Received date: December 17, 2013; Accepted date: January 24, 2014; Published date: January 27, 2014
Citation: Fattah Badr SAE, Elmabsout AA, Denna I (2014) Family Support, Malnutrition and Barriers to Optimal Dietary Intake among Elderly Diabetic Patients in Benghazi, Libya. J Community Med Health Educ 4:270. doi: 10.4172/2161-0711.1000270
Copyright: © 2014 Fattah Badr SAE, 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.
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Background: Higher levels of social and family support especially regimen-specific are associated with better diabetes self management and less perceived barriers to diet. Objectives: To determine the level of perceived family support for diet and barriers to diet self care and their relation to malnutrition among elderly Libyan patients with type 2 diabetes. Methods: A cross-sectional study carried out on 312 elderly diabetic patients attending outpatient clinics of Benghazi diabetes Centre from end of February to the 1st of May 2013. Data was collected through personal interview. Perceived family support for diet was assessed with Diabetes Family Behavior Checklist II diet subscale. Barriers to diet were measured with diet subscale of Barriers to Self-care Scale. Participants screened for nutritional risk according to MNA (Mini Nutritional Assessment) tool. Results: Low level of family support was perceived by most of the studied elderly diabetic patients. Family support for diet was significantly correlated to perceived barriers to diet self-care and MNA score (p<0.01). According to diet barrier scale being “around people who are eating and drinking things patient shouldn’t” was the most frequent barrier perceived. Perceived barriers to diet self-care were significantly higher in male patients while their nutritional status found to be better than that of females. Gender, family size, satisfaction with prescribed diet, total MNA score and number of learning barriers were found as significant predictors of diet self-care barriers (Adjusted R2 was 0.357). Conclusion: Healthcare providers, dietitians and health educators should consider involvement of entire family as well as elderly diabetic patients in self management training and education programs with dietary counseling sessions that can enhance adherence to dietary regimen, decrease diet self-care barriers and consequently improve nutritional status of this vulnerable group.
Family support; Diet self-care barriers; Elderly diabetic; Benghazi
Older persons in Libya are under conditions of multiple pathologies mostly diabetes, varying levels of health needs and perceptions depending largely on their economic, life style and socio-demographic background . In Benghazi, the eastern part of Libya, the prevalence of diabetes in 2001 was found to be 14.1% and the mortality from diabetes appears to have nearly doubled over almost 15 years [2,3].
Adults age 60 and older will comprise two-thirds of the diabetic population by the year 2025. Older patients with diabetes are more likely to have coexistent chronic conditions like hypertension, dyslipidemia and cardiovascular disease that may impact their nutritional requirements .
Appropriate dietary practices are a basic and integral part in treating diabetes mellitus . However, most diabetic patients report deviating from recommended dietary guidelines at least several times per week, and deviations occur most frequently in settings of social and personal pressures to eat inappropriately . As such, it seems like social support would be particularly important to maintaining adequate dietary selfcare.
The greater the perceived family support, the greater the self reported adherence with the diabetes regimen and the less the perceived barriers to diet . Previous studies has shown that barriers to self-care play an important role in adherence to diet recommendations [8,9].
In spite of the high number of identified barriers for older people meeting their nutritional requirements and influencing dietary compliance as physical, social, psychological, health-related, financial  and environmental factors as festivals, ceremonies and social gathering , malnutrition in the elderly especially diabetic is often under diagnosed .
Following a recommended diabetes diet regimen may be particularly challenging for elderly Libyan patients with type 2 diabetes because of the traditional Libyan diet that of high carbohydrate and fatty foods. Therefore, the present study sought to determine the level of perceived family support for diet and barriers to diet self care and their relation to malnutrition among elderly Libyan with type 2 diabetes taking patient’s gender into consideration.
Study design, sample and setting
A cross-sectional study carried out on a sample of elderly diabetic patients of both sexes attending the outpatient clinics of Benghazi center for Diabetes and Endocrine glands (Sedi Husain Diabetes Center) from end of February to the 1st of May 2013.
