Factors associated with dietary and exercise compliance among elderly with chronic conditions of hypertension and type 2 diabetes mellitus residing in rural areas of coastal Karnataka: A community-based cross-sectional study

Abstract

BACKGROUND:

Compliance with diet, exercise regimen, and medication is vital to maintain an acceptable range of blood pressure and glycemic level among elderly with hypertension and diabetes mellitus. However, these are considered to be more challenging tasks among elderly. The aim of this study is to identify dietary and exercise compliance among elderly with hypertension and type 2 diabetes mellitus and to find its influencing factors.

MATERIALS AND METHODS:

The community-based survey was done in rural areas of five randomly selected clusters of primary health centers (PHC) using PPS sampling technique. After ethical clearance, a total of 360 consented participants residing in selected clusters were interviewed using pre-designed rating scale and questionnaire on dietary and exercise compliance, respectively. In this study, compliance refers to practicing prescribed diet and exercise regimen regularly by the elderly with HTN and T2DM. The data were analyzed using SPSS version 16.0.

RESULTS:

Eighty percent (n = 287) of study participants had moderate adherence to diet and only, 37.8% (n = 136) of them practice physical exercise. A Chi-square test report confirmed that there is a significant association (P < 0.05) between dietary compliance and level of education, occupation, family income, procurement of insurance, poor memory, multiple functional impairments, duration of hypertensive, and diabetes illness. Exercise compliance is influenced by factors such as gender, level of education, family income, and procurement of insurance (P < 0.05).

CONCLUSION:

Adherence to diet and exercise among elderly with chronic conditions are influenced by various socio-demographic or environmental, poor health or physiological and cognition or psychological factors.

Introduction

Prevalence of chronic disease conditions are increasing among old age people, and it increases with age. Further, these diseases are considered to be the leading cause of death across the globe.[1] According to evidences, it is expected to have a rise in hypertension prevalence among Indian men by 22.9% and women by 23.6% by the year 2025 from 20.6% to 20.9%, respectively, in 2005, and also the prevalence of type 2 diabetes mellitus is predicted to affect 79.4 million people in India by the year 2030.[2,3]

Non-adherence to the therapeutic regimen for hypertensive and diabetic illness can lead to disease-associated complications such as stroke, renal disease, peripheral neuropathy, and retinopathy, which might eventually cause unwanted death among elderly population.[4,5] Lifestyle factors play a vital role in maintaining and controlling blood pressure and glycemic level among elderly with hypertension and diabetes mellitus.[6,7,8]

However, there are certain factors that determine the compliance on physician prescribed dietary and exercise regimen among patients, and these factors could be classified into four categories which include socio-demographic conditions, cognitive level, interpersonal relations, and unintentional or others.[9] Although many evidences from field research and systematic reviews had proven that the lifestyle interventions such as regular physical activity, diet control including restriction of sodium intake and alcohol consumption, and stress reduction have an greater positive impact on lowering blood pressure and glycemic level,[10,11,12,13,14,15,16,17] only a countable number of elderly patients are integrating these into their regular treatment practices along with other pharmacological therapy due to certain risk factors associated with non-compliance, including their cognitive impairment.[18,19] Hence, this study intended to specifically assess the factors associated with dietary and exercise compliance among elderly with chronic conditions of hypertension and type 2 diabetes mellitus. Understanding these factors might help the health care professionals to give patient-specific recommendations which will further lessen the disease-associated complications and mortality.

Materials and Methods

Study design and setting

This community-based cross-sectional study used quantitative approach to identify the dietary and exercise compliance among elderly and to determine the factors associated with diet and exercise compliance among elderly with chronic conditions of hypertension and diabetes mellitus residing in rural areas of coastal Karnataka.

Study participants and sampling

The study was conducted in rural areas that are covered under five randomly selected primary health centers (PHC) in Udupi District, Karnataka, India. A total of 360 elderly were interviewed, and the sample size was calculated scientifically based on the pilot study report. The study used probability proportional to size sampling technique (PPS sampling) to identify the five random (sampled) clusters from selected seven primary health centers during the first stage of study. The study chosen this method of sampling, as there are only limited elderly with both the conditions of HTN and DM in which size measure was identified for seven cluster units and the scientific method is used for the probability of selecting five units proportional to its size. The identified PHC clusters/units were Hirebettu, Pernankila, Peradoor-Kukkehalli, Kolalagiri, and Pethri, and the study proportionally recruited 72 samples from each cluster which accounts for 360 from the population estimates of all clusters of 874.

