IMPACT OF NUTRITION COUNSELLING ON NUTRITIONAL STATUS TUS OF NON-INSULIN DEPENDENT DIABETIC SUBJECTS

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1 J. Dairying, Foods & H.S., 31 (2) : , 2012 AGRICULTURAL RESEARCH COMMUNICATION CENTRE ccjournals.com / indianjournals.com nals.com IMPACT OF NUTRITION COUNSELLING ON NUTRITIONAL STATUS TUS OF NON-INSULIN DEPENDENT DIABETIC SUBJECTS Savita Budhwar and Sudesh Jood* Department of Foods and Nutrition CCS Haryana Agricultural University Hisar , India Received: Accepted: ABSTRACT A study was conducted on 40 adults (male and female) ranging from years and suffering from non-insulin dependent diabetes mellitus (NIDDM). The subjects were divided into control and experimental groups. Nutrition counseling was imparted only to the experimental subjects for 3 months. Its impact was assessed in terms of their dietary intake, anthropometric measurement, biochemical parameters and gain in knowledge. Before nutrition counseling, daily consumption of protective foods like pulses, leafy and other vegetables and fruits by NIDDM patients was found inadequate. But after nutrition counseling mean daily intake of energy yielding foods such as cereals, roots and tubers, fats and oils and sugar and jaggery and milk and milk products decreased which resulted in significantly lower mean daily intakes of nutrients the mean daily intake of protein, fibre, riboflavin, niacin, iron, folic acid, magnesium and zinc was significantly improved as per their suggested intakes. Increased consumption of protective foods, decreased energy and fat intake by the experimental diabetic subjects might contribute in reduction of their body weight and BMI. Fasting blood glucose and post prandial glucose was reduced significantly by 16, 10 and 16, 14%, respectively espectively.. Similarly,, significant reduction was also noticed in lipid profile and liver enzymes. After nutrition counseling, majority of the experimental subjects had adequate nutrition knowledge. Key words: NIDDM subjects, Nutrition counseling, Food and nutrient intake, Biochemical assessment, Anthropometric measurements, Knowledge assessment. INTRODUCTION Diabetes mellitus is heterogeneous primary disorder of carbohydrate metabolism with multiple etiological factors. It generally involves absolute or relative insulin deficiency, or insulin resistance, or both. Whatever the cause, diabetes mellitus ultimately leads to hyperglycemia, which is landmark of this disease syndrome. There are about 143 million people suffering from diabetes world wide, almost five times more than estimated ten years ago. It is estimated that the number of people with diabetes in India in 2000 to be 31.7 million, which is likely to rise to 79.4 million by 2030 (Agarwal et al., 2007). India is rapidly becoming industrialized and urbanized which leads to unhealthy lifestyle changes which adversely affect metabolic functions and increase the disease rate several fold. It has also been associated with an increased risk for premature *Corresponding author: ramjood@rediffmail.com arteriosclerosis due to increase in triglycerides and low density lipoprotein levels. About 70-80% of deaths in diabetic patients are due to vascular disease. Diabetes is closely related to diet and management. The two major goals of management of diabetes are, to achieve metabolic control near normal and to prevent or delay the complications. Lack of knowledge of the simplest facts of nutrition is at the root of a high proportion of causes of diabetes mellitus in India. To prevent the increasing problem of diabetes in India, it is undoubtedly ideal to make public aware of the alarming state of the disease by improving knowledge levels. Nutrition education/counseling is therefore needed to motivate and create public awareness to preserve healthy life styles and adopt healthy dietary habits to reduce risk factors of diabetes. Nutrition counseling is one of

