,, A study conducted in Saudi Arabia reported negative attitude of the patients toward recommended diet. A similar study presented that one-third of the T2DM patients were aware about the importance of diet planning and limiting cholesterol intake to prevent cardiovascular diseases but low compliance level. Likewise, there are documentation of increased prevalence of eating disorders in T2DM patients., These studies discussed about the binge eating disorder, due to its strong correlation with obesity, a condition that complicates the management of T2DM. In support of this view, a study was carried out and found that the weight gain among diabetes patients was associated with the eating disorder resulting from psychological distress. Moreover, similar study that examined eating disorder-related symptoms in T2DM patients, suggested that the dieting-bingeing sequence is associated with diabetes, which is common in obese diabetes patients. Unhealthy eating habits and physical inactivity are the leading causes of diabetes, and failure to follow a strict diet plan and workout, along with prescribed medication are leading causes of complications among patients of T2DM. Based on the reviewed papers, this study found that most diabetes patients in Nigeria do not regard the advice given by their physicians regularly regarding diet planning, diet modification, and exercise and this is associated with the high incidence of diabetes-related complications in the country.
Dietary regimen for diabetes has been evolving for more than 100 years as the pathophysiological basis of complications due to the disease becomes more explicit. Nutrition therapy is extremely important for diabetic patients and prediabetic patients so that adequate glycemic control can be achieved. However, this is mainly infiuenced by cultural backgrounds as it concerns the type of prescribed dietary regimen, there were significant positive relationships between knowledge regarding diabetic diet and compliance to dietary regimen. Knowledge and health belief are a salient factor related to dietary behaviors control. In addition to that, patients' knowledge on a recommended diet indicates their understanding of dietary guidelines which infiuenced their food selection and eating patterns. The association between dietary knowledge and dietary regimen among T2DM patients in the previous studies was inconsistent. A study revealed that there was no relationship between dietary knowledge and compliance of dietary regimen. On the other hand, another study found that a high dietary knowledge score was associated with following dietary recommendations and knowledgeable patients performed self-management activities in a better way. In Indonesia, a study was conducted to measure dietary regimen among diabetes patients and found that despite high knowledge among indonesian's, they still preferred to consume high-fat foods which lead to an increased risk of cerebrovascular diseases (CVD). Other major factor in the literature is the trend of skipping breakfast, which has dramatically increased over the past 10 years among children, adolescents, and adults and this is related to overweight and other health issues, at the same time, frequent eating or snacking may also increase the body weight and risk of metabolic diseases. Nigerian dietary pattern is characterized by an increased consumption of processed and red meat, chips, dairy products, refined grains, and sweets and desserts, which is associated with T2DM risk. In support of this, a study conducted in Lebanon demonstrated direct correlation of the refined grains and desserts and fast food patterns with T2DM, however, in the same study also found that there is an inverse correlation between the traditional food pattern and T2DM among Lebanese adults.
Dietary Routines in Diabetes Management
People with T2DM have reported being more resistant to dietary change than individuals with other chronic conditions. Following dietary recommendations are the most critical and challenging aspect of type 2 diabetes care because many patients struggle with reframing their eating habits to promote a healthy body and lifestyle. Dietary change requires adoption of new food habits while modifying old eating behaviors. Studies have shown a strong correlation between the ability to stop the progression of diabetes with the patient's ability to lose weight, reduce overall fat intake, reduce saturated fat intake, reduce simple carbohydrate intake, increase complex carbohydrate intake, and increase fiber intake., In many cases, after a family member is diagnosed with diabetes, family dietary routines need to be altered. Dietary routines are daily eating habits and meal-taking behaviors, including all aspects of mealtime and the conversations surrounding eating activities. Dietary routines act as organizers of family life as they impact physical care, connection, and sociability for household members. Daminger worked on the cognitive dimension of household labor and found that feeding is an ongoing task that takes a significant amount of time and consideration and involves the invisible work of planning, shopping, cooking, and serving meals. The gender perspective that caring for other members of the family is women's work conveys the message that women are primarily responsible for providing food for the family. Female participants disclosed feelings of obligation that if they did not feed the family no one else would and ideas that the food provided cannot simply be any food, but must be food that satisfies each family member's taste preferences. Few families now eat two meals together each day, which makes it essential to keep the household supplied with products used by each family member in their day-to-day dietary routines.
