|Year : 2021 | Volume
| Issue : 1 | Page : 22-27
Assessment of nutritional knowledge and dietary patterns of patients with pancreatitis in South India
Julia Sunil1, AR Pranavi1, Subair Mohsina1, Mahalakshmy Thulasingam2, Sathasivam Suresh Kumar1, Vikram Kate1
1 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||29-Apr-2021|
|Date of Decision||29-Apr-2021|
|Date of Acceptance||12-May-2021|
|Date of Web Publication||30-Jun-2021|
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Background: Pancreatitis is common in South India, with a 20-fold higher incidence than the West. Objectives: This study was carried out to assess the nutritional knowledge and dietary pattern of patients with pancreatitis in South India. Materials and Methods: A validated food frequency questionnaire was used to assess the dietary pattern. An authorial questionnaire (98 questions) was used to assess nutritional knowledge, attitude, and adherence to advice. The data were entered in Microsoft Excel and analyzed in SPSS version 20. Results: A total of 86 patients with pancreatitis (acute: 50, chronic: 36) were included. Of them, 13%, 45%, and 42% of the patients had <25%, 25%–50%, and >50% scores, respectively, in nutritional knowledge assessment. Fifty-nine patients perceived their nutritional knowledge to be average (46%) or above average (22%). Restricted food items were avoided by majority, such as fried snacks (34%), raw chilly (67%), garlic (88%), and coffee (48%). Intake of recommended food items like cooked vegetables (94%) was practiced, but frequencies of consuming low-fat milk (0%), egg (8%), etc., were not adequate. Seventy-three percent of the patients knew high-fat/oil consumption was detrimental. Doctor was the source of dietary advice in 92% of patients. Only 32% were satisfied with the dietary advice received. There were no significant correlations between nutritional knowledge, adherence, and factors such as age, gender, education, type of pancreatitis, and disease duration. Conclusion: The dietary pattern, nutritional knowledge, and adherence to recommendations in patients with pancreatitis are insufficient, irrespective of demographic/clinicopathological factors.
Keywords: Acute pancreatitis, chronic pancreatitis, food pattern, nutrition
|How to cite this article:|
Sunil J, Pranavi A R, Mohsina S, Thulasingam M, Kumar SS, Kate V. Assessment of nutritional knowledge and dietary patterns of patients with pancreatitis in South India. Int J Adv Med Health Res 2021;8:22-7
|How to cite this URL:|
Sunil J, Pranavi A R, Mohsina S, Thulasingam M, Kumar SS, Kate V. Assessment of nutritional knowledge and dietary patterns of patients with pancreatitis in South India. Int J Adv Med Health Res [serial online] 2021 [cited 2021 Nov 29];8:22-7. Available from: https://www.ijamhrjournal.org/text.asp?2021/8/1/22/319771
| Introduction|| |
Pancreatitis is one of the most common conditions afflicting South India, with an almost 20-fold higher incidence than the West., It is speculated that lifestyle and dietary patterns are significant etiological factors in the development of pancreatitis, affecting both progression and recurrence.,,,, In a study by Lankisch et al., the incidence of recurrence was 16.5%. The relationship between dietary, lifestyle habits, and pancreatitis cannot be overstated. Smoking affects the course of pancreatitis, and alcohol consumption has a 40% attributable risk in chronic pancreatitis (CP) – thought to synergize with coffee as a pancreatic toxin., Lowering a high triglyceride level can significantly reduce recurrence and morbidity. A high-fiber diet results in increased steatorrhea and flatulence in patients with CP-induced pancreatic exocrine insufficiency., Micronutrient and protein deficiency is also postulated to negatively affect the condition via its role in preventing free radical damage.
A high incidence of recurrence in India may be attributed to nonalteration in dietary pattern owing to a lack of nutritional knowledge and adherence. Similarly, in Poland, a study assessing nutritional knowledge showed that only 44.4% and 33.3% of individuals knew they had to abstain from alcohol and avoid fried food items, respectively.
Many patients of pancreatitis follow popular but detrimental myths on nutrition, which are based on hearsay rather than evidence. Understanding existing dietary patterns and nutritional knowledge is essential to curb inappropriate diets and increase compliance among patients toward the recommended pattern.
