The Relationship between Self-Awareness and Dietary Compliance in Patients with Type 2 Diabetes Mellitus

Endang Yuswatiningsih1*, Arum Dwi Ningsih2

1Departement of Nursing, Faculty of Health, Institut Teknologi Sains dan Kesehatan Insan Cendekia Medika, Jombang, Jawa Timur 61419, Indonesia

2Departement of Nursing, Faculty of Health, University of Bina Sehat PPNI Mojokerto, Jawa Timur 61363, Indonesia

*Corresponding Author’s Email: farenramazza@gmail.com

ABSTRACT

Background: The aim of this study was to investigate the correlation between self- awareness and dietary compliance in patients with type 2 diabetes mellitus. Methods: This study was correlational with a cross-sectional approach. The population was 253 respondents, all type 2 DM patients in the Jelakombo Jombang Health Center working area. The total sample had 147 respondents. The sampling technique used is simple random sampling. The independent variable is self-awareness, and the dependent variable is dietary compliance in type 2 DM patients. The data collection technique was a questionnaire, and then the data was processed. The process involved editing, coding, scoring, tabulating, and analysis the data using the Spearman correlation test with an error rate of 0.05. Results: The data revealed that most of the respondents' self-awareness was good (69%) and that most of the respondents were obedient to their diet (65%). The results of the analysis using the Spearman Correlation test show that the probability value of 0.006 is smaller than the alpha value of 0.05, so H1 is accepted. Conclusion: The conclusion in this study is that there is a correlation between self-awareness and dietary compliance in type 2 diabetes mellitus patients. It is expected that type 2 diabetes mellitus patients will further increase their self- awareness in meeting their dietary needs.

Keyword: Self-Awareness; Dietary; Compliance; Type 2 Diabetes Mellitus

INTRODUCTION

One of degenerative diseases that the number keep increase is Diabetes Mellitus (DM). The higher revenue people get, the higher lifestyle changing they adopt. The increasing prevalence of DM patients can be caused by poor self-management by DM patients. Diabetes Mellitus is a chronic metabolic disease, which means insufficient quantities of insulin can be produced or the body is unable to use insulin effectively, resulting in excess glucose in the blood. Diabetes mellitus is caused by unhealthy habits such as overeating, a lack of exercise, and stress. Patients with diabetes mellitus find it difficult to regulate their own dietary behavior (American Diabetes Association, 2020). Dietary compliance is a big problem that occurs in patients with type 2 diabetes today. Overeating, a lack of exercise, and stress are some of the unhealthy habits that cause Diabetes Mellitus. The principle of dietary regulation is based on the nutritional status of diabetic patients and modifying the diet by paying attention to lifestyle and eating habits. Disobedience to diet rules is one of barriers to achieving treatment purposes (Soegondo, & Subekti, 2015).

Data from International Diabetes Federation (IDF) showed DM sufferers tends to increase year by year. By 2030, 552 million people in the world will be affected by diabetes. In Indonesia, according to WHO prediction, the number will increase from 8.4 million to around 21.3 million from 2000 to 2030. Meanwhile, the International Diabetes Federation (IDF) predicts an increase from 7.0 million in 2009 to 12.0 million in 2030 (Indonesia, 2015). Therefore, Indonesia become fourth rank in the world. India, China, and United States are the first three world rank. According to data from the Jombang Disctrict Health Office in 2020, the number of DM sufferers in the Jombang district was 34,261 people, and 20.7% have not received services that are in accordance with standards (Dinas Kesehatan Kabupaten Jombang, 2020).

Diabetes mellitus is caused by a lack of a hormone called insulin and a lack of insulin production by the pancreas. Consuming sugary foods and sweetened drinks can cause high blood sugar. Uncontrolled diabetes mellitus will cause complications such as heart disease, kidney disease, eye disorders, stroke, atherosclerosis, and even the amputation of parts of the body. If the patient has the self-awareness to comply with his diet, diabetes mellitus will be controlled. The success of a treatment is influenced by the quality of service, the attitudes and skills of officers, the attitudes and lifestyles of patients and their families, and patient compliance with the treatment program. Laili, Dewi, & Wahyuni, (2019) states that the patient's glycemic index could be controlled when the patient obeyed the dietary recommendations, including the type and amount of food consumed. Patient disobedience is one of the obstacles to achieving treatment goals and will also result in patients requiring examinations or treatments that are not actually needed. This requires serious attention and handling from health workers to reduce the incidence of DM by obediently implementing a diet program ( Laili, Dewi, & Wahyuni, 2019).

