FACTORS INFLUENCING EATING BEHAVIORS AMONG TYPE 2 DIABETES

MELLITUS PATIENTS IN SIDOARJO SUB-DISTRICT,

EAST JAVA, INDONESIA

KUSUMA WIJAYA RIDI PUTRA

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE MASTER DEGREE OF NURSING SCIENCE

(INTERNATIONAL PROGRAM)

FACULTY OF NURSING

BURAPHA UNIVERSITY

MAY 2015

COPYRIGHT OF BURAPHA UNIVERSITY

This master thesis has been supported by

the master and doctoral thesis support grant

from Burapha University,

fiscal year 2015

ACKNOWLEDGEMENT

There are many people who have made this journey possible through their

generous support. I would like to express my deep appreciation to my advisor,

Assistant Professor Dr. Chanandchidadussadee Toonsiri for her patience, unending

guidance, support, encouragements and believing in me. I am indebted to my

co-advisor, Associate Professor Dr. Suwanna Junprasert for her countless influential

supports. Their tireless efforts and inspiring discussions are instrumental for my

achievement. I would like to offer my special gratitude to thesis examination

committee members for providing their suggestions and enriching my thesis.

I also wish to extend my heartfelt thanks to the Institutional Review Board at

the Faculty of Nursing for providing invaluable comments and suggestion to improve

my thesis writing. My great appreciation is given to the Dean at the Faculty of

Nursing, Burapha University, Associate Professor Dr. Nujjaree Chaimongkol and all

lecturers and staff of the Faculty of Nursing, Burapha University for providing

excellent teaching and learning environment to complete my Master of Nursing

Science degree in Thailand.

I extend my deeply felt gratitude to the Indonesian planning and cooperation

of foreign affairs for granting me the scholarship for a full time study in Thailand. I

also extend my deeply felt gratitude to Graduate Studies of Faculty of Nursing for

supporting me the research fund. I would like to offer my sincere appreciation to the

Health Resources of Sidoarjo Health Department for expediting the ethical approval.

Special thanks to the staff working at Sidoarjo Community Health Center for their

kind assistance. I am also very grateful to those people who participated in this study,

for taking their time to complete the questionnaires. And also I would like to say a big

thanks to someone who has been editing my thesis so it becomes better.

Lastly, I am totally indebted to my mother and my grandmother for their

strong prayers and blessings during my two years away from home. I also would like

to deeply thank my brother and my wife for their immense support and

encouragement. I will always remember the sacrifices they made for me.

Kusuma Wijaya Ridi Putra

v

56910104: MAJOR: NURSING SCIENCE; M.N.S.

KEYWORDS: EATING BEHAVIORS/ SELF-EFFICACY/ FAMILY SUPPORT/

PSYCHOLOGICAL STRESS/ TYPE 2 DIABETES MELLITUS

PATIENTS

KUSUMA WIJAYA RIDI PUTRA: FACTORS INFLUENCING EATING

BEHAVIORS AMONG TYPE 2 DIABETES MELLITUS PATIENTS IN

SIDOARJO SUB-DISTRICT, EAST JAVA, INDONESIA. ADVISORY

COMMITTEE: CHANANDCHIDADUSADEE TOONSIRI, Ph.D., SUWANNA

JUNPRASERT, Dr.P.H. 127 P. 2015.

This correlational predictive study aimed to describe and examine predictive

factors toward eating behaviors among type 2 diabetes mellitus (T2DM) patients in

Sidoarjo Sub-district, East Java, Indonesia. A simple random sampling was conducted to

recruit 117 people with T2DM from Sidoarjo Community Health Center, Sidoarjo Sub-

district, East Java, Indonesia. Research instruments consisted of the demographic data

questionnaire, the eating behaviors questionnaire, the knowledge of DM eating behaviors

questionnaire, the self-efficacy on eating behaviors questionnaire, the psychological stress

questionnaire, the family support questionnaire, and the health worker communication

questionnaire. Data were collected from January to February, 2015. Descriptive statistics

and Stepwise multiple regression analysis were used to analyze data.

The results revealed that T2DM patients reported having eating behaviors,

monthly income of family, self-efficacy on eating behaviors, psychological stress, and

family support at moderate level. Educational level and knowledge of DM eating

behaviors were considered as high level and health worker communication was at

a sufficient level. The influences of self-efficacy on eating behaviors (β = 0.36, p < .001)

together with family support (β = 0.31, p < .001), monthly income of family (β = 0.24,

p < .001), and psychological stress (β = -0.18, p < .01) were significantly predicted

66.5 % of the variance of eating behaviors.

The results provide important information for nurses and other health

professionals. Development a nursing intervention to promote eating behaviors in order to

control blood sugar among T2DM should focus on increasing their self-efficacy, motivate

family support, and decrease psychological stress. In addition, the intervention should be

integrated in their everyday life and suit with the income of the family.

vi

CONTENTS

Page

ABSTRACT .............................................................................................................. v

CONTENTS ............................................................................................................... vi

LIST OF TABLES .................................................................................................... viii

LIST OF FIGURES ................................................................................................... ix

CHAPTER

1 INTRODUCTION ......................................................................................... 1

Background and significance ................................................................... 1

Research objectives .................................................................................. 5

Research hypotheses ................................................................................ 6

Scope of the study .................................................................................... 6

Operational definitions............................................................................. 7

Conceptual framework ............................................................................. 9

2 LITERATURE REVIEWS ............................................................................ 11

Overview of type 2 diabetes mellitus ....................................................... 11

Eating behavior of type 2 diabetes mellitus ............................................. 21

Factors influencing eating behavior of type 2 diabetes mellitus patients 24

3 RESEARCH METHODOLOGY................................................................... 30

Population and sample ............................................................................. 30

Research instruments ............................................................................... 32

Quality of instruments.............................................................................. 35

Protection of human subjects ................................................................... 36

Data collection procedure ........................................................................ 36

Data analysis ............................................................................................ 37

4 RESULTS ..................................................................................................... 38

Part 1 Description of T2DM patients’ characteristics .............................. 38

vii

CONTENTS (CONTINUED)

CHAPTER Page

Part 2 Description of eating behaviors, monthly income of family,

educational level, knowledge of DM eating behaviors, self-efficacy on

eating behaviors, psychological stress, family support, and health worker

communication of T2DM patients .......................................................... 40

Part 3 Examination of the influences of predisposing factors, reinforcing

factor, and enabling factor toward eating behaviors among T2DM

patients ..................................................................................................... 42

5 CONCLUSION AND DISCUSSION ........................................................... 45

Conclusion .............................................................................................. 45

Discussion ............................................................................................... 46

Implication of the findings ....................................................................... 53

Recommendation for future research ...................................................... 54

REFERENCES .......................................................................................................... 55

APPENDICES ........................................................................................................... 66

Appendix A ......................................................................................................................... 67

Appendix B ......................................................................................................................... 74

Appendix C ........................................................................................................................ 90

Appendix D ........................................................................................................................ 108

Appendix E ........................................................................................................................ 116

Appendix F ........................................................................................................................ 118

Appendix G ........................................................................................................................ 120

Appendix H ........................................................................................................................ 122

Appendix I ......................................................................................................................... 125

BIOGRAPHY .......................................................................................................................... 127

viii

LIST OF TABLES

Tables Page

1 Description of T2DM patients’ characteristics ............................................... 38

2 Mean, standard deviation, and level of eating behaviors ............................... 40

3 Mean, standard deviation, and level of monthly income of family, educational

level, knowledge of DM eating behaviors, self-efficacy on eating behaviors,

psychological stress, family support, and health worker communication ....... 41

4 Correlation between predictors and eating behaviors ..................................... 43

5 Results of final model of stepwise multiple regression analysis examining

factors influencing eating behaviors among T2DM patients .......................... 44

6 Description of items of eating behaviors ........................................................ 109

7 Description of items of self-efficacy on eating behaviors ............................... 111

8 Description of items of psychological stress .................................................. 112

9 Description of items of family support ........................................................... 113

10 Description of items of health worker communication .................................. 115

ix

LIST OF FIGURES

Figures Page

1 Conceptual framework .................................................................................... 10

2 Precede-proceed model ................................................................................... 25

3 Sampling diagram ............................................................................................ 32

CHAPTER 1

INTRODUCTION

Background and significance

Diabetes Mellitus (DM) is one of the leading causes of death due to serious

complications (National Conference of State Legislature [NCSL], 2014). According

to the World Health Organization [WHO] (2013), 347 million people worldwide have

diabetes. Based on data from the Indonesian Ministry of Health in 2012, the number

of diabetic patients has reached 5.7 % of Indonesian population or about 12 million

people (Indonesian Ministry of Health, 2013). The number of diabetes mellitus cases

in Sidoarjo obtained from Sidoarjo’s Health Department as of 2013 reached 55,107

cases. This is the second highest incidence for the province of East Java after

Surabaya. The cases were diagnosed and recorded by the Health Department, but

there are still many cases of undiagnosed diabetes incidence in the community (East

Java Health Department, 2011).

Diabetes mellitus in Indonesia accounted for 4.2 % of deaths in the age

group 15-44 years in urban areas and this is the sixth leading cause of death

(Indonesian Ministry of Health, 2013). In the developing countries such as Indonesia,

increasing incidence of diabetes will have an impact on economic growth because

most people with diabetes are at a productive age (Indonesian Ministry of Health,

2013). Diabetes Mellitus, if not handled properly will result in the onset of

complications in various organs such as the eyes, heart, kidneys, leg veins, nerves and

others. Diabetes is difficult to be controlled in good condition, but it will be more

difficult if the state of type 2 diabetes mellitus (T2DM) exacerbated by emotional

disturbances, instability home, or lack of desire to try because of the lack of

motivation due to insufficient knowledge (Guthrie & Guthrie, 2002). Many people

with diabetes are admitted to hospital because they have an active diabetes

complication (Dunning, 2009). This situation occurs in Sidoarjo sub-district, there are

still many cases of undiagnosed diabetes incidence in the community and T2DM

patients only learned about their condition when they had to be hospitalized because

of their active complications from diabetes, among the most frequently recorded

2

coronary heart disease, kidney disease and diabetic foot (Sidoarjo Community Health

Center, 2014).

Nutrition intervention in type 2 diabetes mellitus is one of the parts that are

integral with the other treatments (Yannakoulia, 2006). Therefore, changes in lifestyle

associated with eating behaviors in T2DM patients greatly impact on their quality of

life. By having healthy eating behaviors, they can keep their blood sugar levels in

a stable state, and they are also able to control the progression of the disease so that

they can avoid the complications that can aggravate their condition and reduce insulin

resistance (Albarran, Ballesteros, Morales, & Ortega, 2006; Whittemore, Melkus, &

Grey, 2005).

According to some previous research, there are many factors that can affect

food selection and eating patterns of T2DM patients. According to Savoca and Miller

(2001), factors that affect selecting foods and eating patterns are divided into 3

domains, including personal dimension, behavioral patterns and environmental

characteristic. Personal dimension is the desire of individuals to consume favorite

foods when suffering emotional stress, along with nutrition-related knowledge, and

lifelong history of eating beyond the point of self-satisfaction. All of that affects the

type and quantity of food consumed by T2DM patients.

Planning arrangements for a diabetic diet would be more effective if it

involves a certain pattern of behavior, such as organizing meals in advance,

alternative identification favorite foods, and learning to prepare unfamiliar foods

(ex. vegetables). The environment can also affect the behavior of T2DM patients in

selecting foods and their eating habits. For example, when T2DM patients go out to

eat outside, the tendency of a T2DM patient will be to have difficulty in selecting

healthy foods because of the limitation alternative menus, such as vegetables and

low-fat foods. As an example, in the home, family support is key characteristic that

makes it easy or difficult to maintain a healthy diet plan. It is caused by the presence

of family support which will further facilitate in decision making for planning healthy

meals and the family will have a tendency to motivate T2DM patients undergoing

healthy eating behaviors. In addition, there are also researchers who recognize that

income, health care services, environmental insecurity and misleading "popular"

knowledge become key barrier to behavior change (Albarran et al., 2006).

3

For example, income and misleading "popular" knowledge, T2DM patients who have

low incomes are likely to have difficulty in making decisions of food consumed and

do not have the chance to separate the foods that should be consumed by T2DM

patients with the food consumed by the entire family. Misleading "popular"

knowledge, often due to lack of information obtained and already trusted by the

community around T2DM patients. In addition, the usual supported by the low level

of education thus making T2DM patients easily to believe that information.

In precede-proceed model developed by Green and Kreuter (2005) to assess

the factors can influence behavior, especially on fourth phase (educational and

organizational diagnosis). There are three factors on educational and organizational

diagnosis phase: Predisposing factors (monthly income of family, educational level,

knowledge, self-efficacy, psychological stress, belief, attitude, etc.), reinforcing

factors (family support, peer support, social support, etc.) and enabling factors (health

worker communication, program services, and resources or development of new

skills). These factors have become references for the researcher in conducting the

preliminary study in March to April 2013 by interviewing six people with diabetes

mellitus in Pamotan village. For preliminary study, the researcher used an open-ended

questionnaire. It was found that the participants had budget limitation for daily living,

the lack of information obtained by the family (only getting information from

neighbors), and ineffective communication between patients from health workers so

often misunderstanding of the information submitted from the health workers, most of

them also have a belief that they do not feel any effects of the disease so they tend to

neglect their health. Some of the interviewed patients experience stress which affects

the decision to consume foods that cause them not to control their blood sugar levels.

Based on previous research, there are multiple factors that can affect self-

management in patients with diabetes mellitus, as well as eating behaviors. The

factors include monthly income of family, level of educational, knowledge, co-morbid

illnesses of hypertension, hyperlipidemia and cardiac diseases, the level of family

functioning, family support, social support, health care service especially provider-

patient communication on self-management, misleading "popular" knowledge and

advice, belief, and self-efficacy (Alavi, Alami, Taefi, & Gharabagh, 2011; Albarran

et al., 2006; Marcy, Britton, & Harrison, 2011; Savoca & Miller, 2001; Wen,

4

Parchman, & Shepherd, 2004; William et al., 2010; Xu, Toobert, Savage, Pan, &

Whitmer, 2008).

Based on the results of research conducted by Marcy et al. (2011), they

found several barriers associated with low income and eating behaviors among T2DM

patients. When asked about the considerations in selecting foods, the highest response

obtained were about taste and price. This is resulting in the emergence of a barrier.

A major obstacle that arises is that they want food to taste good at a price that is

affordable to them and which is also healthy. Finally it was the result of them

experiencing stress which cause over-eating or unhealthy food choices as well as

difficulty in resisting the temptation to eat unhealthy food. Income is also often

associated with education level. In the group with low income will have a lower level

of education that will influence the decision making for the selection of foods and

understanding the information related to the importance of eating behaviors for

T2DM patients (Mocan & Altindag, 2014; William et al., 2010). Mocan and Altindag

(2014) also mentioned that the level of education had limitations which impact on

health behaviors, but these can be over if health workers can provide information

related to the management of the disease (especially changing behaviors) which must

be adhered to and should be clearly and easily understood by T2DM patients.

Other factors such as family support and health worker communication can

impact directly or indirectly on self-management, especially dietary behaviors. These

factors can exert their influence indirectly when they affect the confidence of people

with diabetes that will motivate them to follow good dietary behavior (Xu et al.,

2008). Communication and support of families will create a social environment that is

feasible for a patient with diabetes mellitus for treatment by medical professionals

(Hara et al., 2013). Just medical and drug treatment for chronic diseases such as

diabetes mellitus are not enough, but they also to be aware of self-management,

especially eating behaviors. Provision of information about disease suffered by the

patient is the duty of a health workers. The process of providing information or

communication by medical practitioners greatly affect the understanding of the patient

so that they can carry out self-management independently. Effective communication

of health workers is more important to decision-making styles in predicting diabetes

self-management (Heisler, Bouknight, Hayward, Smith, & Kerr, 2002).

5

Dietary self-efficacy is a variable that may affect eating behaviors, such as

foods selection and eating patterns. Increased self-efficacy will impact decision

making stage and adherence to the treatments. In addition to self-efficacy,

psychological stress can also influence a person in making decisions regarding

diabetes dietary needs. According Polonsky (2002), emotional stress can affect

the mindset of patients in decision-making related to diabetes health behaviors that

can affect their quality of life. Patients with diabetes often have to know about their

illness, but they often fail to perform good health behaviors because of psychological

stress and cope less well so that they have difficulty in establishing patterns of

behaviors to solve the problem of diet (Nomura et al., 2000).

In conclusion, the process to determine the factors that can affect eating

behaviors of a given population is very important to follow because it enables health

care providers to see which factors can influence the eating behaviors of T2DM

patients so that they can use these factors in the preparation of program planning for

eating behaviors within the population. Research in Indonesia is often performed on

T2DM patients who are undergoing treatment in hospital and is still rarely carried out

on patients living in community.

This research studied factors influencing eating behaviors among type 2

diabetes mellitus patients, which consist of predisposing factors (monthly income of

family, educational level, knowledge of DM eating behaviors, self-efficacy on eating

behaviors, and psychological stress), reinforcing factor (family support), and enabling

factor (health worker communication). The results of this study can be used as a

reference to assist anyone to will learn about the factors that influence the

management of type 2 diabetes mellitus, especially eating behaviors, and used as

input for health professionals to prepare effectively and efficient nursing plan or

program for T2DM patients.

Research objectives

The objectives of the study were to:

1. Describe eating behaviors, predisposing factors (monthly income of

family, educational level, knowledge of DM eating behaviors, self-efficacy on eating

6

behaviors, and psychological stress), reinforcing factor (family support) and enabling

factor (health worker communication) of Indonesian people with T2DM.

2. Examine the influences of predisposing factors (monthly income of

family, educational level, knowledge of DM eating behaviors, self-efficacy on eating

behaviors, and psychological stress), reinforcing factor (family support) and enabling

factor (health worker communication) toward eating behaviors among T2DM patients

in Sidoarjo sub-district, East Java, Indonesia.

Research hypotheses

Predisposing factors (monthly income of family, educational level,

knowledge of DM eating behaviors, self-efficacy on eating behaviors, and

psychological stress), reinforcing factor (family support) and enabling factor (health

worker communication) predict eating behaviors among T2DM patients in Sidoarjo

sub-district, East Java, Indonesia.

Scope of the study

This study has been conducted to examine the influences of predisposing

factors (monthly income of family, educational level, knowledge of DM eating

behaviors, self-efficacy on eating behaviors, and psychological stress), reinforcing

factor (family support) and enabling factor (health worker communication) toward

eating behaviors among T2DM patients diagnosed with diabetes mellitus in the

Community Health Center Sidoarjo, Sidoarjo district, East Java, Indonesia. Data

collection was conducted from January to February 2015 with the total of participants

are 117 people.