Hence, this study was carried out to assess the nutritional knowledge, both theoretical and practical, and the dietary patterns in patients with pancreatitis in South India. This study also assessed the correlation between various demographic and clinicopathological characteristics and nutritional knowledge, and the comparability of dietary pattern to recommendation.
| Materials and Methods|| |
The study was designed as a prospective, observational, cross-sectional study. The group studied was patients with acute or chronic pancreatitis fulfilling the inclusion criteria of being ≥18 years of age and who were admitted to the department of surgery at a tertiary care hospital in South India during the study period (June 2017 to August 2018). Patients with high likelihood of death within 72 hours, patients who were pregnant, and patients who did not give consent for participation were excluded. Eighty-six patients were included in the study after obtaining informed consent. The study was approved by the institute ethics committee.
All participants were interviewed by the principal investigator, using an author-modified questionnaire based on the questionnaire reported by Cotî et al. It consisted of three parts – part A was a food frequency questionnaire and parts B and C had a total of 53 close-ended questions and 45 open-ended questions based on food types and preparations common in South India. Part B assessed the patients' nutritional knowledge, perception of their own nutritional knowledge, sources of nutritional information, and attitude toward these sources, while part C assessed the patients' adherence to any dietary advice given in the past. The patient's nutritional knowledge score for each question was recorded as follows: 0 for a wrong answer, 1 point if the answer was correct but the reasoning wrong, and 2 points if the patient gave both the answer and the reason correctly. The maximum possible score was 89. A picture card was also provided to aid in administering the questionnaire. A pro forma was utilized to record demographic and clinicopathological variables. Economic status was determined using a document issued under the order of authority of the state government, as per the public distribution system, for purchase of essential commodities from fair price shops – the ration card.
The data were entered in Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Released 2011. Nutritional knowledge of patients was summarized as mean knowledge score with standard deviation and 95% confidence interval. The current dietary pattern, source of information, patients' perception of their knowledge, and adherence to nutritional advice were summarized as frequency and percentage with a 95% confidence interval. The association between these factors and sociodemographic parameters was analyzed using Student's t-test and analysis of variance. p < 0.05 was considered statistically significant.
| Results|| |
Demographic and clinicopathological details were obtained via a pro forma. Majority had received a secondary level education (52%), were below poverty line (97%), and were cases of acute pancreatitis (58%). For most of the patients with acute pancreatitis, the onset of episodes was <3 months prior to the current admission. The onset of episodes was more than 1 year prior for most of the patients with CP (inclusive of acute on chronic).
Majority ate mainly from home (59%) and only 39% from restaurants. Majority drank alcohol (64%) but did not smoke (38% smoked). None had ever consumed low-fat milk, cooked/dried fruits. More people consumed tea than coffee. Among carbohydrate sources, rice and idli/dosa were staples while semolina and chapati were rarely consumed. There was also a significant oil and spice usage.
[Table 1] shows data on adherence. Of “food not to be taken,” adherence was mostly low for legumes and high-fat spreads/oils. Of “food to be taken in moderation,” adherence was highest for poultry (not fried) and least for animal milk. Adherence was lowest for low-fat milk, cooked fruits, and semolina, with 0% adhering to the recommendation for each, among “food to be taken frequently.”
Patients' knowledge of nutrition in pancreatitis was tested using a questionnaire. A general question was asked pertaining to a food group (e.g. high-fat/oil consumption): whether it was good or bad for patients of pancreatitis. The same question was then asked of individual food items. The two possible responses were “food to be taken frequently” and “food to be avoided” (which includes “food not to be taken” and “food to be taken in moderation”). The response was a “correct answer” if both the response and the reasoning for it were given correctly, and a “partially correct answer” if the patient gave the right response but an incorrect reason for the same [Table 2]. In the section on high-fat/oil consumption, 73% correctly answered the general question. The highest number of incorrect answers was for “high-fat cow's milk,” and a number of patients found “butter” (9%) healthy.
|Table 2: Scores in individual sections of the test segment of authorial questionnaire (n=86)|
Click here to view
In the miscellaneous food section [Table 3], majority gave “correct answers” regarding “alcohol,” but opinion about “coffee” was split in half. A significant percentage gave incorrect answers to “boiled egg with yolk” (77%) and “semolina” (81%). In fact, with regard to “boiled egg with yolk,” 52% responded opposite to the recommendation.
|Table 3: Scores in miscellaneous section of the test segment of authorial questionnaire (n=86)|
Click here to view
[Table 4] shows the various (incorrect) reasons given by patients in the case of “partially correct answers” mentioned earlier, and [Table 5] shows the reasons given for avoiding recommended food items. Many food items were believed to be “heaty”, flatulence-inducing, or jaundice-causing foods, etc.
|Table 4: Incorrect reasons* given for avoiding “food item to be avoided” (n=86)|
Click here to view
|Table 5: Reasons* given for avoiding “food to be taken frequently” (n=86)|
Click here to view
After tabulating, the mean nutritional knowledge score was found to be 40 ± 13.4 out of a possible 89, with 45% of patients scoring between 50% and 25%, 41% of patients scoring between 50% and 75%, and 13% scoring <25%. A substantial proportion of participants (46%) rated their own nutritional knowledge as being average, while 32% of them rated it as being poor or very poor.
