Research Article - Journal of Public Health and Nutrition (2022) Volume 5, Issue 4

Context-specific food-based dietary guidelines for managing diabetes among hospitalized patients in Tanzania.

Happyness Kisighii A^1*, Jofrey Raymond¹, Musa Chacha²

¹Department of Food Sciences and Technology, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania

²Department of Sustainable Agriculture Biodiversity and Ecosystem Management, The Nelson Mandela African Institution Science and Technology, Arusha, Tanzania

*Corresponding Author:

Happyness Kisighiia A
Department of Food Sciences and Technology
Nelson Mandela African Institution of Science and Technology
Arusha
Tanzania
E-mail: amanihappy9@gmail.com

Received: 13-Jan-2022, Manuscript No. AAJPHN-22-51666; Editor assigned: 17-Jan-2022, Pre QC No. AAJPHN-22-51666(PQ); Reviewed: 01-Feb-2022, QC No. AAJPHN-22-51666; Revised: 18-Apr-2022, Manuscript No. AAJPHN-22-51666(R); Published: 25-Apr-2022, DOI: 10.35841/aajphn-5.4.117

Citation: Kisighii HA, Raymond J, Chacha M. Context-specific food-based dietary guidelines for managing diabetes among hospitalized patients in Tanzania. J Pub Health Nutri. 2022;5(4):117

Abstract

Food-based dietary guidelines for managing diabetes among inpatients are currently not well established in Tanzania. This significantly contributes to delayed recovery of patients and increased burden to families and communities. This study aimed at developing context-specific food-based dietary guidelines to guide healthcare professionals make rational decisions in planning diets for patients. A cross-sectional study was conducted to collect data on dietary intake among diabetic inpatients to inform the formulation of food-based dietary guidelines. A 7-days weighed food record was used to assess dietary intake among 100 diabetic patients. Data on prices of common foods were obtained from hospitals’ requisition books and nearby markets. Findings showed that there are inadequate intakes of existing food plans. Linear goal programming was used to optimize dietary intake for diabetic inpatients by developing food-based dietary guidelines. Optimal dietary guidelines that are context-specific for managing diabetes for hospitalized patients can be formulated using culturally acceptable foods.

Keywords

Optimal dietary pattern, Linear programming, Diabetes mellitus, Food-based dietary guidelines.

Introduction

Diabetes is now one of the stressing public health concerns in Tanzania. The prevalence was estimated at 3.7% for adults aged 20-79 years in 2020 and is expected to triple by 2045 with linked health, social, and economic costs [1]. The country is currently spending about $2.7 for insulin supply only to manage diabetes. Urgent solutions for slowing, or even reversing, this trend is needed, especially from investment in modifiable factors including diet, physical activity, and body weight [2]. Dietary management of diabetes has a vital role in helping diabetic patients achieve and maintain optimal glycaemic control, the benefits of which have been demonstrated particularly in diet interventions that are context-specific [3].

Dietary management aims to complement medical treatment for diabetes in various roles [4]. Some of these roles include; maintaining blood glucose levels within and /or as close to the normal range as is safely possible to reduce or prevent the risk of diabetic complications, together with optimal nutrition, activity and appropriate medication; minimizing the risk of hypoglycemia for those taking insulin or oral hypoglycaemic agents; adjusting energy intake to achieve reasonable weight, normal growth and development; achieving blood pressure and lipid levels that reduce the risk for micro-and macrovascular disease or complications; reducing the risk of long-term complications; maintaining the quality of life; and addressing individual nutritional needs, taking into consideration personal, ethnic and cultural preferences and lifestyle while respecting the individual’s requirements and willingness to change [3].

Executing dietary management of diabetes is usually smoothened out when dietary guidelines that take into account local socio-cultural factors and personal preferences are in place [5]. This is particularly important in hospital settings [6]. Dietary guidelines form the basis for designing advice on healthy eating patterns that link nutrients to food intake and ensure overall dietary quality for health [7,5]. Dietary guidelines for managing diabetes do not exist in many Tanzanian hospital settings [8]. Besides, the existing guidelines are outdated or adapted from developed countries and therefore may not apply to the local situation [3]. The high-quality research to inform the development of food-based dietary guidelines that are context-specific are also not available in the country [3]. This makes it difficult for healthcare professionals to make a rational decision on diet planning to help people with diabetes achieve and maintain optimal metabolic and physiological outcomes during treatment.

