Diabetes and : food choices

CENTRALE LANDBOUWCATALOGU S

0000 0330 5675 Promotoren:dr .J.G.A.J .Hautvast ,hoogleraa ri nd elee rva nd evoedin g end evoedselbereidin g dr.ir.N.G .Röling ,hoogleraa ri nd evoorlichtingskund e A.C. Niewind anddiet : food choices

PROEFSCHRIFT terverkrijgin gvei nd egraa dva n doctori nd elandbouwwetenschappen , opgeza gva nd erecto rmagnificus , dr.H.C .va nde rPlas , inhe topenbaa rt everdedige n opwoensda g7 jun i198 9 desnamiddag st evie ruu ri nd eaul a vand eLandbouwuniversitei tt eWageninge n BIBLIOTHEEK LANDBOUWUNIVERSITEIT WAGENINGEN

HetDiabete sProjec twaarva nd estudies ,di ei ndi tproefschrif tworde n beschreven,dee luitmaken ,wer dfinanciee londersteun ddoo rhe tMinisteri eva n Welzijn,Volksgezondhei de nCultuu re ndoo rd eLandbouwuniversitei t Wageningen. (OWC7CH, \d&ô

STELLINGEN

1. Mensenme tdiabete slegge nzichzel fonnodig ee ni nhe tlich tva n gezondevoedin gonjuist ebeperkinge no pi nhu nvoedselkeuze . (ditproefschrift )

2. Veeldieetadvieze ndi eaa ndiabete nworde ngegeven ,zij nnie tgeën to p dehuidig ewetenschappelijk einzichten . (ditproefschrift )

3. Voordiabete ni she tvolge nva nhe tdieetadvie she tmoeilijkst easpec t vand ebehandelin gva ndiabetes . (o.a.di tproefschrift )

4. Bijhe tverandere nva nvoedingsgewoonte nmoe te rva nuitgegaa nworde n datvoedse lzowe lgezondheidswaard eal sgenotswaard eheeft .

5. Aaninsuline-afhankelijk ediabete nzonde rovergewich tzo ugee nvast e hoeveelheidenergi ei nd evoedin gmoete nworde nvoorgeschreven .

6. Dieet/voedingsadviezenworde nte nonrecht egeïnterpreteer d inge -e n verboden.

7. Wanneerdiabete ndieetadvieze nnie topvolgen ,i sdi tnie tt ewijte naa n onvoldoendemotivatie ,maa raa nonvoldoend ekenni sva nhe tdoe lva nhe t dieete naa nontoereikend evoorlichting .

8. Iti smuc heasie rt ochang ea ninsuli nregime ntha nt ochang ea person'seatin ghabits . Nuttal,F.Q. :J .AM .Coll .Nutr .6 ,5-9 ,1987 .

9. Wehav et oremembe rtha tdietar yguideline sar esuggestion st ohel pt o maintaingoo dhealth .The yar en oprescription st osav elives ;i ti s likesayin gth eTe nCommandment swil lge tyo uint oheaven . Kritchevsky,D. :JAOC S6 ,708-717 ,1986 .

10.D ebijdrag eaa nhe tto tstan dkome nva nee nproefschrif tva nd e laatstgenoemde inhe tvoorwoor dword tonderschat .

11.Gezie nd ebeperkthei dva nd eNederlands eonderzoekswerel d isvoo r wetenschappersee nverblij fi nhe tbuitenlan dee nnoodzaak .

12.He ti sergerniswekken dda the tmestoverscho tva nd eklein ehuisdiere n opstraa tword tgedeponeerd .

13.He tgetuig tva nweini ginzich ti nd eprobleme nva nslachtoffer sva n geweldplegingal sme nhu nallee npsycho-social ehul pbied te ngee n financiëlecompensatie .

14.D ediscussi eove rho evrouwe nhe topvoede nva nkindere nkunne n combinerenme the tverrichte nva nbetaald earbei dtoon taa nda td e emancipatieva nd evrou wno gnie ti svoltooid .

15.D ediscussi eove rho evrouwe nhe topvoede nva nkindere nkunne n combinerenme the tverrichte nva nbetaald earbei dtoon taa nda td e emancipatieva nd ema nno gnie ti svoltooid .

ProefschriftA.C .Niewin d Diabetesan dDiet :Foo dChoice s Wageningen,7 jun i198 9 aanmij nouder s aanChri s DIABETESAN DDIET :FOC »CHOICE S

THESIS,DEPARTMEN TO FHUMA NNUTRITION ,WAGENINGE NAGRICULTURA LUNIVERSITY ,TH E NETHERLANDS,JUN E7 1989 .

A.C. Niewind

This thesis reportso n the foodchoice s ofdiabeti c patients.Tw o studieswer e undertaken considering thebarrier s thesepatient sexperienc ewit h the diabeticdiet .Furthermore ,th echange s infoo d choicesdurin g the firstyear s after thediagnosi so f -dependentdiabete sa swel l aspatients 'foo d choicemotive swer e investigated. It isconclude d thatdespit e the barriers diabeticpatient sexperienc ewit h theirdiets ,the yar emotivate d tochang e food choices forhealth-relate d reasonso na short-terman d amor e long-term basis.However ,th eactua l changes infoo dus epatient smak eafte r being diagnosed asdiabetic s areonl ypartl y inagreemen twit h theprinciple so f the diabeticdiet .Man yo f thechange s infoo dus ear eno tnecessar yan d some are evenundesirabl e froma nutritiona l perspective.I t isadvise d thatpatients ' understanding of thediabeti cdie ta swel l asnutritio neducatio n programmes fordiabeti cpatient snee d tob e improved. CONTENTS Page Voorwoord 1

Chapter 1Introductio n 3

Part I Chapter 2Th ediabeti cdiet :Patients 'perspective s (submitted) 11 Chapter 3Barrier s experiencedwit h thedie tamon g insulin-treateddiabeti c patients (submitted) 21

Part II Chapter 4Change s in food choiceso f recentlydiagnose d insulin-dependent diabetic patients (submitted) 32 Chapter 5Change s in food choiceso f insulin-dependent diabetic patients:on eyea r follow-up (submitted) 46

Part III Chapter 6Foo d perceptionsan d foodus eo f recently diagnosed insulin-dependentdiabeti c patients (submitted) 57 Chapter 7Difference s infoo dperception san d foodus e between insulin-dependentdiabeti c and non-diabetic subjects (submitted) 68

Chapter 8Genera l discussion 78

Summary 84

Samenvatting 88

Curriculumvita e 92 -1-

Voorwoord

Dei ndi tproefschrif tbeschreve nonderzoeke nmake ndee lui tva nhe t DiabetesProjec tda tsind s198 5word tuitgevoer do pd eVakgroe pHuman e Voedingva nd eLandbouwuniversitei tWageningen .D eLandbouwuniversitei t Wageningene nhe tMinisteri eva nWelzijn ,Volksgezondhei de nCultuu r leverdenaa ndi tonderzoe kfinanciël ebijdragen .I nhe tDiabete sProjec t staatd evraa gcentraal :Wa tbeteken the to mnie tlange rt ekunne nete n waarj ezi ni nhebt ,maa ree ndieetadvie st emoete ngaa nhoude nal sgevol g vanhe tkrijge nva nDiabete sMellitu s(suikerziekte )e ndi tadvie sda gi n daguit ,jaa ri njaa ruit ,t emoete nvolgen ? Vand evel emense ndi ehu nbijdrag ehebbe ngelever daa ndi tproefschrif twi l ikenkele ni nhe tbijzonde rnoemen .I nd eeerst eplaat swi li kmij npromoto r prof.dr .J.G.A.J .Hautvas tbedanke nvoo rzij nenthousiast ebegeleidin gva n hetonderzoe ke nzij nvel ewaardevoll eadvieze no ppraktisc he nwetenschap ­ pelijkgebied ,e nmij nander epromotor ,weliswaa rwa tmee r 'opafstand' , prof.dr .ir .N.G .Rölin gvoo rzij nzinvoll ee ncreatiev einbren gvanui td e voorlichtingskunde.Hu nbereidhei do md emanuscripten ,waa rda noo kte r wereld,kritisc he nzee rsne lva ncommentaa rt evoorzie ne nhe ti nmi j gesteldevertrouwe nhe bi kzee rgewaardeerd . Dedagelijks ebegeleidin gva nhe tonderzoe kwa sgedurend ed eeerst ejare ni n handenva nMw .drs .J.M.P .Edema .Haa rwi li kdan kzegge nvoo rhaa r kritischekanttekeninge ne nvoo rhe tzee rnauwkeuri gdoorleze nva nd e manuscripten. Graagwi li koo kdr .Magdalen aKrond lnoeme ndi emi jtijden smij n verblijfaa nd euniversitei tva nToront ova n1983-198 5z oenthousias thaa r ideeënove rhe tonderzoe knaa rvoedingsgewoonte nbijbracht ,da ti ka lgau w gefascineerd raaktedoo rdi ttyp eresearch .Tijden she tuitvoere nva nhe t DiabetesProjec the bi kno gvaa kaa nonz ediscussie sgedach te ne rmij n voordeelme egedaan .Thank ss omuch . Vand ebegeleidingscommissi ebe ni ki nhe tbijzonde rdr .Fran sva nde r Horstzee rerkentelij kvoo rzij nnuttig esuggesties . Hetmees tintensie fhe bi ksamengewerk tme tRolan dFriele .Same nhebbe nw e hetDiabete sProjec topgeze te nuitgevoerd .Me tvee lplezie rden ki kteru g aanonz eurenlang ediscussie sove rhe tonderzoe ke nander ezaken .I khe b grotewaarderin gvoo rvoo rzij ncreatiev eideeën ,enthousiasm ee n gezelligheid.Vee lsucce swen si khe mto ebi jhe tschrijve nva nzij n proefschrift. Eenaanta lander emedewerker sva nd eVakgroe pHuman eVoedin gdroe goo k hunsteentj ebi jaa ndi tonderzoek :Kee sd eGraa fi nd evor mva nwaardevo l commentaaro ptwe eva nd emanuscripten ;Ja nBurem adoo rhe tlevere nva n statistischeadvieze ne nAde lde nHarto gdoo rzij nbetrokkenhei dbi jhe t wele nwe eva nhe tonderzoek . Essentieelwa sd emedewerkin gva nd eDiabete sVerenigin gNederlan d (DVN),di ehaa rledenbestan dte rbeschikkin gsteld evoo rdi tonderzoe ke n hetbestuu rva nd eDV Ni nd eregi oEde-Wageningen ,da tregelmati gtij dvri j maakteo mo pdrukk ebestuursvergaderinge nove rhe tonderzoe kt eprate ne n velebruikbar esuggestie sdeed .Apart evermeldin gverdiene nuiteraar dall e deelnemerse ndeelneemster saa ndi tonderzoek .Zonde rhu ntoegewijd e medewerkingzo uhe tDiabete sProjec tonmogelij kzij ngeweest .Alle nhee l hartelijkbedankt . Bijd everzamelin ge nverwerkin gva nd egegeven sspeelde nvele nee nrol . JaapjeNooy-Michel sna mee ngroo tdee lva nd einterview svoo rhaa rrekenin g endee ddi tuiters tnauwkeurig .Mariett aEimers ,In eHalverkam pe nJaco bva n Klaverenorganiseerde nd ecomputerverwerkin gva nd egegeven se nvoerde n nauwgezetvel eberekeninge nuit .Oo kleverd eee naanta ldoktoraalstudente n enstagiaire sbelangrijk ebijdrage naa nhe tonderzoek .He nwi li kbedanke n voord evaa kinspirerend esamenwerkin ge nconsciëntieus ewijz eva nwerken : JacolienBakker ,Annemiek eva nBerlo-Wijma ,Ensk eGerbrandy ,Jok e Hoogenboom,Carienek eKandou ,Jeann eva nLoon ,Stepha nMeershoek ,Harrie t Ordelman,Rit ad eVries ,Petr ava nWezel ,Margrie td eWinke le nIngri d Wijtten. Praktischeondersteunin gi sbi jiede ronderzoe kva nwezenlij kbelang .Pie t Middelburge nMarce lva nLeutere nwi li kgraa gdan kzegge nvoo rhu nhul pbi j definanciël ee npraktisch ekante nva nhe tonderzoek ,Sjoeki eKroes-Li e voorhe topzoeke nva nliteratuur .Bab ste nHage nontwier pd eomsla gva ndi t proefschrift.Cole tBroekmeije re nKari nHum ebe ni kzee rerkentelij kvoo r hetcorrigere nva nd eEngels etekste ne nd emedewerkers/ster sva nhe t secretariaatva nd eVakgroe pHuman eVoeding ,me tnam eBianc aDijksterhuis , voorhe tz ozorgvuldi guittype nva ndi tproefschrift . Tenslottewi li kmij nouder sbedanken ,di emi jstimuleerde nee n wetenschappelijkestudi et evoltooie ne nmij neige nwe gt ezoeke ni nhe t leven,e nChris ,mij ngrot esteu ne ntoeverlaa tgedurend edez ejaren .

Maart198 9 AnjaNiewin d -3-

1 Introduction

1.1.Genera l

Changing food choiceso fpopulation si norde rt oimprov e foodus ei scurrentl y a major issue inpreventiv emedicine. I ti srecognize d that foodchoice sar e difficultt ochang e inpopulation swit hhealth-relate d problems treated with medically prescribed diets.I ti seve nmor edifficul tfo rth egenera l populationt ochang e food choicesi norde rt oimprov ehealt h status (1-3). TheDiabete s Projectwa sstarte d in198 5a tth eDepartmen to fHuma nNutrition , WageningenAgricultura l Universityt oinvestigat eth efoo d choiceso fa population requiredt ochang e their foodchoice sfo rhealth-relate d reasons. Forou rstud ypopulatio nw echos ediabeti c patients.Diabeti c patientsar e requiredt ochang e their foodchoices ,a spar to fthei rdiabeti c regimen.Th e constraints thesepatient sexperienc ewil l revealth epossibilitie san d impossibilitieso fchangin g foodchoices .Th eresult so fthi s study,wil l yield somealternativ e approachest ochang e food choiceso fth egenera l public.

1.2.Diabete sMellitu s

DiabetesMellitu si sa heterogeneou smetaboli c diseasewit h profound nutritional implications.Diabeti c patientshav ea defici to finsuli n utilization.Accordin gt oth edegre eo fthi sdeficit ,tw otype so fdiabete s canb edistinguished : insulin-dependentdiabete san dnon-insuli n dependent diabetes. Thetw otype so fdiabete sar edifferentiate db yetiology ,ag eo fonset , prognosisan dtherapy . Insulin-dependentdiabete si scharacterize db ya sever e lacko finsuli nproduction ,i tstart sa ta nearl yage ,an daffect sth ebod y fora lon g time.Non-insuli ndependen tdiabete susuall y startsa ta late rage , butit sprevalenc e exceeds thato finsulin-dependen tdiabete s (4). Untreated diabeteswil l causebloo d glucose levelst oincreas ewel l above1 0 mmol/1, leadingt oketoacidosis .Currently ,diabete smanagemen tha sprogresse d beyondmerel y surviving .Th eemphasi sno wlie so nincreasin g longevityan dpreventin gth elong-ter m complicationso fdiabetes ,whic h especially affectth ebloo dvessel san dnerves .Metaboli c derangements associatedwit hpoo rglycémi econtro lar ea majo r determinanto fth efrequenc y and severityo fthes e complications.Thi sha sbee nth erational e forcurren t attempts tomaintai nnear-norma l glycemia inpatient swit hdiabete s (5,6). Toacquir e near-normal glycemia,consistenc y inth e timingo fmeal san d appropriate food choices togetherwit h regular activity and insulin injections areo fparamoun t importance for insulin-dependentdiabetics .Fo r non-insulin-dependent diabetic patientsmetaboli c controlma yb e achievedwit h proper food selection,weigh t lossan dphysica l exercise,sometime s combined with theus e ofora lhypoglycemi cagents .I nbot htype so fdiabete s thedie t hasbee n recognized asa nessentia l element inbot h themanagemen t ofdiabete s and inminimizin g the risko fdevelopin g long-termcomplications .

1.3.Dietar y recommendations

Nutritional recommendations fordiabeti c patientsar e still controversial (7-13). It isagree d that theenerg y contento f thedie t should result in achieving andmaintainin g adesirabl ebod yweight .-ric h diets will improvemetaboli c controlo fdiabeti c patients (14-16), although there is muchcontrovers y regarding theoptima l carbohydrate intake (8,17). Theadvise d amounto f shouldb eu p to50 %o f the totalenerg yintake . Although sucrosewa s forbidden inth ediabeti c diet fora long time,toda y it is recognized thatmodes tamount so f sucrose (upt o 50gram sa day )ar e acceptable,provide d it isuse d incombinatio nwit hothe rnutrient s (18,19). Total fat intake should be restricted toles s than 30-35%o f total energy intake,an d intake should notexcee d 200-300mg/day . Replacement of saturated fatswit hunsaturate d fatsma y slowdow n theprogressio no f atherosclerosis.Th enutritiona l compositiono f thediabeti cdie t is similar toth edie tadvise d for thegenera lpopulatio nb yth eDutc h government (20-21). Currently,mos t insulin-treated diabetic patientshav e learned tous e an exchange system, inwhic h foodsar eexchange d on thebasi so fthei r carbohydrate content.

1.4.Dietar y compliance

Compliancewit h thediabeti cdie t islow .I ti ssuggeste d thatonl yhal f of thediabeti c patients complywit h theirdietar y regimens,althoug hmeasurin g dietary compliance isver ydifficul t (22-24). -5-

Studieshav epointe d outth edie ta s themos tdifficul t aspecto f the diabetic regimen (25-30). To increasedietar yadherence ,McCau le t al. suggested identifying thebarrier sdiabeti c patients experiencewit h thedie t(30) .

1.5. Food choices

Untilver y recently, the studyo f foodchoice swa smainl y carried outb y social anthropologists. In recentyear s sociologistshav eals odisplaye d an interest inthi ssubject .Bot hsocia lanthropologist san d sociologistswen t from theassumptio n thatther e isa culturalbasi s for food choices(31) . Despite the structural approach inth e1970' s (32)an d themor epractica l or materialistic approach of the1980' s (33,34), there islittl e explicit theoretical discussion on theapproac h tob euse db y social scientists inth e studyo f foodchoices . Amongnutritionist s there isconsensu s thatmor e knowledge is required about the factors influencing food choices inorde r toacquir edesire d changes in food habits.Nutritionist sworkin g inthi s fieldhav ebee n focusingmor e on doing research thano n thedevelopmen t ofa theoretical approach to investigate food choices.Th emos t comprehensive theoryo n food choicesbase d onempirica l studieswa sdevelope db yKrond lan d co-workers (35,36). According toKrond l thebasi c requirement for foodchoice s isa navailabl e food supply. Inothe rwords ,ther emus tb e foodaccessibility , and thisdepend so na complex social system. Limited foodacces swil l reducediversit y in foodus e and decrease the chance ofa nutritionall ybalance d diet.Foo d abundancewil l increase the risk ofexcessiv eus eo f some food components.Acces s toa food will allowa perso n theopportunit y totaste ,evaluat ean d then toaccep t or rejecta food.Thi sproces s of choosing foodsprecede sactua l food consumption. Food choice isinfluence d by learnedmotive swhic h arebase d on liking fora food,emotiona l response toth e foodo r factual knowledge about it. Identifiedmotive sare :taste ,perceive d health,convenience , familiarity, prestige and tolerance.Tast e andhealt hhav ebee n shown tob e themos t importantmotive s influencing food choices (35-40). Most studiesb yKrond l and co-workerswer e carried outamon ghealth yan d elderlypopulations ,wh ower e not restricted inthei r food choices.The ydi d not investigate food choiceso f subjectswit hmedicall y prescribed dietsno rdi d they carryou tan y studyo n theproces so f changing foodchoices . 1.6.Objective so f theprojec t

Food choicesar edifficul t tochange .O n thebasi so f the literature we assumed that recentlydiagnose d diabetic patientswoul d change their food choices in response toth ediagnosi so f thediseas e and the concurrent dietary guidelines.However ,a scomplianc e islo wan d changing food choices is difficult, itwa sexpecte d thatpatient swoul d experience barriers,whe n changing food choices,woul d onlyb eabl e tochang e their foodchoice s toa certainexten tan dwoul d likelyb eunabl e tomaintai n these changesove ra longer period of time.Dietar ybarrier sar e assumed tob e responsible for low dietary compliance.Therefore ,w e studiedho wpatient s copewit h these barriers andwhethe r thesebarrier swoul d cause them todeviat e from the diabeticdiet . More insight inthi sproces s isnecessar y to improve theproces s of changing food choiceso fdiabeti cpatients . The specific objectiveso f theDiabete s Projectwere : A. to identify thebarrier s that insulin-treated diabetic patients experience with theirdiets ; B. toasses s changes in food choiceso f recentlydiagnose d insulin-dependent diabeticpatients ; C. to investigate the foodchoic emotive so f recentlydiagnose d insulin-dependentdiabeti cpatients ; D. toassess thechang e indietar ybarrier s among recently diagnosed insulin-dependent diabeticpatients ; E. tocompar ebarrier sexperience d bydiabeti c patientswit hdifferen t types of treatment; F. to identify theway sdiabeti c patients copewit h thesebarriers .

This thesis isa discussio no f the first three objectives.Th e other three objectives aredeal twit h ina separatethesis .

1.7.Desig no f the study

Thebarrier sdiabeti c patientsexperienc ewit h theirdiet swer e identified by means ofqualitativ e andquantitativ e cross-sectional studies.A s theai mo f theDiabete s Project included anassessmen t of the changes indietar ybarrier s and food choices,w e carried outa study inwhic hw e collected information on food choicemotive san d onchange s indietar ybarrier san d food choiceswhic h -7-

had occured during the firstyear s after thediagnosi s ofdiabete s from recently diagnosed insulin-dependent diabetic patients.A more uniform treatment and easier accessibility ledu s to thedecisio n to select insulin-dependent diabetics above non-insulin-dependent diabetics.I n this study the sameparticipant s were interviewed several times about their food choices. A limitation of this type of studymigh t be that the sample could be more selective than is ingenerall y true for cross-sectional studies,especiall y in case ofa low response rate.Wit h this inmind ,w e tried toobtai n ahig h rate of response.Anothe r concern relates toth epossibl e sensitizing of the subjects.Th e interviewmigh t cause patients tobecom emor e aware of their dietary barriers and food choices,wit h the subsequent chance ofa change in behavior.Unfortunatel y there isno tmuc h tob edon e topreven t this.W e tried tominimiz e thiseffec t by carrying out the interviews in thehome s of the participants, so thatparticipant s would notmee t and exchange experiences. Furthermore, interviewers were expressly instructed and trained to abstain from giving any typeo fdietar y advice,an d fromexpressin g value judgements about participants' food choices.

1.8. Subjects

The selection of subjectspresente d uswit h several problems.Firs t of all there isn o registration ofdiabeti c patients in theNetherlands . Selecting respondents throughmedica l specialists and/or hospitals has several disadvantages. TheDepartmen t ofHuma nNutritio n isno t affiliated with any medical institution. Therefore, sampling ofpatient s through hospitals is dependent on the recruitment process carried outb y themedica l specialists and thusbeyon d our control.Recruitmen t of respondents via medical specialists,ma y get respondents the impression thatpurpos e of the study would be to 'control'them . Besides,non-insulin-dependen t diabetic patients are rarely treated bya medica l specialist. In this studyw e recruited our subjects largely through theDutc h Diabetes Association. TheDutc h DiabetesAssociatio n has 38,000members ,80-90 % of which is insulin-treated (41).Th e total number of insulin-treated diabetics in theNetherland s isapproximatel y 100,000.I t isknow n thatmos t patients who have been diagnosed as insulin-dependent, arebein g advised by medical personnel to join the organization.A n increasing percentage of the patients cancel theirmembership s after a fewyears .Thi s suggests that any particular member of theDutc hDiabete sAssociatio nma ywel l bea relatively recently diagnoseddiabetic . Patients joining theDutc hDiabete sAssociatio nma yb emor e interested in their disease.I t isknow n thatmember so f theDutc hDiabete sAssociatio n have more knowledge about theirdisease ,ar ebette r educated thannon-members ,an d that femalemember s outnumbermal emember s(42) . In lighto f thepurpos e ofth eProject ,recruitmen to f insulin-dependent subjects through theDutc hDiabete sAssociatio nwa sconsidere d themos t appropriate. Thedatabas e of theDutc hDiabete sAssociatio n contains onlya small fraction of thenon-insulin-dependen t diabeticpatient s inth eNetherlands .Therefore , non-insulin-dependentdiabeti cpatient swer e recruited throughdietitians .

1.9. Outline of this thesis

This thesis consists of threeparts . Part I (chapters 2an d 3)identifie s thebarrier s insulin-dependent diabetic patientsexperienc ewit h theirdiets .Chapte r 2present s the resultso fa qualitative study, inwhic h insulin-treated diabetic patientsdescrib e these barriers.Chapte r 3i sa nassessmen t of theprevalenc e of thebarrier s identified inth epreviou sstud yamon g 540insulin-treate d diabeticsubjects . The changes infoo d choicesamon g recentlydiagnose d insulin-dependent diabetic patientsar e the topico fpar t II (chapters 4an d 5). Chapter 4 compares food choicesbefor ean d shortlyafte r thediagnosi so fdiabetes . Chapter 5present s the resultso fa on eyea r follow-up studyo n the changes in food choiceso f thispopulation . Food choicemotive san d their relationship to foodus e are thetopi c ofpar t III (chapters6 an d 7). The foodchoic emotive san d foodus eo f insulin-dependent diabetic patientsar edescribe d inchapte r 6.Difference s in food choicemotive san d foodus ebetwee ndiabeti can dnon-diabeti c subjects aredeal twit h inchapte r 7. The eighth and lastchapte r isa generaldiscussio n of the studies presented inthi sthesis .

