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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 3  |  Page : 109-114

Effect of nutrition education package on dietary modification and anthropometry among attendees of a noncommunicable disease clinic at a rural primary health-care facility in Delhi


Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission22-Apr-2021
Date of Decision16-May-2021
Date of Acceptance17-Sep-2021
Date of Web Publication22-Nov-2021

Correspondence Address:
Dr. Rohit Katre
Department of Community Medicine, Maulana Azad Medical College, 2 BSZ Marg, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_22_21

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  Abstract 


Context: The global burden and threat of noncommunicable diseases (NCDs) constitutes a major public health challenge that undermines social and economic development throughout the world. NCDs are one of the leading causes of adult morbidity and mortality globally. The disease burden in India due to NCDs has increased from 30% to 55% between 1990 and 2016.
Aims: We aimed to assess the effect of nutrition education intervention on dietary awareness, practices, and anthropometry.
Settings and Design: This design was a facility-based before-and-after intervention study without control.
Materials and Methods: This study was conducted in five phases: planning and recruitment, preintervention, intervention, washout, and postintervention. Data were collected using a pretested, semi-structured interview schedule under the following heads – personal, sociodemographic, and behavioral risk factors of NCDs. Anthropometric examination included weight, height, waist, and hip circumference measurement.
Statistical Analysis: Collected data were entered into MS Excel and analyzed using IBM SPSS 25 for descriptive and inferential statistics.
Results: There was a significant increase in mean score for dietary practices and knowledge regarding different food items in the study group. The mean number of servings of fruits and vegetables increased significantly following intervention in the study group (P = 0.001). Significant change in body mass index before and after intervention was found to be in the age group of >60 years (P = 0.041).
Conclusions: The study has shown the usefulness of intervention aimed at improving dietary behavior among patients of NCDs. With growing burden, there is a need for such innovative and cost-effective measures for halting the rising burden.

Keywords: Consumption, fruits, noncommunicable diseases, nutrition education, vegetables


How to cite this article:
Katre R, Banerjee B, Lal P, Sharma P. Effect of nutrition education package on dietary modification and anthropometry among attendees of a noncommunicable disease clinic at a rural primary health-care facility in Delhi. Int J Non-Commun Dis 2021;6:109-14

How to cite this URL:
Katre R, Banerjee B, Lal P, Sharma P. Effect of nutrition education package on dietary modification and anthropometry among attendees of a noncommunicable disease clinic at a rural primary health-care facility in Delhi. Int J Non-Commun Dis [serial online] 2021 [cited 2021 Nov 27];6:109-14. Available from: https://www.ijncd.org/text.asp?2021/6/3/109/330906




  Introduction Top


The global burden and threat of noncommunicable diseases (NCDs) constitutes a major public health challenge that undermines social and economic development throughout the world, and inter alia has the effect of increasing inequalities between countries and within populations.[1] NCDs are one of the leading causes of adult mortality and morbidity globally. NCDs are rapidly increasing globally and have reached epidemic proportions in many countries, especially in low- and middle-income countries.

Population in India is passing through an epidemiological transition with high rates of urbanization. This has led to economic improvement, the consequences of which are increased food consumption, tobacco use, and decreased physical activity. NCDs such as cardiovascular diseases, diabetes mellitus, and stroke have emerged as major public health problems in India.[2] Four noncommunicable diseases – diabetes, cardiovascular diseases, cancers, and chronic respiratory diseases – constitute about 80% of noncommunicable diseases.[3]

As per “India: Health of the Nation's States-The India State-Level Disease Burden initiative” (2017) report by the Indian Council of Medical Research (ICMR), disease burden due to NCDs increased from 30% to 55% between 1990 and 2016 in comparison to disease burden due to communicable, maternal, neonatal, and nutritional diseases, which dropped from 61% to 33% during the same period measured using disability-adjusted life years.[4]

Four major behavioral modifiable risk factors that are associated with increased risk of NCDs are tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity.[5]

The current study was undertaken with the objective of assessing the effect of nutrition education intervention on dietary awareness, practices, and anthropometry. In this paper, we present the effect of intervention on dietary awareness, practices, and anthropometry among attendees of a noncommunicable disease clinic at a rural primary health-care facility in Delhi.


