Download Comparison of Dietary Patterns and Socio

Comparison of Dietary Patterns and
Socio-economic Status of Uncontrolled and Controlled
Diabetic Patients in K.V. Kuppam Block
Love Odetola
Rural Unit for Health and Social Affairs (RUHSA)
St. Olaf Biology in South India Program
Fall 2013
Table of Contents
Abstract……………………………………………………………………………………………………………………………………………2
Introduction……………………………………………………………………………………………………………………………………..2
Types of diabetes …………………………………………………………………………………………………………………3
Why such high diabetes prevalence in India? ………………………………………………………………...……3
Burden of Diabetes in India………………………………………………………………………………………………….4
RUHSA and diabetes prevalence…………………………………………………………………………………………..5
Risk factors of uncontrolled diabetes……………………………………………………………………………………5
Symptoms of uncontrolled diabetes…………………………………………………………………………………….6
Research Project…………………………………………………………………………………………………………………..7
Materials and Methods….……………………………………………………………………….……..…………………………………7
Background………………………………………………………………..……………………………………………………..…7
Participation…………………………………………………………………………………………………………………………7
Procedure…………………………………………………………………………………………………………………………….8
Results……………………………………………………………………………………………………………………………………………..8
Sex, Age, Caste in relation to Diabetes condition………………………………………………………………….9
Wealth, Occupation and Education in relation to Diabetes condition…………………………..………9
Health history and Diabetes condition……………………………………………………………………………….10
Habits and depression history in relation to diabetic condition……………………………………..…..10
Dietary patterns and diabetic condition……………………………………………………………………………..11
Discussion………………………………………………………………………………………………………………………………………12
Social Factors and Uncontrolled diabetes……………………………………………..……………………………12
Economic factors and uncontrolled diabetes………………………………………………………………………13
Medical History and Uncontrollable diabetes…………………………………………………………..………..13
Habits and Depression history in relation to Diabetes condition…………………………………………14
Amount and Frequency of Food…………………………..…………………………………………………………….16
Conclusion…………………………………………………………………………………………………………………………………….16
Acknowledgments………………………………………………………………………………………………………………………...16
Literature Cited……………………………………………………………………………………………………………………………..18
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Abstract
Home to over 63 million diabetic patients, India is rapidly becoming the diabetes ‘capital’ of the
World, where many people have little to no access to diagnosis or treatment. The rural
population of K.V. Kuppam Block in Vellore is fortunate in that it has easier and subsidized
access to diabetic care through services provided by RUHSA. However, 10% of the patients
receiving care at RUHSA are still unable to control their diabetic condition. Therefore the
purpose of this study is to analyze the reasons behind this inability to control one’s sugar level.
by assessing dietary patterns and socio-economic status of the controlled and uncontrolled
patients in K.V. Kuppam Block. This study looks at what socio-economic factors and dietary
patterns contribute to uncontrolled diabetes. To delve into this question, diabetic patients within
K.V. Kuppam Block in Vellore, India were interviewed. Out of the 14 characteristics considered,
eight factors appeared to affect the incidence of uncontrolled diabetes. These included the
patient’s caste, age, number of years with the illness, depression, physical activity, gender,
family medical history and dietary patterns. The scheduled caste and patients who were male or
were within the ages of 46 – 55 appeared to be the most susceptible to developing uncontrolled
diabetes. Seventy percent of the patients who exercised were able to control their sugar level.
And all patients who smoked had uncontrolled diabetes. Depression also appeared to affect the
occurrence of uncontrolled diabetes as 60% of depressed patients were uncontrolled diabetic
patients. Additionally, on average patients with uncontrolled diabetes ate more of the food that
should be avoided, namely rice, dosa, and iddli (rice cake). However, the consumption of
recommended foods such as vegetables and fruits did not differ greatly between both groups.
Introduction
With more than 63 million diabetic patients, India is rapidly becoming the diabetes
capital of the World (Abdelhadi 2012). Unfortunately half of those with diabetes remain
undiagnosed. “Diabetes is a chronic condition that occurs when the body cannot produce enough
or effectively use insulin” (International Diabetes Foundation 2012). Insulin is a hormone
produced by the pancreas that enables glucose from ingested food to enter the body’s cells so as
to be used for energy. As a result of diabetes, glucose is not taken up from the gastrointestinal
tract cells and hence remains in the blood streams (hyperglycemia) damaging tissues over time.