References

1. Ministerieva nWelzijn ,Volksgezondhei d enCultuur :Not a Voedingsbeleid. 'sGravenhage ,1984-1987 . 2. World HealthOrganisation :Target s forHealt h forAll .WHO-Copenhagen , 1985. -9-

3. NationaleRaa dvoo rLandbouwkundi gOnderzoe k (NRLO):Meerjarenpla n LandbouwkundigOnderzoe k1987-1991 .' sGravenhage ,1986 . 4. Alberti,K.G.M.M. ,Krall ,L.P. :Th eDiabete sAnnual/1 .Amsterdam , Elsevier,1985 . 5. Gerich,J.E. :Insulin-dependen tdiabete smellitus :Pathophysiology .May o ClinPro c61 :787-791 ,1986 . 6. Clements,R.S. :Ne wtherapie sfo rth echroni ccomplication so folde r diabeticpatients .A mJ Me d80 :54-60 ,1986 . 7. Wood,F.C. ,Bierman ,E.L. :I sdie tth ecornerston ei nmanagemen to f diabetes?Ne wEn gJ Me d Nov.6 :1224-1226 ,1986 . 8. Reaven,G.M. :Ho whig hth ecarbohydrate ?Diabetologi a19 :409-413 ,1980 . 9. Mann,J.I. :Die tan ddiabetes .Diabetologi a18 :89-95 ,1980 . 10.Mann ,J. :Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J A mCol lNut r5 :1-7 ,1986 . 11.Crapo ,P.A. :Carbohydrat ei nth ediabeti cdiet .J A mCol lNut r5 :31-43 , 1986. 12.America nDiabete sAssociation :Nutritiona lrecommendation san dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 :126-132 , 1987. 13.Nuttal ,F.Q. :Th ehigh-carbohydrat edie ti ndiabete smanagement .Ad vInter n Med33 :165-184 ,1988 . 14.Jenkins ,D.J.A. ,Taylor ,R.H. ,Wolever ,T.M.S. :Th ediabeti cdiet ,dietar y carbohydratean ddifference si ndigestibility .Diabetologi a23 :477-484 , 1982. 15.Simpson ,H.C.R. :High-carbohydrate ,high-fibr ediet sfo rdiabetics .Pro c NutrSo c40 :219-225 ,1981 . 16.Anderson ,J.W. ,Gustafson ,N.J. ,Bryant ,CA . Tietyen-Clark,J. :Dietar y fiberan ddiabetes :A comprehensiv erevie wan dpractica lapplication .J A m DietAsso c87 :1189-1197 ,1987 . 17.America nDiabete sAssociation :Glycémi eeffect so fcarbohydrates . DiabetesCar e7 :607-608 ,1984 . 18.Mann ,J.I. :Simpl esugar san ddiabetes .Diabeti cMedicin e44 :135-139 , 1987. 19.Peterson ,D.B. ,Lambert ,J. ,Gerring ,S. ,Darling ,P. ,Carter ,R.D. , Jelfs,R. ,Mann ,J.I. :Sucros ei nth edie to fdiabeti cpatient s- jus t anothercarbohydrate ?Diabetologi a29 :216-220 ,1986 . 20.Voedingsraad :Advie sRichtlijne nGoed eVoeding .De nHaag ,1986 . 21.Heine ,R.J. ,Schouten ,J.A. :He tdiabetesdieet :Nie tander sda nvoedin g voorgezond emensen .Ne dTijdsch rGeneesk d128 :1524-1528 ,1984 . 22.West ,K.M. :Die ttherap yo fdiabetes :A nanalysi so ffailure .An nInter n Med79 :425-434 ,1973 . 23.Christensen ,N.K. ,Terry ,R.D. ,Wyatt ,S. ,Pichert ,J.W. ,Lorenz ,R.A .: Quantitativeassessmen to fdietar yadherenc ei npatient swit h insulin-dependentdiabete smellitus .Diabete sCar e6 :245-250 ,1983 . 24.Glanz ,K. :Nutritio neducatio nfo rris kfacto rreductio nan dpatien t education:A review.Pre vMe d14 :721-752 ,1985 . 25.Lockwood ,D. ,Frey ,M.L. ,Gladish ,N.A. ,Hiss ,R.G. :Th ebigges tproble m indiabetes .Th eDiabete sEducato r12 :30-33 ,1986 . 26.Glasgow ,R.E. ,McCaul ,K.D. ,Schäfer ,L.C. :Barrier st oregim eadherenc e amongperson swit hinsulin-dependen tdiabetes .J Beha vMe d9 :65-77 ,1986 . 27.Jenny ,J.L. :A compariso no ffou rag egroups 'adaptatio nt odiabetes .Ca n JPubli cHealt h75 :237-244 ,1984 . 28.Jenny ,J.L. :Difference si nadaptatio nt odiabete sbetwee n insulin-dependentan dnon-insulin-dependen tpatients :Implication sfo r patientseducation .Patien tEdu cCounse l8 :39-50 ,1986 . 29.Ary ,D.V. ,Toobert ,D. ,Wilson ,W. ,Glasgow ,R.E. :Patien tperspectiv eo n factorscontributin gt ononadherenc et odiabete sregimen .Diabete sCar e9 : 168-172,1986 . -10-

30.McCaul ,K.D. ,Glasgow ,R.E. ,Schafer ,L.C. :Diabete sregime nbehaviors . MedCar e25 :868-881 ,1987 . 31.Murcott ,A. :Sociologica lan dsocia lanthropologica lapproache st ofoo d andeating .Wl dRe vNut rDie t55 :1-40 ,1988 . 32.Douglas ,M. :Implici tMeanings .Essay si nAnthropology .London ,Routledg e &Kega nPaul ,1975 . 33.Harris ,M. :Goo dt oEat .Riddle so fFoo dan dCulture .London ,Alle n& Unwin,1986 . 34.Mennell ,S. :Al lManner so fFood .Eatin gan dTast ei nEnglan dan dFranc e fromth eMiddl eAge st oth ePresent .Oxford ,Basi lBlackwel lLtd ,1985 . 35.Krondl ,M.M. ,Lau ,D. :Foo dhabi tmodificatio na sa publi chealt hmeasure . CanJ Publi cHealt h69 :39-43 ,1978 . 36.Krondl ,M. ,Coleman ,P. :Socia lan dbiocultura ldeterminant so ffoo d selection.Pro gFoo dNut rScienc e10 ,179-203 ,1986 . 37.Zimmerman ,S.A. ,Krondl ,M.M. :Perceive dintoleranc eo fvegetable samon g theelderly .J A mDie tAsso c86 :1047-1051 ,1986 . 38.George ,R.S. ,Krondl ,M. :Perception san dfoo dus eo fadolescen tboy san d girls.Nutritio nan dBehavio r1 :115-125 ,1983 . 39.Krondl ,M. ,Lau ,D. ,Yurkiw ,M.A. ,Coleman ,P.H. :Foo dus ean dperceive d foodmeaning so fth eelderly .J A mDie tAsso c80 ,523-529 ,1982 . 40.Reaburn ,J.A. ,Krondl ,M. ,Lau ,D. :Socia ldeterminant si nfoo dselection . JA mDie tAsso c74 :637-641 ,1979 . 41.Pennings-va nde rEerden ,L. :Probleme ne nOplossinge nva nAdolescente nme t DiabetesMellitus .Utrecht :Rijksuniversitei tUtrecht ,1986 . 42.Visser ,A .Ph. ,va nd eBoogaard ,P.R.F. ,va nde rVeen ,E.A. :Participati e vandiabeten .Medisc hContac t40 :1502-1504 ,1985 . -11-

2 The diabetic diet: Patients' perspectives

byA.C .Niewind ,R.D .Friele ,J.M.P .Edema ,J.G.A.J .Hautvas t& N.G .Rölin g

ABSTRACT

Theai mo fthi s studywa st oidentif y thebarrier s that insulin-treated diabetic patients experience withth ediabeti c diet.Dat awer e collectedb y meanso fa semi-structure d questionnaire,i nwhic h respondents were requested todescrib e thebarrier s theyha dencountere d with thediabeti c diet.Thes e respondentswer e10 4insulin-treate d diabetic patients,al lmember so fth e Dutch DiabetesAssociation . Theymentione d atota lo f54 2barrier swhic h were classified into1 0mai n categoriesan d3 7subcategories .Result s show that only parto fth ebarrier sar edirectl y related toth erequirement s setb yth e diabetic diet.Man ybarrier sar edu et oth epatient' s stricto reve n incorrect interpretationo fth erequirement sa sse tb yth ediabeti c dieto rt oinabilit y toadap tth edietar y guidelines tohis/he row nhedonic , socialan dbodil y needs.Dietar y counsellors should discuss these barrierswit h their patients. Special attention shouldb epai dt oth epatients ' interpretations ofth e principles ofth ediabeti cdiet .

INTRODUCTION

To insulin-treated diabetic patientsa die t isessentia l inth emanagemen to f their disease.Th eai mo fthi sdie t istwofold . First,a distributio n ofth e carbohydrate intake toachiev ea fla tan dmedicall y adequate profileo fbloo d sugar levels.Second ,a reduction infa tconsumptio n toslo wdow nan y developmentan dprogressio no flong-ter m complications. Therefore, thisdie t requireso fth epatien t consistency inth etimin go f ,a swel la sconsistenc y inth eamoun to fcarbohydrate s consumed with eachmeal . Inadditio n itprescribe s appropriate food choices according toth e nutritional recommendations fordiabetic s (1-4). Current recommendations includea carbohydrat e intakeo fove r 50%o fth etota l energy intake.Tota l fat intake shouldb erestricte d toles s than35 %o ftota l energy intake,whil e saturated fats shouldb ereplace db yunsaturate d fats.Cholestero l intake shouldb erestricte d aswell .Th edie t ist ob eadapte d toth eindividua l according topersona l preference andinsuli n regimen.Fo ra lon g time,th eus e of sucrosewa sprohibite d inth ediabeti c diet,bu ttoda ymodes t amountso f -12-

sucrosear e allowed,provide d that thepatien tdiscount s iti nhis/he rdiet . Some caution isi norde rwit h respect toth eus e ofalcohol ,sinc ealcoho l is a hypoglycemic agent.Finally , the total energy intake should be such that it will achieve ormaintai na desirabl ebod yweigth . Most studieshav e shownlo wcomplianc ewit h thediabeti c regimen,especiall y with thediabeti c diet.I ti sestimate d thatonl yabou thal f of thediabeti c patients comply sufficientlywit h theirdietar y regimen (5-7). Studieshav e pointed out thedie ta sth emos tdifficul taspec to f thediabeti c regimen (8,9-13).A varietyo f reasons fornon-complianc ewit h thediabeti cdie thav e been identified forbot h insulin-treated andnon-insulin-treate d diabetic patients.Thes ema yb epsycho-social ,feeling so fhunger ,certai n food preferences, special occasions,lac k ofmateria l resources,lac k of understanding of thedie tan d otherpeopl e offering inappropriate foods (9,14-17). To increase adherence toth edie tMcCau l et al. (18)hav e suggested to identify thebarrier sdiabeti c patients experiencewit h theirdiets .Th e objective ofou r studywa s toidentif y thesebarriers .

METHODS

Design Thedesig no f the studywa sa cross-sectiona l oneusin ga sample of insulin-treated diabetic patients.A largenumbe r of subjectswa s required in order to identifyal lbarrier s experienced by thediabeti c patients.Sinc e the purpose of this studywa s toacquir ea novervie wo f thesebarriers ,a convenience sample seemedsuitable . We developed aquestionnair e inwhic hw e asked respondents todescrib e the barriers theyha d encountered asa resulto f theirdiets .A serieso f open interviewswit hdiabeti c patients onthei r experiencesha d shownbarrier s to bepartl y resulting from the requirements setb y thediet ,suc ha seatin g regular mealsan d snacksan d consistency inth e intake of carbohydrateswit h eachmeal .Wit h thisobservatio n inmin d a systemwa sdevelope d inwhic h all barriers couldb e classifiedwit hminima l ambiquity.Thi ssyste mwa s developed by the first twoauthors .A s the codingo f suchdat a tendst ob e susceptible to subjective interpretation, two independent judgescode d all barriers according toth ecategorizatio n system. Inter-codersconcurrenc e was calculatedusin g Kappa-value (K). K=0.78 indicating that the concurrence exceedsb y 78%tha t tob eexpecte d onth ebasi so fpur e chance(19) . -13-

Questionnaire Thedevelopmen t of thequestionnair ewen t through several stages.I n its final form itha dbecom e a semi-structured questionnaire.O neac hpag e the respondentswa s asked toimagin e certain situationsan d aspects of the dietary regimen thatmigh t be felta sa barrier .Next ,respondent swer e invited to describe their ownexperiences .Th e following suggestionswer emade : situationsa thome ;work ,schoo lo rmeetings ;sports ,partie so rholidays ; tripso rvacation .Furthermore ,w e asked forcertai n foods thatha d been prescribed orprohibited ; the regularityo feating ;th eamoun t of foods that theywer e required toeat ;an dabou tbein ghungry . Finally,w e asked them to mention situations thatha d occurreddurin g thepas tweek . During thedevelopmen t of thequestionnair e itbecam eapparen t that some respondentsdislike d the ideao fwritin g down thebarrier s encountered with thediabeti c diet.Instea d theypreferre d tob e interviewed.Therefore ,w e decided tooffe r theoptio no fa n interviewt ob e conducted byon e of the first twoauthors .Th e introduction of thisoptio npresente d the complication ofhavin g toappl y twodifferen tmethod s indat a collection. Inorde r to minimize differences in responsedu e tomethodologica ldifferences , respondentswer e interviewedwhil ephrasin g the samequestion s from the questionnaire,onl yaskin g for clarificationwhe n theanswer swer eunclear .

Population A sample ofdiabeti cpatient swa s recruited from thepatien tmember s of the DutchDiabetes Associatio n (DDA).Thi sassociatio nha s38.00 0patien tmembers , ofwhic h 80-90% are insulin-treated.A sampleo f 70-75person swa s considered adequate for thepurpos e of thisstudy .W e expected anon-respons e of about 40% (20)an dwen t from theassumptio n that10 %woul d be non-insulin-treated diabetics (21).Thu sa total sample of 153person swit hdiabete sbetwee n the ageso f 20an d 65wa s randomly selected fromth eDDA-database .Fo r logistical reasons the samplewa s restricted toth e regiono fWageningen .T o guarantee the respondentsanonymity ,al lmai lwa shandle db y themailin g department of theDDA . Inadditio n toth equestionnair e themai l contained a card stating thata n interviewwoul d bepossibl e asa nalternativ e towritin gdow n the diet-related barriers.A pre-stampedenvelop ewa s enclosed for returno f the questionnaire or card. Studieshav e indicated that three tofou r follow-upso r reminders increase the response rate (22,23).Therefore ,tw oweek s after thedat e ofmailin gw e sent -14-

a letter toal l respondents reminding themo f thequestionnaire .Afte r six weeksa follow-uplette rwit ha nextr aquestionnair ewa s forwarded toeac h non-respondent,agai n followed twoweek s laterb ya reminder.T o thosewh odi d not respond toan yo f these four letters,anothe r letterwa s sent together with a reply-card onwhic hw easke d them tostat e the reason(s)wh y theydi d notwis h toparticipat e inth e study.Respondent s could indicateon e ormor e reasons suchas :n oproblem swit h thediet ,lac k of timeo rn o interest in participation.

RESULTS

We received a response from13 7ou to f 153diabeti c patients,o r 90%.O f these,10 4wer e insulin-treated diabetic patientsan dw e included allo f them inth e study. 33 respondents couldno tparticipat e fora variet yo f reasons: twoo f themdi d nothav ediabete swhil e sixha dnon-insulin-treate d diabetes. Furthermore,fou r respondents indicated that theywer e too illt oparticipat e and threeperson sha d diedbefor e thequestionnair e had reached them.Tw o respondents hadmove d and 16 informedu s that they refused toparticipat e in the study.Th e typeo f responsewa sa s follows:72 %returne d the questionnaire,18 %wer e interviewed and 10%o f the respondents returned the reply-card.O n the card theyha d eitherdescribe d one ormor ebarrier so r indicated nobarrier swit h thediabeti c diet.Tabl e 1describe s the characteristics of the 104 insulin-treated diabeticsparticipatin g inth e study.

Table 1.Subjects 'Characteristics .

Demographic variables N %

Sex: male 50 48 female 53 51 unknown 1 1

Age: 20-40 55 53 41-65 44 42 unknown 5 5

Durationo fdiabetes : <1 0year s 45 43 > 10year s 51 49 unknown 8 8 -15-

Seventy-sixo f10 4insulin-treate dpatient s(73% )reporte da tota lo f54 2 barriers,rangin gfro m1 t o3 7barrier spe rrespondent .Twenty-eigh tpatient s (27%)reporte dt oexperienc en obarrier swit hthei rdiets .Th edescription so f thebarrier swer eclassifie dint o1 0mai ncategorie swi t3 7subcategories .Th e maincategorie shav ebee nliste di nTabl e2 togethe rwit hth efrequenc ythe y werementione dt oindicat ethei rrelativ eprevalence .

Table2 .Barrier sExperience dwit hth eDiabeti cDie t(1) .

MainCategor y N

1.Barrier sa sa consequenc eo frequire dregularit yo featin g 81 2.Genera lrestriction si nth eamoun tan dtyp eo ffood s 77 3.Restriction si nth eus eo fspecifi cfood s 68 4.Restriction swit hregar dt odiabeti cspecialit yfood s 61 5.Lac ko fdietar yvariet y 11 6.Barrier swit heatin gan ddrinkin gi nsocia lsituation s 59 7.Reaction sfro mother si nsocia lsituation s 75 8.Feeling so fhunge ro rsurfei t 42 9.Disruptio no fnorma lroutine/specia levent s 29 10.Genera lbarrier s 39 Total 542

(1)1*=10 4insulin-treate ddiabeti cpatients .

Maincategor y1 wa sth elargest .Thi scategor ycomprise sbarrier sexperience d asa resul to fth ediet' srequiremen to fregula reatin gan dsnacking . Maincategorie s2- 5 relatet obarrie rdiabeti cpatient sexperience dregardin g theus eo ffoods ,coverin g40 %o fal lbarrier smentioned .Thes ewer edivide d into4 mai ncategorie saccordin gt oth enatur eo fth ementione dfoo ditems . Maincategor y2 list sgenera lrestriction sa st otyp ean dquantit yo ffood s feltt ob eprescribe do rprohibited .Fo rexample ,patient sindicate dbein g unablet oea twhateve rthe ypreferre do rbein gunsur eabou tth eamoun to ffoo d allowed.Furthermore ,thi scategor yinclude sbarrier swhic haros eafte rth e patientha dneglecte dth edietar yguidelines ,barrier swhic hrange dfro m feelingso fguil tt ofeeling so fbodil ydiscomfort .Mai ncategor y3 describe s barriersfel tbecaus eo fth erestriction si nth eus eo fspecifi cfood ssuc ha s sugaran dsugar-containin gproduct ;food shig hi nstarc hsuc ha spasta ,rice , potatoes,pot-pies ;food swit hhig hfa tconten tsuc ha sbacon ,sausages , meats,sauces ,dressings ,butter ;snack swit hhig hfa tan dhig hsal tcontents ; fruitsan dvegetables ;an dalcoholi cbeverages .Mai ncategor y4 relate st o barriersconcernin gth eus eo fdiabeti cspecialit yfoods .Patient sdescribe d theseproduct sa sexpensive ,unhealthy ,poo ri ntast ean dquality .I nmai n -16-

category 5,th e smallestone ,patient s indicate thatthe ywer eunabl e toea ta variety offoods . Manybarrier s (25%)ar e the resulto f eating insocia l situations.Mai n categories 6an d 7 containbarrier sexperience dwhe n thepatien t ist oadher e to thediabeti cdie t inth epresenc e ofothe rpeople .Mai n category 6 describes thepatient' sdisconten tbein gunabl e toea t thesam e foodso r to eata t the same timewhe nhavin gmeal so rdrink swit h others.Mai n category 7 also concernsbarrier s regarding others.However ,i nthi scategor y barriers occur asa consequence ofothe r people's reaction towards thediabeti c person because ofhi so rhe r special foodhabits .Unpleasan t reactions from others hadbeen :a complete disregard of thediabeti cdie tan d remarkso n the patient'smanagin g of thediet .O n theothe rhan d excessive consideration was alsomentione d asa nunpleasan t reaction. Main category 8consist s ofbarrier s related to feeling ofbodil ydiscomfort . Patientsdescribe d feelings ofhunge r or thirsta ttime swhe nthe y should refrain fromeatin g ordrinking .However ,opposit e feelingswer e also described: namely those of surfeita t timeswhe naccordin g toth ediet ,th e patient ist oea to rdrink . Thebarrier smentione d inmai ncategor y9 aris ewhe nnorma l routine is disrupted, sucha s inunexpecte d situationso r incas e of special events such astrip so rvacations . Finally,mai ncategor y 10describe s somegenera l barriers sucha s the costso f followinga diabeti cdie t and the feeling that thedie t isa constantburden .

DISCUSSION

Up tillno w literaturediscusse d only reasons fordietar ynon-compliance . In this studyw ehav e identified thebarrier s thatth ediabeti c patients experiencewit h theirdiabeti cdiets .Thes ebarrier sar eno t necessarily leading todietar ynon-compliance .Howeve r inthi s study several of the reasons fordietar ynon-complianc e asalread ydescribe d inliterature ,hav e alsobee n identified asbarrier s (9,14-17). Thedie t for insulin-treated diabeticpatient s requires consistency inth e timing ofmeal san d inth eamoun to fcarbohydrate s consumedwit h eachmeal . Furthermore,patient s should lower their fat intake,especiall y of saturated fats.Th ebarrier s reflecting these aspectswhic h are characteristic of the diabeticdie tare ,therefore ,har d toovercome .However ,man yothe r barriers thatpatient s experience areno t typical of thediabeti cdiet . -17-

Manybarrier s seemt ob e connectedwit h theus eo f foods.Thi s shows that patientsma yhol dver y strictan deve n incorrect interpretations of the dietary guidelines.Restriction s inth eus e of foodswit h ahig h starch content or total elimination ofal l surgary foodsar eno t inagreemen twit h or even contrary to the latestnutritiona l recommendations (1-4). These interpretationsma y result inexcessiv e andunnecessar y restrictions inth e use ofpreferre d foodsan dma ydetrac t fromth ehedoni cqualit yo f their diets.Afte r all food isa source ofpleasur e toal lhuman s(24) . Thepatient' s feelingso fbodil ydiscomfor t are ofcritica l importance. Feelings ofhunge r couldb e causedb ya die twhic hdoe sno tmee t the energy requirements of thepatient .Dat a showtha tpatients 'energ yneed sar e frequently underestimated (25).However ,lac k ofadaptio n skillso n the side of thepatient sma y result infeeling so fhunge r or surfeittoo . Patientsals oappea r toexperienc e barrierswit h thediabeti c dietwhe n they eatan ddrin k incompany .Obviously ,diabetic swis h toea t the same foodsan d at the same time asothers .Restriction s tocertai n typesan dquantitie s of foodsan d aeatin g scheduledifferen t fromthei r social environment tend to hinder thediabeti c patients'socia l functioning. Eating issubjec t to certain social rulesan d normsan d anydeviatio n from thesenorm sma yevok e reactions from the social environment.Thos e reactions,althoug h notalway s negatively intended, also forma seto fbarrier s todiabeti cpatients .Thes e barriers might bepartl y liftedwhe npatient shav eachieve d abette r understanding of theprinciple s of thediabeti cdiet .Howeve r barriers resulting froma n eating schedule that isdifferen t from thato f the social environment aremor e difficult to solve.Som ehav e suggested thatpatient s require additional social skills tocop ewit h these situations(9) .

Dietary adherence and thepatient' s feelingo fwell-bein g canb epromote d by awareness on the sideo f thedietar y counsellor and by thedevelopmen t of specific skillso r educational planning tailored to theneed so f the individualpatient . Inligh to f thehig h response,th e resultso f this studyar e considered representative forth egrou po f the insulin-treated patientmember so f the DutchDiabete sAssociatio n between theage so f20-6 5years .I t should be recognized, though,tha tmember so fa patien t organizationma yb emor e concerned about theirdiseas e thannon-members .However ,i nligh to f the purpose of this study,thi s isno t amajo r issue. This study isa qualitativ e onean dw e cannot concludeho wman y patients actually experience the identified barriersan dho w frequently.W e did not -18-

attemptt o investigatewhethe r patientsha d received the latest nutritional recommendations forunsulin-treate d diabetic patients.A sman ypatient sd ono t frequentlyvisi t adietitia n andbecaus e somehav eha ddiabete s for a long period of time itmigh tver ywel l bepossibl e that somepatient s still live according tooutdate d dietaryprescriptions .Thi smigh texplai n someo f our findings. Thebarrier s found inthi s studyar eonl ypartl ya direc t resulto f the obligations imposed by thedietar yguideline s fordiabetics .Thi s suggests thatwit h othermedicall y prescribed dietspatient sexperienc e similar barriersan d that thesebarrier s areonl ypartiall y a reflectiono f the requirements setb y thediet .Thes epatient sma yals opu t excessive restrictions on their food choicesbecaus e of their inability toadap t the diet to their social,hedoni c andbodil yneeds .

Inconclusion ,th e studyoffer sa novervie wo f thebarrier s regarding the diabeticdie ta sexperience d bydiabeti c patients.A proportion of the barriers ischaracteristi c of thediabeti c diet itself.Man ybarrier s are experiencedbecaus eo fpatients 'interpretation so f thediet .Thi s interpretation iseithe r toostric to r incorrect.I naddition ,w e see inability of thepatient s toadap t thedie t tohis/he rbodily , social and hedonicneeds .

ACKNOWLEDGEMENTS

Thisprojec twa s supported by grants from theMinistr yo fWelfare ,Healt han d CulturalAffairs ,Th eHague ,th eNetherlands ,an d from theWageninge n Agricultural University, theNetherlands .Th ehel p from theDutc h Diabetes Association,especiall y fromM r P.va nde rWiel , inth e recruitment of respondents ismos tgratefull y acknowledged,a swel l asassistanc e fromMr s S.K. Kroes-Lie,Mr sJ.C.M.M .Nooy-Michels ,Mr sJ .va n Loonan dMr sH . Ordelman with the categorizationo f thedata .Th eauthor sals oappreciat e comments from DrsM . Krondl and F.va nde rHors to nearlie r versionso f thispaper .

Notes 1.Th equestionnair e isavailabl e fromth eauthor supo n request. -19-

REFERENCES

1.Crapo ,P.A .Carbohydrat ei nth ediabeti cdiet .Journa lo fth eAmerica n Collegeo fNutritio n5 ,31-43 ,1986 . 2.Mann ,J .Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.Journa lo fth eAmerica nColleg eo fNutritio n5 ,1-7 ,1986 . 3.America nDiabete sAssociation .Nutritiona lrecommendation san dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 ,126-132 , 1987. 4.Nationa lInstitute so fHealth .Consensu sdevelopmen tconferenc eo ndie ta d exercisei nnon-insulin-dependen tdiabete smellitus .Diabete sCar e10 , 639-644,1987 . 5.Christensen ,N.K. ,R.D .Terry ,S .Wyatt ,J.W .Picher tan dR.A .Lorenz . Quantitativeassessmen to fdietar yadherenc ei npatient swit h insulin-dependentdiabete smellitus .Diabete sCar e6 ,245-250 ,1983 . 6.West ,K.M .Die ttherap yo fdiabetes :A nanalysi so ffailure .Annal s InternalMedicin e79 ,425-434 ,1973 . 7.Glanz ,K .Nutritio neducatio nfo rris kfacto rreductio nan dpatien t education:A review.Preventiv eMedicin e14 ,721-752 ,1985 . 8.Lockwood ,D. ,M.L .Frey ,N.A .Gladis han dR.G .Hiss .Th ebigges tproble m indiabetes .Th eDiabete sEducato r12 ,30-33 ,1986 . 9.Ary ,D.V. ,D .Toobert ,W .Wilso nan dR.E .Glasgow .Patien tperspectiv eo n factorscontributin gt ononadherenc et odiabete sregimen .Diabete sCar e9 , 168-172,1986 . 10.Jenny ,J.L .A compariso no ffou rag egroups 'adaptatio nt odiabetes . CanadianJourna lo fPubli cHealt h75 ,237-244 ,1984 . 11.Jenny ,J.L .Difference si nadaptatio nt odiabete sbetwee n insulin-dependentan dnon-insulin-dependen tpatients :Implication sfo r patientseducation .Patien tEducatio nan dCounselin g8 ,39-50 ,1986 . 12.House ,W.C. ,L .Pendleto nan dL .Parker .Patients 'versu sphysicians ' attributionso freason sfo rdiabeti cpatients 'noncomplianc ewit hdiet . DiabetesCar e9 ,434 ,1986 . 13.Glasgow ,R.E. ,K.D .McCau lan dL.C .Schäfer .Barrier st oregime nadherenc e amongperson swit hinsulin-dependen tdiabetes .Journa lo fBehaviora l Medicine9 ,65-77 ,1986 . 14.Broussard ,B.A. ,M.A .Bas san dM.Y .Jacksons .Reason sfo rdiabeti cdie t noncomplianceamon gCheroke eindians .Journa lo fNutritio nEducatio n14 , 56-57,1982 . 15.Daschner ,B.K .Problem sperceive db yadult si nadherin gt oa prescribe d diet.Th eDiabete sEducato r12 ,113-115 ,1986 . 16.Lang ,G.C .Diabetic san dhealt hcar ei na Siou xcommunity .Huma n Organization44 ,251-260 ,1985 . 17.Verdonk ,G. ,A .va nde rSchueren ,A .Notte-d eRuyte ran dM.J . Huyghebaert-Deschoolmeester.Moeilijkhede nbi jhe tvolge nva nee n diabetesdieet.Voedin g37 ,611-619 ,1976 . 18.McCaul ,K.D. ,R.E .Glasgo wan dL.C .Schäfer .Diabete sregime nbehaviors . MedicalCar e25 ,868-881 ,1987 . 19.Cohen ,J .A coefficien to fagreemen tfo rnomina lscales .Educationa lan d PsychologicalMeasuremen t20 ,37-46 ,1960 . 20.Peters ,V.A.M .Docente ne nhu nProbleemsituaties .Dissertation ,Nijmegen : KatholiekeUniversitei tNijmegen ,1985 . 21.Pennings-va nde rEerden ,L .Probleme ne nOplossinge nva nAdolescente nme t DiabetesMellitus .Utrecht :Rijksuniversitei tUtrecht ,1986 . 22.Kanuk ,L .an dC .Berenson .Mai lsurvey san drespons erates :A literatur e review.Journa lo fMarketin gResearc h12 ,440-453 ,1975 . 23.Wierdsma ,A.I .an dH.F.L .Garretsen .Gezondheidsenquête :Pe rpos to fo p bezoek?Resultate nva nee nvooronderzoe k inRotterdam .Tijdschrif tSocial e Gezondheidszorg63 ,592-595 ,1985 . -20-

24.Krondl ,M .an dP .Coleman .Socia lan dbiocultura ldeterminant so ffoo d selection.Progres si nFoo dan dNutritio nScienc e10 ,179-203 ,1986 . 25.Lean ,M.E.J ,an dW.P.T .James .Prescriptio no fdiabeti cdiet si nth e 1980s.Th eLancet ,Marc h29 ,723-725 ,1986 . -21-

3 Barriers experienced with the diet among insulin-treated diabetic patients byA.C .Niewind ,R.D .Friele ,J.M.P .Edem a& J.G.A.J .Hautvas t

ABSTRACT

Dietha sbee n identifieda sth emos tdifficul t aspecto fth eregime nfo r diabetic patients.Th eai mo fthi s studywa st odetermin e thenumbe ro f patientsexperiencin g barrierswit hth ediabeti cdie ta swel la st odescrib e the relationshipwit hdemographi can dhealth-relate d variables.W eha d54 0 insulin-treated diabeticpatient s categorize theirpersona l diet experiences into2 2previousl y identifieddie tbarriers .Patient smentione da naverag eo f four barriers.W efoun d thatth enumbe ro fbarrier swer e significantly influencedb yth evariable sbod ymas s index (BMI), levelo feducatio nan dth e prescriptiono fa nadditiona ldie to nto po fth ediabeti c diet.Result shav e shownth ebarrier s resulted frompatients 'incorrec tknowledg ean dvie wo fth e diabetic dietan dthei r inabilityt oadap tth edie tt oindividua l bodily, hedonican dsocia lneeds .Barrier sca nb ereduce db yprescribin g diabetic dietsbase dupo n recentnutritiona l recommendations.Also ,diet swit h fixed energy contents shouldn olonge rb eprescribe d topatient swh od ono tnee dt o loseweight .