2 Vol. 31, No. 2, the most effective tools of changing the food habits Adequacy Ratio (FAR) was calculated as per the of the people without affecting their sentiments. It is method of ICMR (1998): a process by which the beliefs, attitude, Food intake environmental influents and knowledge about food FAR (%) = x 100 and health are canalized into actual practices RDI (Borbora et al., 2009). Hence, there is urgent need to increase the public awareness regarding risk Nutrient intake: Different nutrients namely, factors and their association with non-insulin energy, protein, fat, thiamine, riboflavin, niacin, dependent diabetes mellitus, keeping these facts in vitamin B 12, folic acid, ascorbic acid, calcium, view, the present community based study was carried phosphorus, magnesium and zinc were calculated out in Hisar city, Haryana to assess the impact of from foods consumed by the subjects using food nutrition counseling on dietary and nutrient intake, composition table (Gopalan et al., 2000) and anthropometric measurements and biochemical Nutrient Adequacy Ratio (NAR) was calculated as parameters of non-insulin dependent diabetes per the method of ICMR (1998): mellitus (NIDDM) patients. Nutrient intake MATERIALS AND METHODS NAR (%) = x 100 Selection of subjects: Forty adults (male and Nutrient RDA female) of years age were selected purposively Anthropometric measurements: The height, from Hisar city, Haryana from government hospitals, weight, waist circumference, hip circumference, private hospitals and nursing homes etc. based on waist-hip ratio, triceps skin fold thickness (TSFT) their BMI and fasting blood glucose levels. A and mid upper arm circumference (MUAC) of the knowledge testing questionnaire was used to pretest subjects were measured according to the methods the knowledge of the respondents before counseling. of Jelliffe (1966). BMI was calculated by Weight (kg)/ In addition to this, information was also collected Height (m) 2 equation given by Garrow (1981). on food and nutrient intake, anthropometric Biochemical assessment: Fasting and measurements and biochemical assessment. After postprandial blood glucose levels, serum lipid profile pre-testing the knowledge and assessment of above and liver enzymes were assessed before and after mentioned parameters, nutrition counseling was nutrition counseling in experimental diabetic subjects imparted only to the experimental group for a period as well as control diabetic subjects (without nutrition of 3 months. The control group was not imparted counseling). Five ml of fasting and postprandial (2 any counseling. After 3 months, impact of nutrition hour after meal) blood samples of 40 selected counseling was assessed in terms of food and nutrient NIDDM subjects were collected for biochemical intake, anthropometric measurements, biochemical estimation using standard procedures. parameters (serum glucose, serum enzymes and lipid Blood glucose and liver enzymes: Blood profile) and gain in knowledge of selected patients. glucose (fasting and postprandial) were estimated Dietary assessment: Information regarding the by Ames Auto Blood Analyzer using Glucose intake of food for three consecutive days was oxidase/peroxidase (GOD/POD) method of Trinder collected from the diabetic subjects (control and (1969) and liver enzymes such as serum glutamate experimental) using 24-hour recall method. Cooked oxalaoacetate transminase (SGOT) and serum food consumed was converted into their raw glutamate pyruvate transferase (SGPT) were equivalents. Mean daily intake of different food estimated by Ames Auto Blood Analyzer using UV groups including cereals, pulses, fruits, green leafy kinetic method of IFCC (1976). vegetables, roots and tubers, other vegetables, milk and milk products, sugar and jaggery and fats and Serum lipid profile: Serum total cholesterol oils was calculated by taking mean intake of three (Allain et al., 1974), HDL-cholesterol (Richmond, consecutive days. Average daily dietary intake of 1973) and triglycerides (Annoni et al., 1982) were the respondents was compared with the suggested determined by Ames Auto Blood Analyzer using intake given by Raghuram et al. (1998). Food Autopak Kits (M/S Miles India Limited). Serum LDL-