Role of Dietary Regimen in Diabetes Management
Nutrition is an important part of a healthy lifestyle in patient with T2DM. Along with other benefits, following a healthy meal plan can help the patient keep his or her blood glucose level, also called blood sugar, in target range. A study showed that high carbohydrate and high monounsaturated fat diets improve insulin sensitivity, whereas glucose disposal dietary measures comprise the first-line intervention for the control of dyslipidemia in diabetic patients. Several dietary interventional studies recommended nutrition therapy and lifestyle changes as the initial treatment for dyslipidemia, and metabolic control is considered as the cornerstone in diabetes management and its complications prevention.,, Acquiring HbA1c target minimizes the risk for developing microvascular complications and may also protect CVD, particularly in newly diagnosed patients. Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the principal macronutrient of worry in glycemic management., In addition, an individual's food choices and energy balance have an effect on body weight, blood pressure, and lipid levels directly. Therefore, the mutual efforts of the family, health-care professionals, and the patients can help in achieving health goals by individualizing their nutrition interventions and continuing the support for changes. Studies suggested that intake of virgin olive oil diet in the Mediterranean area has a beneficial effect on the reduction of progression of T2DM retinopathy,, and they affirmed that dietary habits are essential elements of individual cardiovascular and metabolic risk. Numerous health benefits have been observed to the Mediterranean diet over the last decades, which contains abundant intake of fruits and vegetables. The beneficial effects of using fish and olive oil have been reported to be associated with improved glucose metabolism and decreased risk of T2DM, obesity, and CVD., This study found that T2DM patients can still take carbohydrate, especially solid food but should comply with standard measurement, which is not bigger than a clutch fist with plenty of vegetables.
Dietary Compliance and its Influencing Factors among Patients With Type 2 Diabetes Mellitus
Compliance of recommended dietary regimen
Difficulty in adhering to the recommended diet is a common problem in individuals with T2DM. Recommended dietary regimen includes consuming more fruits and vegetables, nuts and whole grains, and choosing unsaturated vegetable oil as opposed to saturated animal based fats. It also includes limiting consumption of snacks that are high in fat, sugar, or salt. Examples of foods high in fat are Margarine, potato chips, and white rice. Patients should consume high-fiber foods, observe portion sizes as well as meal timings. Patients with T2DM should therefore follow an individualized meal plan developed by a qualified health worker (a dietician, a diabetes educator, a diabetes nurse, or a physician). A study found that more than 50% of patients with T2DM believed that adherence to dietary recommendations would improve their condition, but most of them found it difficult to initiate and sustain the recommended dietary regimen. In the study conducted in Botswana, it was found that patients had 63% adherence to recommended dietary regimen, and this may be responsible for low incidence of T2DM complications when compared to Nigeria.
Factors influencing compliance of dietary regimen in diabetes management
Compliance to recommended lifestyle changes improves glucose levels, decreases blood pressure, and corrects lipid abnormalities which are factors associated with complications of diabetes. Compliance to dietary recommendations is one of the important factors in management of T2DM but this can be hindered or influenced by several factors. A study showed that compliance of dietary regimen is influenced by health beliefs of patients concerning the diseases. Another study conducted by Mugo in 2018 came up with more elaborate determinants of compliance. According to the study, compliance to dietary guidelines was determined by factors such as lifestyle, self-consciousness, family support, good professional advice, family income, and quality of advice given. On the other hand, other study reported that the major factors that influence compliance are psychosocial factors such as burdening high cost of medication, frustration due to the dietary restrictions, limited spousal support and family conflicts, feelings of helplessness, feelings of inconvenience, unavoidable temptations and suggested that the support of family and spouse/partner is beneficial to improve adherence to the lifestyle interventions and pharmacotherapy required to achieve optimum glycemic control and avoid associated complications.