Benghazi Diabetes Centre (BDC) was established in 1969. It is an outpatient diabetic clinic, serving Benghazi area and administrating a number of diabetes clinics in Eastern Libya. All patients are registered. Daily attendance rate at BDC is around 250 patients. A total of 56852 patients (31952 females) had been registered by the end of the year 2012. Among them 11346 (6922 females) type 2 diabetic patients aged 60 years old and above with a percentage of nearly 20% of the total registered diabetic patients.
Based on statistical sampling techniques , a sample size of at least 312 diabetic patients was considered to be enough for our study of which 116 males and 196 females were to be enrolled
Participants and procedures
Participants were recruited and consented to complete a survey describing barriers to optimal diet, diet specific family support and finally screened for nutritional risk. They were approached in the waiting reception area of the nutrition and other outpatient clinics provided services for diabetic patients where trained researcher assistants briefly explained the purpose of the study to patients and screened them for eligibility for the study.
The inclusion criteria included: elderly (adults ages 60 or older as defined by the World Health Organization and United Nations) , diagnosed with diabetes (type 2) for at least 1 year, prescribed diabetes medication, Libyan nationality, living in a family environment and able to provide informed consent. Living in a family environment was defined as living with a spouse/significant other only, living with spouse/significant other and children, living with children, or living with extended family.
Among 335 elderly diabetic patients who fulfilled the inclusion criteria, a total of 312 patients who agreed to participate and complete questionnaire with clearly filled up entries were finally included in the study according to previously calculated sample size with a response rate of (93.1%).
Ethical approval was obtained from Ethical Research Review Committee. The objectives of the study were explained to individual patients and voluntary informed consent of the patients was obtained.
Data were collected on each clinic day through personal interview using a predesigned structured questionnaire until the required number of participants was reached. Three research assistants were trained on the use of the instruments, anthropometric measurements and filling the questionnaire.
Before the start of the study, the questionnaire was pre-tested after translation to Arabic language with 20 patients as validation. They were excluded from the study. Some essential modifications were made to better adapt the statements and answers to Arabic context.
Demographic and health variables
The study questionnaire involves data regarding patients’ sociodemographic as age, sex, marital and household status, educational level, family size and diabetes related information as years with diabetes, number of diabetes related co morbidities and self perceived age related or medical problems involving GIT or interfering with eating process for example: oral or dental problems, dyspepsia, loss of appetite, constipation which defined as food related problems in addition to questions concerning patient’s learning barriers as reported by patient himself or companion like impaired vision, hearing loss, amnesia, illiteracy and cognitive dysfunction or depression.
Perceived family support for diet was assessed with the diet subscale from the Diabetes Family Behavior Checklist II (DFBC-II) modified by Glasgow and Toobert . The DFBC scale was developed to assess supportive and non supportive family behaviours specific to diabetes on a 5-point Likert-type scale in the following areas: medication compliance, glucose testing, exercise, and diet. Scores can be calculated in several ways: a supportive summary score, a non supportive summary score, and regimen-specific composite scores [8,15].
The present study used diet regimen-specific subscales, which are composed of the following 2 positive support and 2 negative support items to assess diabetes family support specific to diet where participants were asked to rate how often a particular family member will “praise you for following your diet”, “eat at the same time that you do” (2 positive support) and “eat foods that are not part of your diabetic diet”, “nag you about not following your diet” (2 negative support). The response format is a 5-point scale from 1 (never) to 5 (at least once a day [8,16].
Non supportive or negative support items in this subscale were reverse coded, summed for a total subscale score, and then averaged to obtain a mean score. The range for the scale is -8 to 8, with higher numbers or scores indicating more perceived positive support. To complete the DFBC-II, respondents were asked to think about one family member with whom they generally have the most contact .
