Diabetes mellitus has become the biggest public health issue in Asia, where more than 110 million people have diabetes and a great number of them die from it, reaching over a million individuals every year [1,2]. According to the "International diabetes federation", around 537 million individuals suffer from diabetes worldwide in 2021 [3]. Additionally, it is predicted that by 2040, over 780 million people will have diabetes, type 2 diabetes is an important factor in morbidity and mortality so due to this disease, every five seconds one person loses their life [4]. Also, the World Health Organization states that type 2 diabetes is the most common form of chronic diseases in adults worldwide and that its prevalence is rising due to lifestyle changes [5]. In Iraq, the age-adjusted prevalence of type 2 diabetes in individuals over 19 was 19.7% in 2012 [6]. Diabetes is a chronic disorder characterized by high blood sugar levels either because there is a defect in the secretion of the appropriate amount of insulin, or because the cells in the body do not respond properly to insulin and thus glucose accumulates in the body and causes significant damage to many essential organs in the body [7,8]. Everyone, regardless of their age or socioeconomic background, is significantly impacted by diabetes. But in low- and middle-income nations, where people could have trouble getting access to sufficient healthcare and resources for managing their diabetes, the prevalence of diabetes is noticeably higher. Diabetes has consequences that go beyond individual health, placing a heavy financial load on healthcare systems and whole societies [9,10]. Iraq is located among the countries where type 2 diabetes has become more common [11]. Type 2 diabetes is a serious chronic condition that needs for the patient to make daily decisions on their own care, such as what they eat each day [12]. Many scientific studies highlight the dietary practices are of paramount importance in the care, treatment and avoidance of type 2 diabetes so the important challenge for diabetic patients is adherence to dietary advice in the context of food selections [13,14]. Although the significance of diet in managing and avoiding the development of type 2 diabetes (type 2D) through its impact on body weight and metabolic regulation is clear. However, the most contentious and demanding component of managing type diabetes is nutrition [13]. In addition, obesity, hypertension and insulin release  are just a  few of the diseases that healthy eating habits can improve also lack of a healthy eating routine is a significant barrier to achieving glycemic control in type 2 diabetes. Despite the importance of a nutritious diet in the management of type 2 diabetes, most diabetic patients are unaware of its benefits in ensuring improved glycemic control [15]. It is crucial to understand variations in food consumption practices, due to diet one of the modifiable factors in the prevention of type 2 diabetes [16]. To help the diabetic patient maintain normal glucose levels, healthy dietary practice alone may be sufficient. Numerous studies had shown that a diet high in protein and low in carbohydrates can assist people with untreated diabetes in achieving glycemic control [17,18]. In this respect, an experimental study found that eating type2D patients a diet rich in protein and low in carbohydrates for six weeks improved their metabolic control and lipid profiles [19]. Therefore, this study's goals included assessing dietary practices and detecting the relationship between diabetes patients’ dietary practices and certain of their socio-demographic characteristics. According to our investigation, no previous studies on these matters have been carried out in Kirkuk City, Iraq.

The descriptive approach was used to study dietary practices for people with type 2 diabetes. The study was carried out on 120 patients of both sexes, 58 males and 62 females. To meet the study's goals, the sample was chosen using a purposive sample (non-probability). Two health facilities in the first sector (The Health Center at Baghdad Road and The Health Center at Al-Mansour) and two health facilities in the second sector (The Health Center at Al-Eskan and The Health Center at Rahimawa) were carried out in Kirkuk City, Iraq. Data was gathered using the interview technique for each participant older than eighteen years and with a diagnosis of not less than one year attending the primary health care centers from (2nd March to 2nd August) 2023, utilizing a structured questionnaire developed and then adapted according to the study's objectives. Fifteen participants underwent a pilot test, excluding them from the final sample. The interview lasted, on average, 20 minutes. To assess the validity of the questionnaire, the tool has been presented to a panel of six experts in the specialty. The reliability of the questionnaires was assessed using Cronbach's alpha correlation coefficients (r = 0.82%). The subjects were informed of the study's objectives and the suggested use of the results. The study tool has four components in its final form:

• First Part: It has included Participants, Characteristics, such as (gender, age, education background, household income, knowledge about diabetic nutrition and getting dietician consultation)

