UNIVERSITY OF IBADAN

COLLEGE OF MEDICINE
FACULTY OF PUBLIC HEALTH
DEPARTMENT OF HUMAN NUTRITION AND DIETETICS
Dear respondent,
I am an undergraduate student of the Department of Human Nutrition and Dietetics,
University of Ibadan. I am conducting a research project titled “effectiveness of a designed
food portion control tool in improving glycaemic control among diabetic patients attending
university health services, Ibadan”. This is an invitation to participate in this study, kindly fill
this questionnaire with utmost sincerity. Your response will be needed before and after the
intervention and it will be used for academic purpose ONLY. Confidentiality is highly
guaranteed. Thank you!
INFORMED CONSENT: Please, kindly indicate your consent to participate in this study.
Name and Phone No. ______________________________________________________
Your Signature _________________________

QUESTIONNAIRE NUMBER ____________ DATE ____________________

SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS
Kindly tick the most appropriate answer

S/N VARIABLE RESPONSE

1.1 Age (years) a) 18 - 30 b) 31 - 45 c) 46 - 60 d) > 60

1.2 Gender a) Male [ ] b) Female [ ]

1.3 Marital Status a) Single [ ] b) Married [ ] c) Divorced [ ]

d) Widowed [ ]

1.4 Religion a) Christianity [ ] b) Islam [ ] c) Traditional [ ]

d) Others (specify) ________________

1.5 Ethnicity a) Yoruba [ ] b) Igbo [ ] c) Hausa [ ]

d) Others (specify) ________________

1.6 Place of Residence a) Urban [ ] b) Rural [ ]

1.7 Educational Level a) Primary [ ] b) Secondary [ ] c) Tertiary [ ]

1.8 Occupation a) Retired/Unemployed [ ] b) Self Employed [ ]

 c) Civil Services [ ] d) Employee of Private Org. [ ]

1.9 Income in Naira a) <20,000 [ ] b) 20,000 – 40,000 [ ]

(per month) c) 40,000 – 60,000 [ ] d) > 60, 000 [ ]

SECTION B: CLINICAL DATA (Diabetic related information of the patients)

S/N VARIABLE RESPONSE

2.1 Duration of Diagnosis a) < 5yrs b) 5 - 10yrs c) > 11yrs

2.2 Type of Diabetes Mellitus a) Type 1 [ ] b) Type 2 [ ]

2.3 Use of Medications a) Yes [ ] b) No [ ]

2.4 Smoking a) Yes [ ] b) No [ ]

2.4.1 If Yes, above, how many

stick/day

2.5 Alcohol a) Yes [ ] b) No [ ]

2.5.1 If Yes, above, how many

bottle/day/sitting

PRE-TEST POST-TEST

2.6 Fasting Blood Sugar (mg/dL)

SECTION C: DIETARY PATTERN (QUANTITATIVE)

Kindly choose the most appropriate option.

S/N VARIABLE RESPONSE

PRE-TEST POST TEST

3.1 How many servings of a) 1 - 2 servings a) 1 - 2 servings

cooked vegetables do you
b) 3 - 4 servings b) 3 - 4 servings
eat at a time? E.g. soko, tete
c) 5 or more servings c) 5 or more servings
1 serving = 1 serving spoon

3.2 How many servings of fruits a) 1-2 servings a) 1 - 2 servings

and raw vegetables do you
b) 3-4 servings b) 3 - 4 servings
eat at a time?
c) 5 or more servings c) 5 or more servings
 1 serving of;
Cucumber = 1 medium size
Carrot = 2 medium sizes
Garden egg = 3 medium
sizes
Banana = 2 medium sizes
Apple = 1 medium size
Orange = 1 medium size

3.3 How many servings of a) 1 serving a) 1 serving

semo, amala or eba do you
b) 2 servings b) 2 servings
eat at a time?
c) 3 or more servings c) 3 or more servings
1 serving = ½ fist/100g

3.4 How many servings of rice a) 1 - 2 servings a) 1 - 2 servings

do you eat at a time?
b) 3 - 4 servings b) 3 - 4 servings
1 serving = 1 serving spoon
c) 5 or more servings c) 5 or more servings