Role of Family in Dietary Compliance of Diabetes Management
Families have the potential to help or hinder efforts to eat appropriately. Supportive family members that motivate and maintain the same nutritional habits as the family member with diabetes are beneficial to the self-management process. Females with diabetes report struggle with family member's meal preferences interfering with personal needs. A woman with diabetes, who serves as the primary cook of the household, often prepares meals with less concern for her needs than for those of other family members. Women with diabetes also report making two meals, one meal for themselves and another meal for the rest of the family, to accommodate the families desire to continue eating high-fat meals. Males with diabetes on the other hand report that their wives' efforts ensure that food choices and cooking regimen support healthful eating strategies at home and that their families typically eat the same meals prepared by their wives in adherence to the diabetic diet. A study which assessed family eating patterns effect on self-management of diabetes found barriers to making dietary change to be deep-rooted individual dietary routines, food preferences, and lack of family support, family traditions, economic concerns, and societal influences. Disruption of family routines through travel, holidays, and dining out creates challenges for persons with diabetes to continue to follow the recommended meal plan. The perception that a healthy diet is expensive is another barrier for appropriate diet pursuit with constant advertisements of special diabetes products contributing to misunderstandings and erroneous perceptions. Depending on the type of food emphasis within a given culture and the social context in which food is typically consumed, individuals may differ in their experience and attempts to modify dietary habits after being diagnosed with diabetes. Nigerians expressed more difficulty in adapting their diet to the requirements of the disease in a family context because adapting required them to eat differently than the rest of the family and forfeit consumption of food that is easily affordable, especially now that food is expensive in the country and most families only eat what they see and not what they want to eat. Therefore, Nigeria's agriculture sector needs to be improved, to have food sufficiency in the country and solve the problem of persistent increase in prices of food.
Type 2 diabetes mellitus is both national and global burden that requires rigorous management to avert diabetes complications and mortality attributable to the diseases. Correct dietary intake is crucial in the management of T2DM. This present study discovered that majority of studies on diabetes focus on overall knowledge, attitudes, and regimen in the management of diabetes mellitus as well as other aspects of diabetes mellitus; however, there is limited literature on compliance to recommended dietary regimen. Determination of factors that influence compliance to these recommendations is also not well documented. This study, therefore, conducted to determine the compliance level to dietary recommendations among patients with T2DM as well as establish some of the factors that influenced compliance. Based on the findings of this study, the researchers recommend as following: there is need for comprehensive education at the health facility for patients with T2DM, including those aspects that are often neglected for instance the need to observe meal times. There is also need to reduce the food price, especially diabetic recommended diets and also review the educational package for T2DM patients in a way to promote compliance to regimen. Likewise, the Nigeria government is encouraged to come up with a strategies or policies of reducing cost of diabetes care and also establishment of diabetes club and support group to enhance management and reduce compilations among T2DM patients in the country.
The authors wish to thank all that contributed to the success of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Olorunfemi O, Ojewole F. Medication belief as correlate of medication adherence among patients with diabetes in Edo State, Nigeria. Nurs Open 2019;6:197-202.|