• Second Part: It included participants' clinical Information, like (duration of disease, medication, Body Mass Index (BMI) and cumulative sugar HbA1c)

• Third Part: It has included two elements (positive practices and negative practices). Likert scales were used to evaluate each item. Each answer to the dietary practice questions received a score between 1 and 3. Positive practices: Yes (3), Sometimes (2) and No (1); negative practices: Yes (1), Sometimes (2) and No (3). And cut-off point (poor = 1-1.66, moderate = 1.67-2.33, good = 2.34-3.0)

After the questionnaires had been gathered, we emptied them and analyzed them statistically using the Statistical Package for Social Sciences (SPSS) version 22. using descriptive statistical techniques including (frequencies, percentiles), chi-square, ANOVA and T-test

Table 1 displays the characteristics of the study's participants. Of the 120 diabetic patients shared in this study, the majority were female (51.7%); the rest (48.3%) were male. About (78.3%) of the participants were ≥45 years old and the rest were under the age of 45 years (21.7%). Regarding educational background, approximately half of them (49.2%) were college graduates and above, followed by (16.7%) who were secondary education graduates. Regarding participants' household income, most of them ranged from 301,000 to 600,000, with (35.0%), followed by (28.3%) of them with less than 300,000 Iraqi dinars. Concerning knowledge about diabetic nutrition, nearly three-quarters (74.2%) of them were knowledgeable of the subject. Lastly, more than half of the participants (55.8%) had a dietician consultation.

Table 1: Participants, Characteristics (N = 120)

Table 2, display participant’s clinical information. More than half of the participants (53.3%) duration of their diabetes affected ranged between (6-10) years. 

More than three-quarters of the participants (84.2%) take prescription medication regularly. Regarding BMI, it was found that (36.7%) of them are obese. Of similar importance, (74.2%) of the diabetic patients' cumulative sugar (HbA1c) was found to be less than seven.

Table 2: Participants, Clinical Information (N = 120)

Table 3, displays the level of dietary practices of participants with diabetes. The findings indicate that the majority of diabetes patients had moderate levels of dietary practices (mean = 1.67–2.33). While items (4, 6, 8 and 16) show a good level of practice (mean = 2.34–3.0), Only item 13 shows a poor level of practice (mean = 1.66).

Table 3: Diabetic Patient Responses Regarding to Positive and Negative Dietary Practices (n = 120)

The results of the Table 4, revealed that the majority of diabetes patients 72.5% had moderate practices. Simultaneously, only 20.8% had good practices and 6.7% had poor levels of dietary practices.

Table 4: Overall Dietary Practices of Participants with Diabetes (N=120)

The Table 5, displays the results of the T-test. From it, we conclude that there are statistically significant differences in the dietary practices of diabetic patients according to the age variable, where the p-value (0.01) was less than 0.05, favor of the age group under 45 years, with a mean of 2.18 and a standard deviation of 0.28. Also, the previous table indicates highly significant differences in the dietary practices of diabetic patients according to their knowledge about diabetic healthy nutrition, where the p-value is 0.00. In favor of knowledgeable diabetic patients, with a mean (2.21) and standard deviation (0.27). Likewise, the finding indicated highly significant differences in the dietary practices of diabetic patients according to the consulted a dietician, where the p-value was 0.00. In favor of diabetic patients that consulted a dietician, with a mean (2.26) and standard deviation (0.24).

Table 5: Results of T-test According to Gender, Age, Knowledge and Consulted a Dietician (N=120)

The Table 6, indicates the results of the ANOVA, which conclude that there are statistically significant differences in dietary practices according to the education variable, where the value of (F) was 5.204 and the p-value (0.002) was smaller than 0.05, which is statistically significant. The previous table also shows the high value of a mean for higher academic achievement than the lowest academic achievement; the highest value was for those having graduated and above, with a mean of 2.25 and a standard deviation of 0.282. For the household income variable, there are no statistically significant variations in dietary practices.

