INTRODUCTION
Diabetes is one of the most common chronic diseases worldwide. As of 2021, there were 537 million adults with diabetes worldwide, and this number is expected to reach approximately 774 million by 2045[1]. Furthermore, the prevalence of undiagnosed patients with type 2 diabetes mellitus (patients with T2DM) is also high, at approximately 45%[1]. If undiagnosed patients with T2DM are included, the number of patients with T2DM is expected to be even higher. These findings emphasize the urgent need for prompt and comprehensive healthcare management for patients with T2DM.
People with diabetes should pay special attention to diabetes complications, and it is crucial to prevent these complications [2]. Patients with T2DM account for 90% to 95% of all diabetes cases and require self-management to maintain proper blood sugar levels and prevent complications [2]. Regularly measuring blood sugar, adhering to medications, maintaining a suitable diet, and engaging in physical activity are ways to maintain normal blood sugar levels [2]. However, research indicates that self-management scores for people with type 2 diabetes, including aspects like diet, medication adherence, physical activity, and blood sugar monitoring, are generally low [3]. Particularly, when there is a lack of family support and a varie-ty of food groups available, dietary management is challenging. Dietary compliance rates are generally lower when compared to blood sugar monitoring and other health management activities [4].
Among the diabetes self-care activities, adopting dietary behaviors, such as having a healthy diet and controlling calories, is challenging for many individuals with diabetes. Moreover, in Korean culture, food is considered to “ prevent and treat diseases” [5], implying that the food one eats is closely related to one's belief in protecting one's health and treating diseases. However, even fresh seasonal foods, considered to help prevent and treat diseases, may not be suitable for patients with T2DM and can disrupt diabetes management. Furthermore, with the increase in single-person households and changes in life-style, convenient home-cooked meals or delivery meals that require less effort and time in meal preparation are preferred [6]. However, indiscriminate consumption of such convenience foods can be detrimental to the health of patients with T2DM who require portion control and compliance with dietary requirements due to blood sugar regulation.
Meanwhile, in Korean culture, alcohol consumption plays a significant role in human relationships [7]. Korea has a unique aspect in its legal system regarding alcohol consumption, and there is a cultural tolerance and leniency towards those who consume alcohol. As a result, alcohol is often considered part of leisure activities with others rather than just the act of drinking itself [7]. However, excessive drinking affects diabetes progression and impedes blood sugar management in patients with diabetes [8]. Therefore, in South Korea, maintaining proper dietary intake for patients with T2DM is a self-management behavior that requires strong determination and motivation.
1. Theoretical Background
Various theories have explained the self-care behavior of individuals with diabetes. Among them, the Self Determination Theory (SDT) describes the process of focusing on external factors applied to humans and internal motivations inherent in human nature and interacting in ways that individuals can growth and development [9]. It focuses on humans acting voluntarily and explains and predicts the initiation and maintenance of a wide range of health activities. Autonomous motivation, a crucial aspect of the SDT, is the motivation that arises from a genuine interest in an activity, personal support, or valuation. It plays a complex role in one's implementation of health behaviors, such as dietary control in chronic diseases [9]. Autonomously motivated individuals participate more regularly in health behaviors, gain positive results, and achieve more positive health outcomes [10].
Previous studies grounded in SDT have shown that patients with diabetes and higher levels of autonomous motivation exhibit better dietary self-management behavior [10]. Austin et al. [11] examined the dietary self-management of adolescents with type 1 diabetes and found that autonomous motivation improves dietary self-management behavior. Senecal et al. [12] investigated the relationship between dietary self-management, life satisfaction, self-efficacy, and autonomous regulation among individuals with diabetes and found that autonomous regulation significantly and positively affects dietary self-management. Further, numerous studies have examined the dietary habits and nutrition of patients with diabetes in Korea [13,14]. However, most have relied on secondary data from national surveys or focused on general aspects of diet and nutrition.
The SDT can help examine whether autonomous motivation affects dietary behavior. It can also prove useful in identifying the determinants of diabetic dietary behavior as it can provide an overall understanding of motivation, education, and health behavior change. Research remains scant on the therapeutic dietary behavior of individuals with diabetes. Therefore, this study aim to analyze the factors influencing the dietary behavior of patients with T2DM. Grounded in the SDT, the study seeks to utilize this analysis as a basis for developing effective strategies to enhance diabetic dietary behaviors in the future.
METHODS
1. Study Design
A cross-sectional descriptive design was used to explore the factors associated with the dietary behavior of patients with type 2 diabetes.
2. Sample Size and Study Population
The sample size for the regression analysis was determined using the G*power 3.1.5 program. Based on previous study [15], an effect size of 0.15, a significance level (σ) of .05, a power of .80 according to Cohen's power analysis [16], and 7 predictor variables, a sample size of 103 was calculated for this study. Taking into account a dropout rate of 20%, 129 surveys were distributed, and ultimately 109 were collected, meeting the required sample size.