Variables of this study included the following:

1. Independent variables: Monthly income of family, educational level,

knowledge of DM eating behaviors, self-efficacy on eating behaviors, psychological

stress, family support, and health worker communication.

2. Dependent variable: Eating behaviors

7

Operational definitions

T2DM patients referred to as adult residents in Sidoarjo sub-district who

have been diagnosed with diabetes mellitus by doctors.

Monthly income of family referred to the total of family income of T2DM

patients in each month. According Central Bureau of Statistics (2008), monthly

income of family classified into 3 levels, including low income (< 1,500,000 IDR),

moderate income (1,500,000-2,500,000 IDR), and high income (≥ 2,500,001 IDR).

Educational level referred to the total years of education of T2DM patients.

Law no. 2 of 1999 on the measurement of the level of formal education, educational

level classified into 3 levels, including low educational level (6 years), moderate

educational level (9 years), and high educational level (≥ 12 years).

Knowledge of DM eating behaviors referred to the T2DM patients’

cognitive about eating behaviors of diabetes mellitus, including healthy eating pattern,

inappropriate foods, the important of eating behaviors than other treatments, and

dietary self-management. Knowledge of DM eating behaviors was measured using

combination of the Diabetes Knowledge Questionnaire (DKQ) from two previous

study. In this study, DKQ measured using 18 items, which derived from 7 items of

Garcia, Villagomez, Brown, Kouzekanani, and Hanis (2001) and 11 items of Park

et al. (2010). The potential response choice were used, “yes”, “no”, and “don’t know”.

The higher scores indicated high levels of the T2DM patients’ knowledge.

Self-efficacy on eating behaviors referred to the T2DM patient’s

perception of their ability to maintain their eating behaviors, including the start of the

measurement of choosing appropriate foods, following eating plan in any conditions,

and controlling T2DM conditions. In this study, self-efficacy on eating behaviors was

measured using 10 items of modification self-efficacy of diet from 15 items of the

Diabetes Management Self-Efficacy Scale-UK (DMSES-UK) are considered to be

interpreted T2DM patient self-efficacy for diet. DMSES-UK developed by Sturt,

Hearnshaw, and Wakelin (2010). This used rating scale from 0-10. The higher

scores indicated high levels of the T2DM patients’ self-efficacy.

Psychological stress referred to the feelings of T2DM patients for potential

problems that may be faced by them, including emotional burden, physician-related

distress, regimen-related distress, and interpersonal distress. In this study,

8

psychological stress was measured using 16 items from Diabetes Distress Scale (DSS)

developed by Polonsky et al. (2005). This used rating scale, which included “not a

problem”, “a slight problem”, “a moderate problem”, “somewhat serious problem”,

“a serious problem”, and “a very serious problem”. The higher scores indicated high

levels of the T2DM patients’ distress.

Family support referred to the perception of supporting system and motivation

given by the family to help engage in healthy eating behaviors of T2DM patients

which aims to improve the quality of life of these patients, including give motivation

to keep compliance with the healthy eating behaviors, meet the food needs in

accordance with the T2DM patients conditions, and choose place that serve

appropriate foods for T2DM.Family support was measured using 20 items of Diabetic

Social Support Questionnaire-Family (DSSQ-family) in Om (2013). This used rating

scale, “never”, “less than 2 times a month”, “twice a month”, “once a week”, “several

times a week”, and “at least once a day”. The higher scores indicated high support

from family.

Health worker communication referred to the T2DM patient’s perception

about communications made by health workers in providing information associated

with diabetes mellitus, including attitude of health workers while communicating with

T2DM patients, readiness of health workers in conveying information, and readiness

of health workers while consulting related to healthy eating behaviors. Health worker

communication was measured using Health Care Communication Questionnaire

(HCCQ) developed by Gremigmi, Sommarugo, and Peltenburg (2007). This used

rating scale, “not at all”, “a little, somewhat”, “very much”, and “completely”.

The higher scores indicated good communication between health worker and T2DM

patients.

Eating behaviors referred to the response of T2DM patients associated with

the consumption of foods that are recommended for diabetic patients, including the

start of the measurement of food intake, the selection of a healthy diet, the

consumption of meal planning that appropriate, and challenges dietary settings

(selecting a place to eat for good health when eating out and portion control). Eating

behaviors were measured using the Self-Management Dietary Behaviors

Questionnaire (SMDBQ) which has been developed by Primanda, Kritpracha, and

9

Thaniwattananon (2011). This used rating scale, “never”, “sometimes”, “often”, and

“routinely”. The higher scores indicated good dietary behaviors.

Conceptual framework

Precede-proceed model address by Green and Kreuter (2005) has nine

phases. Precede section, there are five phases. They consists of social diagnosis

(phase 1), the epidemiological diagnosis (phase 2), behavioral and environment

diagnosis (phase 3), educational and organizational diagnosis (phase 4), and

administrative and policy diagnosis (phase 5). To perform the evaluation associated

with behaviors that will be aimed at the end of the evaluation of the level of health

and quality of life, it can be done through an evaluation of the factors contained in the

educational and organizational diagnosis. It should be noted that the administrative

and policy diagnosis phase can affect the educational and organizational diagnosis

phase.

The conceptual framework of this study was educational and organizational

diagnosis phase of precede-proceed model that consists of three factors: predisposing

factors, reinforcing factors and enabling factors. While the impact evaluation phase is

the phase in which to evaluate the implementation of which is based on the

assessment of three factors on educational and organizational diagnosis phase.

According to Green and Kreuter (2005), predisposing factors are any characteristics

of a person or population that motivates behavior prior to or during the occurrence of

that behavior. The predisposing factors in this study were monthly income of family,

educational level, knowledge of DM eating behaviors, self-efficacy on eating

behaviors, and psychological stress. Reinforcing factors are rewards or punishments

following or anticipated as a consequence of a behavior. They serve to strengthen the

motivation for behavior. The reinforcing factor in this study was family support.

Enabling factors are those characteristics of the environment that facilitate action and

any skill or resource required to attain specific behavior. The enabling factor in this

study was health worker communication.

In present study, eating behaviors of diabetes mellitus patient can be

influenced by multiple factors as figure 1. Based on precede-proceed model

10

developed by Green and Kreuter (2005), changes in lifestyle or behavior, especially

eating behaviors in T2DM patients greatly impact on their quality of life.

Figure 1 Conceptual framework

CHAPTER 2

LITERATURE REVIEWS

This chapter contains the information and study findings relevant to this

research. This section is divided into 3 main parts as follows:

1. Overview of type 2 diabetes mellitus

2. Eating behaviors of type 2 diabetes mellitus

3. Factors influencing eating behaviors of type 2 diabetes mellitus patients

Overview of type 2 diabetes mellitus

The overview of type 2 diabetes mellitus described the definition,

pathophysiology, complications, and management of type 2 diabetes mellitus

(T2DM).

1. Definition of type 2 diabetes mellitus

According to American Diabetes Association [ADA] (2004), type 2 diabetes

mellitus is a group of metabolic diseases characterized by hyperglycemia resulting

from defects in insulin secretion, insulin action, or both.

A person is said to suffer from type 2 diabetes when their body does not

produce enough insulin to function properly, or the body's cells do not respond to

insulin, which is commonly known as insulin resistance. That situation can be caused

by age, obesity, lack of exercise, and increase in unhealthy diets (National Health

Service [NHS], 2014).

According to the Indonesian Society of Endocrinology [Perkeni] (2006),

a person is suffering from diabetes who has a fasting plasma glucose (FPG) level

> 126 mg/ dl and the oral glucose tolerance test (OGTT) > 200 mg/ dl. Blood sugar

levels vary throughout the day which will increase after a meal and returning to

normal within 2 hours. As for T2DM itself is a medical condition that is often

characterized by elevated blood glucose levels that are usually caused by metabolic

disorders such as insulin resistance and/ or insulin deficiency.

T2DM is a condition that is most dominant in the world because it

represents 90 % of cases of diabetes (Hassan, 2013).

12

Based on the above understanding, it can be concluded that T2DM is

a condition of endocrine disorders caused by several factors, such as insulin resistance

and or insulin deficiency and characterized by elevated levels of blood sugar, fasting

plasma glucose (FPG) levels ≥ 126 mg/ dl and the oral glucose tolerance test (OGTT)

> 200 mg/ dl.

2. Etiology or risk factors of type 2 diabetes mellitus

The factors that may influence the occurrence of T2DM, among others

genetic factors leading to susceptibility, age, obesity and physical inactivity, and

ethnic and environmental factors (Alexander, Fawcett, & Runciman, 2006).

` 2.1 Genetic factors leading to susceptibility.

The role of genes is very strong in T2DM. Having a certain combination

of genes will increase or decrease the risk factors for developing this disease. This is

evident from the high rate of diabetes mellitus in the family and identic twins and

a wide variation in the prevalence of diabetes by ethnicity (National Institute of

Health, 2011; Watkins, 2003). Type 2 diabetes occurs more frequently in African

Americans, Alaska Natives, American Indians, Hispanics/ Latinos, and some Asian

Americans, Native Hawaiians, and Pacific Islander Americans than it does in

non-Hispanic whites (National Institute of Health, 2011).

Recent studies have combined genetic data from many people and accelerate

the pace of gene discovery. These studies have identified many gene variants that

increase susceptibility to T2DM. Also gene variants that affect the production of

insulin rather than insulin resistance. The researchers are also trying to identify

additional gene variants and learn how they interact with each other and with

environmental factors that cause diabetes. Much research on T2DM-gene and

genomics related to the increase in the incidence of T2DM. People with T2DM who

have the unique phenotype may show an increase in the incidence of T2DM (Grant,

Moore, & Florez, 2009). The diabetes prevention program clinical trial involving

people at high risk found that if the group with this variant, if used the appropriate

diet and physical activity for weight loss, it would have helped them to delay

the occurrence of T2DM (National Institute of Health, 2011).

13

2.2 Age

The incidence of T2DM will increase significantly with age. One in ten

people at the age of 70 years have a tendency to suffer from T2DM (British Diabetic

Association, 1996). Metabolism of glucose in the blood will begin to decline in the

third or fourth decade of life, especially at the age above 60 years, and will be

exacerbated and accelerated by other factors that also contribute to the onset of

diabetes (Alexander et al., 2006; Valliyot, Sreedharan, & Muttappallymyalil, 2013).

2.3 Obesity and physical inactivity

Obesity and physical activity have a very strong relationship to

the incidence of T2DM, especially in those who are genetically susceptible to diabetes

mellitus will further increase the risk. The imbalance between caloric intake and

physical activity can lead to obesity, which causes insulin resistance and is common

in people with T2DM. This condition decreased glucose tolerance caused by

increased body weight and tolerance it will return to normal with a decrease in body

weight. Excess abdominal fat is a major risk factor not only as a cause of insulin

resistance and type 2 diabetes but also can be a cause of heart and blood vessel

disease, also called cardiovascular disease (CVD). That is because excess "belly fat"

will produce hormones and other harmful substances that may cause chronic effects in

the body such as blood vessel damage (Alexander et al., 2006; National Institute of

Health, 2011; Wei, Gaskill, Haffner, & Stern, 1997).

2.4 Ethnic and environmental factors.

There is a wide geographical variation in the incidence of T2DM with

"Western" diet style and lack of physical activity. In addition, the incidence will be

growing in the urban areas with hard working atmosphere and diet are more

dependent on high-fat diets and lack of time to exercise or physical activity can lead

to obesity. This is a health burden experienced by urban areas. In the UK,

the prevalence of T2DM is particularly high in Asian and Afro-Caribbean people,

with 20 % of Asians and 17 % of Afro-Caribbean over the age of 40 known to

have T2DM (Alexander et al., 2006; Griggs, 1998; National Institute of Health, 2011;

Watskins, 2003).

14

3. Pathophysiology of type 2 diabetes mellitus

T2DM is a common type of diabetes and is usually caused by a combination

of factors, including insulin resistance, where the body's muscle, fat and liver cells do

not use insulin effectively. T2DM can also be caused by the body can no longer

produce enough insulin to compensate for the impaired ability to use insulin (National

Institute of Health, 2011).

3.1 Impaired insulin secretion

Impaired insulin secretion is a condition in response to a decrease in

blood glucose was observed before the clinical onset. It is particularly in impaired

glucose tolerance (IGT) caused a decrease in insulin secretion in the early phase of

glucose-responsive, insulin secretion and a decrease in additional after eating that

causes postprandial hyperglycemia. An oral glucose tolerance test (OGTT) in the case

of IGT generally indicates an over-response in Caucasian people and Hispanics who

have a high incidence of resistance to insulin. On the other side, Japanese patients

often decrease insulin secretion. Even when over-response was seen in people with

obesity or other factors, they showed a decrease in the early phase of secretion

response. The decline in the early phase of secretion is an important part of this

disease, and is very important as a basic pathophysiological changes during the onset

of the disease in all ethnic groups (Abdul-Ghani, Matsuda, & Jani, 2008).

Impaired insulin secretion generally occurs progressively, and involves

the development of glucose toxicity and lipo-toxicity. If not treated, it is known to

cause a decrease in pancreatic β cell mass. Pancreatic β cell destruction affect

the long-term control of blood glucose. While patients in the early stages after

the onset of the disease mainly showed increased postprandial blood glucose as

a result of increased insulin resistance and decreased early-phase secretion,

development of impaired function of pancreatic β cells which then will lead to

a permanent elevation of blood glucose (Kaku, 2010).

3.2 Insulin resistance

Insulin resistance is a condition in which insulin in the body cannot act in

proportion to the concentration of the blood. Decreased insulin action in organs such

as liver and muscle are in general pathophysiological feature that occurs in T2DM.

In the experiment for the molecular mechanism of action of insulin showed that

15

insulin resistance associated with genetic factors and environmental factors

(hyperglycemia, free fatty acids, inflammatory mechanisms, etc.). On genetic factors

keep in mind that not only includes the insulin receptor and insulin receptor substrate

(IRS)-1 gene polymorphisms that directly affect insulin signaling, but also genetic

polymorphisms such as β3-adrenergic receptor genes and uncoupling protein (UCP)

gene, which is associated with obesity visceral and increased insulin resistance.

Glucolipotoxicity and inflammatory mediators have an important effect on

the mechanism of impaired insulin secretion and decreased insulin signaling.

Attention is focused on the involvement of adipocyte-derived bioactive substances

(adipokines) in insulin resistance. While TNF-α, leptin, resistin, and free fatty acids

act as an ingredient to improve insulin resistance whereas adiponectin will help

increase the insulin resistance. An easier way to estimate the increase in insulin

resistance is by examining the presence of high fasting blood insulin, visceral obesity,

hyper triglyceridemia, etc. (Kaku, 2010; Matsuda & DeFronzo, 1999).

4. Sign and symptoms of type 2 diabetes mellitus

Patients with T2DM will show different clinical symptoms from one person

to another. In fact, there are some patients who do not experience clinical symptoms

until at a certain moment that they knew that they was suffering from diabetes

mellitus type 2. In general, there are three symptoms that often occur in people with

T2DM that is polydipsia, polyuria, and polyphagia. Based on Alexander et al. (2006),

the effects due to the relative lack of insulin is divided into 4, including

hyperglycemia-related symptoms, genital or oral fungal infections, staphylococcal

skin infections and non-specific symptoms.

4.1 Hyperglycaemia-related symptoms

In the circumstances we find symptoms of hyperglycemia such as

nocturia, polyuria and possibility of thirst gradually and in patients with risk factors

such as obesity.

4.2 Genital or fungal infections

Candida infection is a common thing that happens in people with T2DM.

The candida infection can be pruritus vulvae in the female and balanitis in male.

The condition is caused by high levels of glucose from urine around the genitals and

16

the lack of hygiene in the area so that the area becomes a place that is favorable for

the proliferation of candida.

4.3 Staphylococcal skin infections

The incidence of infection is usually detected in patients with type 2

diabetes who had boils and abscesses and usually it is that drives them to see

the doctor for consultation.

4.4 Non-specific symptoms

This condition is usually in the form of tiredness and lethargy - often

reported as the symptoms experienced by patients with T2DM. It is not clearly

known, but the cause is suspected to be the result of fluid and electrolyte imbalance in

the body.

In addition to the four above symptoms, there are also symptoms associated

with the occurrence of complications. Incidence of vascular and neurological

complications, such as proteinuria, sexual dysfunction, and retinopathy, developed

when people with diabetes mellitus type 2 is coming to the medical personnel. This is

likely to occur when the patient is likely to have diabetes with hyperglycemia

persistent asymptomatic for several years before diagnosis (Alexander et al., 2006).

5. Complication of type 2 diabetes mellitus

For people with diabetes mellitus either type 1 diabetes mellitus or T2DM

should be able to maintain body condition of the occurrence of hyperglycemia

because these conditions will improve morbidity and mortality in patients with

diabetes mellitus. Complications that may occur as a result of prolonged

hyperglycemia and uncontrolled are divided into two, namely macrovascular

(coronary artery disease, peripheral arterial disease, and stroke) and microvascular

(diabetic nephropathy, neuropathy, and retinopathy) (Alexander et al., 2006; Fowler,

2008; Lemone & Burke, 1996).

5.1 Macrovascular complication

Macrovascular complication include cardiovascular disease (such as

coronary artery disease, myocardial infarction, etc.), peripheral arterial disease,

hypertension, stroke and paralysis (Alexander et al., 2006; Lemone & Burke, 1996;

Smelter, Brenda, Hinkle, & Cheever, 2010).

17

Based on the results of research conducted by the British Diabetic

Association in collaboration with the World Health Organization [WHO] on 497

people aged 35-54 years old with diabetes mellitus showed that the prevalence of

cardiovascular disease was 45 % and the prevalence of obtained 43 % had coronary

disease. It also obtained cerebrovascular disease and peripheral vascular disease

(4.5 % and 4.2 %, respectively) (British Diabetic Association, 1995). Based on

research by Stratton et al. (2000) found that in patients with T2DM have risks of

complications associated with previous hyperglycemia. This is evident from the

results of research that found 14 % of participants suffered myocardial infarction.

In addition, diabetes is also a strong independent predictor of the risk of stroke and

cerebrovascular diseases, such as in coronary artery disease. Patients with T2DM

have a 150 % - 400 % increase in the risk of stroke (Fowler, 2008).