The elderly with chronic illnesses of hypertension and diabetes mellitus aged 60 years and above living in selected rural clusters were included in the study and approached them using purposive sampling technique within clusters. This study excluded the elderly who were diagnosed and taking treatment for illnesses such as chronic kidney disease, cancer, tuberculosis, and HIV/AIDS as these diseases demand varied and complex dietary regimens.

Data collection tools

Validity

The rating scale to assess the dietary compliance and the questionnaire on exercise compliance was developed by the primary investigator based on the extensive review of literatures, and it was given to seven experts from the field of community medicine, pharmacy practice, and medical surgical nursing to establish validity. The items were retained in the tool based on the calculated content validity index (CVI), and all necessary modification was done based on the suggestion given by the validators and subject experts. Initial tool on rating scale on dietary compliance had 25 items, and five items were removed as they had CVI score less than 85% and based on the suggestion from the subject experts. Hence, the final tool consisted of 20 items. While, the questionnaire on exercise compliance had five items and all items were retained after the validation as they had 100% content validation index.

To establish the language validity, the research tools were translated into regional language of Kannada (official language of Karnataka) by the language expert and retranslated back to English by another expert, and there was no discrimination found in the meaning or sentence construction between tools.

Reliability

The validated research tools in Kannada language were administered to 20 samples to establish reliability, and the computed reliability score of rating scale on dietary compliance using Cronbach’s alpha method was 0.90 (n = 20). The test–retest method (intra-item correlation co-efficient) was used for testing reliability of questionnaire on exercise compliance, identified overall reliability score was 0.92 (n = 20), and item-wise reliability score for item 2 was (r = 0.97); item 3 (r = 0.77); item 4 (r = 0.99), and item 5 (r = 0.98).

Descriptions

Rating scale to assess dietary compliance

The final tool consisted of 20 items, each item in the tool had five options, all positive items which denote healthy dietary behavior in the tool were scored from 5 to 1, and negative items were scored in reverse order. Final scores were classified arbitrarily into four categories.

Questionnaire on exercise compliance

The five-items short questionnaire on exercise compliance had the first item as general descriptive question on their daily routines that contributes to some exercise which considered to be the leading question for the next item on “time duration” that they normally spend on each activity. Followed by that, the questions on practice of regular physical exercise such as type (this item allowed multiple response from the participants), frequency, and duration of performing exercise were included.

Data collection procedure

After obtaining permissions from district authorities and medical officer, primary health centers, the pilot study was conducted among 40 elderly in same research settings using PPS sampling method to identify the feasibility of conducting the present study using selected methodology.

The data collection was carried out from mid of December 2019 to end of February 2021. The written informed consent was obtained after explaining the study details based on the patient information sheet (PIS form) and fully understood by the elderly those who met the inclusion criteria and were available at the time of house visit. The study included the elderly people aged ≥60 years living in selected clusters and diagnosed and taking prescribed treatment/therapeutic regimen for the conditions of HTN and T2DM and excluded those who had other major illness such as cancer, chronic kidney disease, and infectious diseases such as tuberculosis, HIV/AIDS, and the elderly living with any other illness which had varied and complex treatment regimen or strategies. The consented participants were interviewed on their dietary and exercise practices using pre-structured and reliable questionnaires by the primary researcher. The quality of data was cross-verified by other two co-investigators.

Ethical consideration

The study was conducted in line with the Declaration of Helsinki and obtained Institutional Ethical Clearance from committee at KMC and KH Manipal (IEC No: 487/2018). This study also was registered in Clinical Trials Registry of India (No: CTRI/2018/10/015962). The study included the participants those who were consented to be part of the study and provided written informed consent.

Statistical analysis

The coded data were entered in SPSS version 16.0 and analyzed. The entered data were also cross-checked by doing random check of the responses against the filled questionnaire for its accuracy. The dietary and exercise compliance scores of the elderly were analyzed using both descriptive and inferential statistics.

Results

Sample characteristics

The study had included all 360 responses for the analysis. The mean age of study participants was 69.2 years (σ =7.31), most of them (63.9%; n = 230) were between the ages 60 and 70 years, and more than 60% (n = 223) of them were female. 74.4% (n = 268) had completed their primary or secondary/higher secondary school education. A limited number of elderly were employed or self-employed (16.9%’ n = 61); above the poverty line (APL card holders) in India (36.1%; n = 130) and not enrolled in any government or private insurance scheme (38.1%; n = 137).

