To investigate the knowledge-attitude-practice (KAP) score in diabetes patients living in urban China regarding Medical Nutrition Therapy (MNT) and explore the influencing factors, this national survey recruited diabetes and prediabetes patients in 40 hospitals across 26 provinces in China. A self-designed questionnaire was used to collect the data and assess the knowledge, attitude, and practice regarding MNT. Logistic regression was used to explore the factor influencing KAP scores. A total of 6441 diabetes patients (mean age:
Diabetes is a common chronic metabolic disease that greatly affects people’s health and quality of life. It is estimated that about 415 million individuals aged 20–79 years lived with diabetes in 2015, while another 318 million were diagnosed with impaired glucose tolerance. In addition, the number of patients with diabetes aged 20–79 years is expected to increase to 642 million by 2040 [
MNT has already been applied in China for several years and received extensive attention from health care professionals. However, the application of this tool is still not optimal, due to its dependence on the communications between clinicians and patients and requirement of high cooperation of the patients. Several studies have already investigated the application of MNT in Chinese diabetes patients in recent years [
A multicenter cross-sectional study was conducted by the Diabetes Care and Education Study Group of the Chinese Diabetes Society in 40 tertiary, secondary, and community hospitals across 26 cities in China. Fixed-point continuous sampling was adopted to recruit patients with diabetes and prediabetes. The patients were mainly included from the outpatient department, while the ones from the inpatient department accounted for no less than 10% of all the patients included.
The inclusion criteria for the patients were as follows: (1)
A structured questionnaire was developed by a panel of experts consisting of clinicians, nurses, dieticians, and other investigators. Each question in the questionnaire was developed from clinical practices and was closely associated with current MNT education in China. The questionnaire was discussed and modified several times before being applied in the survey. The preliminary survey was conducted before the initiation of this study to help modify the questionnaire and improve the validity and reliability of the questionnaire. The Cronbach’s alpha values were 0.679, 0.717, 0.412, and 0.440 for the total KAP score, K score, A score, and P score, respectively.
The questionnaire contains two parts. The first part of the questionnaire collects the demographic and disease information, as well as physical examination data, including gender, age, height, weight, occupation, education level, residence, blood glucose level, and duration and type of diabetes. The second part of the questionnaire includes the questions on KAP regarding MNT (Appendix). Knowledge (K) of MNT is assessed by 6 questions (Q4, Q5, Q8, Q9, Q10, and Q15), attitude (A) is assessed by 3 questions (Q11, Q12, and Q20), and practice (P) is assessed by 10 questions (Q2, Q3, Q6, Q7, Q13, Q14, Q16, Q17, Q18, and Q19). Question
The total KAP score and the scores of K, A, and P are considered poor when the score is less than or equal to the median value (the median values for total KAP, K, A, and P score were 9, 3, 1, and 5, resp.).
The questionnaire survey was conducted by trained investigators (clinicians, education nurses, or dieticians) assigned by each of the participating hospitals, through face-to-face interviews with the patients.
Physical examinations were performed by experienced nurses. The following data were collected during the physical examinations: height, weight, waist circumference, hip circumference, systolic blood pressure, diastolic blood pressure, fasting plasma glucose (FPG), 2-hour postprandial blood glucose (2h-PG), and glycosylated hemoglobin (HbA1c). All these data were measured by standard methods that have been widely accepted and applied in clinical practice within 3 months prior to the study initiation.
Over 6000 patients were included in this study to provide a sufficient sample size. Strict quality control was applied throughout the processes of data collection and processing. The investigators were uniformly trained several times before the study to minimize the bias and improve the validity and reliability of the questionnaire. Repetitive checks were executed by special investigators after the questionnaires were completed. In addition, double entry and validation of the data were performed within 72 h after the questionnaires were completed.
This study was approved by the Ethics Committee of Peking University First Hospital and was performed strictly according to the Declaration of Helsinki. All the participants were informed of the contents and other essential information, and written informed consent forms were obtained from all patients before the survey was started. This study was also registered in the Chinese Clinical Trial Registry (number
SAS 9.2 (SAS 9.2; SAS Institute Inc., Cary, NC, USA) was used for the statistical analyses in this study. Quantitative data are described with means ± standard deviation (SD), while qualitative data are described as frequencies and percentages. Independent
Between May 18, 2014, and August 22, 2014, 6932 patients were recruited in this study, and 6441 completed questionnaires were obtained after deleting those with missing data or logical errors, yielding an effective rate of 92.9%. Importantly, 94.67% of these patients had type 2 diabetes, while only 5.32% of the patients had type 1 diabetes, prediabetes, or other types of diabetes. Among these patients, 3061 were females and 3380 were males, and their mean age was
General characteristics of the patients.