There are three types of diabetes: mellitus type 1 diabetes, type 2 diabetes and gestational
diabetes (GDM).
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Types of diabetes
Type 1 diabetes is caused by an auto-immune reaction, where the patient’s body destroys
the insulin-producing beta cells in the pancreas. The body can therefore not produce the insulin it
needs. Without insulin, individuals with type 1 diabetes will die. This disease can affect people
of all ages. On the other hand, type 2 diabetes usually affects adults. A type 2 diabetes patient is
either not producing enough insulin or the insulin produced is not working properly. This leads
to a build-up of glucose in the blood. Unlike the first two forms of diabetes, gestational diabetes
mellitus (GDM) affects only women. GDM is diabetes that is first diagnosed in women during
pregnancy. It usually occurs later in pregnancy when her body is unable to produce or utilize
enough insulin needed for the pregnancy. Most women with GDM do not remain diabetic after
the baby is born. However, once a mother has had GDM, she is at a higher risk of getting it again
during a future pregnancy and of developing type 2 diabetes later in her life (National Diabetes
Information Clearinghouse 2013).
Why such high diabetes prevalence in India?
The high prevalence of diabetes in India might be due to a couple of factors. First, studies
have suggested the existence of an “Asian Indian Phenotype” that increases the probability of
getting diseases like diabetes. This phenotype refers to biochemical and clinical differences in
Indians including “increased insulin resistance, greater abdominal adiposity i.e., higher waist
circumference despite lower body mass index, lower adiponectin and higher sensitive C-reactive
protein levels” (Mohan et al. 2007). With this metabolic phenotype, Indians are more prone to
premature coronary disease and diabetes. However it is important to note this genetic
predisposition is not the primary cause for such high diabetes incidence.
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Rather, the primary influencing factors are the rapidly evolving changes in dietary
patterns and decreased physical activity in the last 50 years due to recent economic growth
(International Diabetes Foundation 2012). Although this urbanization and globalization process,
encompassing an improved access to healthcare, increased food intake, control of various
communicable diseases, and better hygiene has resulted in increased longevity, it has also
resulted in non-communicable diseases such as diabetes, obesity, and heart disease. And
although the prevalence of diabetes complications such as nephropathy and retinopathy are
relatively lower in Indians, the prevalence of premature coronary artery disease is highest in
Indians when compared to other ethnic groups. The growing ‘fast food culture’ and sedentary
livelihood is also a main contributing factor to the high levels of diabetes in India (Hu, 2011). It
is important to note that the studies reflecting an increase in the prevalence of diabetes also
indicate high proportions of undiagnosed diabetes, hence revealing a hidden danger.
Burden of Diabetes in India
Developing countries, including India, face the greatest burden of diabetes (International
Diabetes Foundation 2010). But unfortunately, many health practitioners ignore the magnitude
and the predicted future increase in diabetes, as well as the nefarious effects of such dramatic
epidemiological changes. Diabetes, on one hand, brings about an economic burden, and on the
other, an emotional burden to individuals and families. In India, the medical costs of a diabetic
patient are two to fivefold higher than those of non-diabetic individuals (Singh 2013). Families
within the lowest socioeconomic strata and in rural areas bear the greatest economic burden.
Poorer families in villages spend direct expenses of up to 34% of their household income on
diabetic care; while wealthier families in rural areas spend 5-12.6% of their income. On a
national level, in 2010, the Indian government spent only about 1% of the global diabetes
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spending, while the US spends about 53%. With the critically increasing levels of diabetes, the
Indian government might have to spend much more on the disease.
RUHSA and diabetes prevalence
This research project focuses on type 2 diabetes in K.V. Kuppam Block. RUHSA is a
secondary health center located in K.V. Kuppam Block, one of the 20 government administrative
blocks that make up Vellore district in the Indian State of Tamil Nadu. RUHSA is a department
of Christian Medical College, situated 30 km from Vellore town (Matthews 2013). It serves well
over 120,000 people in its 39 panchayat villages. Panchayats are local self-governments at an
Indian village or small town level. RUHSA was founded with three objectives: to provide service
to the people of K.V. Kuppam Block, to offer training for nursing, medicine, and other health
and development students and finally to conduct research in development and health. In order to
serve K.V. Kuppam residents, RUHSA runs a secondary health clinic.
The Clinic is where the Friday diabetic clinics are held. Every Friday, RUHSA attends to
up to 120 diabetic patients. Most of these patients have type 2 diabetes, very few are diagnosed
with type 1 or gestational diabetes. However, although most patients are able to manage their
illness, about 10% of the diabetic patients have been diagnosed with uncontrolled diabetes.