This study aimed at formulating food-based dietary guidelines that take into account healthy dietary patterns, socio-cultural factors and personal preferences to complement medical treatment for patients with diabetes in Tanzanian hospital settings. We believe that accessibility of these guidelines-both physical availabilities (e.g., through a website or clinic) and comprehensibility for patients and healthcare professionals will enhance early recovery, reduce hospital readmission and mortality and consequently reduce the economic burden of diabetes in the country.

Materials and Methods

Site description

This study was conducted in 5 hospitals located in the Northern zone of Tanzania. Inclusion criteria were that a hospital must be currently attending diabetic patients and providing food catering services to hospitalized patients.

Study participants

A cross-sectional survey was conducted from April to August 2021 to assess the dietary intake of 100 (50 each gender) hospitalized patients with diabetes in 5 hospitals located in Northern Tanzania. Inclusion criteria was that an inpatient is receiving food services from the hospital. Ethical approval for this study was obtained from the Ethics Review Committee of the School of Life Sciences and Bioengineering at The Nelson Mandela African Institution of Science and Technology (NMAIST). The written informed consent was obtained from each hospital’s administration.

Anthropometric measurements

Anthropometric measurements such as the height and weight of the patients were recorded from the patients’ profile form for admission. Then, the obtained height and weight were used to calculate the Body Mass Index (BMI) of each patient included in the study. The BMI is calculated by dividing the weight in kilogram by height in meters squared (kg/m2). Obtained BMI was classified according to World Health Organization (WHO) standards for adults to understand the nutritional status of hospitalized diabetic patients included in the study.

Dietary assessment

Dietary assessment was used to estimate food intake (type and amount of food), nutrient intake and dietary patterns of hospitalized diabetic patients during the study period. Dietary assessment was also used to assess energy intake for each patient. Observed food intake, nutrient intake, and dietary patterns data were used for diet optimization.

Food intake

The amount and type of food and beverage consumed by inpatients at the hospital were assessed using Weighed Food Records (WDR) for 7 days to include the distribution of intakes provided in hospitals per schedule. Foods and beverages were weighed using a digital electronic weighing scale. Food weighing utensils such as plates and cups were supplied to all research assistants to assist with food weighing. The raw ingredients of all foods and beverages available in the hospitals’ kitchen were weighed before cooking, followed by weighing the final cooked dish and the remaining uneaten foods from patients. Food intake data were subsequently converted into daily energy and nutrient intake using Tanzania, Kenya and Uganda Food Composition Tables. Data were then entered into an Excel sheet 2016 for nutrient analysis.

Dietary pattern

Diet index-based pattern was used to assess quantities, proportions, variety, and/or combination of different foods, drinks, and nutrients in diets, and the frequency with which they were routinely consumed by hospitalized diabetic patients. The pattern was then used to determine the quality or adequacy (in terms of nutrient-dense) of diets given to diabetic patients in hospitals under this study. The results of the optimized dietary patterns served as a basis for deriving the recommended daily amounts for food groups. To send consistent and understandable messages to health care professionals, the results of the optimization calculations were converted from grams to practical quantities or serving sizes.

Dietary diversity

Dietary Diversity Score (DDS) was calculated by summing a given quantity of any food group that has been eaten at least once per day by diabetic patients during hospitalization. Food items recorded from catering units that were used to prepare menus for the patient in all hospitals were grouped according to FAO food group guidelines to calculate DDS. The DDS was calculated based on 13 food groups which are: green leafy vegetables, red and orange vegetables, starchy vegetables, beans, lentils and peas, other vegetables, whole grains, refined grains, fruits, dairy, oils, meat, poultry and eggs, fish and seafood, nuts, seeds and soy products.

Nutrient intake

Energy and nutrient intakes from each food item were computed from nutritional databases such as food composition tables, nutrient databases for each food item recorded from patients' food intakes were used to calculate median intake for each patient to determine daily nutrient intake per patient. The median calculations for each nutrient intake were compared with daily Recommended Nutrient Intakes (RDI) to identify nutrient adequacy and the quality of dietary patterns among diabetic patients.

Food market survey

A food market survey was conducted on markets and shops available near the hospital settings to validate the price of foods and identify other nutrient-dense local foods that were missing in the hospital food catering menu. The data was used in formulating optimal dietary patterns for hospitalized diabetic patients. The price was obtained from raw food ingredients.