INTRODUCTION

The regimenfo rcontrollin g insulin-treated diabetesmellitu s isdifficul tfo r manypatients .Th epatient sar easke d toadministe r insulin,t otes t their blood glucose levels,t oge tregula rexercis ean dt ofollo wa diabeti c diet forth eres to fthei r lives.Thes e activitiesmus tb ecoordinate d inorde rt o complementeac hother .Th epurpos eo fthes e self-careactivitie si st o normalize blood glucose levelsan dt oreduc eth eonse tan daggravatio no f complications causedb yth edisease . Thedie tha sbee npointe dou ta sth emos tdifficul t aspecto fth ediabeti c regimen (1-5),wit hnon-adherenc e beinga prevalen tproble m (6,7). Adherence toa prescribe d diet requireso fth epatien tt olear nth especifi c dietary principles,t ochang epreviou seatin ghabit san dt oreorganiz e dietary activities intoa ne wdail y routine.Recentl yi twa ssuggeste d that identificationo fbarrier s regarding self-care shouldb ehelpfu l towardsth e developmento fspecifi c seIf-managementplan st oovercom e thesebarrier s (8). -22-

Only few studies have identified reasons fordietar y non-compliance or barriers experienced with thediabeti c diet (2,5,9-12). Inou r previous study (9)usin g aqualitativ e methodology,w e identified diet-related barriers among over 100 insulin-treated diabetic patients.Result s showed these barriers to arise asa consequence of the required regularity ineating . Inaddition , patients experience hedonic barriersdu e to restrictions inth equantit y and type of foods.Also ,barrier s are felt in social situations. Furthermore respondents mentioned feelings ofbodil y discomfort such ashunge r and surfeit. Finally, costswer e identified as abarrier . The aim of this studywa s toasses s theprevalenc e of the identified barriers among insulin-treated diabetic patients.

MATERIALSAN D METHODS

Subjects A sample of insulin-treated diabetic patientswa s recruited from the patient members of theDutc h DiabetesAssociatio n (DDA). Individuals between the ages of 20an d 65wer e eligible. Participationwa s restricted to those members having joined the last five years.A sample of 478person swit h diabetes was required based ondifference s of 15%i n frequency of experienced barriers between population segments and allowing aprobabilit y of type Ierro r of 5% and type II error of 10%.Allowin g for 20%non-insulin-treate d members and a non-response rate of 35%,90 4patien t memberswer e randomly selected among the eligible members.

Questionnaire Thequestionnair e consisted of 22diet-relate d items classified into five categories and adapted with respect toth ebarrier s identified inou r previous study (9).Th equestionnair e was tested for comprehensiveness among diabetic patients and experts.Tw o items regarded regularity of eating and one item the barriers thatma y occur when thedail y routine isdisrupted . Four items referred to feelings of bodilydiscomfor t sucha s feeling ill or feelings of and surfeit.On e item related to the costs of thediabeti c diet. Eight items concerned hedonic barriers,suc ha sbein g restricted in the choice of certain foodso rn o longer taking pleasure ineating . Six items referred to social barriers: for instance being anexceptio n incertai n social situations with respect toeatin g anddrinkin g and the social environment interfering with or neglecting thepatient' sdiet . -23-

Patients indicated foreac hbarrie r whether orno t theyexperience d this item asa barrier .N oattemp twa smad e toas k about the frequencyo foccurrenc e as studieshav e shown that frequencyan d severity ratingo fbarrier sar e highly correlated (2,13). Furthermorevariable s sucha sage ,sex ,bod ymas s index (BMI), levelo f education,duratio no fdiabete san d anydiet(s )i nadditio n to thediabeti c dietwer e assessed,a swel l asth e frequency of insulinadministratio n ando f selfbloo d glucosemonitorin g (SBGM).

Data collection All 904diabeti c patients received a letter explaining the study, together with thequestionnair e anda pre-stampe denvelop e for returno f the questionnaire. Inaddition ,a car dwa s included tob e returned incas e the individualwoul d beunabl e orunwillin g toparticipate .T o guarantee respondents'anonymit yal lmai lwa shandle d by themailin gdepartmen t of the DEJA. To increase the response ratew e senta reminder threean d eightweek safte r thequestionnair e had beenmaile d toal l respondents.I nadditio n theDD Apu t anannouncemen t in itsnewslette r regarding the studyan durgin g itsmember s toparticipate .

Analysis Datawer e analyzedusin g procedures fromth eSPSS/PC +statistica lpackage . Frequencieswer euse d toasse sth enumbe r ofbarrier s and thepercentag e of thepopulatio n experiencing eachbarrier .Differen t subgroupso fpatient s based on theeigh tdemographi c andhealth-relate d measureswer e compared on themedian so fexperience d barriersb yus eo f theno nparametri cmedia ntest . Medians instead ofmean swer e chosena smeasure s of central tendencydu e to the apparent skeweddistributio n of thenumbe r ofbarriers .

RESULTS

Out of90 4patient s approached 730 (81%)sen t inth equestionnaire ;4 3 patients returned thecar d stating that theycoul dno to rdi dno twan t to participate inth e study.54 0ou to f73 0questionnaire swer eanswere d by insulin-treated diabeticpatients .Al l otherswer e non-insulin-treated diabetics. Thenumbe r of 540exceede d the required sample sizeo f478 . -24-

Table1 .Sampl echaracteristics. *

Demographican dHealt hVariable s

Gender (%males ) 52 Age (meany r+ sd ) 45.9 + 13.6 Durationo fdiabete s (meany r+ sd ) 8.7 + : 5.6 BodyMas sInde x (mean+ sd ) 24.3 + 3.6 <25.00 (%o fsubjects ) 67 25.01-30.00 27 >30.01 7 Education (%o fsubjects )# firstleve l 20 secondlevel ,firs tstag e 37 secondlevel ,secon dstag e 29 thirdleve l 14

RegimenCharacteristic s (%o fsubjects )

Diabeticdie tadvise d nodie t 2 specificmea lpla n 73 sugar-freedie t 40 restrictedcarbohydrat eintak e 19 restrictedcalori cintak e 10

Advisedadditiona ldiet s 21 limitcholestero lintak e 7 limitnatriu mintak e 14

Frequencyo finsuli nadministratio n oncea da y 32 twicea da y 53 >3 time sa da y/usin ginsuli npum p 15

Frequencyo fsel fbloo dglucos emonitorin g

*N=54 0insulin-treate ddiabeti cpatients . #firs tleve leducatio n= primar yeducatio n secondlevel ,firs tstag e= genera leducation ,grade s1- 3 secondlevel ,secon dstag e= genera leducation ,grade s4- 6an dsenio r vocationaltrainin g thirdleve l= vocationa lcolleges ,universit yeducation .

Table1 describe sth echaracteristic so fth e54 0subjects :52 %wer emales ,th e averageag ewa s45. 9yr s(rang e(20-6 5yrs) .Th eaverag eduratio no fdiabete s was8. 7yr s (range0.4-53. 4yrs) .Th eaverag eBM Iwa s24. 3 (range15.2-49.5) . Twenty-sevenpercen to fth epopulatio nha da BM Ibetwee n25.0 1an d30.00 , indicatingoverweight .Seve npercen to fth epopulatio nha da BM I> 30.0 1 -25-

indicating (14).Educatio nwa s classified according to the International Standard Classification of Education byUnesco ,adapte d to the Dutch educational system (15).Firs t level education (primary education), had been completed by 20%o f the subjects.Thirty-seve n percent of the population had completed second level education, first stage (general education, grades 1-3). Second level,secon d stage education (general education, grades 4-6 and senior vocational training),ha d been completed by 29%o f the subjects. Fourteen percent of thepopulatio n had completed third level education (vocational college and university).Dat aar e alsopresente d on regimen as recalled by subjects inTabl e 1.Nearl y three quarters of the population had been advised to followa specific planwit h 40%o f the subjects indicating that theyha d been advised a sugar-free diet and 19%a restricted carbohydrate intake.Te npercen t of all subjects stated that theyha d been advised to restrict their caloric intake.Additiona l diets had been advised to 21% of the subjects.O f these 14%ha d adie t to limitnatriu m intake and 7% to limit the intake of cholesterol. Fifty-three percent of the subjects administered insulin twice aday ,whil e 15%di d so three times ada y or more oruse d an .Thirty-on e percent of thepopulatio n carried out self three times awee k ormore ,wit h 11%o f the population performing thisa s adail y task.

Table 2.Diabeti c regimen characteristics ranked asmos t difficult to adhere tob y insulin-treateddiabeti c patients.*

Diabetic regimen characteristic Percent of population

Diabetic diet 50 Insulin administration 30 Self blood glucose monitoring 20

* N=540 insulin-treateddiabeti c patients.

Table 2show s the characteristics of thediabeti c regimen ranked according to perceived degree ofdifficulty . Fiftypercen t of the respondents indicated that they saw thedie t as themos tdifficul t aspect of thediabeti c regimen, while 30%fel t thisabou t theadministratio n of insulin and 20%abou t self blood glucose monitoring. Figure 1 shows the total number ofbarrier s experienced. Themedia nnumbe r of barriers was 4 (range 0-19).Thirtee n percent of thepatient s reported no barrierswit h thediabeti c diet.Th evariable s gender,age ,duratio n of the -26-

percent ofsampl e

15n

12

nn on n r-n n f~l 0 1 2 3 U 5 6 7 8 9 10 11 12 13 % 15 16 17 18 19 number of barriers reported Figure 1 : Percentile distribution of barriers reported by 540 insulin-treated diabetic patients.

diabetes, frequencyo finsuli n administration andsel fbloo d glucose monitoring were found tohav en osignifican t effecto nth enumbe ro fbarrier s experienced. Significant differences were found regarding thevariable sBMI , levelo feducatio nan dadditiona l diets (Table 3).Al lthre eBM Igroup s were

Table 3.Th eeffec to fleve lo feducation , bodymas s indexan dadditiona l dietary guidelineso nth enumbe r ofbarrier s experienced.*

Variable N Percentage ofpopulatio n experiencing more than themedia n numbero fbarrier s#

Body Mass Index <25.00 346 42 25.01-30.00 138 53 >30.01 35 71-1

Levelo feducatio n firstan dsecon d level 455 bO-i' third level 75 32J

Advised additional diets yes 104 56-1' no 402 44J

*N=54 0 insulin-treateddiabeti c patients. #Media n test,* *p < 0.01 ,* p < 0.05 . -27-

significantdifferen t fromeac hothe rwit h respect toth enumbe r ofbarrier s experienced.A sBM I increasespatient sexperienc emor ebarriers .Patient swit h third level education appeared toexperienc e significantly fewer barriers compared tothos ewit hprimar yan d secondary schooleducation .Th e prescription ofdiet s inadditio n toth ediabeti c diet increased thenumbe r of barriers patientsexperienc e significantly.

Table 4.Barrier sexperience d bya minimu m of 25%o f thepopulation* .

Category TotalNumbe r Items Percent of ofBarrier s population inCategor y

Regularity 3 Disruptiono f thedail y routinemake s it ofeatin g difficult tofollo wth edie t 46 Bodily 4 Feeling illbecaus e of irregular eating 45 Discomfort Feelinghungr ywhil eno tallowe d toea t 38 Feeling illbecaus e ofeatin gmor e than allowed 30 Having toea twhil eno t feelinghungr y 25

Financial 1 The costso f thediabeti cdie t 42

Hedonic 8 Tob eallowe d only small amountso f certain foods 27 Iti sdifficul t tosta yawa y from sweets 26 Wanting a food excluded by thedie t 25

Social 6 Others interferewit hm y eating 25

* N=540 insulin-treateddiabeti cpatients .

Table 4show s thebarrier s experienced bya t least 25%o f thepopulation .Th e barriermos t frequently citedwas :"Disruptio no fth edail y routinemake s it difficult tofollo wth ediet " (46%). Allbarrier s relating tobodil y discomfortwer e experienced bylarg e segmentso f thepopulation : "Feeling ill because of irregular eating" (45%), "feelinghungr ywhil eno tallowe d toeat " (38%), "feeling illbecaus e ofeatin gmor e thanallowed " (30%), "having toea t while not feelinghungry " (25%). Forty-twopercen t ofth epatient smentione d the costso f thediabeti c dieta sa barrier .O f theeigh thedoni c barriers threewer e cited bymor e than25 %o f thepopulation : "Tob eallowe d only small amounts of certain foods","i ti sdifficul t tosta yawa y from sweets"an d "wanting a foodexclude d by thediet" .O f the six socialbarrier s theon e that said "others interferewit hm yeating "wa smentione d by 25%o f thepopulation . -28-

DISCUSSION

Consistentwit hothe r studies (1-5)w e found thatth ediabeti cdie twa s regarded themos tdifficul t aspecto f the therapeutic regimen.A s 40%o f the subjects toldu stha t theyha dbee nadvise d a sugar-freediet ,an dwit h 19%o f the subjectshavin g tolimi t their carbohydrate intake,i tmus tb e concluded thata large groupo fpatient sha sbee nprescribe d inadequatediabeti c diets (16,17). Itappear stha t thesepatient s liveaccordin g tooutdate d dietary prescriptions. Itma yb eassume d that theseoutdate ddietar y prescriptions causemor ebarrier san d increased dietarynoncomplianc e compared toth e diabetic dietswhic har ebase dupo n thelates tnutritiona l recommendations. All barrierswhic h related to feelingso fbodil ydiscomfor twer e frequently mentioned.Th eobservatio ntha tpatient sexperienc e feelingso fhunge r and surfeit isals o found inothe r studies (10,11,18). Feelingso fhunge r are a powerfulurg e toea t for themaintenanc e ofbod yweight .Dat a showtha twhe n diabetic patientsexperienc e feelingso fhunger ,the y tend todisregar d the diabetic diet (13).Patients ,keepin gnorma l bodyweight ,shoul dno t experience feelingso fhunge rwhe n ona diet .Howeve rwhe nw e calculated the percentage ofpatient sexperiencin g feelingso fhunge r according toBMI ,w e found that34 %o fth epatient swit ha BM I <25experience d feelingso fhunger , 41% of thosewh ower e and 54%o f thosewh ower e obese.Therefore , feelingso fhunge r are experienced byon e third of thepatient swit h normal bodyweight .Th eenerg y requirement of thesepatient s areno tme tb y the energy intake.Lea nan d James (19)demonstrate d that routinemethod sused by for theestimatio n ofa patient' s energy intake,systematicall y lead toa nunderestimatio n ofenerg yneeds .Furthermore ,th e appropriateness ofprescribin g a fixed level ofenerg y intake toinsulin-treate d diabetic patientswit hnorma lbod yweigh t isdoubtful ;dat a suggest thatdiabeti c non-obese patients regulate their energy intakemor e or lesslik e healthy individualswit hnorma lbod yweigh t (20,21). Therefore,i tshoul d be considered ton o longerprescrib e a fixedenerg y intake todiabeti c patients withnorma l bodyweight .Instea dmor e emphasis should bepu to nappropriat e food choices.Thi smigh tconsiderabl y reduce thenumbe r ofbarrier s patients experiencewit h theirdiets .

Thebarrie r experienced bymos tpatient swa s thatdisruptio no f the daily routinemake s itdifficul t tofollo wth ediet .I nsituation s of irregular eating a large segmento f thepopulatio nals o reported feelingso fbodil y discomfort.Thi s indicatestha tno t onlyth e requirement toea t regularmeal s -29-

causesbarrier sbu tals o situationswher e thenorma l routine is interrupted by the patient himself ofb yunexpecte d events.Increasin g the skills tocop e with these typeso f situations is indicated. Diabetic dietshav e the reputationo fbein g expensive.I naccordanc ewit h other studies (11)w e found thatpatient s consider thedie t tob e costly. Germandat a from 1978 showth ecost so fa diabeti c diet toexcee d the average costo fa norma ldie tb y20 %(22) .Currentl y iti sgenerall y accepted that there isn onee d topurchas e special foodst ofulfi lnutritiona lneeds . However,man ypatient sus ediabeti c speciality foodsan d theseproduct sar e more expensive thanthei rno ndiabeti c counterparts (23).Furthermor e after thediagnosi so fdiabetes ,patient sus e themor e expensive leanmeat smor e frequently thanbefor e thediagnosi s of theirdiseas e (23).Mor e attention fromnutritio n counsellors for low-cost foods is indicated. Hedonic barrierswer ementione d less frequently thanexpecte d basedupo n the resultso fou rqualitativ e study (9).However ,the y reveal thatpatient s feel restricted inth echoic eo f foods,especiall y sweets.Currentl y iti s accepted that sugar and sugar-containing foodsca nb e included inth ediabeti c diet and that therear en o 'forbidden'food s (16,17). Thesebarrier s showtha t patients maypu texcessiv e andunnecessar y restrictions on their food choices,whic h maydetrac t from thehedoni cqualit y of theirdiets .Thi s isa nunfortunat e phenomenon,afte r all food isa source ofpleasur e tohumans . Level ofeducatio nwa s inverselyassociate dwit h thetota lnumbe r of barriers experienced.Whethe r this relationship iscausa l ormediate d by other variables,suc ha shealt h knowledge canno tb e concluded from thisstudy . Whether orno t thisassociatio n iscausal ,i tappear s topoin t ata nee d for more effective education for thosewit h a lowleve l ofeducation . Bodymas s indexwa spositivel yassociate dwit h totalnumbe r of barriers experienced. Thismigh t reflecttha toverweigh t andobes epatient s should lose weight.Patient swh oha dbee nprescribe d diets inadditio nt othei r diabetic diet experiencedmor ebarrier s thanthos ewit ha diabeti c dietonly .Thi s showstha tan yadditiona l dietmean sa significant increase inth enumbe r of barriers experienced. Theprescriptio n ofan yadditiona ldie tneeds , therefore,a critical assessmento f thehealt h situationo f thepatient . The studyquantifie s thebarrier s that insulin-treated diabetic patients experiencewit h theirdiets .Thes ebarrier s canprobabl y be substantially reducedb yprescribin g diabetic dietsaccordin g toth e latest nutritional recommendations andb yn o longerprescribin g a fixedenerg y intake todiabeti c patientswit hnorma lbod yweight .Dietar ycounsellor s shouldpa ymor e -30-

attentiont opatients 'knowledg ean dopinion so fth ediabeti cdie ta swel la s theirabilit yt oadap tth edie tt othei row nbodily ,hedoni can dsocia lneeds . Specialattentio nshoul db epai dt othos ewit hlo wlevel so feducation .

ACKNOWLEDGMENTS

Thisstud ywa ssupporte db ygrant sfro mth eMinistr yo fWelfare ,Healt han d CulturalAffairs ,Th eHague ,th eNetherlands ,an dth efro mWageninge n AgriculturalUniversity ,th eNetherlands .Th ehel pfro mth eDutc hDiabete s Association,especiall yfro mM rP .va nde rWiel ,i nrecruitmen to frespondent s ismos tgratefull yacknowledged .W eexpres sappreciatio nt oJacolie nBakke r andRit ad eVrie sfo rassistanc ei ndat acollectio nan dMariett aEimer sfo r statisticalsupport .

REFERENCES

1.Lockwood ,D. ,Frey ,M.L. ,Gladish ,N.A. ,an dHiss ,R.G. :Th ebigges t problemi ndiabetes .Th eDiabete sEducato r12 :30-33 ,1986 . 2.Glasgow ,R.E. ,McCaul ,K.D. ,an dSchäfer ,L.C. :Barrier st oregime n adherenceamon gperson swit hinsulin-dependen tdiabetes .J Beha vMe d9 : 65-77,1986 . 3.Jenny ,J.L. :A compariso no ffou rag egroups 'adaptatio nt odiabetes .Ca n JPubli cHealt h75 :237-244 ,1984 . 4.Jenny ,J.L. :Difference si nadaptatio nt odiabete sbetwee ninsulin - dependentan dnon-insulin-dependen tpatients :Implication sfo rpatient s education.Patien tEdu cCounse l8 :39-50 ,1986 . 5.Ary ,D.V. ,Toobert ,D. ,Wilson ,W. ,an dGlasgow ,R.E. :Patien tperspectiv e onfactor scontributin gt ononadherenc et odiabete sregimen .Diabete sCar e 9:168-172 ,1986 . 6.West ,K.M. :Die ttherap yo fdiabetes :A nanalysi so ffailure .An nInter n Med79 :425-434 ,1973 . 7.Glanz ,K. :Nutritio neducatio nfo rris kfacto rreductio nan dpatien t education:A review.Pre vMe d14 :721-752 ,1985 . 8.McCaul ,K.D. ,Glasgow ,R.E. ,an dSchafer ,L.C. :Diabete sregime n behaviors.Me dCar e25 :868-881 ,1987 . 9.Niewind ,A.C. ,Friele ,R.D. ,Edema ,J.M.P. ,Hautvast ,J.G.A.J. ,an d Röling,N.G. :Th ediabeti cdiet :Patients 'perspectives .Submitted . 10.Broussard ,B.A. ,Bass ,M.A. ,an dJackson ,M.Y. :Reason sfo rdiabeti cdie t noncomplianceamon gCheroke eindians .J Nut rEdu c14 :56-57 ,1982 . 11.Daschner ,B.K. :Problem sexperience db yadult si nadherin gt oa prescribe d diet.Th eDiabete sEducato r12 :113-115 ,1986 . 12.House ,W.C. ,Pendleton ,L. ,an dParker ,L. : Patients'versu sphysicians ' attributionso freason sfo rdiabeti cpatients 'noncomplianc ewit hdiet . DiabetesCar e9 :434 ,1986 . 13.Friele ,R.D. ,Niewind ,A.C. ,Edema ,J.M.P. ,an dHautvast ,J.G.A.J. : Diabetics'dietar ybarriers :Har dt oovercome .Submitted . 14.Garrow ,J.S. :Trea tObesit ySeriously .Edingburgh ,Churchil lLivingstone , 1981. 15.Netherland sCentra lBurea uo fStatistics :Statistica lYearboo ko fth e Netherlands1987 .Th eHague ,Staatsuitgeverij/CBS-publications ,1988 . -31-

16.Mann ,J.I. :Simpl esugar san ddiabetes .Diabeti cMedicin e44 :135-139 , 1987. 17.America nDiabete sAssociation :Nutritiona lrecommendation san dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 :126-132 , 1987. 18.Pate ,CA. ,Dorang ,S.T. ,Keim ,K.S. ,Stoecker ,B.J. ,Fischer ,J.L. , Menendez,C.E. ,an dHarden ,M. :Complianc eo finsulin-dependen tdiabetic s witha low-fa tdiet .J A mDie tAsso c86 :796-798 ,1986 . 19.Lean ,M.E.J. ,an dJames ,W.P.T. :Prescriptio no fdiabeti cdiet si nth e 1980s.Th eLancet ,Marc h29 :723-725 ,1986 . 20.Nuttal ,F.Q. :Die tan dth ediabeti cpatient .Diabete sCar e6 :197-207 , 1983. 21.Chantelau ,E.A. ,Frenzen ,A. ,Gösseringer ,G. ,Hansen ,I. ,an dBerger ,M. : Intensiveinsuli ntherap yjustifie ssimplificatio no fth ediabete sdiet :A prospectivestud yi ninsulin-dependen tdiabeti cpatients .A mJ Cli nNut r 45:958-962 ,1987 . 22.Buchenau ,H. ,Frenz ,R. ,Schumacher ,W. ,an dGries ,F.A. :Relativkoste n einerdiabetes-diät .Aktuell eErnährungsmedizi n5 :247-251 ,1980 . 23.Niewind ,A.C. ,Friele ,R.D. ,Kandou ,C .Th. ,Hautvast ,J.G.A.J. ,an d Edema,J.M.P. :Change si nfoo dchoice so frecentl ydiagnose dinsulin - dependentdiabeti cpatients .Submitted . -32-

4 Changes in food choices of recently diagnosed insulin- dependent diabetic patients

byA.C .Niewind ,R.D .Friele ,C.Th .Kandou ,J.G.A.J .Hautvas t& J.M.P.Edem a

ABSTRACT

Current foodus ea swel la sth ehabitua l foodus eprio rt oth ediagnosi so f diabeteswa smeasure d usinga foo d frequencyquestionnair e ina grou po f recentlydiagnose d insulin-dependent diabetic patients.Patient s (51M ,2 9F ) werebetwee nth eage so f2 0an d4 0an dha dbee ndiagnose da sinsulin-dependen t diabetics lesstha n6 month sprio r toth estudy .Result s showtha t patients after thediagnosi so fdiabete s reduceth econsumptio no fhigh-suga r foodsan d beverages,o fsnack san do fhigh-fa t foods fromth edair yan dmea t groupsan d incorporate low-fat foodsi nthei r foodpattern .Som eo fth echange shav e been less favorable froma nutritiona l perspective sucha sth eincrease d consumptiono fdiabeti c speciality foods,th ereduce d consumptiono fpulses , andth elowe r overall foodvariety .I nconclusio n patientsar eabl et ochang e their foodus eafte r thediagnosi so fth einsulin-dependen t diabetes.Howeve r towhic h degreepatient swil l change their food choiceso na lon g termbasi s remainst ob edetermined .

