Optimizing Dietary Concordance Through Self-Management in Type 2 Diabetes: Insights From Indonesia

Abstract

Purpose

The purpose of this study was to examine the relationship between self-management dietary behaviors and dietary concordance among patients with type 2 diabetes mellitus (T2DM) in West Java, Indonesia.

Methods

A cross-sectional study was conducted among 278 adult patients with T2DM at a public hospital in West Java, Indonesia, selected through purposive sampling. Data were collected using validated questionnaires assessing self-management, dietary behaviors, and dietary concordance. Descriptive statistics summarized demographic data, and the Kendall Tau-c correlation analysis evaluated the association between self-management practices and dietary concordance.

Results

The study demonstrated a positive association between self-management dietary behaviors and dietary concordance among patients with T2DM. Key practices such as meal planning, caloric awareness, and healthy food selection were linked to improved adherence, contributing to better glycemic stability and a reduced risk of diabetes-related complications. However, challenges such as dietary monotony (a lack of variety in meals) and limited nutritional knowledge remained obstacles to consistent engagement.

Conclusion

Strengthening self-management dietary behaviors is vital for enhancing dietary concordance in patients with T2DM. Targeted educational programs that emphasize meal planning, portion control, and food variety may significantly improve adherence. Integrating dietary management into routine clinical care and community health initiatives can bridge gaps between recommendations and patient habits. Expanding nutritional education and support in primary health care is essential for sustainable long-term adherence and improved health outcomes.

Type 2 diabetes mellitus (T2DM) is a major global health challenge, affecting over 537 million adults worldwide as of 2021, with projections suggesting this number will rise to 643 million by 2030.¹ Characterized by chronic hyperglycemia due to insulin resistance and progressive β-cell dysfunction, T2DM imposes substantial economic and health care burdens, contributing to increased rates of cardiovascular disease, neuropathy, and renal failure.^2,3 In Southeast Asia, Indonesia is among the countries experiencing the most significant increase in T2DM prevalence, with cases expected to exceed 16.7 million by 2045, largely driven by urbanization, dietary shifts, and lifestyle changes.⁴ This rising trend underscores the urgent need for effective management strategies to mitigate the health impacts of T2DM.

Despite advancements in pharmacological treatments, optimal management of T2DM heavily relies on effective self-management, particularly in dietary regulation.⁵ This is underscored by frameworks, such as the Association of Diabetes Care & Education Specialists ADCES7 Self-Care Behaviors^®, which identifies healthy eating as a core self-care behavior essential for diabetes management.⁶ Self-management of diet is a critical component of diabetes care, involving the regulation of meal schedules, portion control, appropriate food selection, and consistent physical activity.⁷ Empirical evidence consistently indicates that engagement with dietary guidelines significantly improves glycemic stability, reduces the risk of complications, and enhances the quality of life for patients with T2DM.⁸ However, sustaining dietary adherence remains challenging for many patients due to various barriers, including limited nutritional knowledge, cultural dietary habits, lack of family support, and low health literacy.^9,10 Dietary concordance reflects the extent to which patients’ eating behaviors are aligned with mutually agreed dietary recommendations developed in partnership with health care providers. This framing emphasizes collaboration, engagement, and shared decision-making rather than a prescriptive model of compliance.

In Indonesia, low levels of dietary concordance among patients with T2DM remains a critical concern, contributing to poor glycemic control and heightened risks of complications. Data from West Java Province reveal an annual increase of 8.5% in T2DM cases, with projections estimating 262 260 cases by 2023.¹¹ Local studies indicate that up to 62.5% of patients with T2DM do not follow with recommended dietary practices, resulting in suboptimal glycemic target.¹² This aligns with broader research highlighting that poor dietary concordance is often linked to inadequate self-management behaviors and low health literacy.¹³

Barriers to effective dietary self-management are further exacerbated by misconceptions about caloric needs, lack of meal planning skills, and limited access to culturally appropriate dietary education.¹⁴ Many patients report confusion about permissible foods under dietary guidelines and struggle to maintain long-term dietary concordance. Moreover, the monotony of prescribed diet plans often diminishes motivation, making dietary concordance even more challenging.¹⁵ Addressing these barriers requires targeted interventions that integrate nutritional education with practical self-management strategies tailored to local cultural contexts.

