title: Barriers to following dietary recommendations in Type 2 diabetes.
abstract: OBJECTIVE
  To evaluate barriers to following dietary recommendations in patients with Type 2 diabetes.
  
  
  METHODS
  We conducted focus groups and surveys in urban and suburban VA and academic medical centres. For the written survey, a self-administered questionnaire was mailed to a random sample of 446 patients with diabetes. For the focus groups, six groups of patients with diabetes (three urban, three suburban) were conducted, with 6-12 participants in each group. The focus groups explored barriers across various types of diabetes self-management; we extracted all comments relevant to barriers that limited patients' ability to follow a recommended diet.
  
  
  RESULTS
  The written survey measured the burden of diabetes therapies (on a seven-point rating scale). Moderate diet was seen as a greater burden than oral agents (median 1 vs. 0, P = 0.001), but less of a burden than insulin (median 1 vs. 4, P < 0.001). A strict diet aimed at weight loss was rated as being similarly burdensome to insulin (median 4 vs. 4, P = NS). Despite this, self-reported adherence was much higher for both pills and insulin than it was for a moderate diet. In the focus groups, the most commonly identified barrier was the cost (14/14 reviews), followed by small portion sizes (13/14 reviews), support and family issues (13/14 reviews), and quality of life and lifestyle issues (12/14 reviews). Patients in the urban site, who were predominantly African-American, noted greater difficulties communicating with their provider about diet and social circumstances, and also that the rigid schedule of a diabetes diet was problematic.
  
  
  CONCLUSIONS
  Barriers to adherence to dietary therapies are numerous, but some, such as cost, and in the urban setting, communication with providers, are potentially remediable. Interventions aimed at improving patients' ability to modify their diet need to specifically address these areas. Furthermore, treatment guidelines need to consider patients' preferences and barriers when setting goals for treatment.
authors.affiliation: Veterans Affairs Center for Practice Management & Outcomes Research, Ann Arbor, MI, USA. svjan@umich.edu
authors.forename: S
authors.initials: S
authors.lastname: Vijan
authors.forename: N S
authors.initials: NS
authors.lastname: Stuart
authors.forename: J T
authors.initials: JT
authors.lastname: Fitzgerald
authors.forename: D L
authors.initials: DL
authors.lastname: Ronis
authors.forename: R A
authors.initials: RA
authors.lastname: Hayward
authors.forename: S
authors.initials: S
authors.lastname: Slater
authors.forename: T P
authors.initials: TP
authors.lastname: Hofer
mesh_terms: D003924:Diabetes Mellitus, Type 2 / Q000178:diet therapy*; D005260:Female; D017144:Focus Groups; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012648:Self Care / Q000379:methods; D018881:Suburban Health; D014504:Urban Health