Most patients (72%) did not actively seek nutritional information. Of those who did, majority sought it from doctors (92%) – with 99% stating that doctors were the most reliable source. Other sources were nurses (4%) and relatives (4%). Among those who had received dietary advice previously, majority (45%) only “slightly” adhered to recommendations.
There were no significant correlations among nutritional knowledge, adherence, and demographic/clinicopathological factors such as age, sex, socioeconomic status, education, type of pancreatitis, and duration of disease.
| Discussion|| |
On reviewing nutritional knowledge test scores, most patients in the present study scored 50% and below. There was a lack of awareness about complications of pancreatitis such as hyperlipidemia and vitamin deficiencies. The dietary pattern observed in the present study is different from that in other studies, such as Wtochal et al. on factors such as spicy food and raw vegetable consumption. Alcohol consumption was overwhelmingly frequent in our study population, disproportionate to smoking frequency, which is in contrast to the North American Pancreatitis Study 2.
Questions in the present study regarding food groups were similar to those in Wtochal et al. but with individual food items tailored to the South Indian lifestyle and diet. In our study, patients with pancreatitis were also required to state a reason for their answer as to whether a food item was detrimental or not, irrespective of whether their answer was correct or incorrect. This gave a deeper understanding of the patients' mindset. It was found that most patients in the current study scored 50% and below in the test, which was consistent with the findings of the Scandinavian study  and Unlike the majority of patients in the Scandinavian study who rated their nutritional knowledge to be good/very good, majority in this study gave themselves a negative rating.
In individual food groups, 73% of the patients in the current study knew high-fat and oil consumption was detrimental, consistent with 61% in the Scandinavian study. Unlike in that study, majority in the current study were aware of the detriments of spicy food, possibly due to it being an integral entity in Indian cuisine. There is also an incorrect discrimination between similar food items, for example, oil, butter, and ghee. This goes to show that the nutritional knowledge of patients in the current study is incomplete, despite appearing good superficially. Only a few in the present study were aware of dietary fiber, an entity they described as “difficult to digest” or “sticking to the digestive tract.” The patients in the current study were also not aware of the concept of substituting with a low-fiber carbohydrate source, and instead tended to cut down on carbohydrate intake, leading to malnutrition. The importance of nutritional knowledge in averting such outcomes was demonstrated in a South Korean study, in which patient participation-based dietary interventions resulted in significant improvements in nutritional and functional status in patients who had undergone a gastrectomy.
Practical knowledge regarding cooking modalities did not extend equally for egg – probably many felt the nutritious value of egg outweighed the detriments of frying it. The benefits of cooking poultry without skin and bones and eating egg without the yolk are still unknown to most, being unfamiliar cooking modalities.
Several patient misconceptions have been highlighted by this study, such as “food leading to body heat” and “jaundice-causing” food, the former being a key reason why many avoid semolina. There was also the false belief in the benefits of consuming the skin of fruits, where nutrients are thought to be availed. There were no significant correlations between nutritional knowledge and other factors in the present study, probably due to the low sample size. It could also be due to the lack of variability and consistently poor knowledge. Educational status did not show a significant correlation with nutritional knowledge, perhaps because the patients were a mix of two extremes. With highly educated patients, lifestyle intervenes – there is a shift toward processed food and a westernized diet, with a lack of knowledge of its implications. There was no significant correlation between the duration of illness and knowledge, probably due to lack of information seeking and dispensing, and poor adherence. The HEALTH study showed that in addition to lack of knowledge, several other factors such as cost, taste, lack of meal preparation skills or recipes, difficulty in changing eating habits, and issues faced by caregivers proved to be significant barriers in consumer adherence.
Nutritional information and adherence
Unlike in Wtochal et al ., patients in the current study did not actively utilize resources other than the doctor. This highlights the importance of the doctor as the primary source of nutritional information in developing countries where the ability to access information from other sources is less. There is a lack of emphasis on nutritional education, as shown by only 50% of patients spontaneously receiving information from health-care workers, and their dissatisfaction with it.