5.2 Microvascular complication

Microvascular complications are caused by blockage of the small blood

vessels, especially capillaries. Microvascular complication diagnosis sometimes

originated from the reduction in visual acuity or other disorders of the eye that can

lead to blindness. Diabetic retinopathy is divided into 2 groups, namely

non-proliferative retinopathy and proliferative retinopathy. Non-proliferative

retinopathy is an early stage with a marked presence of micro-aneurysms.

Proliferative retinopathy is characterized by the growth of capillary blood vessels,

connective tissue and the presence of hypoxia in the retina (Alexander et al., 2006;

Permana, 2009).

In the early stages, retinopathy can be repaired with good blood sugar

control. But at an advance level, it can hardly be repaired only with blood sugar

control, even going to get worse if there is a decrease in blood sugar levels which are

too drastic and short. That situation would be exacerbated if patients with T2DMare

also suffering from hypertension (Alexander et al., 2006; American Diabetes

Association [ADA], 2007; Permana, 2009).

Aside from being the cause of retinopathy, T2DM is a cause of the most

widely nephropathy. And nephropathy is a major cause of terminal renal failure.

Specific renal damage in diabetes mellitus results in changes in the function of the

filters, so that large molecules such as proteins can escape into the urinary system

18

(eg. Albuminuria). Diabetic nephropathy can lead to the onset of progressive renal

failure (Permana, 2009).

Diabetic nephropathy is characterized by persistent proteinuria (> 0.5

gr/ 24 hours) and urinary albumin loss is between 30-300 mg/ day, and there is

retinopathy and hypertension. Thus preventive efforts on nephropathy are by

controlling metabolism and blood pressure control (ADA, 2007; Permana, 2009).

Diabetic neuropathy is a frequent complication in patients with diabetes,

50 % of patients suffering from diabetes mellitus. Clinical manifestations may include

sensory disturbances, motoric, and autonomic. The process of incident neuropathy

usually occurs where there is a progressive degeneration of nerve fibers with

symptoms of pain or numbness, which is usually affected limb nerve fibers. This is

due to the presence of damage and dysfunction in neural structures due to an increase

in polyol pathway, decreased the formation of myoinositol, decreased Na/ K ATPase,

causing structural damage to the nerves, demyelination segmental, or axonal atrophy

(Permana, 2009).

6. Management of type 2 diabetes mellitus

Management in patients with T2DM required multidisciplinary treatment.

Management of diabetes mellitus conducted by professionals in the diabetes care team

will be adapted to needs of each individual with diabetes mellitus. Management of

diabetes mellitus is aimed at the achievement and maintenance of normoglycemia,

monitor response to therapy, prevention and early detection of diabetic complications

that may appear, facilitating the self-care education, promotion of social and

psychological adjustment.

Based on Alexander et al. (2006), there are 4 main therapeutic approaches in

the management of diabetes; those are weight control, dietary therapy, oral

hypoglycemic therapy, and insulin therapy.

6.1 Weight control

Weight control is an important thing done by people with T2DM because

of obesity will lead to an increase in blood glucose levels. Aside from dietary

adjustments, advice for physical activity should also be performed (Alexander et al.,

2006; International Diabetes Federation, 2012).

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6.2 Dietary therapy

Appropriate dietary advice in patients with diabetes mellitus is

an effective effort in the management of diabetes. Provision of information about diet

in diabetes management aims to train people with diabetes to be able to have their

own types and is able to determine the quantity of food they eat. Dietary therapy is

associated with consumption of carbohydrate restriction, restriction of fat intake,

consumption of fruit and alcohol consumption (Alexander et al., 2006).

6.2.1 Carbohydrate

All foods that contain carbohydrates can lead to the increasing of blood

glucose levels. Increased blood glucose levels are influenced by the amount of food

consumed, carbohydrate source such as glucose or starch, cooking method and other

components of food. Sucrose is no longer considered to be more harmful to the blood

glucose levels than other carbohydrates. However, sucrose is still a source of empty

calories and harmful to the teeth so that we can consume them sparingly. Fruit

containing fructose consumption should be encouraged because it has a low glycemic

effect. In addition, fruits consumption are also used to meet the needs of fibers so that

people with diabetes should be encouraged to eat five portions of fruit and vegetables

per day. However, excessive consumption of fruits can also lead to increased blood

glucose levels so that number should also be considered (Alexander et al., 2006;

International Diabetes Federation, 2012).

6.2.2 Fat

Fat should not be overlooked when giving dietary advice for people

with diabetes. This is one of the main sources of dietary energy. Decrease fat intake

generally required for weight control. Diabetes mellitus patients generally should be

encouraged to consume less fat and, if possible, within the selected fat consumption,

which comes from monounsaturated sources (Alexander et al., 2006; International

Diabetes Federation, 2012).

6.2.3 Alcohol

People with T2DM should avoid alcohol consumption because

it impacts to insulin sensitivity which is resulting to the decrease of blood glucose

levels drastically. In such conditions, it should be noted that adequate carbohydrate

intake to avoid diabetes is the condition of hypoglycemia (Alexander et al., 2006).

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6.3 Oral hypoglycemic therapy

Oral hypoglycemic therapy will work effectively if β cells are still able to

secrete insulin. Oral hypoglycemic therapy used specifically in patients with T2DM.

Based on United Kingdom Prospective Diabetes Study Group [UKPDS] (1998), there

are five groups of oral agents play are available for use, such as sulphonylureas,

biguanides (metformin), prandial glucose regulators, thiazolidinediones, and alpha-

glucosidase inhibitors.

6.3.1 The sulphonylureas

These drugs stimulate the β cells of the pancreas to produce more

insulin in response to blood glucose levels, improve insulin sensitivity and decrease

hepatic metabolism for insulin productions. Side effects often occur from the use of

these drugs is hypoglycemia. Other side effects may include weight gain,

gastrointestinal disturbance and skin rash.

6.3.2 The biguanides (metformin)

The effects of metformin are reducing glucose absorption in the

intestine, reduce insulin resistance in peripheral tissues, and inhibit liver glucogenesis.

Common side effects are gastrointestinal upset occurs. The use of metformin may also

result in malabsorption of vitamin B12 and an increase in lactic acid. Metformin

should not be used in patients with diabetes mellitus with renal, liver and severe

cardiovascular disease or serious systemic illness.

6.3.3 Prandial glucose regulators

These drugs designed to stimulate additional insulin to coincide with

the digestive process. These drugs usually taken 15 minutes before meals; so

it contains can be absorbed quickly by the body. Side effects tend to be very rare, but

still it can lead to gastrointestinal upset, nausea, and skin rash.

6.3.4 Thiazolidinediones

These drugs handling in insulin resistance and improve insulin

sensitivity in peripheral tissues, increases glucose uptake in peripheral tissues, and

decrease hepatic glucose production. These drugs are usually used in conjunction with

other oral agents. Side effects that arise are weight gain, headaches, and fluid

retention. The use of this drug is not recommended in people with cardiac failure or

poor liver function.

21

6.3.5 Alpha-glucosidase inhibitor

Acarbose is the name of drugs classified on this type. Acarbose is now

very rarely used because of the side effects which is stand out. Mechanism of action

of this drug is delaying the formation of monosaccharides derived from sucrose and

starch. Side effects of these drugs are flatulent and diarrhea.

6.4 Insulin therapy

Insulin therapy is the treatment of which people with type 1 diabetes

mellitus should carry out throughout their life. But for T2DM patients, the most

important is the management of change in lifestyle. According UKPDS (1998), only

25 % of T2DM patients who use insulin therapy or intensive blood-glucose control

can decrease the risk of microvascular complication. Insulin is only given to T2DM

patients who have prolonged periods at elevated blood glucose control despite

lifestyle changes and taking hypoglycemic drugs (Casey, 2011). Insulin therapy has

several purposes, among others, to keep blood glucose levels under normal

circumstances, relieve symptoms of hyperglycemia, improve metabolic/ biochemical

disturbances, and prevent complications associated with hyperglycemia.

In conclusion, the main purpose of doing management in patients with

diabetes are keeping their blood glucose levels in normal and prevent complications.

Diabetes management can be done in 4 ways, including weight control, dietary

therapy, oral hypoglycemic therapy, and insulin therapy. One of the four most

important ways management for T2DM patients is dietary therapy. All the way

diabetes management cannot be separated with lifestyle changes and physical activity

done by T2DM patients.

Eating behaviors of type 2 diabetes mellitus

Eating behaviors are always associated with three factors, type, frequency

and amount of food consumed by a person. Eating behaviors are difficult condition to

conceptualize and complex behaviors of a person or group of people to meet the

demand for food which includes attitudes, beliefs, culture, lifestyle, and choice of

food (food groups, individual foods, components of foods, specific micronutrients or

phytochemicals) that describes the daily food consumption, including the type of

food, amount and frequency of eating (Handjani, 1996; Jacobs, Gross, & Tapsell,

22

2009; Jacobs & Tapsell, 2007; Jacobs & Steffen, 2003; McKeown & Jacobs, 2010).

They also define eating behaviors as a condition that is difficult to conceptualize

because it all depends on the diversity of belief, culture, and lifestyle patterns within

community. Individual conceptualization of eating behaviors come from faith and

lifestyle that they profess in their daily life, which have the possibility of not being in

accordance with scientific recommendations (Sangperm et al., 2008).

Based on the above understanding, it can be concluded that eating behaviors

are complex behaviors of a person or group associated with the fulfillment of the need

to eat who are often influenced by their beliefs, culture and daily lifestyle which will

result in the selection of the type, frequency and amount of food consumed.

After a person has been diagnosed with T2DM, the problems that often

appear are always associated with eating behaviors. The eating behaviors of T2DM

patients who are diagnosed early will remain the same as others who do not suffer

from T2DM, especially in women, they are often less able to make dietary changes

early after being diagnosed and having received dietary advice (Van De Laar et al.,

2006). There are several factors that can affect eating behaviors among T2DM, such

as gender, knowledge, income, education level, belief, family support, social support,

time management, health care services, and dietary self-efficacy (Alavi et al., 2011;

Albarran et al., 2006; Kaiser, Razurel, & Jeannot, 2013; Savoca & Miller, 2001).

Based on the research of Savoca & Miller (2001), which according to them with

increased knowledge of healthy diets diabetics with diabetes will affect one's

awareness of eating behaviors. The same thing is also expressed by Albarran et al.

(2006), they provide health education intervention that they think will improve the

knowledge of the respondents and care givers about how to benefit the families and

the people around T2DM patients so as to raise awareness about the treatments that

T2DM patients are undergoing and with emphasis on their eating behaviors.

In addition to the factors derived from individuals with T2DM patients and

the surrounding environments, the health care service also plays an important role in

improving the quality of life of T2DM patients such as health care service, which is a

support system that can affect the patient's self-efficacy and lifestyle behaviors (Lee et

al., 2011). According to Lee et al. (2011), there should be a partnership between the

23

general clinical and social work to conduct programs related to improve quality of life

of T2DM patients.

T2DM patients must have a strict adherence to the activities and actions

related to the condition, one of which is healthy eating behaviors to maintain and

sustain their health. By adhering to a diet that has been recommended so that they can

keep their blood sugar levels in a stable state and controlling progression of

the disease so that they can avoid complications (Whittemore et al., 2005).

The diabetic food pyramid recommended by the ADA is often used as a guide to

healthy eating for diabetics in which there is the calculation of the proportion of

consumption of carbohydrates, fats and proteins for diabetics. The proportion

recommended by the ADA, among others are 10 % to 20 % protein, 30 % fat, and

50 % to 60 % carbohydrate. But in addition to these three components, fiber contained

in each food consumed by T2DM patient is also very important because the fiber is

often associated with a significant reduction in fasting blood sugar levels, lipid levels,

and also reduction of body weight in diabetics (Ding & Malik, 2008).

T2DM is always related to lifestyle, especially eating behaviors. It is

expected that adherence to good eating behaviors would impact on blood glucose,

blood pressure, cholesterol levels and also help to control weight. Several studies have

explained that by changes in eating habits can help to overcome T2DM disease

progression and prevent the sufferer from the occurrence of complications and reduce

insulin resistance (Albarran et al., 2006; Kaiser et al., 2013; Mohan, Sandeep, Deepa,

Shah, & Varghese, 2007).

In Indonesia, the Indonesian people have a habit of eating rice. Indonesian

people did not feel able to eat until they have eaten rice or other food made from rice

(Primanda et al., 2011). Regarding traditional Indonesian culture and ceremonies,

many traditional events and ceremonies that combine food and invite relatives and/

or other guests to share a meal. They prepare food that is high in fat and too sweet.

Though both of these food types are not recommended for diabetics. In such

conditions, people with diabetes are expected to manage their own eating behaviors.

Often the management of eating behaviors of patients with diabetes is associated with

self-confidence in their health-illness and is always associated with the religious or

traditional beliefs that they profess.

24

The habit of consuming foods containing saturated fats, trans-fats,

cholesterol, high-salt, added sugar which are eaten in large portions are habits that can

be the cause of T2DM. These habits can cause a person to become overweight and

obese, which will result in a decline in organ function. Therefore, to understand the

importance of eating behaviors and make decisions to choose healthy eating behaviors

is most crucial to maintain the condition of T2DM patients.

Factors influencing eating behaviors of type 2 diabetes mellitus

patients

1. Precede-proceed model

Precede-proceed model address by Green and Kreuter (2005) is used for

delivering programs in practice settings and conducting behavior change

interventions. Precede-proceed model is community-oriented, participatory model for

creating successful community health promotion interventions. The model offers a

framework within which individual level theories, community level theories,

interpersonal communication, interactive technologies media campaigns, and grass

roots organizing can be utilized. Precede-proceed model has nine phases. Precede

section, there is five phases. It consists of social diagnosis (phase 1), epidemiological

diagnosis (phase 2), behavioral and environment diagnosis (phase 3), educational and

organizational diagnosis (phase 4), and administrative and policy diagnosis (phase 5).

Proceed section, there is four phases. It consists of implementation (phase 6), process

evaluation (phase 7), impact evaluation (phase 8), and outcome evaluation (phase 9).

To perform the evaluation associated with behaviors which aims to evaluate the health

and quality of life, it can be done through an evaluation of the factors contained in the

educational and organizational diagnosis. It should be noted that the administrative

and policy diagnosis phase can affect the educational and organizational diagnosis

phase.

Educational and organizational diagnosis phase of precede-proceed model is

used to determine the influencing factors of eating behaviors among T2DM patients.

It consists of three factors: Predisposing factors, reinforcing factors and enabling

factors. Once behavioral and environment factors have been selected for intervention

25

the next step is to identify antecedent and reinforcing factors that need to be in place

to initiate and sustain the change process. There are 3 specified:

Predisposing factors – antecedents to a behavior that provide rationale or

motivation for that personal behaviors, such as monthly income of family, educational

level, knowledge, self-efficacy, stress management, belief, attitude, etc.

Reinforcing factors – factors that following a behavior provide continued

reward or incentive for repetition of that behavior, such as family support, peer

support, social support, etc.

Enabling factors – antecedents to behavioral or environmental change that

allow a motivation or environmental policy to be realized, such as communication of

health care provider, programs services and resources or development of new skills.

Figure 2 Precede-proceed model (Green & Kreuter, 2005)

2. Predisposing factors

2.1 Monthly income of family

Family income had direct and indirect impact between eating behaviors

and health among T2DM patients (Vlismas, Stavrinos, & Panagiotakos, 2009).

26

According Marcy et al. (2011), in low-income communities often found the incidence

of diabetes is caused by factors related to the cost of healthy food, stress-related

eating inappropriate, and the temptation to eat unhealthy food. With low income

levels and supported by a low-SES environment would affect one's perception of

health and result in health disparities (Gallo, Smith, & Cox, 2006). Type of work and

the ability to pay for treatment are often the cause of disparities in health care so that

it will affect a person's perception of health behaviors (Shawahna et al., 2012). On the

other hand, income affects a person in making decision in determining the food they

consume. At higher income levels, some people have a tendency to choose unhealthy

foods more due to the custom of the environment around them then ability to buy it

(Muhammad, Karim, Othman, & Ghazali, 2013).

2.2 Educational level

Low educational level is often drive T2DM patient had difficulty in

understanding all the information related to self-management, especially the

importance of eating behaviors to maintain their condition. It also makes them will

have difficulty in making decisions related to eating behaviors, such as food selection

and eating patterns. However, these problems will be over if the health worker can

provide information related to the management of the disease (especially changing

the behaviors of everyday life, such as eating behaviors) that must be endured by

those with a clear and easily understood and in accordance with their conditions

(Mocan & Altindag, 2014). The same thing also expressed by Atak, Gurkan, and

Kose (2008), who state that the level of education has a limited impact on health

behaviors.

2.3 Knowledge of DM eating behaviors

According Serrano-Gil and Jacob (2010), T2DM patients will achieve

successful clinical outcomes and health if they have knowledge about their health so

that they are involved in controlling and managing their condition. More information

lead to a more selection methods too choose good diets based on the patient’s

experience, but still it must be balanced with the proper knowledge so that patients

know when they should still consult to doctor and when they can take action on their

own (Alavi et al., 2011). T2DM patients are expected to remain informed and more

critical in assessing the information about their treatment that lead to motivate them to

27

change behavior generated by the learning (Hartayu, Izham, & Suryawati, 2012).

Health education on nutrition knowledge is needed to improve the nutritional

knowledge, skills, and food intake behaviors (Fitzgerald, Damio, Pérez, & Escamilla,

2008).

2.4 Psychological stress

Emotional distress is common in diabetes. Emotional distress can affect

the mindset of patients with diabetes-related health behaviors that lead to health-

related quality of life (Polonsky, 2002). Statement of Polonsky is reinforced by the

statement of Lustman, Penckofer, and Clouse (2008) who state that the stress

condition of patients with diabetes will affect insulin sensitivity and resulted in a

sustained reduction in HbA1c. Psychological stress can affect eating behaviors, either

directly or indirectly. Stigma or psychosocial problems are obtained by T2DM

patients will deliver tremendous impact stress on the concept of health-illness in

people so that they will experience problems related decisions taken by health

behaviors, especially for diet (Guthrie, Bartsocas, Jarosz-Chabot, & Konstantinova,

2003). Patients with diabetes often have to know about their illness, but they often fail

to perform health behaviors because of stress management and coping less well so

that they have difficulty in establishing patterns of behaviors to solve the problem of

diet and exercise therapy (Nomura et al., 2000). The patients of chronic diseases such

as diabetes mellitus who are confident, motivated, able to regulate their emotions, and

are equipped to use a rational approach to solving the problem should be adjusted in

routine and stressful circumstances. However, it will be the opposite when they

experience a variety of challenges and cannot manage the stress (Elliott, Shewchuk,

Miller, & Richards, 2001).