Risk factors of uncontrolled diabetes
Certain factors appear to affect the occurrence of controlled or uncontrolled diabetes.
Obesogenic environments - environments fostering low levels of physical activity combined with
the access to energy-rich diets - have proven to increase the probability of uncontrolled diabetes
(Unwin et al. 2010). There is also an association between socio-economic status and occurrence
of uncontrolled diabetes (Corsi et al. 2012). The highest socio-economic classes appear to be the
most susceptible to diabetes; however, they might not be the most vulnerable to uncontrolled
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diabetes. Depression, race, hypertension, obesity and non-adherence to medication have also
been associated with high occurrence of uncontrolled diabetes. Additionally, family history and
age could affect the occurrence probability of uncontrolled type 2 diabetes (Mayo Clinic 2013).
As explained earlier, race may contribute to the high prevalence of diabetes among Indians, in
the form of the “Asian Indian Phenotype” (Mohan et al. 2012). However, according to Mayo
Clinic (2013), being overweight is the primary risk factor for type 2 diabetes. Cells become more
resistant to insulin with increased fatty tissue.
Symptoms of uncontrolled diabetes
The symptoms of uncontrolled diabetes include complications that affect the heart and
blood vessels (Mayo Clinic 2013). Illnesses such as chest pain, high blood pressure, stroke and
atherosclerosis could ensue. For example, the risk of stroke in a diabetes patient is two to four
times higher than in non-diabetic individuals. Additionally, excess sugar can damage the walls of
capillaries that nourish the nerves, especially in the legs and feet. Therefore poor blood flow to
the feet and nerve damage in the feet increases the risk of other foot complications. Severe
damage might necessitate toe, foot, or leg amputation. Nerve damage could also occur in other
parts of the body as a result of diabetes. Damage to the nerves in the digestive system could
result in vomiting, diarrhea, nausea or constipation. And damage to the nerves in the
reproductive system could lead to erectile dysfunction.
The complications could also affect the eyes by causing disorders such as glaucoma,
cataracts and diabetic retinopathy, in addition to affecting the gums and teeth (AADE 2011).
Uncontrolled diabetes also affects the kidneys. It can damage the glomeruli, tiny renal blood
vessel clusters that filter the blood. Severe damage then leads to irreversible final-stage kidney
disease or kidney failure, demanding dialysis or kidney transplant. Other complications in
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uncontrolled diabetes include increased thirst and hunger, headaches, blurred vision, frequent
urination, fatigue, weight loss, dry warm skin, increased infections, male impotence, vaginal
yeast infections, and genital itching (Mayo Clinic 2013).
Research Project
Diabetes – specifically uncontrolled diabetes- is obviously a painful and costly disease
one should strive to avoid. This research aims at pinpointing socio-economic factors and dietary
patterns that influence the prevalence of uncontrolled diabetes in K.V. Kuppam block.
Materials and Methods
Background
On Friday, RUSHA conducts the diabetes clinic. This clinic receives up to 120 patients.
About 10% of this weekly group is made up of uncontrolled diabetic patients. Patients come in
for check-ups every three months. But the uncontrolled patients are usually advised to attend the
clinic more regularly, depending on how critical their health condition is. A patient is considered
uncontrolled if the fasting glucose level (AC value) is more than 200mg/dL or the post-prandial
(PC) glucose level is over 300mg/dL.
Participation
The study conducted was cross sectional. We selected our sample size from the list of
diabetic patients who registered for and attended the clinic on the 4th, 11th and 18th of October
2013 at RUHSA. All available uncontrolled diabetic patients were selected for the study,
amounting to 29 individuals. 29 controlled patients were however selected by systematic random
method from the list of diabetic patients who attended the same three clinics. Therefore 50% of
the study participants had uncontrolled diabetes and 50% had controlled.
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Procedure
In order to gather the data, in-depth interviews were conducted to assess socio-economic
conditions and the dietary patterns of the patients. During the interviews, the diabetes survey
entitled “Socioeconomic Factors and Dietary Patterns that affect the Occurrence of Controlled or
Uncontrolled Diabetes in K.V. Kuppam Block” was completed. The survey consisted of two
sections. The first was designed to evaluate the socio-economic status of the patient, including
questions on wealth, social status and health. The second part consisted of a table detailing the
most common foods and was designed to pinpoint the amount and eating frequency of the
common food items that are recommended or contraindicated for diabetic patients. The questions
were a combination of open-ended and close-ended questions in order to more accurately judge
the socioeconomic status and dietary patterns of the patients. However, in order to gather data
such as the BMI, blood pressure and blood glucose, the patient’s ‘health notebooks’ were
consulted. The notebooks are provided by RUSHA and summarize the health condition and
status of the person in question. The survey is presented in Appendix I.