INTRODUCTION

Overth elas tdecad eth edietar y recommendations fordiabeti c patients have been subjectedt ochanges .Curren t recommendations forinsulin-dependen t diabetics include consistency inmea l timing,an di nth eamoun to f carbohydrates consumedwit heac hmeal . Furthermorediabetologist sa swel la s national diabetic associations tendt orecommen da nincrease d carbohydrate intakeu pt oapproximatel y 50%o fth etota l energy intake.Thi spreferabl yb y inclusiono ffood s richi ncarbohydrates ,food swit hhig h fiber contentan d lowglycémi e index foods (Crapo,1986 ; Mann,1986 ;America n Diabetes Association, 1987). Theyals oadvis et orestric tfa tintake ,t oreplac e saturated fatsb yunsaturate d fatsan dt olowe r cholesterol intake inorde rt o reduceth eonse to fdiabeti c complications.I nth eNetherland s patientshav e beenadvise d tofollo wadditiona lguideline s fromth eDutc hNutritio n Council fora pruden tdie twhic h recommend eatinga variet yo ffoods ,a lowe r salt -33-

intakean dreduce dalcoho lconsumption .Fo ra lon gtim esucros ewa sforbidde n inth ediabeti cdiet .Toda yi ti srecognise dtha tther ei sn oevidenc etha t moderateamount so fsucros e (upt o5 0g/day )wil lproduc edeterioratio no f glycémiecontro lo rbloo dlipi dlevel si ninsulin-dependen tdiabeti cpatients , providedtha ta nisocalori cquantit yo fcarbohydrat ei sremove dfro mth e calculateddail yenerg yrequiremen t (Mann,1987) . Literatureshow scomplianc ewit hth ediabeti cdie tt ob egenerall ylo w(West , 1973; Glanz,1985) .Die tha sbee ndescribe da sth emos tdifficul taspec to f thediabeti cregime n (Jenny,1984 ;Ar ye tal ,1986 ;Glasgow ,McCau l& Schäfer , 1986; House,Pendleto n& Parker ,1986 ;Jenny ,1986) . Compliancewit hthes eguideline softe ndemand schang ei nfoo dchoices .Th e extentt owhic hdiabeti cpatient swil lb eabl et ochang ethei rfoo dchoice s accordingt oth edietar yguideline sha sbee ndisputed .Studie so npatient s withcoronar yhear tdiseas eshowe da chang ei nnutrien tintak eo na shor ta s wella so na mor elong-ter mbasi s(Rei de tal ,1984 ;Thuesen ,Hendrikse n& Engby,1986 ;Rei d& Mulcahy ,1987) . Thepurpos eo fthi sstud ywa sa documentatio no fth edifference si nth eus eo f individualfood sbefor ean dafte rth ediagnosi so finsulin-dependen tdiabete s ina grou po fyoun gadult sa swel la sa nassessmen to fth econcomitan t nutritionalimplication sresultin gfro mthes echanges . Inthi styp eo fstud yfoo dus ebefor eth ediagnosi so fth ediseas eca nonl yb e assessed retrospectively.Th evalu eo fretrospectiv edietar ydat adepend so n thevalidit yan dreproducibilit yo fdietar yassessmen tmethods .Validatio no f retrospectivedat ai srarel ypossible ,reproducibilit yca nb eevaluated . Therefore,w edecide dt oinvestigat eth ereproducibilit yo fth eretrospectiv e obtaineddietar ydata .

METHODS

Subjects Thetw ocriteri afo rselectin grespondent si nth estud ywere :ag erangin g between2 0an d4 0year san da diagnosi so finsulin-treate ddiabete sn olonge r thansi xmont hprio rt oth estudy . Individualswer erecruite dfro mth epatient-member so fth eDutc hDiabete s Association (DDA).A sth edatabas eo fth eDD Adi dno tcontai nan yinformatio n regardingth etyp ean dduratio no fth ediabetes ,al lne wmember sbetwee nage s 20an d4 0joinin gth eDD Ai nth ethre emonth sprio rt oth estud ywer e approachedfo rparticipating .W ereceive da reactio nfro m17 6ou to f18 7 -34-

patientsapproache d (94%).Eighty-fou ro fthos edi dno tmee tth eselectio n criteriaan dwer eexclude dfro mth estudy .Fro m9 2person smeetin gth e selectioncriteri a8 4(91% )wer ewillin gt oparticipate .

Foodus e Theai mo fth estud ywa sa nassessmen to fth echange si nth eus eo ffoods , thereforeth ever ysam edietar yassessmen tmetho dmus tb euse dt omeasur efoo d usebefor ean dafte rth ediagnosi so fth ediabetes .A sth einteres tla yi nth e useo ffoods ,a foo dfrequenc ywa sused .A foodfrequenc yquestionnair e consistso fa lis to ffood san da se to ffrequenc yrespons eoption st o indicatefrequenc yo fconsumptio no feac hfoo ddurin ga give ntim eperiod .Th e foodlis trepresente da cross-sectio no ffood scommonl yavailabl ei nth e Netherlandsan dfood sknow nt ob euse db ydiabeti cpatient s(Niewin de tal , 1988).I tcontaine dfood sexpecte dt ob echange di nfrequenc yo fus eb y diabeticpatient safte rth ediagnosi so fdiabetes .Therefore ,low-fa tan d high-fatitem swer einclude da swel la sproduct swit hvaryin gamount so f fiber. Thefoo dlis tcontaine d17 7food ssubdivide dint oeigh tgroups .Th ebrea dan d cerealgrou pa swel la sth edair ygrou pinclude dbot h2 1items .Th emea tan d alternategrou pcontaine d2 7items ,an dth efrui tan dvegetabl egrou p4 3 items.Als oo nth elis twer e1 4food swit hhig hsuga rconten tan d1 5 beverages.Twenty-on esnac kan dmiscellaneou sitem swer eincluded .I n addition,th eus eo f1 5diabeti cspecialit yfood swa sassessed . Furthermore,w easke drespondent sho wofte nthe yuse dfrie do rgrille dmeats , friedo rboile dfis han dfrie do rboile deggs . Theus eo feac hfoo dwa sassesse db ymean so fa 9-poin tfoo dfrequenc yscale . Thepoint so fth escal ewere :> 3time sa day ,2- 3time sa day ,onc ea day ,4- 6 timesa week ,2- 3time sa week ,onc ea week ,2- 3time sa month ,onc ea mont h andles stha nonc ea month . Respondentswer eals oaske dwhic htyp eo fsweetene rthe yuse di nthei rte aan d coffeean dth etyp eo fsprea dthe yuse do nbreads :butter ,margarine ,low-fa t margarineo rmargarin ewit hhig hamount so fpoly-unsaturate dfatt yacids .Als o whichtyp eo ffa tthe yuse dfo rfrying :butter ,margarine ,low-fa tmargarine , margarinewit hhig hamount so fpoly-unsaturate d fattyacid so roil .Th eus eo f theseitem swa srecorde db ymean so fa dichotomou svariabl ewit hanswe r categoriesyes/no . -35-

Data collection We contacted all 84participant s andexplaine d the studyt othem .W e sent them a self-administered questionnaire toobtai ndemographi cdata .Interviewers , trained instandardize d interview techniques,an d instructed toavoi dvalu e judgments about respondents'foo duse ,collecte d thedemographi c questionnaireswhic h theychecke d formissin gdat awhil e at the same time they collected informationo n foodus e atth eparticipants 'homes .Accordin g to Axelson &Csernu s (1983)simultaneou s recallo fpresen tan d retrospective intake foreac h foodha s theadvantag etha talthoug h respondentsma yno tb e able to remember theexac t frequencyo fus e foreac h timeperiod ,th e relative frequency for the twoperiod swoul d indicate changestha tdi d occur in theus e of foods.Therefor e foreac h food subjects indicated theconsumptio no fApri l 1987, that isafte r thediagnosi so f thediabete san d subsequently their intake in the correspondingmont h of thepreviou syear .Thi slatte rdat e had been chosen toavoi d inaccuratedat adu e toseasona l effectso n fooduse .T o freshenu p respondent's recall of thisperiod ,w ementione d somemajo r political and social issueswhic hha d occurred inth e recallperio d of1986 .

Data analysis Thelarg e sampleapproximatio n ofth eWilcoxo nmatche dpai r testwit h corrections for tieddifference swa suse d toasses sth edifference s inth eus e between 1986 and 1987 foreac h individual food.Fo r zerodifference s the midrank (P+ l)/2wa s assigned toth ep zerodifferences .Hal f thedifference s received apositiv emidrank ,hal fa negativ emidrank .Th edistributio n of the computed Z-valuesapproache s the standard normaldistributio n (Marascuilo& McSweeney, 1977). A chi-square test forhomogeneit yo fproportion s forcorrelate d dichotomous variables,th eMcNema r test,wa suse d toanalyz e changes inth eus e of sweeteners inte aan d coffee aswel l as for the typeo f spreaduse d onbread s and the type of fatuse d for frying (Marascuilo& McSweeney , 1977).

Reproducibility of retrospectivedietar ydat a To test the reproducibility of retrospective obtaineddietar ydata ,w e contacted all respondentson eyea r later (1988)an d asked themt o retrospectively report their foodus eo f 1987.Th e 1988 retrospective report of 1987an d thebaselin edat ao f198 7allowe d examinationo f the reproducibility.Reproducibilit ywa sdefine da sagreemen tbetwee nbaselin e and retrospective reporto f 1987.Reproducibilit ywa s calculatedusin gweighte d -36-

Kappastatisti c (Cohen,1968) . Systematicdifference sbetwee nbaselin ean d retrospectivedat awer eassesse db ymean so fth eWilcoxo nmatche dpai rtes t withcorrection sfo rtie dan dzer odifferences .

RESULTS

direction of change food group decrease increase

High-sugar foods Snacks, Miscellaneous 13 Meats and alternates Beverages mmmm Bread and cereals Dairy II I HI'l I I' 1 I Vegetables and fruits E2H 1 Diabetic speciality foods Mœ&m

100 80 60 40 20 0 20 40 60 80 10 percentage of foods significantly changed in frequency ofus e

Figure1 :Percentag eo ffood swithi neigh tfoo dgroup schange di nfrequenc yo f usepos tdiagnosi so finsulin-dependen tdiabete s (1,2).

1.Onl yfood swit hZ-value sa tp < 0.0 1ar ereporte d 2.N=8 0

Subjects Fromth erespondent swillin gt oparticipat efou rperson swer eexclude dfro m thestudy .O fthes ethre ewer epregnan tan don eperso nha da histor yo f glucoseintolerance .Therefore ,8 0patient sparticipate d inth estudy ,5 1 -37-

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males en 29 females.Thei r age Inyear swa s 29.1+ 5.7 (mean+ sd).A t the time of the interview theduratio no f thediabete s inyear sha d been 0.33 + 0.09 (mean+ sd). Twenty-three percent of theparticipant s had an elementary school education, 40%ha d finished high school educationan d 35%ha d university education.Fo r 2 respondentsn o information regarding educationwa s available. For92 %o f the respondents insulin-dependent diabeteswa s the only disease theywer e treated for.

Foodus e Figure 1 illustrates the changes infoo duse .Fo r 64 foods (36%)a significant decreasewa s found (p< 0.01) . For 27 foods (15%)a significant increase in frequency of consumption had occurred (p< 0.01). Foodswit h statistically significant Z-valuesbetwee n the frequencybefor e andafte r dietary treatment havebee n shown inTabl e 1. Theus e ofnearl yal l foodshig h insuga r (93%)showe d a significant reduction inus e after thediagnosi so f thediabetes .Tabl e 2 shows thepercentag e of thepopulatio n consuming these foodswit hhigh-suga r contentbefor e and after thediagnosi s ofdiabetes .Food s showing thehighes tdecreas e inus eare : cakes,cookies ,candies ,chocolate san d candy bars.

Table 2.Us e of foodshig h insuga rb y8 0 insulin-dependentdiabeti c patients pre andpos tdiagnosi so fdiabetes . use High-sugar foods pre diagnosis post diagnosis <— % _ >

Cakes 87 27 Cookies 82 22 Candy 77 17 Chocolates 75 17 Fruit pies 67 17 Tarts 67 19 Jams/jellies 66 24 Candy bars 66 10 Chocolate spread 65 12 Rolls 52 2 Honey 47 7 Yoghurt pies 27 10 Small pastries 24 6 Homemad e jams, jellies 14 6

1.Mor e thanonc ea month . -39-

Seventy-onepercen to f the snack andmiscellaneou s itemssa wa reducedus e after thediagnosi so fdiabetes .Nearl yal l these foodshav ehigh-fa t and/or high-salt contents.I nth emea tan dalternate s group the frequencyo fus eo f many foodswit h high-fat contentdiminished .Th e samewa s found forbeverage s with high-sugar and/or alcohol level.I nth ebrea d and cereal groupa dro pwa s found infrequenc y ofus e ofproduct swit ha lo wfibe r content.Patient s also reduced the frequency ofus eo f fatand/o r sweetdair yproducts .Fro mth e fruitan dvegetabl egrou ppulses ,frie dpotatoes ,frenc h friesan d potato disheswer e consumed lessofte na swel l asbananas ,canne d fruitsan d applesauce. The largest increase occurred inth eus e ofdiabeti c speciality foods.Non eo f these foods,excep t sugar-free chewing gum,wer euse dmor e thanonc ea mont h before thediagnosi so fth ediabetes .Howeve r for73 %o fth ediabeti c speciality foodsa significant increase infrequenc y ofus ewa s found. Artificial sweeteners,diabeti c lemonade,jams ,chewin g guman d candieswer e useddail yb y 39,38 ,21 ,1 6an d 15%o f thepopulatio n respectively. Forth e meat,dair yan d snack groupsa n increasedus e of foodswit h low-fatan d low-sugar contentwa s found.Withi n thebrea d and cereal group theus e of wholewhea t and brownbrea dwa s increased aswel l as theus eo f crackersan d biscuits.A s forvegetable san d fruitsw e founda n increase inth eus eo f salads,apple s andoranges .Finall y theus e ofminera lwate rwa s increased.

Table 3.Increase d anddecrease dus e of foodspos tdiagnosi so f insulin- dependentdiabete sb y8 0patient s( 1).

Increasedus epos t Decreased usepos t Foods diagnos]L S Of diabetes diagnosis ofdiabete s

C Î N 0 > Cheese/meat snacks 24 22 Eggs 15 28 Rusk 29 14 Ginger cake 11 30 Tea 26 13 Ham 23 16 Biscuits,whol ewhea t 28 10 Cheese,fa t 22 14 Spirits 10 26 Yoghurt, fat 14 21

1.Changin g the frequencyo fus e foron ecategor yo fth e food frequency scale minimally. -40-

For 49%o f the foodsn o significant change inus e occurred. For some foods thiswa sowin g to the fact that somepatient sha d increased theus e of these foodsafte r thediagnosi so f thediabetes ,whil e othersha ddecrease d it.Th e foods listed inTabl e 3ha d changed foron e categoryo f the food frequency scaleminimall yb ya tleas t 35%o fth epopulation .Hal fo f these foodswer e foodwit h high-fat content from thedair yan dmea t group,whil e also gingercake,whol ewhea tbiscuits ,rusk ,te aan d spiritswer e inthi s category.

Food preparation With regard to foodpreparatio nn o changewa s observed inth e frequency ofus e of fried and grilledmeat s and fried andgrille d fish.Patient sdecrease d the use of fried eggs (p< 0.01 )whil e theus e ofboile d eggsdi d notchange . A significant increase inth eus eo fartificia l sweeteners inbot h coffee (p< 0.01) and tea (p< 0.01 )wa sobserved .Consequentl y the frequencyo fus eo f sugar inthes ebeverage swa s significantly decreased (bothp < 0.01) For the typeo f spreadso nbrea d a significant increase inth eus e of margarinewit hpoly-unsaturate d fattyacid s (p< 0.01 ) wasobserve dwit h a simultaneous decrease inth eus e ofmargarin e andbutte r (bothp < 0.01). The type of fatsuse d for frying foodschange d inth e sameway :margarin ewa s used less (p< 0.01 )whil e margarineswit hpoly-unsaturate d fattyacid swer e used more frequently (p< 0.01).

Reproducibility Resultso f the reproducibility study showed thataccordin g toth e classification of Landis& Koc h (1977)fo rKapp a statistic the reproducibility was fair tover ygoo d for72 %o f the foods.Fo r 13 foods (7%)significan t differencesbetwee nbaselin e and retrospective datawer e found (p< 0.01). For all 13 foods the retrospectivedat awer e lower thanth ebaselin edata .

DISCUSSION

In this studyw e investigated the foodchoice so f recently diagnosed insulin-dependentdiabeti c patients.T othes epatients ,al lbetwee n 20an d 40 yearso fage ,th edevelopmen to fa chronic life-threatening illness isa majo r disruptive experience.A s thedie t isa mean s tocontro l the long-terman d short-term complications of thisdiseas e toa certai nextent ,patient s recently confrontedwit h thisdisease ,chang e their food choices.Fo r 51%o f the foodsa s included inth e food frequency food list,w e found a significant -41-

change in the frequencyo fuse . The changes inth e foodus e ofthes epatient shav epositiv e aswel l as negative nutritional implications.A decrease inth eus eo f foodshig h in saturated fatsan d replacement ofhigh-fa tdair yan dmea t productsb y low-fat items isi naccordanc ewit h the latestdietar yguidelines .Thi sals ogoe s for the increasedus eo fmargarine swit hpoly-unsaturate d fattyacid s (Crapo, 1986; Mann,1986 ;America nDiabete sAssociation , 1987). A change less favorable froma nutritiona l pointo fvie w isth ehig h consumption ofdiabeti c speciality foodswhic hmigh t contradict the decreased use of foodswit h high fatconten t as someo f these foodscontai n rather large amounts offat . The observed reduction in theconsumptio n of foods rich incarbohydrate s such aspulse san d pasta isi ncontradictio n to theofficia l recommendations which advisepatient st o increase their intake of foods richi ncarbohydrate s and foodswit h a lowglycémi e index.Thi sphenomeno nma yb eexplaine d asfollows . The amount of carbohydrates allowed ina mea l isprescribe d inth e diabetic diet.Exchang e of foods ispossibl e andbase d on the chemically determined amounto f carbohydratespresen t ina food rather than in itsglycémi eindex . In thecas e of andpast a however,th eportion sallowe d ateac hmea l arever y small.A sa consequence patients tend toomi t these foods from the diets. Another negativedevelopmen t istha tth enumbe r of foodsdecrease d inus e surpass thenumbe r of foodstha tar e increased inuse .Thi swil l result ina lower foodvariety .Al l currentdietar yguideline semphasiz e thateatin g a variety of foods isth eke y tooptima l nutrition,althoug h theoptima l dietary variety in foodus eha sno tye tbee ndefined .Als o humanshav e anee d fora variety in foodus ewhil e palatability declineswit h foodpattern s low in overall foodvariet y (Siegel &Pilgrim , 1958;Kame n& Peryam , 1961). The reduction inus e ofnearl yal l foods richi n sugar isno t necessarily beneficial to thenutritiona l statuso f the insulin-dependent diabetic patient.Thi s reduction isno tnecessar y according tocurren t scientific insightswhic h allowmodes t amountso f sucrose inth ediabeti c diet (Crapo, 1986; Mann,1986 ;America n DiabetesAssociation , 1987;Mann , 1987). The reduction inhigh-suga r foods leadst o theus eo fdiabeti c speciality foods andma ydecreas e thepalatabilit y of the foodpatter n to thediabeti cpatient . These implications of the reduced consumption of foodshig h in sugar are not favorable. It is remarkable that,althoug h theconsumptio n ofman y foodschanged ,n o -42-

changewa s reported inth epreparatio n ofmea tan d fish.Changin g from frying meat togrillin g could result ina considerabl e reduction in fatintake . Although theus eo fmargarin ewit hpoly-unsaturate d fattyacid s for fryingha s increased,n o changewa sobserve d forth eus eo foi l for frying.Thi s suggests thatpatient sar emor e likely tochang e the typeo f food theyea t instead of thewa y ofpreparin g thesefoods . The observation that somepatient shav e increased the frequencyo fus e of some foodswhil e othersdecrease d it,suggest s thatpatient shav edifferen t ideas about the characteristicso f these foods.Cheese/mea t snacks,eggs , ham, cheese (fat)an dyoghur t (fat)al lhav ebot hpositiv e andnegativ e health characteristics fordiabeti c patients.Thes e foodscontai n saturated fats,a reason for a lower frequencyo fuse .Howeve r patientsma y increase theus e of these foodsbecaus e theycontai n smallo rnegligibl e amountso fcarbohydrates . Wholewhea t biscuitsan d rusk are foods somepatient sma yus e asa carbohydrate snack.Howeve r theyals ocontai nmonosaccharide s resulting in rejectionb yothers .Patients 'perception so fth ehealt hcharacteristic so f thiscategor y of foodswarran t furtherattention . Inthi s studya food frequencyquestionnair ewa suse d toasses sbot h current and retrospective fooduse .Althoug h the reproducibilitywa s generally fair to verygood , studies showtha t retrospective dataar e influenced by current measures (Beyerse t al, 1983;Roha n &Potter ,1984 ;ftolle rJense ne t al,1984 ; McKeown-Eyssen,Sin gYeun g &Bright-See ,1986 ;Thompso n etal ,1986 ;Va n Staverene tal ,1986 ;Bakku me tal ,1988) . This finding applies to situations inwhic h the changes in foodus e are relativelyminor .Assessin g the current and the retrospective dataa t the sametime ,implie s thatonl y the changes respondentsar e aware of,wil l be reported,leadin g toa noverestimatio no f the stability of thedietar ypattern .Howeve r forth e recallperio d inthi s study 1986-1987 adifferen t situationapplie sa sdurin g thatperio d patients consciously changed theirdiets .McKeown-Eysse n eta l (1986)hav e shown that respondentswh odi d change their foodus e forhealt h reasonshav e abette r recall of their retrospective foodus e than thosewh odi d not.Therefo r iti s likely that the retrospective reporto f 1986 isa t leasta sgoo d as the 1987 one,althoug h anunderestimatio n of thechange s infoo dus edurin g 1986-1987 mayhav e occurred. Changes in foodus emigh thav e beenoverestimate d as respondentshav e given informationabou t foodus e after thediagnosi so f thediabete smor e onth e basis of theprescriptio n given tothe mtha no nactua ldietar y intake.W e tried tominimiz e thisproble mb y interviewing thepatient sabou t their food -43-

use rather thanusin g a self-administered food frequencyquestionnaire .W e also instructed interviewers toavoi dvalu e judgments atal l times.I n addition,w euse d anextensiv e and specific food list.Whe npatient s give information about foodus emor e on thebasi so f theprescriptio n than on actualdietar y intake,i ti sunlikel y that they recall this information one year later.A s the reproducibility of the198 7dat awa s fair tover y good for 72% of the foods,thi simplie stha t iti sunlikel y thatpatient shav e recalled their dietaryadvice . The overall conclusion of thisstud y istha t recently diagnosed insulin-dependent diabeticpatient sd omak edietar y changes.Som e of these are consistentwit h thedietar y guidelines fordiabeti cpatients ,whil e others are less favorable froma nutritiona l perspective.T owhic hdegre e patientswil l change their foodus e ona long-ter mbasi san dwhethe r theywil l be able to maintain the lowerus e of foodshig h infa twil l be the subject ofa follow-up studyo f the samepopulation .

ACKNOWLEDGEMENTS

Thiswor k hasbee n supported bygrant s from theMinistr y ofWelfare ,Healt h and CulturalAffairs ,Th eHague ,th eNetherland s and theWageninge n Agricultural University, theNetherlands .Th e cooperation received from the Dutch DiabetesAssociation ,especiall y fromM r P.va nde rWiel , in recruitment of the respondents ismos t gratefully acknowledged,a swel l asassistanc e from MrsJ.C.M.M .Nooy-Michel swit hth e collection ofdata ,an d fromM sM . Eimers with data analysis.W e are grateful toD rM . Krondl from theDepartmen t of Nutritional Sciences,Universit y ofToronto ,Canada , forhelpfu l suggestions ona n earlier version of thismanuscript .

REFERENCES

American DiabetesAssociatio n (1987): Nutritional recommendations and principles for individualswit hdiabete smellitus :1986 .Diabete s Care10 , 126-132. Ary,D.V. , Toobert,D. ,Wilson ,W . &Glasgow ,R.E . (1986): Patient perspective on factors contributing tononadherenc e todiabete s regimen.Diabete s Care 9,168-172 . Axelson,J.M . &Csernus ,M.M . (1983): Reliabilityan dvalidit y ofa food frequency checklist.J .Am .Diet .Assoc .83 ,152-155 . Bakkum,A. ,Bloemberg ,B. ,Va nStaveren ,W.A. ,Verschuren ,M . &West , CE. (1988): The relativevalidit y ofa retrospective estimate of food consumptionbase d ona curren tdietar yhistor yan d a food frequencylist . Nutr.Cance r 11,41-53 . -44-

Beyers,T.E. ,Rosenthal ,R.I. ,Marshall ,J.R. ,Rzepka ,T.F. ,Cummings ,K.M .& Graham,S . (1983):Dietar yhistor yfro mth edistan tpast :A methodologica l study.Nutr .Cance r5 ,69-77 . Cohen,J . (1968):Weighte dKappa :Nomina lscal eagreemen twit hprovisio nfo r scaleddisagreemen to rpartia lcredit .Psychol .Bull .70 ,213-220 . Crapo,P.A . (1986):Carbohydrat ei nth ediabeti cdiet .J .Am .Coll .Nutr .5 , 31-43. Glanz,K . (1985):Nutritio neducatio nfo rris kfacto rreductio nan dpatien t education:A review.Prev .Med .14 ,721-752 . Glasgow,R.E. ,McCaul ,K.D .& Schafer ,L.C . (1986):Barrier st oregime n adherenceamon gperson swit hinsulin-dependen tdiabetes .J .Behav .Med .9 , 65-77. House,W.C. ,Pendleton ,L .& Parker ,L . (1986):Patients 'versu sphysicians ' attributionso freason sfo rdiabeti cpatients 'noncomplianc ewit hdiet . DiabetesCar e9 ,434 . Jenny,J.L . (1984):A compariso no ffou rag egroups 'adaptatio nt odiabetes . Can.J .Publi cHealt h75 ,237-244 . Jenny,J.L . (1986):Difference si nadaptatio nt odiabete sbetwee n insulin-dependentan dnon-insulin-dependen tpatients :Implication sfo r patientseducation .Patien tEduc .Counsel .8 ,39-50 . Kamen,J.M .& Peryam ,D.R . (1961):Acceptabilit yo frepetitiv ediets .Food . Tech.5 ,173-177 . Landis,J.R .& Koch ,G.G . (1977):Th emeasuremen to fobserve ragreemen tfo r categoricaldata .Biometric s33 ,159-174 . Mann,J . (1986):Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J .Am .Coll .Nutr .5 ,1-7 . Mann,J.I . (1987):Simpl esugar san ddiabetes .Diabeti cMedicin e4 ,135-139 . Marascuilo,L.A .& McSweeney ,M . (1977):Nonparametri can dDistribution-Fre e Methodsfo rth eSocia lSciences .Monterey :Brooks/Col ePublishin gCompan y Inc. McKeown-Eyssen,G.E. ,Sin gYeung ,K .& Bright-See ,E .(1986) :Assessmen to f pastdie ti nepidemiologi cstudies .Am .J .Epidemiol .124 ,94-103 . MeilerJensen ,0. ,Wahrendorf ,J. ,Rosenqvist ,A .& Geser ,A . (1984):Th e reliabilityo fquestionnaire-derive dhistorica ldietar yinformatio nan d temporalstabilit yo ffoo dhabit si nindividuals .Am .J .Epidemiol .120 , 281-290. Niewind,A.C. ,Friele ,R.D. ,Edema ,J.M.P. ,Hautvast ,J.G.A.J .& Röling ,N.G . (1988):Th ediabeti cdiet :Patient' sperspectives .Submitted . Reid,V. ,Graham ,I. ,Hickey ,N .& Mulcahy ,R . (1984):Factor saffectin g dietarycomplianc ei ncoronar ypatient sinclude di na secondar ypreventio n programme.Hum .Nutr. :Applie dNut r38A ,279-287 . Reid,V .& Mulcahy ,R . (1987):Nutrien tintake san ddietar ycomplianc ei n cardiacpatients :6-yea rfollow-up .Hum .Nutr. :Applie dNutr .41A , 311-318. Rohan,T.E .& Potter ,J.D . (1984):Retrospectiv eassessmen to fdietar yintake . Am.J .Epidemiol .120 ,876-887 . Siegel,P.S .& Pilgrim ,F.J . (1958):Th eeffec to fmonoton yo nth eacceptanc e offood .Am .J .Psych .71 ,756-759 . Thompson,F.E. ,Lamphiear ,D.E. ,Metzner ,H.L. ,Hawthorne ,V.M .& Oh ,M.S . (1987):Reproducibilit yo freport so ffrequenc yo ffoo dus ei nth e Tecumsehdie tmethodolog ystudy .Am .J .Epidemiol .125 ,658-671 . Thuesen,L. ,Henriksen ,L.B .& Engby ,B . (1986):One-yea rexperienc ewit ha low-fat,low-cholestero ldie ti npatient swit hcoronar yhear tdisease .Am . J.Clin .Nutr .44 ,212-219 . -45-

Staverenvan ,W.A. ,West ,CE. ,Hoffmans ,M.D.A.F. ,Bos ,P. ,Kardinaal , A.F.M.,Va nPoppel ,G.A.F.C ,Schipper ,H.J. ,Hautvast ,J.G.A.J .& Hayes , R.B. (1986):Compariso no fcontemporaneou san dretrospectiv eestimate so f foodconsumptio nmad eb ya dietar yhistor ymethod .Am .J .Epidemiol .123 , 884-893. West,K.M . (1973):Die ttherap yo fdiabetes :A nanalysi so ffailure .Ann . Intern.Med .79 ,425-34 . -46-

5 Changes in food choices of insulin-dependent diabetic patients: one year follow-up

byA.C .Niewind ,R.D .Friele ,J.M.P .Edem a& J.G.A.J .Hautvas t

ABSTRACT

This studywa scarrie dou ta sa follow-u p froma previou s studyo f insulin-dependentdiabeti cpatient s (Niewinde tal ,1989a) . Inth epreviou s studyw edocumente d considerable changesi nfoo dus ea tfou rmonth s afterth e diagnosiso fth ediabete s compared tobefor e thatdiagnosis .Som eo fth e changes sucha sa lowe rus eo fhigh-fa t foods,wer e consistentwit hth e dietary guidelinesfo rdiabeti c patients,whil e increasedus eo fdiabeti c speciality foodsan dth ereductio n infoo dvariet ywer e less favorable froma nutritional perspective.Seventy-tw o subjects (45M ,2 7F ;90 %o fth eorigina l group)participate d inthi s follow-up study.Foo dus ewa sassesse da t1 6 months after thediagnosi so fdiabete sb ymean so fth esam e food frequency lista suse d inou rpreviou s study. Itappeare d that foodus ea t1 6month s after thediagnosi swa sno tremarkabl edifferen t from foodus ea tfou rmonths . Favorable froma nutritiona l perspectivewa sth ereductio ni nth eus eo f diabetic speciality foods.Unfavorabl e howevera decreas e inth eus eo f low-fat foods fromth emeat ,dair yan dsnac k food groups,an dth econcurren t increase inus eo fhigh-fa t foods.I twa sconclude d that insulin-dependent diabeticpatient sha dretaine dmos to fth efavorabl e changes infoo dus efo r at least1 6month s after thediagnosi so fth ediabetes .

