DOI: 10.5061/dryad.sqv9s4n2n
title: Dietary intake among urban adults with diabetes: COPEN (Colombian Nutritional Profiles), a cross-sectional study

description: Objectives: The prevalence of diabetes is increasing rapidly in developing
 countries. We aimed to estimate the prevalence of diabetes and to describe
 its main correlates and associated dietary intake in urban adults from
 Colombia. Setting: The Colombian Study of Nutritional Profiles (COPEN) was
 a population-based, cross-sectional, multi-stage probabilistic sampling
 survey designed to represent the five main Colombian cities. Participants:
 Between June and November 2018, we studied 736 non-pregnant participants
 aged 18 or older. Diabetes was defined as a random plasma glucose ˃= 200
 mg/dL, self-reported prior diagnosis of diabetes or use of any oral or
 injectable antidiabetic agent(s). Participants also fulfilled a detailed
 157-item food frequency questionnaire (FFQ). Primary and secondary outcome
 measures: Prevalence of diabetes, dietary intake of key nutrients,
 achievement of dietary goals among individuals with diabetes. Results: The
 overall estimated prevalence of diabetes was 10.1%, with no difference by
 sex (9.6% in women, 10.8% in men, p=0.43). Socioeconomic level (SEL)
 correlated positively with diabetes prevalence, the absolute difference in
 prevalence for the highest vs lowest SEL was 5.6%. The association between
 diabetes and education level depended on sex, diabetes was more prevalent
 among more educated men and less educated women. Abdominal obesity was
 associated with a 65% increase in diabetes prevalence among men, and a
 163% increase in women. The proportion of non-achievement of dietary
 intake goals among participants with diabetes was 94.4% for saturated
 fats, 86.7% for sodium, 84.4% for fiber and 80% for trans fats. In
 multivariate logistical regression models, age was the strongest
 independent correlate of diabetes. Conclusions: Self-reported
 diabetes was highly prevalent among Colombian adults, much more than
 described in most official reports. There were large differences by
 abdominal obesity status, region of residence, SEL and educational level.
 The proportion of individuals with diabetes meeting dietary
 recommendations was alarmingly low.
description: COPEN (Estudio Colombiano de Perfiles Nutricionales – Colombian
 Study of Nutritional Profiles) was a population-based, cross-sectional,
 multi-stage sampling survey designed to represent five cities, one from
 each of Colombia´s major regions: Bogotá (Central plateau), Barranquilla
 (Caribbean region), Cali (Pacific region), Medellín (Northwest or
 "paisa" region) and Bucaramanga (Northeast/Andean region). The
 sampling frame was obtained from the last census of the Colombian
 population, cartography was obtained from the national geostatistical
 frame developed by the Colombian National Department of Statistics
 (Departamento Administrativo Nacional de Estadística - DANE) and data on
 socioeconomic level (SEL) came from the National Superintendence of Public
 Services. In the first stage of sampling we selected cartographic sectors,
 within sectors we selected blocks (on average 8 per cartographic sector),
 within blocks we selected households, and within households we selected
 individual participants. Within each household, individuals were randomly
 selected employing a Kish grid. The sample was stratified by city, sex,
 age group and SEL. With this design and including the design effect, the
 complete study sample yielded an overall sampling error of 2.2%. The
 sampling errors for each city were respectively: Bogotá 4.0%, Medellín
 5.0%, Cali 5.0%, Barranquilla 5.6% and Bucaramanga 6.8%. We excluded
 foreigners living in Colombia, individuals in hemodialysis or peritoneal
 dialysis therapy and persons with disabilities that precluded a reliable
 fulfillment of the study questionnaire. The complete study for COPEN was
 1942 individuals, from which a random subsample of 736 non-pregnant
 participants aged 18 or older (representing 47.8% of all non-pregnant
 adults in COPEN) participated in the analyses reported in this
 paper. Information was captured using a tablet device
 containing digital forms with proper validation rules, developed for the
 study. All staff in charge of data collection was extensively trained by
 the study Principal Investigator. A random 10% of participants were
 re-contacted by phone in order to double-check the accuracy of the
 information provided on date of birth, sex, city of residence, marital
 status, job status, educational level and date of initial contact. All
 data were collected between June and November 2018.
 Patient and Public Involvement Patients were
 not involved in the design of the study, but aggregated results will be
 presented to local and national authorities to inform public health
 policies concerning nutrition and primary prevention of
 diabetes. Measurements We collected
 information on sex, date of birth, SEL, marital status, educational level
 and employment status using a standardized questionnaire. The SEL that we
 employed for analyses was the one registered in DANE for that particular
 block. After a brief introduction about the importance of the accuracy of
 the measurements to be performed, we measured height and weight in all
 participants, and waist circumference in patients aged 18 and older.
 Height was measured using a portable stadiometer supported on a firm
 surface, taking care that the patient was barefoot, standing right and
 with heels and calves touching the stadiometer. Weight was measured in a
 solar digital scale with 100g sensitivity and 200 Kg capacity, all study
 scales were calibrated simultaneously the day before the study start, and
 every week afterwards. Waist circumference was measured by a sitting
 observer, directly over the participant´s skin, at the midpoint between
 the las rib and the anterosuperior iliac crest, using a flexible metallic
 measuring tape. All measurements were performed in duplicate, and if there
 was a between-measures discrepancy greater than 1 cm for height, 100g for
 weight or 1 cm for waist circumference, a third measurement was collected.
 For analyses we used the average of each anthropometric measure.
 Socioeconomic level is classified in Colombia by the Statistics
 Department DANE in 6 strata according to characteristics of the residence
 (with stratum 1 being the lowest and stratum 6 being the highest) (19).