Interviews were conducted at RUHSA and in multiple villages in K.V. Kuppam Block.
The interviews completed at RUHSA were done in the same large room where the doctor
attended to the patients on three Fridays, the 4th, 11th and 18th of October. However, the
interviews in the villages were usually completed in the homes of the interviewees during the
week between Monday Oct. 6th and Monday Oct. 14th.
Results
A total of 14 factors were evaluated to assess the socio-economic status of the patients.
These factors included: sex, age, caste, wealth, educational qualification, occupation, the number
of years with diabetes, family health history, and physical activity, in addition to blood pressure,
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whether the patient smokes, drinks, is depressed and takes the medication as prescribed. Out of
the 14 factors, only 8 proved to affect the occurrence of uncontrolled diabetes. In the following
paragraphs, a summary of the findings of each factor in relation to occurrence of uncontrolled
and controlled diabetes. A total of 58 patients were interviewed – 29 uncontrolled and 29
controlled diabetes patients.
Sex, Age, Caste in relation to Diabetes condition
The prevalence of uncontrolled diabetes was higher in the male diabetic population, with
61% of all males interviewed considered as uncontrolled diabetic patients; while 55% of the
female population have their diabetes under control (Fig 1). Concerning age, uncontrolled
diabetes patients were younger with ages between 46 and 55 years old; while 42% of all patients
who were able to manage their diabetes were between the ages of 56 and 65 years old (Fig 2).
Additionally, 64% of the Scheduled Caste interviewees had uncontrolled diabetes, whereas only
43% of the Backward Caste patients were not controlling their disease (Fig 3).
Wealth, Occupation and Education in relation to Diabetes condition
Forty-nine percent of the uncontrolled patients live under thatched roofs, thus suggesting
that they are poorer. This is because thatched roofs are typical for poorer households. But 69% of
the controlled group had tiled roofs, hence could be considered wealthier than most uncontrolled
patients. About the patient’s occupation status, the study stated that 45% of all interviewees are
housewives and 54% of these housewives are unable to control their diabetes condition. This was
followed by 23% of all patients working as ‘casual laborers’ and 54% of these laborers fit under
the uncontrolled category. Additionally, 50% of all interviewed are illiterate; 47% of those
without education could not manage their diabetes. However, 8 out of the 14 individuals who
had been in school till at least the 6th grade were uncontrolled diabetic patients.
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Health history and Diabetes condition
All controlled diabetes patients have been sick with diabetes for 10 years or less.
However, although 79% of all uncontrolled patients have also been sick for the same number of
years, 20.6% have had diabetes for more than 10 years (Fig 6). A few uncontrolled diabetic
patients have had the illness for up to 25 years. So the patients who have been sick for a longer
period of time appear to be unable to manage their diabetes. Family health history was another
factor that proved to affect the prevalence of uncontrolled diabetes. Thirty-one percent of those
within the uncontrolled group have at least one other diabetic family member; this is compares to
20% in the controlled group (Table 1). On the other hand, blood pressure of the patient did not
seem to affect diabetes condition as the results were similar in both groups: approximately the
same number of individuals in both categories had abnormal blood pressure (Fig 9). Similarly,
all interviewees regularly took their medication as prescribed. The only person who did not
comply with the medical prescriptions, could not because she had been ill for a week. During
that week, she did not take her medication as she would throw up anything she consumed and
was barely able to keep any food or substance in her digestive system.
Habits and depression history in relation to diabetic condition
Physical activity, smoking and drinking habits were considered during the study. Fiftysix percent of those who do not exercise were also unable to control their diabetes (Table 1).
However, 70% of those who did exercise were able to manage their blood sugar level. This is
therefore indicating that there might be a relationship between physical activity and the patient’s
diabetic condition. Contrarily, drinking did not seem to affect diabetic condition as none of the
patients drank regularly and even among those who did drink, there was no clear difference
between both groups. Only 3 patients stated that they smoked. All three patients had uncontrolled
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diabetes. Depression also appeared to affect the severity of diabetes. 60% of depressed patients
were uncontrolled diabetic patients, while 70% of the individuals that were not depressed
managed their blood glucose levels relatively well.