The study population was patients with type 2 diabetes mellitus registered at the Hypertension and Diabetes Registration Management Center of public health center in Sejong city. Individuals diagnosed with type 2 diabetes in a community outpatient setting, aged 19 or older, had a clear consciousness and understanding of the questionnaire's content, and did not have any physical or mental difficulties in completing the questionnaire were included in the sample. Participants who were hospitalized, had gestational diabetes, or used alternative therapies for controlling blood glucose were excluded.
3. Data Collection
The data were collected between August and September 2019 from diabetic patients registered at the s Health Center's Hypertension and Diabetes Registration management Center. Data collection for the study was conducted through an offline survey using a self-reporting method that took approximately 15 minutes. Researchers explained the research purpose to the participants, assured them of confidentiality and no harm, and then had the participants read the questionnaire and provide responses after obtaining written consent. A total of 129 questionnaires were distributed, and 109 were completed and returned, resulting in a response rate of 84.4%.
4. Measurements
1) Sociodemographic and diabetes-related characteristics
Data were collected on six sociodemographic characteristics of participants: gender, age, marital status, education level, income satisfaction, and employment status. Data were also collected on nine diabetes-related characteristics: duration of having diabetes, family history of diabetes, complications, self-monitoring of blood sugar, diabetes education experience, nutrition education experience, number of nutrition education sessions, smoking status, and alcohol consumption.
2) Treatment self-regulation
Treatment self-regulation was measured using the Dietary Self-Regulation scale developed by Williams et al.[17] based on the SDT. The scale comprises questions on why one would start or continue to eat a healthier diet and assesses the degree to which one's motivation for a healthier diet is autonomous or self-determined. The scale comprises three subdomains: autonomous motivation, externally controlled motivation, and amotivation. Autonomous motivation, externally controlled motivation, and amotivation are measured using six, six, and three items. The scores for each item are on a 7-point scale ranging from ‘1 point’ to ‘7 points’ depending on motivation, with a minimum total score of 15 points and a maximum score of 105 points. When this tool was developed, the Autonomous motivation's Cronbach's ⍺ coefficient was .85, externally controlled motivation's Cronbach's ⍺ coefficient was .73, and amotivation's Cronbach's ⍺ coefficient was also .73 [17]. In this study, Cronbach's ⍺ coefficient was .68 for the total scale, .73 for autonomous motivation, .70 for externally controlled motivation, and .62 for amotivation.
3) Dietary behavior
Dietary behavior was measured using the Summary of Diabetes Self-Care Activities developed by Toobert et al.[18] and translated and modified by Song et al. [19]. The items consist of four questions: two to evaluate the general diet and two to evaluate a particular diet. The score for each item is based on the number of days practiced, ranging from ‘0 days practiced’ to ‘7 days practiced’ on a 8- point scale, with a minimum score of 0 points and a maximum score of 28 points. When the Korean version of the tool was developed, its Cronbach's ⍺ coefficient was .68 [19], and the coefficient was .73 in this study.
5. Data Analysis
The data was analyzed using the SPSS 16.0 program. Descriptive statistics were used to calculate the frequency (%) of sociodemographicsand diabetes-related characteristics and calculate the mean (± standard deviation) of treatment self-regulation and dietary behavior. The skewness and kurtosis of treatment self-regulation and dietary behavior were within the range of -1 to 1, satisfying the assumption of normal distribution. Differences were analyzed in participants’ treatment self-regulation and dietary behavior based on their sociodemographic and diabetes-related characteristics using t-tests and one-way ANOVA with Scheffé post hoc test. Pearson's correlation coefficients were used to examine the correlations between participants’ sociodemographic characteristics, diabetes-related characteristics, treatment self-regulation, and dietary behavior. Multiple regression analysis was per-formed to identify the factors associated with dietary behavior. The reliability of the measurement tool was analyzed by calculating the Cronbach's ⍺ coefficient.
6. Ethical Considerations
This study was approved by the Institutional Review Board of C University (Approval number 201905-SB-053-01). The questionnaire was accompanied by a consent form for participation in the study. The form explained the purpose and contents of the study, guaranteed anonymity, and stated that the research contents included in the survey would not be used for any purpose other than research. All collected data and documents were converted to numbers and stored in a locked cabinet.
