Research Article - Diabetes Management (2017) Volume 7, Issue 3

Factors associated with adherence to diet and exercise among type 2 diabetes patients in Yemen

*Corresponding Author:
Abdullah Alhariri
National University of Malaysia
Bangi, Selangor, Malaysia
E-mail: [email protected]


Aim: Diabetes is considered a worldwide epidemic syndrome affecting a huge number of people. Most of the people with diabetes could not adapt to the established diabetic regime. This study aimed to evaluate the factors affecting adherence of diabetic patients towards recommendations of diet and exercise and to assess effect of patients' adherence on glycated haemoglobin (HbA1c). Methods: A cross-sectional study was conducted during 1st May to 15th November 2016 in Hodeidah City, Yemen. Data were collected through face-to-face interview using a standardized questionnaire. Data were organized, verified and analysed using the Statistical Package for Social Sciences, version 21. Results: A total of 210 participants were included in this study, of them 54.8% were males. The rate of adherence to diet and exercise was 21.0% and 15.2%, respectively. Adherence to diet was significantly higher among urban residents (P=0.012), employees (P=0.006) and those who had a diabetes for a duration ≤5 years (P=0.040). However, adherence to exercise was significantly higher among patients who were under 60 years old (P<0.020), and who were taking oral hypoglycaemic medication (P=0.001). Good glycaemic control (HbA1c<7%) was significantly associated with adherence to dietary regimen (P=0.001) and regular exercise (P=0.032). Conclusion: The rate of adherence to both diet and exercise among type-2 diabetes patients in Yemen was low, and it could be attributed to a combination of several socio-demographic and clinical factors. This poor adherence was reflected on the lack of glycaemic control among patients.


adherence, diet, exercise, hemoglobin A1C, type 2 diabetes


Diabetes Mellitus (DM) is a chronic metabolic disorder that occurs when the body cannot produce enough insulin or cannot use it, leading to hyperglycemia. Type 2 Diabetes (T2D) is the most common type of diabetes that accounts for about 90% of all diabetes cases in the world. Mostly, T2D affecting adults as a result of insufficient insulin production or ineffectiveness of produced insulin [1]. The prevalence of T2D had increased dramatically during the last decades. According to the World Health Organization (WHO) estimation in 2014, about 422 million adults (8.5% of the world’s population) had DM compared to 108 (4.7%) in 1980 and this would rise to 642 million by 2040 [2].

Life-style changes such as balanced diet and physical exercise are important factors in achieving good controlling on T2D and avoiding its long-term complications [3]. Adherence has been defined as the extent to which a person’s behavior–taking medication, following a diet and or executing lifestyle changes–corresponds with agreed recommendations from a health care provider [4].

Healthy dietary habits such as minimizing the consumption of high glycemic foods, fats and carbohydrates will contribute in decreasing the level of blood glucose, which will lead to reduce the amount of needed insulin [5]. Physical exercises, also reduces blood glucose levels, thereby reducing the amount of insulin needed and increasing insulin sensitivity [6].

Yemen is not an exception to this trend of sharp increases in the numbers of people developing DM, where the prevalence of T2D among adults in Yemen was reported to be 9.75% [7]. In addition, poor adherence among diabetic patients in the Yemeni community becomes more prevalent than previously thought. Therefore, the burden of this disease may be increasing gradually. Consequently, this study was designed to determine the association between adherence to diet and physical exercises among T2D patients with demographic and clinical factors. It also aims to evaluate the relationship between patients’ adherence and the glycated hemoglobin (HbA1c) levels.


▪ Study population

A cross-sectional study was conducted in the period from 1st May to 15th November 2016. It was carried out in two hospitals in Hodeidah city: The Military Hospital that belongs to the Ministry of Defense and Al-Amal Hospital, which is a private hospital. Hodiedah is a coastal city and port on the Red Sea, which is about 230 km to the west of Sana’a, the capital of Yemen.

The target population was T2D patients who attended to Diabetes clinic in the above-mentioned hospitals during the data collection period. Individuals aged ≥20 years, previously diagnosed with T2D for at least 1 year was recruited. Patients were excluded from the study if they were diagnosed with type 1 or gestational diabetes or if they were disabled.

The sample size was calculated to be 166 using this formula: N=Z 2 P q/d 2 (Aroaye, 2003), where Z (standard deviation)=1.96, P (the estimated prevalence of T2D in Yemen)=9.75% [7], q=1-p, d (error margin)=0.05. In addition, a 20% rate was added to compensate for any missing data in the questionnaire.