Despite the critical role of dietary self-management in diabetes care, there is a lack of region-specific research examining the link between self-management behaviors and dietary concordance among patients with T2DM in Indonesia. Although international studies have explored dietary concordance broadly, local insights are limited, particularly in West Java, where the burden of T2DM is rapidly escalating. Understanding the specific behaviors that contribute to dietary concordance in this population is essential for developing culturally relevant interventions aimed at improving glycemic goals. This study aimed to examine the relationship between self-management dietary behaviors and dietary concordance among T2DM patients in West Java, Indonesia.

Research Question

Research Question 1: What is the relationship between self-management dietary behaviors and dietary concordance among patients with T2DM in West Java, Indonesia?

Methods

Study Design and Setting

A cross-sectional correlational study was conducted to examine the relationship between self-management dietary behaviors and dietary concordance among patients with T2DM. The study took place at the outpatient clinic of a major public hospital in Bandung Regency, West Java Province, Indonesia. The clinic provides routine diabetes care and education to a large and diverse patient population from the surrounding urban and semi-urban areas, making it a representative setting for this study. Data collection occurred during routine outpatient visits from May to August 2023.

Study Participants and Sampling

The study population consisted of adult patients with T2DM who attended the outpatient clinic during the study period. A target sample size of 278 participants was determined through power analysis, ensuring a 95% confidence level and a 5% margin of error for sufficient statistical power. Participants who met the eligibility criteria were recruited using purposive sampling. The inclusion criteria included (1) diagnosed with T2DM for at least 1 year, (2) receiving routine outpatient care, and (3) able to communicate effectively in Bahasa Indonesia. Patients were excluded if they (1) had severe chronic complications, such as coronary heart disease, congestive heart failure, or stroke, or (2) required inpatient treatment during the study period.

Outcome Measures

Two previously validated questionnaires were used to measure the study’s main variables. Self-management dietary behaviors were measured using the Self-Management Diet Questionnaire by Willianto et al.¹⁶ This 16-item tool covers 4 domains: caloric needs, healthy food choices, meal planning, and dietary behavior challenges. Responses are recorded on a 4-point Likert scale (1 = never, 2 = sometimes, 3 = often, 4 = always), with higher scores indicating better self-management practices. In this study, the questionnaire demonstrated high reliability (Cronbach’s α = .89).

Dietary concordance was measured using the Dietary Adherence Questionnaire by Khusna et al.¹⁷ This tool was developed and validated for the Indonesian population and is based on Indonesian national dietary guidelines for T2DM, assessing adherence across 3 culturally relevant dimensions: dietary frequency (amount), food types (type), and meal scheduling (schedule). This tool also showed good reliability in the present study (Cronbach’s α = .78).

Data Collection Procedures

Data were collected using 2 structured and validated questionnaires administered during routine outpatient visits. Participants were approached in the clinic’s waiting area and provided with information about the study. After obtaining informed consent, they independently completed the questionnaires, with assistance available if clarification was needed. Each questionnaire required approximately 10 to 15 minutes to complete. Data were checked for completeness by the research team before being entered into a secure, password-protected database by trained research personnel.

Bias Control

To minimize selection bias, all eligible patients attending the clinic during the study period were invited to participate, and those who declined were recorded. Information bias was minimized through the use of standardized and validated questionnaires, and recall bias was mitigated by collecting data directly during clinic visits.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics were used to summarize demographic characteristics and key variables. The normality of data distribution was assessed using the Kolmogorov-Smirnov test. Given the ordinal nature of the variables, Kendall’s tau-c was used as the primary measure of association. For the regression plot in Figure 1, we additionally report the Pearson correlation (derived from the linear model’s R²) to align the visualization and numeric summary. Statistical significance was set at P < .05.

Figure 1.

Positive linear association between total self-management and total dietary concordance (Pearson r = .95; R² = .91; P < .001).