The DFBC II has not been validated in Libyan population. However, lower internal consistency would be expected in subscales given the few items contributing to the scores . Previous studies indicate that subscales are stronger predictors of their respective areas of regimen adherence than either the overall supportive or non supportive summary score. The Arabic subscale was formulated guided by the original study done by Glasgow, studies using the same subscale as Choi study and the two studies done by Wen et al. [8,16,17].
Barriers to diet self-care
Barriers to diet self-care were measured with the diet subscale of the Barriers to Self-care Scale developed by Glasgow and associates. The seven-item scale measures the frequency of both environmental and cognitive factors that interfere with following a recommended diet. The scale has been validated on adults with type 2 diabetes. The internal consistency for the diet subscale ranges from 0.55 to 0.92 [18,19].
The instrument asks respondents to rate how frequently they experience various barriers to diet self care using a 7-point frequency of occurrence scale from 1 (very rarely or never) to 7 (daily). The scale was scored by averaging the responses across the items. Higher scores indicate a higher frequency of barriers .
Mini Nutritional Assessment Tool (MNA)
Nutritional screening was done according to MNA. Mini Nutritional Assessment (MNA) was developed as a reliable screening test to detect malnutrition in old-aged people. Without any laboratory data, nutritional status of the patients can be easily predicted with questions and anthropometric measurements .
The MNA is 18-item questionnaire comprising anthropometric measurements (BMI, mid-arm and calf circumference, and weight loss) combined with a questionnaire regarding dietary intake (number meals consumed, food and fluid intake, and feeding autonomy), a global assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or depression) and a self assessment (self-perception of health and nutrition). It is a two step procedure; screening with the MNA small form (MNA-SF, 6 questions) followed by the assessment (9 questions and 3 anthropometric measurements), if needed, by the full MNA [21,22].
MNA-SF score equal or more than 12 excludes malnutrition and/ or malnutrition risk, which rendered further assessment unnecessary. MNF-SF score less than 12 indicates full MNA test. Total score more than 23 means normal nutritional status, 17-23 shows malnutrition risk and less than 17 indicates malnutrition. Mid-arm circumference less than 21 cm and calf circumference less than 31 cm are related with malnutrition risk [20-22].
A guide to complete the MNA  was used to have a uniform system of addressing the questions towards the patients as well as to have a uniform and clearer definition of some of the terms used in the questionnaire.
Height and weight measurements used to calculate BMI were taken in a private area using standard techniques or alternative methods when needed as recommended by the WHO . Body mass index (BMI) was calculated manually as the weight in kilograms divided by the square of the height in meters). Body Mass Index (BMI) between 20.00 and 24.99 kg/m2 is optimal weight in elderly according to ESPEN guidelines. A BMI <20.00 kg/m2 suggests that the patient is underweight. MAC and CC was measured as per standard techniques applicable for the ambulatory and non-ambulatory individuals [24-26].
SPSS 16.0 (SPSS Inc., Chicago, IL) statistical software was used to analyze data. Continuous variables were described by means ± standard deviations. Discrete variables were described as counts and percentages. The differences of means were tested with the independent group t test and the distribution of proportions with the chi-square test. Bivariate analyses were conducted to evaluate the relationship between the independent variables and barriers to diet self care. Univariate analysis was used to reduce the pool of initial variables entered into the multiple regression analysis. The level of 0.25 was used as significant point for the final multiple regression analysis. A multiple regression analysis was used to examine the relationship between the variables and barriers to diet self care. All statistical significance was set at P-value of 0.05 levels.
A total of 312 patients (62.8% females) were included in the study. The total sample mean age in years’ ± SD was 63.8 ± 7.1 ranged from 60-88 years old. According to different age subgroups  (92%) of patients were young elderly (60-74 years), (6.1%) were older elderly (75-84 years) and only (1.9%) patients were oldest old (≥ 85 years ) with no significant difference between males and females patients.