|2||Lovic D, Piperidou A, Zografou I, et al. The growing epidemic of diabetes mellitus. Curr Vasc Pharmacol 2020;18:104-9.|
|3||Twig G, Zucker I, Afek A, et al. Adolescent obesity and early-onset type 2 diabetes. Diabetes Care 2020;43:1487-95.|
|4||Arokiasamy P, Salvi S, Selvamani Y. Global burden of diabetes mellitus: Prevalence, pattern, and trends. In: Handbook of Global Health. Mumbai, India: Springer, Cham; 2021. p. 495-538.|
|5||Iloh GU, ANk A. Epidemiology of diabetic emergencies in the adult emergency department of a tertiary hospital in South-Eastern Nigeria. Int J Trop Dis Health 2018;31:1-10.|
|6||Uloko AE, Musa BM, Ramalan MA, et al. Prevalence and risk factors for diabetes mellitus in Nigeria: A systematic review and meta-analysis. Diabetes Ther 2018;9:1307-16.|
|7||Omenai SA, Ezenkwa US, Ajani MA. Mortality patterns in patients with diabetes mellitus at a Nigerian tertiary hospital: A 10-Year autopsy study. Niger Postgrad Med J 2020;27:83-6.|
|8||Khazaeinejad A, Salmani F, Moodi M. Evaluating knowledge and stages of nutritional behavior change in diabetic patients covered by comprehensive health service centers in Ghayenat city in 2020. Mod Care J 2021;18:1-7.|
|9||Kayyali R, Slater N, Sahi A, et al. Type 2 Diabetes: How informed are the general public? A cross-sectional study investigating disease awareness and barriers to communicating knowledge in high-risk populations in London. BMC Public Health 2019;19:138.|
|10||Adam L, O'Connor C, Garcia AC. Evaluating the impact of diabetes self-management education methods on knowledge, attitudes and behaviours of adult patients with type 2 diabetes mellitus. Can J Diabetes 2018;42:470-7.e2.|
|11||Świątoniowska N, Sarzyńska K, Szymańska-Chabowska A, et al. The role of education in type 2 diabetes treatment. Diabetes Res Clin Pract 2019;151:237-46.|
|12||Sami W, Alabdulwahhab KM, Hamid MR, et al. Dietary attitude of adults with type 2 diabetes mellitus in the Kingdom of Saudi Arabia: A cross-sectional study. Medicina (Kaunas) 2020;56:91.|
|13||Sanford K, Rivers AS. Treatment Adherence Perception Questionnaire: Assessing patient perceptions regarding their adherence to medical treatment plans. Psychol Assess 2020;32:227-38.|
|14||Mohammad NB, Rahman NA, Haque M. Knowledge, attitude, and practice regarding the risk of cardiovascular diseases in patients attending outpatient clinic in Kuantan, Malaysia. J Pharm Bioallied Sci 2018;10:7-14.|
|15||Jaworski M, Panczyk M, Śliwczyński AM, et al. A ten-year longitudinal study of prevalence of eating disorders in the general polish type 2 diabetes population. Med Sci Monit 2018;24:9204-12.|
|16||Brode CS, Mitchell JE. Problematic eating behaviors and eating disorders associated with bariatric surgery. Psychiatr Clin North Am 2019;42:287-97.|
|17||McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: Associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci 2018;1411:96-105.|
|18||Abbott S, Dindol N, Tahrani AA, et al. Binge eating disorder and night eating syndrome in adults with type 2 diabetes: A systematic review. J Eat Disord 2018;6:36.|
|19||Magkos F, Hjorth MF, Astrup A. Diet and exercise in the prevention and treatment of type 2 diabetes mellitus. Nat Rev Endocrinol 2020;16:545-55.|
|20||Abidi S, Vallis M, Piccinini-Vallis H, et al. Diabetes-related behavior change knowledge transfer to primary care practitioners and patients: Implementation and evaluation of a digital health platform. JMIR Med Inform 2018;6:e25.|
|21||Alikari V, Tsironi M, Matziou V, et al. The impact of education on knowledge, adherence and quality of life among patients on haemodialysis. Qual Life Res 2019;28:73-83.|
|22||Hailu FB, Moen A, Hjortdahl P. Diabetes self-management education (DSME) – Effect on knowledge, self-care behavior, and self-efficacy among type 2 diabetes patients in Ethiopia: A controlled clinical trial. Diabetes Metab Syndr Obes 2019;12:2489-99.|
|23||Pulungan AB, Afifa IT, Annisa D. Type 2 diabetes mellitus in children and adolescent: An Indonesian perspective. Ann Pediatr Endocrinol Metab 2018;23:119-25.|