Table 6: Results of ANOVA According to the Education and Household Income

Several studies have shown the importance of a healthy diet in managing type 2 diabetes, of which dietary practices are crucial for control and management and consuming enough calories and nutrients will help to lower high blood sugar levels and stop the disease's progression [20]. The dietary practices of type 2 diabetic patients were assessed in this cross-sectional study for 120 participants; the majority were female and most of them were aged above or equal to 45 years old. In more than half of the subjects, the duration of their diabetes ranged from [6-10] years. More than three-quarters of them were taking prescribed medication regularly. Most of them were obese and the majority of them had a cumulative sugar (HbA1c) of less than seven. And findings demonstrated that the majority of diabetes patients (72.5%) had moderate levels of diabetic dietary practices. Concurrently, only 20.8% had good levels and 6.7% had poor levels of diabetic dietary practices. These practices are more acceptable than the study outcomes done in Pakistan at Lahore Hospital, where 17.6% had good practices and 82.4% of them had poor practices regarding diabetic diet [21]. The difference could be explained by the interval between the two studies; presently, more information about diabetic diet nutrition is provided than in the past. Additionally, internet accessibility and media coverage have improved compared to the past, which may help spread knowledge about diabetic diets. On the other hand, these practices are less common than what was discovered in a study done in Addis Ababa, Ethiopia, where 35.9% of the patients reported having healthy eating habits [20]. This difference may be the result of different study settings, cultures and study participants. Younger patients were more likely to have good dietary practices than their older patients. This finding is similar to the study results in Nepal [22]. This can be because younger or middle-aged people's cognitive function is better than older and the degree of compliance with dietary practices declines with age for a variety of reasons; most older people have memory impairment and reduced cognitive function. Patients who got Knowledge about diabetic healthy nutrition had statistically significant differences with healthy dietary practices. This finding is like to the study outcome in Ethiopia [23] and Kenya [24]. This can be because receiving nutrition knowledge may improve eating habit patient who got consulted a dietician were significant difference with healthy dietary practices. This finding is like to the study outcome that stated a considerable chance for dietitians to improve the nutrition maintenance delivered to diabetes patients. Which is in the development and care of healthy eating habits in individuals with type 2 diabetes [25]. Similarly, study finding in India observed that those who saw dieticians were more adept at following their diets [26]. May be explained when people have been seen by a dietician they are more likely to adhere to a dietary regimen and adopt the new healthy dietary behavior and it makes sense since dieticians are obligated to possess a wider range of expertise, including suggestions for nutritious foods, culinary techniques and useful advice on how to handle lifestyle-related problems. Educational status of diabetic patients had statistically significant with healthy dietary practices. This finding in line with the study outcome in in Kiambu County, Kenya [27]. That patients with higher levels of education have easier to obtain knowledge from literature, leaflets, book, newspapers and internet than do patients with lower levels of education. Furthermore, educated individuals could understand dietary information provided by professionals or in the media more easily than uneducated individuals.

According to the results, less than a quarter of diabetic patients have good dietary practices. There are differences in dietary practices attributable to variables (age, educational levels, knowledge about diabetic nutrition and consulted a dietician). Therefore, good dietary practices among diabetic patients require improvement due to inadequacy. By improving the education level of populations, raising awareness rate about diabetic healthy nutrition and increasing the role of dieticians in health institutions. These are the results obtained, it opens horizons in expanding research on a sample of diabetic patients and its association with other variables such as psychological status, differences between rural and urban residents, cultural background and health beliefs. The results of this research will contribute to the pursuit of developing health strategies and projects by health officials and specialists to serve this group.

1. Mahmoud, J.H. “Measurement of glycated hemoglobin and levels of depression in diabetic patients in Kirkuk City, Iraq.” Annals of the Romanian Society for Cell Biology, 2021, pp. 6846–6852.

2. Sami, W. et al. “Effect of diet on type 2 diabetes mellitus: A review.” International Journal of Health Sciences, vol. 11, no. 2, 2017, pp. 65.

3. International Diabetes Federation. IDF Diabetes Atlas. 10th ed., Brussels, Belgium, 2021, www.diabetesatlas.org.

4. International Diabetes Federation. IDF Diabetes Atlas. 10th ed., Brussels, Belgium, 2022, www.diabetesatlas.org.

5. World Health Organization. Global Report on Diabetes. World Health Organization, 2016.

6. Mansour, A. and F. Al-Douri. “Diabetes in Iraq: Facing the epidemic. A systematic review.” Wulfenia Journal, vol. 22, 2015, pp. 258–273.

7. Sugandh, F.N.U. et al. “Advances in the management of diabetes mellitus: A focus on personalized medicine.” Cureus, vol. 15, no. 8, 2023.

