Association between physical activity knowledge and attitude on diabetes among normal weight and overweight/obese type-2 diabetic patients: a rural community-based cross-sectional study

Background Physical activity is one of the most important regimens for the treatment of diabetes. Hence, we aimed to examine the association between physical activity knowledge (PAK), knowledge and attitude on diabetes among rural T2DM patients. Objectives The PAK, knowledge and attitude on diabetes were targeted to evaluate in rural Indian T2DM patients. Methodology A cross-sectional community-based survey was carried out with eighty-four patients with known T2DM in rural population of India Results Among 84 patients, 46 were overweight/obese and 38 patients with normal weight were participated in our study. The odds of smoking were found to be a significant socio-demographic risk factor (OR: 4.42, 95% CI 0.93–20.33 and P<0.001) compared to non-smokers. The PAK categories such as A, B & D had associated with BMI. The OR, 95% CI and P. Value are (5.610, 2.18–14.38 and P<0.001; 1.72, 0.72–4.12 and P 0.030; 2.55, 1.05–6.20 and P 0.047) except in category C. Iilliterates, low annual income, poor knowledge on T2DM and negative attitude, OR (4.50; 12.87; 10.80 and 47.66) were reported disagree or don't know with PAK questionnaire. Conclusion The results have impact on the design of new education programs will assist in preventing and managing complications related to T2DM.


Introduction
Type 2 diabetes mellitus (T2DM) in an ever-growing ma-jor epidemic lifestyle disease, according to the international diabetes federation (IDF), diabetes atlas (2015). It is predicted that the number of adults with diabetes will increase to more than 640 million by 2040. The numbers will be increased highly in low & middle-income countries 1 . This is probably because of the staggering rise in obesity. Diabetes has manifested as a global epidemic. The change in life expectancy and lack of improvement in healthcare are in part responsible for the astounding rise in the incidence of this disease. Even in rural India, the population is undergoing lifestyle transitions due to socioeconomic growth which can also be a reason for the increasing incidence of diabetes in rural areas 2 .

African Health Sciences
Physical activity is the cornerstone of lifestyle modification aimed at preventing and managing T2DM and its related morbidities. Physical activity has been shown to improve glycemic control via increasing insulin sensitivity and glucose tolerance 3 . The evidence from randomized control trials has been demonstrated that maintenance of modest weight loss through physical activity and low carbohydrate diet reduces thencidence of T2DM up to 40-60% 4 . This is more effective than pharmacological interventions5. The risk of mortality is also reduced in individuals with T2DM 6 . Therefore, they are required to follow certain self-care practices to achieve optimal glycemic control and prevent complications. These practices include regular physical activity, appropriate dietary practices, daily foot care practice, compliance with the treatment regimen, and tackling complications such as hypoglycemic episodes 7 . Thus, the objective of this study was (i) to assess the physical activity knowledge, knowledge & attitude on diabetes disease among the rural type 2 diabetic population, (ii) to identify the valuable demographic and lifestyle factors that possibly influence the association between physical activity knowledge (PAK) among normal weight and overweight/obese patients and (iii) to examine the association between PAK and body weight, knowledge and attitude on diabetes disease and body weight of the study participants. So, this study will serve as a benchmark for future comparisons to assess the effectiveness of any educational training program for diabetic patients.

Materials & methods Participants
A rural community based cross-sectional study was conducted during the January to March-2020.The patients willing to participate in the study were either gender with T2DM. The patients with less than one year of history of diabetes, pregnant women's with diabetes and the subjects unwilling to give interview were excluded from the study.

Materials
In our study we adopted The PAK questionnaires8, consisting of 20 questions, and these were categorized into four types (Category A, B, C & D). The Category-A questionnaires consist of (1-4) knowledge pertaining to physical activity benefits, Category-B questionnaires consist of (5-9) knowledge pertaining to health benefits of physical activity in respect of DM, category-C questionnaires consist of (10-11) knowledge pertaining to details of physical activity for diabetes treatment and category-D questionnaires consist of (12-20) knowledge pertaining to physical activity conferring health benefits. The choices of response for questionnaires were ''Agree/Yes'', ''Disagree/ No'', and ''Don't know''. The participants scored one point for each correct response and zero for an incorrect or ''I don't know/No'' response. The respondent's score out of each determined his or her degree of understanding of the influences of PAK on diabetes-related health.
The linguistic, validated questionnaires were tested on enrolled subjects. Physical Activity Knowledge (PAK) questionnaires: 8. Agree /Yes = 1 Point Disagree/No = Zero Point Don't Know = Zero Point Category A. Basic understanding of physical activity benefits 1.
Do you believe the physical activity of a single session of 30 min per day is sufficient (T) 2.
Do you believe greater health benefits can be achieved by increasing the amount (duration, frequency, or intensity) of physical activities (T) 3.
Do you believe performing physical activities only on weekends is enough to achieve health benefits? (F) 4.
Do you believe performing vigorous physical activities for 3 hours once a week is enough to experience health benefits? (F) Category B. Health benefits of physical activity in respect of diabetes 5.
Do you believe physical activity most days of the week can provide health benefits? (T) 6.
Do you believe physical activity alone will provide health benefits? (F) 7.
Do you believe patients with Type 2 diabetes should be physically active at least 5 days a week? (T) 8.
Do you believe patients with Type 2 diabetes should avoid exercising in the evening? (T) 9.
Do you believe regular exercise or being physically active helps to control your diabetes? (T) Category C. Details of physical activity for diabetes treatment 10.
Do you believe patients with Type 2 diabetes should have resistance training that involves all major muscle groups? (T) 11.
Do you believe resistance training can improve insulin resistance and increase insulin sensitivity? (T) Category D. Physical activity conferring health benefits Which of the following physical activities do you believe will provide health benefits? 12.
Weightlifting? (T) Have you ever heard of diabetes? 2.
Do you know what glucose tolerance test is? 3.
Do you know how to measure diabetes? 4.
Do you know diabetes can cause eye disease? 5.
Do you know diabetes is a genetic disease? 6.
Do you know exercise can be helpful to prevent diabetes? 7.
Do you know that reducing carbohydrate intake can reduce diabetes? 8.
Do you know that reducing sugar intake, reduce diabetes? 9.
Do you know diabetes can be controlled by avoiding smoking? 2.
Family /friends/ healthcare professionals expect me to do exercise 2.
Family /friends/ healthcare professionals expect me to follow a diabetic diet 3.
Family /friends/ healthcare professionals expect me to lose weight 4.
Do you know the value of exercise 5.
Do you know the value of following a diabetic diet 6.
Do you know the value of losing bodyweight 7.
Up to you whether to do exercise 8.
Up to you whether to follow a diabetic diet 9.
Up to you whether to lose bodyweight