Efforts to control DM in the community have been carried out through primary and secondary prevention to reduce the risk of complications, death, and also reduce treatment costs. Primary prevention is an action to prevent DM in at-risk individuals through lifestyle modifications, including appropriate diet, physical activity, and weight loss, with ongoing education programs. Secondary prevention is the prevention of acute and long-term complications. The program includes examinations, blood pressure treatment, diabetic foot care, routine eye examinations, an examination of protein in the urine, as well as programs to reduce or stop smoking habits (Depkes RI, 2022). DM treatment can be successful if done regularly. Compliance with regular maintenance requires self-discipline. Patients must take an active role in efforts to improve health, through the management of DM, where patients will work closely with nurses to determine appropriate and necessary interventions (Al- Khawaldeh, Al-Hassan, & Froelicher, 2012). DM patients who can play an active role in their care are those who have good self-awareness. Self-awareness of various aspects of DM management can prevent complications in DM patients and for the prevention of someone who has a risk of DM disease (Yanti, 2009).Therefore, the aim of this study was to investigate the correlation between self-awareness and dietary compliance in type 2 diabetes mellitus patients.

METHODOLOGY

This is correlational analytic research with a cross-sectional approach. The research was conducted in one of the villages in the Jombang district, East Java Province, Indonesia. The population were 232 respondents with type 2 DM. The sample in this study included some type 2 DM patients. Then, Slovin formula applied to obtain the number of random sampling. The result was 147 respondents as random sampling. The simple random sampling (Nursalam, 2020) used in this study.

Data Collection uses questionnaires. The questionnaire about self-awareness consists of 20 statements developed by the researcher. It covers recognizing emotions, strong self- recognition, and self-confidence taken from Goleman's (2010) theory. It provides four options: (4) always, (3) often, (2) rarely, and (1) never. The compliance variable consisted of 15 statements, starting with the right schedule, the right type, and the right amount of parameters. Respondents answered by choosing one of four options: (4) always, (3) often, (2) rarely, and (1) never. The questionnaire has been tested for validity and reliability before use.

Univariate and bivariate analysis used to analyze data collection. In univariate data analysis, both the results of data processing from the self-awareness variable and diet compliance are presented in percentage form. Bivariate analysis was tested by using the Spearman correlation test to determine whether the two variables had a correlation or not and using ordinal data scales.

Ethical Consideration

This study obtained ethical approval from the Research Ethics Committee of STIKES Insan Cendekia Medika with reference number 023/KEPK/ICME/III/2021 dated March 08, 2021. Respondents were informed about the research’s purpose and the estimated time to participate in this research, as well as the guarantee of confidentiality of their identity and personal data. They also have the right to choose whether or not to participate in this research.

RESULTS

1. Respondents’ Characteristics by age

   
   

   Table 1: Respondents’ Age Frequency

   
   

   Age	Frequency	Percentage (%)
   45-59 years old 60-74 years old 75-90 years old	53 84 10	36 57 7
   Total	147	100.0

   
   

   Table 1 shows 57% respondents aged 60-74 years were 84 people.

   
   

2. Characteristics of respondents by gender

   
   

   Table 2: Frequency Distribution of Respondents by Gender

   
   

   Gender	Frequency	Percentage (%)
   Male Female	89 58	61 39
   Total	147	100.0

   Table 2 shows that 61% respondents were male, total of 89 people.

   
   

3. Respondents’ education level

   
   

   Table 3: Frequency Distribution of Respondents by Education Level

   
   

   Education	Frequency	Percentage (%)
   Elementary School Junior High School Senior High School College	31 78 24 14	21 53 16 10
   Total	147	100.0

   
   

   Table 3 shows 53% of respondents had a junior high school education level.

   
   

4. Characteristics of respondents by occupation

   
   

   Table 4: Frequency Distribution of Respondents by Occupation

   
   

   Occupation	Frequency	Percentage (%)
   Private Self-employed Farmer Civil Servant Unemployed	15 17 24 15 76	10 12 16 10 52
   Total	147	100.0

   
   

   Table 4 shows that 76 people (52%) respondents did not work (unemployed).