 Residential dwellings are classified according to their physical
 characteristics and environment. The methodology for this classification
 creates homogeneous strata taking as input information about land use,
 public utilities, access routes, topography, land valuation and property
 characteristics. The stratification unit is the sub-zone, corresponding
 generally to a block. Residential dwellings are classified in the
 predominant stratum of the sub-zone, as long as their characteristics do
 not differ ostensibly from the predominant conditions in the group.
 Otherwise, they are considered outliers and their stratum is assessed
 based on their particular characteristics. This information is very well
 established, updated and freely accessible for all the country. Given that
 sociodemographic, income and human development indicators are more similar
 for individuals living in strata 4 to 6 than among the other strata (19),
 we analyzed SEL in three groups, corresponding to strata 1-2 (low SEL), 3
 (medium SEL) and 4-6 (high SEL). We interpreted BMI according to the cut
 points proposed by the World Health Organization (WHO): Underweight
 (BMI˂18.5 Kg/m2), normal weight (BMI &gt;=18.5 and ˂25 Kg/m2),
 overweight (BMI&gt;=25 and ˂30 Kg/m2) and obesity (BMI&gt;=30
 Kg/m2). We defined abdominal obesity as a waist circumference &gt;=
 90cm for women, and &gt;= 94cm for men, according to the proposed
 cutoffs for Latin American adults (20). Capillary blood
 specimens were collected by trained staff following standardized
 procedures, blood glucose levels were promptly measured and registered
 using an Accu-Check meter. Since fasting could not be guaranteed, we
 considered that an individual had diabetes if he/she met one of these
 three conditions: 1. A capillary blood glucose level ˃= 200 mg/dL, 2. A
 self-reported prior diagnosis of diabetes or 3. Self-reported use of any
 oral or injectable antidiabetic agent (s). Usual
 dietary intake was assessed employing a 157-item semi-quantitative
 food-frequency questionnaire (FFQ). The FFQ was an enhanced and adapted
 version of an earlier FFQ specifically designed for the Colombian
 population (21). In a prior validation against four independent 24-hour
 dietary recalls, a shorter version of the FFQ showed a percent of
 classification in the same quartile of nutrient intake between 61 and 83%,
 and Pearson correlation coefficients between 0.51 for protein and 0.77 for
 carbohydrate (I). Portion sizes were established according to the
 reference unit most frequently consumed for each food. There were 9
 possible ingestion frequencies: i. Never, ii. One to three times/month,
 iii. At least once/week, iv. Two to four times/week, v. Five to six
 times/week; vi. Once a day, vii. Two to three times a day, viii. Four to
 five times a day and ix. Six or more times a day. Participants were asked
 to make their selections based on their usual intake over the last year.
 FFQs were individually administered by study staff. The nutrient
 contribution of each food was calculated according to composition tables
 by the Colombian Institute for Family Welfare (Instituto Colombiano de
 Bienestar Familiar - ICBF), the United States Department of Agriculture
 and manufacturer´s information. Data analysis
 All prevalence estimations were projected to the target study
 population using city, sex, age group and SEL-specific expansion factors
 according to the study multi-stage sampling design. We did not have any
 missing data points for the analyses reported in this paper
 (sociodemographic factors, diabetes status and dietary intake variables).
 The univariate associations between nominal predictors and diabetes status
 were examined using chi-square independence tests. To test for a linear
 trend in the association between ordinal predictors and diabetes status,
 we report the p-value associated with a rank-correlation (Spearman) test
 between predictor and outcome. We also ran multivariable logistical models
 in which sex, age group, SEL and educational level were the independent
 variables and diabetes status was the outcome. We initially compared mean
 consumption of macronutrients and micronutrients of interest between
 individuals with or without diabetes using a one-way ANOVA, with diabetes
 as fixed factor. Since a higher BMI is associated with diabetes risk and
 also with a higher dietary nutrient intake, we performed multivariable
 linear regression analyses in which age, sex, BMI, SEL and diabetes status
 were the predictors and the daily consumption of each nutrient was the
 dependent variable (one model per nutrient). We explored the achievement
 of dietary recommendations among individuals with diabetes, expressed as
 the percent of individuals with diabetes who met the protein (˃=15% of
 total caloric intake [TCI]), saturated fat (SFA) (˂7% of TCI),
 monounsaturated fat (MUFA) (˃=12% of TCI) and trans fat (˂1g/day)
 recommendations set by the by the Latin-American Diabetes Association (22)
 and the fiber (14 g per each 1,000 Calories) and sodium (˂2300 mg/day)
 goals set by the American Diabetes Association (23). In order to explore
 factors associated with achievement of dietary goals, we also built a
 series of nested multivariable logistic models, in  which achievement of
 each dietary goal was the outcome. Model 1 had as predictors only sex and
 age, model 2 had all variables in model 1 plus SEL, model 3 had all
 variables in model 2 plus city, model 4 had all variables in model 3 plus
 BMI, and model 5 had all variables in model 4 plus diabetes status. All
 analyses were performed in SPSS for Windows, v.21 (Cary, NC,
 USA). Ethical aspects All
 participants provided written informed consent. All study procedures were
 performed according to the principles of the Helsinki Declaration, and to
 local rules and regulations as provided by Resolution 8430 of 1993 of the
 Colombian Ministry of Health. The study was approved by the IRB of
 Universidad de los Andes (Comité de Ética de la Vicerrectoría de
 Investigaciones), according to minute 1016 of April 27, 2018. 
description: Please see the attached EXCEL file "Variable list COPEN
 Diabetes" to see the type and labels of variables in the
 dataset.