Knowledge, Attitudes, and Practices on Lifestyle and Cardiovascular Risk Factors Among Metabolic Syndrome Patients in an Urban Tertiary Care Institute in Sri Lanka

Abstract

Metabolic syndrome (MetS) is a significant predictor of cardiovascular diseases (CVDs). A pretested questionnaire was used to assess knowledge, attitudes, and practice (KAP) of CVD and its risks among Sri Lankan urban adults (35–55 years) with MetS. KAP scores were predefined as high, moderate, and low. Of the participants (n = 423), 13% were males and 87% were females. Attitudes scores were high among this population, though their knowledge and practices scores on CVD risk factors were moderate. Participants with high mean knowledge scores had significantly lower waist circumference (WC) and showed a trend toward reduced fasting blood glucose levels. Participants with high practice scores had significantly lower BMI and WC, which signify that better knowledge and practices are associated with decrease in CVD risk markers in these patients. The study reveals that urban MetS patients have a moderate knowledge and practice score, though their attitude score is high regarding CVD risk factors.

Background

Non communicable diseases (NCDs) have become the main contributor to disease burden in Sri Lanka because of the demographic and epidemiological transition of previous decades. NCDs account for an estimated 85% of ill-health, disability, and early death^1–3.

Metabolic syndrome (MetS) represents a combination of NCDs and risk factors and has been defined by the International Diabetes Federation (IDF)⁴ as the “presence of central obesity together with any 2 of the following parameters: raised triglycerides or specific treatment for hypertriglyceridaemia, low HDL [high-density lipoprotein]-cholesterol or specific treatment for low HDL-cholesterol, raised blood pressure or treatment for previously diagnosed hypertension and dysglycaemia”. MetS is a significant predictor of cardiovascular diseases (CVDs)^5–9. In 2005, a prevalence of 34.8% was reported for MetS in urban Sri Lankan adults, which was significantly higher than that for rural adults, with women (40.8%) having a greater prevalence than men (24.3%)¹⁰. Unhealthy diet and lifestyle are the main modifiable risk factors that contribute to MetS and CVDs^11,12. Many studies have demonstrated that knowledge and attitudes toward NCDs and risk factors as well as healthy living practices are associated with CVD morbidity and mortality^13–16.

The effect of inadequate knowledge, attitudes, and practice (KAP) regarding diabetes and CVD on its prevalence have been emphasized in many studies; the Teheran lipid and glucose study has reported that age, education, and gender influence KAP on nutrition¹³. Islam et al¹⁴ who conducted the Bangladeshi rural adults study recommended that public health programs are needed to increase KAP on diabetes and its complications. A KAP study on hypertension in Seychelles concluded that participants had good knowledge, but attitudes and practices toward healthy lifestyle were inadequate¹⁵. A Nigerian survey indicated that good knowledge on ill-health of respondents with secondary education may not represent better action toward prevention of CVDs and diabetes¹⁶. Most of these studies advocate the necessity of improving KAP for control and management of a single NCD^13–16. However, studies related to KAP in CVD and risk factors among MetS patients remain relatively scarce. Furthermore, the cultural influences make it difficult to generalize the results of cross-cultural studies, especially on lifestyle interventions^17–21.

Sri Lanka is an island with a multiethnic society having a mix of traditional beliefs, with varied food consumption patterns and lifestyle. This study was conducted as the preliminary part of a randomized controlled trial that aimed at developing and evaluating the effectiveness of a culturally relevant diet and lifestyle management program to prevent CVD risk in urban patients with MetS. The objective of this study was to assess KAP on CVD and the risk factors among urban adults with MetS.

Materials and Methods

The study was conducted at the Nutrition clinic of the National Hospital of Sri Lanka from March to December 2013.

Ethics Approval

Ethical approval (EC/11/193) for the main study was obtained from the Ethics Review Committees of the Faculty of Medicine, University of Colombo, and National Hospital of Sri Lanka. The main study was registered in the Clinical trials registry of Sri Lanka (SLCTR/2013/002). Ethical principles of health care research were followed²².

Eligibility Criteria

The participants (n = 423) for the main study were randomly selected by screening (n = 3243) patients who attend the medical clinics at the hospital to meet the eligibility criteria outlined below.

Participants were free-living, 35–55-year-old urban individuals from Colombo district with MetS. IDF criterion was used to define MetS⁴. Eligibility criteria included patients with diabetes, hypertension, and/or dyslipidemia of <5 years’ duration and conversant in any of the 3 main languages (Sinhala, Tamil, and English). Pregnant, breastfeeding, or postmenopausal women²³ whose profile would be complicated by postmenopausal changes; patients with secondary complications, including ischemic heart diseases, stroke, or past history of hospitalization resulting from CVDs; and those with acute or chronic kidney disease or other chronic diseases were excluded. Written informed consent was taken from eligible participants.

