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Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 3-5

The second Diabetes Attitudes Wishes and Needs (DAWN2) study: Insights into nutritional management of diabetes in India

1 Department of Endocrinology, Bharti Hopsital and BRIDE, Karnal, India
2 Department of Endocrinology, Excel Hospitals, Guwahati, India
3 Department of Endocrinology, Osmania Medical College, Hyderabad, India

Date of Web Publication24-Dec-2013

Correspondence Address:
Sanjay Kalra
Departments of Endocrinology, Bharti Hospital, Kunjpura Road, Karnal, Haryana - 132 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-019X.123428

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How to cite this article:
Kalra S, Baruah MP, Sahay R. The second Diabetes Attitudes Wishes and Needs (DAWN2) study: Insights into nutritional management of diabetes in India. J Med Nutr Nutraceut 2014;3:3-5

How to cite this URL:
Kalra S, Baruah MP, Sahay R. The second Diabetes Attitudes Wishes and Needs (DAWN2) study: Insights into nutritional management of diabetes in India. J Med Nutr Nutraceut [serial online] 2014 [cited 2022 Aug 11];3:3-5. Available from: https://www.jmnn.org/text.asp?2014/3/1/3/123428

The second Diabetes Attitudes Wishes and Needs (DAWN2) study is a large multicounty survey of health care professionals, persons with diabetes and family members of persons with diabetes. Conducted in 17 countries, including India, it assesses apart from psychosocial issues, various nutrition-related aspects of diabetes care. [1],[2],[3] This editorial discusses the possible correlations between behavior of Indian health care professionals and Indian persons with diabetes, as related to nutritional management.

  Persons with Diabetes Top

Persons with diabetes were asked two life style-related questions as part of the SD SCA-6 (Summary of Diabetes Self- care Actions -6) questionnaire. [1] These were: "On how many of the last seven days-- have you followed a healthy eating plan? Did you participate in ≥30 min of physical activity?" They were also questioned about the inclusion of nutritional advice in the health care provided to them: "In the past 12 months, did anyone from your health care team ask about the types of foods you have getting?"

People with diabetes scored higher on healthy eating as compared to most other aspects of self-management. The overall mean for following a healthy eating plan was 4.9 days out of the preceding 7 days, as compared to 3.4 to 3.6 days for participating in physical activity, blood sugar testing, following recommended frequency of blood sugar testing and checking one's feet. People with diabetes however, reported a better adherence to diabetes medication (6.2 days) than to healthy eating (4.9 days).

The nutrition related DAWN2 results from India are highly surprising. Indians with diabetes rank second best in following a healthy eating plan (5-8 days, 95% confidence interval 5.4-6.1 days), just behind China (5.9 days; 5.5-6.2 days) and ahead of Spain (5.4 days; 5.0 to 5.8 days) and the Netherlands (5.4 days; 4.8 to 5.9 days). In physical activity, Indians with diabetes ranked sixth (4.2 days; 3.8 to 4.6 days) behind China, Spain, Germany, the Netherlands and Denmark and above the overall mean of 3.5 days.

In all other domains of self-care, Indians with diabetes bring up the rear ranking 16 th in blood sugar testing, 15 th in checking their feet and 16 th in taking diabetes medications exactly as agreed with their healthy care provider. The leading countries in these domains are Poland, USA, and Mexico.

This singular healthy self-care behavior correlates with the patient reported quality indicators of health care provision. Indians with diabetes reported that 56.9% (95% confidence interval 50.9-62.7%), of them had been asked about their food habits by a health care team member. This was the fourth best result among the DAWN2 countries (overall mean 45.4%) after the Russian Federation, Mexico and Poland. In contrast, Indian health care providers ranked a lowly 14 th in measuring long term blood sugar (66.3 59.9-72.2%), and 13 th in foot examination (42.2 33.2-51.8%), below the overall means of 76.6% and 52.8% for these health care interventions.

  The Question? Top

What is responsible for this "isolated" healthy self-care practice in Indians with diabetes? Is it health care provider behavior? Or is it health care training? Does training influence clinical practices, or does clinical practice inform the need for further training amongst health care professionals?

Perhaps health care provider behavior can influence patient behavior. Or is it the other way round? It is possible that patients tend to follow nutritional advice if their physicians or dieticians stress upon it. It is also feasible that patients who are conscientious about their diet ensure that their health care providers discuss the issue with them.

  Health Care Professionals: Practice Top

Almost all health care professional surveyed in the DAWN2 study felt that their patients needed major improvement in self-management related to 'eating healthy'(91.6%)' being physically active (93.4%) and maintaining healthy weight (90.4%). [3] These proportions were much higher than the percentage of health care professionals who felt their patients needed to improve their adherence to medication (62.9%), testing of blood sugar (64.7%) or dealing with diabetes-associated emotions (63.2%).

Indian health care professionals had the 7 th higher response in identifying a need for major improvement in eating healthy but the 3 rd lowest for improvement in physical activity and 4 th lowest for improvement in maintaining weight. Their most strongly felt needs for improvement related to adherence to medication (3 rd highest position, after Algeria and China) and testing blood sugar (3 rd highest, after China and Algeria).

Indian health care professionals however do tend to view healthy eating, physician activity, and weight maintenance as relatively more important short comings in self-management in absolute numbers. In fact, Indian health care professionals ranked highest in agreeing that they needed more tools to help people at risk of diabetes lose weight (84.177.5-89.0%), above Mexico and the Russian Federation.

  Training Top

As part the DAWN2 survey, health care professionals were also asked about the post graduate training they had received, or wished to undertake. While (66.3% 7.3-74.3%) of Indians health care professionals had undergone training in dietary/nutritional management (rank 6) 59.4% wished to receive more training in this field, the 4 th highest, after Turkey, China and Mexico. The countries which led the list for highest proportion of health care professionals with postgraduate training in diet/nutrition were China, Poland and Mexico.

Therefore it seems that there may be a multidirectional link between adherence to diet, provision of dietary advice as part of health care, attendance in postgraduate training in dietary/nutritional management and demand for further training in this field [Figure 1].
Figure 1: Healthy eating in diabetes: Inspiration from DAWN-2

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  Implication Top

These descriptive statistics highlight the almost concordant emphasis laid on dietary and nutrition advice, by persons with diabetes, as well as their health care professionals, in Indian health care professionals Active focus on this aspect of self-management seems to occur in spite of poor involvement in other spheres of care. Professionals seem to respond to this situation by seeking and accessing more training in diet and nutrition.

This relationship, whether causal or not can be used to improve diabetes management. Persons with diabetes should be encouraged to ask health care professionals for dietary advice and to adhere. This will sensitize health care professionals to the need for postgraduate training in dietary/nutritional management. Such training should be provided on an ongoing or regular basis, to help improve the quality of care provided to people with diabetes. Results of the multinational DAWN2 study, viewed through an Indo centric lens, can help in formulating best practices which can be used across cultures and countries.

  References Top

1.Nicolucci A, Kovacs Burns K, Holt RIG, Comaschi M, Hermanns N, Ishii H, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med 2013;30:767-77.  Back to cited text no. 1
2.Kovacs Burns K, Nicolucci A, Holt RI, Willaing I, Hermanns N, Kalra S, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national benchmarking indicators for family members living with people with diabetes. Diabet Med 2013;30:778-88.  Back to cited text no. 2
3.Holt RI, Nicolucci A, Kovacs Burns K, Escalante M, Forbes A, Hermanns N, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national comparisons on barriers and resources for optimal care - healthcare professional perspective. Diabet Med 2013;30:789-98.  Back to cited text no. 3


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