Dietary patterns and diabetic condition
On average uncontrolled diabetic patients ate more of the foods that they should avoid.
Foods such as rice and ragi ball, are great sources of sugar. Ragi ball is made of finger millet
flour and water. Upon mixture, it is molded into a ball-like shape. On average uncontrolled
patients ate more rice. No uncontrolled patient ate less than 200g of rice per day. But a few
controlled diabetic patients ate a lower amount of 100g per day. Additionally the maximum
amount of rice a controlled diabetic ate was 200g, while the maximum amount the uncontrolled
patient ingested was 600g. But the a few controlled patients ate 100g per day. Uncontrolled
patients also ate a larger quantity of wheat ball. The maximum amount of wheat ball a ‘normal’
diabetic patient ate was 300g, while the maximum within the uncontrolled group was 400g. On
average, there was not much of a difference in the amount of ragi ball consumed by both groups.
The consumption of staple breads such as dosa and chappati was not remarkably different
between the two groups. However, the maximum of number of iddli (rice cakes) eaten at a time
in the uncontrolled group was 7. This is higher compared to the maximum number of 5 iddli
eaten among the controlled patients.
Consumption of foods low in glucose and more profitable for diabetic patients did not
greatly differ between both groups. On average, the uncontrolled diabetic patients ate less
‘greens’ than the controlled. However, individuals in the two groups ate about the same quantity
of pulses, roots and tuber. Both groups ate between 100g to 500g of pulses and legumes per day.
And they ate between 25g and 200g of roots and tubers daily.
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Discussion
Study Question
The goal of this study was to observe and analyze dietary patters and socio-economic conditions
of uncontrolled and controlled diabetes.
Social Factors and Uncontrolled diabetes
The study discovered that social factors, namely gender, age, caste, affect the occurrence
of uncontrolled diabetes, with the greatest impact. 64% of patients from the Scheduled Caste
have uncontrolled diabetes. Hierarchically, Scheduled Caste is the lowest social and economic
caste. According to the Indian constitution, the Scheduled Castes are of the weaker people in the
Indian population (Constitution of India Article 46). It therefore appears that uncontrolled
diabetic patients are often within the poorer strata of the society, namely the Scheduled Caste.
Less financially stable individuals and families may not be able to afford the medication needed
to curb the disease. Hence their health worsens, slowly leading to uncontrolled diabetes.
Age is another factor that might have affected the occurrence of uncontrollable diabetes.
The prevalence of type 2 diabetes increases with age. For example, in America a study revealed
that 13.6% of diabetic patients are between the ages of 45-64 years old; and 26.9% are over 65
years old (niddk 2008). However, in my study almost 60% of those with uncontrolled diabetes
were between the relatively early ages of 49-55 years old. This might be because when the
disease first starts manifesting itself in the life and body of the patient, he or she is unable to
control the sugar level. However, after a couple of years and with advice and help from health
practitioners, the patient is able to get their glucose level under control. But there is the group of
patients who is simply unable to get its sugar level under control. Approximately 25% of the
patients between the ages of 56 and 65 years old have uncontrolled diabetes. A portion of this
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population might be those, who despite heeding to the advice of health practitioners are still
unable to control their glucose levels. This may be because they have lived with the disease for
many years and their bodies are
Economic factors and uncontrolled diabetes
Forty-nine of the uncontrolled patients live under thatched roofs, while 69% of the
controlled group has tiled roofs. In India roof type is a major indicator of the family’s wealth
(Rustein 2004). Homes with roofing made of natural material usually house the poorest Indian
families. About 50% of all uncontrollable patients live under ‘natural’ roofs. Since these families
are from lower-income families, they might not have enough funds to afford medication or the
modified more balanced meals vital to maintaining normal glucose levels.
Forty-five percent of all interviewees were housewives and 23% were Casual Laborers;
54% of each group were uncontrolled diabetic patients. This suggests that occupation in the rural
population outside Vellore may not affect the occurrence of uncontrolled diabetes. Increased
physical activity has been shown to lower blood sugar levels, improve blood flow and blood
pressure, as well as burn extra calories to help manage weight (Mayo Clinic 2013). All these
contribute to decreasing the risk of occurrence of uncontrolled diabetes. Perhaps being a
housewife, completing chores and taking care of the family, involves a similar amount of activity
as ‘casual laborers’.