2.5 Self-efficacy on eating behaviors

Dietary self-efficacy in T2DM patients identified as one of variables that

can affect eating/ dietary behaviors, such as food selection and eating patterns

(Savoca & Miller, 2001). Increased self-efficacy influence the development of

depression and will impact the decision-making process and adherence to

the treatments (Sacco & Bykowski, 2010). There is also research which states that

increasing self-efficacy in T2DM patients will lead to a good impact in the diabetic

self-management behaviors, such as dietary, exercise, blood sugar testing, and taking

28

medication, so it is predicted better glycemic control (Al-Khawaldeh, Al-Hasan,

&Froelicher, 2012; Atak et al., 2008).

3. Reinforcing factor

Family support

Communication and support of families create a social environment that is

feasible for a patient with diabetes mellitus treatment of medical professionals (Hara

et al., 2013). For example, in children who suffer from diabetes mellitus, parental

negative behavior will greatly affect the metabolic control and the level of adherence

to treatment regimens that are being undertaken (Lewin et al., 2005). It is proved that

family support is very closely related to medication adherence, metabolic control, and

quality of life. Higher family social support leads to the higher diabetes management

adherence to control glycemic status and higher quality of life. On the other hand,

higher family conflict predicts lower quality of life (Pereira, Berg-Cross, Almeida, &

Machado, 2008). According Wen et al. (2004), the increasing of family support leads

to decreasing of perceived-barriers toward dietary self-care. This idea comes from

their assumption that the function of the family to support the needs of patients with

diabetes obtained a good quality of life can be fulfilled. Therefore, the role of health

workers when T2DM patients come to check themselves for the first time is to

explore the role of family support and family function of the patients with T2DM.

4. Enabling factor

Health worker communication

The severity of illness and stress management problems in patients with

diabetes mellitus are often increase the number of visits to health care so that they

may influence the views of paramedics to services as well as the influence of

prescription issued (TzOu et al., 2012). In the treatment of chronic diseases such as

diabetes mellitus, it is not enough to run medical and drug treatment, but they should

also aware their self-management. Provision of information about the disease suffered

by the patient is the duty of a health worker. The process of providing information or

communication by medical practitioners greatly affect the understanding of the patient

so that they can carry out self-management independently. Ratings of provider

communication effectiveness are more important than a participatory decision-making

style in predicting diabetes self-management (Heisler et al., 2002). Giving the right

29

information will have a much better effectiveness in improving patient empowerment

in diabetes mellitus in terms of self-management and diabetes patients to modify

lifestyle rather than just involving those in decision making about their care will live

(Lee et al., 2011).

From the literature review, it can be concluded that T2DM is

a non-communicable chronic disease, which is caused by a deficiency of insulin and/

or insulin resistance. Controlling blood sugar levels is an important thing done by

T2DM patients. One way to control blood sugar levels is through eating behaviors as

a mean of therapy. Non-compliance in the management of eating behaviors in

accordance with the rules will result in poor glycemic control, increasing the value of

mortality and morbidity, and increase health care utilization and cost. Literature

review shows that many factors can affect eating behaviors among T2DM patients.

Among these factors are the monthly income of family, educational level, knowledge

of DM eating behaviors, psychological stress, self-efficacy on eating behaviors,

family support and health worker communication. Accordance to the conditions in

Indonesia which have a wide variety of cultures, find out the factors that influencing

eating behaviors among T2DM patients are very important. Since by finding out its

factors, professionals teams can make and prepare programs that more effective and

efficient in improving glycemic control of T2DM patients.

CHAPTER 3

RESEARCH METHODOLOGY

A predictive correlation research was selected to examine predictive factors

between predisposing factors (monthly income of family, educational level,

knowledge of DM eating behaviors, self-efficacy on eating behaviors, and

psychological stress), reinforcing factors (family support), and enabling factors

(health worker communication) to eating behaviors among T2DM patients in Sidoarjo

sub-district, East Java, Indonesia.

Population and sample

Population referred to adult people who were diagnosed with T2DM from

doctor, they live in Sidoarjo sub-district. Sidoarjo sub-district has three Community

Health Center with total of T2DM patients were 5,788 people (Sidoarjo Health

Department, 2013).

Sample referred to adult people who were diagnosed with T2DM from

doctor, they live in Sidoarjo sub-district, and visited the Sidoarjo Community Health

Center for follow up. The inclusion criteria were used to include T2DM patients

become participants, among others:

1. Age between 20-60 years old

2. Able to read, write, and comprehend Indonesia language

3. Willing to participate in the study

Sample size

In this study, researcher used Tabachnick and Fidell (2007) to calculate the

sample size, due to the calculation method of Tabachnick and Fidell had been

recommended to use multiple regression test with several independent variables.

Formulation of Tabachnick and Fidell:

n = 50 + 8m

Explanation:

n = the sample size

m = the number of independent variables

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There are seven independent variables that will be used, so the sample size:

n = 50 + 8m

n = 50 + 8(7)

n = 106

In this study, the sample size was 106 participants. In social science research

does not rule out the presence of missing data. The determination of the number of

missing data is not consistent definition of a variety of literature, but the literature

suggests that 20 % or less of values (Little & Rubin, 2002 citied in Saunders et al.,

2006). Therefore, this study used 10 % to compensate for missing data, so the total

number of samples in this study was 117 participants.

Setting

Participants were gathered from the Sidoarjo Community Health Center.

Researcher conducted the research by home visits. T2DM patients who become

participants are people who live within the scope of Sidoarjo Community Health

Center only.

Sampling technique

The total of T2DM patients in Sidoarjo sub-district were 5,788 people.

Sidoarjo sub-district has three Community Health Center with the same characteristics

of participant. By using cluster random sampling, from three Community Health

Center, Sidoarjo Community Health Center was elected as the research location,

within nine villages for their scope with the total of T2DM patients were 3,356

people. Participant recruitment process performed by making person with diabetes

mellitus who visited the Sidoarjo Community Health Center for follow up as potential

participant. The researcher asked their willingness to participate, when T2DM patients

are willing to become a participant, then researcher continued for collecting the data.

With time limitation for collecting data in the Sidoarjo Community Health Center,

researcher obtained address of T2DM patients from Sidoarjo Community Health

Center and conducted research by home visit. The number of participants whom the

data obtained from is approximately 7 up to 8 participants per day. The researcher

continuously doing this until the number of participants reach 117.

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Figure 3 Sampling diagram

Research instruments

The seven instruments used in this study were Indonesian version, including:

1. Demographic data questionnaire developed by the researcher. It

consists of questions for gender, age, marital status, educational levels, and monthly

income of family.

2. Eating behaviors questionnaire: Using self-management diabetes

dietary behaviors questionnaire (SMDBQ) developed by Primanda et al. (2011).

SMDBQ had commonly used for various researches in Indonesia since it is valid with

the situation in Indonesia. Researcher wants to measure the response of T2DM

patients toward the consumption of foods that are recommended for diabetic patients,

including food intake, the selection of a healthy diet, the consumption of meal

planning that appropriate, and challenges dietary settings (selecting a place to eat for

good health when eating out and portion control). SMDBQ consists of four

dimensions with the total of statement are 33 items: Recognizing the amount of

calorie needs (4 items), selecting a healthy diet and amount (16 items), arranging a

meal plan (6 items), and managing dietary challenges (7 items). In SMDBQ there are

28 items that are positive statements and 5 items that are negative statements.

SMBDQ using a 4-point rating scale from never to routinely with scoring for never =

33

"1", sometimes = "2", Often = "3", and routinely = "4" for positive statements.

In contrast to the negative statements to never = "4", sometimes = "3", Often = "2",

and routinely = "1". Which include positive statements are numbers 1-12, 14-18, 21,

22, 24-28, and 30-33. As for the negative statements are numbers 13, 19, 20, 23, and

29. The total score of SMDBQ ranges from 33 to 132, with the higher scores

indicated good eating behaviors. According Primanda et al. (2011), SMBDQ

classified by the number of scores into three levels, namely high (101-132), moderate

(67-100), and low (33-66). Based on the result from Primanda et al. (2011), SMDBQ

attained a reliability coefficient of Cronbach's alpha .73.

3. Knowledge of DM eating behaviors questionnaire: Using diabetes

knowledge questionnaire (DKQ) from combination of diabetes knowledge

questionnaire developed by Garcia, Villagomez, Brown, Kouzekanani, and Hanis,

(2001) and Park et al. (2010). This questionnaire consists of 18 items, which derived

from 7 items of Garcia, Villagomez, Brown, Kouzekanani, and Hanis, (2001) and 11

items of Park et al. (2010). The choice of the potential response are 1) Yes, 2) No, and

3) Don’t know. Items were scored as correct or incorrect, and the correct items were

summed to attain a total score. The total score ranges from 0 to 18, with the higher

scores indicated high level of the patient’s knowledge. Based on two previous study,

the scoring of the DKQ in this case is classified into 3 levels, including low

knowledge (0-5), moderate knowledge (6-11) and high knowledge (12-18).

4. Self-efficacy on eating behaviors questionnaire: Using modification of

diabetes management self-efficacy scale-United Kingdom (DMSES-UK) version

developed by Sturt et al. (2010). The researcher used10 items of modification self-

efficacy for diet from15 items of DMSES-UK statements with scale of 0-10. The total

score of DMSES ranges from 0 to 100, with the higher scores indicated high level of

the patient's self-efficacy. According Sturt et al. (2010), the scoring of the DMSES in

this case is classified into 3 levels, including high self-efficacy (68-100), moderate

self-efficacy (34-67), and low self-efficacy (0-33).

5. Psychological stress questionnaire: Using diabetes distress scale (DDS)

developed by Polonsky et al. (2005). The DDS were used to measure potential

problem areas that people with diabetes may experience. The DDS consists of 17

items that contain the distress that occurred in diabetics and it is divided into 4

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subscales, including emotional burden (numbers 2, 4, 7, 10, and 13), physician

distress (numbers 1, 5, 11, and 14), regimen distress (numbers 3, 6, 8, 12, and 15), and

interpersonal distress (numbers 9 and 16). The DDS were rated on a rating scale that

lined the start of “not a problem” to “a very serious problem” with scoring for not a

problem = “1”, a slight problem = “2”, a moderate problem = “3”, somewhat serious

problem = “4”, a serious problem = “5”, and a very serious problem = “6”. The total

score of DDS ranges from 16 to 102, with the higher scores indicated high level of the

patient's distress. Based on Polonsky et al. (2005), the scoring of the DDS in this case

is classified into 3 levels, including low distress (16-31), moderate distress (32-47),

and high distress (≥ 48). The DDS had adequate reliability coefficient to Cronbach’s

alpha .87 and validity yielded significant linkages with the Center for Epidemiological

Studies Depression scale, meal planning, exercise, and total cholesterol (Polonsky et

al., 2005).

6. Family support questionnaire: Using diabetic social support

questionnaire-family (DSSQ-Family) from La Greca and Bearman citied in Om

(2013) was used to measure family support. The DSSQ-Family consists of 20 items

for meal plan. The DSSQ-Family were rated on a rating scale that lined the start of

“never” to “at least once a day” with scoring for never = "0", less than 2 times a

month = "1", twice a month = "2", Once a week = "3", several times a week = "4",

and at least once a day = “5”. The total score of DSSQ-Family ranges from 0 to 100.

According Om (2013), the DSSQ-Familyis divided into 3 levels, which are a low

family support (0-33), moderate family support (34-66), and high family support

(67-100). The higher score indicated high support from family. Based on the result of

Om (2013), DSSQ-Family had adequate internal consistency score to Cronbach’s

alpha .95.

7. Health worker communication questionnaire: Using health care

communication questionnaire (HCCQ) developed by Gremigmi et al. (2007).

The HCCQ used by researcher to determine the perception of T2DM patients about

communications made by health workers in providing information associated with

diabetes mellitus. HCCQ statements composed of 13 items using a 5-point rating

scale that lined the start of “not at all” to “completely” with scoring for not at all =

"1", a little = "2", somewhat = "3", very much = "4", and completely = "5". The total

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score of HCCQ ranges from 13 to 65, with the higher scores indicated good

communication from health worker to T2DM patients. Under these conditions and

according Gremigmi et al. (2007), the communication of health worker is classified

into 3 T2DM patients levels, among others, good communication (48-65), sufficient

communication (30-47), and bad communication (13-29).Based on the result of

Gremigmi et al. (2007), Cronbach’s alpha values met the criterion of .70, ranging

from .72 to .86.

Instrument translation

In order to have the appropriate instrument of demographic data, eating

behaviors, knowledge of DM eating behaviors, self-efficacy on eating behaviors,

psychological stress, family support, and health worker communication and it can be

used in Indonesia, all questionnaires was translated from English to Indonesian

language by back-translation technique (Cha, Kim, & Erlen, 2007). The specific

translation procedures that were used in this study, are in follow: 1) the original

English versions translated into the Indonesian language by one person (the person

who is expertise both of languages, English and Indonesian), 2) Indonesian-native

bilingual who is expertise related to this study was a review and revise Indonesian

version, then 3) the revised Indonesian version was translated again into English by

an another bilingual, and 4) both of instrument in the form of English version

(the original and the back-translation) was reviewed again to see compatibility.

Quality of instruments

Content validity

The researcher used the instruments had been tested for validity, therefore

content validity in this study was skipped.

Reliability

The researcher gave the questionnaire to 30 people with T2DM who visited

the Buduran Community Health Center with the same characteristics as the sample in

this study. The Cronbach’s alpha coefficient was used to determine the reliability for

eating behavior, self-efficacy on eating behaviors, psychological stress, family

support, and health worker communication. The Kuder-Richardson formula 20

(KR-20) coefficient was used to identify the reliability of the knowledge of DM

36

eating behaviors questionnaire. The results of Cronbach’s alpha test for eating

behaviors (SMDBQ) was .83, self-efficacy on eating behaviors (DMSES) was .89,

psychological stress (DDS) was .85, family support (DSSQ-Family) was .97, and

health worker communication (HCCQ) was .90. The reliability of knowledge of DM

eating behaviors was KR-20 = .61.

Protection of human subjects

The research proposal prior to use in further research must obtain ethical

approval from the Institutional Review Committee of the Faculty of Nursing, Burapha

University and through permission from Sidoarjo Health Department. In conducting

the study, researcher informed consent prior to the approval for T2DM patient as the

respondents in this research. Researcher also explained participant have the right to

end their participation in this study at any time without any penalty and no identified

risks involved with participation in this study. In addition, confidentially and

anonymity will be maintained by the researcher. To that end, each form submitted to

each respondent is always a no-name and the identity of the patient remains awake.

Every form and the data will still be stored properly so that no one knows about the

form and the data of T2DM patients who were respondents in this research. The data

will be destroyed by the researcher after 1 year from the publication of this research.

Data collection procedure

Collecting data in this study conducted in the following manner:

1. Before conducting the study, researcher conducted a test of ethics by the

Institutional Review Committee of the Faculty of Nursing, Burapha University and

obtained a legal permit from the Sidoarjo Health Department.

2. Letter from Burapha University used as an attachment to get permission

from Sidoarjo Health Department in case of collecting data.

3. Participants were gathered from the Sidoarjo Community Health Center.

Participant recruitment process performed by making person with diabetes mellitus

who visited the Sidoarjo Community Health Center for follow up. With time

limitation for collecting data in the Sidoarjo Community Health Center, researcher

37

obtained address of T2DM patients from Sidoarjo Community Health Center and

conducted research by home visit.

4. Before starting data collection, the researcher explained about the human

protection, purpose and method used in this study, if a potential respondent is

accepting and willing to serve, then they sign an agreement proved they were agreed

to give contribution to this research.

5. After declaring consent as respondent, the researcher explained briefly

about the direction to fill the questionnaire and allowed respondents to fill it out

according to their own circumstances. Each respondent will be given 20-30 minutes to

answer each questionnaire package.

6. The researcher continued conducting the data collection until the number

of target samples is reached.

Data analysis

1. To describe eating behaviors, monthly income of family, educational

level, knowledge of DM eating behaviors, self-efficacy on eating behaviors,

psychological stress, family support, and health worker communication by Mean and

SD, researcher used descriptive statistic, especially central tendency and dispersion/

variation.

2. In the analysis of data, the researcher used stepwise multiple regression to

check the prediction factors of eating behaviors. Statistical significance level was

assumed when p < .05.

CHAPTER 4

RESULTS

This chapter presents the results of the study. The study aims to examine the

influences of monthly income of family, educational level, knowledge of DM eating

behaviors, self-efficacy on eating behaviors, psychological stress, family support, and

health worker communication toward eating behaviors among T2DM patients in

Sidoarjo sub-district, East Java, Indonesia. The results of this study are presented as

the followings:

Part 1 Description of T2DM patients’ characteristics.

Part 2 Description of eating behaviors, monthly income of family,

educational level, knowledge of DM eating behaviors, self-efficacy on eating

behaviors, psychological stress, family support, and health worker communication of

T2DM patients.

Part 3 Examination of the influences of predisposing factors, reinforcing

factor, and enabling factor toward eating behaviors among T2DM patients.

Part 1 Description of T2DM patients’ characteristics

Table 1 presents characteristics of the T2DM patients including gender, age,

marital status, educational level, and monthly income of family.

Table 1 Description of T2DM patients’ characteristics (n = 117)

Characteristics Number (n) Percentage (%)

Gender

Male 42 35.90

Female 75 64.10

Age (M = 47.07, SD = 7.83, Min = 27, Max = 60)

21-30 4 3.42

31-40 21 17.95

41-50 53 45.30

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Table 1 (Continued)

Characteristics Number (n) Percentage (%)

51-60 39 33.33

Marital status

Single 2 1.71

Married 90 76.92

Divorced/Widow 25 21.37

Educational level (M = 12.43, SD = 2.45)

6 years (primary school) 1 0.90

9 years (junior high school) 21 17.90

12 years (high school) 65 55.60

15 years (diploma) 7 6.00

16 years (undergraduate) 20 17.10

18 years (graduate) 3 2.50

Monthly income of family (M = 1,746,846.15, SD = 521,828.66, Min = 750,000;

Max = 3,775,000) (1 USD = 12,000 IDR)

≤ 1,499,999 29 24.79

1,500,000-2,500,000 82 70.09

≥ 2,500,001 6 5.12

Table 1 shows that most of participants (64.10 %) were female. Age range

41-50 years (45.30 %) followed by age range 51-60 (33.33 %). For marital status,

majority of participants (76.92 %) were married. In educational level, more than half

of participants (55.60 %) completed 12 years (high school). The majority of

participants (70.09 %) earned monthly income of family per month between

1,500,000-2,500,000 IDR (125 USD-208.33 USD).