Category | Subcategory | Data |
---|---|---|
Total number | 6441 | |
| ||
Age (y) | | |
18–65, | 3995 (62.02) | |
65-, | 2446 (37.98) | |
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Gender | Female, | 3061 (47.53) |
Male, | 3380 (52.47) | |
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BMI | | |
<24, | 2791 (43.33) | |
24-, | 3650 (56.67) | |
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Duration (y) | | |
1–10, | 3995 (62.04) | |
10-, | 2444 (37.96) | |
| ||
Educational status | Middle school or below, | 2690 (41.76) |
Senior high school, | 1517 (23.55) | |
Junior college, | 1075 (16.69) | |
Undergraduate or above, | 1159 (18.00) | |
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Occupation | Retiree, | 3763 (58.42) |
In service, | 2005 (31.13) | |
Others, | 690 (10.71) | |
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Diagnosis | Type 1 diabetes, | 161 (2.50) |
Type 2 diabetes, | 6098 (94.67) | |
Other types of diabetes, | 33 (0.51) | |
Prediabetes, | 149 (2.31) | |
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MNT education experience | Yes, | 3450 (53.56) |
No, | 2991 (46.44) | |
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FBG (mmol/L) | | |
<6. | 21.2 | |
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2h-PG (mmol/L) | | |
<7. | 12.1 | |
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HbA1c (%) | | |
<7. | 38.92 | |
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BP (mmHg) | | |
<140/9 | 77.35 |
The mean FBG of the patients was
A relatively poor KAP score was obtained from 54.54% of the patients. In addition, 62.79%, 61.85%, and 56.16% of the patients had poor K, A, and P scores in this study (Table
Distribution of the MNT, knowledge, attitude, and practice scores.
Category | Subcategory | Frequency ( | Percentage (%) |
---|---|---|---|
KAP score | 0–9 (poor) | 3513 | 54.54 |
10–19 (good) | 2928 | 45.46 | |
Knowledge score | 0–3 (poor) | 4044 | 62.79 |
4–6 (good) | 2397 | 37.21 | |
Attitude score | 0-1 (negative) | 3984 | 61.85 |
2-3 (positive) | 2457 | 38.15 | |
Practice score | 0–5 (poor) | 3617 | 56.16 |
6–10 (good) | 2824 | 43.84 |
The FPG, 2h-PG, and HbA1c levels in the patients educated about MNT before were significantly lower than those in patients not educated before (Figure
Comparison of FBG, 2h-PG, and HbA1c between KAP score groups.
KAP score | FPG | 2h-PG | HbA1c | |||
---|---|---|---|---|---|---|
| | | | | | |
0–9 | | 19.58 | | 11.07 | | 31.85 |
10–19 | | 25.41 | | 17.48 | | 46.59 |
SD, standard deviation, mmol/L; CR, controlling rate (%);
Chi-square test showed that total KAP scores of the patients were influenced by gender, BMI, education level, occupation, residence, and MNT education (Table
Factors associated with MNT KAP, knowledge, attitude, and practice, scores [
Category | KAP score | Knowledge score | Attitude score | Practice score | ||||
---|---|---|---|---|---|---|---|---|
Good | Poor | Good | Poor | Good | Poor | Good | Poor | |
Gender | ||||||||
Female | 1447 (47.27) | 1614 (52.73) | 1155 (37.73) | 1906 (62.27) | 1116 (36.46) | 1945 (63.54) | 1389 (45.37) | 1672 (54.63) |
Male | 1481 (43.82) | 1899 (56.18) | 1242 (36.75) | 2138 (63.25) | 1341 (39.67) | 2039 (60.33) | 1435 (42.46) | 1945 (57.54) |
| | | | | | | | |
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Age | ||||||||
18–65 | 1702 (42.60) | 2293 (57.40) | 1418 (35.49) | 2577 (64.51) | 1491 (37.32) | 2504 (62.68) | 1677 (41.98) | 2318 (58.02) |
65- | 1226 (50.12) | 1220 (49.88) | 979 (40.02) | 1467 (59.98) | 966 (39.49) | 1480 (60.51) | 1147 (46.89) | 1299 (53.11) |
| | | | | | | | |
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BMI | ||||||||
<24 | 1326 (47.51) | 1465 (52.49) | 1100 (39.41) | 1691 (60.59) | 1041 (37.30) | 1750 (62.70) | 1266 (45.36) | 1525 (54.64) |
24- | 1602 (43.89) | 2048 (56.11) | 1297 (35.53) | 2353 (64.47) | 1416 (38.79) | 2234 (61.21) | 1558 (42.68) | 2092 (57.32) |
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Duration (y) | ||||||||