Ethical Considerations

This study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Research Ethics Committee of Universitas ‘Aisyiyah Bandung (Approval No. 418/KEP.01/UNISA-Bandung/V/2023). Written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly maintained, with personal data securely stored and accessible only to authorized research team members.

Result

Participants Characteristics

A total of 278 participants with T2DM were enrolled in this study. The majority were male (67.6%) and between 45 and 59 years old (68.3%). Most participants had completed elementary education (76.3%) and had been living with T2DM for over 2 years. All participants reported routine outpatient visits for diabetes management. Self-management behaviors were generally high (81.7%), with 91.7% demonstrating good dietary concordance (Table 1).

Table 1.

Participant Characteristics (N = 278)

Characteristic	Frequency	Percentage
Gender
Men	188	67.6
Women	90	32.4
Age
Middle age (45-59 y)	190	68.3
Older adults (60-74 y)	84	30.2
Very old (>75 y)	4	1.4
Educational level
Elementary school	212	76.3
Junior high school	42	15.1
Senior high school	24	8.6
Duration of diabetes mellitus
More than 2 y	279	100.0
Routine health check-ups
Yes	279	100.0
Self-management index
High	227	81.7
Moderate	51	18.3
Dietary adherence index
Good	255	91.7
Poor	23	8.3

Self-Management Dietary Behaviors

Participants reported high levels of caloric awareness and healthy food selection, with mean scores of 3.58 (±0.49 SD) for recognizing caloric needs and 23.38 (±2.96 SD) for choosing healthy foods. Key behaviors included avoiding high-cholesterol foods, opting for healthier cooking methods, and consuming plant-based proteins. Meal schedule management was also well practiced, with a mean score of 17.03 (±2.07 SD), indicating regular mealtimes and balanced compositions. However, challenges were identified through responses to specific items in the dietary behavior challenges domain of the questionnaire, including reports of dietary monotony (eg, difficulty maintaining food variety) and eating in response to stress or emotions (Table 2).

Table 2.

Self-Management Dietary Behaviors (N = 278)

Items	Mean	(±SD)
Recognizing caloric needs	3.58	0.49
I estimate the number of calories in food for each meal.	3.58	0.49
Choosing healthy foods	23.38	2.96
I avoid foods high in cholesterol (organ meats, fatty meats, fried foods).	3.44	0.52
I avoid high-calorie fruits (durian, jackfruit, rambutan, grapes).	3.32	0.73
I prefer grilled, boiled, or steamed foods over fried ones.	3.18	0.60
I (or the person who cooks for me) use coconut milk or oil in cooking.	3.39	0.75
I eat fish and plant-based proteins (tofu, tempeh) more often than red meat.	3.19	0.65
I avoid salty foods.	3.38	0.74
I avoid sweets and high-sugar foods (compote, cakes, pudding, jam).	3.48	0.50
Managing meal schedules	17.03	2.07
I eat 3 times a day.	3.45	0.55
I intentionally set mealtimes.	3.19	0.79
I have breakfast in the morning.	3.45	0.52
I eat a variety of foods at each meal.	3.45	0.52
I eat healthy snacks (low-sugar fruits, whole grains) between main meals.	3.48	0.52
Managing dietary behavior challenges	10.01	1.05
I finish all the food served, even if I am full.	2.53	0.81
I prefer to exercise (eg, walking) instead of eating when stressed.	3.48	0.50
I carry candy or sugar cubes to prevent hypoglycemia.	4.00	0.00

Dietary Concordance Levels

Dietary concordance was assessed in 3 dimensions: amount, type, and schedule. Participants generally demonstrated concordance with dietary frequency and food types, with mean scores of 15.08 (±2.99 SD) for amount and 25.30 (±5.25 SD) for type. Concordance with meal scheduling was moderate, reflected in a mean score of 13.67 (±2.5 SD), with some participants reporting difficulties in maintaining regular mealtimes due to demanding activities (Table 3).

Table 3.