3 128 J. DAIRYING, FOODS & H.S. cholesterol and VLDL-cholesterol was calculated by average intakes of green leafy vegetables, other using the formula given by Friedwald s et al. (1972): vegetables and fruits increased significantly after LDL-cholesterol = Total cholesterol - HDLcholesterol - 1/5 th Triglycerides. diabetics but still lower than their suggested intakes nutrition counseling which has protective role for might be due to seasonal availability. The adequacy VLDL-cholesterol = Total cholesterol (HDLcholesterol + LDL-cholesterol). of green leafy vegetable, other vegetable and fruit intakes by the experimental subjects was 19 and 28, Assessment of knowledge: The impact of 36 and 50, 58 and 72%, respectively. nutrition counseling was assessed using pre and post Nutrient intake: Average daily nutrient intake of knowledge level of the NIDDM patients (control and diabetic subjects in experimental and control group experimental) through prepared knowledge inventory are presented in Table 2. The mean daily intake of schedule after imparting full package of knowledge. energy by diabetic subjects in experimental group For evaluating questionnaire 1 score was awarded before nutrition counseling decreased significantly for each correct and zero for wrong answer. Gain in after 3 months of nutrition counseling, which may knowledge was calculated using the following be associated with decreased intakes of roots and equation. tubers, fats and oils, sugar and jaggery. The Gain in knowledge = Score of post test Score of adequacy of energy intake before and after nutrition pre test counseling was 110 and 10% in experimental group Statistical analysis: The data on all the and 116 and 117% of the suggested intake in control parameters viz. food and nutrient intake, group. Similarly, significant decrease was observed anthropometric measurements and blood in carbohydrate intake after nutrition counseling in parameters were analyzed statistically with the help experimental group. However, mean consumption of mean, standard error, percentage and paired t of carbohydrates by both the groups was still higher test (Panse and Sukhatme, 1961). than the suggested intake i.e. 262 g. Significant reduction in carbohydrate intake by experimental RESULTS AND DISCUSSION group was mainly due to avoidance of refined foods, Food intake: Mean daily food intake by sugar and jaggery and fast foods and also inclusion experimental and control diabetic subjects and their of high fibre fruits and vegetables, whole wheat flour, comparison with suggested intake are given in Table dalia etc. in their daily diets as explained during 1. Mean daily intakes of energy yielding foods such nutrition counseling. as cereals, roots and tubers, fats and oils and sugar and jaggery decreased significantly in experimental The increase in protein intake was found group after nutrition counseling. Whereas nonsignificant change was observed in control subjects. counseling but was still lower as compared to significantly higher after 3 months of nutrition There was significant (P<0.05) increase in pulse suggested value of 74.5 g/day for diabetic subjects intake after nutrition counseling in experimental whereas in control group (without nutrition group but non-significant change was observed in counseling), there was non-significant change in control group. However, mean daily consumption mean daily consumption of pulses before and after of pulses by both the groups was still lower than the 3 months. suggested intake (67 g/day). The adequacy of the pulse intake by experimental subjects before and after nutrition counseling was 61 and 89% of suggested intake, respectively. Consumption of milk and milk products decreased significantly after nutrition counseling in experimental subjects but was still higher than the suggested intakes whereas mean daily intakes of milk and milk products by control group were found almost similar before and after 3 months. Whereas A significant decrease was found in total and saturated fats intakes might be another contributory factor in lowering the energy intake after nutrition counseling but total fat intake was found still higher than the suggested intake (37 g/day). On the other hand, in case of control group, mean daily intake of total fats, saturated fats and unsaturated fats before and after were found almost same. Others workers also reported significant reduction in fat intakes after nutrition counseling (Borbora et al., 2009).

