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India alongside the world has witnessed a huge epidemiological transition in the 21st century. This has led the non-communicable disease turn into major health problems of growing magnitude. Diabetes, one among them have emerged as a major health care problem. Earlier considered as a disease of affluence, diabetes is no more associated only with it and its rise can be seen across the world.

Diabetes, a global public health problem is now emerging as a pandemic and by the year 2025, three quarters of world's 300 million adults with diabetes will be in non-industrialized countries and almost a third in India and China alone[1] (Mohan,2021).There is evidence from several studies that the prevalence of Type-II disease is increasing. In this era of globalization, there are several diseases related to the pattern of human life and descent. One of these diseases in diabetes mellitus that none of the drugs is being able to cure. In the case of diabetes, the patients expected to be able to apply a healthy lifestyle, manage the daily food intake and perform positive activities for exercise. One of the small but very essential forms of management is done by recording the foods eaten and recording the activities are performed according to the advice of experts in exercise for diabetics[2]. Kurnianda and Sari(2018)

Lifestyle intervention is the first line intervention and should be aggressively implemented in individuals with diabetics and awareness should be spread regarding the causes and complication of disease. Lifestyle interventions among patients can go a long way in controlling the disease and associated morbidity.

Keeping in view the increasing incidence of Type-II diabetes and role of lifestyle modifications, it becomes important to take steps for management of disease for benefit of people and for the country overall. Knowledge and awareness level of patients about diabetes is not adequate in India. Various education programmes are essentially required to solve the problem and manage the disease. Therefore, the present effort was made and a lifestyle modification programme was planned and implemented. 

A list of 100 Type-II diabetic patients coming to Tulip Hospital, of Vivekanand Chowk Delhi road, Sonipat (Haryana) at OPD time was prepared. A pre survey was done to assess their nutritional status. Out of these, 50 patients willing to cooperate in the study were randomly selected for the present study. The information on knowledge, attitude and practices, their food intake, physical activity, blood Profile was also obtained with the help of pre structured interview schedule. Lifestyle modifications were suggested with the help of charts, posters, booklet etc for three months on monthly basis. The impact was assessed at the start of intervention and at the end of third month.

Patients were mainly advised to correct their faulty food habits, increase physical activity, cessation of smoking and alcohol intake under life style modification program me. Changes in these habits, blood profile and KAP were recorded, presented and discussed in this paper.
The impact of lifestyle modification in terms of improvement in various parameters was seen. Therefore, the present investigation suggested that for long-term effects, nutrition counseling should be imparted at regular interval and for long term to see significant improvement in life style changes. It can be concluded that a sound approach is to improve the nutritional knowledge and health dietary practices for effective management of diabetic mellitus.
Correction of Faulty Dietary Habits
Patients were advised on each visit about the ill effects of fast food and advantages of using healthy food items. The data was collected from selected 50 diabetic patients before intervention and at the end of every month i.e.1^st, 2 ^nd and 3^rd. Variations in intake were observed on all the visits but efforts were make to quantify the data. The results were compared with the data of intervention i.e. 0 month with the data of 3^rd month as not much or slight changes were observed on 1^st and 2^nd month. The result presented in Table 1 indicated that 94 percent were consuming fast foods before the intervention and only 6 percent were not consuming fast foods. At the end of 3^rd month after attending the lifestyle modification program me, 44 percent were consuming fast foods while 56 percent stopped consumption of fast food.
In case of healthy snacks, only 24 percent were consuming healthy snacks and 76 percent were not consuming before the intervention period. After 3 months, the consumption of healthy snacks increased in 54 percent of patients instead of 24 percent of patients. At the end of 3^rd month, 46 percent were not consuming healthy snacks. However, consumption of healthy snacks increased and consumption of fast foods decreased.
The desirable visible fat intake recommended by ICMR is 20g/day. Patients were advised to consume 15-20 g/d; information was collected and presented in Table 2. Before intervention, there were only 8 percent of patient where consuming 15-20 fat i.e. desirable fat. The percentage of patients increased to 78% Ninety-two percent of patients were consuming more than 20g fat & oil, which decreased to 22 percent of patients this, clearly shows the impact of lifestyle modification program me as at the end of the study most of the patients (78%) started consuming less than 20g of fat.
Table 1 Impact of lifestyle modification on the consumption of fast foods & healthy snacks in diabetic patients                      (n=50)
 

Consumption of fast foods	Before Intervention	At the end of 3rd month
Yes	47 (94.0)	22 (44.0)
No	3 (6.0)	28 (56.0)
Healthy Snacks
Yes	12 (24.0)	27 (54.0)
No	38 (76.0)	23 (46.0)

Figure in parenthesis indicate percentages.
Table 2 Impact of lifestyle modification on consumption of fats & oils by diabetic patients    (n=50)

Amount of Visible fat	Pre-Intervention	End of 3rd month
15-20 g/day	4 (8.0)	39 (78.0)
More than 20g/day	46 (92.0)	11 (22.0)