Diet Concordance for Diabetes Mellitus

Items	Mean	(±SD)
Amount	15.08	2.99
I eat more than 3 times a day.	2.59	0.90
I regularly monitor my blood sugar levels at health services.	2.96	0.99
I do not follow the dietary rules because it is troublesome.	3.23	0.84
I eat foods according to the recommendations of health professionals.	3.25	0.75
I always eat vegetables and fruits as recommended.	3.04	0.95
Type	25.30	5.25
I consume foods and drinks that are sweet or contain sugar.	3.07	0.88
I consume foods high in oil/fat (fast food, fried foods, liver).	3.07	0.92
I consume foods rich in vitamins and minerals.	3.15	0.88
I consume high-protein foods (eggs, meat).	3.28	0.81
I vary the foods in my diet to avoid boredom.	3.22	0.88
I use sugar substitutes when consuming sweet foods or drinks.	3.11	0.90
I like to eat salty foods.	3.17	0.92
I always eat snacks/small meals.	3.30	0.87
Schedule	13.67	2.5
I eat on time according to the meal schedule.	3.09	0.94
I am too busy to eat on time.	3.03	0.88
The recommended dietary schedule feels burdensome.	3.06	0.93
I do not record my daily meal menu.	3.49	0.88
I regularly weigh myself every month.	1.00	0.00

Association Between Self-Management and Dietary Adherence

Figure 1 illustrates a robust linear association between total self-management behaviors and overall dietary concordance (Pearson r = .95; R² = .91; P < .001), consistent with the rank-based Kendall’s tau-c (τ-c = .962). Kendall’s tau-c correlation analysis revealed significant positive relationships across all domains of self-management and dietary concordance (P < .001). The strongest associations were observed between choosing healthy foods and type adherence (τ-c = .702) and between managing meal schedules and type adherence (τ-c = .743). Furthermore, the overall relationship between total self-management and total dietary concordance was exceptionally strong (τ-c = .962, P < .001), indicating that effective self-management correlates with improved dietary concordance outcomes (Table 4).

Table 4.

Associations Between Self-Management Dietary Behaviors and Dietary Adherence (N = 278)

Domains	Kendall’s τ-c	P value
Recognizing caloric needs → amount adherence	0.546	<.001*
Recognizing caloric needs → type adherence	0.600	<.001*
Recognizing caloric needs → schedule adherence	0.526	<.001*
Choosing healthy foods → amount adherence	0.583	<.001*
Choosing healthy foods → type adherence	0.702	<.001*
Choosing healthy foods → schedule adherence	0.597	<.001*
Managing meal schedules → amount adherence	0.427	<.001*
Managing meal schedules → type adherence	0.743	<.001*
Managing meal schedules → schedule adherence	0.606	<.001*
Dietary behavior challenges → amount adherence	0.427	<.001*
Dietary behavior challenges → type adherence	0.547	<.001*
Dietary behavior challenges → schedule adherence	0.521	<.001*
Total self-management → total dietary adherence	0.962	<.001*

P < .001, indicating a statistically significant relationship.

Discussion

Summary of Key Findings and Implications

Study findings illustrate that self-management dietary behaviors play a pivotal role in promoting dietary concordance among patients with T2DM in West Java, Indonesia. Key behaviors, including meal planning, caloric awareness, and healthy food selection, were found to be strongly associated with higher dietary concordance with dietary guidelines. This dietary concordance is a key element for achieving optimal glycemic stability and reducing the risk of diabetes-related complications, as reflected in lower A1C levels and improved self-regulation.^18,19

The findings align with self-regulation theory,²⁰ which posits that individuals who set clear dietary goals and consistently monitor their intake are more successful in managing chronic conditions, such as T2DM. Specifically, participants who actively engaged in meal planning and caloric estimation demonstrated better dietary concordance, suggesting that structured dietary self-management enhances patient outcomes. This supports existing evidence that personalized dietary management significantly improves clinical parameters in T2DM care.¹⁹

Moreover, the strong correlations between choosing healthy foods, managing meal schedules, and type adherence underscore the importance of structured dietary planning. Effective self-regulation in these domains minimizes glucose variability, thus preventing the long-term complications often associated with suboptimal glycemic stability.²¹ These results reflect the principles of the health belief model, which emphasizes that individuals are more likely to engage in health-promoting behaviors when they perceive significant risks and recognize the benefits of preventive actions.^22,23 It is also plausible that individuals who proactively manage their diet are more likely to engage in other beneficial self-care behaviors, such as physical activity and medication adherence, creating a positive feedback loop for overall health.