Unaffordability of healthier alternatives and the lack of importance given to diet have resulted in poor adherence to the recommended diet among patients in the current study. This is unlike the 97% adherence seen in the Scandinavian study. For several people in the present study who are manual laborers, food choices are not an option during working hours, and drinking has become a significant part of their lives – peer pressure makes it difficult for many to abstain from alcohol.
| Conclusion|| |
This study sheds light on the dietary pattern of South Indian patients with pancreatitis as well as on how much it matches a recommended dietary pattern. It has also shown where and by how much their nutritional knowledge is lacking – paving the way for a more targeted educational approach. However, this study is not without limitations. The information obtained for assessing the dietary pattern was based on recall by the patient. A prospective study would have analyzed these factors more comprehensively but would have required more resources and time. In conclusion, the nutritional knowledge, both theoretical and practical, is poor among patients with pancreatitis in South India. Although patients were aware of the general components to avoid, they were unable to identify the food items that contained them. Adherence and nutritional information-seeking was low compared to developed countries. Unlike the more varied sources utilized in other countries, the doctor was the sole source of nutritional information here. There were no statistically significant correlations between nutritional knowledge, adherence, and other demographic/clinicopathological factors. Hence, more emphasis should be given to nutritional education among patients of all age groups. Similarly, the importance of adherence to nutritional advice in reducing the frequency and duration of episodes should also be stressed upon.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Garg PK, Tandon RK. Survey on chronic pancreatitis in the Asia-Pacific region. J Gastroenterol Hepatol 2004;19:998-1004.
Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology 2013;144:1252-61.
Otsuki M, Tashiro M. 4. Chronic pancreatitis and pancreatic cancer, lifestyle-related diseases. Intern Med 2007;46:109-13.
Banks PA, Conwell DL, Toskes PP. The management of acute and chronic pancreatitis. Gastroenterol Hepatol (N Y) 2010;6:1-16.
Rajesh G, Girish BN, Vaidyanathan K, Balakrishnan V. Diet, nutrient deficiency and chronic pancreatitis. Trop Gastroenterol 2013;34:68-73.
Talukdar R, Vege SS. Acute pancreatitis. Curr Opin Gastroenterol 2015;31:374-9.
Lankisch PG, Breuer N, Bruns A, Weber-Dany B, Lowenfels AB, Maisonneuve P. Natural history of acute pancreatitis: A long-term population-based study. Am J Gastroenterol 2009;104:2797-805.
Cotî GA, Yadav D, Slivka A, Hawes RH, Anderson MA, Burton FR, et al.
Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2011;9:266-73.
Morton C, Klatsky AL, Udaltsova N. Smoking, coffee, and pancreatitis. Am J Gastroenterol 2004;99:731-8.
Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterol 2003;36:54-62.
Sempere L, Martinez J, de Madaria E, Lozano B, Sanchez-Paya J, Jover R, et al.
Obesity and fat distribution imply a greater systemic inflammatory response and a worse prognosis in acute pancreatitis. Pancreatology 2008;8:257-64.
Dutta SK, Hlasko J. Dietary fiber in pancreatic disease: Effect of high fiber diet on fat malabsorption in pancreatic insufficiency and in vitro
study of the interaction of dietary fiber with pancreatic enzymes. Am J Clin Nutr 1985;41:517-25.
Heinrich S, Schäfer M, Rousson V, Clavien PA. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg 2006;243:154-68.
Balakrishnan V, Nair P, Radhakrishnan L, Narayanan VA. Tropical pancreatitis-a distinct entity, or merely a type of chronic pancreatitis? Indian J Gastroenterol 2006;25:74-81.
] [Full text]
Wtochal M, Swora-Cwynar E, Karczewski J, Grzymistawski M. Assessment of nutritional knowledge of patients with pancreatitis. Prz Gastroenterol 2015;10:229-33.
Yadav D, Hawes RH, Brand RE, Anderson MA, Money ME, Banks PA, et al.
Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch Intern Med 2009;169:1035-45.
Kim H, Suh EE, Lee HJ, Yang HK. The effects of patient participation-based dietary intervention on nutritional and functional status for patients with gastrectomy: A randomized controlled trial. Cancer Nurs 2014;37:E10-20.
Nicklas TA, Jahns L, Bogle ML, Chester DN, Giovanni M, Klurfeld DM, et al.
Barriers and facilitators for consumer adherence to the dietary guidelines for Americans: The HEALTH study. J Acad Nutr Diet 2013;113:1317-31.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]