4 Vol. 31, No. 2, TABLE 1: Impact of nutrition counseling on mean daily food intake by the selected diabetic subjects Food group (g) Cereals (103) Experimental group (n=20) Before NC After NC t-value (92) 2.16** (102) Control group (n=20) Before After 3 mon t-value Suggested intake (100) 1.02* 257 Pulses (61) Green leafy vegetables (19) (81) (28) 3.18* (60) 9.98* (20) (63) (21) NS 67 NS 223 Roots & tubers ** NS NA Other vegetables (36) Fruits (58) Milk & milk products (111) (50) (72) (85) 3.62** (34) 6.61** (54) 1.92** (109) (35) (56) (110) NS 223 NS 112 NS 335 Fats & oils (103) Sugar & jaggery (219) (103) (130) 3.46* NS ** (201) (209) NS NA Average of suggested intake of male and female (Raghuram et al., 1998) *Significant at 5% level **Significant at 1% level NS = Non-significant NC = Nutrition counseling NA = Not available

5 130 J. DAIRYING, FOODS & H.S. TABLE 2: Impact of nutrition counseling on mean daily nutr ient intake by the selected diabetic subjects Nutrients Experimental group Before NC After NC t-value Control group Before After 3 mon t-value Suggested intake Energy (Kcal) (110) (101) 4.65* (116) (117) NS 1676 Carbohydrate (g) (148) (86) 4.68* (149) (150) NS 262 Protein (g) (78) (89) 5.13* (80) (81) NS 74.5 Total fat (g) (174) (122) 9.28* (165) (169) NS 37 Saturated fat (g) * NS - Unsaturated fat (g) * NS - Dietary fibre (g) (56) (93) 4.10* (61) (64) NS 42.5 *Significant at 5% level Figures in parentheses indicate % of suggested RDA Average of suggested intake of male and female (Raghuram et al.,1998) NC -= Nutrition counseling

6 Vitamins/Minerals Thiamine (mg) (248) Experimental group Before NC After NC t-value (195) Vol. 31, No. 2, TABLE 3: Impact of nutrition counseling on mean daily intake of vitamins and minerals by the selected diabetic subjects 3.98* (247) Control group Suggested intake Before After 3 mon t-value NS 0.85 (245) Riboflavin (mg) (97) (160) 4.09* (95) (96) NS 1 Niacin (mg) (92) (132) 4.24* (97) (99) NS Vitamin C (mg) (90) (242) 4.42* (99) (102) NS 40 Folic acid ( g) (68) (105) 3.05* (70) (71) NS 100 Iron (mg) (49) (69) 8.83* (43) (48) NS 29 Calcium (mg) (249) Zinc (mg) (50) (206) (67) Average of suggested intake of males and females (ICMR, 1998) Figures in parentheses indicate % of suggested RDA *Significant at 5% level NS = Non-significant NC = Nutrition counseling 2.31* (246) 7.20* (51) (247) (52) NS 400 NS 15.5 The increase in fibre intake was found significantly higher after 3 months of nutrition counseling but still lower as compared to suggested value of 42.5 g/day. Whereas in control group, there was non-significant change in mean daily consumption of fibre before and after 3 months. The increase in fibre intake in daily diet of experimental group could be the impact of counseling. Similarly, Kapoor (2001) reported higher fibre intake by NIDDM subjects after nutrition intervention. Mean daily intake of thiamine and calcium before and after the nutrition counseling by the experimental subjects was found significantly higher as compared to their suggested intakes (Table 3). The percent adequacy was 248, 195 and 249, 206, respectively which was almost two folds higher than their suggested intakes. On other side, initial mean daily intakes of riboflavin, niacin, vitamin C, folic acid, iron and zinc were found inadequate. But after nutrition counseling significant increase was observed in intakes of riboflavin, niacin, vitamin C and folic acid but iron and zinc intake was found still lower than their suggested intakes. This improvement might be contributed to higher consumption of fruits and vegetables and sprouted pulses. Where as in control group non-significant change was observed in initial and final intakes of all the nutrients. Anthropometric measurements: Mean height and weight of experimental subjects significantly reduced after nutrition counseling as compared to control group. Similarly, significant reduction was also observed in BMI, WHR, MUAC and TSFT of experimental group. WHR is a sensitive indicator to assess the risk for developing various degenerative diseases. Talwar and Srivastava (2003) reported that abdominal obesity (WHR > 0.92 in males and > 0.85 in females) constituted risk factor for NIDDM. Blood glucose and liver enzymes: Average fasting blood glucose level of the subjects in experimental group before nutrition counseling was mg/dl which came down to mg/dl