INTRODUCTION

Ina stud yo nchange s infoo d choiceso frecentl ydiagnose d insulin-dependent diabetic patients,i twa sfoun d that fourmonth safte r thediagnosi s these patientsha dmad e considerable changesi nthei r food choicesi ncompariso nt o the situationbefor eth ediagnosi so fth ediabetes .Patient sha dreduce d their consumptiono fhigh-suga r foodsan dbeverages ,o ffatt yan dsalt y snacks,o f high-fat foodsfro mth edair yan dmea tgroup san do fcertai n foodswit ha hig h carbohydrate content.The yha dincorporate d low-fatfood san ddiabeti c speciality foods into their foodpattern .Overal l thefoo dvariet yha d decreased.Th estud y showed thatdiabeti c patientsmak ea deliberat e effortt o followth edietar y guidelines,althoug hno tal lth echange sar efavorabl ean d -47-

necessaryfro ma nutritiona lperspectiv e (Niewinde tal ,1989a) . Otherstudie so nchange si nfoo dchoice shav eshow nfavorabl eshort-ter m (Pietinene tal ,1984 ;Cole-Hamilto ne tal ,1986 )an dlong-ter mchange si n healthysubject safte rdietar yadvic e (Warwick,1988) .However ,som eo fthes e studiesuse dhighl ymotivate dsubject s(Cole-Hamilto ne tal ,1986 ;Warwick , 1988).Studie sinvestigatin glong-ter mdietar ycomplianc ei ncardia cpatient s foundgenerall ygoo dcomplianc ei nfollow-up sa t1 yea r (Karvetti,1981 ;Rei d etal ,1984 ;Thuesen ,Hendrikse n& Engby ,1986 )an deve na t6 year s(Rei d& Mulcahy,1987) .Howeve rthes estudie sdiffere dconsiderabl yi nintensit yo f dietarytreatment . Therei slittl einformatio nabou tth echange si nrespons et odietar yadvic ei n diabeticpatient so na short-ter man da mor elong-ter mbasis .N oinformatio n isavailabl eo nho wpatient sexperienc echange si nfoo dchoices .Therefor eth e aimo fthi sstud ywa stwofold .Firs to fal lt oinvestigat ewhethe rth e insulin-dependentdiabetic swh oha dparticipate di nth epreviou sstud yha d maintainedth efavorabl echange si nthei rfoo dchoice ssuc ha sa lowe rus eo f high-fatfood san dabandone dth eunfavorabl echange ssuc ha sa hig hus eo f diabeticspecialit yfood sa ton eyea rfollow-up .Secondly ,t ostud ywhethe r patientsthemselve sconsidere dtha tthe yha dmad echange si nfoo dchoice s duringthi sperio dan dfin dou twhethe rdifferen tcategorie so fpatient scoul d bedistinguished .

METHODS

Subjects Allsubject s (n=80,5 1M ,2 9F )wh oha dparticipate di nth epreviou sstud yo n foodus ebefor ean dafte rth ediagnosi so fdiabete swer einvite db ytelephon e toparticipat ei nth eon eyea rfollow-u po nthei rcurren tfoo duse .

Foodus e Inou rpreviou sstud yo fApri l1987 ,foo dus ewa sassesse db ymean so fa foo d frequencyquestionnaire .I nthi sstud yw euse dth esam eapproac ht odetermin e foodus ea sw eha dapplie di nou rpreviou sstudy .Th estud ywa scarrie dou t exactlyon eyea rafte rth epreviou sstud yt oavoi dan ydistortio ndu et o seasonaleffect so nfoo duse . Thefoo dfrequenc yquestionnair econsist so fa lis to ffood san da se to f frequencyrespons eoption st oindicat efrequenc yo fconsumptio no feac hfoo d duringa give ntim eperiod .Th efoo dlis tcontaine d17 7food srepresentin ga -48-

cross-sectiono ffood scommonl yavailabl ei nth eNetherland san dfood sknow n tob euse db ydiabeti cpatient s (Niewinde tal ,1988) .I naddition ,th e frequencyo fus ewa sassesse do ffrie dan dgrille dmeats ,frie dan dboile d eggsan dfrie dan dboile dfish .Th equestionnair ei sdescribe di ndetai l elsewhere (Niewinde tal ,1989a) . Theus eo feac hfoo dwa sassesse db ymean so fa 9-poin tfrequenc yscale .Th e pointso nth escal ewere :> 3time sa day ,2- 3time sa day ,onc ea day ,4- 6 timesa week ,2- 3time sa week ,onc ea week ,2- 3time sa month ,onc ea mont h andles stha nonc ea month . Respondentswer eals oaske dth etyp eo fsweetene rthe yuse di nthei rte aan d coffeean dth etyp eo fsprea dthe yuse do nbread :butter ,margarine ,low-fa t margarineo rmargarin ewit hhig hamount so fpoly-unsaturate dfatt yacids .Als o thetyp eo ffa tuse dfo rfryin gwa sassessed :butter ,margarine ,low-fa t margarine,margarin ewit hhig hamount so fpoly-unsaturate d fattyacid so roil . Theus eo fthes efood swa srecorde db ymean so fa dichotomou svariabl ewit h answercategorie syes/no .

Self-observedchange si nfoo dchoice s Toexamin ewhethe rpatient sthemselve sthough ttha tthe yha dmad ean ychange s infoo dchoice sbetwee n1987-1988 ,the ywer easke dopen-ende dquestions .The y wereaske dwhethe rthe yha dmad ean ychange si nfoo dchoice sdurin g1987-1988 , andi fso ,whic hkin do fchange san dwha tha dmotivate dthem .Th eeffect so f gender,ag ean deducatio nwer eassesse do nth etyp eo fchang edescribed .

Dataanalysi s Weuse dth elarg esampl eapproximatio no fth eWilcoxe nmatche dpai rtes twit h correctionsfo rtie ddifference st oasses sth edifference si nth efrequenc yo f usebetwee n198 8an d198 7fo reac hindividua lfood .Fo rzer odifference sth e midrank (P+ l)/ 2wa sassigne dt oth ep zer odifferences .Fift ypercen to fth e differencesreceive da positiv emidrank ,th eothe r50 %a negativ emidrank .Th e distributiono fth ecompute dZ-value sapproache sth estandar dnorma l distribution. Achi-squar etes tfo rhomogeneit yo fproportion sfo rcorrelate ddichotomou s variables,th eMcNema rtest ,wa suse dt oanalyz echange si nth eus eo f sweetenersi nte aan dcoffe ea swel la sth etyp eo fsprea do nbrea dan dth e typeo ffa tfo rfryin g (Marascuilo& McSweeney ,1977) . -49-

RESULTS

Subjects Ofth e8 0subject sapproached ,7 2(90% )participate d inth efollow-u pstudy . Eightsubject sdi dno tparticipat efo ra variet yo freasons :on esubjec tha d movedou to fth ecountry ,tw ocoul dno tb ereache do rlocated ,on ewa sunabl e toparticipat edu et osever eillnes san dfou rchos eno tt oparticipat ei nthi s follow-upstudy . Thegenera lcharacteristic so fth esubject so fth efollow-u pstud ywere :4 5 malesan d2 7females ,thei rag ei nyear swa s30. 3+ 5. 6 (mean+ sd),an dth e durationo fthei rdiabete swa s16+ 1 months(mea n+ sd )a tth etim eo fth e interview.Leve lo fschoo leducatio nwa sclassifie daccordin gt oth e InternationalStandar dClassificatio no fEducatio nb yUnesco ,adapte dt oth e Dutcheducationa lsyste m(Netherland sCentra lBurea uo fStatistics ,1988) . Firstleve leducation ,(primar yeducation) ,ha dbee ncomplete db y4 %o fth e subjects.Thirty-tw opercen to fth epopulatio nha dcomplete dsecon dleve l education,firs tstag e (generaleducation ,grade s1-3) .Secon dlevel ,secon d stageeducatio n (generaleducation ,grade s4- 6an dsenio rvocationa ltraining ) hadbee ncomplete db y39 %o fth esubjects .Twenty-fiv epercen to fth e populationha dcomplete dthir dleve leducatio n(vocationa lcolleg ean d university).Fo r93 %o fth erespondent sinsulin-dependen tdiabete swa sth e onlydiseas efo rwhic hthe ywer eunde rmedica ltreatment .

Foodus e Thedifference si nth eus eo ffood sbetwee n4 an d1 6month safte rth e diagnosiso fth ediabete sar epresente di nTabl e1 .Onl y3 2food s(18% )ha d changedsignificantl yi nfrequenc yo fuse ,o fwhic h10 %a tp < 0.0 1an d8 %a t thep < 0.05 .W efoun da decreas ei nfrequenc yo fus ea t1 6month sfo r1 9 foods,whil efo rthirtee nfood sw efoun da nincreas ei nfrequenc yo fus ea t1 6 months. Themos tconspicuou schang ewa sa decreas ei nth eus eo fdiabeti cspecialit y foods.W efoun da decreas ei nfrequenc yo fus ea t1 6month sfo r6 food so f thisfoodgroup .Fou rhigh-suga rfood swer euse dmor efrequentl ya t1 6month s thana tfou rmonth safte rth ediagnosi so fth ediabetes :chocolat espread , cookies,frui tpi ean dcandy . -50-

Table 1.Difference s inth eus eo f 177food sbetwee n 4an d 16month safte r the diagnosiso f thediabete sb y 72 insulin-dependent diabetic patients (1).

Food group N Increase in foodus e -> 4 months 16month s

Diabetic speciality 15 chocolate** foods cookies** candy** jam** lemonade** softdrinks* * High sugar foods 14 chocolate spread** cookies** fruitpie* * candy*

Meats and alternates 27 cold cuts,lean* * fish, fried** fish,lean * bologna,salami * chicken* meat, canned*

Dairy foods 21 cottagecheese * buttermilk* cheese spread,skim *

Snacks,miscellaneou s 21 broth* mayonnais1KP e* vegetablesnacks *

Bread and cereals 21 bread,brown* * bread,white* * crackers** pasta*

Vegetables and fruits 43 vegetables,boiled** frenchfries * potatoes,boiled* * bananas* oranges**

Beverage 15 beer**

1.Onl y foodswit hZ-value sa tp <0.0 5 are reported, **p <0.01 , *p <0.05 .

Several low-fat foodsfro mth emea tan dalternate sgroup ,th edair ygrou pan d the snack andmiscellaneou s group sawa reduction infrequenc y ofus e during the follow-upperiod ,whil ea t the sametim e theus e ofhigh-fa t foods from these foodgroup swa s increased. Theus e ofbrow nbrea d and crackerswa shighe r at fourmonths thana t 16 monthswhil e theus eo fwhit ebrea d andpast awa shighe r at 16months thana t fourmonths afte rdiagnosi so fdiabetes . We found ahighe r consumptiono fboile d potatoes,boile dvegetable s ando f oranges at fourmonths afte r thediagnosi s thana t 16months ,an da highe rus e -51-

offrenc hfrie san dbanana sa t1 6tha na t4 months . Finally,th econsumptio no fbee rwa shighe ra t1 6month stha na tfou rmonths . Table1 suggest sa decreas ei nfoo dvariet ydurin gthi speriod .However ,a moredetaile dloo ka tdietar yvariet yreveale da differen tpatter n (Table2) .

Table2 .Difference si ndietar yvariet ybetwee n4 an d1 6month safte rth e diagnosiso fth ediabete si n7 2insulin-dependen tdiabeti cpatient s (1). Numbero ffood sa t

Typeo fdietar yvariet y 4month s 16month s T-value(2 )

mean+ s d mean+ s d

Totalnumbe ro ffood suse d 68± 1 5 70± 1 4 1.7

Numbero ffood suse dfro monc e amont ht o2- 3time sa wee k 52+ 1 5 57+ 1 4 4.2**

Numbero ffood suse d4- 6 timesa wee ko rmor e 16+4 13+4 6.6**

1.N=7 2insulin-dependen tdiabeti cpatients . 2.Paire dt-test ,* *p < 0.01 .

Theoveral ldietar yvariet y (defineda sth etota lnumbe ro ffood sconsume d overon emonth )(Fanell i& Stevenhagen ,1985 )di dno tchange .However ,w e founda nincreas ei nth enumbe ro ffood suse dbetwee nonc ea mont han d2- 3 timesa wee kan da decreas ei nth enumbe ro ffood suse d4- 6time sa wee ko r more.Th efigure ssho wa noveral ltendenc ytoward sa decreas ei nfood suse d veryfrequentl yan da nincreas ei nfood suse dincidentally .

Foodpreparatio n Withregar dt ofoo dpreparatio nn ochang ewa sobserve di nth efrequenc yo fus e offrie dan dgrille dmeats ,frie dan dgrille dfis han dfrie dan dboile deggs . Alson ochang ewa sfoun di nth etyp eo fsweetene ruse di ncoffe ean dtea ,th e typeo fsprea do nbrea dan dth etyp eo ffa tfo rfrying .

Self-observedchange si nfoo dchoice s Changesi nfoo dchoice sdurin gthi sperio dwer ereporte db y69 %o fth e patients,whil e31 %indicate dtha tthe yha dno tmad ean ychange s(Tabl e3) . -52-

Table3 .Proportio n (%)o fpatient s reporting self-observed changesi nfoo d choicesdurin g 1987-1988(1) .

Typeo fchang ei nfoo d choice N

No change 22 31

Change 50 69 experimenting/mor e relaxed aboutth edie t 37 51 changed living conditions 8 11 more health-conscious 5 7

1.N=7 2 insulin-dependentdiabeti cpatients .

Patientswh oha dmad e changesi nfoo d choiceswer edivide d into threegroups . Mosto fthes e toldu stha t theywer e experimentingo rha drelaxe d their attitude towardsth ediabeti cdie t (51%). Manyo fthe m indicated thata sa result theyha dincrease d thefrequenc yo fus eo fhigh-suga r foods,high-fa t foodso ralcoholi c beverages.Eleve npercen to fth epatient sha dmad e changes infoo d choicesdu et oa chang e inthei r living conditions sucha semploymen t statuso rsiz eo fth ehousehold . Sevenpercen to fth epatient s indicating changes infoo dchoices ,expresse d that theyha dbecom emor ehealt hconscious . They indicated thatcompare d toth eyea rbefor e theyuse dmor e foodswit ha low-fat and/or high-fiber content.Patient swh oha dreporte dn ochang e infoo d choicesdurin gth e1987-198 8perio d expressed that theywer e satisfied with theirdiabeti cdie tan dtha t theyha dfel tn ourg e tomak ean ychanges .

Table4 .Th eeffec to fleve lo fschoolin go nself-observe d changesi nfoo d choices.

Typeo fchang ei n School attainment food choice first, second level third level N=54 N=18

No change 20

Change experimenting/mor e relaxed aboutth edie t 24 13J

* Fisher's exact test, p = 0.02. -53-

Noeffec to fth evariable sgende ran dag eo nth etyp eo fself-observe dfoo d changeswa sfound .Th eeffec to fschoo leducatio no nchange si nfoo dchoice s isshow ni nTabl e4 .Th etendenc yt oexperimen twit hth edie twa s significantlymor eprevalen tamon gthos ewit hhighes teducationa lattainmen t (p= 0.02) .

DISCUSSION

Inthi sfollow-u pstudy ,i nwhic h90 %o fth eorigina lgrou pparticipated ,w e foundonl ymino rchange si nfoo duse .I nth epreviou sstudy ,whic hassesse d thechange si nfoo dus edurin gth efirs tfe wmonth safte rth ediagnosi so f diabetes,51 %o fth efood sshowe da significan tchang ei nus e (p< 0.01) , whilei nthi sfollow-u pstud yonl y18 %o fth efood swa saffected :10 %a t p< 0.0 1an d8 %a tp < 0.05 .Th eresult so fth efoo dus estud ysho wtha t diabeticpatient sjus tlik ecardia cpatient sar eabl et omaintai ndietar y changesi nfoo dus eo na long-ter mbasi s(Karvetti ,1981 ;Rei de tal ,1984 ; Thuesen,Hendrikse n& Engby ,1986 ;Rei d& Mulcahy ,1987) .Th emajo rchange si n foodus edetermine ddurin gth efirs tfe wmonth san dth emino rchange si nfoo d usebetwee n4 an d1 6month safte rth ediagnosi so finsulin-dependen tdiabetes , demonstrateth estrengt ho fmotivatio ni nthes epatients .Othe rstudie sw e carriedou tals osho wtha ti ncompariso nt ohealth yperson sinsulin-dependen t diabeticpatient shav ea tendenc yt obas ethei rfoo dchoice so nperceive d healthcharacteristic so ffoods ,als oa nindicatio nfo rth emotivatio nfo r properfoo dchoice samon gthi spopulatio n (Niewinde tal ,1989b ,Niewin de t al,1989c) . Themos tobviou schang ei nfoo dus edurin gthi sfollow-u pstud yi sth e reductioni nth eus eo fdiabeti cspecialit yfoods .Shortl yafte rth ediagnosi s ofdiabetes ,th eus eo fthes efood sha dbecom erathe rhigh ,especiall yo f sweeteners,lemonades ,jams ,chewin ggu man dcandies .Diabeti cspecialit y foodsar eno ta nessentia lpar to fth ediabeti cdiet .Man yo fthes efood sar e expensivean dofte nar eno tparticularl ypalatable .Th edecrease dus eo fth e diabeticspecialit yfood sdurin gth efollow-u pyea rseem stherefore ,a favorabledevelopment .Th eus eo ffood scontainin gsucros ei sincreasing , althoughth eexten to fthi sincreas ei sno ta sremarkabl ea sth ereductio ni n theus eo fdiabeti cspecialit yfoods .A slon ga si ti sa naccepte dbelie fi n oursociet ytha tpatient swit hdiabete sshoul davoi dal lsugar yfoods , diabeticspecialit yfood sma yb eusefu lfo rrecentl ydiagnose ddiabetics . Obviouslyth epatien twil llear ndurin gth efirs tyea rtha tth edie tallow s -54-

the consumptiono f sucrose.A s a result theywil lus e high-sugar foodsmor e frequently,thu s reducing the frequencyo fus eo fdiabeti c specialityfoods . However,th eus e ofhigh-suga r foods isstil l lower thanbefor e thediagnosi s ofdiabetes . During the first fewmonth safte r thediagnosi s ofth ediabetes ,th eus e of low-fat foodswa s increased,wit h a simultaneousdecreas e inth eus e of high-fat foods.Th eus eo f severalhigh-fa tfood s fromth emeat ,dair y and snack groupswa shighe r at 16month s thana t 4month safte rdiagnosis .A t the same time theus e of the low-fat foods from these foodgroup swa s decreased. Thisdevelopmen t isles s favorable froma nutritiona l perspective (Crapo, 1986;Mann ,1986 ;America nDiabete sAssociation , 1987). Inorde r to reduce the onsetan ddevelopmen to fdiabeti ccomplications ,tota l fatintak e should be less than 30-35%o f totalenerg y intake and saturated fats should be partly replaced byunsaturate d fats.Th e increasedus e of somehigh-fa t foodsmigh t beexplaine d as follows.Fo rpatients ,high-fa t foodsar e generally cheaper thanlea n foodsan dman ypatient sprefe r certainhigh-fa t foods.I nadditio n theus e ofhigh-fa t foodsdoe sno t result inan y short-termnegativ e health effectspatient smigh tnotice .Fo rpatients ,th econsumptio no fhigh-fa t foods has several positive effectso n the short-term,whil e thenegativ e effects might onlyb enoticeabl e at the long-term. Inthi s studyw euse d thedefinitio nb y Fanelli &Stevenhage n (1985)o f dietaryvariet yan d adapted itb y counting the foods frequentlyuse d and the foodsuse d incidentallydurin g the 30-day study.Th e totalnumbe r of foods consumed during this timedi d not change.However ,th enumbe r of foodsuse d very frequentlydecreased , suggesting a lessmonotonou s foodpattern .Th e number of incidentallyuse d foods increased,whic h suggests an increased food variety.Amon gnutritionist sdietar yvariet y ishighl yvalued ,a s it is supposed tob e the key foroptima l nutrition (Fanelli &Stevenhagen ,1985 ; Randall,Nichama n &Contant ,1985 ;Krebs-Smith ,Smiciklas-Wright ,Guthri e & Krebs-Smith, 1987). However,ther e isn oagreemen to n thedefinitio no f dietaryvariet y andwha t itincludes . The resultso f the studyo n self-observed changes in food choices showed that 51% of thepopulatio n expressed having started experimenting or having become more relaxed about thediet ,whic h especiallyapplie d topatient swit h high schooleducation .Th e fact that somepatient s startexperimentin gwit h their dietsan d try foodsbanne d from their foodpatter n for some timeha sals obee n documented byHacLea n& Ora m (1988). Inthei r opinion,b yexperimentin g with thedie t thepatien t learnst otak e responsibility forhi sow ndisease .The y -55-

see experimentationwit h thedie ta sa positiv e development.Th e finding that some subjectsmad echance s infoo dchoices ,whil e othersdi dnot ,ma y explain themino r overall changes infoo duse .Divisio no f thepopulatio n into several subgroupsan d examination of thedifferen t typeso f change in food choices would beuseful . A large sample size is required for this type of study.

Inconclusion , the favorable changes infoo dus e assessed during the first few month after thediagnosi s of thediabete shav ebee nmaintaine d toa large extent at 16month s after thediagnosi s ofth ediabetes .W e found amino r reversal infoo dus edurin g the follow-upstud y inth e formo fa n increased use ofhigh-fa t foodsan da decrease d use oflea n foods.Favorabl e froma nutritional perspective isth edecreas e inus e ofdiabeti c speciality foodsa t 16month s compared to4 month safte r thediagnosis .Som eo f thepatient s had started experimentingwit h thedie tb y trying foodspreviousl y banned from their foodpattern .W e concluded thatpatient sar emotivate d tochang e their food choices ona short-term ando na mor elong-ter mbasis .

ACKNOWLEDGEMENTS

Thiswor k hasbee n supported bygrant s from theMinistr y ofWelfare ,Healt h and CulturalAffairs ,Th eHague ,th eNetherland s and theWageninge n Agricultural University, theNetherlands . The assistance fromMr sJ.C.M.M .Nooy-Michel swit h the collection of thedat a and fromM sM .Eimer swit hdat aanalysis ,i smos t gratefully acknowledged.

REFERENCES

American DiabetesAssociatio n (1987):Nutritiona l recommendations and principles for individualswit hdiabete smellitus :1986 .Diabete s Care10 , 126-132. Cole-Hamilton,I. ,Gunner ,K. ,Leverkus ,C .& Starr ,J . (1986):A studyamon g dietitians andadul tmember s of theirhousehold s of thepracticalitie s and implications of following proposed dietaryguideline s for theU.K . Hum. Nutr.:Appl .Nutr . 40A,365-389 . Crapo,P.A . (1986): Carbohydrate inth ediabeti cdiet .J .Am . Coll.Nutr . 5, 31-43. Fanelli,M.T .& Stevenhagen ,K.J . (1985): Characterizing consumption patterns by food frequencymethods :Cor e foodsan dvariet y of foods indiet s of olderAmericans .J .Am .Diet .Assoc .85 ,1570-1576 . Karvetti,R . (1981): Effectso fnutritio n education.J .Am .Diet .Assoc .79 , 660-667. Krebs-Smith,S.M. , Smiciklas-Wright,H. ,Guthrie ,H.A . &Krebs-Smith , J. (1987): The effects ofvariet y infoo dchoice so ndietar yquality .J . Am. Diet.Assoc .87 ,897-903 . -56-

MacLean,H .& Oram ,B . (1988):Livin gwit hDiabetes .Toronto :Universit yo f TorontoPress . Mann,J . (1986):Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J .Am .Coll .Nutr .5 ,1-7 . Marascuilo,L.A .& McSweeney ,M . (1977):Nonparametri can dDistribution-Fre e Methodsfo rth eSocia lSciences .Monterey :Brooks/Col ePublishin gCompany . NetherlandsCentra lBurea uo fStatistic s (1988):Statistica lYearboo ko fth e Netherlands1987 .Th eHague ,Staatsuitgeverij/CBS-publications . Niewind,A.C. ,Friele ,R.D. ,Edema ,J.M.P. ,Hautvast ,J.G.A.J .& Röling ,N.G . (1988):Th ediabeti cdiet :Patients 'perspectives .Submitted . Niewind,A.C. ,Friele ,R.D. ,Kandou ,C.Th. ,Hautvast ,J.G.A.J .& Edema ,J.M.P . (1989a):Change si nfoo dchoice so frecentl ydiagnose d insulin-dependent diabeticpatients .Submitted . Niewind,A.C. ,Friele ,R.D. ,Edema ,J.M.P .& Hautvast ,J.G.A.J .(1989b) :Foo d perceptionsan dfoo dus eo frecentl ydiagnose dinsulin-dependen tdiabeti c patients.Submitted . Niewind,A.C. ,Friele ,R.D. ,Edema ,J.M.P .& Hautvast ,J.G.A.J .(1989c) : Differencesi nfoo dperception san dfoo dus ebetwee ninsulin-dependen t diabetican dnon-diabeti csubjects .Submitted . Pietinen,P. ,Dougherty ,R. ,Mutanen ,M. ,Leino ,U. ,Moisio ,S. ,Iacono ,J .& Puska,P . (1984):Dietar yinterventio nstud yamon g3 0free-livin gfamilie s inFinland .J .Am .Diet .Assoc .84 ,313-318 . Randall,E. ,Nichaman ,M.Z .& Constant ,CF . (1985):Die tdiversit yan d nutrientintake .J .Am .Diet .Assoc .85 ,830-836 . Reid,V. ,Graham ,I. ,Hickey ,N .& Mulcahy ,R . (1984):Factor saffectin g dietarycomplianc ei ncoronar ypatient sinclude di na secondar ypreventio n programme.Hum .Nutr. :Appl .Nutr .38A ,279-287 . Reid,V .& Mulcahy ,R . (1987):Nutrien tintake san ddietar ycomplianc ei n cardiacpatients :6-yea rfollow-up .Hum .Nutr. :Appl .Nutr .41A ,311-318 . Thuesen,L. ,Henriksen ,L.B .& Engby ,B . (1986):One-yea rexperienc ewit ha low-fat,low-cholestero ldie ti npatient swit hcoronar yhear tdisease .Am . J.Clin .Nutr .44 ,212-219 . Warwick,P.M . (1988):Dietar yintak eo fhealth ysubject sbefor ean don eyea r afterdietar yadvice .Eur .J .Clin .Nutr .42 ,437-444 . -57-

6 Food perceptions and food use of recently diagnosed insulin- dependent diabetic patients

byA.C .Niewind ,R.D . Friele,J.M.P .Edem a& J.G.A.J .Hautvas t

ABSTRACT

We assessed foodperception so feigh tdair yproducts ,fou rmil kan dfou r dairy dessertproducts ,an dth econnectio nbetwee n foodperception san dfoo dus ei n 72 recentlydiagnose d insulin-dependentdiabeti c patients.Th efoo d perceptions studiedwer eth evalu eo fa foo di nligh to fth efollowin g aspects: general health,short-ter man dlong-ter mhealth ,tast ean d convenience.Perception swer eassesse db ymean so fa Likert-typ e scale,us e was ratedo na 9-poin tfoo d frequency scale.Result s showth ethre ehealt h perceptionsan dth econvenienc eperceptio nt ob eclosel y related, indicating thatpatient s perceivea foo da seithe r healthyo rno thealth yan dtha t they dono tdiscriminat ebetwee ndifferen thealt hvalue so ffoods .Generally , diabetic patients tendt orejec t foodswit hhigh-fa tand/o r sugar contents becauseo fthei r supposedlo whealt hvalues .Tast ei sth estronges t determinant forus eo fthos e foodswhic h froma healt hperspectiv ear eno t rejected.Th eimplication so fthes e resultsfo rnutritio neducatio nfo r diabeticpatient sar ediscussed .