Statistical analysis
The data entry and analysis were performed using IBM SPSS software version 2.0. The descriptive statistics such as frequencies and percentage were analyzed using Chi-square test. The levels of PAK among subjectswere assessed between PAK questionnaires and socio-demographic variables using odds ratios (OR) and 95% confidence interval (CI). Similarly, subjects were stratified based on BMI and assessed for the association.

Ethical consideration
Approval for this study was obtained from the Institutional Ethics Committee, Endo-life specialty Hospital (IEC-ESH), Guntur. Participation was voluntary and written informed consent was obtained from each participant.

Results
In our study the socio-demographic details (   Table 2 represents association between PAK &socio-demographic variables. Allvariables are having statistical association (P < 0.05) with PAK (Disagree/don't know/ No) i.e., poor PAK among the variable subjects. Illiterates, low annual income, poor knowledge on diabetes and negative attitude on T2DM of odds ratios (4.50; 12.87; 10.80 and 47.66) were reported as disagree or don't know with PAK questionnaire. Table 3: Shows the relationship between BMI (Overweight/Obese and Normal weight) and categories of physical activity knowledge. The respondents for PAK questionnaire categories (A, B, C and D) were stratified based on BMI. The patients with overweight/obese were more likely to have poor (Disagree/don't know/No) PAK in all categories, except Category-C. The odds ratio (OR), 95% CI and P. Value are (5.610, 2.18-14.38 and P<0.001; 1.72, 0.72-4.12 and P 0.030; 2.55, 1.05-6.20 and P 0.047). The overweight/ obese patients had statistically significant association with poor (Disagree/don't know/ No) PAK except category-C questionnaires.

Discussion
The present study was carried out to assess the PAK, knowledge and attitude on diabetes among normal-weight & overweight/obese patients with known diabetes residing in the rural area of Guntur, Andhra Pradesh, India. Most of the study participants were in the age range of 40-65 years old, which was nearly same populations in studies done by Priyanka and Shah et al 10, 11 . In our study there are 33.3% of illiterates as compared to 36.6% in Shah et al 11 . Therefore, to create awareness regarding the importance of education as well as patient education and lifestyle interventions are essential to maintain good health. The overall PAK was 66.6% in our study and patients agreed with our questionnaires and which was similar to Chennai Urban Rural Epidemiology Study (CURES-9)9 and which also reflect poor knowledge and attitude on the disease 69%.53% of which was observed in the study conducted by Shah et al 11 about sociodemographic variables. The physical activity knowledge is associated with disagree/ don't know/No among socio-demographic variables, the KAP score was significantly associated with occupation and BMI, which was similar to T. Bhurosy et al. 12 . Several studies conducted in the rural community of Bangladesh showed that there is a significant association between higher body mass index (BMI) and attitude of diabetes disease 13 , like wise our study population with obesity/overweight are had poor knowledge on T2DM, and the results were similar with the study conducted in Pretoria 14 and they had positive attitude towards T2DM. Gul N et al 15 were also noticed that, the knowledge, attitude and practice scores were low in their study. Those are similar with our study.
Our study has limitations due to moderate sample, which may limit generalisation of the findings. Nevertheless, there is a need of education strategies to improve PAK and knowledge and attitude on T2DM among the rural population. The efforts can improve diabetes related consequences and hazards.

Summary
In a nutshell, the results may give a true reflection on overweight/obese patient's socio-demographic status and PAK.As evidenced by the study, it was noticed that the socio-demographic variables are statistically influenced by PAK and gender. The PAK was associated with BMI. Normal weight patients were having good PAKand also having good knowledge on diabetic disease along with they have a negative attitude on the diabetic disease. In addition to our summary, there is a much need for patient education on PAK, as well as knowledge on the diabetic disease, is very much essential in order to maintain good health. Moreover, in rural areas where education and information are not readily accessible, there is a greater chance poorer perception and practices. Therefore, efforts should be directed towards developing and making education programs to empower the personswith diabetes. This will enable the patients to change their attitude towards management of diabetes. It is hoped that these findings have major implications for the design of a patient education program which helps to prevent further complications related to the diabetic disease.