RESULTS
1. Participants' sociodemographic and Diabetes-related Characteristics
Table 1 presents participants’ sociodemographic and diabetes-related characteristics. Most participants were women (51.4%), aged more than 60 (87.1%), married (85.3%), had a high school or a lower level of education (66.1%), Above-average income satisfaction (37.6%), and unemployed (69.7%). Further, 45.9% of participants had been diagnosed with diabetes for 10 or more years, and 57.8% did not have a family history of diabetes. Most participants (88.1%) did not experience any diabetic complications and had received diabetes education (66.1%). Approximately half (50.5%) of the participants received no nutrition education, and among those who received nutrition education, 44.0% received it 1 to 3 times. Notably, 91.7% of the participants were non-smokers and 68.8% did not consume alcohol within 3 years.
Table 1.
Participants’ sociodemographic and Diabetes-related Characteristics (N=109)
2. Differences in Participants' Treatment Self-regulation and Dietary Behavior based on Their Sociodemographic and Diabetes-related Characteristics
Dietary behavior was significantly higher among those who had nutrition education (t=5.79, p =.018), received more nutrition education sessions (F=3.42, p=.036), and alcohol consumption (t=6.51, p=.012) (Table 2).
Table 2.
Differences in Treatment Self-regulation and Dietary Behavior based on Participants’ sociodemographic and Diabetes-related Characteristics (N=109)
Autonomous motivation was significantly higher among women (t=4.74, p=.032), those satisfied with their income (F=3.57, p=.032), and those who had received diabetes education (t=4.87, p=.029). Externally controlled motivation was significantly higher among women (t=5.83, p=.017) and those who had high school or a lower level of education (t=7.25, p=.008). Amotivation was significantly higher among those who with college or a higher level of education (t=8.81, p=.004) and those who consume alcohol (t=7.27, p=.008).
3. Participants' Treatment Self-regulation and Diabetic Dietary Behavior Characteristics
In this study, the average scores of autonomous motivation among the analyzed treatment self-regulation were 36.59±5.29, externally controlled motivation had an average score of 21.77±7.36, and amotivation had an average score of 13.81±3.75. Additionally, the average score for dietary behavior was 16.63±4.94. Since the skewness and kurtosis of all variables were not greater than 1 or less than -1, they satisfied the normal distribution (Table 3).
Table 3.
Treatment Self-regulation and Dietary Behavior Characteristics (N=109)
4. Correlation among Variables
Dietary behavior was positively correlated with autonomous motivation (r=.23, p=.015), and number of nutrition education sessions (r=.24, p=.011). An additional file shows this in greater detail (Table 4).
Table 4.
Correlations between Variables (N=109)
5. Factors Influencing Dietary Behavior
This study used multiple regression analysis to identify factors influencing the dietary behavior of patients with T2DM. These factors included nutrition education experience, number of nutrition education session, alcohol consumption, and factors closely associated with autonomy, such as autonomous motivation, externally controlled motivation, and amotivation [21]. The assumptions of the regression analysis were tested, and the results indicated that the residuals show no autocorrelation (Durbin- Wat-son statistic=1.96), thus satisfying the assumptions of homoscedasticity and normal distribution. Among the independent variables, the multicollinearity test showed tolerance values above 0.1, and the variance inflation factor (VIF) was below 10. Furthermore, the number of nutrition education sessions (β=.19, p=.041), alcohol consumption (β=-.22, p=.014), and autonomous motivation (β=.21, p= .029) were found to be the factors affecting dietary behavior. The overall fit of the regression model was statistically significant (F=6.08, p<.001), explaining approximately 12% of the variance in dietary behavior. An additional file shows this in greater detail (Table 5).
Table 5.
Factors Influencing Dietary Behavior (N=109)
| Variables | B | SE | β | t | p |
|---|---|---|---|---|---|
| (Constant) | 10.38 | 3.42 | 3.03 | .003 | |
| Nutrition education experience (yes)† | 0.22 | 0.25 | .06 | 0.25 | .802 |
| Number of nutrition education sessions | 1.56 | 0.75 | .19 | 2.07 | .041 |
| Alcohol consumption (yes)† | -2.39 | 0.96 | -.22 | -2.49 | .014 |
| Autonomous motivation | 0.19 | 0.08 | .21 | 2.22 | .029 |
| Externally controlled motivation | 0.16 | 0.11 | .02 | 0.22 | .829 |
| Amotivation | 0.17 | 0.13 | .01 | 0.12 | .904 |
| Adj. R2=.12, F=6.08, p＜.001 | |||||
DISCUSSION
This study analyzed the factors influencing the dietary behavior of patients with type 2 diabetes mellitus using the SDT. This study analyzed factors influencing the dietary behavior of T2DM patients using SDT. Improvement in HbA1c levels in T2DM can be achieved through dietary management, enabling patients to prevent the occurrence of diabetes complications [2]. The dietary behavior score in the present study was found to be an average of 16.63 points, which is higher than the average score of 14.72 points measured by Gopaldasani et al. [20] for patients with T2DM. Jun et al. [21] indicated that individual with T2DM who received diabetes education only once or twice demonstrated a lack of self-management and self-efficacy, highlighting a positive correlation between the frequency of diabetes self-management education and improvement in knowledge related to dietary management. Hence, actively supporting tailored diabetes nutritional education programs that address the specific needs of patients and promoting continuous education plans are crucial for fos-tering dietary behavior in diabetes patients.