Development and Administration of KAP Questionnaire

An initial literature review gathered information on relevant local and international studies assessing KAP for NCDs, specifically MetS and CVDs. Qualitative data were collected from MetS patients attending medical clinics at the National Hospital of Sri Lanka through focus group discussions (FGDs; n = 5). Each group had 6 to 8 participants. Key informant interviews were held with medical personnel and health education officers (n = 5). FGD themes included lifestyle and cultural practices with regard to food, food and illness-related myths specific to Sri Lankan culture, knowledge and attitudes toward food, physical activity, lifestyle, and diseases. FGDs were held up to the saturation point, and data gathered were used to develop the KAP questionnaire with content validation. The questionnaire was translated into the 2 main languages spoken in Sri Lanka, pretested, and adjusted prior to administration.

There were 7 questions on general perception of own health (not included in the KAP score), 20 knowledge questions, 11 attitude statements, and 11 practice questions. The knowledge questions contained “true,” “false,” or “do not know,” with allocation of 1 point for true, and 0 for incorrect or “do not know” answers. All attitude statements were marked on a 5-point Likert scale of 0 to 4, poorest/negative to healthiest/positive attitude. Practice questions were scored from 0 to 4, with best practices making the highest score. Maximum knowledge, attitude, and practice scores were 20, 45, and 37, respectively. The scores were divided into tertiles, categorized as “low,” “moderate,” and “high.” KAP data were collected from all recruited participants for the main study.

Measurements and Tools

Socio-demographic data were collected, and anthropometric indices (height, weight, and waist circumference [WC]) were measured by trained personnel using standard protocols²⁴. A DIKSON RGZ 120 electronic weighing scale fitted with a stadiometer was used for weighing, and a non-elastic measuring tape was used for the measurement of WC. A 10-mL, 12-hour fasting blood sample was collected from each patient by medical personnel under standard conditions. Biochemical parameters (fasting blood glucose [FBG], HDL cholesterol, and low-density lipoprotein [LDL] cholesterol) were analyzed at the Faculty of Medicine, University of Colombo, by RX Daytona biochemical analyzer (Randox Laboratories Ltd, UK).

Data Collection and Data Analysis

Socio-demographic and KAP questionnaire data were entered and saved in a dedicated computer with password protection by 2 research assistants. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 21 after cleaning the data. Data were summarized as means and standard deviations (SDs). ANOVA and post hoc tests were performed to determine within- and between-group differences. Level of significance was set at P < .05.

Results

The majority (n = 370; 87.5%) of participants were females. The socio-demographic characteristics of participants are given in Table 1.

Table 1.

Demographic Data of the Study Population (n = 423).

Demographic Characteristics	Frequency (%)
Gender
Male	53 (12.5)
Female	370 (87.5)
Age (years), mean = 46.35, SD = 5.283
35–39	47 (11.1)
40–44	109 (25.8)
45–49	129 (30.5)
50–55	138 (32.6)
Ethnicity
Sinhala	299 (70.7)
Tamil	60 (14.2)
Muslim	62 (14.7)
Burger	2 (0.5)
Education level
No schooling	19 (4.5)
Primary schooling	309 (73.1)
Secondary education completed	88 (20.8)
Vocational/Technical/Tertiary education	7 (1.6)
Occupation
Administration/Management/Professional	26 (6.1)
Clerical and related/sales	45 (10.7)
Business own	70 (16.5)
Agriculture/Animal husbandry/Fisheries/Field work	25 (5.9)
Housewife/Unemployed	257 (60.7)
Income category
Not mentioned	25 (5.9)
<LKR 10 000	8 (1.9)
LKR 10 000–20 000	145 (34.3)
LKR 20 000–50 000	217 (51.3)
>LKR 50 000	28 (6.6)

Perceptions of Own Health

Nearly one-sixth believed that their health status was good. Though 80.1% of participants had previously attempted to educate themselves on CVDs and risk factors, only 18.4% were satisfied with their knowledge. Also, 17% believed that NCDs, specifically diabetes, hypertension, and dyslipidemia, are curable. Though 79.2% were aware of their current weight, 59.1% remained unaware of the healthy weight range suitable for themselves, according to BMI categorization.

Knowledge

The majority (66%) of participants had a moderate mean knowledge score (Table 2), but scores for some specific knowledge questions were low Knowledge on contribution of salt toward hypertension was high (93%). Almost all were aware of the necessity of dietary alterations to control their disease. Only 3% were aware of the range for healthy BMI. Many identified common CVD risk factors, but the relationship between high blood glucose and CVD risk was unknown by one-third of participants, as was the relationship between WC and menopause with CVD risk (36% and 25%, respectively). Almost half the study population (45.4%) was unaware of increased vegetable consumption as a positive factor for CVD risk control. Oil was not recognized as a high energy source by two-thirds, and 79.8% thought that green leafy vegetables contained more energy than rice. More than half believed that sweet molasses was better than sugar for diabetic patients.