▪ Study instruments/tools

The study questionnaire was adapted from previous studies after obtaining authors’ permission [8,9] This tool included four sections; the first section include information about participants’ socio-demographic and clinical characteristics. The second section included 10 close-ended questions used to assess patients’ adherence to prescribed dietary regimens during the month preceding the study. Responses were rated on a three point scale according to Likert scale, which sought to determine whether the patients (always=2, sometimes=1 or never=0) followed dietary advice. According to the overall score, which ranged from 0 to 20, the patients’ adherence were classified as ‘’good adherence ‘’ if the score was >15, ‘’partial adherence’’ if the score was between 10 and 15 and ‘’ non-adherence’’ if the score was <10. The third section was used to assess the patients’ adherence to physical exercise during the month preceding the study. According to their responses, participants were categorized into three groups. Those who reported within recommended levels of exercise (≥30 min/session, for at least 5 days/week) were considered as “good adherence”, while those who reported less than recommended levels of exercise (2–4 times/week) were considered as “partial adherence”, and who reported exercising less than twice weekly or don’t follow at all were considered as “non-adherence”. The fourth section included the laboratory parameters of Fasting Blood Sugar (FBS) and HbA1c to assess glycemic control. In addition, patients’ height and weight to calculate the Body Mass Index (BMI).

▪ Data collection

Data were collected through face-to-face interview using an Arabic structured questionnaire. The interview of each participant took 10–15 min and 10–15 participants were interviewed daily. Body weight and height were measured by nurses during the time of interviewing. For laboratory investigation, 3 ml of blood sample were drawn from the patient’s vein after patients fasting for 8–10 h. FBS was measured directly after sample collection using ACCU-CHECK glucometer, while HbA1c was measured in the laboratory of Al-Aqsa Hospital using SD A1c Care™ Analyzer (Immunochromatography method).

FBS was considered as controlled if its level was ≤140 mg/dl or uncontrolled if its level was >140 mg/dl [10]. For HbA1c, glycemic status was considered as good if HbA1c level was <7% or poor if its ≥7% [11] BMI was categorized according to the WHO classification as normal (<25 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2) [12].

▪ Definition of the variables

Independent variables were the socio-demographic variables (sex, age, marital status, residence, educational level, occupation and khat chewing) and clinical variables (smoking history, duration of disease and type of treatment). The dependent variable was the patient’s adherence to diet and exercise recommendations.

Diet refers to the recommended diet for people with DM who should ate small meals spread throughout the day (at least 5/day), ate fruits and vegetables daily, and ate foods high in fibers and whole grain but low in fats, sugars and carbohydrates that have high glycemic index [11]. Exercise refers to bodily movement produced by the contraction of skeletal muscle that requires energy expenditure in excess of resting energy expenditure. For diabetic patients at least 30 min/day of suitable physical activity is recommended [13].

▪ Statistical analysis

Data were organized, verified and analyzed using the Statistical Package for Social Sciences (SPSS), version 21. Descriptive statistics were used to determine the prevalence of adherence and to characterization the variables. Pearson’s chi-square test was used to investigate the association between the dependent and independent variables. For the quantification of this association the Crude Odds Ratio (COR) was calculated by logistic regression test. A P-value <0.05 was considered as statistically significant.

▪ Ethical considerations

Ethical approval was obtained from the Research Ethics Committee of the University of Science and Technology (UST) in Yemen. Participants were informed about the purpose of the study, and informed consent was obtained from each participant before data collection. Data confidentiality assured according to the revised Helsinki Declaration of Bioethics.


▪ Characteristics of participants

A total of 210 patients were included in this study. Of them, 54.8% were males. The mean age ± SD was 47.6 ± 12.6 years. The majority of participants were married (79%), from urban areas (72.9%) and khat chewers (60.5%). Nearly one-third was illiterate (32.4%) and employees (37.6%). In relation to clinical variables, the majority of participants were taking oral hypoglycemic medications (68.6% vs. 23.0% for insulin) and non-smokers (71.9%). More than a half of them (51.0%) had DM for ≤5 years and (55.2%) had a BMI of ≥25 kg/m2 (Table 1).