1–10 | 1727 (43.23) | 2268 (56.77) | 1406 (35.19) | 2589 (64.81) | 1500 (37.55) | 2495 (62.45) | 1716 (42.95) | 2279 (57.05) |
10- | 1200 (49.10) | 1244 (50.90) | 990 (40.51) | 1454 (59.49) | 956 (39.12) | 1488 (60.88) | 1107 (45.29) | 1337 (54.71) |
| | | | | | | | |
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Education | ||||||||
Middle school or below | 948 (35.24) | 1742 (64.76) | 768 (28.55) | 1922 (71.45) | 958 (35.61) | 1732 (64.39) | 936 (34.80) | 1754 (65.20) |
Senior high school | 719 (47.40) | 798 (52.60) | 579 (38.17) | 938 (61.83) | 618 (40.74) | 899 (59.26) | 664 (43.77) | 853 (56.23) |
Junior college | 590 (54.88) | 485 (45.12) | 489 (45.49) | 586 (54.51) | 421 (39.16) | 654 (60.84) | 574 (53.40) | 501 (46.60) |
Undergraduate or above | 671 (57.89) | 488 (42.11) | 561 (48.40) | 598 (51.60) | 460 (39.69) | 699 (60.31) | 650 (56.08) | 509 (43.92) |
| | | | | | | | |
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Occupation | ||||||||
Retiree | 1888 (50.40) | 1858 (49.60) | 1535 (40.98) | 2211 (59.02) | 1508 (40.26) | 2238 (59.74) | 1782 (47.57) | 1904 (50.83) |
In service | 814 (40.60) | 1191 (59.40) | 673 (33.57) | 1332 (66.43) | 704 (35.11) | 1301 (64.89) | 809 (40.35) | 1196 (59.65) |
| | | | | | | | |
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MNT education | ||||||||
Yes | 2181 (63.22) | 1269 (36.78) | 1874 (54.32) | 1576 (45.68) | 1293 (37.48) | 2157 (62.52) | 1988 (57.62) | 1462 (42.38) |
No | 747 (24.97) | 2244 (75.03) | 523 (17.49) | 2468 (82.51) | 1164 (38.92) | 1827 (61.08) | 836 (27.95) | 2155 (72.05) |
| | | | | | | |
Association of the factors with MNT knowledge, attitude, and practice scores.
Category | KAP score | Knowledge score | Attitude score | Practice score | ||||
---|---|---|---|---|---|---|---|---|
OR (95.0% CI) | | OR (95.0% CI) | | OR (95.0% CI) | | OR (95.0% CI) | | |
| ||||||||
Male | 1.00 | 1.00 | 1.00 | 1.00 | ||||
Female | 1.24 (1.10–1.40) | 0.001 | 1.08 (0.96–1.22) | 0.212 | 0.86 (0.77–0.96) | 0.008 | 1.23 (1.10–1.39) | 0.000 |
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18–65 | 1.00 | 1.00 | 1.00 | 1.00 | ||||
>65 | 1.02 (0.89–1.17) | 0.744 | 0.92 (0.80–1.06) | 0.260 | 0.99 (0.87–1.12) | 0.833 | 0.99 (0.87–1.12) | 0.872 |
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>24 | 1.00 | 1.00 | 1.00 | 1.00 | ||||
<24 | 1.17 (1.05–1.31) | 0.007 | 1.21 (1.08–1.37) | 0.001 | 0.95 (0.85–1.06) | 0.341 | 1.12 (1.00–1.25) | 0.050 |
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10- | 1.00 | 1.00 | 1.00 | 1.00 | ||||
1–10 | 1.03 (0.91–1.16) | 0.689 | 1.03 (0.91–1.17) | 0.639 | 1.02 (0.91–1.14) | 0.718 | 0.92 (0.82–1.04) | 0.164 |
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Middle school or below | 1.00 | 1.00 | 1.00 | 1.00 | ||||
Senior high school | 1.65 (1.42–1.91) | 0.000 | 1.50 (1.29–1.75) | 0.000 | 1.22 (1.06–1.41) | 0.005 | 1.40 (1.21–1.62) | 0.000 |
Junior college | 2.30 (1.95–2.72) | 0.000 | 2.11 (1.78–2.50) | 0.000 | 1.17 (1.00–1.36) | 0.052 | 2.12 (1.81–2.50) | 0.000 |
Undergraduate or above | 2.92 (2.47–3.45) | 0.000 | 2.58 (2.18–3.05) | 0.000 | 1.25 (1.07–1.45) | 0.005 | 2.65 (2.26–3.12) | 0.000 |
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In service | 1.00 | 1.00 | 1.00 | 1.00 | ||||
Retiree | 1.55 (1.34–1.79) | 0.000 | 1.51 (1.30–1.75) | 0.000 | 1.35 (1.17–1.54) | 0.000 | 1.44 (1.25–1.66) | 0.000 |
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No | 1.00 | 1.00 | 1.00 | 1.00 | ||||
Yes | 5.06 (4.50–5.69) | 0.000 | 5.45 (4.81–6.17) | 0.000 | 0.87 (0.78–0.97) | 0.013 | 3.45 (3.08–3.86) | 0.000 |
Consistent with the total KAP score, the results of this study also showed that the K scores were significantly higher in patients with a
The A score in this study was significantly associated with only gender, education level, occupation, and MNT education. In detail, the A score was significantly higher in female patients than in the male patients (OR, 0.86; 95% CI, 0.77–0.96;