40

Part 2 Description of eating behaviors, monthly income of family,

educational level, knowledge of DM eating behaviors, self-efficacy on

eating behaviors, psychological stress, family support, and health

worker communication of T2DM patients

1. Description of eating behaviors of T2DM patients

Table 2 presents description of eating behaviors.

Table 2 Mean, standard deviation, and level of eating behaviors (n = 117)

Variables Total

score M SD Mean % Level

Overall eating behaviors 132 75.44 10.58 57.15 Moderate

Arranging a meal plan 24 16.51 1.92 68.79

Selecting a healthy diet and

amount

64 36.28 4.87 56.69

Recognizing the amount of

calorie needs

16 8.97 2.28 56.06

Managing dietary

challenges

28 13.68 2.82 48.86

The table 2 shows that eating behaviors were considered as moderate level

(M = 75.44, SD = 10.58). For dimensions of eating behaviors, the highest of Mean %

(68.79) was arranging a meal plan and followed by selecting a healthy diet and

amount (Mean % = 56.69). The lowest of Mean % (48.86) was managing dietary

challenges.

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2. Description of monthly income of family, educational level,

knowledge of DM eating behaviors, self-efficacy on eating behaviors,

psychological stress, family support, and health worker communication of T2DM

patients

Table 3 presents description of monthly income of family, educational level,

knowledge of DM eating behaviors, self-efficacy on eating behaviors, psychological

stress, family support, and health worker communication.

Table 3 Mean, standard deviation, and level of monthly income of family,

educational, knowledge of DM eating behaviors, self-efficacy on eating

behaviors, psychological stress, family support and health worker

communication (n = 117)

Variables Total

score M SD Level

1. Monthly income of family - 1,746,846.15 521,828.66 Moderate

2. Educational level - 12.43 2.45 High

3. Knowledge of DM eating

behaviors 18 12.08 2.29 High

4. Self-efficacy on eating

behaviors 100 60.88 6.30 Moderate

5. Psychological stress 102 42.59 5.77 Moderate

6. Family support 100 55.38 13.83 Moderate

7. Health worker

communication 65 33.42 5.34 Sufficient

Table 3 shows that monthly income of family, self-efficacy on eating

behaviors, psychological stress, and family support were considered as moderate level

(M = 1,746,846.15, SD = 521,828.66; M = 60.88, SD = 6.30; M = 42.59, SD = 5.77;

M = 55.38, SD = 13.83, respectively). Educational level and knowledge of DM eating

behaviors were considered as high level (M = 12.43, SD = 2.45; M = 12.08,

42

SD = 2.29, respectively) and health worker communication was considered as

sufficient level (M = 33.42, SD = 5.34).

Part 3 Examination of the influences of predisposing factors,

reinforcing factor, and enabling factor toward eating behaviors

among T2DM patients

Stepwise multiple regression analysis was used to predict eating behaviors

among T2DM patients in Sidoarjo sub-district, East Java, Indonesia. Assumption of

regression analysis were tested including normality of dependent and independent

variables, autocorrelation, multi-collinearity, homoscedasticity, and linearity. For

normality, normal distribution was tested using both Kolmogorov-Smirnov with

significance value > .05 and Skewness-Kurtosis coefficient with significance value

between -1.96 to +1.96. The results found that normal distribution of eating

behaviors, educational level, monthly income of family, knowledge of DM eating

behaviors, self-efficacy on eating behaviors, psychological stress, family support, and

health worker communication. Autocorrelation means the scores of a sample are not

independent. Autocorrelation can be known through Durbin-Watson value.

In the model summary table, Durbin-Watson value in this study equals to 2.212

indicated no autocorrelation. In the colinearity statistics, the tolerance values were all

greater than .10 and Variance Inflation Factor (VIF) values were less than 10, it

means no multicollinearity among predictors. However, it was found that some

correlation coefficient had value greater than 0.5 which might affect the estimates of

the regression coefficients. According Tabachnick and Fidell (2007) stated that

the correlation coefficients if less than 0.85 is not indicative of multicollinearity

(Table 4). The value of standard residual was between +3.00 and -3.00, it means no

multivariate outlier. Linearity was tested using both statistic and scatterplot. There

were all significant for indicating linearity. Scatterplot of regression standardized

residual were on the same straight line, therefore linearity and homoscedasticity

assumption was met.

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Table 4 Correlation between predictors and eating behaviors (n = 117)

1 2 3 4 5 6 7 8

1. Educational level 1.00

2. Monthly income of

family

.63*** 1.00

3. Knowledge of DM

eating behaviors

.21* .31*** 1.00

4. Self-efficacy on

eating behaviors

.57*** .54*** .31*** 1.00

5. Psychological

stress

-.15 -.14 -.21* -.09 1.00

6. Family support .49*** .46*** .28** .60*** -.27** 1.00

7. Health worker

communication

.09 .18* .34*** .33*** -.05 .33*** 1.00

8. Eating behaviors .60*** .61*** .33*** .69*** -.33*** .68*** .27** 1.00

According results of stepwise multiple regression analysis, table 5 showed

the factors influences eating behaviors among T2DM patients.

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Table 5 Results of final model of stepwise multiple regression analysis examining

factors influencing eating behaviors among T2DM patients (n = 117)

Independent variables b SE(b) Beta t p-value

1. Self-efficacy on eating

behaviors

0.60 7.41 0.36 4.83 < .001

2. Family support 0.24 0.13 0.31 4.27 < .001

3. Monthly income of

family

4.95*10-6 0.056 0.24 3.67 < .001

4. Psychological stress -0.33 0.00 -0.18 -3.14 .002

Constant 31.07 0.11 4.19 < .001

R² = .665, F(4, 112)= 55.63, p < .001

From table 5, the results shows that self-efficacy on eating behaviors

(β = 0.36, p < .001), family support (β = 0.31, p < .001), monthly income of family

(β = 0.24, p < .001), and psychological stress (β = -0.18, p < .01) were significant

predictors of eating behaviors and accounted for 66.5 % in the variance of eating

behaviors (R² = .665, F(4, 112)= 55.63, p < .001). Educational level, knowledge of DM

eating behaviors, and health worker communication were not significant predictors of

eating behaviors. The prediction equations were showed as follows:

1. The typical multiple regression equation based on raw scores

Eating behaviors = 31.07 + 0.60 (self-efficacy on eating behaviors) + 0.24

(family support) + 4.95*10-6 (monthly income of family)

- 0.33 (psychological stress).

2. The typical multiple regression equation based on Z scores

Zeating behaviors = 0.36 (Zself-efficacy on eating behaviors) + 0.31 (Zfamily support) + 0.24

(Zmonthly income of family) - 0.18 (Zpsychological stress).

CHAPTER 5

CONCLUSION AND DISCUSSION

This study aims to describe and examine predictive factors toward eating

behaviors among T2DM patients in Sidoarjo sub-district, East Java, Indonesia. A

simple random sampling was conducted to recruit 117 people with T2DM from

Sidoarjo Sub-district. The research instruments consist of demographic data

questionnaire, eating behaviors questionnaire, knowledge of DM eating behaviors

questionnaire, self-efficacy on eating behaviors questionnaire, psychological stress

questionnaire, family support questionnaire, and health worker communication

questionnaire. The results of Cronbach’s alpha test for eating behaviors (SMDBQ)

was .83, self-efficacy on eating behaviors (DMSES) was .89, psychological stress

(DDS) was .85, family support (DSSQ-Family) was .97, and health worker

communication (HCCQ) was .90. The result of test reliability values of knowledge of

DM eating behaviors (DKQ) KR-20 was .61. Data were collected during January to

February, 2015. Descriptive statistics and stepwise multiple regression were used to

analyze data.

Conclusion

1. Most of participants (64.10 %) were female. Age range 41-50 years

(45.30 %) followed by age range 51-60 (33.33 %). For marital status, majority of

participants (76.92 %) were married. In educational level, more than half of

participants (55.60 %) completed 12 years (high school). The majority of participants

(70.09 %) earned monthly income of family per month between 1,500,000-2,500,000

IDR (125 USD-208.33 USD).

2. Eating behaviors, monthly income of family, self-efficacy on eating

behaviors, psychological stress, and family support were considered as moderate level

(M = 75.44, SD = 10.58; M = 1,746,846.15, SD = 521,828.66; M = 60.88, SD = 6.30;

M = 42.59, SD = 5.77; M = 55.38, SD = 13.83, respectively). Educational level and

knowledge of DM eating behaviors were considered as high level (M = 12.43,

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SD = 2.45; M = 12.08, SD = 2.29, respectively) and health worker communication

was considered as sufficient level (M = 33.42, SD = 5.34).

3. The stepwise multiple regression analysis shows that self-efficacy on

eating behaviors (β = 0.36, p < .001), family support (β = 0.31, p < .001), monthly

income of family (β = 0.24, p < .001), and psychological stress (β = -0.18, p < .01)

were significant predictors of eating behaviors and accounted for 66.5 % in the

variance of eating behaviors (R² = .665, F(4, 112)= 55.63, p < .001). Educational level,

knowledge of DM eating behaviors, and health worker communication were not

significant predictors of eating behaviors. The prediction equations were showed as

follows:

3.1 The typical multiple regression equation based on raw scores

Eating behaviors = 31.07 + 0.60 (self-efficacy on eating behaviors) + 0.24

(family support) + 4.95*10-6 (monthly income of family)

- 0.33 (psychological stress).

3.2 The typical multiple regression equation based on Z scores

Zeating behaviors = 0.36 (Zself-efficacy on eating behaviors) + 0.31 (Zfamily support) + 0.24

(Zmonthly income of family) - 0.18 (Zpsychological stress).

Discussion

The findings of this study were discussed as follows:

1. Eating behaviors

In the current study, the most of participants have moderate level of eating

behaviors. The model showed that the highest of Mean % (68.79) was arranging a

meal plan and followed by selecting a healthy diet and amount (Mean % = 56.69).

The lower score of Mean % (48.86) was managing dietary challenges. That is one of

the causes in which T2DM patients have moderate level of eating behaviors, but there

are several other causes, such as the habit of Indonesian people for eating rice in huge

portions and also Indonesian culture for many events or ceremonies. The dietary

management was as recommended by ADA: proportion of 50 % to 60 %

carbohydrates, 30 % fats, and 10 % to 20 % protein for T2DM patients. Further, fiber

and complex carbohydrates become the most important consumption for T2DM

patients because it contains fructose which will lead to significant reduction in fasting

47

blood sugar level, lipid level, and also reduction of body weight in diabetics

(Alexander et al., 2006; Ding & Malik, 2008; International Diabetes Federation,

2012). But for the Indonesian people will find it difficult to replace their habits, where

the majority of Indonesian people did not feel able to eat until they have eaten rice or

some other foods made from rice (Primanda et al., 2011). In traditional Indonesia

culture, Indonesian people often serves foods contain high fat and very sweet for most

of the party, traditional events or ceremonies. This condition often makes the

Indonesian people who have difficulties to manage dietary challenges, especially

outside the home or attending a party. The results of this study showed that

participants in this study had difficulty in choosing a place that can provide a low-fat

dishes and low-cholesterol (M = 1.51, SD = 0.64), and they had a low propensity to

consume vegetables and fruit when outside the home (M = 1.57, SD = 0.62).The

results also found that Indonesian people have inappropriate habit as recommended

for food selection. Participants reported that they are more frequent using any oil for

cooking than vegetable oils, such as sunflower, soybean or saffola oil for cooking

their food (M = 1.66, SD= .44). In addition, many of Indonesian people still apply

bulk oil which actually should have been no longer allowed to be used because it

contains highly saturated fat. Those habits can cause someone get overweight, which

in turn will disrupt the work of organs’ function. The findings of this study is line

with the statement of Yannakoulia (2006), nutrition intervention in T2DM is one of

the parts that integrated with the other treatments and changes in lifestyle associated

with eating behaviors so T2DM patients should increase their awareness about

healthy dietary behaviors, both in understanding the importance of eating behaviors

regarding their condition, including to choose healthy eating behaviors. It is intended

to enable them to achieve a good quality of life.

2. Monthly income of family

In the current study, the majority of participants (70.09 %) have moderate

level of monthly income of family, they earned monthly income of family between

1,500,000-2,500,000 IDR (125 USD-208.33 USD). Total income per month was still

below the minimum district standard of Sidoarjo for years 2015 which is 2,705,000

IDR (225.42 USD) (East Java Provincial Government, 2014). The low income in this

study due to several factors, among others, most of participants were retirees who

48

earn a monthly salary of 1,500,000-2,500,000 IDR. In addition, some of them work as

a pedicab driver and vegetable vendors in the market who earn approximately

750,000-1,500,000 IDR per month. With monthly income of family between

1,500,000-2,500,000 IDR per month, people can meet the needs of the household for

3-4 people, but this number had limitation on the cost of children's education and

health care costs. This is somewhat becomes problem for T2DM patients to adhere

healthy eating behaviors (Central Bureau of Statistics, 2008). According Marcy et al.

(2011), in low-income communities often found the incidence of diabetes is caused by

factors related to the cost of healthy food, stress-related eating inappropriate, and the

temptation to eat unhealthy food.

3. Educational level

The present study shows that the most of participants have high level of

educational. More than a half of participants (55.60 %) completed 12 years for

educational level. Only a few of them completed 9 years (17.90 %) and 6 years

(0.90 %). This relatively high level of education can be achieved by them since it is

already become Indonesian government agenda to state 12 years as the minimum

compulsory education needs. This is evidenced by the budget allocation revenues and

expenditures of the central government which reach146.4 trillion Rupiahs (USD 12.2

billion), that 10.5 % of budget revenues and expenditures allocated for the education

sector (Finance Ministry, 2014). Low educational level is often drive T2DM patients

had difficulty in understanding all the information related to self-management and

making decisions related to eating behaviors, such as food selection and eating

patterns (Mocan & Altindag, 2014).

4. Knowledge of DM eating behaviors

The most of participants have high level of knowledge of DM eating

behaviors. It shows that participants have a good understanding and able to analyze

their needs to continue performing appropriate eating behaviors. High level of

knowledge in this study due to participants already well informed by health worker of

Sidoarjo Community Health Center. Health education on nutrition knowledge is

needed to improve the nutritional knowledge, skills, and food intake behaviors

(Fitzgerald et al., 2008).

49

5. Self-efficacy on eating behaviors

In this study, participants mostly have moderate level of self-efficacy on

eating behaviors. The model shows that participants had been able to choose

appropriate foods for their circumstances (M = 6.81, SD = 0.79), but they had

difficulty in scheduling meal time when in a condition of sick, away from home, and

feeling depressed or anxious (M = 5.64, SD = 1.16; M = 5.64, SD = 0.86; M = 5.61,

SD = 0.87, respectively). Dietary self-efficacy in T2DM patients identified as one of

variables that can affect eating/ dietary behaviors, such as food selection and eating

patterns (Savoca & Miller, 2001).

6. Psychological stress

In this study, the most of participants have moderate distress. There are

several reasons that might contribute to the level of psychological stress among

T2DM patients. The model shows that participants feel that their doctor is still pay

less attention to their problems associated with eating behaviors (M = 3.07, SD =

0.63). Further, this leads participants to give a little concern regarding their health

condition, particularly counseling related to healthy eating behaviors (M = 2.78, SD =

0.69). Additionally by their conditions, participants feel less appreciated by the family

or friends (M = 2.93, SD = 0.58) and also feel that their family or friends provide a

lacking emotional support to them (M = 2.96, SD = 0.76). Patients with diabetes often

have to know about their illness, but they often fail to perform health behaviors

because of stress management and coping less well so that they have difficulty in

establishing patterns of behaviors to solve the problem of diet and exercise therapy

(Nomura et al., 2000).

7. Family support

The most of participants in this study have moderate level of family support.

Family support in this study actually being nice. Other family members tend to

support by giving advice to avoid inappropriate foods for T2DM patients (M = 3.91,

SD = 0.77) and even continuously notice and warn them when they are trying to eat

unsuggested foods for T2DM (M = 3.92, SD = 0.96). In addition, other family

members also show that they understand how important to eat right for T2DM

patients (M = 3.81, SD = 0.91), and they show their pleased when participants eaten

right (M = 3.82, SD = 1.02). But the family members also faced difficulty in buying

50

special foods that can be eaten by T2DM patients (M = 2.80, SD = 1.16) and had

difficulty in choosing a place to eat which accordance with the needs of participants

when they go outside (M = 2.49, SD = 1.09). In addition, some of T2DM patients

living with children who worked from morning until evening, this condition then

leads the children gave them less attention, especially related to healthy eating

behaviors. According Wen et al. (2004), the increasing of family support leads to

decreasing of perceived-barriers toward dietary self-care.This idea comes from their

assumption that the function of the family to support the needs of patients with

diabetes obtained a good quality of life can be fulfilled.

8. Health worker communication

The most of participants in this study assume that health worker

communication in sufficient level. They assume that the way to communicate on the

health worker is good enough and able to provide the information required by T2DM

patients. The model shows that participants felt their need were being respected

(M = 2.82, SD = 0.82) and healthcare provider was able to manage to the consultation

(M = 2.80, SD = 0.63). But on the other hand, participants sometimes also feel that the

information given was not enough and delivered with inappropriate manner or rough

(M = 2.05, SD = 0.51). Sufficient level of health worker communication means that

health workers have good communication skills and able to convey enough

information needed by patients, so there was effective communication between health

workers and patients (Haq & Hafeez, 2009). Ratings of provider communication

effectiveness are more important than a participatory decision-making style in

predicting diabetes self-management (Heisler et al., 2002). Giving the right

information will have a much better effectiveness in improving patient empowerment

in diabetes mellitus in terms of self-management and diabetes patients to modify

lifestyle rather than just involving those in decision making about their care will live

(Lee et al., 2011).

9. Factors predicted eating behaviors

9.1 Self-efficacy on eating behaviors

Self-efficacy on eating behaviors was significant predictor of eating

behaviors. It was asserted that by increasing self-efficacy of T2DM patients then it

would be give a good effect on diabetic self-management, especially eating behaviors.