INTRODUCTION

Studieshav e shownthat ,afte rth ediagnosi so fthei rdisease , insulin-dependent diabetic patients significantly changeth efrequenc yo fus e ofman y foods.However ,no tal lchange si nfoo dus ear ebeneficia lan d necessary froma nutritiona lperspectiv e (Niewinde tal. , 1988). Theselectio n ofa particula r foodfo rconsumptio ni sdetermine db ya numbe ro flearne d food choicemotive so rfoo dperceptions .Thes e havebee ncategorize db yKrond l and Lau (1978)a scultural ,socia lan dpersonal .Other shav e referredt oth esam e phenomenaa s'connotativ emeanings ' (Fewster,Bostia n& Powers ,1973 ) or 'attributions' (Prättälä& Keinonen , 1984). Resultso fsevera l studiesamon ghealth yan delderl ypopulation s showtha tth e foodperception s sucha staste ,health ,convenience ,familiarity ,prestig ean d tolerance haveth estronges t correlationswit h fooduse ,tast ean dhealt h beingth emos t important food selectiondeterminants .Furthermore ,se xan dag e -58-

differences in foodperception shav ebee n identified (Zimmerman &Krondl , 1986; Prättälä &Keinonen ,1984 ;Georg e &Krondl ,1983 ;Krondl ,Lau ,Yurki w& Coleman, 1982;Lau ,Hanada ,Kaminsky j& Krondl ,1979 ;Reaburn ,Krond l &Lau , 1979). Toou r knowledge,n o studieshav eye t investigated the foodperception s of insulin-dependent diabeticso r anyothe r populationwit ha chronic illness. Thehealt hperceptio n of foods issuppose d tob ever y important topatient s who havebee ndiagnose d ashavin g a chronic illness (Krondl &Coleman , 1986). Todiabeti c patientshealt hha s severalaspects :Firs to fal l theaspec to f general health,secondl y short-termhealth ,relate d toth e regulationo f blood glucose levelsan d thirdly long-termhealth ,relate d toth epreventio n of long-termdiabete s complications,especiall yhear tdisease .W e assumed that investigation of these three healthperception swoul dproduc e information useful tounderstan d theproces s that leads toa healt hperceptio n offoods . Taste, representing sensory experienceswit h foods,i sa strong foodus e determinant toal l individuals.A sdiabeti c patientshav e toea t threemai n meals and three snacks containing carbohydratesdurin g theday ,th e convenience perception of foodswa s supposed tob e relevant for thisgroup . Inthi spape rw e examined the foodperception so fgeneral ,short-ter m and long-termhealth ,tast e andconvenienc e ina grou po f recently diagnosed insulin-dependent diabetic patients.Th eai mwa s specifically tocompar e the foodperceptio n profiles andus e of thedifferen t foods.Informatio no nth e use of foodswa sutilize d toclarif y thepossibl e relationsbetwee n foodus e and foodperceptions .

METHODS

Subjects All subjectswer e participants ina studyo n foodus e before and after the diagnosis of theirdiabete s (Niewind et al., 1988). Individualswer e recruited among those patient-members of theDutc hDiabete sAssociatio nwh oha d joined theorganizatio ndurin g the threemonths prio r toth e foodus e study.O f the 187person s approached 176 (94%)wer ewillin g toparticipate .However , 50%o f thegrou pdi dno tmee t the selection criteria applied for the foodus e study. Theyha d either non-insulin-dependent diabetes orwer ediagnose d as diabetics too longago .Fro mth e8 8peopl ewh odi dmee t the selectioncriteria ,7 2 (45 males, 27 females)participate d inthi s study. All subjectswer ebetwee n 20 -59-

and 40year s ofag e andha dbee ndiagnose d as insulin-dependent diabetics between 14 to1 8month sprio r toth e foodus e study.

Food perceptions The foodswer e judged forgenera l health,preventio no fhear tdisease ,bloo d glucose level control,tast e and convenience.Al l perceptionswer emeasure d by means ofa 5-pointLikert-typ e scale,rangin g from 'verygood ' to 'verybad' . As the aimo f thisstud ywa s tocompar e foodperceptio nprofiles ,a homogeneousgrou po f foodsha d tob e selected.W e conducted apre-tes t to investigate other important conditions foods shouldmeet .Result s showed that besides theabove-mentione d selection criterion,a second criterionwa s that foods should notb eeate n togetherwit h other foods,a s thiswoul d create difficulties for the interpretation of foodperceptions .A third conditionwa s that foods shouldb e consumedwit hvaryin g frequencies.Finally , foods should havedifferen t nutrientprofiles ,meaningfu l toth epopulatio n of the study. Fordiabeti c patients foods shouldb e includedwit hdifferen t amounts of fat and/or sugar and/or starch.Dair y foods fulfilled all above-mentioned requirements. Fourmil k products (low-fatmilk ,whol emilk ,chocolat emil k and buttermilk)an d fourDutc hdair ydesser tproduct s (skimyoghurt ,whol e yoghurt,cottag e cheese and custard)wer e selected for the study.

Foodus e Toasses s theus eo f theeigh tdair yproducts ,th e food frequencymetho d was applied.Thi smetho d consistso fa lis to f foodsan d a seto f frequency response options toindicat e frequencyo fconsumptio no f each fooddurin ga given timeperiod .Th eus e ofeac h foodwa smeasure d bymean s ofa 9-poin t food frequency scale.Th epoint so n the scalewere :> 3time sa day ,2- 3 times a day,onc e aday , 4-6 timesa week , 2-3 timesa week ,onc e aweek ,2- 3 times a month,onc e amont h and less thanonc ea month .

Data analysis Due to skewed data,no nparametri c statisticswer eused .T o compare the food perception profilesan d theus eo f thedair yproducts ,th eWilcoxo n matched-pair testwa suse dwit h corrections for tiedan d zeroobservations . The effect ofgende r on foodperception san d foodus ea swel l as theeffec to f user-type on foodperception swer e assessed bymean so f theMann-Whitne y test. As the sample sizewa s larger than 30,th eZ-statisti c was calculated (Marascuilo &McSweeney , 1977). Todetermin e the relationshipbetwee n the five -60-

food perceptions foreac hdair yproduc tan d theassociatio nbetwee n foodus e and foodperceptions ,Kendall' s taucorrelation swer e applied. In circumstances inwhic h Kendall's taucorrelatio n isnormall yused ,a coefficientvalu e inth e0.75-1.0 0rang ewoul d indicate a strong relationship; however, inligh to f thenatur eo f thisstudy ,wit hnumerou s factors influencing fooduse ,i twa sunlikel y thata single factorwoul d be found having anassociatio nwit h foodus e inthi s range.Therefore ,i n foodus e studiesassociation s of 0.30 orhighe r are considered a relatively strong relationship (George& Krondl ,1983) .Al l testswer edon eusin ga two-tailed test for significances.

RESULTS

Thepercentag e ofuser-type so f theeigh tdair yproduct sar epresente d in Table 1.Result s showsignifican tdifference s inth eus e of the following foods (p< 0.01). Low-fatmil k isuse dmor e frequently thanwhol emilk , chocolate milk,o rbuttermilk .Buttermil k isuse dmor e frequently than chocolatemilk .Ski myoghur t isuse dmor e frequentlytha nwhol eyoghurt , custard and cottage cheese,wit hwhol eyoghur t beinguse dmor e frequently than custard.

Table 1.Percentage so fuse r typeso fdair yproduct s (n=72).

Dairy Product < — Users — > Non-users Daily Weekly Monthly Lesstha n oncea mont h (1) (2) (3)

Low-fatmil k 54 17 4 25 Buttermilk 17 8 14 61 Whole milk 3 8 10 79 Chocolatemil k - 8 3 89

Skimyoghur t 26 40 8 25 Custard 6 25 13 57 Cottage cheese 1 8 22 68 Whole yoghurt 1 13 4 82

1.a t leastonc ea day . 2.a t leastonc ea week ,bu tno t daily. 3.a t leastonc e amonth ,bu tno tweekly .

The average ratingso fal l fiveperception s foreac hmil k product are displayed inFigur e 1.Compariso no f the foodperceptio nprofile s revealed -61-

convenience convenience

Figure 1 : The average ratings (1-5) of low fat Figure 2: Theaverag e ratings(1-5 ) of skim milk(i), buttermilk!»), whole milk(•) yoghurt (»), custard(•) , cottage and chocolate milk(•) (N= 72). cheese(i) andwhol eyoghurt!» ) (N=72). significant differences (p< 0.01 )fo rth efollowin g pairso fmil k products. Onal lfiv eperception s low-fat milk isperceive d ofa spreferabl e comparedt o whole milk. Low-fat milk isperceive d ashealthier ,bette r forth epreventio n ofhear t diseasean dfo rbloo d glucose level control,als o iti sconsidere d more convenient than chocolate milk.Buttermil k isperceive d ashealthier , preferable with respectt ohear tdiseas ean dbloo d glucose level control,an d more convenient thanbot hwhol e milk andchocolat e milk. Low-fat milki s perceived asbette r tasting thanbuttermilk .Whol e milk isperceive da s healthier,bette r forbloo d glucose levels,an dmor e convenient than chocolate milk. The average ratingso fal lfiv e perceptions foreac hdair y dessert productar e displayed inFigur e 2.Compariso no fth efoo dperceptio n profiles revealed significant differences (p< 0.01 )fo rth efollowin g pairso fdair ydesserts . Skimyoghur t isperceive d ashealthier ,preferabl e with respectt ohear t disease andbloo d glucose level control,an da smor e convenient than whole yoghurtan dcustard . Cottage cheese isperceive d ashealthier ,preferabl efo r heart disease preventionan dbloo d glucose level control anda smor e convenient thanbot h custardan dwhol eyoghurt .However ,whol e yoghurt isperceive d asbette r tasting than cottage cheese.Ski myoghur t isperceive d aspreferabl e forbloo d glucose level control,an dbette r tasting than cottage -62-

cheese.Whol e yoghurt isperceive d aspreferabl e forbloo d glucose level control andmor e convenient than custard. Gender differences in foodperception swer e found forbuttermilk , cottage cheese, skimyoghur t and custard (Table 2). Females perceived buttermilk as healthier,bette r forbloo d glucose level control and for thepreventio n of heart disease,an d better tasting thanmale s did. Females also perceived cottage cheese ashealthier ,preferabl e forbloo d glucose level control,an d more convenient thanmales . Skimyoghur twa sperceive d ashealthie r by females aswell . Malesperceive d custard asmor e preferable forbloo d glucose level control than females did.Wit h respect to foodus e the onlydifferenc e was thatmale suse d low-fatmil k more frequently than females (p< 0.05).

Table 2.Difference s between males and females in foodperception s among insulin-dependentdiabeti c patients(1) .

Perceived asmor e valuable Perceived asmor e valuable by males by females

Product Perception Z (2) Product Perception Z (2) custard blood glucose 2.3* buttermilk health 3.4** blood glucose 2.8** heart disease 2.3* taste 2.0* cottage cheese health 2.5** blood glucose 2.4* convenience 2.3* skim yoghurt health 2.4*

1.Onl y foods indicating a significant difference in foodperception s at p <0.0 5 are reported. 2. Levels of significance **p <0.01 ; *p < 0.05.

Differences in food perception betweenuser s and non-users for each of the eight dairy products are shown inTabl e 3.User swer e defined as those using the food at least once amonth ,an d non-users as thoseusin g the food less than once amonth . For foodswit h a small percentage of respondents inon e of the twouse r groups,n odifference s in food perceptions were found, except for taste perception of low-fat milk and chocolate milk. Significant differences in food perceptionswer e observed for foodswit h amor e equal distribution of users and non-users,suc h asbuttermilk , custard and cottage cheese.Fo r these three foodsuser s had ahighe r opinion of these foods onmos t food perceptions compared tonon-users . -63-

Table 3.Difference s in foodperception s ofuser s andnon-user s (1)o f dairyproduct s among insulin-dependentdiabeti c patients(2) .

Perceived asmor e valuable Perceived asmor evalueabl e by users bynon-user s

Product Perception Z (2) Product Perception Z (2)

buttermilk health 3.5** blood glucose 3.5** heart disease 3.0** convenience 2.6** taste 4.8** custard health 2.7** blood glucose 3.8** convenience 2.8** taste 4.8** cottage cheese health 3.9** heart disease 3.2** blood glucose 2.9** taste 4.4** low-fat milk taste 4.2** chocolate milk taste 2.3*

1.User s are thosewh ous e the food at least once amonth ,non-user s those whous e the food less thanonc e amonth . 2.Onl y foods indicating a significant difference in food perceptions at p <0.0 5 are reported, levelso f significance ** p <0.01 ; *p < 0.05.

The correlations between foodperception s and foodus e are shown inTabl e 4. It isapparen t that taste perceptions have thehighes t correlation with food use, both in termso f association (allabov e 0.45) and inth e number of foods. The perception of general healthwa s associated with theus e ofbuttermil k and cottage cheese,whil e thebloo d glucose level perception related to theus e of buttermilk, cottage cheese and custard.Al l associations were inth e0.30-0.4 0 range.Th e heart disease and convenience perceptions were associated with the use of cottage cheese only. For each of the eightdair y products,w e evaluated the relationships between perceptions of general health,hear tdisease ,bloo d glucose level and convenience. Out of the 48correlations ,4 0wer e between 0.30 and 0.68. Correlations between taste andhealt h perceptions of foods showed the following correlations tob e higher than 0.30. The taste perception of buttermilk and cottage cheese correlated positivelywit h the four other perceptions.Tast eperceptio n of custard correlated positivelywit h general health and blood glucose levelperceptions . Forwhol eyoghurt , taste and blood glucose level perceptions correlated. The tasteperceptio n did not show any -64-

significant correlationwit han yothe rperception s for low-fatmilk ,whol e milk,chocolat emilk ,an d skimyoghurt .

Table 4.Foo dperception s related tofrequenc yo fus eo feigh t dairy productsb y insulin-dependentdiabeti cpatient s( 1).

Perceptions Kendall's taub (2)

Taste Low-fatmil k 0.47** Buttermilk 0.48** Cottage cheese 0.46** Custard 0.49**

Healthiness Buttermilk 0.37** Cottage cheese 0.39**

Blood glucose Buttermilk 0.36** Cottage cheese 0.30** Custard 0.40**

Heartdiseas e Cottage cheese 0.34**

Convenience Cottage cheese 0.40**

1.Onl y correlationsabov e 0.30 are reported. 2. Positive Kendall's taub indicatehighe rus ewhe n food isperceive d as morevaluable ,* *p <0.01 .

DISCUSSION

This study showsth edifferen t foodperception smeasure d inthi s study to correlatewit heac hother .Fo rmos tdair yproduct sth eperception so f general health, short-term and long-termhealth ,an d convenience areassociated . This suggests thatdiabeti cpatient sperceiv ea food tob eeithe r healthy or not healthyan d that theyd ono tdiscriminat e betweengenera lhealth , short-term health (blood glucose level)an d health inth elonge r term (heart disease). Surprisingly,th e factwhethe r orno ta foodwoul db e convenient tous e asa snack, isals oconsidere d interm so fhealt han dno t somuc h interm so f convenience. For several dairyproduct s tasteperception s correlatedwit h thedifferen t healthperceptions ,suggestin g that tastean dhealt hperception sar eno t always independent,bu t that theyma y influence eachother . Ifa patien t likes a food,he/sh eals oma ybeliev e itt ob ehealth yan dvic eversa .A s most studieshav eno t reported anycorrelatio nbetwee n foodperceptions ,thi s -65-

phenomenonha sno tye tbee ndescribe d inth eliterature . The low-fatdair yproduct s sucha s low-fatmilk ,buttermil k and skimyoghur t areperceive d ashealthie r thanth e foodswit hhighe r amountso f fatan d sugar sucha swhol emilk ,whol eyoghur t and chocolatemilk .Mos tdiabeti c subjects reject foods forconsumptio nperceive d asunhealth y sucha swhol emilk , chocolatemil k andwhol eyoghurt .Howeve r 43%o f thediabetic sdi dus e custard,whic h contains fatan d sugar.I nth eNetherlands ,custar d isa widel y used dessert and there isn oalternativ ewit h similar characteristics.Whil e low-fat substitutes forwhol emil k andwhol eyoghur t are easy toget . Therefore,i tma yb e concluded thatdiabeti cpatient s rejectdair y products withhig h fatand/o r sugar contentsbecaus eo fperceive dunhealthiness . However,i fn o suitable alternative isavailable ,the npatient swil l likely continue tous e thesefoods . For those foods thatar eno t rejected onth ebasi so f theirperceive d health characteristics,perceive d taste showsa strong correlationwit h fooduse . Tastema yeve noverrul e theperceive d health characteristics asshow nb y the foodperception s and foodus epatter no fcottag e cheesean dwhol eyoghurt . Todefin e the relationshipbetwee n foodus ean d foodperceptions ,a n assessmentwa smad e ofth edifference s infoo dperception sbetwee nuser s and non-users ofa certain foodan do f thecorrelatio nbetwee n foodus e and food perceptions.Difference s intast eperception sbetwee nuser s andnon-user swer e found forever y food thatwa suse db y a substantial parto f thepopulation , withuser s liking the foodsbette r thannon-users .Fo rbuttermilk ,custar d and cottage cheese,user sdiffere d fromnon-user s inthei rperceptio no f the healthvalue s of these foods.Correlatio nbetwee n foodus e and food perceptions revealed a similarpattern :tast ewa s the strongestdeterminan t of fooduse .Th e slightdifferenc e between the resultso f the correlation data and theuser sversu snon-user sdat a aredu e todifference s inth e shape of the distributionso f thevariable s involved ineac ho f theanalyses . Itcoul d be concluded fromthes e resultstha t theperceive d healthvalu e ofa food serves tolimi t theavailabl e food supply fordiabeti c subjects,wit h perceived lowhealt hvalu e beingassociate dwit h food rejection. Inthi scase , food selectionwoul d bemad e fromth e foodstha td ohav e anacceptabl e health value todiabeti cpatients ,wit h tastebein g themos t important food selection determinant.

Several gender differenceswer e observed infoo dperception s of foods that were usedb y a substantial parto fth epopulation ,althoug h foodus edi d not differ between the sexes.Thes eobserve d gender differences,wit h females -66-

beingmor ehealt horiente d thanmales ,ar e inaccordanc ewit h the literature (George &Krondl ,1983) . The effecto fag eo n foodperception s could notb e evaluated due toth ehomogeneou s agedistribution . This study ison e of the fewwhic h compares foodperception san dus e of foods of one foodgroup .Mos t studies investigating foodperception shav euse d rather heterogenous foods,whic hmad ean ycompariso nbetwee n foods problematic.Prättäl ä &Keinone n (1984),wh o investigated foodperception s of several typeso f sweet foods,conclude d that sweet foodsmigh tb eperceive d rather different inspit eo f their similar nutrient composition.Thi s suggests that further studieso n foodperception san d foodus e should include foods from similar foodgroup s inorde r toallo wcompariso nbetwee nfoods . The resultso f this study illustrate thedifficultie snutritio neducator sar e facedwit h regarding theeducatio no fdiabeti c patients.Stressin g the differenthealt hvalues o f foodswil lno tnecessaril y result ina desire d change in fooduse .Th ediabeti c patientuse s some foods sucha s skimyoghur t or low-fatmil k becausehe/sh eperceive s thema shealthy .O n theothe r hand, some foods sucha s custard,ma yb euse d in spite of the fact that theyar e generally perceived asno tver yhealthy . Furthermore,healt hvalu e of buttermilk isperceive d toequa l thehealt hvalu e of low-fatmilk .However ,i t isno tuse d byman ypatient sbecaus eo fperceive d lowtaste .

ACKNOWLEDGEMENTS

This studyha sbee n supported by grants from theMinistr yo fWelfare ,Healt h and CulturalAffairs ,th eHague ,th eNetherlands ,an d theWageninge n Agricultural University,th eNetherlands .Th ehel p from theDutc h Diabetes Association,especiall y from Mr P.va nde rWiel , inth e recruitment of respondents ismos tgratefull yacknowledged .W e expressou r appreciation to JokeHoogenboo m and StephanMeershoe k for their assistance indat a collection andMariett a Eimers for statistical support.

REFERENCES

Fewster,W.J. ,Bostian ,L.R. , &Powers ,R.D . (1973)Measurin g the connotative meaningso f foods.Hom eEconomic sResearc hJournal ,2 ,44-53 . George,R.S. ,& Krondl ,M . (1983)Perception san d foodus e ofadolescen t boys and girls.Nutritio n andBehavior ,1 ,115-125 . Krondl,M.M. , &Lau ,D . (1978)Foo dhabi tmodificatio n asa publi c health measure.Canadia nJourna l ofPubli cHealth ,69 ,39-43. -67-

Krondl,M. ,Lau ,D. ,Yurkiw ,M.A. ,& Coleman ,P.H . (1982)Foo dus ean d perceivedfoo dmeaning so fth eelderly .Journa lo fth eAmerica nDieteti c Association,80 ,523-529 . Krondl,M. ,& Coleman ,P . (1986)Socia lan dbiocultura ldeterminant so ffoo d selection.Progres si nFoo dan dNutritio nScience ,10 ,179-203 . Lau,D. ,Hanada ,L. ,Kaminskyj ,0. ,& Krondl ,M .(1979 )Predictin gfoo dus eb y measuringattitude san dpreference .Foo dProduc tDevelopment ,13 ,66-72 . Niewind,A.C. ,Friele ,R.D. ,Kandou ,C .Th. ,Hautvast ,J.G.A.J. ,& Edema , J.M.P.(1988 )Change si nfoo dchoice so frecentl ydiagnose dinsulin - dependentdiabeti cpatients .Submitted . Marascuilo,L.A. ,& M cSweeney ,M .(1977 )Nonparametri can dDistribution-Fre e Methodsfo rth eSocia lSciences .Montery :Brooks/Col ePublishin gCompan y Inc. Prättälä,R. ,& Keinonen ,M . (1984)Th eus ean dth eattribution so fsom eswee t foods.Appetite ,5 ,199-207 . Reaburn,J.A. ,Krondl ,M. ,& Lau ,D . (1979)Socia ldeterminant si nfoo d selection.Journa lo fth eAmerica nDieteti cAssociation ,74 ,637-641 . Zimmerman,S.A. ,& Krondl ,M.M .(1986 )Perceive dintoleranc eo fvegetable s amongth eelderly .Journa lo fth eAmerica nDieteti cAssociation ,86 , 1047-1051. -68-

7 Differences in food perceptions and food use between insulin-dependent diabetic and non-diabetic subjects

byA.C .Niewind ,R.D . Friele,J.M.P .Edem a& J.G.A.J . Hautvast

ABSTRACT

We examined differences infoo d perceptionsan dus eo feigh tdair y products among7 2recentl ydiagnose d insulin-dependent diabetican d5 7non-diabeti c subjects.W eals o investigated gender differences infoo dperception s andfoo d use.Th efoo d perceptions studiedwere : healthvalue ,valu e inrelatio nt o heartdiseas e prevention, conveniencean dtaste .Perception swer e assessedb y meanso fa Likert-typ e scale,us eb ymean so fa 9-poin t food frequency scale. Results showed thatth efrequenc yo fus eo ffou rou to fth eeigh t dairy productsdiffere d between insulin-dependent diabetican dnon-diabeti c subjects,whil e thetw ogroup sha dsimila r foodperception s forthes e foods. This suggests thatth erol eo ffoo d perceptionso nfoo dus ema yb edifferen t indiabeti c compared tonon-diabeti c subjects.Gende r differenceswer e more prominent among thenon-diabeti c thanamon gth ediabeti c subjects.Thi s study suggests thati norde r tob eeffective ,nutritio n education programs should notb ebase do nth eassumptio n that changed foodperception s will automatically bring thedesire d changesi nfoo d choices,unles shealt h isa prevalent issue forth erecipient .

INTRODUCTION

Ina previou s study food perception profileswer e compared ofeigh t dairy productswit hdifferen t nutrient compositions.Als ow einvestigate dth e connection between food perceptionsan dfoo dus einvestigate d among recently diagnosed insulin-dependent diabetic patients (Niewind, Friele,Edem a& Hautvast, 1989).W ehypothesize d thathealt h perceptionso ffood swoul db e important foodus edeterminant s forpatient swh oha drecentl y been diagnosed ashavin ga chroni c illness.Therefore ,severa l health perceptions offood s were investigated. Results showed however, that these patients perceive a food aseithe r healthyo runhealthy . Diabetic patients reject foodswit h highfa t and/or sugar contents becauseo fperceive d lowhealt hvalues .Tast e isth e strongest determinant offoo dus efo rfood s thathav eno tbee n rejected onth e basiso fperceive d healthvalue .Furthermore ,severa l gender differencesi n -69-

foodperception swer e found. Notman y studieshav ebee n carried out investigating foodperception s and food choices.Thes e studieshav e shown that forhealth ypopulation s the perceptions taste,healt hvalue ,convenience ,familiarity ,prestig e and tolerance have strong correlationswit h food choices,wit h taste andhealt hvalu ebein g the most important food selectiondeterminants .Furthermore ,se xan dag e differences infoo dperception shav ebee n identified amonghealth y populations (Zimmerman &Krondl ,1986 ;Prättälä ,Keinonen ,1984 ;Georg e &Krondl ,1983 ; Krondl,Lau ,Yurki w& Coleman ,1982 ;Lau ,Hanada ,Kaminsky j& Krondl ,1979 ; Reaburn,Krond l &Lau , 1979). Inthi spaper ,th eperception s andus e ofth eeigh tdair yproduct so f insulin-dependentdiabetic sar ecompare dwit hthos eo fnon-diabeti c subjects. Secondlya nassessmen twa smad eo f theeffec to fgende r on food perceptions and fooduse .