Table 2.

Knowledge, Attitude, and Practice Score Categories With CVD Risk Markers (n = 423)^a.

CVD Risk Marker	Knowledge Score			Attitudes Score			Practice Score
	(n = 42) Lowa (Mean Score ≤ 6.66)	(n = 279) Moderatea (6.66 < Mean Score ≤ 13.33)	(n = 102) Higha (Mean Score > 13.33)	(n = 01) Low (Mean Score ≤ 15.00)	(n = 92) Moderate (15.00 < Mean Score ≤ 30.00)	(n = 330) High (Mean Score > 30.00)	(n = 23) Low (Mean Score ≤ 12.33)	(n = 329) Moderate (12.33 < Mean Score ≤ 24.66)	(n = 71) High (Mean Score > 24.66)
Age (years)	45.84 ± 4.8	46.13 ± 5.6	47.19 ± 4.4	49.00	46.65 ± 5.3	46.26 ± 5.3	45.77 ± 5.1	46.35 ± 5.2	46.54 ± 5.6
BMI (kg/m2)	31.53 ± 5.3	31.24 ± 5.0	30.30 ± 4.5	27.16	30.08 ± 4.7	31.33 ± 4.9	33.22 ± 7.9b,c	30.86 ± 4.7b	31.19 ± 4.6c
WC (cm)	98.89 ± 12.8	98.48 ± 9.8d	95.05 ± 9.4d	84.00	94.66 ± 9.2	98.58 ± 10.3	101.47 ± 14.2e	97.29 ± 9.9e	98.35 ± 9.8
FBG (mg/dL)	134.14 ± 46.9f,g	117.65 ± 44.4f	112.74 ± 38.7g	268.00	128.08 ± 44.55	114.96 ± 42.3	106.45 ± 23.2	117.63 ± 42.5	124.27 ± 52.5
HbA1c (%)	7.83 ± 1.8	7.47 ± 1.8	7.40 ± 1.7	9.90	8.12 ± 1.8	7.31 ± 1.8	6.95 ± 1.5	7.47 ± 1.8	7.73 ± 1.7
HDL-C (mg/dL)	41.09 ± 9.4	44.11 ± 11.4	44.05 ± 8.9	51.00	44.30 ± 11.3	43.62 ± 10.5	42.04 ± 8.8	43.76 ± 10.7	44.40 ± 10.9
LDL-C (mg/dL)	108.51 ± 37.1	108.42 ± 34.5	106.18 ± 30.6	179.40	105.26 ± 29.8	108.40 ± 34.7	109.26 ± 36.8	108.75 ± 33.8	103.53 ± 32.7

Abbreviations: CVD, cardiovascular disease; BMI, body mass index; WC, waist circumference; FBG, fasting blood glucose; HbA1c, glycated hemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.

^aLow, moderate, and high was determined according to tertiles in the distribution of the respective variable.

^bSignificantly lower BMI, P = 0.013.

^cSignificantly lower BMI, P = 0.037.

^dSignificantly lower WC, P = 0.009.

^eTrend toward lower WC, P = 0.068.

^fTrend toward lower FBG values, P = 0.063.

^gSignificantly lower FBG, P = 0.021.

Attitudes

The mean attitude score was high in the majority of participants (n = 330) (Table 2). Nearly a third thought that weight reduction was difficult, but 91.7% agreed with the necessity of reducing their current fat and oil consumption. About 20% were not willing to reduce salt and sugar consumption, citing alteration in taste of foods as a reason;. 25% did not want to change their current diet and lifestyle habits despite awareness of the risk of their current lifestyles. Of the 20 smokers (male) in the study, 65% did not want to stop smoking.

Practices

The majority (78%) of participants had moderate mean practice scores and, similar to the pattern seen for knowledge (Table 2), had low scores for specific practices; only one-third ate at least 2 portions of vegetables per day; and general portion size reduction was practiced irregularly by 52% of participants during the past 6 months. Regular 30 minutes of exercise was never attempted by two-thirds (63%), whereas 13.7% had started but given up exercises. Almost 91% shared family meals, whereas 4% had specially prepared meals, and almost half were not careful of foods eaten outside the home.

Participants with high knowledge scores had a significantly lower WC compared with those with moderate knowledge scores (P = 0.009). Participants with high knowledge scores had significantly lower FBG compared with those with low knowledge scores (P = 0.021), and participants with moderate knowledge showed a trend toward significantly lower FBG levels when compared with those with low knowledge (P = 0.063). Significantly higher BMIs were seen in participants with low practice scores when compared with those with high (P = 0.037) or moderate practice scores (P = 0.013). A trend toward a lower WC was observed for those with moderate practice scores compared with participants who had low practice scores (Table 2).