51

Increasing self-efficacy impacted decision-making process for food selection and

eating patterns and other treatments adherence (Rygg, Rise, Grønning, & Steinbekk,

2012). This finding was consistent with many previous studies. Dietary self-efficacy

in T2DM patients identified as one of variables that can affect eating behaviors, such

as food selection and eating patterns (Savoca & Miller, 2001). The statement was

reinforced by other statements, increasing self-efficacy in T2DM patients will lead to

a good impact in the diabetic self-management behaviors, such as dietary (odds ratio

(OR) = 0.13, 95 % confidence interval (CI): 0.07–0.23), exercise (OR = 0.07, 95 %

CI: 0.03-0.13), blood sugar testing (OR = 0.33, 95 % CI: 0.12-0.91), and taking

medication (OR = 0.09, 95 % CI: 0.03-0.31), so it predicted better glycemic control

(Al-Khawaldeh et al., 2012; Atak et al., 2008).

9.2 Family support

The present study showed that family support predicted eating behaviors.

There are several reason about it, the model showed that the presence of family

support to T2DM patients in the form of advice and criticism would make T2DM

patients more aware of the importance of glycemic control through healthy eating

behaviors. This finding was consistent with many previous studies. Pereira et al.

(2008) found higher family support leads to the higher adherence of treatments (β =

0.226, p < .01) and had good quality of life (β = -0.309, p < .001). On the other hand,

higher family conflict predicts lower quality of life (β = -0.188, p < .05) (Pereira et al.,

2008). According Wen et al. (2004), higher family support should be decreased the

perceived-barriers of T2DM patients to dietary self-care because they assume that the

function of the family to support the needs of T2DM patient obtained a good quality

of life can be fulfilled. Communication and support of families is creating a social

environment that is feasible T2DM patients’ treatments from medical professionals

(Hara et al., 2013).

9.3 Monthly income of family

The result of this study showed that monthly income of family predicted

eating behaviors. Monthly income of family in this study impacted on eating

behaviors among T2DM patients, the model showed that T2DM patients had

inappropriate food selection and their habit of using bulk oil. This finding was

consistent with many previous studies. Family income had direct and indirect impact

52

between eating behaviors and health among T2DM patients (Vlismas et al., 2009).

The statement is reinforced by the statement of Marcy et al. (2011), in low-income

communities often found the incidence of diabetes is caused by factors related to cost

of healthy food, stress-related eating inappropriate, and the temptation to eat

unhealthy food. With low income levels and supported by a low-SES environment

would affect one’s perception of health and it results on health disparities (∆R2 = .02,

F(2, 293) = 3.52, p < .01) (Gallo et al., 2006).

9.4 Psychological stress

In this study, psychological stress as one of factors that predicted eating

behaviors. Psychological stress in this study impacted on eating behaviors among

T2DM patients since it had a strong correlation with the decision-making process for

food selection and eating patterns (Guthrie et al., 2003). This finding was consistent

with previous studies. Symptoms of depression significantly affected eating behaviors

of T2DM patients in a different form based on age, sex, and education for people in

the highest quartile of depressive symptoms (relative hazard [RH], 1.63; 95 % CI,

1.31-2.02) (Golden et al., 2004). Polonsky (2002) found that emotional stress affects

the mindset of patients in decision-making related to health behaviors-diabetes that

further also impact to their quality of life. Patients with diabetes often had to know

about their illness but they often failed to perform health behaviors because of

psychological stress and coping less well so that they had difficulty in establishing

patterns of behaviors to solve the problem of diet (Nomura et al., 2000).

10. Factors unpredicted eating behaviors

10.1 Educational level

Educational level was not a predictor of eating behaviors. The results of

this study is in accordance with some previous researches, which mentioned that the

level of education had limitation impact on health behaviors (Atak et al., 2008; Mocan

& Altindag, 2014). In this study, the model showed that the number of T2DM patients

were more than half completed 12 years for their educational level and 25.60 % of

T2DM patients completed more than 12 years who must be able to manage

information toward eating behaviors so that increasing their awareness of the

importance of healthy eating behaviors, which in this study it is showed at moderate

levels.

53

10.2 Knowledge of DM eating behaviors

Knowledge of DM eating behaviors was not a predictor of eating

behaviors. Eventhough T2DM patients have found out information about healthy

eating behaviors, but they still have limitations to continue performing healthy eating

behaviors due to other factors. This finding was inconsistent with previous studies.

Some researchers even considered the knowledge about healthy eating behaviors is

very important for T2DM patients because they assume that T2DM patients are

expected to remain informed and more critical in assessing the information about their

condition and how to maintain, which in turn will lead to motivate them to change

their behaviors, especially eating behaviors (Hartayu et al., 2012). Health education is

needed to improve the nutritional knowledge, skills, and food intake behaviors due to

prevent increasing number of T2DM in the community (Fitzgerald et al., 2008).

10.3 Health worker communication

Health worker communication was not a predictor of eating behaviors.

Eventhough in general T2DM patients considered health worker communication was

good enough but still they got slightly less favorable treatment which sometimes little

rushed and they also did not get enough counseling related to healthy eating

behaviors. This finding was inconsistent with previous study. Some researchers

considered that the process of providing information by health worker greatly affect

the understanding of the patient in improving their healthy behaviors and also modify

their lifestyle (Heisler et al., 2002; Lee et al., 2011). In the treatment of chronic

diseases such as diabetes mellitus, it is not enough to run medical and drug treatment,

but they should also aware their self-management. Provision of information about the

disease suffered by the patient is the duty for health worker. Ratings of provider

communication effectiveness are more important than a participatory decision-making

style in predicting disease self-management (Heisler et al., 2002).

Implications of the findings

1. Nursing practice

The results of this study, community nurses are expected to make

interventions related how to improve T2DM patients’ self-efficacy, increase family

support for the creation of an atmosphere which aware of T2DM patients situation,

54

and decrease psychological stress that affects the decision-making for food selection.

For monthly income of family, community nurses cannot improve it, but from the

result of this study, community nurses can determine the low income population to be

the main target of nursing intervention.

2. Nursing education

Nurse educators should educate nurse student about the importance of some

factors related to the management of type 2 diabetes mellitus, especially which is

discussing eating behaviors.

Recommendation for future research

1. Sample in this study were limited only T2DM patients who visited the

Sidoarjo Community Health Center and living in Sidoarjo district, therefore future

research should replicate the study in the different setting and in the large areas.

2. This study were limited on seven factors of behaviors (monthly income

of family, educational level, knowledge of DM eating behaviors, self-efficacy on

eating behaviors, psychological stress, family support, and health worker

communication), therefore future research should be adding by other factors

associated with eating behaviors and making interventions.

3. The findings suggested that researchers or nurses can apply the advance

research related to effective interventions or programs associated with increasing

T2DM patients’ self-efficacy, family support, and also decreasing T2DM patients’

psychological stress and make a long term commitment toward healthy eating

behaviors.

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APPENDICES

67

APPENDIX A

Permission letter to use instruments

68

Permission letter to use “Self-Management Dietary Behaviors Questionnaire

(SMDBQ)”

Yanuar Primanda

To Me, andromeda_prim@yahoo.com

4 Agt

Dear Kusuma Wijaya,

I'm so sorry for my late respond. Here I attached the Self-Management Dietary

Behaviors Questionnaire. You can adopt or modify it depend on your need and the

population in the area of your study. Hope that it will useful for your research. Good

luck for your thesis.

Yanuar Primanda, MNS

School of Nursing

Faculty of Medicine and Health Science

Muhammadiyah University Yogyakarta

Mobile:

+62 878 383 05050

+62 821 3553 1188

69

Permission letter to use “Diabetes Knowledge Questionnaire (DKQ)”

Garcia, Alexandra A (agarcia@mail.nur.utexas.edu)

10/10/2014

To: kusuma putra

Dear Kusuma Wijaya Ridi Putra,

Thank you for your interest in the DKQ-24. You are welcome to use the questionnaire

in your research. I believe it has been translated to Indonesian, however, I do not have

a copy of the Indonesian version. Please let me know if you have questions about

scoring or other aspects of its use. Do you already have a copy of the questionnaire

from the Diabetes Care journal? If not, I will be happy to share it with you. You are

welcome to modify the questionnaire for your use. I would very much appreciate it if

you would send me a copy of the modifications and a brief summary of your findings.

Best regards,

Alexandra Garcia

Alexandra Garcia, PhD, RN, FAAN

Associate Professor

The University of Texas at Austin

School of Nursing

1700 Red River

Austin, TX 78701

Office: 5.156, 512/471-7973

Fax: 512/471-3688

70

Permission letter to use “Diabetes Management Self-Efficacy Scale (DMSES)”

Sturt, Jackie

To: kusuma putra

Thank you for your interest in using the DMSES UK. Yes you may use it. I have

attached the scale and the scoring instructions for your use. Good luck with your

project. Yes, you are welcome to do this although there is no supporting data for the

validity or reliability of a sub scale associated with eating behaviours so you might

want to do the psychometric analysis at the same time and establish whether this is

valid and reliable. That would make an additional paper for you if you have enough

participants (roughly 10 participants per item so, for example, if there are 6 dietary

items you would need 60 respondents/participants).

Best wishes

Jackie Sturt

Professor of Behavioural Medicine in Nursing

Florence Nightingale Faculty of Nursing and Midwifery

King's College London

Room 4.30

James Clerk Maxwell Building

57 Waterloo Road

LONDON

SE1 8WA

Tel: 020 7848 3108

Mob 07743190301

Email: jackie.sturt@kcl.ac.uk

www.kcl.ac.uk

71

Permission letter to use “Diabetes Distress Scale (DDS)”

William Polonsky

To Me

Okt 8 pada 11:24 PM

Dear Kusuma,

Yes, you are very welcome to use the DDS in your research. And I wish you very

good luck!

One request: If you are going to be creating a translated version of the DDS, I would

greatly appreciate if you could send me a copy when you are done.

Thanks,

Bill

William H. Polonsky, PhD, CDE | President | Behavioral Diabetes

Institute | Associate Clinical Professor | University of California, San Diego |

760.525.5256

72

Permission letter to use “Diabetes Social Support Questionnaire-Family (DSSQ-

Family)”

Phuntsho Om

To Me

29 Jul

Hello Kusuma,

Happy to know that you are interested to the same topic in your country. You can use

the questionnaire. Hope it brings beneficial changes among the Type 2 Diabetes in

your country.

Cheers.

Phuntsho Om

Associate Lecturer

Royal Institute of Health Sciences

University of Medical Sciences, Thimphu

Bhutan

"For every minute you are angry you lose sixty seconds of happiness.” - Ralph Waldo

Emerson

73

Permission letter to use “Health Care Communication Questionnaire (HCCQ)”

Sommaruga Marinella

10/10/2014

To: kusuma putra

Cc: paola.gremigni2@unibo.it

We give you the permission, Prof. Gremigni will send you some suggestions.

I remain

Marinella Sommaruga

APPENDIX B

Questionnaires (English version)

75

No. of Responden : ……

The date of issue : ……

QUESTIONNAIRE

“FACTORS INFLUENCING EATING BEHAVIORS AMONG TYPE

2 DIABETES MELLITUS PATIENTS IN SIDOARJO

SUB-DISTRICT, EAST JAVA, INDONESIA”

There are several question formats. Please read each question carefully and give the

most honest response you can. No one else will read your answers. There is no time

limit for completing the questionnaire, but it is best to work as quickly as you are

comfortable with. There is no right or wrong answers. Please answer all questions.

Part I: DEMOGRAPHIC DATA

Direction: Please fill out your information in the space below.

1. Gender

Male Female

2. Age ___________ years old

3. Marital status

Single Married Divorced Widow

4. Education level __________ Years

5. Monthly income of the family __________________ Rupiahs

76

Part II: EATING BEHAVIORS QUESTIONNAIRE

Direction: Below are statements about your dietary behaviors to manage your diabetes

during the past month. Please fill the statements by circle in the column which indicates

your usual dietary behaviors. There is no right or wrong answer. If you have any

question, please feel free to ask the person giving you this questionnaire.

Scoring

Positive

Statement

Negative

Statement

Never: Never conduct it at least last whole month 1 4

Sometimes: Once at a time, not habitual 2 3

Often: Repeat the activity for several times, but not

as a habit 3 2

Routinely: Continuously, regularly, and always

conduct the activity 4 1

No Statements Never Some

Times Often Routinely

1

Recognizing the Amount of Calorie

Needs

I am concerned about the best amount of

calorie in foods to be consumed each day.

1 2 3 4

2 …………………………………………

………………………. 1 2 3 4

3 I estimate the amount of calorie in my

food at one meal by using at least one of

the following techniques:

a. Using simple measurements such as

palm or handful.

1 2 3 4

77

No Statements Never Some

Times Often Routinely

b. Measuring the meal using a cup/glass,

gram/ounce, tablespoon/teaspoon, or

serving size.

c. Using plate method (using a 9 inch

plate and divide it into 2 parts. Half part is

for vegetables and the other half is

divided into 2 parts; one for carbohydrate,

and one for food with protein).

4 …………………………………………

…………………… 1 2 3 4

5

Selecting a Healthy Diet+ Amount

When choosing the prepared foods, I

always read the nutrition facts

information on the food label.

1 2 3 4

6 I eat variety of fruits every day for 2-4

servings per day such as:

2 - 4 small to medium apple, guava,

peer, orange, etc

1 - 2 cup canned fruits

4 - 8 tablespoon dried fruits

1 2 3 4

7 …………………………………………

…………………………………………

………………..

1 2 3 4

8 I choose foods containing complex

carbohydrate such as brown rice, peas,

bran, beans, whole wheat/brown bread,

oats, and potatoes.

1 2 3 4

9 …………………………………………

……………………………………. 1 2 3 4

78

No Statements Never Some

Times Often Routinely

10 I avoid high calorie fruit such as jackfruit,

sweet mango, and grape. 1 2 3 4

11 …………………………………………

………………… 1 2 3 4

12 I more often consume baked, boiled, or

steamed foods than the fried ones. 1 2 3 4

13 …………………………………………

………………….. 4 3 2 1

14 I (or the person cooking for food) use

vegetable oil such as sunflower or

soybean or saffola oil to cook.

1 2 3 4

15 …………………………………………

………………. 1 2 3 4

16 I avoid salty food. 1 2 3 4

17 I avoid eating sweets or desert high in

sugar such as fruit cocktail with cream,

cake, pudding, and jam.

1 2 3 4

18 …………………………………….. 1 2 3 4

19 …………………………………………

………………. 4 3 2 1

20 ………………………………… 4 3 2 1

21

Arranging a Meal Plan

I eat 3 meals a day. 1 2 3 4

22 I eat meal in the same time within interval

at least 6 hours every day. 1 2 3 4

23 ……………………….. 4 3 2 1

24 …………………………………… 1 2 3 4

25 I eat various kind of food in every meal

daily including vegetables, whole grains/ 1 2 3 4

79

No Statements Never Some

Times Often Routinely

rice/ bread/ cassava (shingkewa/ potato),

fruits, non-fat dairy products, beans, lean

meats or lean poultry, and fish.

26 I take snack that contain low

carbohydrate and low sugar between meal

such as an apple (medium size), orange/

guava (medium size), tea without sugar,

green tea, orange juice without sugar,

fruits salad without mayonnaise, etc.

1 2 3 4

27

Managing Dietary Challenges

…………………………………………

…………………………………………

………………

1 2 3 4

28 …………………………………………

…………………………………. 1 2 3 4

29 I finish all foods served by the restaurant

although I have been full. 4 3 2 1

30 …………………………………………

……………………………………… 1 2 3 4

31 I eat the same portion of food as my daily

meal in family events or other

invitations/social gathering/parties.

1 2 3 4

32 …………………………………………

…………………………………………

…………………….

1 2 3 4

33 I have candy bar/ sweets with me always,

for hypoglycemia prevention when going

out.

1 2 3 4

80

Part III: KNOWLEDGE OF DM EATING BEHAVIORS

QUESTIONNAIRE

Direction: Please mark a check (√) in the column that best applies to your response.

There is no right or wrong answer. If you have any question, please feel free to ask

the person giving you this questionnaire.

Questions Yes No Don’t know

1. Eating too much sugar and other sweet foods is a

cause of diabetes.

2. ………………………………………………………

3. ……………………………………………………….

………………………………………

4. Only carbohydrates have to be restricted for diabetic

patients.

5. Instant foods or Junk foods have to be restricted for

diabetic patients.

6. ……………………………………………………….

………………………………………

7. Drink coffee or tea no sugar doesn’t have to be

restricted for diabetic patients.

8. ……………………………………….

9. …………………………………………………

10. Sodium doesn’t have to be restricted for diabetic

patients.

11. Fresh vegetables should be consumed by the diabetic

patients.

12. ………………………………………………………

13. Medication is more important than diet and exercise

to control my diabetes.

14. ……………………………………………………….

………………………………………

81

Questions Yes No Don’t know

15. A diabetic diet consists mostly of special foods.

16. ……………………………………………………….

………………………………………

17. ……………………………………………………….

………………………………………

18. The meal plans for diabetes is eat 3 meals a day in

time.

Part IV: SELF-EFFICACY ON EATING BEHAVIORS

QUESTIONNAIRE

Direction: Below is a list of activities you have to perform to manage your diabetes.

Please read each one and then put a line [/] through the number which best describes

how confident you usually are that you could carry out that activity.

For example, if you are completely confident that you are able to check your blood

sugar levels when nessessary, put a line through 10. If you feel that most of the time

you could not do it, put a line through 1 or 2.

I am confident that……..

Cannot do Maybe Yes Certain

At all Maybe no Can do

1. ……………………………………

1 2 3 4 5 6 7 8 9 10

2. I am able to keep my weight under control

1 2 3 4 5 6 7 8 9 10

3. ……………………………………………..

1 2 3 4 5 6 7 8 9 10

4. I am able to follow a healthy eating pattern most of the time

1 2 3 4 5 6 7 8 9 10

5. …………………………………………………………….

1 2 3 4 5 6 7 8 9 10

82

I am confident that……..

Cannot do Maybe Yes Certain

At all Maybe no Can do

6. ……………………………………………………..

1 2 3 4 5 6 7 8 9 10

7. ……………………………………………………………………

1 2 3 4 5 6 7 8 9 10

8. I am able to adjust my eating plan when I am feeling stressed or anxious

1 2 3 4 5 6 7 8 9 10

9. …………………………………………………………….

1 2 3 4 5 6 7 8 9 10

10. I am able to control diabetes complication with healthy eating pattern

1 2 3 4 5 6 7 8 9 10

83

Part V: PSYCHOLOGICAL STRESS QUESTIONNAIRE

Direction: This questionnaire is asking about potential problem areas that participant

may experience. There is no right or wrong answer. If you have any question, please

feel free to ask the person giving you this questionnaire. Give mark a circle on the

scale that you think is appropriate to your condition.

Please note that we are asking you to indicate the degree to which each item may be

bothering you in your life, NOT whether the item is merely true for you. If you feel

that a particular item is not a bother or a problem for you, you would circle "1". If it

is very bothersome to you, you might circle "6".