The P score in this study was significantly influenced by gender, education level, occupation, place of residence, and MNT education. The P score in female patients was significantly higher than that in male patients (OR, 1.23; 95% CI, 1.10–1.39;
To our knowledge, this is the first large-scale study investigating the application of MNT and the influencing factors in patients with diabetes living in urban China. In this national cross-sectional survey with over 6000 patients included, the results showed that over half of the patients with diabetes in urban China received MNT education. However, the knowledge and practice of MNT in the patients with diabetes were suboptimal, and the total KAP score as well as K, A, and P scores was poor in more than half of the patients.
A previous study in China has shown that patients with diabetes had positive attitudes but relatively poor nutrition knowledge and practices [
Both individualized and group MNT could effectively improve the control of blood glucose in patients with diabetes. Previous studies showed that after the application of MNT the FPG, postprandial blood glucose, and HbA1c levels all decreased significantly [
Many factors could affect the knowledge, attitude, and practice of MNT in patients with diabetes. The findings in this study showed that the total KAP score as well as the K, A, and P scores of the patients was significantly associated with gender, occupation, education level, residence, and MNT education. A previous study showed that female patients tend to have higher total KAP scores and K and P scores but lower A scores than male patients, suggesting that although male patients have more active attitude to MNT than female patients, the practice is still lagging behind.
The findings in this study showed that in-service patients had lower total KAP scores as well as lower K, A, and P scores than retired patients. We speculated that this could be associated with the fact that the in-service patients still have careers to worry about, and thus their work and accompanying social activities restricted them from remaining concerned about the disease conditions [
The findings in this study showed that the total KAP scores as well as the K, A, and P scores in patients who received MNT education were significantly higher than those in the patients who did not, which is in agreement with the results reported in previous studies [
As a cross-sectional study, this study could not clarify the causal relationship between the factors and KAP scores on MNT. In addition, the retrospective method for collecting data could also introduce recall bias. However, this study could still provide valuable evidence for helping us to understand the factors influencing the application of MNT in Chinese diabetes patients and thus further provide evidence for further clinical studies and practices. To minimize the bias, investigators were uniformly trained before the survey started. In addition, the preliminary survey, as well as strict quality control in this study, could also help minimize, although not prevent, the bias. This study used a self-designed questionnaire to collect the data, and the Cronbach’s alpha values for A and P scores were relatively low. However, the previous adoption of the same questionnaire by many other researchers in China suggests that this questionnaire can reflect well the MNT attitude and behaviors of diabetes patients. Therefore, this questionnaire was still used in our study despite the relatively low alpha values for A and P scores.
In conclusion, this study showed that although over half of the patients with diabetes living in urban China had received MNT education, over half of the patients still had poor understanding and practices of MNT, and the control rate of blood glucose was still very low. Patients with higher KAP scores were with better control of blood glucose. These findings suggest that MNT education is critical for patients with diabetes. However, the method of MNT education should be different, according to gender, BMI, occupation, and education level of the patients.