|24||Paoli A, Tinsley G, Bianco A, et al. The influence of meal frequency and timing on health in humans: The role of fasting. Nutrients 2019;11:719.|
|25||Holmes MD, Dalal S, Sewram V, et al. Consumption of processed food dietary patterns in four African populations. Public Health Nutr 2018;21:1529-37.|
|26||Nasreddine L, Tamim H, Itani L, et al. A minimally processed dietary pattern is associated with lower odds of metabolic syndrome among Lebanese adults. Public Health Nutr 2018;21:160-71.|
|27||Davies MJ, D'Alessio DA, Fradkin J, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018;61:2461-98.|
|28||Holmen H, Wahl A, Torbjørnsen A, et al. Stages of change for physical activity and dietary habits in persons with type 2 diabetes included in a mobile health intervention: The Norwegian study in RENEWING HEALTH. BMJ Open Diabetes Res Care 2016;4:e000193.|
|29||Ma Q, Li Y, Li P, et al. Research progress in the relationship between type 2 diabetes mellitus and intestinal flora. Biomed Pharmacother 2019;117:109138.|
|30||Daminger A. The cognitive dimension of household labor. Am Sociol Rev 2019;84:609-33.|
|31||Westman EC, Tondt J, Maguire E, et al. Implementing a low-carbohydrate, ketogenic diet to manage type 2 diabetes mellitus. Expert Rev Endocrinol Metab 2018;13:263-72.|
|32||Ponticelli C, Arnaboldi L, Moroni G, et al. Treatment of dyslipidemia in kidney transplantation. Expert Opin Drug Saf 2020;19:257-67.|
|33||Dolatkhah N, Hajifaraji M, Shakouri SK. Nutrition therapy in managing pregnant women with gestational diabetes mellitus: A literature review. J Family Reprod Health 2018;12:57-72.|
|34||Olatona FA, Airede CA, Aderibigbe SA, et al. Nutritional knowledge, dietary habits and nutritional status of diabetic patients attending teaching hospitals in Lagos, Nigeria. J Community Med Prim Health Care 2019;31:90-103.|
|35||Mitri J, Tomah S, Mottalib A, et al. Effect of dairy consumption and its fat content on glycemic control and cardiovascular disease risk factors in patients with type 2 diabetes: A randomized controlled study. Am J Clin Nutr 2020;112:293-302.|
|36||Cherbuin N, Walsh EI. Sugar in mind: Untangling a sweet and sour relationship beyond type 2 diabetes. Front Neuroendocrinol 2019;54:100769.|
|37||Yubero-Serrano EM, Lopez-Moreno J, Gomez-Delgado F, et al. Extra virgin olive oil: More than a healthy fat. Eur J Clin Nutr 2019;72:8-17.|
|38||Martín-Peláez S, Fito M, Castaner O. Mediterranean diet effects on type 2 diabetes prevention, disease progression, and related mechanisms. A review. Nutrients 2020;12:2236.|
|39||Jurado-Ruiz E, Álvarez-Amor L, Varela LM, et al. Extra virgin olive oil diet intervention improves insulin resistance and islet performance in diet-induced diabetes in mice. Sci Rep 2019;9:11311.|
|40||Chinenye NC, Felicia CI, Doris UC. Fatty acid profile of some selected locally consumed vegetable oils in Enugu State, Nigeria. Am J Clin Nutr 2019;7:130-5.|
|41||García-Pérez LE, Alvarez M, Dilla T, et al. Adherence to therapies in patients with type 2 diabetes. Diabetes Ther 2013;4:175-94.|
|42||Rwegerera GM, Moshomo T, Gaenamong M, et al. Retracted Article: Antidiabetic medication adherence and associated factors among patients in Botswana; implications for the future. Alexandria J Med 2018;54:103-9.|
|43||Mugo IM. Compliance to Recommended Dietary Practices Among Patients with Type 2 Diabetes Mellitus Attending Selected Hospitals in Nakuru County. Kenyatta University; 2018.|
|44||Gupta L, Khandelwal D, Lal PR, et al. Factors determining the success of therapeutic lifestyle interventions in diabetes – Role of partner and family support. Eur Endocrinol 2019;15:18-24.|
|45||Whittemore R, Vilar-Compte M, De La Cerda S, et al. Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: A qualitative descriptive study. Int J Equity Health 2019;18:133.|
|46||Dennison RA, Ward RJ, Griffin SJ, et al. Women's views on lifestyle changes to reduce the risk of developing Type 2 diabetes after gestational diabetes: A systematic review, qualitative synthesis and recommendations for practice. Diabet Med 2019;36:702-17.|
|47||Brundisini F, Vanstone M, Hulan D, et al. Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: A qualitative meta-synthesis. BMC Health Serv Res 2015;15:516.|