8. Pasquel, F.J. et al. “Management of diabetes and hyperglycaemia in the hospital.” The Lancet Diabetes & Endocrinology, vol. 9, no. 3, 2021, pp. 174–188.

9. Petrie, J.R. et al. “Diabetes, hypertension and cardiovascular disease: clinical insights and vascular mechanisms.” Canadian Journal of Cardiology, vol. 34, no. 5, 2018, pp. 575–584.

10. Ellahham, S. “Artificial intelligence: The future for diabetes care.” The American Journal of Medicine, vol. 133, no. 8, 2020, pp. 895–900.

11. Al-Marmadi, S.H. and M.T. AlTameemi. “Effect of rs17817449 of the FTO gene in the incidence of obesity and type 2 diabetes mellitus in Iraqi Women.” 2022.

12. Powers, M.A. et al. “Diabetes self-management education and support in adults with type 2 diabetes: A consensus report.” Journal of the American Pharmacists Association, vol. 60, no. 6, 2020, pp. e1–e18.

13. Forouhi, N.G. et al. “Dietary and nutritional approaches for prevention and management of type 2 diabetes.” BMJ, vol. 361, 2018.

14. Sami, W. et al. “Dietary habits of type 2 diabetes patients: frequency and diversity of nutrition intake kingdom of Saudi Arabia.” Journal of Community Medicine and Primary Health Care, vol. 22, no. 2, 2020, pp. 521–527.

15. Mannethodi, K. et al. “Dietary practices and related elements among patients with type 2 diabetes in rural Kerala, India.” Clinical Medicine, vol. 1, no. 1, 2023, pp. 36–43.

16. Sachdev, M. and A. Misra. “Heterogeneity of dietary practices in India: Current status and implications for the prevention and control of type 2 diabetes.” European Journal of Clinical Nutrition, vol. 77, no. 2, 2023, pp. 145–155.

17. Shah, A. and A.M. Kanaya. “Diabetes and associated complications in the south Asian population.” Current Cardiology Reports, vol. 16, 2014, pp. 1–16.

18. Prenissl, J. et al. “Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 Years.” BMC Medicine, vol. 17, 2019, pp. 1–12.

19. Skytte, M.J. et al. “A carbohydrate-reduced high-protein diet improves HbA1c and liver fat content in weight-stable participants with type 2 diabetes: A randomised controlled trial.” Diabetologia, vol. 62, 2019, pp. 2066–2078.

20. Demilew, Y.M. et al. “Dietary practice and associated factors among type 2 diabetic patients in felege hiwot regional referral hospital, bahir dar, ethiopia.” BMC Research Notes, vol. 11, 2018, pp. 1–7.

21. Bano, A. et al. “Dietary knowledge, attitude and practices of diabetes patients at services hospital Lahore.” International Journal of Applied Sciences and Biotechnology, vol. 5, no. 2, 2017, pp. 227–236.

22. Parajuli, J. et al. “Factors associated with nonadherence to diet and physical activity among nepalese type 2 diabetes patients: A cross-sectional study.” BMC Research Notes, vol. 7, 2014, pp. 1–9.

23. Mohammed, M.A. and N.T. Sharew. “Adherence to dietary recommendation and associated factors among diabetic patients in Ethiopian teaching hospitals.” The Pan African Medical Journal, vol. 33, 2019.

24. Wahome, E.M. et al. “Predictors of dietary practices and nutritional status among diabetic type II patients in Kiambu county, Kenya.” International Journal of Community Medicine and Public Health, vol. 5, no. 7, 2018, pp. 2726–2734.

25. Ball, L. et al. “The nutrition care needs of patients newly diagnosed with type 2 diabetes: Informing dietetic practice.” Journal of Human Nutrition and Dietetics, vol. 29, no. 4, 2016, pp. 487–494.

26. Adisa, R. et al. “Factors contributing to non-adherence to oral hypoglycemic medications among ambulatory type 2 diabetes patients in southwestern Nigeria.” Pharmacy Practice, vol. 7, no. 3, 2009, pp. 163.

27. Wahome, E.M. et al. “Predictors of dietary practices and nutritional status among diabetic type II patients in Kiambu county, Kenya.” International Journal of Community Medicine and Public Health, vol. 5, no. 7, 2018, pp. 2726–2734.