  Materials and Methods Top


We conducted a facility-based before-and-after intervention study without control over a period of 1 year from January 2019 to December 2019. The study site was conducted at an NCD clinic of a rural health-care facility under the department of community medicine of a medical college in Delhi. The study was approved by the institutional ethics committee of the college and was registered with the Clinical Trials Registry of India (CTRI/2019/02/017433).

All adults aged 18 years and above suffering from diabetes and/or hypertension attending an NCD clinic for at least 2 months were included in the study. Participants were enrolled in the study after taking informed and written consent.

A previous study conducted at rural health-care facility,[6] reported that mean servings of fruits and vegetables among study participants in post-intervention phase was 2.8 increased from 1.2 mean servings during pre-intervention phase. Based on this and at 95% confidence level and power of study at 80% with an expected relative difference of 10% of mean increase in servings, the sample size was calculated as 77. Assuming an attrition rate of 20%, the final sample size came to be 93. We rounded up and took 95 as the final sample size.

All eligible study participants attending NCD clinic were enrolled in the study after taking written informed consent. Consecutive sampling was done. Flow of study participants in the study have been shown in [Figure 1].
Figure 1: Flowchart showing recruitment of study participants

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We conducted the study in five phases – planning and recruitment, preintervention, intervention, washout, and postintervention with duration of 2, 3, 3, 3, and 2 months, respectively. In preintervention phase, baseline data were collected using a pretested, semi-structured interview schedule based on the Integrated Disease Surveillance Program-NCD Risk Factor Surveillance Schedule[7] (which is based on the WHO STEPS approach). We collected personal and sociodemographic data along with detailed information about behavioral risk factors of NCDs (tobacco use, harmful use of alcohol, insufficient physical activity, and unhealthy diet). This was followed by physical and anthropometric examination which included measurement of weight, height, waist and hip circumference, and blood pressure. Body mass index (BMI) was calculated using weight and height.

Intervention phase lasted for 3 months, during which the individuals were given nutrition education by using individual and group approach.

Individual approach

Participants were given nutrition education by the investigator by face-to-face counseling for dietary modifications in their daily life. The participants were also referred to a dietician. The dietician was associated with the Medical College and Hospital. This was done so that the participants could be provided individual specific diet charts for better compliance, management and motivation. However, none of the subjects consulted the dietician at the hospital.

Group approach

Nutrition education program was conducted for dietary modification in group sessions of 30–32 participants once a week for about 60-min duration. There were three groups made of 30–32 participants each, and each group received one group session from the dietician and two group sessions from the investigator, where dietary guidelines prepared by a dietician of an associated hospital were explained and demonstration was done to show measured portions of raw materials to be consumed in a day as per dietary guidelines, using standard measuring instruments. Handouts in Hindi were given to all participants and explained properly, which included dietary guidelines prepared by a dietician, recipes for food preparation by ICMR, and food exchange list. The dietician from the dietary department of the hospital visited once a month during group sessions to provide expert inputs for participants.

Every participant received three group sessions, and if any participant was unable to attend his/her session on the assigned day, he/she was asked to attend subsequent session.

During group session, feedback from participants was also taken to ensure that message has been properly communicated. Any queries were also addressed during group sessions.

Washout phase was of 3-month duration, during which participants were given nutrition education in a clinic as part of routine services and no group education was done. It was followed by postintervention phase which lasted for 2 months. The interview and physical examination were carried out again in this phase as in preintervention phase using the same schedule.

The data was collected and entered in Microsoft Excel 2016 and was analyzed using Statistical Package for the Social Sciences (SPSS for Windows, Version 25.0, IBM Corporation, Armonk, New York, United States).

For statistical analysis, study participants were divided into three bands of age groups – 31-45 years, 46-60 years and above 60 years comprising of 21, 50 and 24 participants respectively. Distribution of study participants according to age and gender have been shown in [Table 1]. Appropriate statistical tests were applied for qualitative and quantitative data.