Formulation of optimal dietary pattern

The linear goal programming model was formulation for the generation of the optimal diet for inpatients with diabetes. The constraints in the model for this study were WHO, Diabetic Association, ESPEN manual and other authorized published reports. Cultural traditions and individual preferences were included by ensuring that foods to be included in the model were suited from common food patterns in the hospitals. The cost of food items y is the objective function that we aim to minimize.

The minimum and maximum value of essential nutrients were set based on the WHO, Diabetic Association, ESPEN manual and other authorized published reports when choosing food items to ensure a menu generated per meal avoids repetition of food items.

Constraints

Constraints were set for each food item and nutrient composition obtained from nutrient databases. Then, minimum and maximum constraints for all essential nutrients and calories were based on the DRI for patients with diabetes as recommended by WHO, the world health cancer research fund, ESPEN guidelines and the American diabetic association as well as other published studies (Table 1). The constraints were also set for food groups to meet daily adequate food intake from each food group as per recommendation. The obtained results were used in formulating food-based dietary guidelines for hospitalized diabetic patients.

Table 1. Food constraints list for diabetic patients used in the optimization calculations for the formulation of food-based dietary guidelines for diabetes management

The constraints were the RDI for all essential nutrients to ensure patients meet the recommended level of each nutrient.

Qi ≤ Σainxn ≤ Qiand xn ≥ 0

Where Q is the RDI for a specific nutrient; Qi denoted the minimum or maximum acceptable quantity of nutrient i. ain denotes the amount of nutrient i in one portion of food item n; The weight of food item n is represented as an.

The minimum and maximum values for all essential nutrients were set based on WCRF/AICR 2018, WHO, ESPEN guidelines and IDF as shown in (Table 2). We included more than food items 150 and their corresponding 34 nutrients.

Table 2. Food groups and their criteria to include or exclude specific foods in optimization of a healthy dietary pattern

1Less content of a defined nutrient in a given food group

3High content of a defined nutrient in a given food group

2Medium content of a defined nutrient in a given food group

xLess or no content of a defined nutrient in a given food group

Decision variables

Food ingredients used to prepare meals for the patients during hospitalization were termed as decision variables. These were presented as follows:

xn = weight (g) of a food item n.

Objective function

The objective was to minimize the cost of the food items used for the preparation of diets for hospitalized patients. The diet is formulated to meet nutritional requirements for each individual per recommendation. This is shown by the equation below:

n Minimize y = Σc_n x_n

Where y is cost, cn was the cost of a quantity(weight) of food item n

Preparation of mathematical model calculations

Linear goal programming was used to model the food-based dietary guidelines for diabetic patients hospitalized in northern Tanzanian hospitals into everyday healthy food choices. Local foods commonly consumed were identified to be used in mathematical modeling. Local nutrient-dense foods including some neglected foods were included in developing a healthy dietary pattern for the management of diabetes. To come up with an affordable diet, the modeling considered the prices of foods that are most commonly consumed. The cost of each identified most commonly eaten food item to be taken from hospitals’ requisition books and markets and shops nearby hospitals.

Excel solver installation

The Solver-add-inn was installed from the Microsoft Excel version 2016 to produce the linear programming (LP) for generating optimal solutions from the food lists and their identified nutrients and costs. Details filled in Microsoft Excel 2016 include food items and their nutrient content, and price per serving, and the constraints for all nutrients (macronutrients and micronutrients) to allow the LP to determine the optimal quantity of selected food ingredients to meet the nutritional requirement for diabetic patients as recommended by WHO, ESPEN guidelines and other published reports at a minimum cost. To identify healthy dietary patterns food groups and subgroups median in intakes grams were included in the models.

The dietary guidelines development process

A multidisciplinary technical working group was formed and assigned to formulate food-based dietary guidelines for the management of type 2 dietary among hospitalized patients in Tanzania. The technical working group was composed of nutritionists, food scientists, agriculture, health, education and research specialists. The key evidence-based dietary recommendations for addressing diabetes among patients hospitalized in different health facilities concerning developed guidelines were evaluated. Then, dietary patterns were then translated into guidelines formulated based on cultural appropriateness, acceptability, comprehensibility and practicality to consumers by considering key issues for developing food-based dietary guidelines according to FAO and WHO.

Statistical analysis

The data obtained from the nutritional assessment were entered in an Excel sheet to allow statistical analyses using Excel solver to be carried out. All data were checked to remove errors. Dietary intakes were initially analyzed using nutritional databases such as food composition and nutrient value tables including Tanzanian, Kenyan and USDA respectively and compared with reference dietary intake (RDI) according to different recommendations from WHO, ESPEN guidelines, and other authoritative recommendations. Demographic data were presented as mean and standard deviations and percentages. The, paired t-test was performed using Jamovi Software to compare cost variables between observed and optimized dietary patterns.

