Introduction

Dietary diversity is a widely accepted strategy in the management of Non-Communicable Diseases (NCDs) like diabetes, hypertension, dyslipidaemia, and other lifestyle disorders in later stages of life. Type 2 Diabetes Mellitus (T2DM) has affected many people globally and poses considerable socioeconomic issues. As per the global report on diabetes by the World Health Organization (WHO), 1.5 million deaths were attributed to diabetes in 2019, with 48% of these occurring before the age of 70. Diabetes also caused nearly 460,000 deaths from kidney disease, while raised blood glucose levels contributed to 20% of cardiovascular deaths. There was a 3% increase in age-standardized mortality rates from diabetes between 2000 and 2019. By 2025, it is anticipated that 80% of all new diabetes cases will occur in emerging countries. In poorer countries, T2DM affects 85-95% of the general population. Hence, dietary management becomes crucial for preventing diabetes, managing various health conditions and preventing the risk of associated complications (1).

The development of an effective diabetes management intervention requires assessment of the diet quality. Better dietary habits were found to have a wide range of benefits on health outcomes. All-cause mortality was reduced by 17-42%, cardiovascular disease (CVD) mortality was reduced by 18-53%, and CVD risks were reduced by 14-28% (2). Inadequate consumption of fruits and vegetables is estimated to contribute to 5% of excess mortality globally. The importance of supporting individuals in achieving a healthy balanced diet has been reinstated in national and international policies. Dietary guidelines emphasize the importance of consumption of varied diets from different food groups (3).

There is an observed correlation where a more varied diet tends to result in higher diet costs. According to a study, participants who consumed all five food groups had 18% higher adjusted mean cost than those who consumed only three or fewer groups. In light of the global five-a-day campaign promoting fruit and vegetable diversity, public health initiatives must acknowledge that adopting diverse diets rich in fruits and vegetables may not be financially feasible for all consumers, potentially exacerbating socioeconomic disparities in diet (3).

Since there are few studies related to dietary diversity and diet cost in the diabetic population, this study focuses on exploring diet diversity with diet cost in the urban population. The study could be used to assess the impact of diet diversity on diabetes. Furthermore, it will assist policymakers and nutritionists in developing viable and long- term diet diversification strategies to aid in better diabetes management.

Material and Methods

Baseline information

Baseline information on age, gender, education level, occupation and family status were collected. As per the Kuppuswamy scale (2022), the socioeconomic status (SES) of the population was classified into the upper, upper middle, lower middle, upper lower and lower upper class (3). Anthropometric measures such as weight (kg.) and height (in m.) were recorded using standardized procedures, and Body Mass Index (BMI) was calculated using the WHO Asian population classification. (Underweight:<18.5 kg/m2, normal: 18.5-22.9 kg/m2, overweight: 23-24.9 kg/m2, Obese: >25 kg/m2) (4). Fasting blood sugar (mg/dl), postprandial blood glucose level (mg/dl) and glycated hemoglobin (HbA1c %), were noted from their latest report in the hospital record (Table 1).

Results

Table 1: Baseline information

Source: own elaboration.

Note: *N= total number of participants, *FBS= Fasting Blood Sugar level,*PPBS= Post Prandial Blood Sugar level, *HbA1c= Glycated Hemoglobin

A total of 150 subjects with a mean age of 51 years participated in the study. Most of the study population were females (59.3%), had completed schooling (69.3%) and belonged to upper middle class (51.3%). More than half of the subjects had poor diabetic control with HbA1c of 7-8%, accompanied by post prandial blood glucose values greater than 180 mg/dL Table 1.

Figure 1 shows that the majority of the population (67%) had medium Individual Dietary Diversity Scores (IDDS), with only 33% achieving high IDDS, indicating consumption from eight out of fourteen food groups. None of the participants fell into the low diet diversity category. As detailed in Table 2, dietary diversity assessed by Food Variety Score (FVS) was generally low across all food groups, including vegetables (62%) and fruits (50.7%), except for energy-dense foods, where cereal consumption (45%) was relatively higher.

Figure 1. : Distribution of Individual Diet Diversity Score (IDDS) Note: *IDDS= Individual Diet Diversity Score

Source: own elaboration

Table 2: Dietary diversity of food groups

Source: own elaboration.

Note:*n= number of participants, *FVS= Food Variety Score.

Table 3 depicts factors associated with diet diversity. The mean IDDS was higher for the participants with high FVS (8.37 ± 2.47). High FVS was observed in participants belonging tobupper-middle-class SES (59.5%), living with their spouse and children (55.4%) and with lower HbA1c (24.3%).

Table 3: IDDS, Sociodemographic Characteristics, BMI, and HbA1c Status in Low and High Diet Diversity Groups

Source: own elaboration.

Note: n= number of participants, FVS= Food Variety Score,

IDDS=Individual Diet Diversity Score, SES= Socio Economic Status,

BMI = Body Mass Index, HbA1c=Glycated Hemoglobin.

As indicated in Table 4, the mean per day cost was higher for females (INR 80.54± 44.76) and lower in middle SES group (INR 78.24±38.69).

Regarding Table 5, the per day cost increased with increased consumption of macronutrients.

Table 4: Factors influencing per day cost

Source: own elaboration.

Note: FVS= Food Variety Score, SES= Socio Economic Status.

Table 5: Correlation of per day cost with macronutrients consumption

Source: own elaboration.