Characteristics N (%) Mean ± SD
Sex Male 115 54.8 -
Female 95 45.2 -
Age (Years) - - 47.6 ± 12. 6
Marital status Married 166 79.0 -
Un-married 44 21.0 -
Residence Urban 153 72.9 -
Rural 57 27.1 -
Educational level Illiterate 68 32.4 -
Intermediate 42 20.0 -
Secondary 53 25.2 -
University& above 47 22.4 -
Occupation Employed 79 37.6 -
Manual worker 35 16.7 -
House wife 64 30.5 -
Unemployed 32 15.2 -
Khat chewing  Yes 127 60.5 -
No 83 39.5 -
Smoking Smoker 59 28.1 -
Non-smoker 151 71.9 -
Type of treatment Diet 18 8.6 -
Oral 144 68.6 -
Insulin 48 22.9 -
Duration of diabetes (Years) - 6.8 ± 5.2
BMI (kg/m2) - - 25.9 ± 4.8
Glycemic control: HbA1c (%) 8.8 ± 2.2
- Good <7% 44 21.0 -
Poor ≥ 7% 166 79.0 -
FBS (mg/dl) 194.4 ± 70.1
- Controlled ≤ 140 50 23.8 -
Un-controlled >140 160 76.2 -

Table 1. Socio-demographic and clinical characteristics of participants (N=210).

▪ Adherence to diet

In viewing the distribution of the participants among different groups 21.0, 46.7, and 32.4% showed good adherence, partial adherence and non-adherence to the recommended dietary regimen, respectively (Figure 1).


Figure 1: The prevalence rate of adherence to diet and exercise among T2D patients.

There was a significant association between adherence to diet and the variables of present residence, occupation and the duration of DM. Urban residents were two times more likely to adhere to the diet than rural residents [COR (95% CI)=2.2 (1.2-4.2), P-value=0.012]. Employees [COR (95% CI)=3.3 (1.4-7.9), P-value=0.006] and housewives [COR (95% CI)=3.1 (1.3-7.6), P-value=0.012] were three times more likely to adhere to the diet compared with unemployed individuals. Patients who had DM for ≤5 years adhered to diet about two times higher than those who had DM for >5 years [COR=1.8 (1.0 -3.3), P-value=0.040 ] (Table 2).

Factor Adherence to diet COR (95% CI) P-value
N (%)
N (%)
Sex Male 41 (35.7) 74 (64.3) - -
Female 27 (28.4) 68 (71.6) 1.4 (0.8-2.5) 0.265
Age category (Years) <40 18 (27.7) 47 (72.3) 2.1 (0.9-4.9) 0.249
40-60 35 (31.5) 76 (68.5) 1.7 (0.8-3.8) -
>60 15 (44.1) 19 (55.9) 1.0 -
Marital status Married 50 (30.1) 116 (69.9) 1.6 (0.8-3.2) 0.174
Unmarried 18 (40.9) 26 (59.1)    
Present residence Urban 42 (27.5) 111 (72.5) 2.2 (1.2-4.2) 0.012*
Rural 26 (45.6) 31 (54.4) - -
Educational level Below secondary (110) 40 (36.4) 70 (63.6) - -
Secondary and above (100) 28 (28.0) 72 (72.0) 1.5 (0.8-2.6) 0.196
Occupation Employed 20 (25.3) 59 (74.7) 3.3 (1.4-7.9) 0.006*
Manual worker 14 (40.0) 21 (60.0) 1.7 (0.6-4.5) -
House wife 17 (26.6) 47 (73.4) 3.1 (1.3-7.6) 0.012*
Unemployed 17 (53.1) 15 (46.9) 1.0 -
Smoking Smoker 24 (40.7) 35 (59.3) 0.6 (0.3-1.1) 0.108
Non-smoker 44 (29.1) 107 (70.9) - -
Khat chewing Yes 40 (31.5) 87 (68.5) 1.1 (0.6-2.0) 0.735
No 28 (33.7) 55 (66.3) - -
Duration of the disease (Years) ≤5 28 (25.9) 80 (74.1) 1.8 (1.0 -3.3) 0.040*
>5 40 (39.2) 62 (60.8) - -
Type of treatment Oral 45 (31.2) 99 (68.8 ) 1.3 (0.7- 2.6) 0.424
Insulin 18 (37.5) 30 (62.5 )    
BMI (kg/m2) <25 29 (30.9) 65 (69.1) 1.1 (0.6- 2.0) 0.670
≥25 39 (33.6) 77 (66.4) - -
* Statically significant variables

Table 2. Association between socio-demographic and clinical factors and adherence to diet among type 2 diabetes patients.