The questionnaire about the knowledge, attitude, and practices of patients with diabetes and prediabetes toward MNT is shown in Table
Item | Question |
---|---|
| |
Q4 | Knows the dietary management of diabetes has been upgraded into MNT. |
Q5 | Knows that a lot of professional associations recommend MNT as the foundation of diabetes prevention and treatment both at home and abroad. |
Q8 | Understands and remembers MNT recommendations provided by HCPs. |
Q9 | Knows the total amount of daily food that should be consumed. |
Q10 | Knows how to allocate the daily intake of food groups. |
Q15 | Knows the food restrictions or other factors that may induce malnutrition. |
| |
Q11 | Too frightened to take a meal (or reduce intake) because of concerns about increased post-prandial glycaemia |
Q12 | Too frightened to eat fruits and sweets because of concerns about increased blood glucose. |
Q20 | Feels distressed or difficult to adhere to self-management according to the MNT recommendations provided by HCPs (multiple choices). If “yes”, the main obstacles for acceptance or adherence to MNT is; (1) no chance to understand; (2) the content is too difficult to be understood; (3) the requirement is too high to adhere to. |
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Q2 | Correctly determined their body-weight group (refer to BMI, kg/m2, low weight ≤18.5; normal 18.6–23.9; overweight 24.0–27.9; obesity ≥28). |
Q3 | Can calculate the ideal body weight. |
Q6 | Routinely pay attention to the nutrition status. |
Q7 | Are routinely provided with MNT recommendations by doctors, clinical dietitians, or nurses. |
Q13 | Has experienced hypoglycemia due to irregular life style choices. |
Q14 | Has experienced between-meal hypoglycemia, bedtime hypoglycemia, or nocturnal hypoglycemia |
Q16 | Routinely follows the recommendations of doctors or clinical dietitians when arranging daily diet, |
Q17 | Routinely eats more vegetables than meat in order to control blood glucose. |
Q18 | Routinely increases the intake of snacks as a compensation of the reduction of meals or staple food recommendations. |
Q19 | Routinely unable to execute the MNT recommendations because of various reasons. |
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Zijian Li and Haimin Jin contributed equally to this work.
The authors are grateful to Abbott China (Shanghai, China), which provides a grant for the study. Meanwhile, the authors thank China NEEDs Study Group and Diabetes Care and Education Group of the Chinese Diabetes Society for the support. The members of Study Group are as follows: Li Shen from Beijing Tsinghua Changgung Hospital, Wenxia Li from the First Affiliated Hospital of Nanchang University, Jin Huang from the Second Xiangya Hospital of Central South University, Li Yuan from West China Hospital, Qingqing Lou from Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Rongwen Bian from Jiangsu Province Official Hospital, Hongdi Yuan from Sir Run Run Shaw Hospital, Qiu Zhang from First Affiliated Hospital of Anhui Medical University, Ping Zhang from Second Affiliated Hospital, Dalian Medical University, Zhuping Wang from the Affiliated Hospital of Guizhou Medical University, Jing Liu from Gansu Provincial Hospital, Zhiping Liu from the First Affiliated Hospital, Chongqing Medical University, Sunjie Yan from the First Affiliated Hospital of Fujian Medical University, Hong Li from First Affiliated Hospital of Kunming Medical College, Jianxin Ma from Henan Provincial People’s Hospital, Yongzhen Mo from Jiangsu Province Institute of Geriatrics, Ning Zhang from Nanjing Drum Tower Hospital, Kai Kan from Sixth Affiliated People’s Hospital of Shanghai Jiao Tong University, Fang Zhao from China-Japan Friendship Hospital, Mingxia Zhang from Peking University People’s Hospital, Min Li from the First Hospital of China Medical University, AiLing Chen from the First Affiliated Hospital, Sun Yat-Sen University, Canhua Chen from the First Affiliated Hospital, Zhejiang University, Aixia Ma from Qilu Hospital, Jianqin Sun from Huadong Hospital Affiliated to Fudan University, Changping Ju from Zhongda Hospital, Jie Liu from Shanxi Provincial People’s Hospital, Qiaojun Peng from First Affiliated Hospital of Xinjiang Medical University, Lijuan Xu from Heilongjiang Provincial Hospital, Yanhua Zhu from the Third Affiliated Hospital, Sun Yat-Sen University, Huili Zhang from Qinghai University Affiliated Hospital, Junhua Meng from General Hospital of PLA, Qiuling Xing from Metabolic Disease Hospital of Tianjin Medical University, Qun Wang from Third Hospital of Peking University, Jianqin Liu from Chinese PLA 306TH Hospital, Boqing Ma from Hebei General Hospital, Jing Tao from Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, and Meng Li from the First Affiliated Hospital of Xi’an Jiaotong University.