Medical History and Uncontrollable diabetes
A proportion of patients who had suffered from diabetes for under 10 years had
uncontrollable diabetes. However, all patients who had suffered from diabetes for over 10 years
were all in an uncontrollable state. The results therefore suggest that with time, patient might
develop complications and suffer from uncontrollable diabetes. Additional research shows that
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with age, the risk of diabetes increases (Northwestern Memorial Hospital 2011). The risk of
developing health complications that may contribute to uncontrolled diabetes also increases.
Family history of diabetes not only increases the probability of getting diabetes, but also
of getting uncontrolled diabetes. 31% of the uncontrolled group has at least one diabetic family
member; this is compared to 20% within the controlled group. Specifically having a parent or a
sibling with type 2 diabetes affects the risk of getting Type 2 diabetes (Northwestern Memorial
Hospital).
Habits and Depression history in relation to Diabetes condition
Although heavy alcohol use has been associated with an increased risk of diabetes, this
trend was not observed during this study. This is because most patients interviewed, both
controlled and uncontrolled claimed that they drink only occasionally. Smoking on the on other
hand might be a risk factor for uncontrolled diabetes. Only three individuals in the study smoked,
and all three had uncontrolled diabetes. There is a mild association between the subsequent
occurrence of diabetes and the development of diabetes (Haire-Joshu et al. 2011). With
continued smoking, diabetes could become complicated as insulin resistance is aggravated with
such continued habits.
Contrarily, physical activity appeared to reduce the risk of uncontrolled diabetes. Almost
60% of uncontrolled patients do not exercise. The lack of activity might contribute to their
complicated health status. However, the complicated health status might also lead to inability to
exercise. Amputations as a result of diabetic complications for example, might impede the
patient’s activity capabilities. Amputations due to diabetes are indeed common. In the U.S., 60%
of non-traumatic lower-limb amputations occur in diabetic patients (NDIC 2011).
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About 50% of the individuals with uncontrolled diabetes were depressed, compared to
approximately 30% of the controlled group being depressed. According to an article in published
Diabetic Medicine, a higher number of diabetic patients with psychiatric symptoms developed
uncontrolled diabetes compared to controlled diabetics (Robinson et al. 2009). Complications
such as heart disease, hypertension, blindness, and amputations can make the patient worried. He
or she is unable to complete chores and activities as before. This in turn could lead to sadness
and depression, as the patient is unsure of the future or unsure of he or she will become healthier.
Amount and Frequency of Food
On average, uncontrolled diabetic patients consume much higher amount of rice and iddli
(rice cakes). The higher consumption of rice might contribute to the uncontrolled levels of blood
sugar in diabetic patients. Indeed, starches such as rice, ought to be reduced or avoided in a
diabetic patient’s diet because they do lead to higher blood levels (Mercy Medical Center 2006).
Rather the patient, whether controlled or uncontrolled, ought to eat more vegetable, fish, and
skinless chicken. In this study, there was not a remarkable difference between the consumption
of the ‘right’ food. Both the controlled and uncontrolled diabetic patients ate similar amounts of
pulses and legumes. However, on average, the uncontrolled patients did eat slightly less greens,
roots and tubers. Non starchy vegetables are full of fiber, vitamins, minerals and phytochemicals.
Some these components can lower oxidative stress in type 2 diabetes patients (Asgard et al.
2007). Lower amounts of vegetables might be contributing to their much higher sugar levels.
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Conclusion
In conclusion, the socio-economic factors and dietary patterns of uncontrolled diabetic
patients do differ. Of the 14 factors studied, 8 were found to be remarkably different between
both groups. These 8 factors included sex, caste, age, wealth, the number of years with diabetes,
family health history, depression, and smoking habits. This study shows that the development of
uncontrolled diabetes is a combination of multiple factors – social, economic, health and dietary.
And often times, one’s socio-economic setting is a both a remarkable predictor and contributor to
the state of uncontrolled blood sugar levels. The subjects’ socio-economic background often
impeded their ability to exercise frequently, to adhere to medication prescriptions, or to eat
healthier, simply because they could not afford to. At RUHSA, treating uncontrolled patients
might involve much more than just offering subsidized curative care. But for real improvement
to be made in the health of the patient, it is important that health practitioners and RUHSA staff
pay close attention to the holistic picture, perhaps focusing a little bit more on the socioeconomic factors that influence the patient’s health decisions. Truly, it is by looking at the
holistic picture that the Rural Unit for Health and Social Affairs can assist uncontrolled diabetic
patients on their road to being healthier.