Most of the study participants were (55.3%; n = 199) living with multiple age-related functional disablements such as diminishing vision (82.2%; n = 296), poor memory or forgetfulness (42.8%; n = 154), poor hearing ability (31.9%; n = 115), and physical disability (20.6%; n = 74). Majority of them were reported that they are diagnosed and taking treatment for hypertensive (65.8%; n = 237) and diabetic illness (69.7%; n = 251) for less than or equal to ten years. The median duration of hypertensive and diabetic illness among elderly is 8 years, and the IQR is 10 years and 8.75 years, respectively.

Dietary compliance among elderly with chronic conditions of hypertension and diabetes mellitus

The data presented in pie Figure 1 displayed that most of the elderly with chronic conditions (80%; n = 287)) were having moderate adherence to prescribed diet for their health conditions of hypertension and diabetes mellitus by the health care provider.

Figure 1.

Dietary compliance among elderly with chronic conditions of hypertension and type 2 diabetes mellitus

Exercise compliance among elderly chronic conditions of hypertension and diabetes mellitus

The result depicted that 320 (88.9%) among 360 elderly have informed that they carry out daily activities which involve some amount of walking inside or outside the house or community. Further, they involved in cooking-related activities at home (51.9%; n = 187); ironing their own or relative’s clothes (4.4%; n = 16); and gardening their backyard (47.2%; n = 170). In addition, a considerable number of participants reported that they involve in other household activities (43.6%; n = 157) such as washing and drying cloths, washing kitchen utensils, cleaning their own house and surroundings, taking care of their animal pets, and working in their farming field.

Average time spent on the above-mentioned daily activities was computed using the central tendency measure of median and interquartile range (IQR) as the variable showed the deviation from 0 to 740 minutes and found that 32.2% (n = 116) elderly spend 61–180 minutes (1–3 h) per day for all their daily routine activities which contributes some amount of exercise to their body. The median time taken for such activity is calculated to be 180 minutes (3 h) and IQR is 220.

However, only a limited number of participants were reported to practice physical exercise (37.8%; n = 136) in addition to their daily routines and the remaining 62.2% (n = 224) were not performing any exercise activities except their household routines. Among those who were practicing regular physical exercise, 26.1% (n = 94) of them reported to go for a brisk walk; perform active exercise (10.0%; n = 36); yoga (1.1% (n = 4); involved in sports activity (0.3%; n = 1), and rekhi (0.3%.; n = 1). Limited elderly (3.33%; n = 12) are involved with multiple physical exercise activity, that is, brisk walk and yoga/exercise. It is also found that only 29.4% (n = 106) of them daily perform physical exercise for the duration of 15 minutes (12.5%; n = 45) and 30 minutes (12.8%; n = 48) [Table 1].

Table 1.

Frequency and percentage of practice of physical exercise among elderly with chronic illness (n=360)

Variables	Frequency (f)	Percentage
Practicing physical exercise as per physician suggestion
Yes	136	37.8
No	224	62.2
*Type of exercise activity involved by the elderly
Brisk walk	94	26.1
Exercise at home	36	10.0
Yoga	4	1.1
Brisk walk/exercise/yoga**	12	3.33
Sports activity	1	0.3
Others	1	0.3
Frequency of performing physical exercise
Daily	106	29.4
<3 times per week	10	2.8
≥3 times per week	07	1.9
Once a week	0	0
Rarely, when I find time	13	3.6
Duration of performing physical exercise
15 min	45	12.5
30 min	46	12.8
1 h	29	8.1
>1 h	16	4.4
None	224	62.2

*Study participants were given multiple responses. Hence, the total number is varied. **Elderly practicing all three physical exercise activities of brisk walk/exercise and yoga

Determinants of dietary and exercise compliance among elderly with hypertension and diabetes mellitus