▪ Adherence to physical exercise

Only 15.2% of participants reported good adherence to the recommended levels of physical exercise and 21.0% reported partial adherence to the recommended levels of physical exercise, while the majority (63.8%) reported non-adherence to any exercise advices at all (Figure 1).

Adherence to exercise was significantly associated with the age category, and type of medication. Patients who were under 60 years old were about four times more likely to be engaged in regular exercise compared with those who were above 60 years [<40 years: COR (95% CI)=3.6 (1.2- 10.6), P-value 0.019 ; 40-60 years COR (95% CI)=4.1(1.5-11.4), P-value=0.006]. Patients who treated with oral hypoglycemic medications adhered to physical exercise about four times more than who treated with insulin injection [COR (95% CI)=4.2 (1.8-10.0), P-value=0.001] (Table 3).

Factor Adherence to Exercise COR
(95% CI)
N (%)
N (%)
Sex Male 73 (63.5 ) 42 (36.5) - -
Female 61 (64.2 ) 34 (35.8) 1.0 (0.6-1.8) 0.912
Age category (Years) <40   40 (61.5) 25 (38.5) 3.6 (1.2-10.6) 0.019*
40-60 65 (58.6) 46 (41.4) 4.1 (1.5-11.4) 0.006*
>60 29 (85.3) 5 (14.7) 1.0 -
Marital status Married 110 (66.3) 56 (33.7) 0.6 (0.3- 1.2) 0.150
Unmarried 24 (54.5) 20 (45.5) - -
Present residence Urban 98 (64.1) 55 (35.9) 1.0 (0.5-1.8) 0.905
Rural 36 (63.2) 21 (36.8) - -
Educational level Below secondary 70 (63.6) 40 (36.4) - -
Secondary and above 64 (64.0) 36 (36 .0) 1.0 (0.6-1.7) 0.956
Occupation Employed 47 (59.5) 43 (37.7) 1.0 (0.4-2.3) 0.589
Manual worker 24 (68.6) 11 (31.4) 0.8 (0.3-1.8) -
House wife 44 (68.8) 20 (31.2) 0.7 (0.3-1.6) -
Unemployed 19 (59.4) 13 (40.6) 1.0 -
Smoking Smoker 36 (61.0) 23 (39.0) 1.2 (0.6-2.2) 0.599
Non-smoker 98 (64.9) 53 (35.1) - -
Khat chewing Yes 78 (61.4) 49 (38.6) 1.3 (0.7-2.3) 0.372
No 56 (67.5) 27 (32.5) - -
Duration of the disease (Years) ≤5 64 (59.3) 44 (40.7) 1.5 (0.9- 2.7) 0.158
>5 70 (68.6) 32 (31.4) - -
Type of treatment Oral 84 (58.3) 60 (41.7) 4.2 (1.8-10.0) 0.001*
Insulin 41 (85.4) 7 (14.6) - -
BMI (kg/m2) <25 57 (60.6) 37 ( 39.4) 1.3 (0.7- 2.3) 0.389
≥25 77 (66.4) 39 (33.6) - -
*Statically significant variables

Table 3. Association between socio-demographic and clinical factors and adherence to physical exercise among type 2 diabetes patients.

▪ Adherence rate and glycemic control

The results illustrated that only 24.0% of patients had controlled blood sugar (FBS ≤ 140 mg/dl), while almost 21.0% had a good controlled (HbA1c level of <7%), with relatively high mean FBS level of 194.4 ± 70.1 mg/dl and a mean HbA1c of 8.8 ± 2.2%. Moreover, adherence to diet and physical exercise was significantly associated with HbA1c levels. The chances of patients who followed recommended diet [COR (95% CI)=4.8 (1.8- 12.7), P-value 0.001] and participated in physical exercise [COR (95% CI)=2.1 (1.1-4.1), P-value 0.032] to have a good glycaemic control were almost five and two times higher than the chances of patients who had not adhere to diet and exercise, respectively (Table 4).

Adherence HbA1c COR
(95% CI)
Poor ≥ 7
N (%)
Good <7
N (%)
Adherence to Diet
Adherent 103 (72.5) 39 (27.5) 4.8 (1.8-12.7) 0.001*
Non-adherent 63 (92.6) 5 (7.4) 1.0 -
Adherence to Exercise
Adherent 54 (71.7) 22 (28.9) 2.1 (1.1-4.1) 0.032*
Non-adherent 22 (16.4) 112 (83.6) 1.0 -
*Statically significant variables, HbA1c: Glycated hemoglobin

Table 4. Relationship between patients’ adherence to diet and exercise with HbA1c.


