"Type 2 diabetes mellitus (T2DM) is a non-communicable disease (NCD) and a growing problem in sub-Saharan Africa (SSA) in conjunction with infectious diseases, chronic undernutrition and micronutrient deficiencies. Self-management of T2DM is critical for optimal glycemic status; however, socio-environmental factors pose a challenge in achieving it. Therefore, the specific aims of this cross-sectional mixed method study conducted in urban and semi-urban districts in Malawi were to: 1) assess glycemic status (glycosylated hemoglobin- A1C) associated factors and estimate cost of care and related expenditures for T2DM based on glycemic status, 2) assess diet quality and its association with glycemic status and factors affecting diet quality such as food insecurity, 3) qualitatively assess socio-environmental factors affecting self-management of T2DM, specifically diet and physical activity. Of a total n=428, the A1C status of 60.3% of the participants was above the acceptable clinical glycemic target (≥8%). A1C was significantly inversely associated with age and physical activity level and positively with distance to the clinics, underweight status, number of comorbidities, duration of diabetes, additional blood glucose monitoring at home/private clinics and diabetes peer group and participant perceptions of fluctuating blood glucose. The total median expenditure for diabetes care was significantly higher in the urban than semi-urban areas per quarter year and A1C was negatively associated with total out-pocket expenditure. Additionally, consumption of a diet high in carbohydrates and consuming ≤3 meals per day increased the odds of not achieving the recommended clinical A1C target. The severity of food insecurity positively associated with A1C and negatively with dietary diversity. The socio-environmental barriers to an appropriate diet included cost and access to food; household size; lack of knowledge on what and how much to eat; separate preparation and purchase of food; dilemmas of what to eat during functions and travel; and conflicting dietary information from different sources. Comorbidities and fear of public ridicule were primary barriers reported by participants being physically active. The facilitators to diet and physical activity were similar such as family and friends, health workers, diabetes support groups, as well as social support systems. The majority of adults with T2DM were not meeting the acceptable clinical glycemic target and incurred significant amount of expenses associated with diabetes care. The diet quality was poor especially relative to high carbohydrate intake and meal irregularities, which were primarily impacted by food insecurity, unreliable dietary information and inadequate nutrition knowledge. The findings provide important health and nutrition implications for Malawi to strengthen existing health systems and improve services to decrease diabetes-related complications and reduce the economic burden of this vulnerable population and the nation. Additionally, dietary interventions that focus on carbohydrate counting, portion size control, total dietary quality, and meal planning are urgently needed in Malawi. Furthermore, the focus on socio-environmental factors should be prioritized by nutritionists, dietitians, and health workers when developing and providing nutrition and physical activity education in Malawi."--Pages ii-iii.
Read
