Basic characteristics of T2DM patients
A majority of the newly diagnosed T2DM patients were between 51 and 60 years old (72, 15.4%) among male patients and 41–50 years old (99, 30.6%) among female patients. The findings for male patients were comparable with those of the NHMS, which reported that the prevalence of newly diagnosed T2DM was highest among 50–59 years old Malaysian male (143, 47.4%) [5]. While for female, the NHMS has reported that the highest prevalence of newly diagnosed T2DM were also 50–59 years old (160, 52.6%) which is older compared to this study that show the highest prevalence among 41–50 years old [5].
In the present study, patients with overweight BMI were most common among those who were diagnosed for ≤5 years for male (314, 56.1%) and female (350, 53.5%). Similar trends were observed for obese patients with percentages of 56.3 and 53.3% among male and female patients respectively. A study done by Mafauzy et al. reported that 72% of T2DM patients were obese, which reflects the imbalance between energy intake and expenditure [27,28,29]. According to a Malaysian report, obese persons were recommended to reduce their initial weight by 5–10% over a period of 6 months. [29]. To achieve this goal, medical nutrition therapy (MNT) was provided via individualized nutritional recommendations for T2DM patients with obesity. [29]. Although overweight and obesity are well-known risk factors for type 2 diabetes, the disease also noticeable among newly diagnosed T2DM patients with normal BMI in this study (male: 77, 32.6%; female: 79, 30.7%). According to Gujral et al., diabetes development among patients with BMI < 25 kg/m2 might be due to impairments in insulin secretion, in utero undernutrition, and epigenetic alterations to the genome [30].
Our results showed that patients already diagnosed with T2DM for ≤5 years had a notably high prevalence of hypertension comorbidities (male: 302, 57.4%; female: 410, 56.6%), compared to newly diagnosed patients (male: 43, 8.2%; female: 59, 8.1%). Increased comorbidities would increase the risk of complications such as cardiovascular disease and impact the management of comorbidities, long-term survival and the health care system [6]. Other than that, family history of diabetes also shows similar trends. This is because comorbidities are heritable [31]. The results of the present study also showed that active smoking status among male participants was significantly related to T2DM. Smoking behaviors have been reported as risk factors contributing to T2DM [32].
Pattern of macronutrient intake among T2DM patients
The Chi-square analysis showed significant differences among the three groups of T2DM patients in terms of carbohydrate and protein intake by male patients. Compliance with the recommended carbohydrate intake (50–65% of TEI) among the newly diagnosed, ≤ 5 years and > 5 years groups was 83 (18.1%), 239 (52.2%) and 136 (29.7%), respectively. Similarly, carbohydrate consumption less than recommended intake (<50% of TEI) among the newly diagnosed, ≤ 5 years and > 5 years groups was 49 (19.4%), 131 (51.8%) and 73 (28.9%), respectively. Meanwhile, T2DM patients who consumed carbohydrate at proportions > 65% of TEI was highest among the group newly diagnosed (20, 45.5%), compared to ≤5 years (16, 36.4%) and > 5 years groups (8, 18.2%) .
Compliance with the recommended protein intake (10–20% of TEI) among the newly diagnosed, ≤ 5 years and > 5 years groups was 123 (19.9%), 320 (51.8%) and 175 (28.3%), respectively. Similar patterns were observed for a protein intake of > 20% of TEI among the newly diagnosed, ≤ 5 years and > 5 years groups (18.5, 49.2 and 32.3%, respectively). In addition, very few T2DM patients consumed protein in amounts less than the recommended proportions. Although the differences were not significant, the majority of the T2DM patients consumed amounts of fat higher than the recommended proportion (> 30% of TEI).
A previous study conducted at the outpatient clinic of the University of Malaya Medical Center reported that the mean proportions of carbohydrate, protein and fat consumed by T2DM patients were 56.9, 14.7 and 28.4% of TEI, respectively [15]. Another study by Chin et al. found that the mean proportions of carbohydrate, protein and fat consumed by T2DM patients were 60.0, 16.0 and 24.0% of TEI, respectively [17]. Meanwhile, this study shows that the mean proportions of carbohydrate, protein and fat intake among T2DM patients were 51.9, 17.7 and 30.4% of TEI, respectively (results were not shown). The present study found that the mean carbohydrate intake among T2DM patients was lower than in previous studies (51.9% vs 56.9 and 60.0% of TEI) [15, 17]. Conversely, the mean intake of protein (17.7% of TEI) and fat (30.4% of TEI) among T2DM patients in this study was higher compared to the previous studies [15, 17]. The mean proportions of macronutrients consumed by participants in this study were found to be within the range recommended in the clinical practice guidelines for the nutritional management of T2DM patients. [12].
Overall, the results of this study showed that T2DM patients mainly consumed carbohydrate and protein within the range of recommended nutrient intakes (RNI) for Malaysia but had a high fat intake (Table 2). This pattern contradicted a review by Hussein et al., which concluded that Malaysian diabetics were more prone to consuming high amounts of carbohydrate and fat [29]. The differences may be because the former study included only already known T2DM patients, while this study included both newly diagnosed and already-diagnosed T2DM categories. Several studies have highlighted that the general dietary intake recommendations based on macronutrients were not easily followed by both the general population and T2DM patients [7, 14, 33, 34]. Furthermore, previous reviews have stated that the effectiveness of the existing guidelines, which set goals based on macronutrient quantity, was still equivocal in efforts to reduce the risk of T2DM [33, 34]. Thus, the Malaysian Ministry of Health (MOH) has been implementing MNT to provide individualized nutritional recommendations based on personal preferences to manage the dietary intake of T2DM patients [31]. However, this approach only showed a 16.4% rate of compliance among Malaysian T2DM patients despite its effectiveness in glycemic control [31]. Despite the efforts of the MOH to manage T2DM, lack of patient compliance with dietary counseling remains a huge challenge for both health practitioners and T2DM patients themselves.
The main limitation of this study was the cross-sectional study design that only included baseline data. The causal and temporal effects of macronutrient intake on T2DM patients were not considered. Future research should include controlled trials or prospective data analyzes so that the causal effects of specific components of carbohydrate, protein and fat can be studied.