A Chi-square test of independence was confirmed that there is a significant association between dietary compliance and level of education (χ² = 16.2; P = .039;); occupation (χ² = 13.9; P = .007); family income (χ² = 12.7; P = .002); procurement of insurance (χ² = 21.6; P = .000); poor memory (χ² = 9.2; P = .010); multiple functional impairments (χ² = 6.1; P = .045); duration of hypertensive illness (χ² = 9.4; P = .009); and diabetic illness (χ² = 7.3; P = .025). Therefore, it is evident that dietary compliance among rural elderly with chronic conditions is influenced by various personal and clinical factors, and they are less likely to follow their physician prescribed hypertensive and diabetic diet. It is also estimated uncertainty co-efficient value of different determinants such as level of education (.038; 3.8%); occupation (.032; 3.2%); family income (.029; 2.9%); procurement of insurance (.046; 4.6%); poor memory (.020; 2.0%); multiple functional impairments (.010; 1.0%); duration of hypertensive illness (.156; 15.6%); and diabetic illness (.146; 14.6%) with dietary compliance, and it confirms the percentage of involvement of various factors in maintaining dietary compliance among elderly. And, this study found that the age of elderly person, vision or hearing impairment, and presence of physical disability does not affect (P > 0.05) the dietary compliance among them [Table 2].

Table 2.

Factors associated with dietary compliance (n=360)

Variables	High adherence to diet		Moderate adherence to diet		Low adherence to diet		χ2 (df)	P
Age in years
60–70	28	7.77	183	50.8	19	5.27	0.281(4)	0.991
71–80	12	3.33	80	22.2	7	1.94
>81	4	1.11	24	6.66	3	0.83
Gender
Male	18	5	104	28.8	15	4.16	2.853(2)	0.240
Female	26	7.22	183	50.83	14	3.88
Educational status:
Illiterate	5	1.38	64	17.77	2	0.55	16.282(8)	0.039*
Primary school education	16	4.44	127	35.27	18	5
Secondary/higher secondary	17	4.72	81	22.5	9	2.5
Diploma/graduate	6	1.66	14	3.88	0	0
Postgraduate	0	0	1	0.27	0	0
Present occupation:
Employed/self-employed	4	1.11	46	12.77	11	3.05	13.969(4)	0.007*
Not employed	40	11.11	241	66.94	18	5
Family income status
Below poverty line (BPL)	20	5.55	185	51.38	25	6.94	12.783(2)	0.002*
Above poverty line (APL)	24	6.66	102	28.33	4	1.11
Obtained insurance scheme (Government/private)
Yes	30	8.33	101	28.05	6	1.66
No	14	3.88	186	51.66	23	6.38	21.649(2)	0.000*
Functional status
Diminishing vision
Yes	38	10.55	238	66.11	20	5.55
No	6	0.16	49	13.61	9	2.5	4.100(2)	0.129
Diminishing hearing ability
Yes	17	1.94	88	24.44	10	2.77	1.209(2)	0.546
No	27	7.5	199	55.27	19	5.27
Diminishing memory
Yes	28	7.77	116	32.22	10	2.77	9.289(2)	0.010*
No	16	4.44	171	47.5	19	5.27
Physical disablement
Yes	13	3.61	55	15.27	6	1.66	2.518(2)	0.284
No	31	8.61	232	64.44	23	6.38
Number of functional disablements
Live with more than one or multiple impairment (>1)	32	8.88	152	42.22	15	4.16	6.190(2)	0.045*
Live with single impairment (<1)	12	3.33	135	37.5	14	3.88
Duration of hypertensive illness (in years)
≤10 years	20	5.55	196	54.44	21	5.83	9.454(2)	0.009*
>10 years	24	6.66	91	25.27	8	2.22
Duration of diabetic illness (in years)
≤10 years	23	6.38	208	57.77	20	5.55	7.384(2)	0.025*
>10 years	21	5.83	79	21.94	9	2.5

This test also had proved that there is an influence of certain socio-demographical factors such as gender (χ² = 6.3; P = .012); level of education (χ² = 46.7; P = .000); family income (χ² = 20.2; P = .000); and procurement of insurance (χ² = 8.7; P = .003) on practice of regular exercise regimen among rural elderly with hypertension and diabetes mellitus. It is also predicted through uncertainty co-efficient value of various determinants such as gender (.013; 2.3%); level of education (.102; 10.2%); family income (.042; 4.2%); procurement of insurance (.018; 1.8%); with practice of physical exercise, and it confirms percentage of involvement of particular factor in maintaining exercise compliance. However, it is not influenced (P > 0.05) by the other factors such as age, occupation, diminishing vision, hearing and memory, duration of illness, and number of physical disablement [Table 3].