The study also highlights the influence of self-efficacy in dietary concordance, consistent with Bandura’s self-efficacy theory.²⁴ Participants who were more confident in their ability to manage caloric needs and make healthy food choices were more consistent in aligning their dietary practices with recommendations. This aligns with previous findings that patient empowerment through nutritional education and self-monitoring improves dietary concordance and long-term health outcomes.²⁵ Self-efficacy not only initiates healthy dietary behaviors but also sustains dietary concordance amid barriers such as cravings and social pressures.^15,26,27

From a practical perspective, these findings suggest that integrating structured dietary education into routine clinical care could significantly enhance dietary concordance rates. Educational interventions focusing on caloric estimation, meal scheduling, and food selection could empower patients to manage their dietary behaviors more effectively, contributing to better health outcomes. Given the limited availability of dietary self-management programs in Indonesia,¹⁰ this study addresses a critical gap, offering evidence-based insights for health practitioners and policymakers. Implementing these strategies at the primary care level could improve glycemic stability, reduce complications, and ease the health care burden associated with T2DM.^5,28

Additionally, the findings suggest that family and community involvement is essential for sustainable dietary concordance. Integrating family support into meal planning and dietary education could further strengthen dietary concordance given that social support is a key predictor of self-management success.²⁹ Policymakers are urged to consider community-based dietary interventions that are culturally tailored to address local food preferences and eating habits, potentially enhancing long-term dietary concordance.

Strengths and Limitations

A major strength of this study is its focus on real-world clinical settings in Indonesia, which enhances its external validity. The use of validated questionnaires to measure self-management behaviors and dietary concordance also adds methodological robustness.¹⁶ However, the cross-sectional design limits causal inference, and reliance on self-reported data introduces the potential for recall bias. Furthermore, although the study measured self-management behaviors, it did not include a specific measure of self-efficacy, which is a key psychological construct theorized to influence these behaviors. Future research should incorporate a validated self-efficacy scale, such as the Diabetes Management Self-Efficacy Scale, to provide a more comprehensive understanding of the psychological drivers of adherence. Longitudinal studies could also help to establish temporal relationships and assess long-term dietary concordance.²⁵

Limitations and Future Directions

Although the study affirms the benefits of dietary self-management, challenges such as dietary monotony, cultural food preferences, and limited nutritional knowledge remain significant barriers. Addressing these barriers requires culturally adapted educational interventions that incorporate local food preferences and practical meal planning strategies. Future research should also explore the role of mobile health applications in monitoring dietary concordance and family-based dietary education to further enhance outcomes. Additionally, exploring community-based interventions that engage local food markets and culturally relevant meal planning could foster sustainable dietary concordance.

To address the limitations of self-reported dietary concordance, future studies should consider using objective dietary assessment tools, such as digital food diaries or wearable devices that monitor eating patterns. Furthermore, longitudinal studies assessing the impact of sustained dietary concordance on clinical outcomes would be valuable to establish causal relationships.

Conclusion

This study reinforces the importance of structured dietary self-management in T2DM care. Enhancing patient education and integrating dietary interventions into primary health care could improve adherence and glycemic goals. Future research should explore sustainable long-term strategies, digital health innovations, and family-based interventions to optimize dietary concordance in diabetes care.

Footnotes

Acknowledgements

We want to express our gratitude to all who participated in this research. We would also like to thank Universitas ‘Aisyiyah Bandung for supporting this study.

Author Contributions

All authors contributed to the study conception and design. The conceptualization and first draft of the manuscript was written by Angga Wilandika, and all authors commented on previous versions of the manuscript. Material preparation, data collection, and analysis were performed by Angga Wilandika, Dandi Yohanes, and Inggriane Puspita Dewi. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Research Ethics Committee of Universitas ‘Aisyiyah Bandung (Approval No. 418/KEP.01/UNISA-Bandung/V/2023). Informed consent was obtained from all individual participants included in the study.

ORCID iD

Angga Wilandika

Data Availability

The data sets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

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