Most of the studied elderly diabetic patients (74.6%) were living with their spouse and children. A total of 274 subjects (87.8%) were suffered from one or more diabetes-related co morbidities (mean ± SD) 2.7 ± 2.3 of which 28.7% had peripheral neuropathy followed by coronary heart (27.3%) and nephropathy in 14.7%. Moreover, 303 (97.1%) of them were suffering also from one or more physiological or medical food related problems (40.7% had dentition problems as partial or total loss of teeth without dentures or with use of ill fitting dentures, 18.6% had constipation and 10.6% had gastritis). Only one patient among six (14.4%) was satisfied with diet regimen prescribed by dietitian (Table 1).
Years with diabetes
Diabetes related comorbidities
Food related problems
|Gender||n ( percentage)|
|Young elderly (60-74 years)
Older elderly (75-84 years)
Oldest old (≥ 85 years)
Secondary and its level
|Income adequacy perception|
To some extent
( 48.7 ) 152
| With spouse /significant other only
With spouse and children
|Satisfied with prescribed diet regimen
Dissatisfied with prescribed diet regimen
Table 1: Patients demographics and characteristics.
MNA scores showed poor nutritional status in 136 (43.6%) patients (malnutrition risk: 32.1%, malnutrition: 11.5%). Malnutrition rates were increased in female elderly patients (15.3%) while significantly less in males (5.2%) (Table 2). When different age groups were taken into consideration, 31.4% (n=90) of the young elderly group, 52.6% (n=10) of the older elderly patients were found at nutritional risk (MNA scores ≤ 23). The malnutrition rates revealed by MNA scores (score<17) were 7.3% (n=21) of young elderly, 47.4% (n=9) of older elderly and all oldest old diabetic patients group (n=6).
|Characteristic||Male patients||Female patients||Total||Sig.|
Risk of malnutrition
|Total||(37.2) 116||((62.8 196||312|
Table 2: Nutritional status of studied patients based on total Mini Nutritional Assessment (MNA) scores.
The mean barrier score for diet (BDSC) as shown in Table 3 for males was 4.28 (once per week) (SD=0.60) which was higher than that of females 3.59 (more than twice per month (SD=0.70) and the difference was highly significant. According to diet barrier scale (BDSC) being “around people who are eating and drinking things patient shouldn’t” was the most frequent barrier perceived by both male and female elderly diabetic patients (6.72 ± 0.67, 6.62 ± 0.75 respectively) followed by “ Don’t have time to prepare foods” for males and “ won’t matter if don’t follow diet” for females.
|Items||Male patients (n=116)||Female patients (n=196)|
|*Around people who are eating and drinking things I shouldn’t
*Not home for meals
*Think about costs of foods
*Unsure about foods
*Still feel hungry
*Don’t have time to prepare foods
*Won’t matter if don’t follow diet
|6.72 ± 0.67
2.29 ± 0.46
2.91 ± 2.43
3.11 ± 1.81
3.52 ± 1.94
5 .96 ± 0.46
4.40 ± 1.92
|6.62 ± 0.75
2.31 ± 0.46
2.81 ± 2.41
3.29 ± 2.05
3.56 ± 1.94
2.56 ± 1.58
4.00 ± 1.98
|Overall scale score||4.28 ± 0.60||3.59 ± 0.70**|
Table 3: Mean Scores for Barrier to Diet Self-care Scale.
Mean MNA scores as shown in Table 4 was significantly higher in male patients (23.81 ± 3.39) than of females (22.27 ± 5.15) while number of self perceived physiological and food related health problems was significantly higher in females. No significant differences were found regarding the mean score of diet DFBC subscale; mean number of diabetes related co morbidities or learning barriers between male and female elderly diabetic patients.
|Variable||Male patients||Female patients||t-value||Sig|
|Diet DFBC score||0.74 ± 1.71||0.79 ± 1.71||-0.252||0.801|
|Total MNA scores||23.81 ± 3.39||22.27 ± 5.15||2.861||0.005*|
|Food related health problems||1.23 ± 1.70n1||2.07 ± 2.50n2||3.146||0.002*|
|Diabetes related co morbidities||2.17 ± 1.43||1.87 ± 1.43||1.819||0.07|
|Learning barriers||1.22 ± 0.97||1.45 ± 1.23||-1.709||0.08|
Table 4: Mean MNA, diet DFBC subscale scores and some related variables by gender.