Alcohol consumption significantly impacted participants’ dietary behavior; those who did not consume alcohol exhibited more dietary behavior. This finding aligns with that of previous studies. Neighbors et al. [22] suggested that individuals with positive beliefs or attitudes toward alcohol are more likely to engage in hazardous drinking behaviors. In South Korea, where there is a relatively positive attitude towards alcohol, this is likely to have had a greater impact as a factor. Park et al. [23] found that among patients with T2DM, those who do not consume alcohol were more proficient in self-care practices than those who consumed alcohol 1 to 3 times a week. Additionally, Kassahun et al. [24] discovered that alcohol consumption is a significant factor in determining self- care behavior among patients with T2DM. This supports the fact that alcohol intake has a negative impact on self- care practices. Thus, variables such as alcohol consumption, individual characteristics, and cultural attitudes toward drinking should be considered in providing self-care education. Particularly in Korea, the cultural aspect of alcohol consumption must be incorporated into raising awareness about alcohol consumption-related issues.
Alcohol consumption and amotivation were found to be significantly related. Moreover, participants with T2DM who consumed alcohol exhibited less dietary behavior than those who did not consume alcohol. These findings suggest that the higher the amotivation of drinkers, the more likely they are to react impulsively, and the lower the performance of goal-oriented behavior, the more likely amotivation is to directly or indirectly affect the drinking behavior of individuals with T2DM. Vancampfort et al. [25] found that, in patients with alcohol use disorder, amotivation significantly affects the pre-, middle-, and maintenance stages of behavioral practice. Therefore, interventions for amotivation are necessary to control all processes of action.
Externally controlled motivation and amotivation are factors that have a significant impact on autonomous motivation and practical behavior, but it was found that they do not have a significant influence on diabetes dietary behavior [26]. This differs from the results of other previous studies, where externally controlled motivation and amotivation had significant positive or negative effects on health behavior [27]. This may be due to the diversity of motivations that affect the complexity and diversity of dietary management in patients with T2DM.
In contrast to externally controlled motivation or amotivation, autonomous motivation has been found to have a statistically significant impact on dietary behaviors, leading to a higher level of autonomous motivation being associated with better adherence to dietary behaviors. This finding is consistent with that of previous studies, which showed that autonomous motivation is associated with positive changes in health behaviors [15,28]. Similarly, in studies involving individuals diagnosed with T2DM, autonomous motivation played a crucial role in one's adherence to dietary recommendations and predicted one's maintenance of a healthy diet [29]. These findings confirm that merely having knowledge and skills is insufficient to motivate one's behavior; one must also have autonomous motivation, as proposed by the SDT [29].
Autonomous motivation was found to be positively related to income satisfaction. This finding aligns with Baluku et al.'s [30] finding: higher income levels are associated with increased autonomy and satisfaction. Autonomous motivation was also found to be positively related to diabetes education experience and the number of nutrition education sessions, consistent with Liu et al.[26], who emphasized the interplay between various educational interventions and motivation. Based on the results, it is anticipated that increasing income satisfaction and enhancing autonomous motivation through various diabetes and nutrition education can ultimately improve the adherence rate of diabetes self-management behaviors.
Despite its utility, this study has some limitations. First, the explanatory power was shown to be 12.4%, which is lower compared to previous research [28]. Therefore, it is necessary to conduct investigations on whether important variables influencing dietary behavior have been omitted, and empirical studies in various fields are needed. Second, the generalizability of its findings is limited because its sample was obtained from public health centers located in certain area. Third, this study collected data using a cross- sectional method over a short period. Thus, the researchers could not infer causal relationships. To address these limitations, future studies must focus on patients with diabetes and employ the SDT. To gain a better understanding of autonomous motivation and diabetic dietary behavior in patients with T2DM, qualitative research should be conducted along with policy research. This would contribute to a more effective management of the health of patients with T2DM.
CONCLUSION
The dietary behavior of patients with T2DM is significantly associated with their alcohol consumption, the number of nutrition education sessions they have received, and the degree of their autonomous motivation. To improve their dietary behavior, it is necessary to boost their motivation, implement policies on alcohol consumption, and provide them with continuous education on nutrition.
PDF Links
PubReader
ePub Link
XML Download
Full text via DOI
Download Citation 
Print 
