Discussion

The findings of the current study indicated a substantial higher walking, and positively a higher
consumption of vegetable and fruit, and a positively lower consumption of high fat and sugary foods,
but not in oily fish and milk products following a three-month self-management intervention
completion amongst patients in experimental group compared to control arm with no education
implementation. The study did not show a substantial difference in weight, waist circumference and
Body Mass Index of patients. Although a recent study found an overall improvement in weight and
BMI at three and six months of the study intervention [18], this is the most difficult part of the
intervention as previous efforts were less successful in weight management and long-term weight
maintenance in diabetics compared to non-diabetic peoples [19]. It is hard to achieve weight loss and
its maintaining is encountered with a greater challenge [20]. The meta-analyses reviewed several
randomized and non- randomized-controlled trials on impacts of self-management education have
not shown congruent findings [21] about biochemical, dietary, and physical activity changes in
patients with type 2 diabetes mellitus. Some [9–11] demonstrated a substantial improvement in
glycated hemoglobin (A1C) between 0.36% and to 0.81%. A recent study confirmed a significant
decrease in HbA1c by 0.7% at three months (p < 0.0001) and by 0.5% at six months (p < 0.001) of
follow up [18], and contrast with others [12]. A substantial difference was not seen in HbA1c level in
the present study. Total energy restriction is seminal for glycemic control [22,23] and a diet with low-
fat calorie has its effect on glycemic control in T2DM patients [24]. Other studies showed a little
reduction in HbA1c percentage, by 0.4% [25]through applying menu plans and by 0.37 in a meta-
analysis [26]. However, even a little change in HbA1c is clinically so effective in long-term diabetes
complications [27,28]. The ALP-Phosphatase was significantly lower at follow-up (77.00 U/L)
compared to control (112.00 U/L) in type 2 diabetic patients. This is the hopeful finding of the study
as it has been documented that rising ALP is significantly associated with an increased risk of diabetes
[29], but we are unable to determine whether this decrease was owing to medication, healthy foods,
or physical activity. It has been confirmed that healthy eating lifestyle positively linked to particular
food habits such as lowering foods with a high sugar and high-fat and raising the portion or large
amounts of vegetables and fruit and limiting specific carbohydrates [30]. In congruence with the
literature, a considerable higher consumption of fruit and vegetables and lower consumption of full-
fat foods were seen in the experimental arm following the three-month self- management strategy. It
appears that general practitioners and medical specialists have limited time period (a few minutes) to
discuss the dietary matters with their diabetic patients in public health settings. Therefore, we see the
need to establish the healthy eating plans in this perspective by a health professional to pay attention
to diabetic patients’ diets to set the dietary goal more rapidly. The alcohol consumption is religious
prohibited material in this region as reflected in interventional group study findings. Therefore, the
authors did not discuss this particular point in training sessions. In addition, it must be considered
weight management, selecting favorite foods, and portion control and dining out as they influence the
dietary diabetes management. Moreover, it seems that level of social support, self-efficacy degree,
and personal skills of time management could facilitate or impede self-management. Moreover, new
food habits adoption is a hard achieving goal [31]. The patients did not show their interest towards
the milk and fish products at all despite wide availability and accessibility in this region and the special
focus in educational sessions. We leave this phenomenon to be uncovered for the next attempts. The
significant point here must be taken into account that majority of the patients were illiterate (68.8%
of patients) and remaining were a primary school (3 patients), intermediate school (1 patient), and
high school graduates (1 patient) and predominately were females (11 patients). In our consider-
ations, the patients participated in the present study had not sufficient literacy despite the educational
sessions were conducted by local language in relevance with cultural or religious perspectives.
Possibly, the environmental and familial challenges and barriers faced by patients in conducting self-
management have not been examined sufficiently and appro-priately in this study. The study showed
a significantly higher change in frequency and duration of walking among interventional patients and
no a change in vigorous-intensity activities following the study completion in accordance with previous
studies [18,32,33]. and no significant difference in moderate-intensity physical activity between two
study groups. Nonchange in vigorous- intensity activities was in agreement with our purpose as
discussed in educational sessions to prevent hypoglycemia [34]. In addition, it was not possible to
supervise the patients for the possible adverse outcomes [35,36] during the study intervention,
therefore, the concern of complications insisted us to not advise the patients to conduct vigorous-
intensity physical activities. However, the authors were astonished that why no substantial difference
was found between two study arms following considerable focus on advantages of moderate physical
activities to glycemic control. It may be due to having more females in an experimental group of the
study or non- having proper and desirable setting for physical activity conduction to female
populations in this city.

4.1. Mode and program of intervention delivery

The face-to-face group sessions with individually follow-up mode were used in the present study. It
seems that the different formats of intervention delivery have various biochemical and dietary
changes in these kinds of patients as these programs are different in delivery, content, and contact
time [3].

4.2. Strengths and limitations of the study

The findings reported in the present study must be interpreted in the illumination of study design and
intervention type. The dietary questionnaire used in this study entitled as “UKDDQ” has been
considered to be a new and twenty-first century dietary questionnaire with excellent test-retest
reliability designed in particular for diabetic patients. However, the study was not exempt from the
flaws. The study authors did apply flexible criteria to control the patients’ food behaviors as the
authors were aware the issue of higher vulnerability to eating issues of a rigid control of eating
behaviors [37]. It is possible that the study has been faced with measurement bias in dietary habits of
the patients owing to self reported technique. To reduce this kind of bias, the entire self- reported
information was collected by first author only. In additionentire biochemical measures were
performed by the second author in the same medical laboratory.

5. Conclusions

The current study showed a substantial statistically higher participation of patients in the
experimental arm in walking and higher consuming some healthy foods and a statistically considerable
lower consumption of some unhealthy foods following a three-month self-management intervention.
These kinds of efforts are noteworthy as they are in the proper directions and do not present confusing
and contradictory advice as media and public.