For further studies, in order to have more accurate results and better serve the patients, a
larger sample size would be recommended, along with a focus group session during which
patients and friends of patients can build off each other and come up with concrete examples of
assisting individuals with uncontrolled diabetes. Additionally, future research should be carried
out on the relationship between depression and diabetes, as this appeared to be an issue
especially among uncontrolled diabetic patients.
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Acknowledgments
RUHSA was my first research site in India and I absolutely loved it. For the first time, I was exposed
to the joys and challenges of independent research work in a foreign land. In the process, I was lucky
to be supported and guided by amazing advisers and staff members.
First, I would like to thank Dr. Rita for warmly welcoming Lee, Erica and me to RUHSA. Despite
her busy schedule, Dr. Rita took time to sit down with us and ensure that we were doing well and
settling in. She then went ahead to partner us up with advisers who suit our interest best.
I was fortunate enough to to be peered up with the experienced Ms. Jay Lakshmi who is remarkably
knowledgeable on the topic of diabetes and was able to painstakingly and patiently guide me through
every step of the research project. She willingly and openly shared her knowledge on dietary
patterns, thus enriching my project.
Lovely Ms. Jay Laksmi also introduced me to my talented translator, Ms. Latha. Ms. Latha is a
patient and beautiful soul, who was dedicated to this project. On top of all the project-related work
we accomplished, Ms. Latha was kind enough to invite me to her home multiple times for delicious
meals. She introduced me to her neighbors and family members, during which I was served delicious
tea. Ms. Latha not only did an absolutely amazing job translating, she was also kind-hearted,
hospitable and eager to help.
In addition to Ms. Latha, Ms. Lay Lakshmi also introduced me to Mr. Murigan, who patiently
introduced me to the complexities of the SPSS statistical program, ensuring that I conducted proper
analysis of my data.
This project would also not have been successful without Dr. Kumaran, a chief doctor in a rural
setting where medical practitioners are so rare. Despite his unbelievably busy schedule, Dr. Kumaran
put time into advising me on what would be best to include in the study to ensure the most
comprehensive results.
Big thank you to Mr. Matthews and Nr. Muniraj for offering us an informative orientation,
introducing us to all the different and diverse aspects of RUHSA. They both ensured that we got a
taste of the approximately 22 departments thriving at RUHSA. After the orientation, I was able to
make a more informed decision on what direction to go with my project.
Ms. Ritika also ensured that we had a great time, often checking in with us, making sure we have the
correct bus schedule or that we have things to do on the weekends.
In addition to working on the project, I also made time for ‘extra-corricular’ activities. And I would
like to thank Mr. Charles for offering me the opportunity to accompany the field crew on rural
educational expeditions. This was one of my favorite things to do: jump on one of the firld jeeps or
buses and get to see first-hand public health work at-hand. It was beautiful seeing how the
practitioners related to the villagers and how they served them.
I also was able to play either board games, or badminton or volleyball almost every night. I would
therefore like to thank Lee Vang and Erica Loon, my site partners for accommodating my beginner
skills as we played. I also appreciate the young men who allowed Lee and I to volleyball with them.
It truly was a blast! And Gloria, I love the way you just accepted me and went out of your way to
befriend me. I absolutely enjoyed speaking with you both in the canteen, in your room or even
randomly on the road. You certainly made our time at RUHSA special.
Anne, Mike and Kathy Tuma, thank you for offering me this amazing opportunity to conduct
independent research in Vellore, India. This project would have been nonexistent without your
intricate planning and flexibility.
From the bottom of my heart, I would like to say THANK YOU to RUHSA staff and to Anne, Mike
and Kathy. This opportunity was a remarkable blessing.
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Appendix I
Controlled
Uncontrolled
Yes
No
Yes
No
Exercise (Does patient
exercise?)
72.4
27.6
44.8
55.2
History (Does any other
family member have
diabetes)
31
69
25.9
74.1
Depression (Is patient sad?)
31
69
44
55.2
Table 1- Health factors and Diabetes Condition.
Percentage od Diabetic Patients
70.00%
60.00%
50.00%
40.00%
Type C
30.00%
Type U
20.00%
10.00%
0.00%
F
M
Sex
Fig 1. Sex and Diabetes Condition. Percentage of controlled and uncontrolled diabetes within each sex.
61% of all males and only 45% of all females interviewed are uncontrolled diabetic patients.