   
   

5. Respondents based on self-awareness

   
   

   Table 5: Frequency Distribution of Respondents Based on Self-Awareness

   
   

   Self-awareness	Frequency	Percentage (%)
   Good	101	69
   Poor	46	31
   Total	147	100.0

   
   

   Table 5 shows that 101 people (69%) of the respondents have good self-awareness.

   
   

6. Characteristics of respondents’ dietary compliance

   
   

   Table 6: Frequency Distribution of Respondents Based on Dietary Compliance

   
   

   Obedience	Frequency	Percentage (%)
   Obey	96	65
   Disobey	51	35
   Total	147	100.0

   Table 6 shows that 96 people (65%) of the respondents adhered to their diet.

   
   

7. The correlation between self-awareness and dietary compliance in type 2 DM patients

Table 7: Cross Tabulation of Self-Awareness with Dietary Compliance in Type 2 DM Patients

Based on table 7, it is known that most patients with type 2 Diabetes Mellitus have good self-awareness with adherence to a compliant diet of 68 patients (46%).

The results of the analysis using the Pearson Correlation Test obtained a probability value of 0.010, which is smaller than an alpha value of 0.05, so that H1 is accepted or H0 is rejected, which means that there is a correlation between self-awareness and dietary compliance in Type 2 Diabetes Mellitus patients in Candimulyo Village, Jombang District.

DISCUSSION

According to the result of the study, most of the respondents had good self-awareness. Good self-awareness could be influenced by the age of the respondent. Most respondents' ages ranged from 60-74 years. According to WHO, age 60-74 is included in the elderly. Age is one of the variables that affect the development of personality elements. Personality elements grow and develop simultaneously, including the very influential initial element, namely self-awareness (Malikah, 2013). According to researchers, age contributes to self- awareness because it under-standing and response to health changes experienced by a person.

Level of education effected Self-awareness. Mostly respondents' education level is junior high school. According to researchers, junior high school education is included in basic education, so it will affect someone’s ability to obtain information. Education affects a person's understanding of information because it relates to their background knowledge. The basic education level does not have more insight into self-awareness in terms of dietary compliance in type 2 DM is good.

Education’s basic concept is process. It means there is a process of growth, development, or change to be more mature as oneself, as a group, or as a community (Notoatmodjo, 2014). Cognitive abilities that shape a person's way of thinking include the ability to understand the factors associated with disease in order to maintain their health (Rahayu, Hudha, & Umah, 2015).

Another factor that affects self-awareness is gender. In this study, most of the respondents were male. Then, based on the results of the questionnaire, which covers three parameters: recognizing emotions, accurate self-recognition, and self-confidence. The largest percentage is accurate self-recognition. Men tend to solve problems by using logic, so their self-awareness is good. This is also due to the role of men as breadwinners and heads of families, thus motivating themselves to be healthier (Haque, 2013). According to Goleman self- awareness is understand what we feel at any given moment and use it as guidedance for our own decision-making; realize logic standard of self-ability and high self-confidence. People with high self-awareness means that they know themselves well. They are able to control themselves, for example, by controlling emotions and other impulses. By knowing themselves, people also know other people and can read the intentions and desires of others. Self-awareness is state of paying constant attention to one's inner state. In this self-reflection awareness, the mind observes and explores experiences, including emotions. John Mayer, self-awareness means being aware of both our moods and thoughts of them. Self-awareness can be a non-reactive observer, not judging inner states.

Some studies are in accordance with the result of this study, as follow: in the study conducted by Laili, Dewi, & Wahyuni, 2019, education with the principle approach of Diabetes Self- Management Education (DSME) improved dietary compliance behavior in patients with type 2 diabetes mellitus. with the DSME principal approach ( Laili, Dewi, & Wahyuni, 2019).

The study conducted by Munir, 2021 entitled the correlation between family support and self-care in patients with diabetes mellitus which shows good family support results of 92.7%. The conclusion stated that family support and the implementation of self- care have correlation for diabetes mellitus patients. The family is expected to continue to provide support both in patient self-care and psychologically (Munir, 2021).

Other study conducted by Dwi Kurniawati, Yunita Galih, & Susilo, (2020). The result showed there is a significant correlation between self-awareness and self-care management among hypertension sufferers in Jimbaran Village, Bandungan. Managing a healthier lifestyle to increase self-awareness is expected to reduce their blood pressure.

