Diabetes has become a global epidemic affecting an estimated 371 million people (in 2012), a number that is expected to reach 552 million by 2030 [
Recent research has revealed that 58% of type 2 diabetes (T2DM) cases can be prevented or delayed through lifestyle changes such as increased physical activity, healthy eating, and weight loss [
In order to provide insight into the justification for (and development of) an effective and patient-focused education program, a survey of patients and clinicians was undertaken to assess the awareness, confidence, perceived barriers and promoters, and educational needs for using a plant-based diet in the prevention and management of T2DM.
The Diabetes Education Centre (DEC) at Southlake Regional Health Centre (SRHC) provides assessment and therapeutic and self-management education for adults with type 1, type 2, gestational diabetes, and prediabetes in York Region, ON, Canada. With the mission of providing a broad-based education on the prevention and management of diabetes, the DEC has approximately 12,500 patient visits annually. This pilot study was approved by the Research Ethics Board prior to patient enrolment and study commencement. Participants from the DEC community were subsequently recruited for one of two surveys: a patient survey or a health professional survey. All patients visiting the clinic for an appointment during the survey period were approached in the waiting room and given the option to complete the patient survey. The patient survey ran from April 22, 2013, to June 5, 2013, and 100 individuals agreed to participate. Inclusion criteria for patient participation included being a patient of the DEC diagnosed with prediabetes, type 1 diabetes, or type 2 diabetes. Patients with gestational diabetes and type 1 diabetes on insulin pump therapy and nonpatients were excluded from the study. The final analytic sample included 98 individuals (prediabetes:
Survey data was derived from dichotomous (yes/no) and Likert-type scale closed-ended questions. Additional open-ended questions were used to acquire more specific demographics, health history, and behavioural information (e.g., height, weight, and opinions about diabetes education needs). Since a validated questionnaire in this particular topic was not available, questions were carefully designed to address the following areas: (1) present knowledge, (2) confidence level, (3) potential barriers/promoters, and (4) interests and needs for establishing a future education program.
Staff members of the diabetes team were also asked to provide responses to a brief questionnaire on their attitudes and practices regarding plant-based diets. The health professional survey was offered to all staff members working at the DEC and included registered nurses (RN), endocrinologists, and registered dietitians (RD). The survey ran from March 25, 2013, to April 12, 2013, and was completed by 25 staff members: 11 RN, 1 endocrinologist, and 13 RD.
Mean values (
In general, study participants tended to be male (55%), over age 50 (71%), be overweight or obese (73%), have T2DM (68%), be diagnosed in the last 10 years (65%), and be returning patients (55%) (Table
Knowledge and perception of plant-based diets in patients attending a Diabetes Education Centre.
Age | |
<50 y | 28 (28.6%) |
≥50 y | 70 (71.4%) |
Sex (% male) | 54 (55.1%) |
Body Mass Index | |
Normal weight (18.5–24.9 kg/m2) | 26 (26.5%) |
Overweight (25.0–29.9 kg/m2) | 26 (26.5%) |
Obese (≥30.0 kg/m2) | 46 (46.9%) |
Diabetes type | |
Prediabetes | 14 (15.1%) |
Type 1 diabetes | 17 (18.7%) |
Type 2 diabetes | 62 (68.1%) |
Time since diagnosis of diabetes |
|
0–10 years | 57 (65.5%) |
10+ years | 30 (34.5%) |
Dietary practices | |
Not on plant-based diet | 85 (91.4%) |
Semivegetarian | 6 (6.5%) |
Pesco-vegetarian | 2 (2.2%) |
Patient history in diabetes clinic | |
New patient | 41 (44.6%) |
Returning patient | 52 (55.4%) |
Note: values may not add up to 100% due to missing responses and rounding.
Values for continuous measures are
Overall, less than half of all participants were aware of the benefits of a plant-based diet to improve diabetes, weight, heart disease, high blood pressure, or high cholesterol. Awareness also varied according to DEC attendance (Figure
Percentage of patients who are aware of the benefits of a plant-based diet on various chronic conditions. Chi-square analysis comparing willingness to change diet and status of patient, all nonsignificant.