A multiple regression analysis was used to examine the relationship between a number of independent variables and barriers to diet self care. The linear combination of the predictors as shown in Tables 5 and 6; age, gender, family size, years with diabetes, learning barriers, food related problems, satisfaction with prescribed diet, diet DFBC subscale scores and MNA scores in the regression model was significantly related to the level of diet self-care barriers (F =19.610; P<0.00001). The adjusted R2 was 0.357, indicating that the model explained 35% of the variance in diet self-care behavior.
|Years with diabetes||0.023||0.112||1.750||0.081|
|Food related problems||0.161||0.026||0.369||0.712|
|Satisfaction with prescribed diet||0.721||-0.146||-2.968||0.003**|
|Diet DFBC subscale scores||0.158||0.058||1.123||0.262|
Table 5: Multiple Linear Regression Analysis of Barriers to Diet Self-care.
|Variables||Age||Female gender||Family size||Years with diabetes||Learning barriers||Food related Problems||Satisfaction with diet||Diet DFBC||MNA score||BDSC|
|Years with diabetes||0.60#||-0.02||-0.01||1|
|Food related problems||0.47#||0.17#||0.09||0.44#||0.52#||1|
|Satisfaction with diet||0.05||0.05||0.07||0.13*||-0.09||-0.12*||1|
|Diet DFBC score||0.18#||0.01||-0.10||0.32#||0.35#||0.27#||0.16#||1|
Table 6: Bivarriate correlations of variables in final regression model.
After adjusting for the demographic and health variables, gender, family size, satisfaction with prescribed diet, the total MNA score and number of learning barriers were found as significant predictors of diet self-care barriers.
Diet specific family support (Diet DFBC) score was positively correlated with age, years with diabetes or diabetes duration, number of learning barriers, food related problems, satisfaction with prescribed diet and barrier to diet score (BDSC) (p<0.01). Whereas, MNA score inversely correlated with age, female gender, diabetes duration, number of learning barriers, food related problems and diet specific family support (Diet DFBC) score (p<0.01) as shown in Table 6.
Higher levels of social and family support especially regimenspecific associated with better diabetes self management . In the present study the majority of elderly diabetic patients (89.5%) reported that at least once a day family members were selected to eat foods that were not a part of diabetic patients’ diet that explains the reason behind the most frequent diet barrier reported by participants as being “around people who are eating or drinking things that I shouldn’t”according to the diet barrier scale.
It may be a problem for most of elderly patients with diabetes to adhere to diet regimen prescribed if the rest of the family was not willing to eat the same foods and for family member also to prepare two types of meals as have been reported by participants in studies done by Maillet et al.  and Dye et al.  and given as explanation to similar result in study done by Wen et al. . Moreover, eating healthily would be more difficult for participants in the presence of those who were eating unhealthily, particularly if they lived with them.
The overall mean score for diet family support was 0.77 ± 1.71 and the median was 0.58 out of 8 indicating low level of positive support in spite of living within large family (family size mean ± SD was 8.09 ± 3.4). Diet DFBC score was lower than that perceived by elderly diabetic in other populations where it was 0.98 ± 2.42 among older Mexican Americans and its median score was 1 among older Hispanic diabetic patients [7,17].
The low level of family support perceived by studied elderly patients might be attributed to many reasons. One of them, the lower educational level of most of the studied sample (92.3% between illiterate and basic education) and may be similarly their spouse (74.6% were living with their spouse and children) that may decrease awareness level of disease management and family support needed. Other potential explanation was the dissatisfaction reported by most of elderly patients (85.6%) with the prescribed diet regimen that may reflect some defects in quality of services provided for this group of patients as education, self management training programs or dietary counselling.