Scoring for knowledge assessment of study participants was done on the basis of two (2) sub-groups of different food items dividing food items into “safe for consumption” and “food items that should be avoided”. Participants' response for each food item was scored 1 (correct response) and 0 (incorrect response) depending on answers given. For assessment of knowledge of all participants, irrespective of their dietary practice, were asked about all food items, both vegetarian and non-vegetarian, as correct knowledge is desired in all to enable them to disseminate the same to others. The maximum and minimum for this score was 32 and 0 respectively.
Table 1: Distribution of study participants according to age and gender

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Scoring for assessment of practice was done in the same way as for knowledge explained earlier. However, for participants who were following vegetarian diet, maximum and minimum scores were 28 and 0 respectively. Similarly, for participants who were following mixed diet, the maximum and minimum scores were 32 and 0 respectively as non-vegetarian food items were also included. Alcohol was excluded from both sets of participants in calculation of this score.


  Results Top


[Table 1] shows distribution of study participants according to age and gender. Out of total, around two-third of study participants were females (60) and rest males. Around fifty percent of study participants belonged to age group of 46-60 years (50).

[Table 2] shows the mean score for knowledge regarding different food items among study participants by gender and different age groups. There was an increase in mean score of knowledge from 24.25 ± 2.22 to 24.94 ± 2.01 and difference was found to be statistically significant (P = 0.010). Increase of score was maximum in 31–45 years' age group which was statistically significant (P = 0.007).
Table 2: Mean score for knowledge regarding different food items

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[Table 3] shows the mean score for dietary practices regarding different food items. The difference was statistically tested using paired t-test and mean scores were seen to have significantly increased following intervention in both the groups, i.e., vegetarian diet (P = 0.006) and mixed diet (P = 0.001). For the group which took mixed diet, the difference was found to be statistically significant for age groups 31–45 years (P = 0.004), 46–60 years (P = 0.047) and total participants (P = 0.001).
Table 3: Mean score for practice regarding different food items

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The mean number of servings of fruits and vegetables per day increased significantly following intervention in the study group. The mean number of daily servings of fruits and vegetables consumed per day increased from 2.15 to 2.42 (Z = -3.261 P = 0.001) after the intervention. The differences were statistically tested using Wilcoxon signed-rank test and found that the mean number of servings of fruits and vegetables per day before and after intervention was significant among age groups 46–60 years and >60 years and total study participants [Table 4].
Table 4: Mean number of servings of fruits and vegetables per day before and after intervention among study participants according to gender and age

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[Table 5] shows the comparison of mean of waist circumference before and after intervention among study participants. Reduction in mean waist circumference was observed in all age groups among females and in the 31–45 years' age group among males. Statistical test using Wilcoxon signed-rank test showed that the difference was not statistically significant among different age groups and total participants.
Table 5: Comparison of mean waist circumference before and after intervention among study participants according to gender and age

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[Table 6] shows changes in mean body mass index from pre-intervention to post-intervention phase among the study participants. The difference was tested using paired t-test and found that there was a statistically significant difference between mean BMI taken before and after intervention among >60 years' age group (P = 0.041). Overall, the mean BMI before and after intervention was found out to be 25.70 ± 3.59 kg/m2 and 25.68 ± 3.31 kg/m2, respectively.
Table 6: Comparison of mean body mass index before and after intervention among study participants according to gender and age

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  Discussion Top


Our study showed that using interventions such as nutrition education for behavioral change can be effective in reducing inadequate diet among study population. In our study, we found that there was a statistically significant difference in 46–60 years' age group with respect to mean number of servings of fruits and vegetables and mean score for practices regarding different food items in both the groups, i.e., vegetarian diet and mixed diet groups. Similarly, there was a statistically significant difference in >60 years' age group in mean BMI and mean number of servings of fruits and vegetables.