Discussion

Our results indicate that the patients with MetS had a moderate mean level of knowledge and practices and high attitude toward CVD risk reduction, but knowledge and practice in some specific areas were low. An important facet of our article is the association of KAP with biochemical and anthropometric variables. Participants with high mean knowledge scores had significantly lower WCs and showed a trend toward reduced FBG levels. Similarly, participants with high practice scores had significantly lower BMIs and WCs, which clearly signify that better knowledge and practices are associated with better anthropometric and biochemical parameters that would reduce the risk of CVD in these patients^19,25.

Female participation was very high (87.5%) in this randomized controlled trial. There are number of reasons for the imbalance. The prevalence of MetS in Sri Lanka indicates a difference between male and female patients in the urban setting¹⁰. Furthermore, male patients, often being the wage earners in the family, are reluctant to attend morning clinics in government hospitals with its long waiting hours and prefer going to private sector hospitals after working hours. Most male patients, if they attended the clinics, were reluctant to get enrolled in a study because of time constrains. It would be important to consider these behaviors in interventional studies as well as in the development and application of CVD risk reduction programs in situations similar to this setting.

Despite regular attendance at medical clinics after the diagnosis of NCDs such as diabetes, hypertension, and/or dyslipidemia, participants had failed to gain knowledge on important aspects of controlling the components of MetS, such as diet, exercise, and smoking and adherence to healthy lifestyle habits. Knowledge of dietary habits in controlling MetS was low; most participants were unaware of some fundamental facts of diet—for example, failure to recognize commonly consumed energy-rich foods. However, an encouraging aspect was the recognition of their limited knowledge and the need to improve knowledge, which could be an initiating measure for reducing CVD risk. Even though almost all respondents knew the importance of physical activity, 63% had never attempted at least 30 minutes of regular exercises even after diagnosis with MetS, indicating that there are some barriers in putting into practice the knowledge they gain.

Though the mean practice score was moderate, the benefits were not clear on biochemical parameters: FBG, glycated hemoglobin, HDL cholesterol, or LDL cholesterol.

In comparison to other studies on CVDs and risk factors, this population also demonstrated wide gaps in knowledge as well as a discrepancy between knowledge and practices with attitudes^13–16. For example, the Teheran lipid glucose study revealed that although more than 60% claimed to know the meaning of cholesterol, less than 50% were able to identify the sources. Similarly our study population also had problems in identifying food sources; only 13% knew that coconut oil does not contain cholesterol, and 15% knew that rice contained more energy than green leafy vegetables. The same study¹³ shows that age influenced KAP on nutrition, but we were unable to see a relationship. KAP are important to modify a person’s diet and lifestyle for control of MetS. However, sustainable changes in lifestyle practices are not easy achieve²¹. Several studies conducted on NCDs have shown that there are many interrelated issues connected to individual behavior, so that even when knowledge and attitudes are high, practice remains low^14–16,21.

Usually, at the National Hospital clinics, diet and lifestyle advises are not tailored for individuals, and there is inadequate follow-up regarding diet and lifestyle change. It is shown that individual or close attention is required to make changes in diet and lifestyle²¹. Therefore, an approach that is individualized and culturally relevant, with enhanced participatory activities, is likely to be effective. Participants (51%) agreed that family members were helpful in changes and should be made aware of how to support them.

This KAP questionnaire provided a better understanding of behavior of the patients with MetS. It provided valuable information on planning programs to prevent CVD risk. The collected data could be used to plan culturally appropriate diet and lifestyle counseling programs in the management of CVD in clinical settings. The areas in which participants need more knowledge and encouragement, presenting the medical facts, and overcoming cultural and occupational barriers that prevent them from practicing certain suggested measures to control the MetS should be considered in planning the program. Whether tailor-made advice to individuals or sharing experience and knowledge as a peer group would be better than current practice to control CVD risk should be investigated during the main study.

Being a part of a large study, there were certain limitations when carrying out this KAP study. The imbalance in male to female ratio possibly could have caused some bias in the study. Furthermore, because the study was carried out on urban patients with MetS, the KAP results cannot be generalized to other settings.

Conclusion

Urban MetS patients attending medical clinics at the National Hospital of Sri Lanka for treatment have moderate knowledge and practice scores, though their attitude score is high regarding CVD and risk factors. The associations between knowledge, practices, and metabolic and anthropometric profiles is a significant finding and worth highlighting in future intervention programs. Future intervention programs need to be well targeted and more informative to improve knowledge and focus more on the behavioral aspects of risk reduction. The barriers to and opportunities for increasing patient knowledge and practices on prevention/reduction of CVD risk need to be further investigated.