METHODS

Subjects The groupo f insulin-dependent diabetics consisted of7 2 subjects,al l participating ina previou s studyo n food choices.Al l subjectswer e between 20an d 40year s old. Individualswer e recruited from themember so f theDutc h DiabetesAssociation .The yha d beendiagnose d as insulin-dependent diabetics between 14 to1 8month sprio r tothi sstudy .Th e recruitmentproces sha sbee n described elsewhere (Niewind,e t al., 1988). Thenon-diabeti c group also participated ina studyo n food choices.Severa l criteriawer e applied for the recruitment of these subjects.Firs to fall ,i twa s important that these subjectsdi d not followan ymedicall y or self-prescribed diet.Furthermore , theyha d tob e recruited fromsevera l regions inth eNetherland sa s the recruitment of thediabeti c groupwa sals ono t restricted toon e particular area.Third ,th eeducatio n andag eprofile s of thenon-diabeti c group should resemble those of thediabeti c groupa sclosel ya spossible . Table 1describe s thedemographi c profiles of insulin-dependent diabetic and non-diabetic groups.Th enon-diabeti c groupha dmor ewomen ,an d the average agewa s slightlyhigher .Ther ewer en odifference s inleve lo feducation .Th e meanduratio n ofdiabete swa s 16months . -70-

Table1 .Demographi eprofile so f7 2insulin-dependen tdiabeti can d5 7 non-diabeticsubjects .

Variable Diabeticsubject s Non-diabeticsubject s

Gender (%) males 63 44 females 38 56

Age,i nyear s (mean+ sd ) 30.3+ 5. 6 33.2+ 9. 5

Education (%) firstleve l 3 secondlevel ,firs tstag e 31 26 secondlevel ,secon dstag e 40 47 thirdleve l 26 26

Durationdiabetes ,i nyear s (mean+ sd ) 1.3+0.1

Foodperception s Theperception so nwhic hth efood swer ejudge dwer ethei rvalu eregardin g generalhealth ,hear tdisease ,tast ean dconvenience .Al lperception swer e measuredo na 5-poin tLikert-typ escale ,rangin gfro m 'verygood 't o'ver y bad'. Thesam efood sa suse di nth epreviou sstud ywer eselected ;thes ewer efou r milkproduct s(low-fa tmilk ,whol emilk ,buttermil kan dchocolat emilk )an d fourDutc hdair ydesser tproduct s (skimyoghurt ,whol eyoghurt ,custar dan d cottagecheese) .

Foodus e Toasses sth eus eo fth eeigh tdair yproduct sth efoo dfrequenc ymetho dwa s applied.Thi smetho dconsist so fa lis to ffood san da se to ffrequenc y responseoption st oindicat efrequenc yo fconsumptio no feac hfoo ddurin ga giventim eperiod .Th eus eo feac hfoo dwa smeasure db ymean so fa 9-poin t frequencyscale .Th epoint so nth escal ewere :> 3time sa day ,2- 3time sa day,onc ea day ,4- 6time sa week ,2- 3time sa week ,onc ea week ,2- 3time sa month,onc ea mont han dles stha nonc ea month .

Dataanalysi s Duet oskewe ddata ,no nparametri cstatistic swer eapplied .Th enon-diabeti c groupha dmor ewome ntha nth ediabeti cgroup .Therefore ,th ecombine deffec t ofdiabete san dgende ro nal lfoo dperception san dus eo fth eeigh tdair y -71-

productswer eassesse dwit hth eKruskal-Walli stest ,a one-wa yanalysi so f variancetes tfo rno nparametri cdata .Fou rgroup swer edefine dbase do nth e variablesdiabete san dgender .W eapplie dth eMann-Whitne ytes tt oasses s differencesdu et odiabetes ,gende ran dgende rdifference swithi nth ediabeti c andth enon-diabeti cgroup .Fo rsampl esize sabov e3 0th eZ-statisti ci s computed.Al ltest swer edon eusin ga two-taile dtes tfo rsignificance s (Marascuilo& McSweeney ,1977) .

RESULTS

Theus eo fth eeigh tdair yproduct sb yth ediabeti can dnon-diabeti csubject s ispresente di nTabl e2 .Th emea nperceptio nrating sfo reac ho fth edair y

Table2 .Us eo fdair yproduct sb y7 2insulin-dependen tdiabeti can d5 7 non-diabeticsubjects .

DairyProduc t Subjects < Users -> Non-users Daily Weekly Monthly Lesstha n oncea (1) (2) (3) month

<— % > Low-fatmil k Diabetic 54 17 4 25 Non-diabetic 38 14 9 39

Buttermilk Diabetic 17 8 14 61 Non-diabetic 14 14 12 60

Wholemil k Diabetic 3 8 10 79 Non-diabetic 16 9 7 68

Chocolatemil k Diabetic 8 3 89 Non-diabetic 2 18 25 56

Skimyoghur t Diabetic 26 40 8 25 Non-diabetic 11 46 9 35

Custard Diabetic 6 25 13 57 Non-diabetic 4 54 18 25

Cottagechees e Diabetic 1 8 22 68 Non-diabetic 7 21 72

Wholeyoghur t Diabetic 1 13 4 82 Non-diabetic 7 21 13 60

1.a tleas tonc ea day . 2.a tleas tonc ea week ,bu tno tdaily . 3.a tleas tonc ea month ,bu tno tweekly . -72-

n in n c er jr 3" q ^3 2 S-3-S-^l" o m f o o i < ,— "8'S o ö «— —*• —t- ^ n ~*• -+ n r*- —*• 'S"3 ! ° n> tu m „ o n> n> -h lï m aity 0 n> ro -h ia ID T^ J; n QJ *< n> 3 M •< n> a.,2 °J o ia n a O- — H- 3 C HS. ? 01 ro H- 3" n ra rsrr s eu H- 3" o a> SS a ~ a 5 S 0> H- — p" oi •a 3 (5 a °> CL n o a tu 3 ro 3 en 0 -o O n> 3 3 rT 1 H- D. O J. "a H- 3 0) not good CT 1 not gooe o» n ro O) Çor o1) not poor O 3 not poor 3 en ui C ero n 3 L_i. r-h c-rua fl> en en n H- -•p- poor (T 3 -F- poor tn cn C Iff very poor poor

Q, **i C in CT ç— a i n n n H- n in n c er ?r (D h»- IT TT 3«" C ro o c zr —1- o •a *a O m 3' o o_ c m c I" = O O •+* "S nI —t- n —l- 3 n 9 —r -h — Q, ro ro QJ QJ o. a ro m o n> n> ' ni ^< ro" QJ to ah-- ~< irno a. O 3. 3 —1- 3 M — ^ — T m (T CL ld ~•ST* ^i rr CT o 3" (T) TT a U- . • lO n 3 '-'• 3 3" 3- c 5F L fll ro C rt> -J 3_ 3T H- 3 fr 0) "J n> 01 to —1- ro 3 in 5F tr o> rr m 3 H- rr n> rr H- o o a> very o o O to good 0 to — 3 ^TJ H- oi ro 01 to 3 n 5 => a. o a. o 3 Tro) 3 0 rr • O -Njgood O "O 3 H- • e • 3 m o • I r-t Q. 3 0 • O- O N'­ • o O H- ro eu n ai TS er oi ir rr it rr O • ro H- rr H- not good rr o not good M- 3 O -UJ M- 3 en not poor not poor en en O» d rr B" Hi CT H- i_i. 3 rû H- (0 U3 n en ror e3n rr « C -•F- poor en o —• H- r? very —t n poor poor -73-

productsfo rbot hinsulin-dependen tdiabeti can dnon-diabeti csubject sar e displayedi nFigur e1 (a-d).Bot hgroup srate dwhol emilk ,chocolat emilk , custardan dwhol eyoghur tlowe rwit hregar dt ogenera lhealth ,valu efo rhear t diseaseprevention ,an dconvenienc ecompare dt oth edair yproduct slow-fa t milk,buttermilk ,ski myoghur tan dcottag echeese .

Table3 .Th eeffec to fdiabete san dgende ro nfoo dperception san dfoo dus e ofmil kproduct samon g7 2insulin-dependen tdiabeti can d5 7 non-diabeticsubjects .

Product Perception diabetes diabetes gender gender gender andgende r diabetic non- subjects diabetic subjects (1) (2) (2) (2) (2) N=129 N=129 N=129 N=72 N=57 chocolatemil k taste NS 1.9* NS NS NS health 11.7** 3.3** NS NS NS heartdiseas e NS NS NS NS NS convenience 12.1** 2.8** NS NS NS use 17.1** 4.1** NS NS NS wholemil k taste NS NS NS NS NS health 14.1** 3.7** NS NS NS heartdiseas e NS NS NS NS NS convenience NS 1.9* NS NS NS use NS NS NS NS NS buttermilk taste 11.1** NS 3.3** 2.0* 2.6** health 24.9** 2.4* 4.7** 3.4** 2.9** heartdiseas e 17.4** NS 4.1** 2.3* 3.3** convenience 16.4** 2.3* 3.6** NS 3.7** use 9.6* NS 3.0** NS 2.6** low-fatmil k taste NS NS NS NS NS health 13.0** NS 3.4** NS 3.1** heartdiseas e NS NS NS NS 2.0* convenience NS NS NS NS NS use NS NS 2.1* 2.0* NS

1.Kruskal-Wallis ,one-wa yanalysi so fvariance ,* *p < 0.01 ,* p < 0.05 . 2.Mann-Whitne ytests ,* *p < 0.01 ,* p < 0.05 .

Theeffec to fdiabete san dgende ro nfoo dperception san dfoo dus eo fth efou r milkproduct sar eshow ni nTabl e3 .Compare dt onon-diabeti csubjects , diabeticsubject sperceive dchocolat emil kt ob eles stasty ,les shealth yan d lessconvenient .Diabeti csubject sals ouse dchocolat emil ksignificantl yles s frequentlytha nnon-diabeti csubjects .Diabeti csubject sperceive dwhol emil k -74-

and buttermilk asles shealth yan dles s convenient thannon-diabeti c subjects. No differences inth efoo dperception san dus eo flow-fa tmil k between diabetic andnon-diabeti c subjectswer e found.Gende r differenceswer e found inth efoo d perceptionsan dus eo fbuttermilk ,wit h femalesperceivin g ita s more tasty,healthier ,mor evaluabl e forhear tdiseas e prevention andmor e convenient thanmale sdid . Females alsouse d buttermilk more frequently than males.Gende r differenceswer e also found forth ehealt hperceptio nan dus eo f low-fat milk,wit h femalesperceivin g thefoo da shealthie r andusin g itmor e frequently thanmale sdid .

Table 4.Th eeffec to fdiabete san dgende ro nfoo dperception san dfoo d useo fdair ydesser t productsamon g7 2insulin-dependen t diabetic and 57non-diabeti c subjects.

Product Perception diabetes diabetes gender gender gender andgende r diabetic non- subjects diabetic subjects (1) (2) (2) (2) (2) N=129 N=129 N=129 N=72 N=57 wholeyoghur t taste NS NS NS NS NS health NS NS NS NS NS heartdiseas e NS NS NS NS 2.3* convenience NS NS NS NS NS use 11.1** 2.8** NS NS NS custard taste NS NS NS NS NS health NS NS NS NS NS heartdiseas e NS NS NS NS NS convenience 8.8* 2.0* NS NS 2.4* use 10.3* 2.9** NS NS NS skimyoghur t taste NS NS NS NS 2.1* health 22.4** NS 4.4** NS 3.8** heartdiseas e 10.7** NS 2.6** NS 3.3** convenience 16.2** NS 3.6** NS 3.8** use 8.1* 2.2* NS NS NS cottagechees e taste 9.9* NS 2.9** NS 3.4** health 15.1** NS 3.7** 2.5** 3.5** heartdiseas e 12.0** NS 3.1** NS 3.3** convenience 16.8** NS 3.8** 2.3* 3.2** use NS NS 2.5** NS 2.0*

1.Kruskal-Wallis ,one-wa yanalysi so fvariance ,* *p < 0.01 ,* p < 0.05 . 2.Mann-Whitne ytests ,* *p < 0.01 ,* p < 0.05 . -75-

The effecto fdiabete san d gender on the foodperception san dus eo f the four dairydesser tproduct s (Table4 )indicate ddifference s inth eus eo fwhol e yoghurt, custard and skimyoghur tbetwee ndiabeti c andnon-diabeti csubjects . Diabetic subjectsuse dwhol eyoghur tan d custard less frequently than non-diabetic subjectsan d skimyoghur tmor e frequently,an d theyperceive d custard asles sconvenient .Gende r differenceswer e found for skimyoghur t and cottage cheese.Female sperceive d skimyoghur ta sbette r tasting,healthier , morevaluabl e forhear tdiseas ean dmor e convenient.Female sperceive d cottage cheese asmor evaluabl eo nal lperception san dals ouse d itmor e frequently. Gender differences in foodperception swer emor eprevalen t inth enon-diabeti c group than thegroup .

DISCUSSION

This studydemonstrate s that insulin-dependentdiabeti c andnon-diabeti c subjectshav e similarperception so f low-fatmilk ,ski myoghurt ,cottag e cheese,whol eyoghur tan d custard.Difference s inhealt han d convenience perceptionswer e found forwhol emilk ,chocolat emil k andbuttermilk . Differences inus ebetwee n thetw ogroup swer e found for chocolatemilk ,whol e yoghurt, custard and skimyoghurt .Diabeti cpatient s consume chocolatemilk , custard andwhol eyoghur t less frequently,an d skimyoghur tmor e frequently. Generally,th edifference s in food choicesbetwee n the twogroup scoul d notb e explained bydifference s in foodperceptions ,whil edifference s infoo d perceptionsdi dno t result indifference s in food choices.Onl y the differences in the foodperception so f chocolatemil k between thediabeti c and thenon-diabeti c groupar e related toth edifference s inth e frequency ofus e of this food. Inou rpreviou s studyw e foundtha tdiabeti cpatient s generally tend to reject dairyproduct swit hhigh-fa t and/or sugar contents.W e hypothesized that the reasons for this rejectionwer e theperceive d lowhealt hvalue so f these foods.Th e resultso f this study showtha tdiabeti c andnon-diabeti c subjects differ in the frequency ofus eo f chocolatemilk ,whol eyoghurt ,custar d and skimyoghurt ,wit hdiabeti c subjectscompare d tonon-diabeti c subjectsusin g chocolatemilk ,whol eyoghur tan d custard less frequentlyan d skimyoghur t more frequently.Bot h groupso f subjectsevaluate d theperception so f these foods similarly,an dperceive d chocolatemilk ,whol eyoghur tan d custard as having lowhealt hvalues .Thi s suggests thatth e roleo f foodperception s on food choicesma yb edifferen t indiabeti c compared tonon-diabeti csubjects . -76-

Fordiabeti c subjectsth e facttha t theyhav e achroni c illness,ma yb e a motive that iso f special influence on food choices.Thus , foodswhic h are perceived ashavin g lowhealt hvalue swoul db euse d lessoften .Non-diabeti c subjectsperceivin g a foodhavin ga lowhealt hvalu ewoul d not automatically reduce the frequency ofus e of this food. Food choicesar e influencedb yman y factors;perceive d healthbein g only one of them. Studieshav e showntha tamon ghealth ypopulations ,tast e isa strong determinant of food choices (Krondl &Coleman ,1986 ;Georg e &Krondl ,1983 ; Krondl,Lau ,Yurki w& Coleman , 1982). The groupo fnon-diabeti c subjects in this study isno ta representative sampleo fhealth y subjectswithou t any dietsan dwa s alsoa relatively smallgroup .Foo d choicesan d food perceptions ofhealth ypopulation sobviousl ynee dmor eattention . Gender differences in foodperception san d foodus ewer eobserved .Al l foods were perceived asmor ehealthy ,tast yan d convenientb y femalestha nb ymales . George &Krond l (1983)als odescribe dgende r differences in food perceptions and fooduse ,wit h femalesbein gmor ehealth-oriente d thanmales . Analysiso fvarianc e showed thatgende rdifference s applymor e to foodswit h lowamount s of fatan d sugar,suc ha sbuttermilk ,low-fa tmilk ,ski myoghur t and cottage cheese,wit h femalesperceivin g these foodsa smor ehealth y than males.Difference sdu e todiabete sappl y to foodswit h relativelyhig h amounts of fatan d sugar sucha s chocolatemilk ,custar d andwhol eyoghurt ,wit h diabetic patientsusin g these foods less frequently thannon-diabeti c subjects.Althoug h the sample sizewa s small,gende rdifference swer e more frequently observed among thenon-diabeti c subjects.Thi s indicates thata sa group,diabeti c subjectshav emor ehomogeneou s foodperception s than non-diabetic subjects,suggestin g thatnutritio n counseling especially increased thehealt hawarenes s inmales ,thu s reducing the existing gender differences inhealth ygroups . Inou rpreviou s studyw ediscusse d thedifficultie snutritio ncounsellor sar e facedwit h inth eeducatio no f thediabeti cpopulation .Thi s study illustrates thatnutritio n educationprogram s fornon-diabeti c groups should notb ebase d on the assumption that increased awarenesso f thehealt hvalue so f foodswil l automatically result inchange s infoo dchoices . -77-

ACKNOWLEDGEMENTS

Thisstud ywa ssupporte db ygrant sfro mth eMinistr yo fWelfare ,Healt han d CulturalAffairs ,th eHague ,th eNetherlands ,an dfro mth eWageninge n AgriculturalUniversity ,th eNetherlands .Th ehel pfro mth eDutc hDiabete s Association,especiall yfro m MrP .va nde rWiel ,i nrecruitmen to f respondentsi smos tgratefull yacknowledged .W eexpres sappreciatio nt oPetr a vanWezel ,Margrie td eWinkel ,Jok eHoogenboo man dStepha nMeershoe kfo r assistancei ndat acollectio nan dt oMariett aEimer sfo rstatistica lsupport .

REFERENCES

George,R.S. ,& Krondl ,M .(1983 )Perception san dfoo dus eo fadolescen tboy s andgirls .Nutritio nan dBehavior ,1 ,115-125 . Krondl,M. ,& Coleman ,P . (1986)Socia lan dbiocultura ldeterminant so ffoo d selection.Progres si nFoo dan dNutritio nScience ,10 ,179-203 . Krondl,M. ,Lau ,D. ,Yurkiw ,M.A. ,& Coleman ,P.H . (1982)Foo dus ean d perceivedfoo dmeaning so fth eelderly .Journa lo fth eAmerica nDieteti c Association,80 ,523-529 . Lau,D. ,Hanada ,L. ,Kaminskyj ,0. ,& Krondl ,M .(1979 )Predictin gfoo dus eb y measuringattitude san dpreference .Foo dProduc tDevelopment ,13 ,66-72 . Niewind,A.C. ,Friele ,R.D. ,Edema ,J.M.P. ,& Hautvast ,J.G.A.J .(1989 )Foo d perceptionsan dfoo dus eo frecentl ydiagnose dinsulin-dependen tdiabeti c patients.Submitted . Niewind,A.C. ,Friele ,R.D. ,Kandou ,C.Th. ,Hautvast ,J.G.A.J. ,& Edema , J.M.P. (1988)Change si nfoo dchoice so frecentl ydiagnose d insulin-dependentdiabeti cpatients .Submitted . Prättälä,R. ,& Keinonen ,M . (1984)Th eus ean dth eattribution so fsom eswee t foods.Appetite ,5 ,199-207 . Reaburn,J.A. ,Krondl ,M. ,& Lau ,D . (1979)Socia ldeterminant si nfoo d selection.Journa lo fth eAmerica nDieteti cAssociation ,74 ,637-641 . Marascuilo,L.A. ,& McSweeney ,M . (1977)Nonparametri can dDistribution-Fre e Methodsfo rth eSocia lSciences .Monterey :Brooks/Col ePublishin gCompan y Inc. Zimmerman,S.A. ,& Krondl ,M.M . (1986)Perceive d intoleranceo fvegetable s amongth eelderly .Journa lo fth eAmerica nDieteti cAssociation ,86 , 1047-1051. -78-

8 General discussion

8.1.INTRODUCTIO N

The aimo fth eresearc h describedi nthi s thesiswa st oinvestigat eth efoo d choiceso fdiabeti c patients. This chapter discussesth erelationship s between thevariou s projects reported inth epreviou s chapters. First,w ewil l outlinet owha t extentth e resultso fthi s study are generally applicablet oinsulin-dependen t diabetic patientsi nligh to fth e population studied. Secondly,w ewil l discussth e major findingso fth estud ywit h respectt ofoo d choicesan dth e diabetic diet. Finally,w ewil l describeth eimplication s fornutritio n education programs.

8.2. STUDY POPULATION

Respondents were recruited through theDutc hDiabete sAssociation . Iti s estimated that approximately 50%o fal l newly diagnosed diabetic patients join the DutchDiabete sAssociation .Th erespons e ratei nth e study among recently diagnosed diabetic patientswa s 90%,whic hmean sa participatio n closet o50 %o fth epeopl e diagnoseda sinsulin-dependen t diabetics during the recruitment periodo fth e study.Therefore ,th e resultso fth estud yo n food choicesan dfoo d choice motivesar e applicablet opatient swh o have been diagnoseda sinsulin-dependen t diabetics.Som eprecaution sar ei norde r regardingth efac t that patient memberso fth e Dutch DiabetesAssociatio nar e knownt ohav emor e interesti nthei r diseasean d havea highe r educational profile thannon-member s (1).A slon ga sther ei sn omajo r changei ndietar y guidelines givent onewl ydiagnose d insulin-dependent diabetic patients, the resultso fthi s study remainvali dfo rinsulin-dependen t diabetic patients.

8.3. FOOD CHOICES

8.3.1. Barriers

Diabetic patients experience several typeso fbarrier si nrelatio nt othei r prescribed diets.W eidentifie dth efollowin g barriers: feelingso fbodil y discomfort,th eimpose d regularityo feating ,th ecost so fth ediabeti c diet, -79-

and hedonic and socialbarrier s (chapters2 an d 3). Suchbarrier smak e it difficult fordiabeti cpatient s tochang e foodchoices .

8.3.2.Motivatio n

After thediagnosi s of thediabetes ,patient s change their food choices toa large extent retainingmos to f these fora tleas t 16month safte r the diagnosis.(chapters 4an d 5). The studieso n foodperception s showtha t health isa n important food choicemotiv e fordiabeti c patients (chapters6 and 7). Thispoint st oth e strengtho fmotivatio n forchangin g food choices among recentlydiagnose d insulin-dependentdiabeti c patients.The yar e motivated tochang e their food choices forhealth-relate d reasonso na short-terma swel l aso na mor e long-termbasis .

8.3.3. Excessive food restrictions

Thedietar y changeswhic hpatient smak eafte rbein gdiagnose d asdiabetic s are onlypartl y inagreemen twit h theprinciple so f thediabeti c diet (chapter 4).Som eo f these changesar eno tnecessar y oreve nundesirabl e from a nutritional perspective (2-4). This implies thatpatient sperceiv e many more foodsa sunhealth y and forbidden thanwoul d be required froma nutritional perspective.Patient s tend to interpret thediabeti cdie t in termso fprescribe d and forbidden foods.Thi s isi ncontradictio n to recent nutritional recommendations fordiabeti c patients that state that there isn o such thinga sa 'forbidden'food .

8.3.4. Education

Level of educationwa s inverselyassociate dwit h the totalnumbe r of barriers experienced (chapter 3). Alsow e found that thosepatient swit hhig h school education are theone swh o startexperimentin gwit h thediabeti cdie t (chapter 5).Thi s shows that level of school educationma y influence patients food choices.I tcanno tb e concludedwhethe r this relationship iscausa l or mediatedb yothe rvariables ,suc ha shealt hknowledge . -80-

8.3.5. Implications for the studyo f food choices

Krondl showed the importanceo f tastean dhealt hmotive so n food choices(5) . This researchdemonstrate s the importance ofhealt hmotive so n food choices ofdiabeti c patients.Th e findingsals o suggest thatperceive d healtho f foods serves tolimi tth eavailabl e foodsuppl y fordiabeti c subjects,wit h lowperceive d healthbein gassociate dwit h food rejection.Foo d selection would subsequently bemad e fromth e foods thatd ohav e anacceptabl e health valuewit h taste thenbein g themos t important food selectiondeterminant .

Among thebarrier smos t frequently citedwer e feelingso fbodil ydiscomfort . This shows that it is important that thedie tmeet spatients 'physiologica l needs. Inth e literature notmuc hattentio nha sbee npai d toth e physiological factorsdeterminin g food choices.Furthe r investigation into these factors is recommended.

8.4.TH EDIABETI C DIET

Itha sbecom eapparen t fromth e studiesdescribe d inthi s thesistha t two issues relating toth ediabeti cdie tar e ofmajo r importance.Thes e are the patient'sunderstandin g and knowledgeo f thediabeti c dietan d secondly, dietary counselling.

8.4.1.Th e patient'sunderstandin g of thedie t

The two studieso ndietar ybarrier s (chapers2 an d 3)indicat e together with the studieso n foodchoice s (chapters 4an d 5)tha tman ydiabeti c subjects do nothav e a clear andup-to-dat eunderstandin g of thebasi c principles of the diabetic diet.Man yhol dver y strictan deve n incorrect interpretations of the requirements setb y thediabeti cdie tan ddispla y an inability toadap t thedietar y guidelines tothei r ownhedonic ,socia lan dbodil yneeds . Dietary counsellors should see toi ttha t thepatien tunderstand s thedie t and pointou tt oth epatien tho w thedie t canb eadapte d toth e above-mentionedneeds . -81-

8.4.2.Dietar y counselling

Manydiabeti c patientshav ebee nprescribe d inadequate diabeticdiet s (3,4). Thisca nb e concluded fromth e findings thatpatient s indicate that theywer e advised to restrict carbohydrate intake and toeliminat e high-sugar foods (chapter 3).I tappear s that thesepatient s still liveaccordin g tooutdate d dietary prescriptions.I tma yb eassume d that these outdated dietary prescriptions causemor ebarrier san dmor edietar ynoncomplianc e compared to thediabeti cdiet swhic har ebase dupo nth elates tnutritiona l recommendations. Dietary guidelinesgive n todiabeti c patients should bebase d on scientific data and be as simplea spossible .An y additional dietaryguideline swil l increase thebarrier spatient sexperienc ewit h thedie tan dma ydistrac t from themai n requirementso f thediabeti cdiet . The scientificprinciple sbehin d thediabeti cdie tar eals oa matte r of concern.Fro m thisthesi san dothe r studies (6-8)i tha sbecom e clear that insulin-treated diabetic patientswit h normal bodyweigh t experience feelings ofhunger .Feeling so fhunge r are apowerfu l urge toea t for themaintenanc e of bodyweight .Patient s ona diabeti cdiet ,keepin gnorma l bodyweight , should notexperienc e feelingso fhunger .Obviously , theenerg y requirements of thesepatient sar eno tme tb y theenerg y intake.Lea n andJame s (9) demonstrated that routinemethod sa suse db ydietitian s for the estimation of a patient'senerg y intake,wil l systematically lead tounderestimatio n of energyneeds .Furthermore ,w ewoul dquer y theappropriatenes s of prescribing a fixed levelo f energy intake toinsulin-dependen t diabetic patientswit h normalbod yweigh t (10,11). Therefore,i ti sou r suggestionno t toprescrib e a fixedenerg y intake todiabeti cpatient swit hnorma lbod yweight .

Finally,a mor e general remark on thedietar y regimen should bemade . Consistentwit h other studies (12-16)w e found that thediabeti cdie twa s considered themos tdifficul t aspect of the therapeutic regimen.A s all patients inthi s studywer e insulin-treated diabetics,a solutionma yb e to adapt the insulin regimen toth eperson' seatin ghabit san dno tvic eversa . Changing an insulin regimen ismuc h easier thanchangin g aperson' s eating habits(17) . -82-

8.4.3. Dietary compliance

Inth e literature it isdescribe d that compliance with thediabeti c diet is generally low (18-20) . The resultso f thisthesi s suggest that thisca nb e attributed to thepatien t misunderstanding thediabeti c diet and to inappropriate dietary counselling andno tt oa lack ofmotivatio n on the side of thepatient .