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Percentage of diabetic patients
70.00%
60.00%
50.00%
40.00%
Type C
30.00%
Type U
20.00%
10.00%
0.00%
35-45
46-55
56-65
66-75
76-85
Age
Fig 2. Age and Diabetes Condition. Prevalence of uncontrolled/controlled diabetes within age
brackets: 35-45, 46-55, 56-65, 66-75, 76-85 years old. 60% of all uncontrolled diabetic patients
are between 46 and 55 years old.
Percentage of Patients
80.00%
70.00%
60.00%
50.00%
Type C
40.00%
Type U
30.00%
20.00%
10.00%
0.00%
BC
SC
FC
Caste
Fig 3. Caste and Diabetes Condition. Percentage of uncontrolled/controlled diabetes patients
within each caste: scheduled caste (SC), backward caste (BC), and forward caste (FC).
64% of scheduled caste patients were uncontrolled diabetes patients, compared to 57% of the
backward caste individuals that in the controlled group.
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Percentage of Diabetic Patients
70.00%
60.00%
50.00%
40.00%
Type C
30.00%
Type U
20.00%
10.00%
0.00%
Thatched
Tiled
Terraced
Govt Grp House
Roof Style (Indicates family wealth)
Fig 4. Family Wealth and Diabetic Condition. Prevalence of uncontrolled/controlled diabetes
in relation to family wealth. Wealth was determined by the state of the house roof.
Percentage of diabetic patients
80.00%
70.00%
60.00%
50.00%
40.00%
C
30.00%
U
20.00%
10.00%
0.00%
<5
5.1 – 10
10.1 - 15
15.1 - 20
20.1 - 25
Number of years with Diabetes
Fig 6. Years of illness and Diabetic Condition. Prevalence of uncontrolled/controlled diabetes
in relation to the Number of years patient has been diagnosed with diabetes.
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Blood Pressure and Diabetes Condition
Percentage of Patients
Fig 9
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Type C
Type U
Abnormal
Normal
Blood Pressure
Fig 9. Blood Pressure and Diabetes Condition.
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Appendix II
Socioeconomic Factors and Dietary Patterns that affect the Occurrence of Controlled or
Uncontrolled Diabetes in K.V. Kuppam Block
Village:
Date:
Address :
I.D.No.
Name of Respondent:
Sex:
Caste:
SC BC FC
M/F
Age:
BMI:
Blood Pressure:
1) Family Wealth
a) Roof style: i. Thatched
b) # of rooms:
Blood Glucose:
ii. Tiled
iii. Terraced
2) Educational Qualification:
a. No Education
b. 1st – 5th Std.
c. 6th – 10th
e. Graduate
g. Diplomat
f.
Post-graduate
AC/PC =
iv. Govt. Group House
d. +1, +2
3) Occupation:
a. Housewife
b. White Collar Job
c.Petty Business
d. Beedi Making
e. Farmer
f. Casual Laborer
g.Family Occupation
h.Unemployment
i. Class IV Employee
j. Others (please specify):
(Cleaner, Driver, Attender, etc)
4) Physical Activity?
a) Do you do exercise? Y / N
b) What do you do?
b) How Often
c) How long
5) When were you diagnosed with diabetes?
6a) Do you have any other diabetic family members?
YES
6b) If YES, i) How many member(s)?
ii) Relationship to diabetic family member(s)?
7) Are you constantly sad? YES
If YES, why?
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NO
NO
8a) Do you smoke? YES
NO
8b) If YES, how Often?
9a) Do you drink?
NO
9b) If YES, how often?
YES
10) Do you take medications regularly as prescribed by doctor? YES
If NO, why?
NO
11) Diet
Food group
Frequency of
consumption *
Raw amounts used per day
(cups, tsps., g, ml)
1. Rice
2. Dosa
3. Itly
4. Chappati
5. Wheat Ball
6. Ragi
7. Ragi Ball
8. Oats
9. Corn
10. Pulses / Legumes
11. Green leafy Veg.
12. Other Veg.
13. Roots & Tubers
14. Milk & Milk
products
15. Fruits
16. Fruit juice
17. Flesh Foods
18. Egg
19. Fats & Oils
20. Sugar & Jaggery
21. Food fried in oil
* FREQUENCY OF CONSUMPTION
1. Daily 2. Once/Twice a week
Occasionally 7. Never
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3. Once in two weeks
4. Monthly
5. Seasonally
6.