The perceived family support for diet was slightly higher in female compared to male with no significant difference. This came in contrast to the study done by Brown et al.  who stated stronger perceptions of social support for diet in males compared to females but it was nearly similar to that found in studies done by Wen and colleagues [7,17]. Our study result may be expected because of the different culture in Arabic and Islamic countries caring for elderly parents specially females.
The perceived low level of diet specific family support together with the high significant correlation between patient age, duration of diabetes and scores of BDSC could explain the high perceived diet barriers among the studied elderly population. However it could not explain the reason behind the positive association found between patients’ perceived family support and perceived barriers to diet or its unpredicted inverse relation with their MNA scores.
These results came in contrast with studies which have demonstrated the inverse relation between perceived family support and barriers to diet [7,17] and what reported by many studies that strong family and social support appear to have a positive impact on self-management behaviours [28,32-34] whereas, no relationship have been found in other ones [35,36].
Patients’ response in a socially desirable manner regarding family support and not according to their true attitudes or opinions putting family relationships as a priority could be the main explanation for the unexpected relations found regarding the perceived family support with MNA score and perceived diet barriers. Patients’ perceptions may be also affected by psychological factors or their attitude specially with dissatisfaction reported by most of studied patients with prescribed diet that certainly make adherence to diet regimen so difficult even with supportive family behaviour.
In spite of the high significant perceived level of barriers to diet in males (4.28 ± 0.60) compared to females (3.59 ± 0.70) which was higher than that of other studies using the same diet barrier subscale [7,17], the nutritional status of male patients was better than that of females as shown in Tables 2 and 4. This may be related to the significant increased number of perceived food related problems that was reported by female patients which inversely correlated with MNA scores. Moreover, the fact those women in Arabic culture are usually caring of cooking, food preparation, feeding, nutritional support for all family members mainly husband and children rather than herself.
The greater the perceived barriers to diet the lower the levels of diet self-care . To examine the factors associated with perceived barriers to diet self-care, a regression analysis resulted in a model that explained a modest 35% of the variance in perceived barriers. Gender, family size, satisfaction with prescribed diet, MNA score and number of learning barriers were found as significant predictors of diet self-care barriers in the present study while the duration of diabetes was found to be the only predictor in Jazayeri and Pipelzadeh study  whereas patient age and family support were found as significant predictors in Wen et al. study .
The present study revealed that lower MNA scores ( poor nutritional status), less family size, increased number of patient’s learning barriers, patient dissatisfaction with prescribed diet regimen and male gender were significantly associated with higher levels of barriers to diet and certainly low level of diet self care.
This study has limitations that must be identified and accounted for when interpreting the results presented. A major limitation is that the design is cross-sectional rather than longitudinal; therefore, causality cannot be determined which limits study findings to reporting of only associations between family support, barriers to diet self care and MNA scores of studied elderly diabetics. The second limitation is that the study involved self-reported data. Therefore, some patients may respond in a different manner regarding family support in spite of the real situation or attitude that could affect the direction of some relations which were found statistically.
For Libyan population, extended family is still considered a primary support group for every family member especially elderly people. Therefore, healthcare providers, dietitians and health educators should consider involvement of entire family as well as elderly diabetic patients in self management training and education programs with dietary counseling sessions that can enhance adherence to dietary regimen, decrease diet self-care barriers and consequently improve nutritional status of this vulnerable group.
Further longitudinal researches are needed to examine the effect of Libyan family members’ involvement in education programs and diabetes self management training activities with elderly diabetic patients on the supportive and non-supportive family behaviours and its relationship to dietary self-care behaviours of patients and their nutritional status.
Periodic nutritional screening by MNA tool is necessary for elderly diabetic patients especially females together with improving quality of nutritional care services provided in Benghazi diabetes centre.
The authors are indebted to the patients who generously volunteered their time in participating in the study and acknowledge the cooperation of all members of Benghazi centre for diabetes and endocrine glands; administrative and registration unit group, dieticians and health care providers.
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