8.5. IMPLICATIONS FORNUTRITIO N EDUCATION PROGRAMS

This thesis demonstrates thatdiabeti c patients arever ymotivate d to change their food choices ona short-term aswel l aso na mor e long-term basis. However, several issues of concern have been raised. First of all,patient s regard thediabeti c diet as themos tdifficul t aspect of the therapeutic regimen,experiencin g many barrierswit h it.Secondly , although patients are very motivated tomak e healthy food choices,i t is frequently seen that the patient lacksunderstandin g of theprinciple s of thediabeti c diet,whic h results inunnecessar y and excessive food restrictions. The results of this research have the following implications for the planning ofnutritio n education programs forhealth y populations. First,i t should be taken intoaccoun t thathealth y populationswil l not easily bemad e to change their food choices.Th e reason for this is twofold: inth e firstplac e there is the fact that barriers are the inevitable result of changing food choices plus, in second place,th e absence of the strong,health-relate d motivation that supports the diabetic patient. Secondly, amajo r concern in trying to change food choices is that the receiver will easilymisunderstan d the message taught to themb ynutritio n education programs.A s pointed out in this thesis,a nutritio n education message mayver ywel l be interpreted in terms of 'forbidden' foods and prescribed foods,whic hwoul d result in changes in food choices not aimed forb ynutritio n education programs. More knowledge on the standards applied byhealth y populations to classify a food, and themeaning s theyattac h to foods isurgentl y needed for the planning ofnutritio n education programs.Especificall y worthwlle whould be an investigation into themotive supo nwhic h a food isclassifie d as unacceptable. -83-

FEFEREWCES

1. Visser,A .Ph. ,va nd eBoogaard ,P.R.F. ,va nde rVeen ,E.A. :Participati e vandiabeten .Medisc hContac t40 :1502-1504 ,1985 . 2. Crapo,P.A. :Carbohydrat ei nth ediabeti cdiet .J A mCol lNut rä :31-43 , 1986. 3. Mann,J. :Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J A mCol lNut r5 :1-7 ,1986 . 4. AmericanDiabete sAssociation :Nutritiona l recommendationsan dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 :126-132 , 1987. 5. Krondl,M. ,Coleman ,P. :Socia lan dbiocultura ldeterminant so ffoo d selection.Pro gFoo dNut rScienc e10 :179-203 ,1986 . 6. Broussard,B.A. ,Bass ,M.A. ,Jackson ,M.Y. :Reason sfo rdiabeti cdie t noncomplianceamon gCheroke eindians .J Nut rEdu c14 :56-57 ,198 2 7. Daschner,B.K. :Problem sexperience db yadult si nadherin gt oa prescribeddiet .Th eDiabete sEducato r12 :113-115 ,1986 . 8. Pate,CA. ,Dorang ,S.T. ,Keim ,K.S. ,Stoecker ,B.J. ,Fischer ,J.L. , Menendez,C.E. ,Harden ,M. :Complianc eo finsulin-dependen tdiabetic s witha low-fa tdiet .J A mDie tAsso c86 :796-798 ,1986 . 9. Lean,M.E.J. ,James ,W.P.T. :Prescriptio no fdiabeti cdiet si nth e1980s . TheLancet ,Marc h29 :723-725 ,1986 . 10.Nuttal ,F.Q. :Die tan dth ediabeti cpatient .Diabete sCar e6 :197-207 , 1983. 11.Chantelau ,E.A. ,Frenzen ,A. ,Gösseringer ,G. ,Hansen ,I. ,Berger ,M. : Intensiveinsuli ntherap yjustifie ssimplificatio no fth ediabete sdiet : Aprospectiv estud yi ninsulin-dependen tdiabeti cpatients .A mJ Cli n Nutr45 :958-962 ,1987 . 12.Lockwood ,D. ,Frey ,M.L. ,Gladish ,N.A. ,Hiss ,R.G. :Th ebigges tproble m indiabetes .Th eDiabete sEducato r12 :30-33 ,1986 . 13.Glasgow ,R.E. ,McCaul ,K.D. ,Schäfer ,L.C. :Barrier st oregime nadherenc e amongperson swit hinsulin-dependen tdiabetes .J Beha vMe d9 :65-77 , 1986. 14.Jenny ,J.L. :A compariso no ffou rag egroups 'adaptatio nt odiabetes .Ca n JPubli cHealt h75 :237-244 ,1984 . 15.Jenny ,J.L. :Difference si nadaptatio nt odiabete sbetwee n insulin-dependentan dnon-insulin-dependen tpatients :Implication sfo r patientseducation .Patien tEdu cCounse l8 :39-50 ,1986 . 16.Ary ,D.V. ,Toobert ,D. ,Wilson ,W. ,Glasgow ,R.E. :Patien tperspectiv eo n factorscontributin gt ononadherenc et odiabete sregimen .Diabete sCar e 9:168-172 ,1986 . 17.Nuttal ,F.Q. :Die tan ddiabetes ,a brie foverview :Persona lperspective . JA mCol lNut r6 :5-9 ,1987 . 18.West ,K.M. :Die ttherap yo fdiabetes :A nanalysi so ffailure .An nInter n Med79 :425-434 ,1973 . 19.Christensen ,N.K. ,Terry ,R.D. ,Wyatt ,S. ,Pichert ,J.W. ,Lorenz ,R.A. : Quantitativeassessmen to fdietar yadherenc ei npatient swit h insulin-dependentdiabete smellitus .Diabete sCar e6 :245-250 ,1983 . 20.Glanz ,K. :Nutritio neducatio nfo rris kfacto rreductio nan dpatien t education:A review.Pre vMe d14 :721-752 ,1985 . -84-

Summary

Changing food choiceso fpopulation s inorde r to improve foodhabits ,i s currentlya majo r issue inpreventiv emedicine .I ti s recognized that food choicesar edifficul t tochang e forpeopl ewit hhealt hproblem swh oar e being treatedwit hmedicall yprescribe d diets.I ti seve nmor edifficul t for the general population tochang e foodchoice s for improved health status (1-3). This thesisdescribe s researcho n thebarrier sdiabeti c patients experience when they change their food choices,o nth eactua l food choicesan d food choicemotive so f recentlydiagnose d diabeticpatients .

DiabetesMellitu s isa heterogeneou smetaboli c disease,wit hprofoun d nutritional implications.Tw o typeso fdiabete smellitu sar edistinguished : insulin-dependent diabetesan dnon-insuli ndependen tdiabetes .Thes e twotype s aredifferentiate d byetiology ,ag e ofonset ,prognosi san d therapy. Inthi s thesis the focus iso n the first typeo fdiabetes . Diet is recognized asessentia l inth emanagemen to fdiabete san d in minimizing the risk ofdevelopin g long-term complications.Th e amounto f energy inth edie t should achievean dmaintai na desirabl e bodyweight .Th e amount of carbohydrates should ideallyb eu p to 50%o f the total energy intake.Diet shig h incarbohydrate s improvemetaboli c control ofdiabeti c patients.Althoug h sucrosewa s forbidden inth ediabeti c diet fora longtime , today iti s recognized thatmodes t amountso f sucrose (upt o 50gram sa day) are acceptable,provide d it isuse d incombination swit hothe rnutrients . Total fat intake shouldb e restricted to 30-35%o f totalenerg y intake and cholesterol intake shouldno texcee d 200-300mg/day .Replacemen t of saturated fatswit hunsaturate d fatsma y slowdow n theprogressio n of atherosclerosis (4-12).

Part Idescribe s thebarrier s insulin-treated diabeticpatient s experience with thediabeti c diet.I nchapte r 2thes ebarrier sar e identified.Base d on the resultso f this studyw edevelope d aquestionnair e listing 22possibl e dietarybarrier s classified into five categories:regularit y ofeating , feelingso fbodil ydiscomfort ,th ecost so f thediabeti cdiet ,hedoni c and socialbarriers .Th eprevalenc e ofthes ebarrier samon g 540 insulin-treated diabetic patientsha sbee nassesse d inchapte r 3.Barrier smos t frequently citedwer e feelings ofbodil ydiscomfor t (being hungry), the imposed -85-

regularity ofeatin gan d the costso f thediabeti cdiet .Hedoni c and social barrierswer ementione d less frequently.

Manyo f thebarrier spatient sexperienc ear edu e toth epatients 'ow n misconceptions andview so f thediabeti cdie tan d their inability toadap t the diet to individualbodily ,hedoni c and socialneeds .I ti sargue d that barriers could be reduced byprescribin gdiabeti c dietsbase dupo n recent nutritional recommendations,an db yn o longerprescribin g dietswit h fixed energy contents todiabeti c patientswh od ono tnee d tolos eweight .

The changes in food choicesamon g recentlydiagnose d insulin-dependent diabeticpatient sar e the central issueo fpar t II.Chapte r 4compare s food choicesbefor e and fourmonth safte r thediagnosi so fdiabetes .I nchapte r 5 we looked into thequestio nwhethe r insulin-dependentdiabeti c patients change their food choicesbetwee n fouran d 16month safte r thediagnosis . Compared tobefor e thediagnosi s considerable changes in food choiceswer e documented at fourmonth safte r thediagnosi so f thediabetes .Som eo f the changes sucha sa decreas e inth eus e ofhigh-fa t foods,wer e consistentwit h thedietar y guidelines fordiabeti cpatients .O n theothe r hand, the increased use ofdiabeti c speciality foodsan d thelowe rus e of foodswit h high carbohydrate contentswer e less favorable froma nutritiona l perspective.Foo d choices 16month s afterdiagnosi so fdiabete sha d notchange d considerably from food choicesa t fourmonths .Favorabl e froma nutritiona l perspective was the reducedus e ofdiabeti c speciality foodsdurin g thisperiod .Unfavorabl e was thedecreas e inth eus eo f low-fat foods fromth emeat ,dair yan d snack foodgroups ,an d theconcurren t increase inus e ofhigh-fa t foods.I twa s concluded that insulin-dependent diabetic patients retainedmos to f the favorable changes infoo dus e fora t least 16month safte r thediagnosi s of diabetes.

Part IIIdeal swit h the food choicemotive s (foodperceptions )an d their relation to fooduse .I nchapte r 6, severalhealth ,convenienc e and taste perceptions ofeigh tdair yproduct san d the connectionsbetwee n food perceptions and foodus ear e investigated. According toth e resultspatient sperceiv ea fooda seithe r healthy orno t healthyan dd ono tdiscriminat e betweendifferen t healthvalue s offoods . Generally,diabeti c patients tend to rejectdair yproduct swit h high-fat and/or sugar contentsbecaus eo f supposed lowhealt hvalues . -86-

The foodperception san dus eo f thedair yproduct shav ebee n compared between insulin-dependent diabetic andnon-diabeti c subjects (chapter 7). Results showed that the frequencyo fus eo f fourou to f theeigh tdair y products differed betweendiabeti c andnon-diabeti c subjects,whil e the twogroup so f subjectsha d similar foodperception so f these foods.Th e effecto f food perceptions on foodus ema yb edifferen t fordiabeti c incompariso n to non-diabetic subjects.Fo rdiabeti c subjects,th e fact that theyhav e a chronic illnessma yb ea motiv e that iso f special influence on foodchoices . Foodswhic h areperceive d ashavin g lowhealt hvalue swoul db euse d less often.Non-diabeti c subjectsperceivin ga foodhavin ga lowhealt hvalu ewoul d notautomaticall y reduce the frequency ofus e of this food.

Inth e generaldiscussio n (chapter 8)th e inter-connections between the various studiesar ediscussed . Iti sargue d thatdespit e thebarrier s experienced,diabeti c patients aremotivate d tochang e their food choiceso na short-term aswel l aso na mor e long-termbasis .Th eactua l changes infoo d usepatient smak e afterbein gdiagnose d asdiabetic sar e onlypartl y in agreementwit h theprinciple so f thediabeti cdiet .Man y of thechange s in foodus e areno t requiredwhil e somear eeve nundesirabl e froma nutritional perspective (2-4). This implies thatpatient sperceiv eman ymor e foods tob e unhealthy thanwoul db e required froma nutritiona l perspective.Wit h regard toth ediabeti cdie t it isconclude d that innutritio neducatio n fordiabeti c patientsmor eattentio n shouldb epai d toth epatient' sunderstandin g of the diabeticdiet .Trainin g thepatien t toadap tth edie t toth e individual need and changing circumstances should bepar to f thediabeti c education program. Furthermore,dietar y guidelines given todiabeti c patients should bebase d on the latestnutritiona l recommendations.Dietar ynoncomplianc e ismos t likely due to thepatient' smisunderstandin g of thediabeti cdie tan d to inappropriate dietary counselling,no t toa lack ofmotivatio no n the sideo f thepatient . The lastpar to f thischapte rdiscusse s the implications of the research for nutritioneducatio nprogrammes .

REFERENCES

1. Ministerie vanWelzijn ,Volksgezondhei d enCultuur :Not aVoedingsbeleid . 'sGravenhage, 1984-1987 . 2. World HealthOrganization :Target s forHealt h forAll .WHO-Copenhagen , 1985. 3. Nationale Raadvoo r LandbouwkundigOnderzoe k (NRLO): Meerjarenplan Landbouwkundig Onderzoek 1987-1991. 'sGravenhage ,1986 . -87-

4. AmericanDiabete sAssociation :Nutritiona l recommendationsan dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 :126-132 , 1987. 5. Anderson,J.W. ,Gustafson ,N.J. ,Bryant ,C.A. ,Tietyen-Clark ,J. :Dietar y fiberan ddiabetes :A comprehensiv erevie wan dpractica lapplication .J A m DietAsso c87 :1189-1197 ,1987 . 6. Crapo,P.A. :Carbohydrat ei nth ediabeti cdiet .J A mCol lNut r5 :31-43 , 1986. 7. Jenkins,D.J.A. ,Taylor ,R.H. ,Wolever ,T.M.S. :Th ediabeti cdiet ,dietar y carbohydratean ddifference si ndigestibility .Diabetologi a23 :477-484 , 1982. 8. Mann,J.I. :Die tan ddiabetes .Diabetologi a18 :89-95 ,1980 . 9. Mann,J. :Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J A mCol lNut r5 :1-7 ,1986 . 10.Mann ,J.I. :Simpl esugar san ddiabetes .Diabeti cMedicin e44 :135-139 , 1987. 11.Peterson ,D.B. ,Lambert ,J. ,Gerring ,S. ,Darling ,P. ,Carter ,R.D. , Jelfs,R. ,Mann ,J.I. :Sucros ei nth edie to fdiabeti cpatient s- jus t anothercarbohydrate ?Diabetologi a29 :216-220 ,1986 . 12.Simpson ,H.C.R. :High-carbohydrate ,high-fibr ediet sfo rdiabetics .Pro c NutrSo c40 :219-225 ,1981 . -88-

Samenvatting

Datmense nhu nvoedselkeuze nveranderen ,te rverbeterin gva nd e voedingsgewoonten,word t tegenwoordigva ngroo tbelan g geachtbinne nd e preventieve gezondheidszorg.Algemee nword t erkendda the tverandere nva n voedselkeuzenmoeilij k is.Geld tdi too kvoo rd eNederlands e bevolkingal s geheel;he tverandere nva nvoedselkeuze ni soo kmoeilij kvoo rmense ndi eo m gezondheidsredenenee ndieetadvie smoete ngaa nvolge n (1-3). Indi tproefschrif tworde nverschillend e onderzoekenbeschreven :naa rd emoei ­ lijkhedendi emense nme tdiabete s (suikerziekte)ervare nme thu ndieetadvies , deveranderinge n invoedselkeuze nva nmense nbi jwi erecentelij k insuline-afhankelijke diabetesi sgeconstateer de nnaa rd eperceptie s (denkbeelden)di eee nro lspele nbi jhu nkeuz eva nvoedingsmiddelen .

DiabetesMellitu si see nstofwisselingsziekt eme tgrot e gevolgenvoo rd e voeding.E rbestaa n twee soortendiabetes :insuline-afhankelijk e diabetese n niet insuline-afhankelijke diabetes.Dez e twee typenverschille ni n ethiologie,leeftij dwaaro pd eziekt eontstaat ,prognos ee ntherapie .I ndi t proefschrift gaatd eaandach tvolledi gui tnaa rd eeerst e soortdiabetes .He t diabetesdieet speeltee ngrot e roli nd eregulati eva nd ediabetes .Oo k verkleinthe tdiee td ekan so pd egevreesd e complicatiesdi eme tdiabete s gepaard kunnengaan .He ti sbelangrij kda td eopnam eva nenergi e zodanigi s dathe tgewenst e lichaamsgewichtword tbereik te ngehandhaafd . Koolhydraten moeten idealiter tenminste 50procente nva nd eenergi e leveren.Ee nhog e opnameva nkoolhydrate nverbeter td eregulati eva nd ediabetes .Hoewe l suiker langverbode nwa svoo rdiabeten ,i svolgen sd ehuidig e inzichtenee n suikeropnameva nminde rda n5 0gra mpe rdag aanvaardbaar ,mit s suikerword t gebruikti ncombinati eme tander evoedingsstoffen .I nd etegenwoordig e opvattingenmoe td evetopnam eworde nbeperk tto t3 0à 3 5energieprocente ne n magd eopnam eva ncholestero ld e20 0to t30 0mg/da g nietoverschrijden .Oo k verondersteltme nda tvervangin gva nverzadig dve tdoo r onverzadigdve td e ontwikkelinge nvoortgan gva natherocleros eka nbeperke n (4-12).

Deel Iva ndi tproefschrif t beschrijftd emoeilijkhede ndi einsuline-afhanke ­ lijkediabete nervare nme the tdieetadvies .Hoofdstu k 2beva tee n inventarisatieva ndez emoeilijkheden .O pgron dva ndi toverzich t zijn2 2 moeilijkheden gedestilleerd,verdeel d overvij f categorieën: regelmatig moeten eten,lichamelijk eongemakken ,d ekoste nva nhe tdieet ,beperkinge ni nd e -89-

voedselkeuze ensocial emoeilijkheden .D eprevalenti eva ndez e moeilijkheden werd vastgesteld bij 540insuline-afhankelijk e diabeten (hoofdstuk 3).D e moeilijkheden died e ondervraagdediabete nhe tvaaks tnoeme nzijn : lichamelijke ongemakken (honger hebben),moeilijkhede nme t regelmatig eten en de extra kostendi ehe tdiee tme t zichmeebrengt .D eander eprobleme n werden minder vaak genoemd. Veelmoeilijkhede n die insuline-afhankelijke diabeten ervarenme the t dieetadvies ontstaandoo r eengebrekki g inzicht ind euitgangspunte n van het dieetadvies.Oo k zijndiabete nvaa k niet zelf in staathe tdiee taa n tepasse n aanhu nbehoefte ne nwisselend eomstandigheden .D emoeilijkhede nme t het volgenva nhe tdieetadvie s kunnenworde nbeperk tdoo r alleendi e dieetadviezen tegeve ndi egebaseer d zijno precent evoedingskundig e inzichtene ndoo r geen vaste hoeveelheid energie ind evoedin gvoo r te schrijvenaa nmense ndi e geen overgewichthebben .

Indee l IIworde nd everanderinge n beschrevendi eoptrede n invoedselkeuz e gedurende de eerste tijdn ad ediagnos eva nd ediabetes .I nhoofdstu k 4 wordt devoedselkeuz e voorhe toptrede nva nd ediabete svergeleke nme tdie ,vie r maanden nad ediagnose .Hoofdstu k 5behandel td evraa g inhoeverr e de voedselkeuze van insuline-afhankelijke diabetenverander t tussenvie r en zestienmaande nn ad ediagnos eva nd ediabetes . Tussenvoedselkeuz e voor dediagnos eva nd ediabete se nvie rmaande n erna werdengrot everanderinge nwaargenomen .Sommig everanderinge n zoalshe t verminderde gebruik vanvett evoedingsmiddele n zijn inovereenstemmin g met de huidigevoedingskundig e inzichten.Ander everanderinge n zijnvanui t dit oogpuntminde r gunstig,bijvoorbeel d deafnam e inhe tgebrui k van koolhydraatrijke voedingsmiddelen end e toename inhe tgebrui k van diabetesprodukten. Devoedselkeuz e nahe tontstaa nva nd ediabete sblee k tamelijk stabiel te zijn.Va nd everschille ndi e tussenvie r en zestienmaande nn ad e diagnose optraden, isd e afname inhe tgebrui k vandiabetesprodukte n gunstig tenoemen . Als ongunstig kand e afnameworde n aangemerkt inhe tgebrui k vanenkel e magere Produkten end e toename inhe tgebrui k vanvetter e voedingsmiddelen. De conclusieva ndi tonderzoe k luidtda t insuline-afhankelijke diabeten in staat zijno mhu nvoedselkeuz e inpositiev e zint everandere n endi t volhouden tot zeker 16maande nn ad ediagnos eva nd ediabetes . -90-

Deel IIIva ndi tproefschrif t behandelt perceptiesove rvoedingsmiddele n end e invloedhierva no phe tgebrui k vandez evoedingsmiddelen .Hoofdstu k 6 beschrijftd eperceptie sdi ed ediabete nhebbe nove rach t zuivelproduktenwa t betreft gezondheid,gebruiksgema k en smaak enwelk e samenhangdez e percepties vertonenme the tgebrui k vandez evoedingsmiddelen . De resultatenva ndi t onderzoek makenduidelij k datmense nme tdiabete s eenvoedingsmidde l waarnemen alsó f gezond óf ongezond. Inhu nbeoordelin g vanee nvoedingsmidde l maken zij geenonderschei d ind emogelijk everschillend e gezondheidswaarden van zuivelprodukten.Ove r hetalgemee n gebruikenmense nme tdiabete s geen zuivelprodukten metvee lve ten/o f suikervanweg e de lagewaard e die zijdez e Produkten toekennenvoo rhu ngezondheid . Deperceptie s diemense nme t insuline-afhankelijke diabeteshebbe nove r de zuivelprodukten zijnvergeleke nme tdi eva nnie tdiabete n (hoofdstuk 7). Deze gegevens zijngerelateer d aanhe tgebrui k vandez eprodukten .He tblijk tda t diabeten ennie tdiabete n over demeest e zuivelprodukten identieke percepties hebben,maa r hetblijk too kda t inhe tgeva lva nd ehelf tva nd ezuivel ­ produktend e frequentieva nhe tgebrui k verschilt.D e invloedva n percepties ophe t gebruikva nd evoedingsmiddele n ligtbi j insuline-afhankelijke diabeten ennie tdiabete n kennelijk anders.He tbese fda tzi jee nchronisch e ziekte hebben, ise rbi jdiabete nwellich t deoorzaa k vanda t zijvoedingsmiddele n die zijee n lagegezondheidswaarderin g geven,nie t frequent gebruiken.Bi j nietdiabete ngeld tvee lminde r dat zijvoedingsmiddele n minder frequent gebruikendi e zijee n lagewaard evoo r de gezondheid toekennen.

Hoofdstuk 8 isgewij daa nd ediscussi e overd e samenhang tussend everschil ­ lende onderzoeken.Mense nbi jwi e insuline-afhankelijke diabetes is vastgesteld, zijngemotiveer d omhu nvoedselkeuz e teverandere n zowelo pd e korte also pd e langere termijn,ondank sd emoeilijkhede n die zijhierbi j ondervinden.D everanderinge n diediabete nmake n inhu nvoedselkeuz e nad e diagnoseva nd ediabete s zijn slechts tendel e inovereenstemmin g metd e uitgangspunten vanhe tmodern e diabetesdieet.Vee lva nd everanderinge n zijn onnodig en sommige zelfsonwenselij k (2-4). Hetgevol ghierva n isda tmense n veelmee rvoedingsmiddele n alsongezon d beschouwenda n striktnoodzakelij k is. Devolgend e conclusies zijngetrokke nme tbetrekkin g tothe tdiabetesdieet . Voorlichtingsprogramma's voormense nme tdiabete s zoudenmee raandach tmoete n besteden aanhe tvergrote nva nd e kennisove rd euitgangspunte n van het dieetadvies.Mee r aandachtverdien too k hetaangeve nva nwege nho e diabeten hetdiee tkunne naanpasse n aanhu neige nbehoefte n enwisselend e omstandig- -91-

heden.Vervolgen szoude nallee ndi edieetadvieze naa nmense nme tdiabete s gegevenmoete nworde ndi egebaseer dzij no pd elaatst ewetenschappelijk e inzichten.Tenslott ei she tnie topvolge nva ndieetadvieze nwaarschijnlij k meerhe tgevol gva ngebrekkig evoorlichtin ge nva nonvoldoend ekenni sdi e diabetenhebbe nva nhe tdieetadvies ,da nva nee ngebre kaa nmotivatie. » Alslaatst eworde nd econsequentie sva ndi tonderzoe kvoo rvoedingsvoorlich ­ tingsprogramma'sbesproken .

LITERATUUR

1. Ministerieva nWelzijn ,Volksgezondhei de nCultuur:Not aVoedingsbeleid . 'sGravenhage ,1984-1987 . 2. WorldHealt hOrganization :Target sfo rHealt hfo rAll .WHO-Copenhagen , 1985. 3. NationaleRaa dvoo rLandbouwkundi gOnderzoe k (NRLO):Meerjarenpla n LandbouwkundigOnderzoe k1987-1991 .' sGravenhage ,1986 . 4. AmericanDiabete sAssociation :Nutritiona lrecommendation san dprinciple s forindividual swit hdiabete smellitus :1986 .Diabete sCar e10 :126-132 , 1987. 5. Anderson,J.W. ,Gustafson ,N.J. ,Bryant ,CA. ,Tietyen-Clark ,J. :Dietar y fiberan ddiabetes :A comprehensiv e reviewan dpractica lapplication .J A m DietAsso c87 :1189-1197 ,1987 . 6. Crapo,P.A. :Carbohydrat ei nth ediabeti cdiet .J A mCol lNut r5 :31-43 , 1986. 7. Jenkins,D.J.A. ,Taylor ,R.H. ,Wolever ,T.M.S. :Th ediabeti cdiet ,dietar y carbohydratean ddifference si ndigestibility .Diabetologi a23 :477-484 , 1982. 8. Mann,J.I. :Die tan ddiabetes .Diabetologi a18 :89-95 ,1980 . 9. Mann,J. :Dietar yadvic efo rdiabetics :A perspectiv efro mth eUnite d Kingdom.J A mCol lNut r5 :1-7 ,1986 . 10.Mann ,J.I. :Simpl esugar san ddiabetes .Diabeti cMedicin e44 :135-139 , 1987. 11.Peterson ,D.B. ,Lambert ,J. ,Gerring ,S. ,Darling ,P. ,Carter ,R.D. , Jelfs,R. ,Mann ,J.I. :Sucros ei nth edie to fdiabeti cpatient s- jus t anothercarbohydrate ?Diabetologi a29 :216-220 ,1986 . 12.Simpson ,H.C.R. :High-carbohydrate ,high-fibr ediet sfo rdiabetics .Pro c NutrSo c40 :219-225 ,1981 . -92-

Curriculum Vitae

AnnaCatharin aNiewin dwer dgebore no p2 4januar i195 7t eNaarden .N ahe t behalenva nhe tgymnasiu mbet adiplom aaa nhe tWille md eZwijger-Lyceu mt e Bussum,bego nzi ji n197 5me td estudi eVoedin gva nd eMen saa nd eLandbouw ­ universiteitWageningen .Tijden shaa rpraktijktij ddee dzi jonderzoe ko phe t gebiedva novergewich taa nd e 'Universityo fUtah' ,Sal tLak eCity ,US Ae n werktebi jhe t'Healt hEducatio nCenter 't ePittsburgh ,USA .I n198 3behaald e zijhe tdoctoraalexame nme tal shoofdva kVoedingslee re nal sbijvakke n Methodene nTechnieke nva nhe tSocial eOnderzoe ke nSocial ee nEconomisch e Geschiedenis.Ee nbeur sva nd e 'WorldUniversit yServic eo fCanada' ,steld e haari nstaa tonderzoe kt edoe nnaa rd evoedselkeuz eva ndivers ebevolkings ­ groepenaa nhe t 'Departmento fNutritiona lSciences ,Universit yo fToronto' , Toronto,Canada .Pe r1 5oktobe r198 5tra d zij,al swetenschappelij kassistent , indiens tbi jd eVakgroe pHuman eVoedin gva nd eLandbouwuniversitei t Wageningenwaa rhe ti ndi tproefschrif tbeschreve nonderzoe kwer dverricht . Sinds1 apri l198 9i szi jwerkzaa mbi jhe tMinisteri eva nOnderwij se n Wetenschappent eZoetermeer .