Based on the result, the respondents were obedient with their diet. Factors related to compliance include age. Most of the respondents' age ranged from 60-74 years. According to WHO, age 60-74 is included in the elderly. Compliance usually increases with age. This is in accordance with Yakaryılmaz, & Öztürk, (2017), who said that age is related to the level of compliance, although sometimes age is not the cause of non-compliance, but the older the patient, the lower the memory, hearing, and vision, so that older patients become disobedient. This is vise versa with research conducted by Aini, Kustriyani, & Arifianto (2019), which showed that there was no significant correlation between age and obedience to the diet of people with Diabetes Mellitus.

People level of education effected to the obedient level as well. In this study, most of the respondents' education level is junior high school. This is in line with research conducted by Ernawati, Harini, and Gumilas, (2020). That the result showed amount of lower education respondents were more than higher education respondent. An inappropriate diet begins with a lack of knowledge about right diet maintenance to avoid the emergence of complications of diabetes mellitus type 2 (Ernawati, Harini, & Gumilas, 2020). Knowledge related to education: Qualified life can be achieve through behaviour change process (Prabowo & Hastuti, 2015). It is easier for a higher-level education person to absorb information and applied it in daily life, especially in applied DM diet. The more educated person will have broader knowledge because education is the main basis for success in treatment (Heryati, 2014).

Compliance is also influenced by gender. The results of this study were mostly male. Gender differences in diet management are not a problem. Because respondents are both female and male, it is very important to manage their diet to prevent complications. According to Agency of Health Research and Development, 2013 the prevalence of woman is higher than men, this is because several risk factors cause the high incidence of DM in women. Research conducted by Wong et al., 2005 shows that there is a correlation between gender and dietary compliance in patients with type 2 DM. A similar study is in Tania's research, 2016 which shows that male gender participation percentage was higher (51%) than women (49%). However, a statistical test showed that there was no significant correlation between gender and dietary compliance in type 2 DM patients according to the theory of the Health Belief Model or health belief model (Tania, 2016). Another similar study, according to Nugroho & Handono, (2017), 77% of men were more obedient than 50.8% of women, although the results showed that there was no significant correlation between gender and dietary obedience among DM patients. It is because gender is not a directly factor related to adherence behavior as stated in the Health Belief Model theory or health belief model (Nugroho & Handono, 2017).

Haryono, Suryati, and Maryam, research (2018) supported this research which revealed significant effect of health education on increasing knowledge about diet, current blood sugar levels, increasing dietary compliance. Some result studies that in line with the results of this study are study by Simbolon, Triyanti, & Sartika (2019) the result that length of suffering and gender were the dominant factors associated with type 2 diabetes mellitus diet compliance (Simbolon,Triyanti, and Sartika, 2019).

According to the results of the study, most type 2 Diabetes Mellitus patients had good self- awareness with adherence to a compliant diet. The analysis using the Pearson Correlation Test obtained a probability value of 0.010 smaller than an alpha value of 0.05. it means H1 is accepted or H0 is rejected, moreover there is a correlation between self-awareness and dietary compliance in Type 2 Diabetes Mellitus patients in Candimulyo Village, Jombang Regency.

Respondents have good self-awareness so that it can affect the level of compliance in their diet settings. Good self-awareness results in good self-management as well, so that patients are more aware of their disease, are better able to control their condition by adjusting their diet, and so on, so that the management of diabetes mellitus is better (Wahyuni & Ramayani, 2020).

Self-management begins with self-awareness; self-awareness is a process of understanding one’s own thoughts, feelings, motivations, and behavior towards something (Butcher et al., 2018). According to Indonesian Endocrinology Association, there are five pillars of DM management, namely education, nutritional diet, physical activity, medication, and blood sugar monitoring. Complications in patients can be prevented by controlling blood glucose levels and diet settings (Bakara & Kurniyati, 2022).

Kholifah, Siti Nur’s study results shows that there is an increase in the compliance of type 2 DM patients in implementing the DM diet, taking medication, and exercising after self- management intervention. Self-management is a form of nursing intervention that aims to establish self-awareness so that people with DM are obedient in carrying out regular care (Lin et al., 2008).

Implication and Limitations

Empirical evidence about self-awareness and dietary compliance in type 2 diabetes mellitus patient reserves in this study. The results of this study imply self-awareness important in dieting diabetes mellitus patient. Self-awareness is important to prevent and treat cases of uncontrolled type 2 diabetes mellitus. Furthermore, socializing the importance of self-awareness in diet management for type 2 diabetes mellitus patients is necessary. Researchers realize that this research has limitations. Dietary settings in the study were specific to type 2 diabetes mellitus patients.