Not

a P

rob

lem

A S

ligh

t P

rob

lem

A M

od

erate

Pro

ble

m

Som

ewh

at

Ser

iou

s P

rob

lem

A S

erio

us

Pro

ble

m

A V

ery S

eri

ou

s

Pro

ble

m

1. Feeling that my doctor

doesn't know enough about

diabetes and diabetes care.

1 2 3 4 5 6

2. ………………………………

………………………………

………………………………

………………

1 2 3 4 5 6

3. Not feeling confident in my

day-to-day ability to manage

diabetes.

1 2 3 4 5 6

4. ………………………………

………………………………

……………………….

1 2 3 4 5 6

5. Feeling that my doctor

doesn't give me clear enough 1 2 3 4 5 6

84

Not

a P

rob

lem

A S

ligh

t P

rob

lem

A M

od

erate

Pro

ble

m

Som

ewh

at

Ser

iou

s P

rob

lem

A S

erio

us

Pro

ble

m

A V

ery S

eri

ou

s

Pro

ble

m

directions on how to manage

my diabetes.

6. Feeling that I am not testing

my blood sugars frequently

enough.

1 2 3 4 5 6

7. ………………………………

………………………………

………………………………

……………………

1 2 3 4 5 6

8. ………………………………

………………………… 1 2 3 4 5 6

9. Feeling that friends or family

are not supportive enough of

self-care efforts (e.g. planning

activities that conflict with

my schedule, encouraging me

to eat the "wrong" foods).

1 2 3 4 5 6

10. ………………………………

…………………. 1 2 3 4 5 6

11. Feeling that my doctor

doesn't take my concerns

seriously enough.

1 2 3 4 5 6

12. ………………………………

………………………………

……………….

1 2 3 4 5 6

85

Not

a P

rob

lem

A S

ligh

t P

rob

lem

A M

od

erate

Pro

ble

m

Som

ewh

at

Ser

iou

s P

rob

lem

A S

erio

us

Pro

ble

m

A V

ery S

eri

ou

s

Pro

ble

m

13. Feeling overwhelmed by the

demands of living with

diabetes.

1 2 3 4 5 6

14. Feeling that I don't have a

doctor who I can see

regularly enough about my

diabetes.

1 2 3 4 5 6

15. ………………………………

………………………………

……………………..

1 2 3 4 5 6

16. ………………………………

………………………………

…………………………….

1 2 3 4 5 6

Part VI: FAMILY SUPPORT QUESTIONNAIRE

Direction: We just want to know how often your family provide help and support

your diabetes. There is no right or wrong answer. Just mark a circle in the column that

best applies to your response.

How often

does this

happen?

0 1 2 3 4 5

Never

Less than

twice a

month

Twice a

Month

Once a

Week

Several

Times a

Week

At Least

Once a

Day

Note: If a behavior listed never happens, mark circle“0” for “never”.

86

No. Statements

Nev

er

Les

s th

an

2 t

imes

a

mon

th

Tw

ice

a m

on

th

On

ce a

wee

k

Sev

eral

tim

es a

wee

k

At

least

on

ce a

day

1. ………………………………

………………………… 0 1 2 3 4 5

2.

Let me know they understand

how important it is for me to eat

right.

0 1 2 3 4 5

3.

Ask if certain foods are okay

for me to eat, before serving

them.

0 1 2 3 4 5

4. ………………………………

………………………… 0 1 2 3 4 5

5. ………………………………

………………………… 0 1 2 3 4 5

6. ………………………………

………………………… 0 1 2 3 4 5

7. Suggest foods I can eat on my

meal plan. 0 1 2 3 4 5

8. ………………………………

………………………… 0 1 2 3 4 5

9. ………………………………

………………………… 0 1 2 3 4 5

10. ………………………………

………………………… 0 1 2 3 4 5

11. Watch what I eat to make sure

that I eat the right foods. 0 1 2 3 4 5

87

No. Statements

Nev

er

Les

s th

an

2 t

imes

a

mon

th

Tw

ice

a m

on

th

On

ce a

wee

k

Sev

eral

tim

es a

wee

k

At

least

on

ce a

day

12. Cook meals for me that fit my

meal plan. 0 1 2 3 4 5

13. ………………………………

………………………… 0 1 2 3 4 5

14. Eat at the same time I do 0 1 2 3 4 5

15. ………………………………

………………………… 0 1 2 3 4 5

16. ………………………………

………………………… 0 1 2 3 4 5

17. ………………………………

………………………… 0 1 2 3 4 5

18. Keep track of my meal plan for

me. 0 1 2 3 4 5

19. Buy special foods that I can eat. 0 1 2 3 4 5

20. Tell me not to eat something I

shouldn't. 0 1 2 3 4 5

88

Part VII: HEALTH WORKER COMMUNICATION

QUESTIONNAIRE

Direction: Please mark a circle in the column that best applies to your response.

There is no right or wrong answer. If you have any question, please feel free to ask

the person giving you this questionnaire. This questionnaire concerns your experience

with the healthcare provider you have just encountered. If you think healthcare

provider had good communication, mark circle completely (5).

No. Statement

Not

at

all

A l

ittl

e

Som

e w

hat

Ver

y m

uch

Com

ple

tely

1. …………………………………………………

……………………………………. 1 2 3 4 5

2. I felt my needs were being respected 1 2 3 4 5

3. ……………………………………………… 1 2 3 4 5

4. I was asked questions in an aggressive manner 1 2 3 4 5

5. I received clear and precise information 1 2 3 4 5

6. …………………………………………………

……………………………………. 1 2 3 4 5

7. I have been treated with kindness 1 2 3 4 5

8. I have been treated in a rude and hasty manner 1 2 3 4 5

9. …………………………………………………

……………………………………. 1 2 3 4 5

10. …………………………………………………

……………………………………. 1 2 3 4 5

11. The healthcare provider was able to manage

the consultation 1 2 3 4 5

12. …………………………………………………

……………………………………. 1 2 3 4 5

89

No. Statement

Not

at

all

A l

ittl

e

Som

e w

hat

Ver

y m

uch

Com

ple

tely

13. The healthcare provider showed respect for my

privacy 1 2 3 4 5

APPENDIX C

Questionnaires (Indonesian version)

91

No. Responden : ……

Tanggal pengisian : ……

KUESIONER

“FACTOR YANG MEMPENGARUHI PERILAKU MAKAN PADA

PASIEN DIABETES MELLITUS TIPE 2 di KECAMATAN

SIDOARJO, JAWA TIMUR, INDONESIA”

Ada beberapa format pertanyaan. Silakan baca setiap pertanyaan dengan hati-hati dan

berikan respon yang paling jujur yang Anda bisa. Tidak ada orang lain akan membaca

jawaban Anda. Tidak ada batas waktu untuk menyelesaikan kuesioner, tapi yang

terbaik adalah untuk bekerja secepat yang Anda bisa dan merasa nyaman dengan itu.

Tidak ada jawaban benar atau salah. Silahkan menjawab semua pertanyaan.

Bagian I: DATA DEMOGRAFI

Petunjuk: Silahkan mengisi informasi anda dibawah ini.

1. Jenis Kelamin

Laki-laki Perempuan

2. Usia _______ tahun

3. Status pernikahan

Belum menikah Menikah Bercerai Janda/Duda

4. Level pendidikan ______ tahun

5. Pendapatan keluarga tiap bulan __________________Rupiah

92

Bagian II: KUESIONER PERILAKU MAKAN

Petunjuk: Di bawah ini adalah pernyataan tentang perilaku makan anda untuk

mengelola diabetes anda selama sebulan terakhir. Silahkan mengisi pernyataan tanda

(√) pada kolom yang menunjukkan perilaku makan anda yang biasa. Tidak ada

jawaban yang benar atau salah. Jika anda memiliki pertanyaan, jangan ragu untuk

bertanya kepada orang memberikan kuesioner ini.

­ Tidak pernah: Tidak pernah melakukannya paling sedikit sebulan penuh

terakhir

­ Kadang-kadang: Sekali waktu, bukan kebiasaan

­ Seringkali: Mengulangi kegiatan selama beberapa waktu, tetapi bukan sebagai

suatu kebiasaan

­ Secara rutin: Terus menerus, secara berkala, dan selalu dilakukan

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

1

Mengenali jumlah kebutuhan kalori

Saya memperhatikan jumlah terbaik kalori

dalam makanan untuk dikonsumsi setiap hari.

2 …………………………………………………

…………………………………………

3 Saya memperkirakan jumlah kalori makanan

yang saya konsumsi dalam satu kali makan

dengan menggunakan teknik-teknik berikut :

a. Menggunakan takaran sederhana seperti

sekepal atau segenggam.

b. Menakar makanan dengan menggunakan

satu cangkir /gelas, gram/ons, sendok

makan/ sendok teh, atau seukuran saji.

93

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

c. Menggunakan metode piring (menggunakan

piring diameter 9 inci dan membaginya dalam

2 bagian. Separuh bagian untuk sayuran dan

separuh bagian lainnya dibagi dalam 2 bagian

lagi; satu bagian untuk makanan

berkarbohidrat, dan satu bagian lainnya untuk

makanan berprotein).

4 …………………………………………………

…………………………………

5

Pemilihan Diet Sehat + Jumlah

Saat memilih makanan yang disajikan, saya

selalu membaca informasi fakta kandungan

nutrisi pada label makanan.

6 Saya makan bermacam-macam buah setiap hari

sebanyak 2 - 4 penyajian seperti:

a. 2 - 4 apel, jambu merah, pir, jeruk, dll.

ukuran kecil hingga sedang

b. 1 - 2 cangkir buah-buahan kaleng

c. 4 - 8 sendok makan buah-buahan kering

7 …………………………………………………

…………………………………………………

……………….

8 Saya memilih makanan yang mengandung

karbohindrat kompleks seperti beras merah,

kacang polong, bekatul, buncis, gandum utuh

94

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

/brown bread (roti tawar dari biji gandum

utuh), gandum, dan kentang.

9 …………………………………………………

…………………………………………………

…………………….

10 Saya menghindari buah-buahan berkalori

tinggi seperti: nangka, mangga manis, dan

anggur.

11 …………………………………………………

……………………………………………

12 Saya lebih sering mengkonsumsi makanan

yang di-oven, direbus atau dikukus dibanding

makanan yang digoreng.

13 …………………………………………………

…………………………………..

14 Saya (atau tukang masak saya) menggunakan

minyak sayur seperti minyak bunga matahari

atau kacang kedelai atau saffola untuk

memasak

15 …………………………………………………

…………………………………………………

…………………………….

16 Saya menghindari makanan bergaram

17 Saya menghindari makanan manis-manis atau

makanan penutup yang sangat tinggi gula,

95

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

seperti koktail buah dengan krim, roti (cake),

puding dan selai.

18 ………………………………………..

19 …………………………………………………

…………………………………………………

…………………

20 ………………………….

21

Pengaturan Jadwal Makan

Saya makan 3 kali sehari.

22 Saya makan dalam waktu yang sama dalam

interval (jeda waktu) paling sedikit 6 jam setiap

hari.

23 …………………………………

24 …………………………………..

25 Saya makan berbagai jenis makanan dalam

satu kali makan, termasuk sayuran, gandum

utuh/ nasi/ roti tawar/ ketela (shing

kewa/kentang), buah-buahan, produk susu

tanpa lemak, buncis, daging tanpa lemak atau

daging unggas tanpa lemak, dan ikan.

26 Saya makan kudapan rendah karbohidrat dan

rendah gula diantara jam makan seperti apel

96

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

(ukuran sedang), jeruk/ jambu merah (ukuran

sedang), teh tanpa gula, teh hijau, jus jeruk

tanpa gula, salad buah-buahan tanpa

mayonnaise, dll.

27

Pengelolaan Tantangan Diet

…………………………………………………

…………………………………………………

…………………..

28 …………………………………………………

…………………………………………………

………………..

29 Saya menghabiskan semua makanan yang

disajikan oleh restoran meskipun sudah

kenyang.

30 …………………………………………………

…………………………………………………

…………………

31 Saya makan makanan dalam porsi yang sama

seperti porsi makan saya sehari-hari saat ada

acara keluarga atau undangan acara lain/

perkumpulan sosial/ pesta-pesta.

32 …………………………………………………

…………………………………………………

…………………

97

No Pernyataan-Pernyataan

Tid

ak

per

nah

Kad

an

g-k

ad

an

g

Ser

ingk

ali

Sec

ara

ru

tin

33 Saya selalu membawa batangan permen/gula-

gula untuk mencegah hypoglycemia

(rendahnya kadar gula darah) saat bepergian

Bagian III: KUESIONER PENGETAHUAN DARI PERILAKU

MAKAN DM

Petunjuk: Silahkan mengisi pernyataan tanda (√) pada kolom yang menunjukkan

perilaku makan anda yang biasa. Tidak ada jawaban yang benar atau salah. Jika anda

memiliki pertanyaan, jangan ragu untuk bertanya kepada orang memberikan

kuesioner ini.

Pertanyaan-Pertanyaan Ya Tidak Tidak

tahu

1. Makan terlalu banyak gula dan makanan-makanan

manis lain merupakan penyebab diabetes.

2. ……………………………………………………...

……………………………………………………...

3.

……………………………………………………...

……………………………………………………...

……………………………………………………...

4. Hanya karbohidrat yang harus dibatasi untuk para

penderita diabetes.

5. Makanan-makanan instan atau Junk foods (makanan

sampah) harus dibatasi untuk para penderita diabetes.

6. ……………………………………………………...

……………………………………………………...

98

Pertanyaan-Pertanyaan Ya Tidak Tidak

tahu

7. Minum kopi atau teh tanpa gula tidak harus dibatasi

untuk para penderita diabetes.

8. ……………………………………………………...

9. ……………………………………………………...

……………………………………………………...

10. Sodium tidak harus dibatasi untuk para penderita

diabetes.

11. Sayur-sayuran segar harus dikonsumsi oleh para

penderita diabetes.

12. ……………………………………………………...

……………………………………………………...

13. Pengobatan lebih penting daripada diet dan olah raga

untuk mengontrol diabetes saya.

14. ……………………………………………………...

……………………………………………………...

15. Diet diabetes banyak yang berupa makanan-makanan

khusus

16. ……………………………………………………...

……………………………………………………...

17.

……………………………………………………...

……………………………………………………...

……………………………………………………...

18. Jadwal makan untuk penderita diabetes adalah makan

tepat waktu 3 kali sehari.

99

Bagian VI: KUESIONER KEMAMPUAN MENGENDALIKAN

DIRI PADA PERILAKU MAKAN

Petunjuk: Di bawah ini adalah daftar kegiatan yang harus Anda lakukan untuk

mengelola diabetes Anda. Silakan baca masing-masing dan kemudian menempatkan

garis [/] melalui nomor yang paling menggambarkan seberapa yakin Anda biasanya

bahwa Anda bisa melakukan kegiatan itu.

Sebagai contoh, jika Anda benar-benar yakin bahwa Anda dapat memeriksa kadar

gula darah Anda saat nessessary, menempatkan garis melalui 10. Jika Anda merasa

bahwa sebagian besar waktu Anda tidak bisa melakukannya, membuat garis melalui 1

atau 2.

Saya percaya bahwa ……..

Tidak bisa Sama sekali Mungkin ya

Mungkin tidak Pasti Bisa

1. ………………………………..

1 2 3 4 5 6 7 8 9 10

2. Saya bisa menjaga berat badan

1 2 3 4 5 6 7 8 9 10

3. ……………………………………………….

1 2 3 4 5 6 7 8 9 10

4. Saya hampir selalu bisa mengikuti pola makan sehat

1 2 3 4 5 6 7 8 9 10

5.

………………………………………………………………………….

……………………………...

1 2 3 4 5 6 7 8 9 10

6. ……………………………………………………...

1 2 3 4 5 6 7 8 9 10

7.

………………………………………………………………………….

……………………………...

1 2 3 4 5 6 7 8 9 10

8. Saya bisa menyesuaikan jadwal makan saat merasa tertekan atau gelisah

1 2 3 4 5 6 7 8 9 10

100

Tidak bisa Sama sekali Mungkin ya

Mungkin tidak Pasti Bisa

9. ………………………………………………………………………

1 2 3 4 5 6 7 8 9 10

10. Saya bisa mengontrol komplikasi diabetes dengan pola makan sehat

1 2 3 4 5 6 7 8 9 10

Bagian V: KUESIONER TEKANAN PSIKOLOGIS

Petunjuk: Kuesioner ini menanyakan tentang perasaan, pikiran, dan cara-cara untuk

mengatasi masalah yang Anda hadapi selama sebulan terakhir. Tidak ada jawaban

benar atau salah. Jika Anda memiliki pertanyaan, jangan ragu untuk bertanya kepada

orang memberikan kuesioner ini. Beri tanda lingkaran pada skala yang anda anggap

sesuai dengan kondisi Anda.

Harap dicatat bahwa kami meminta Anda untuk menunjukkan sejauh mana setiap

item dapat mengganggu Anda dalam hidup Anda, tidak apakah item tersebut hanya

berlaku untuk Anda. Jika Anda merasa bahwa barang tertentu tidak mengganggu atau

masalah bagi Anda, saudara harus melingkari "1". Jika sangat mengganggu bagi

Anda, Anda mungkin lingkaran "6".

Bu

kan

masa

lah

Ag

ak

sed

ikit

masa

lah

Ber

masa

lah

tin

gk

at

sed

an

g

Ag

ak

sed

ikit

ber

masa

lah

ser

ius

Masa

lah

Ser

ius

Ma

sala

h y

an

g

san

gat

seri

us

1. Merasa dokter saya tidak

cukup mengetahui seluk

beluk dan perawatan diabetes.

1 2 3 4 5 6

2. ………………………………

………………………………

………………………………

……………………………

1 2 3 4 5 6

101

Bu

kan

masa

lah

Agak

sed

ikit

masa

lah

Ber

masa

lah

tin

gk

at

sed

an

g

Agak

sed

ikit

ber

masa

lah

ser

ius

Masa

lah

Ser

ius

Masa

lah

yan

g

san

gat

seri

us

3. Saya tidak merasa percaya

diri bisa mengatasi penyakit

diabetes ini dari hari ke hari.

1 2 3 4 5 6

4. ………………………………

………………………………

………………………………

…………………...

1 2 3 4 5 6

5. Saya merasa dokter tidak

cukup memberi pengarahan

yang jelas mengenai cara

menangani diabetes saya.