A study conducted in urban Puducherry by Patel et al. found that there was a significant increase in knowledge regarding portion size and required number of servings of fruits and vegetables in the intervention group compared to the control group.[8] In a study done by Balagopal et al., postintervention study participants were found to have reduced obesity parameters along with improvements in dietary intake.[9] Another study done by Sharma et al. also found that there was an increase in mean servings of fruits and vegetables and decreased BMI among the intervention group as compared to the control group following intervention.[6]

A cluster randomized controlled trial study using school-based intervention in Ecuador reported improved dietary intake and reduced waist circumference in adolescents postintervention among the intervention group than in the control group.[10] However, Mirmiran et al. conducted a nutritional intervention study in Tehran and reported that there was an increase in BMI of both the groups, i.e. intervention and control groups.[11]

The strength of our study is that we evaluated behavioral and physiological risk factors for NCDs. Since behavioral risk factors are self-reported and are based on recall, they are prone to bias. Anthropometric measurements in our study provide objectivity and reduce biases. Our study was conducted at a health facility on patients registered in an NCD clinic, which ensured that there was minimal loss to follow-up.

Our study has certain limitations. First, since there was no control group, the comparison for effectiveness of intervention was not possible. Second, adherence for intervention was not possible to assess objectively. Third, behavioral risk factors were self-reported and hence prone to recall and self-desirability bias is quite possible.


  Conclusions Top


Our study has shown the usefulness of intervention aimed at improving dietary behavior among patients of NCDs. However, large-scale RCTs are required to generate good quality evidence for policy implications. With growing burden of NCDs in the community, there is a need for such innovative and cost-effective measures for halting the rising burden.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Global Action Plan for Prevention and Control of Non-Communicable Diseases 2013-2020. Geneva: World Health Organisation; 2013. Available from: http://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236eng.pdf?sequence=1. [Last accessed on 2021 May 15].  Back to cited text no. 1
    
2.
Reddy KS. Prevention and Control of Non-Communicable Diseases: Status and Strategies July, 2003 Working Paper No. 104. Indian Council for Research on International Economic Relations. Available from: http://www.icrier.org/pdf/WP104.PDF. [Last accessed on 2021 May 15].  Back to cited text no. 2
    
3.
WHO. Non-Communicable Diseases Progress Monitor 2017. Geneva: World Health Organisation; 2017. Available from: https://www.who.int/publications/i/item/9789241513029. [Last accessed on 2021 May 15].  Back to cited text no. 3
    
4.
CBHI. National Health Profile 2019. New Delhi: Central Bureau of Health Intelligence; 2019. Available from: https://cbhidghs.nic.in/showfile.php?lid=1147. [Last accessed on 2021 May 12].  Back to cited text no. 4
    
5.
WHO. Noncommunicable Diseases. Geneva: World Health Organization; 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. [Last accessed on 2021 May 13].  Back to cited text no. 5
    
6.
Sharma M, Banerjee B, Ingle GK, Garg S. Effect of mHealth on modifying behavioural risk-factors of non-communicable diseases in an adult, rural population in Delhi, India. Mhealth 2017;3:42.  Back to cited text no. 6
    
7.
Non-Communicable Disease Risk Factors Survey, Phase-I States of India, 2007-08. IDSP. Available from: https://main.icmr.nic.in/sites/default/files/reports/Phase-1_States_of_India.pdf. [Last accessed on 2021 May 14].  Back to cited text no. 7
    
8.
Patel N, Lakshminarayanan S, Olickal J. Effectiveness of nutrition education in improving fruit and vegetable consumption among selected college students in urban Puducherry, South India. A pre-post intervention study. International Journal of Adolescent Medicine and Health. 2020: 20200077. https://doi.org/10.1515/ijamh-2020-0077.  Back to cited text no. 8
    
9.
Balagopal P, Kamalamma N, Patel TG, Misra R. A community-based diabetes prevention and management education program in a rural village in India. Diabetes Care 2008;31:1097-104.  Back to cited text no. 9
    
10.
Ochoa-Avilés A, Verstraeten R, Huybregts L, Andrade S, Van Camp J, Donoso S, et al. A school-based intervention improved dietary intake outcomes and reduced waist circumference in adolescents: A cluster randomized controlled trial. Nutr J 2017;16:79.  Back to cited text no. 10
    
11.
Mirmiran P, Ramezankhani A, Hekmatdoost A, Azizi F. Effect of nutrition intervention on non-communicable disease risk factors among Tehranian adults: Tehran lipid and glucose study. Ann Nutr Metab 2008;52:91-5.  Back to cited text no. 11
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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