CONCLUSION

According to the results of the study, self-awareness in type 2 DM patients is mostly good. Dietary compliance in type 2 DM patients is mostly obedient. There is a correlation between self-awareness and dietary compliance in type 2 DM patients in Candimulyo Village, Jombang. It is hoped that it can increase the respondent's understanding of the importance of knowledge, attitude, and self- awareness in managing the right diet for type 2 diabetes mellitus patients.

Conflict of Interest

The authors declare that they have no conflict of interests

ACKNOWLEDGMENT

The author would like to thank the Chancellor of the Institute for Health Science and Technology of Insan Cendekia Medika Jombang, Indonesia, for permission to publish this paper. We would also like to thank all the people of Candimulyo Hamlet, Candimulyo Village, Jombang District, East Java, Indonesia, who have given us permission to conduct research there.

REFERENCES

Al-Khawaldeh, O. A., Al-Hassan, M. A., & Froelicher, E. S. (2012). Self-efficacy, self- management, and glycemic control in adults with type 2 diabetes mellitus. Journal of Diabetes and its Complications, 26(1), 10-16.

Agency of Health Research and Development (Indonesia) (2013). Indonesia Basic Health Research 2013. https://ghdx.healthdata.org/organizations/agency-health-research-and- development-indonesia

Aini, D. N., Kustriyani, M., & Arifianto, A. (2019). Increased Depression Affects Hyperglycemia Status in Type II Diabetes Mellitus Patients. Media Keperawatan Indonesia, 2(3), 121-127. https://doi.org/10.26714/mki.2.3.2019.121-127

American Diabetes Association. (2020). Classification and diagnosis of diabetes : Standards of Medical Care in Diabetes - 2020. Diabetes Care, 43(1), S14–S31. https://doi.org/10.2337/dc20-S002

Bakara, D. M., & Kurniyati. (2022). Self-Management Education to Control Blood Sugar Levels and Hba1c Value for Type 2 Diabetes Patients. The Malaysian Journal of Nursing (MJN), 14(1), 84-89. https://doi.org/10.31674/mjn.2022.v14i01.012

Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. M. (2018). Nursing Interventions Classification (NIC) 7th Ed -E-Book. Elsevier Health Sciences.

Depkes RI. (2022). Pedoman Pelaksanaan Pelatihan Stimulasi, Deteksi dan Intervensi Dini Tumbuh Kembang Anak Di Tingkat Pelayanan Kesehatan Dasar. Departemen Kesehatan Republik Indonesia.

Dinas Kesehatan Kabupaten Jombang. (2020). Data DM di Kabupaten Jombang.

Dwi Kurniawati, R. A. T. I. H., Yunita Galih, Y., & Susilo, J. (2020). Hubungan Kesadaran Diri Dengan Manajemen Perawatan Diri Pada Penderita Hipertensi Usia Dewasa Di Kelurahan Jimbaran Kecamatan Bandungan (Doctoral dissertation, Universitas Ngudi Waluyo).

Ernawati, D. A., Harini, I. M., & Gumilas, N. S. A. (2020). Faktor-Faktor yang Mempengaruhi Tingkat Kepatuhan Diet pada Pasien Diabetes Melitus Tipe 2 di Kecamatan Sumbang Banyumas. Journal of Bionursing, 2(1), 63–67. https://doi.org/10.20884/1.bion.2020.2.1.40

Haque, D. F. (2013). Hubungan Antara Pelayanan Kesehatan Dan Faktor Lainnya Dengan Kepatuhan Diet Pada Anggota PERSADIA Penyandang DM Tipe 2 Di Depok. Universitas Indonesia.

Haryono, S., Suryati, E. S., & Maryam, R. S. (2018). Pendidikan Kesehatan Tentang Diet Terhadap Kepatuhan Pasien Diabetes Mellitus. Jurnal Riset Kesehatan, 7(2), 91-96.

Heryati, G. S. (2014). Faktor-Faktor yang Berhubungan dengan Kepatuhan Diet Diabetes Mellitus pada Pasien DM. Jurnal Keperawatan, 1(3), 97-107.