1 2 3 4 5 6

6. Saya merasa tidak cukup

sering mengetes gula darah

saya

1 2 3 4 5 6

7. ………………………………

………………………………

………………………………

………………………………

………………….

1 2 3 4 5 6

8. ………………………………

………………………………

……………………

1 2 3 4 5 6

9. Saya merasa teman-teman

atau keluarga tidak cukup

mendukung usaha perawatan

mandiri (misalnya

1 2 3 4 5 6

102

Bu

kan

masa

lah

Agak

sed

ikit

masa

lah

Ber

masa

lah

tin

gk

at

sed

an

g

Agak

sed

ikit

ber

masa

lah

ser

ius

Masa

lah

Ser

ius

Masa

lah

yan

g

san

ga

t se

riu

s

merencanakan kegiatan-

kegiatan yang bertentangan

dengan jadwal saya,

mendorong saya untuk makan

makanan-makanan yang

"salah").

10. ………………………………

………………………………

…………………..

1 2 3 4 5 6

11. Saya merasa dokter tidak

cukup serius memperhatikan

masalah saya.

1 2 3 4 5 6

12. ………………………............

................................................

..............................

1 2 3 4 5 6

13. Saya merasa kewalahan

dengan tuntutan-tuntutan

yang harus dipatuhi penderita

diabetes.

1 2 3 4 5 6

14. Saya merasa tidak memiliki

dokter yang bisa saya temui

secara teratur untuk

mengkonsultasikan diabetes

saya

1 2 3 4 5 6

103

Bu

kan

masa

lah

Agak

sed

ikit

masa

lah

Ber

masa

lah

tin

gk

at

sed

an

g

Agak

sed

ikit

ber

masa

lah

ser

ius

Masa

lah

Ser

ius

Masa

lah

yan

g

san

gat

seri

us

15. ………………………………

………………………………

………………………………

………………….

1 2 3 4 5 6

16. ………………………………

………………………………

………………………………

…………………

1 2 3 4 5 6

Bagian VI: KUESIONER DUKUNGAN KELUARGA

Petunjuk: Kami hanya ingin tahu seberapa sering keluarga Anda memberikan

bantuan dan dukungan diabetes Anda. Tidak ada jawaban benar atau salah. Hanya

menandai lingkaran pada kolom yang paling berlaku untuk respons Anda.

Seberapa

sering hal

ini

terjadi?

0 1 2 3 4 5

Tak

Pernah

Kurang

dari 2

kali

dalam

sebulan

Dua kali

dalam

sebulan

Sekali

dalam

seminggu

Beberapa

kali

dalam

seminggu

Palings

sedikit

sekali

sehari

Catatan: Jika perilaku terdaftar pernah terjadi, tanda lingkaran "0" untuk

"tidak pernah".

104

No. Pernyataan-Pernyataan

Tid

ak

per

nah

Ku

ran

g d

ari

2 k

ali

dala

m s

ebu

lan

Du

a k

ali

dala

m

seb

ula

n

Sek

ali

dala

m

sem

inggu

Beb

erap

a k

ali

dala

m s

emin

ggu

Pali

ngs

sed

ikit

sek

ali

seh

ari

1. …………………………………

………………………………… 0 1 2 3 4 5

2.

Memberitahu saya bahwa

mereka mengerti betapa

pentingnya saya untuk makan

dengan benar

0 1 2 3 4 5

3.

Bertanya apakah makanan-

makanan tertentu bisa saya

makan, sebelum menyajikan

makanan yang dimaksud.

0 1 2 3 4 5

4. …………………………………

………………………………… 0 1 2 3 4 5

5. …………………………………

………………………………… 0 1 2 3 4 5

6. …………………………………

………………………………… 0 1 2 3 4 5

7.

Menyarankan makanan-

makanan yang bisa saya makan

dalam jadwal makan saya.

0 1 2 3 4 5

8. …………………………………

………………………………… 0 1 2 3 4 5

9. …………………………………

………………………………… 0 1 2 3 4 5

10.

…………………………………

…………………………………

…………………………………

0 1 2 3 4 5

105

No. Pernyataan-Pernyataan

Tid

ak

per

nah

Ku

ran

g d

ari

2 k

ali

dala

m s

ebu

lan

Du

a k

ali

dala

m

seb

ula

n

Sek

ali

dala

m

sem

inggu

Beb

erap

a k

ali

dala

m s

emin

ggu

Pali

ngs

sed

ikit

sek

ali

seh

ari

11.

Mengawasi apa yang saya

makan untuk meyakinkan

bahwa saya makan makanan

sehat

0 1 2 3 4 5

12.

Memasak makanan untuk saya

yang sesuai dengan jadwal

makanan saya.

0 1 2 3 4 5

13.

…………………………………

…………………………………

…………………………………

0 1 2 3 4 5

14. Makan pada waktu yang sama

dengan saya. 0 1 2 3 4 5

15. …………………………………

………………………………… 0 1 2 3 4 5

16.

…………………………………

…………………………………

…………………………………

0 1 2 3 4 5

17.

…………………………………

…………………………………

…………………………………

0 1 2 3 4 5

18. Menjaga jadwal makan saya 0 1 2 3 4 5

19. Membeli makanan khusus yang

bisa saya makan. 0 1 2 3 4 5

20.

Menasihati saya untuk tidak

makan makanan pantangan

saya.

0 1 2 3 4 5

106

Bagian VII: KUISIONER KOMUNIKASI PEKERJA KESEHATAN

Petunjuk: Tandai lingkaran di kolom yang paling berlaku untuk respons Anda. Tidak

ada jawaban benar atau salah. Jika Anda memiliki pertanyaan, jangan ragu untuk

bertanya kepada orang memberikan kuesioner ini. Kuesioner ini menyangkut

pengalaman Anda dengan penyedia layanan kesehatan Anda baru saja mengalami.

Jika Anda berpikir penyedia layanan kesehatan memiliki komunikasi yang baik, tanda

lingkaran sepenuhnya (5).

No. Pernyataan

Tid

ak

sam

a

sek

ali

Sed

ikit

Agak

San

gat

Ben

ar-

ben

ar

1. ……………………………………………...

……………………………………………... 1 2 3 4 5

2. Saya merasa kebutuhan-kebutuhan saya

dihormati 1 2 3 4 5

3. ……………………………………………... 1 2 3 4 5

4. Saya diberi pertanyaan secara kasar 1 2 3 4 5

5. Saya menerima informasi dengan jelas dan

tepat 1 2 3 4 5

6. ……………………………………………... 1 2 3 4 5

7. Saya diperlakukan dengan baik 1 2 3 4 5

8. Saya diperlakukan kasar dan terburu-buru 1 2 3 4 5

9. ……………………………………………...

……………………………………………... 1 2 3 4 5

10. ……………………………………………...

……………………………………………... 1 2 3 4 5

11. Penyedia perawatan kesehatan menguasai

pembahasan konsultasi 1 2 3 4 5

12. ……………………………………………...

……………………………………………... 1 2 3 4 5

107

No. Pernyataan

Tid

ak

sam

a

sek

ali

Sed

ikit

Agak

San

gat

Ben

ar-

ben

ar

13.

Penyedia perawatan kesehatan

menunjukkan rasa hormat pada kehidupan

pribadi saya

1 2 3 4 5

APPENDIX D

Additional analysis

109

Table 6 Description of items of eating behaviors (n = 117).

Item M SD Range = 1 - 4

Recognizing the amount of calorie needs (Total score = 16, M = 8.97, SD = 2.28)

1. The best amount of calorie in foods

to consumed each day

2.32 0.59

2. The same portion size of food every

day

2.30 0.80

3. The amount of calorie in my food at

one meal by using at least one of the

techniques

2.18 0.64

4. The calories of food estimated every

day

2.16 0.67

Selecting a healthy diet and amount (Total score = 64, M = 36.28, SD = 4.87)

5. Reading the nutrition facts

information on the food label

1.90 0.64

6. Eat variety of fruits every day for 2-4

servings per day

2.21 0.45

7. Eat variety of vegetables every day

for 3-5 servings of cooked vegetables

per day

2.54 0.52

8. Choosing foods containing complex

carbohydrate

2.57 0.63

9. Avoid foods that contain high

cholesterol

2.16 0.44

10. Avoid high calorie fruit 2.13 0.41

11. Use artificial sweeteners 1.70 0.59

12. More often consume baked, boiled,

or steamed foods

2.03 0.51

13. Use any oil in cooking 1.89 0.54

110

Table 6 (Continued)

Item M SD Range = 1 - 4

14. Use vegetable oils 1.43 0.58

15. Take fish and soy protein more

often than poultry or red meat

2.62 0.59

16. Avoid salty food 2.32 0.61

17. Avoid eating sweets or desert in

high sugar

2.08 0.51

18. Choose non-fat or low-fat milk 2.27 0.89

19. Eat the meat with fat rather than

remove the fatty part

2.49 0.84

20. Drink alcohol 3.93 0.25

Arranging a meal plans (Total score = 24, M = 16.51, SD = 1.92)

21. Eat 3 meals a day 3.26 0.52

22. Eat meal in the same time within

interval 6 hours

2.11 0.43

26. Take snack that contain low

carbohydrate and low sugar between

meal

2.26 0.49

Managing dietary challenges (Total score = 28, M = 13.68, SD = 2.82)

27. Select a restaurant that serves

appropriate foods

1.51 0.64

28. Order food to include vegetables

and fruits during dining out

1.57 0.62

29. Finish all food served by the

restaurant although have been full

2.55 0.58

30. Order foods in the same portion as

daily meal when eat out in

restaurants

1.92 0.62

31. Eat the same portion of food as 1.93 0.75

111

Table 6 (Continued)

Item M SD Range = 1 - 4

daily meal in family events, other

invitations/social gathering/parties

1.93 0.75

32. Do exercise rather than taking

food when feel stress or depressed

2.50 0.69

33. Have candy bar/sweets for

hypoglycemia prevention when

going out

1.70 0.69

Table 7 Description of items of self-efficacy on eating behaviors (n = 117).

Item M SD Range = 1 - 10

1. Able to choose the correct foods 6.81 0.79

2. Able to keep weight under control 6.40 0.91

3. Able to adjust eating plan when ill 5.64 1.16

4. Able to follow a healthy eating pattern

most of time

6.38 0.79

5. Able to adjust eating plan when taking

more exercise

5.71 0.76

6. Able to follow a healthy pattern when

away from home

5.64 0.86

7. Able to follow a healthy eating pattern

when eating out or at party

5.71 0.95

8. Able to adjust eating plan when feeling

stressed or anxious

5.61 0.87

9. Able to control blood sugar with

healthy eating pattern

6.51 0.82

10. Able to control diabetes complication

with healthy eating pattern

6.47 0.75

112

Table 8 Description of items of psychological stress (n = 117)

Item M SD Range = 1 - 6

1. Feeling that doctor doesn't

know enough about diabetes

and diabetes care

2.79 0.76

2. Feeling that diabetes is taking

up too much of mental and

physical energy everyday

2.74 0.67

3. Not feeling confident in day to

day ability to manage diabetes

2.55 0.55

4. Feeling that doctor doesn't give

clear enough directions on how

to manage diabetes

2.81 0.75

5. Feeling that not testing blood

sugars frequently enough

2.66 0.73

6. Feeling that will end up with

serious long-term complication,

no matter what to do

2.39 0.57

7. Feeling that often failing with

diabetes routine

2.62 0.67

8. Feeling that friends or family

are not supportive enough of

self-care effort

2.34 0.58

9. Feeling that diabetes controls

life

2.59 0.65

10. Feeling that doctor doesn't take

concerns seriously enough

3.07 0.63

11. Feeling that not sticking closely

enough to a good meal plan

2.44 0.64

113

Table 8 (Continued)

Item M SD Range = 1 - 6

12. Feeling that friends or family

don’t appreciate how difficult

living with diabetes can be

2.93 0.58

13. Feeling overwhelmed by the

demands of living with diabetes

2.58 0.73

14. Feeling that don't have a doctor

who can see regularly enough

about diabetes

2.78 0.69

15. Not feeling motivated to keep

up diabetes self-management

2.78 0.68

16. Feeling that friends or family

don’t give emotional support

2.96 0.76

Table 9 Description of items of family support (n = 117)

Item M SD Range = 0 - 5

1. Encourage to eat the right foods 3.74 0.91

2. Let me know they understand

how important to eat right for

me

3.81 0.91

3. Ask if certain foods are okay to

eat, before serving

3.51 1.09

4. Do the grocery shopping for

meals

2.50 1.19

5. Schedule meals at the times

need to eat

3.37 1.14

114

Table 9 (Continued)

Item M SD Range = 0 - 5

6. Remind about sticking to meal

plan

3.68 0.89

7. Suggest foods can eat on meal

plan

3.57 1.06

8. Join eating the same foods 3.16 1.25

9. Get on my case after I ate

something I shouldn’t

3.92 0.96

10. Avoid tempting me with food or

drinks that I shouldn’t have

3.78 1.04

11. Watch what foods consumption

to make sure for the right foods

3.42 1.15

12. Cook meals that fit for meal

plan

3.68 1.17

13. Choose restaurants that serve

appropriate foods

2.49 1.09

14. Eat at the same time 2.87 0.82

15. Praise for following diet 3.52 1.03

16. Tell me when I've eaten too

much or too little

3.62 0.97

17. Show they're pleased when

eaten right

3.82 1.02

18. Keep track of meal plan 3.41 0.94

19. Buy appropriate foods 2.80 1.16

20. Tell me not to eat something I

shouldn’t

3.91 0.77

115

Table 10 Description of items of health worker communication (n = 117)

Item M SD Range = 1 - 5

1. The healthcare provider do eyes

contact when doing

communication

2.61 0.79

2. Felt the needs were being

respected

2.82 0.82

3. Asked questions in a clear

manner

2.73 0.75

4. Asked questions in an

aggressive manner

2.09 0.55

5. Received clear and precise

information

2.63 0.65

6. Have been given answers in an

aggressive manner

2.05 0.51

7. Have been treated with kindness 2.68 0.59

8. Have been treated in a rude and

hasty manner

2.09 0.57

9. The healthcare provider

addressed with a smile

2.77 0.77

10. The healthcare provider was

able to resolve the problem

2.72 0.63

11. The healthcare provider was

able to manage the consultation

2.80 0.63

12. The healthcare provider showed

to be able to stay calm

2.73 0.63

13. The healthcare provider showed

respect for privacy

2.71 0.67

APPENDIX E

Institutional review board approval

117

APPENDIX F

Recommendation letter for data collection

119

APPENDIX G

Certificate of completing the research

121

APPENDIX H

Participants’ information sheet and consent form

123

PARTICIPANT’S INFORMATION SHEET

Dear …………………………………..

I am Kusuma Wijaya Ridi Putra a graduate student at the Faculty of Nursing,

Burapha University Thailand. My study entitled, “Factors Influencing Eating

Behaviors among Type 2 Diabetes Mellitus in Sidoarjo Sub-district, East Java,

Indonesia”. The objective are to describe and examine the influences of eating

behaviors, income, education level, knowledge, self-efficacy, psychological stress,

family support and health worker communication of 117 adults with type 2 diabetes

mellitus who living in Sidoarjo Sub-district and visited the Sidoarjo Community

Health Center for follow up.

If you agree to participate in this study, you will be asked to complete the self-

report questionnaires. It will take you about 20-30 minutes to complete the

questionnaires. There are no identified risks involved with participation in this study.

Participation is voluntary. You have the right to end your participation in this study at

any time without any penalty. Any information received from this study, including

your identity, will be kept confidential. A coding number will be assigned to you and

your name will not used. Findings from the study will be presented as a group of

participants and no specific information from any individual participant will be

disclosed. All data will be destroyed completely within 1 year after publishing or

presenting the findings. You will receive a further and deeper explanation of the

nature of the study upon its completion, if you wish.

The research will be conducted by Kusuma Wijaya Ridi Putra under

supervision of my major-advisor, Assist. Prof. Dr. Chanandchidadussadee Toonsiri. If

you have any questions, please contact me at # telephone: 081331251929 or by email:

tiwix_kusuma@yahoo.co.id, and/or my advisor’s e-mail address:

stoonsiri@hotmail.com. Your cooperation is greatly appreciated. You will be given a

copy of this consent form to keep.

Kusuma Wijaya Ridi Putra

124

INFORMED CONSENT

Title: “Factors influencing eating behavior among type 2 diabetes mellitus

patients in Sidoarjo sub-district, East Java, Indonesia”.

Date of collection data ……………Month ………….Years………………

Before giving my signature below, I have been clearly explained by the

researcher, Mr. Kusuma Wijaya Ridi Putra, about purpose, method, procedures,

benefits and possible risk associated with participation in this study, and I understood

all of that explanation.

I agree to participate in this research project and I have received a copy of this

form.

I, Ms. / Mrs. / Mr. ……………………………..……., hereby give my consent

voluntarily after understanding everything the researcher has explained to me

regarding the nature and purpose, benefit and possible risk associated with

participation in this research with honesty. All data and information of the participant

will only be used for the purpose of this research study.

Signature……………………………………………… Participant

(………………………………………)

Signature……………………………………………… researcher

(Kusuma Wijaya Ridi Putra)

APPENDIX I

List of back-translation persons

126

List of back-translation persons

1. Ery Juliani SWORN Translator

Juliani Language

2. Dra. Nurdjannah Taufiq SWORN Translator

Lugas Language Center

3. Assoc. Prof. Dr. Chintana Wacharasin Chairperson of the IRB Board

Associate Dean for Research and

Academic Services

Faculty of Nursing, Burapha

University, Thailand

127

BIOGRAPHY

Name Kusuma Wijaya Ridi Putra

Date of Birth October 31, 1986

Place of Birth Sidoarjo, East Java, Indonesia

Present address Pagerwojo RT 02 RW 01 No. 31, Gelam

Village, Candi Sub-district, Sidoarjo District,

East Java, Indonesia

Mobile: +62 81331251929

Email: tiwix_kusuma@yahoo.co.id

Position held

2011-current Lecturer

Kerta Cendekia Nursing Academy, Sidoarjo,

East Java, Indonesia.

Education

2005-2010 Bachelor of Nursing

Faculty of Nursing, Airlangga University,

Surabaya, East Java, Indonesia.

2010-2011 Professional Nursing Practice (Ners)

Faculty of Nursing, Airlangga University,

Surabaya, East Java, Indonesia.

2013-2015 Master of Nursing Science

(International Program)

Faculty of Nursing, Burapha University,

Chonburi, Thailand.

Awards or Grants

2015 The master and doctoral thesis support grant,

fiscal year 2015, Burapha University,

Chonburi, Thailand.