The demographic characteristics of T2D patients in the present study are similar or slightly different from those of Yemeni diabetic patients reported in other studies [14,15]. Most people in Yemen wrongly believe that khat chewing has a beneficial effect on lowering the blood glucose level [14]. This could explain the high percentage (61.5%) of khat chewers in our study.

In the present study, only 21.0% of patients adhered to the recommended diet and 15.0% adhered to regular exercise. These rates are consistent with the findings of similar studies in neighboring countries, where the rate of adherence to diet varied between 10.7 and 36.5% [16-20]. However, the rates of adherence to physical exercise varied between 9.5% and 35.6% [16-21]. In Yemen, most people eat together in groups with the family members and friends, and it may be difficult for such patients to follow their special diet regimen that is different from the rest of the family. It should be taken into consideration that the majority of Yemenis diabetics (71.8%) had a poor score of DM knowledge (92.8%), had a negative attitude score towards DM and 44.3% had a wrong belief that there is no benefit of exercise for DM patients [15]. Moreover, poor adherence to exercise among diabetics in Hodiedah may be partly attributed to that fact that the summer season is long and hot.

In relation to the factors affecting adherence to diet, the results showed that urban residents adhered to diet almost twice higher than rural residents. This finding is in contrast to that concluded among diabetics from Bangladesh [22], where rural patients were three times more likely to adhere to diet than urban patients. This difference may be due to the lack of DM health care services and education in rural areas. The analysis of data according to residential groups showed high illiteracy rate among rural residents compared with urban ones (53% vs. 24.8%, respectively). Employed patients and housewives were four times more likely to adhere to diet than the unemployed ones. This finding is consistent with a previous study in Bangladesh [22], where employees were more adherent to diet than unemployed patients. In addition, it is also supported by a study conducted in Oman [23], which revealed that women were more amenable to changing their diet than men. This may be due to differences in knowledge level and economic status, which are usually better among employees. In addition, because cooking in Yemeni society is exclusively done by housewives, it may explain their better adherence to the dietary regimen. Consistent with other studies [18,21], patients with DM duration of ≤5 years in the present study were more adherent to diet than those who had a duration of >5 years.

On the other hand, the investigations indicated that younger age was significantly associated with adherence to physical exercise like other studies [17,22]. In fact, with increasing age, a decline in motor abilities and comorbid disease can occur, that make it difficult to perform routine physical exercises. Patients who were treated with oral hypoglycemic medications were more engaged in physical exercise than those who were treated with insulin. This result is in disagreement with a similar study in Saudi Arabia [19], which found that using insulin was significantly associated with compliance to diet. It seems that there are multiple factors contributing to these findings, which require a further investigation.

Findings related to HbA1c showed a significant association with the rate of adherence to healthy diet and physical exercise, and these findings corroborate those of other studies [20,22- 26], indicating that good diabetes control is significantly higher in those following a diet and taking regular exercise. The low rate of adherence to both diet and exercise found in this study may reflect the lack of glycemic control among patients of this study (only 21.0% of patients had HbA1c <7%).

The low adherence rate concluded in this study highlights the need for further research to assess the reasons for this health problem. The long-term relationship of patients with their DM requires ongoing self-care over a lifetime. Health personnel should direct their efforts in health education programs that should highlight the benefits of lifestyle modification in the context of disease treatment, control and reducing its risk factors.

The present study is limited by some selection bias, where the study population was patients attending clinics that may not reflect the population. In addition, dietary assessment was obtained by self-reporting, and this might lead to recall bias.


Adherence to the recommendations of diet and physical exercise among T2D patients in Yemen is still low. Several socio-demographic and clinical factors were associated with patients’ adherence. The low adherence rate amongst the study patients was reflected on their level of glycemic control (HbA1c).

Conflict of interest

The authors declare that they have no any conflict of interest in this research.

Disclosure summary

The authors have nothing to disclose.


The authors gratefully thank the staffs of laboratory in both the military hospital and Al-Amal hospital in Hodeidah for their help in sample collection and laboratory investigations. Our thanks also go to Dr. Rashad Abdul‑Ghani for his helpful advice during the preparation of the study and to Dr. Farouk AL-Qadasi for his assistance with the statistical analysis.


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