Laili, N. R., Dewi, Y. S., & Wahyuni, E. D. (2019). Edukasi Dengan Pendekatan Prinsip Diabetes Self Management Education (Dsme) Meningkatkan Perilaku Kepatuhan Diet Pada Penderita Diabetes Mellitus Tipe 2. Critical Medical and Surgical Nursing Journal (CMSNJ), 1(1), 1–9. https://doi.org/10.20473/cmsnj.v1i1.11927

Lin, C. C., Anderson, R. M., Hagerty, B. M., & Lee, B. O. (2008). Diabetes self-management experience: a focus group study of Taiwanese patients with type 2 diabetes. Journal of Clinical Nursing, 17(5A), 34–42. https://doi.org/10.1111/j.1365-2702.2007.01962.x

Malikah,M. (2013). Kesadaran diri proses pembentukan karakter islam. Jurnal Al-Ulum, 13(1), 129–150.

Munir, N. W. (2021). Hubungan Dukungan Keluarga Dengan Self Care Pada Pasien Diabetes Melitus. Borneo Nursing Journal (BNJ), 3(1), 7-13. https://akperyarsismd.e- journal.id/BNJ/article/view/29

Notoatmodjo, S. (2014). IPKJRC (2015). Ilmu Perilaku Kesehatan. Jakarta: Rineka Cipta. Biomass Chem Eng, 49(23-6).

Nugroho, Y. W., & Handono, N. P. (2017). Hubungan Tingkat Kepatuhan Diet terhadap Kadar Glukosa Darah pada Penderita Diabetes Mellitus di Kelurahan Bulusulur. Jurnal Keperawatan GSH, 6(1), 1–8.

Nursalam. I. I. (2020). Metodologi Penelitian Ilmu Keperawatan: Pendekatan Praktis Edisi 5. Jakarta Selatan : Salemba Medika.

Indonesia, P. E. (2015). Pengelolaan dan pencegahan diabetes melitus tipe 2 di Indonesia. Pb. Perkeni.

Prabowo, A., & Hastuti, W. (2015). Hubungan pendidikan dan dukungan keluarga dengan kepatuhan diit pada penderita diabetes mellitus di wilayah Puskesmas Plosorejo Giribangun Matesih Kabupaten Karanganyar. Jurnal Keperawatan GSH, 4(2).

Rahayu, H. T., Hudha, A. M., & Umah, U. S. (2015). Perbandingan Self Awareness Pola Konsumsi Makanan dan Olahraga dengan Riwayat Keluarga Memiliki dan Tidak Memiliki Diabetes Mellitus Tipe 2 Pada Mahasiswa PSIK UMM. Jurnal Keperawatan, 6(1), 15–26. https://doi.org/10.22219/jk.v6i1.2848

Simbolon, Y. I., Triyanti, T., & Sartika, R. A. D. (2019). Faktor-Faktor Yang Berhubungan Dengan Kepatuhan Diet Pada Penderita Diabetes Melitus Tipe 2 Di Puskesmas Kecamatan Pasar Minggu Tahun 2018. Jurnal Kesehatan Komunitas, 5(3), 110–117. https://doi.org/10.25311/keskom.vol5.iss3.336

Soegondo, S. & Subekti,I. (2015). Penatalaksanaan Diabetes Melitus Terpadu. Jakarta: balai penerbit FKUI.

Tania, M. (2016). Hubungan pengetahuan remaja dengan perilaku konsumsi minuman rin gan di SMKN 2 Baleendah Bandung. Jurnal Keperawatan BSI, 4(1). https://doi.org/10.31311/.v4i1.403

Wahyuni, A., & Ramayani, D. (2020). the Relationship Between Self-Eficacy and Self-Care in Type 2 Diabetes Mellitus Patients. The Malaysian Journal of Nursing (MJN), 11(03), 68– 75. https://doi.org/10.31674/mjn.2020.v11i03.011

Wong, M., Gucciardi, E., Li, L., & Grace, S. L. (2005). Gender and nutrition management in type 2 diabetes. Canadian Journal of Dietetic Practice and Research, 66(4), 215-220.

Yakaryılmaz, F. D., & Öztürk, Z. A. (2017). Treatment of type 2 diabetes mellitus in the elderly. World Journal of Diabetes, 8(6), 278. https://doi.org/10.4239/wjd.v8.i6.278

Yanti, S. (2009). Analisis hubungan kesadaran diri pasien dengan kejadian komplikasi diabetes mellitus dalam konteks asuhan keperawatan di RSUD Dr. Adnan WD Payakumbuh= The analysis of patient self-awareness to diabetes mellitus complications in nursing context at dr. Adnan WD Hospital Payakumbuh West Sumatera.