7 132 J. DAIRYING, FOODS & H.S. TABLE 4: Impact of nutrition counseling on anthropometric parameters of selected diabetic subjects Parameters Experimental group t-value Control group t-value Reference Standard Before NC After NC Before After 3 mon Male Female Height (cm) NS NS NA NA Weight (kg) ** NS Body mass index (kg/m 2 ) Mid upper arm circumference (cm) Tr iceps skinfold thic kness (mm) ** NS * NS * NS Waist-to-hip ratio * NS Values are mean ± SD of 20 independent determinations *Significant at 5% level **Significant at 1% level NS = Non-significant NA = Data not available NC = Nutrition counseling 1 Raghuram et al. (1998) 2 NIN (1998) 3 ICMR (1991) 4 Jelliffe (1966) 5 NCHS Standards (1985) TABLE 5: Impact of nutrition counseling on fasting and postprandial blood glucose levels of selected diabetic subjects Serum glucose (mg/dl) Normal range Experimental group (n=20) t-value Control group (n=20) t-value Before NC After NC Before After 3 mon Fasting (-15.75) Postprandial (-15.82) Serum enzymes (U/L) SGOT (-16.25) 9.37** (-4.99) 11.40** (-2.12) 20.08** (-0.11) 2.71* NS NS SGPT (-18.23) 18.02** (-0.51) Values are means ± SD of 20 independent determinations *Significant at 5% level **Significant at 1% level NS = Non-significant Figures in parenthesis indicate per cent decrease (-) over their control values NC = Nutrition counseling Raghuram et al. (1998) NS after 3 months of nutrition counseling (Table 5). A significant decrease by about 15.75% was observed. However, the mean values even after nutrition counseling were still higher than desirable levels. Whereas in control group, mean values of blood glucose before and after 3 months were mg/ dl and mg/dl which were found higher than the desirable levels. The postprandial blood glucose levels of diabetic subjects from experimental group before and after nutrition counseling significantly decreased by about 15.82% but higher than desirable level ( mg/dl). Significant reduction in fasting and postprandial blood glucose levels may be attributed to higher intake of dietary fibre in the

8 Vol. 31, No. 2, TABLE 6: Impact of nutrition counseling on serum lipid profile of selected diabetic subjects Values are means ± SD of 20 independent determinations **Significant at 1% level Figures in parenthesis indicate per cent decrease (-) over their control values NC = Nutrition counseling Raghuram et al. (1998) NS = Non-significant form of whole cereals, fibrous fruits and vegetables and lower intake of energy yielding foods which resulted in improved glucose tolerance (Rao and Ramulu 2003). Other workers also reported significant reduction in fasting and postprandial blood glucose levels of NIDDM subjects after nutrition education (Rao and Ramulu 2003), after supplementation of fenugreek seeds (Mathur 2006), wheat bran (Aggarwal et al., 2007) and neelkanthi (Gupta et al., 2007). The data regarding the serum concentration of liver enzymes such as serum glutamate oxalaoacetate transminase (SGOT) and serum glutamate pyruvate transferase (SGPT) has been presented in Table 5. The SGOT and SGPT levels in the serum of experimental subjects before and after nutrition counseling reduced by about 14 and 20 %, respectively, whereas non-significant change was noticed in control group. Hence, in the present study, the concentration of both enzymes SGOT and SGPT was found little higher than the normal range in all the selected patients but in experimental subjects the values of both enzymes decreased and found within the normal range after 3 months of nutrition counseling. Other workers also reported similar results regarding concentration of SGOT and SGPT in diabetic patients (Babu et al., 2003; Sihag, Serum lipid profile 2008). (mg/dl) Normal range Exper imental group (n=20) Serum lipid profile: Serum lipid profile of diabetic Before NC After NC subjects before and after nutrition counseling is presented in Table 6. Mean initial level of serum total Total triglycerides < triglycerides, total cholesterol, HDL, LDL and (-12.79) VLDL Total decreased cholesterol significantly < 200 by about 3, , and %, (-11.43) respectively whereas 8% increase was noticed in HDL-cholesterol level after 3 months of nutrition HDL-C counseling in experimental diabetic subjects. (+8.34) On the other hand non-significant change was observed in lipid LDL-C profile of control diabetic subjects after months. (-8.11) VLDL-C The results obtained from 1.95 the present study 1.49 revealed that before nutrition counseling (-12.53) total triglycerides, total cholesterol levels were higher while LDL-cholesterol, HDL-cholesterol and VLDLcholesterol levels with in the normal range. But after nutrition counseling, significant reduction was observed in triglycerides, total cholesterol, LDLcholesterol (bad cholesterol) and VLDL-cholesterol whereas significant improvement was observed in HDL-cholesterol which considered as good cholesterol. It can be concluded that nutrition t-value 4.46** 8.02** 3.21** 3.45** 4.51**