Table 3.

Factors associated with exercise practice among elderly (n=360)

Variables	Not practice physical exercise		Practice physical exercise		χ2 (df)	P
Age in years
60–70	142	39.44	88	24.44
71–80	60	16.66	39	10.83	1.142 (2)	0.565
>81	22	6.11	9	2.5
Gender
Male	74	20.55	63	17.5	6.338 (1)	0.012*
Female	150	41.66	73	20.27
Educational status
Illiterate	58	16.1	13	3.6	46.723 (4)	0.000*
Primary school education	111	30.83	50	13.88
Secondary/higher secondary	53	14.72	54	15
Diploma/graduate	2	0.55	18	5
Postgraduate	0	0	1	0.28
Present occupation
Employed/self-employed	38	10.55	23	6.38	0.394 (2)	0.821
Not employed	186	51.66	113	31.38
Family income status
Below poverty line (BPL)	163	45.27	67	18.61	20.261 (1)	0.000*
Above poverty line (APL)	61	16.94	69	19.16
Obtained insurance scheme (Government/private)
Yes	72	20	65	18.05	8.794 (1)	0.003*
No	152	42.22	71	19.72
Functional status
Diminishing vision
Yes	183	50.83	113	31.39	0.112 (1)	0.778
No	41	11.39	23	6.39
Diminishing hearing ability
Yes	76	21.11	39	10.83	1.074 (1)	0.300
No	148	41.11	97	26.94
Diminishing memory
Yes	100	27.78	54	15	0.843 (1)	0.381
No	124	34.44	82	22.78
Physical disablement
Yes	44	12.22	30	8.33	0.302 (1)	0.582
No	180	50	106	29.44
Number of functional disablements
Live with more than one or multiple impairment (>1)	125	34.72	74	20.55	0.066 (1)	0.797
Live with single impairment (<1)	99	27.5	62	17.22
Duration of hypertensive illness (in years)
≤10 years	148	41.11	89	24.72	0.015 (1)	0.903
>10 years	76	21.11	47	13.05
Duration of diabetic illness (In years)
≤10 years	158	43.89	93	25.83	0.186 (1)	0.666
>10 years	66	18.33	43	11.94

Discussion

Cardiovascular illnesses and its related risk factors including obesity, dyslipidemia, hypertension, and type 2 diabetes mellitus can be managed and prevented through a combination of right medications and appropriate lifestyle habits which are considered to be effective and safe treatment choice for these chronic conditions among elderly. However, it has been less utilized or practiced by them especially, elderly residing in rural areas. Hence, the present study specifically analyzed the various determinants of dietary and exercise compliance among rural elderly in coastal Karnataka and discussed the findings below.

The study depicted that the mean age of elderly with hypertension and type 2 diabetes mellitus was 69.16 years, most of them (63.9%; n = 230) were in between the age 60 and 70 years, also it is found that 60% were females, this is supported by the findings given by Lionakis N et al.[20], also it is found that 60% were females, and it is favored by the research findings of Asiimwe D et al.[21]

Dietary compliance and exercise compliance among elderly with chronic conditions

According to literatures, compliance to suitable bifurcation of meals and regular exercise regimen is recommended for the patients with chronic conditions especially for those who have uncontrolled blood pressure and glycemic level.[20,21]

Dietary compliance

The present study reports 80% (n = 287) of elderly with chronic conditions of hypertension and type 2 diabetes mellitus were having moderate level of adherence to the physician prescribed diet for their health conditions and minimum participants (12%; n = 44) had perfect adherence to their prescribed diet. Research studies which were done to evaluate self-care management among diabetic patients confirm that considerable numbers of clients have less to moderate adherence to diet.[22,23,24,25,26,27]

Exercise compliance

Further, the report showed that apparently 37.8% (n = 136) were practicing physical exercise along with their daily routines and other household activities and the remaining 62.2% (n = 224) were not involved in any separate exercise-related activities. This study finding is supported by the studies conducted by Durai V et al.,[28]; Ajani K et al.,[29]; and Parajuli J et al.[30] and depicted the adherence to physical activity practice as 46% (n = 390); 24.88% (n = 402); and 21.3%% (n = 385), respectively. Further, the qualitative study which was done analyzes the self-care management among elderly with hypertension specified in their report that no regular exercise practice was identified among elderly.[31]