Note: INR: =Indian Rupee, Kcal=Kilo Calories

Discussion and conclusions

Diabetes presents a growing challenge in India, with a prevalence of 8.7% among individuals aged 20-70 years (7). It affects an estimated 537 million adults worldwide between the age of 20 to 79 years. By 2030, 643 million people will have diabetes globally, increasing to 783 million by 2045 (8). Many factors influence its management with diet diversity being a significant contributor. It evaluates the diet quality of individuals and households.

In our study, the majority of participants were aged 55 years or older. Similar results were found in a cross-sectional study on 194 patients with T2DM where it was established that 162 (83.5%) of the participants were 55 years old, females (53.6%) outnumbered males (46.4%), 8.2 percent were illiterate, 49.0% were homemakers, and 82% were middle class (9). Another study included participants categorized into age groups: 18-44 years, 45-59 years, and 60 years or older, comprising 18.61%, 41.44%, and 39.95% of the total sample, respectively. Most respondents were married (86.44%) with a primary school education or lower (59.05%). In addition, 17.28% of the population were diabetic (10). Socioeconomic status, living status and HbA1c did not impact diet diversity. In a systematic search of peer-reviewed literature for longitudinal studies, it was observed that reduced risk of T2DM was linked to greater dietary diversity across major food groups and diversity within the consumption of fruits and/ or vegetables. Greater adiposity was associated with less healthy foods concluding that public health efforts should promote varied diets as a healthy eating strategy to prevent metabolic- related diseases (11). Contrary results were seen in a study where high-socioeconomic status (P-value = 0.046) were significantly correlated with adherence to dietary-recommendations (12). Additionally, a study identified that single males, single females, and households headed by individuals with no secondary school education or aged over 75 years were more likely to experience lower levels of dietary diversity (13).

Similar results were observed in a study on FVS in T2DM population, which reported that dairy and fruits were the least frequently consumed foods among five food groups. A significant number of individuals with Type 2 diabetes who did not adhere to national dietary guidelines were identified, highlighting the importance of promoting a well-balanced diet according to these guidelines through straightforward approaches, particularly among those with lower educational levels (14). A study concluded that lower diet diversity score was associated with high fasting blood glucose. Therefore, it seems that increase in dietary diversity scores could prevent the prediabetes development to overt diabetes (15). Contradictory findings were observed in a study where increased dietary diversity was positively linked with diabesity after adjusting for confounding factors. The study concluded that a more diverse diet could potentially be a risk factor for obesity among Algerian Type 2 diabetic patients (16).

Most of the study population had moderate dietary diversity, indicative that only 3-8 food groups were consumed. Interestingly, none of them had a low dietary diversity. The results were in line with a study where only one percent consumed three or fewer food groups, whereas roughly 40% had diets ranging from four to six major food groups, with a moderate dietary diversity (17). A study on participants at risk of diabetes who consumed a diet low in DD indicated DD was not associated with nutritional status (18). However, higher diet quality was associated with lower risk of T2D (19). The mean IDDS score of 7.81 was contrary to a study in T2DM patients, where the mean IDDS was 5.6 ± 1.58. Hence, it was concluded that efforts are required to ensure people have better access to knowledge about adequate nutrition (20).

Per-day diet cost was higher for almost all the food groups except for energy-dense food, fried foods, and beverages. The mean diet cost for the lower-income group was higher compared to the high-income group viz. INR 78.24 vs INR 68.02/-. The per day cost for females was high compared to males viz. (Indian Rupee) INR 80.54 vs INR 68.16/-. However, a contrary result was seen where the lowest income group had a mean diet cost of (dollar) $1.37 lower than the diet cost in the highest income group ($8.36 vs. $9.73, p<0.001), and the monetary value of the diet ($/day) was higher for men corresponding to higher quantity of food consumed (21). Moreover, a study concluded on an average, the most affordable nutrient adequate diet exceeds the cost of adequate energy by a factor of 2.66, costing US$1.35 per day to meet median requirements of healthy adult women in 2011 (22). The calculation of individual diet costs can offer insights into economic factors influencing food choices, diet quality, and health outcomes (23).

In the present study, it was seen that nearly half of the diabetic population had moderate dietary diversity which is a concern. Irrespective of socioeconomic class, the per day cost was unaffected however the diet cost had an impact on the macronutrient consumption. The study provides sufficient evidence that a diverse diet influences diabetes and its management.

In conclusion, extending this study to diverse populations to evaluate unique dietary practices, diet diversity, and socio-economic factors in Colombia could enhance the management of diabetes burden and improve overall health outcomes. The study could further influence nutrition education and public health initiatives in Colombia. As suggested by a study, another practice that can be adapted to improve dietary diversity and impart education, is the recognition of importance of inclusion of nutritionally balanced traditional foods. Acknowledging and accepting this simple fact can help to develop and advance more effective and sustainable policy measures to enhance traditional food and nutritional diversity in contemporary diets for improving the health, livelihood, and well-being of the population (24). Hence, it is crucial to recognize and consider dietary diversity with diet cost as an integral component in the management of diabetes.

Ethical statement

The study was approved by the Institutional Human Ethical Committee, Mount Carmel College, Autonomous, Bengaluru (IHEC-MCC No. 007 M.Sc./2021-22). All the subjects were interviewed using a pre-structured questionnaire after informed consent.

Conflict of Interest

None declared by the authors.

Funding

None declared by the authors.

Author’s contributions

Kruti Rathore: Conceptualization, Data Curation, Analysis, Methodology, Resources, Writing (Original Draft), Writing (Reviewing and Editing); Geetha Santhosh: Conceptualization, Methodology, Validation, Supervision, Visualization, Writing (Reviewing and Editing).