Awareness of the benefits and willingness to try a plant-based diet in new and returning patients. Chi-square analysis comparing new and returning patients;
When asked what supports would benefit dietary change, 22% of participants indicated that they did not intend on making a change. Stratified by time since diagnosis, more longer-term than newly diagnosed diabetics (30% versus 10%,
Unadjusted logistic regression between clinical and patient-education factors on willingness to change to a vegetarian diet
Odds ratio | |
---|---|
Patient interest in education on vegetarian diets | |
No | 1.0 (referent) |
Yes |
|
Interest in plant-based diet is to improve health | |
No | 1.0 (referent) |
Yes |
|
Interest in plant-based diet is to lose weight | |
No | 1.0 (referent) |
Yes |
|
Age | |
18–29 y | 1.0 (referent) |
30–49 y | 4.0 (0.6–27.4) |
50–65 y | 3.5 (0.6–20.1) |
65+ y | 1.60 (0.2–11.1) |
Sex | |
Female | 1.0 (referent) |
Male | 1.3 (0.6–2.9) |
Demographic and clinical characteristics | |
Prediabetes | 1.0 (referent) |
Type 1 diabetes | 1.4 (0.3–5.9) |
Type 2 diabetes | 1.0 (0.3–3.1) |
Time since diabetes diagnosis | |
0–10 y | 1.0 (referent) |
10+ y | 1.3 (0.5–3.1) |
Body Mass Index | |
Normal weight (18.5–24.9 kg/m2) | 1.0 (referent) |
Overweight (25.0–29.9 kg/m2) | 0.9 (0.3–2.6) |
Obese (≥30.0 kg/m2) | 1.1 (0.4–3.0) |
Confidence in becoming vegetarian | |
Somewhat confident or confident | 1.0 (referent) |
Not at all confident | 1.2 (0.5–2.9) |
Heard of a plant-based diet | |
No | 1.0 (referent) |
Yes | 2.1 (0.5–8.3) |
Aware of benefits of a plant-based diet | |
No | 1.0 (referent) |
Yes | 1.3 (0.6–2.8) |
Patient history in diabetes clinic | |
First visit | 1.0 (referent) |
Returning patient | 1.3 (0.5–3.1) |
A majority of staff (72%) were aware of the use of plant-based diets for treatment of T2DM, but only 32% are currently recommending this dietary pattern to patients (Table
Staff perception and recommendation for patient use of plant-based diets.
Heard of using a plant-based diet to treat diabetes | |
Yes | 18 (72.0%) |
No | 6 (24.0%) |
No response | 1 (4.0%) |
Perceived confidence planning a plant-based diet | |
Confident | 8 (32.0%) |
Somewhat confident | 3 (12.0%) |
Not confident | 10 (40.0%) |
No response | 4 (16.0%) |
Current practice regarding plant-based diets | |
Currently recommending | 8 (32.0%) |
Not recommending | 14 (56.0%) |
No response | 3 (12.0%) |
Note: values may not add up to 100% due to missing responses and rounding.
Numbers are
Study results reflect that approximately 89% of patients were not aware of using an alternate diet such as a plant-based diet for the prevention and management of T2DM and many of them cited low confidence in adopting this eating pattern. However, two-thirds of the patients showed willingness to follow a plant-based diet for the short-term and expressed interest in attending a vegetarian education program. Patients’ low awareness and confidence level on the use of plant-based diets for managing T2DM can be partially attributed to the fact that, despite the growing interest in the health benefits of a plant-based diet, the vegetarian population remains relatively small in Canada (4%) [
The top three barriers for making dietary changes towards a plant-based diet included family’s influence, preference of eating meat, and meal planning skills. To promote this change, patients cited their top educational needs to be a vegetarian education program consisting of individual or group counselling and cooking instructions components. This result suggests that the traditional theory-based nutrition education at the DEC setting may be insufficient to address patients’ barriers; a bigger focus should be placed on the practical aspects, such as teaching patients and family members how to prepare appetizing plant-based meals, in order to change their perception towards this new eating pattern.
One of the common reasons for diabetes educators not to be recommending this diet to patients was that this dietary approach is too difficult to follow with low perceived approval (i.e., patients are unlikely to accept it). This notion is contrary to the patient survey results that almost two-thirds of patients were willing to follow this dietary pattern at least for short-term when educational support is provided. Katcher et al. (2010) also indicate in a workplace study that a vegan diet is well accepted with over 95% adherence rate, and subjects report increased energy level, better digestion, better sleep, and increased satisfaction when compared with the control group [
As with any study, the results of this preliminary survey must be interpreted with caution. First, the small sample size (
Patient awareness of (and interest in) the benefits of a plant-based diet for the management of diabetes remains suboptimal and may be influenced by the perception of diabetes educators and clinicians. To provide assurance of the acceptability and efficacy of plant-based diets to patients, offering diet-specific education programs by nutrition professionals in community-based diabetes centres is warranted. Developing these programs in partnership with local nutrition service providers such as community kitchens, grocery stores, and local food network could foster exchange of teaching experience and new perspectives amongst educators and enable sharing of important teaching resources such as a demonstration kitchen. As such, additional training on plant-based diets may require the development of a more standardized and user-friendly practice guideline on plant-based diets to facilitate patient education. With its proven multiple health benefits, a plant-based diet has clearly shown to be beneficial in improving clinical outcomes, and also it has great potential to alleviate healthcare cost in the prevention and management of diabetes as well as other chronic diseases. The current study provides support for the need to further investigate the cost-effectiveness of this dietary pattern in a clinical setting.
There is now considerable evidence to support the use of plant-based diets as an effective Medical Nutrition Therapy for chronic diseases such as T2DM [
The authors confirm that all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
The authors declare that there is no conflict of interests regarding the publication of this paper.