Results

Participants

A total of 100 hospitalized diabetic patients (males and females) from 5 hospitals (20 patients from each hospital) located in Northern Tanzania participated in the study. The majority of the respondents were males (75%) and 25% were females. The mean age was 57 ± 12 years among females and 60±5 years for males. More than 60% of the female patients were aged between 45 and 50 years and 50% of male patients ranged from 65 to 89 years.

Anthropometric measurements

The majority (70%) of the patients involved in the study had a Body Mass Index (BMI) of between 25.0 (45%) and 38.2 (25%), indicating that most of them were overweight and obese.

Food intake

Twenty-five (25) (Table 3) food items were obtained from daily hospitalized diabetic patients’ menus. The identified foods include white bread, chapatti, rice, whole maize flour, raw banana, cabbage, carrots, green pepper, onions, tomatoes, ginger, garlic, potatoes, beef, margarine, beans, salt, vegetable oil, eggs, chicken, and amaranth, tea leaves, sugar, and milk. Grains were frequently consumed by hospitalized patients; mainly refined grains such as stiff maize porridge (Ugali), boiled rice and white bread which reached up to 74%. Overall vegetable consumption was 0.9cups (72g) per day, contributed by 0.3g dark green vegetables and 0.6g red and orange vegetables per day, legumes consumption was 0.45g per day mainly kidney beans, meat consumption was 28.3g per day while fruits, dairy products, nuts, seeds, poultry and seafood were absent in all hospital menus.

Table 3. Food items recorded in hospitals’ catering units and their prices

Dietary pattern

The diet optimization model results for amounts of each food group based on daily intake recommendations among diabetic patients were as follows: 2cups (220g) of vegetables, 1 cup (250g) of fruits achieved 51.2% and 71.3% for daily recommendation intake respectively, 48.04g whole grains with the exclusion of refined grains, 2 cups (473.17 ml) of dairy per day for only low-fat milk and milk products and 98.21g, 30.3g, 32.49g for meat, poultry, eggs; seafood and nuts seeds and soy products respectively which achieved 80% of protein food group intake of hospitalized patients (Table 4). Therefore, optimization excluded refined grains and increased whole grains to 85.04g followed by greenleafy and red and orange vegetables, beans, peas and lentils and other vegetables which were increased from 0.3-5 cups, 1.84 to 5.5cups, 0.45 to 1.5 cups, 0.02 to 5cups and 1.8 to 4cups respectively. Differences between the existing pattern and optimized pattern in other food groups were 1.5cups of fruits, 3cups of dairy products and 53.3g of protein foods. The dietary patterns developed had recommended amounts and limits of calories for adult diabetic patients’ maximum of 1800kcal as shown in (Table 5).

Table 4. Recommended daily amounts of food groups for management of diabetes in the food-based dietary guidelines

Table 5. Daily amounts of nutrients delivered by the daily recommended amount for foods in optimized dietary guidelines

Dietary diversity

Minimum dietary diversity for diabetic hospitalized patients was calculated from 13 food groups recorded from hospitals’ catering requisition books. Grains had the highest intakes of about 4% daily. Common foods consumed by patients include rice, white bread, chapatti and pasta and maize flour products. Less than 5% of vegetables were consumed in hospitals, while other food groups such as fruits, seeds, nuts and seafood were not included in hospitals’ menus. Moreover, only 2% of meat, poultry, beans and dairy were consumed by patients. The mean Dietary Diversity Score (DDS) was 3.8 based on observed consumption of foods from different food groups among diabetic patients involved in this study. A higher proportion (74%) was from grains. Overall consumption vegetables and meat were consumed by less than 2% of the participants. While fruits, nuts, dairy, seeds and seafood were absent in hospitals’ menus. Beans and meat consumed in the observed intake pattern to all patients was less than 5%.

Nutrient intake

Nutrient intake results were as follows; 1.5 ± 0.8mg iron, 30 ± 14.9μg folate, 0.56 ± 0.4 μg zinc, 2.3 ± 1.5μg selenium, 76 ± 3.1mg vitamin C, 38 ± 2mg vitamin E, 111 ± 20 μg vitamin A, and 1.9 ± 1.2 μg chromium (Table 6). In addition, dietary fiber and energy intake were 10.5g per day 2000 ± 10kcal respectively (Table 7).

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