3.5 How many servings of a) 1 serving a) 1 serving

whole wheat bread do you
b) 2 servings b) 2 servings
eat at a time?
c) 3 or more servings c) 3 or more servings
1 serving = 1 slice/25g

3.6 How many servings of meat, a) 1 - 2 servings a) 1 - 2 servings

fish or chicken do you eat at
b) 3 - 4 servings b) 3 - 4 servings
a time?
c) 5 or more servings c) 5 or more servings
1 serving = 1 match box/70g

3.7 How many servings of nuts a) 1 - 2 servings a) 1 - 2 servings

do you eat at a time?
b) 3 - 4 servings b) 3 - 4 servings
1 serving = 1 handful
c) 5 or more servings c) 5 or more servings

3.8 How much water do you a) 1 litre a) 1 litre

drink per day?
b) 2 litres b) 2 litres
1 litre = 2 sachets
c) 3 litres or more c) 3 litres or more

3.9 How much salt do you use a) < 1 teaspoon a) < 1 teaspoon
in cooking at a time?
b) 1 teaspoon b) 1 teaspoon
 c) > 1 teaspoon c) > 1 teaspoon

3.1 How much bouillon cube do a) < 1 cube a) < 1 cube

0 you use in cooking at a
b) 1 cube b) 1 cube
time? e.g. Maggi, Knorr
c) > 1 cube c) > 1 cube

SECTION D: DIETARY PATTERN (FREQUENCY)

Kindly choose the most appropriate option

S/N VARIABLE RESPONSE

PRE-TEST POST TEST

4.1 What are your primary a) Meat a) Meat

sources of protein in
b) Fish b) Fish
your diet?
c) Egg c) Egg
d) Tofu d) Tofu
e) Others (Specify) _______ e) Others (Specify) _______

4.2 How many times do you a) Once a) Once

typically eat in a day?
b) Twice b) Twice
c) Thrice c) Thrice
d) More than thrice d) More than thrice

4.3 How many times do you a) Less than 1 time a) Less than 1 time
eat at least a serving of
b) 1 - 3 times b) 1 - 3 times
fruits per week?
c) 4 or more times c) 4 or more times

4.4 How many times do you a) Less than 1 time a) Less than 1 time
eat two or three servings
b) 1 - 3 times b) 1 - 3 times
of vegetables per week?
c) 4 or more times c) 4 or more times

4.5 How often do you a) Less than 1 time a) Less than 1 time
consume fried or greasy
b) 1 - 3 times b) 1 - 3 times
foods per week?
c) 4 or more times c) 4 or more times

4.6 How many times do you a) Less than 1 time a) Less than 1 time
drink regular carbonated
b) 1 - 3 times b) 1 - 3 times
drinks (sodas), fruit
 juices, or glasses of c) 4 or more times c) 4 or more times
sweet tea per week?

4.7 How many times do you a) Less than 1 time a) Less than 1 time
eat chicken without skin
b) 1 - 3 times b) 1 - 3 times
or fish per week?
c) 4 or more times c) 4 or more times

4.8 How many times do you a) Less than 1 time a) Less than 1 time
eat cooked bean or moi
b) 1 - 3 times b) 1 - 3 times
moi per week?
c) 4 or more times c) 4 or more times

4.9 How many times do you a) Less than 1 time a) Less than 1 time
eat regular chips or fried
b) 1 - 3 times b) 1 - 3 times
snacks e.g. puff puff (not
low fat) per week? c) 4 or more times c) 4 or more times

4.10 How many times do you a) Less than 1 time a) Less than 1 time
eat ice creams and other
b) 1 - 3 times b) 1 - 3 times
sweets per week
c) 4 or more times c) 4 or more times

SECTION E: ANTHROPOMETRY

S/N Variable 1st reading 2nd reading Average

5.1 Weight(kg)

5.2 Height(m)

5.3 BMI (kg/m2)

5.4 % Body Fat

5.6 LBM (kg)