9 134 J. DAIRYING, FOODS & H.S. TABLE 7: Impact of nutrition counseling on per cent knowledge scores of the selected diabetic subjects. Score Experimental group(n=20) Control group(n=20) Pre-exposure Post-exposure Pre-exposure Post-exposure Low (1-16) 6 (30.00) 0 (0.00) 5 (25.00) 3 (15.00) Medium (17-33) 11 (55.00) 5 (25.00) 13 (65.00) 15 (75.00) High (34-50) 3 (15.00) 15 (75.00) 2 (10.00) 2 (10.00) Mean scores ± ± ± ± 2.42 t-value 10.42** NS Figures in parentheses indicate percentage **Significant at 1% level NS = Non significant. counseling could be helpful in improving lipid profile which is related to the development of coronary artery disease. Counseling about diet pattern, less saturated fat intake, inclusion of dietary fibre and physical activity to bring about a behavioral change could be the reason in curbing the present lipidemic diabetes and the related complications. In accordance with the present study, other researchers have also reported significant decrease in lipid profile of NIDDM patients after nutrition counseling (Monga 2004; Banga 2005). Assessment of knowledge: It was observed that mean pre-exposure knowledge scores of majority of respondents in experimental and control group were low (Table 7). Whereas after three months of nutrition counseling, a higher percentage (75%) of the subjects in experimental group obtained scores in the range of (high category). Hence, the difference between pre-exposure knowledge scores and mean post-exposure knowledge scores were found highly significant while non-significant improvement in post-exposure knowledge scores of control group was observed. REFERENCES Agarwal, J., Nagi, M. and Gulati, T. (2007). Impact of nutrition education on nutritional profile of non-insulin dependent diabetic females. J. Indian Dietetic. Assoc. 32: 1-5. Allain, C.A., Poon, L.S., Chan, C.S.G., Richmond, W. and Paul, C. F. (1974). Estimation of cholesterol by enzymatic method. Clin. Chem. 20: 470. Annoni, G., Bottasso, B.M., Ciaci, D., Donato, M.F. and Tripoli, A. (1982). Triglycerides estimation. J. Lab. Medic. 9: 15. Babu, V., Gangadevi, T. and Subramanium, A. (2003). Anti-diabetic activity of ethanol extract of Cassia kleinii leaf in streptozotocin-induced diabetic rats and isolation of an active fraction and toxicity evaluation of the extract. Indian J. Pharmacol. 35: Banga, K. (2005). Effect of chromium supplementation and nutrition counselling in male diabetic subjects. Ph.D. Thesis. Punjab Agricultural University, Ludhiana, India. Borbora, M., Bhattacharyya, R., Borthakur, S. (2009). Impact of nutrition counseling on subjects suffering from cardiovascular disease. Asian J. Home Sci. 3: Friedwald, W.T., Levy, R.I and Frederickson, D.P.S. (1972). Estimation of plasma low density lipoprotein cholesterol concentration without use of preparaline ultra centrifuge. Clin. Chem. 18: Garrow, J.S Treat Obesity Seriously. Edinburg Churchill, Livingstone. pp Gopalan, C., Ramasastri, B.V. and Balasubramanian, S.C. (2000). Nutritive Value of Indian Foods. NIN, Hyderabad. Gupta, S., Sood, S., Rekha, A. and Gupta, M. (2007). Effect of neelkanthi (Ajuga bracteosa) and plakhar (Ficus lacor) on blood sugar level and plasma lipid profile of non-insulin dependent diabetic subjects. J. Indian Dietetic. Assoc. 32: ICMR. (1991). Nutrient Requirements and Recommended Dietary Allowances for Indians. NIN, Hyderabad. ICMR. (1998). Dietary Guidelines for Indians. NIN, Hyderabad, India. IFCC. (1976). Expert panel of the IFCC on enzymes. Clinica Chimica Acta. 70: 619. Jelliffe, D.B. (1966). The Assessment of the Nutritional Status of the Community. World Health Organization Monograph Series No. 53, Geneva,

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