Figure in parenthesis indicate the percentage
 
Changes in physical pattern activity-
Diabetic patients were encouraged to start physical activity light to moderate & heavy exercise. They were told about the advantage of physical activity for the maintenance of glucose level and obesity management. Most patients were not aware about the importance of physical exercise and were not doing much of physical exercise at the intervention period information collected on physical activity is presented in Table 3. The data indicated that 74 percent were not doing any specific physical activity and only 26 percent were doing physical activity at the end of third month there was remarkable change and 94 percent started doing physical activity and only 6 percent left were not doing any physical activity physical activity assessment was done through categorization of physical activity to poor, good or excellent physical activity level. In the present study, patients started doing some type of physical activity. Results revealed that 43 patients i.e. 86 percent were doing 15-20 min walk or exercise or yoga, were in poor adherence category (Table 4), and decreased to 26 percent patients at the end of 3^rd month, 50 percent of patients started doing 30-35 min walk or exercise or yoga. Twenty-four percent patients started doing 45 min walk/exercise or yoga and were found in excellent adherence. This clearly shows remarkable changes in physical activity and impact of programme. Parker et al (2014) had also reported that after Medical Nutrition therapy (MNT) for 12 weeks, the percentage of the subjects indulging in 30 min of physical activity increased from 20.9 to 95 percent.
Wannametheeet al (2002) concluded that there is a non-linear relation between alcohol intake and the risk of type II diabetes. Serum insulin and HDL-cholesterol explain a smaller amount (20%) of the reduction in risk of type II diabetes associated with moderate drinking. The adverse effect of heavy drinking seemed to be partially mediated through its effect on body weight.
 Table 3 Impact of life style modification on physical activity of diabetic patients

Physical activity Yes No	No	Frequency	At intervention period	At the end of 3rd
	Yes	Frequency (%)	37 (74.0)	3 (6.0)
			13 (26.0)	47 (94.0)

 

Table 4 Adherence score of different type of physical activity of diabetic patients (n = 50)

Physical activity adherence score	Dmation& type physical activity	Pre Intervention	End of 3rd Month
Poor Adherence	15-20 min walker or exercise or 15 min. Yoga	43 (86.0)	13 (26.0)
Good Adherence	30-35 min walk or 30 min exercise or 30 min. Yoga	7 (140)	25 (50.0)
Excellent adherence	40-45 min walk or 45 min exercise or 45 min yoga		12 (24.0)

Table 5: Impact of lifestyle modification on smoking, alcohol and tobacco consumption (n = 50)

Parameters	At Intervention	3rd Month
Smoking
Smoker	30 (60.0)	18 (36.0)
Non smoker	(40.0)	32 (64.0)
Cigarette/Day
1	10 (33.33)	13 (72.22)
2	15 (50.0)	5 (27.78)
3	5 (16.67)	—
Frequency
Daily	30	12 (66.67)
Thrice a week	—	6 (33.33)
Twice a week	—
Alcohol intake
Alcoholic	25 (50.0)	813 (26.0)
Non alcoholic	25 (50.0)	37 (74.0)
Quantity of Alcohol (ml) Consumed/day
<60		5 (38.46)
60-120	13 (52.0)	8 (61.54)
120-180	12 (48.0)	-
Frequency
Daily	18 (72.0)	3 (23.08)
Thrice a week	-	-
Once a week	8 (20.0)	10 (76.92)
Fort nightly	2 (8.0)	—
Tobacco
Chewers	22 (44.0)	11 (22.0)
Non chewers	28 (56.0)	39 (78.0)
Frequency
Daily	22 (100.0)	11 (100.0)
Twice a week	-
Thrice a week	-

Table 6: Impact of lifestyle modification on the blood profile of diabetic patients n = 50

Blood Profile	Reference value	At Intervention	3rd Month	% change	t value
Systolic Blood Pressure (mmHg)	<130a	147.28+8.29 (113.29)	138.24+9.14 (106.33)	-6.14	7.72x
Diastolic Blood Pressure (mmHg)	<80a	85.11+9.17 (106.38)	82.03+7.6 (102.53)	-3.62	2.77x
Fasting Blood Glucose (mg/dl)	<126b	142.34+18.17 (112.96)	128.06+17.49 (101.63)	-10.04	5.53xx

Values one expressed as mean +SD
a.     American heart association (2017)
b.     American diabetes association (2019)
Changes in smoking, alcohol and tobacco consumption
It is difficult to change these habits but still encouraging results were obtained presented in Table 5. The data revealed that 60 percent diabetic patients were smoker and 40 percent were non-smoker and 40 percent were non-smoker at the time of intervention. At the end of 3 month situation almost reversed indicating that 36 percent remained smoker and 64 percent become non-smoker at the end of 3^rd month out of smoker, 33, 50, 16 percent were taking 1, 2, 3 cigarette per day, respectively. At the end of third month, none of the patient took 3 cigarettes/day while majority 72 percent consumed one cigarette only and 27 percent were taking two cigarettes. This shows remarkable changes in the habit of smoking.
Regarding alcohol intake, 50 percent were alcoholic and 50 percent were non-alcoholic at the intervention stage. At the end of 3^rd month, percentage of alcoholic reduced to 26% from 50 percent and non-alcoholic increased to 74 percent from 50 percent.
At intervention period, most of them (52%) were taking 60-120 ml and 48% consumed 120-180 ml/d. The quantity of alcohol consumed reduced to <60 in 38 percent and 60-120 ml in about 62 percent of patients none of them consumed 120-180 ml at the end of 3^rd month. Frequency also reduced. About 23 percent were consuming daily and 77 percent were consuming on weekly basis. However, it is difficult to change the habit of alcohol intake but like style modification programme showed a remarkable impact.
Regarding tobacco intake; 44 percent were chewers and 56 percent were non-chewers at the start of experiment. At the end of 3^rd month, percentage of chewers was half i.e. 22 percent and non-chewers increased to 78 percent. However, they were taking daily before and at the end of 3^rd month. It was heartening to see the effect of life style modifications.
Adherence to prescribed life style changes have also been shown to improve glucose level, to lead to decreased blood pressure and to correct lipid abnormalities which are factors associated with micro and macro vascular complications of diabetes & CVD.Elevated fasting blood sugar level is a prediction for diabetes but it also predicts increased risk of heart disease and mortality from all causes.

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