Factors associated with dietary compliance

The findings of the present study showed that the dietary compliance among elderly residing in rural areas with chronic conditions of hypertension and type 2 diabetes mellitus is influenced (P < 0.05) by certain socioeconomic factors such as education, occupation, income, acquirement of insurance, and the clinical variables which includes memory impairment, multiple functional impairments, and duration of illness. The influence of socioeconomic factors on dietary compliance was confirmed by the studies that are done by Habib F et.al.[32]; Sami, W et al.,[33]; Tito Borba A K O et al.[34]; and Nikiéma L et al.[35] Research evidences also depicted the involvement of cognition, functional impairments, and duration of illness in maintaining therapeutic compliance[36,37,38], and in particular, the review on nutrition management among elderly with diabetes mellitus specified in their report that memory impairment leads to suboptimal adherence to diet, medication, and other self-care activity.[39]

However, the present study proved that the dietary compliance among elderly with chronic conditions is not influenced (P > 0.05) by the factors such as age, presence of physical disablements, poor vision, and hearing ability. Contradictorily, Habib F et al.,[32] reported that there is a significant relation between age and dietary compliance (r = 0.139, P < 0.05) and the aged patients complied more with the dietary regimen. However, it is proved that age is not a determinant of dietary compliance among elderly with chronic conditions (P > 0.05) by a cross-sectional study which was conducted with the intention to evaluate diet in type 2 diabetes mellitus patients in the city of Mosul, Iraq.[40]

Factors associated with exercise compliance

Compliance on physical exercise activity is the major concern in any age group, and suboptimal adherence to the prescribed exercise programs is often reported among elderly. The studies identified that psychological, physiological, and socioenvironmental characteristics of a person are the possible determinants of exercise compliance or the activity among elderly.[38]

The present study reports the practice of physician prescribed exercise regimen is affected by the factors which includes patient’s gender, education, income, and secured health insurance scheme (P < 0.05). Similarly, Habib F et al.[32] depicted in their report that the socioeconomic factors which include education, income, and insurance have a significant relation with exercise compliance (r = 0.198, P < 0.05), and Xie, Z et al.[38] also found that female patients were less likely to exercise regularly (odds ratio [OR] = 0.49, P = 0.03) than male patients.

Interestingly, the current study also depicted that practice of physical exercise is not influenced by certain prominent determinants such as age, occupation, poor memory, vision and hearing ability, and presence of physical disability (P > 0.05). In contrast, Rhodes R E et al.[41] specified in their review report that differences in age and gender significantly relate with regular exercise rates in senior citizens and deteriorating physical health and psychological variables are constantly associated with exercise activity, and it is a potential barrier to exercise adoption and adherence among elderly individuals. Further, it is specified that adherence to exercise is influenced by the notifiable cognitive, psychological, and practical factors by Hancox JE et al.,[42] and it must be addressed in prospective development of interventions with this population.

Strength, Limitation and recommendation

The study used probability sampling technique to understand the dietary and exercise compliance among elderly. Thus, it increases the generalizability of the data. The study did not assess the quality of diet and exercise regimen as it is meant to assess the compliance among elderly with their physician prescribed diet and exercise regimen. Further studies could be conducted on exploring these components among them.

Implications

This study findings are useful in understanding the determinants of dietary and exercise compliance among elderly with hypertension and diabetes mellitus. Thus, this knowledge could be applied in regular clinical practice of various health care professionals and to improve the quality of care.

Conclusion

Hypertension and type 2 diabetes mellitus are the common co-morbid chronic conditions among elderly, and it requires strict adherence to the therapeutic regimen. Research evidences confirmed that “adherence to the therapeutic regimen is the extent to which a patient’s medication taking behavior, executing lifestyle changes, following a diet that corresponds with agreed recommendations from a health care provider.”[43,44] Dietary and exercise compliance holds paramount importance and plays a vital role in controlling blood pressure and glycemic level. However, adherence to diet and exercise among elderly with chronic conditions are influenced by various socio-demographic or environmental factors, poor health or physiological factors, and cognition or psychological factors. Hence, commitment to strategic interprofessional (IP) approach to self-management would be endorsed by health care professionals, researchers, and policy makers. Further, research must focus on patient tailored strategies to enhance compliance to diet and exercise among elderly. Patient knowledge on importance of following physician prescribed diet and exercise regimen could be improved by providing patient tailored educational programs using various advanced techniques and multi-medias.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.