DETERMINING THE INFLUENCE OF THE LOCAL FOOD ENVIRONMENT ON THE DIETARY COMPLIANCE AND DIET QUALITY OF TYPE 2 DIABETES MELLITUS PATIENTS ENROLLED IN THE CARDIO-VASCULAR DISEASE (CVD) PROGRAM IN DAVAO CITY, PHILIPPINES

Abstract

Background. Diabetes mellitus has been identified as one of the non-communicable diseases that present the biggest public health burden globally. In 2008, the official estimated prevalence of diabetes mellitus was pegged at 4.8%. In Davao City, a medical nutrition therapy (MNT) service, a one-on-one nutrition counseling session, is being provided for diabetic patients enrolled in the Cardiovascular Disease (CVD) Program. This study was designed to assess the impact of the local food environment on dietary compliance and diet quality of Type 2 Diabetes Mellitus (T2DM) patients enrolled in the aforementioned program. Study design. This study was a three-phase study implemented in selected barangays (villages) in Davao City. The first phase was a cross-section study that looked into the influence of the local food environment on the dietary outcomes as well as the willingness of food retailers to sell and willingness of patients to purchase diabetic healthy food options (DHFOs). The second phase focused on assessing the national and local policy environment using qualitative methods. In the third phase, an enhanced medical nutrition therapy (MNT) intervention was designed, implemented and assessed using a quasi-experimental design. Methods. The main study outcomes were dietary compliance and diet quality. For Phase 1, 21 recently-diagnosed diabetic patients were recruited from 6 selected barangays. They were asked to make a 7-day food record to evaluate their dietary intake. An interview questionnaire was also developed to gather the patient’s data related to eating and food shopping patterns as well as the home availability and willingness to purchase DHFOs. A survey questionnaire was used to assess the in-store availability of DHFOs and willingness to sell of food store owners. During Phase 2, a series of key informant interviews were conducted among key local officials regarding the city’s programs and policies related to food availability and accessibility. To develop the enhanced MNT intervention, a 2-part workshop among program nutritionists was conducted. Inputs gathered from the workshop were integrated into the design of the intervention. Two barangays were purposively chosen and assigned as the intervention and control barangays. A 4-session enhanced MNT intervention was implemented in the intervention group. There were 24 diabetic patients in the intervention group and 21 in the control group. Descriptive statistics were computed to explain the food store availability and in-store availability of DHFOs and their willingness to sell DHFOs among 2,315 food stores as well as the patients’ socio-economic, demographic profile, food shopping and eating patterns and their willingness to purchase DHFOs. Average daily energy, macronutrient and micronutrient intake were computed using the Menu-Eval software program and the Food Exchange List. Dietary compliance levels and modified Diet Quality Index-International scores were derived based on the nutrient assessment. Content analysis of the key informant interviews was done. Non-parametric statistical analysis was used to assess the effectiveness of the MNT intervention between the intervention and control groups. Results. Although there were national directives and programs that addressed food accessibility and availability, these programs have more focused on white-rice production and did not directly enhanced food accessibility and availability. At the local level, there were no sustainable institutional mechanisms that systematically strengthen food access and availability. The local food environment was dominated by smaller-sized food stores such as sari-sari stores, karinderias and food carts. This constrained the high in-store availability to fast-moving, non-perishable DHFOs, while fresh DHFOs and low-fat, low-salt dishes was less available. The average daily energy and macronutrient intake of the patients were found to be less than the average prescribed daily levels. The dietary compliance for energy and macronutrients ranges was low and diet quality was poor. Energy compliance was observed to be significantly associated with food store availability within 500 meters of the patient’s residence, although no significant association was found between physical accessibility and diet quality. The enhanced MNT was effective in increasing nutrition knowledge but not energy and macronutrient intake, dietary compliance and diet quality. Conclusions and recommendations. The local food environment landscape was dominated by smaller-sized food stores. This drove the high availability of fast-moving DHFOs and the low availability of fresh food options. The dietary compliance and diet quality of the patients were found to be poor. The MNT intervention was effective in increasing nutrition knowledge, but did not affect other dietary outcomes. With the high presence of food stores at the community level, food accessibility and availability could be greatly enhanced with local policies and programs that link these potential access points to the supply chain. Local fiscal policies that incentivize the provision of fresh DHFOs could also be explored to compliment this initiative.