DIETARY MANAGEMENT IN NATIONAL HOSPITAL ABUJA A CASE STUDY

  CHAPTER    ONE

INTRODUCTION

1.1           Background of the study

Diabetes mellitus is defined as a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances in carbohydrates , protein, and fat metabolism resulting from defects in insulin secretion ,insulin action or both (Alberti ,Defronzo,Keen,Zimmet.,1992). Llioja,Mott,Howard. (1988) reported that the presence of glucose circulating in the blood results in potential pathological complications.

              Famuyiwa,Sulimani,Laajam,AL-Jesser,Mekki. (1992) reported that diabetes may present as an acute disorder with the classic triad of polyuria, polydipsia and unexplained weight loss, some patients may present for the first time in a coma. However, diabetes can also present as a sub acute condition over several months particularly in elderly patients in whom this triad is usually not so dramatic and may even be absent (Abdulkadir, 1993).

Scientists believe that a combination of genetic susceptibility and exposure to environmental factors cause increased incidence of this disease in individuals (Report of the Expert Committee on the diagnosis and classification of diabetes (1997).

Diabetes in addition to being a disease in itself is also a risk factor for coronary heart disease, myocardial infarction, angina and sudden death .It is a disease with specific complications (Mckeigue,Shah,Marmot:, 1991). Obesity is a major risk factor in diabetes mellitus (Alberti et al., 1992). Over 50% of patients with non insulin dependent diabetes mellitus (NIDDM) are obese (Ngwu, 2001)

Lyon,Vincce,. (1993) reported that most people with diabetes (more than 80%) die of cardiovascular disease. Diabetes doubles the risk of death from heart disease in women. Oldrizzi,Rugio,Mashio., (1994) reported that diabetes is classified into type 1 and type 2.It is a life long metabolic disease irrespective of the age of onset.

Type 1 diabetes mellitus also known as insulin dependent diabetes mellitus (IDDM) is an autoimmune disease which destroys the beta cells in the pancreas, the cell which produces insulin (Dietz, 1994). Bonnice (1998) reported that diabetes in childhood and adolescence is almost invariably type 1.The incidence is increasing in developed countries, while it is the subject of debate in Africa.

Type 2 diabetes mellitus also known as non-insulin dependent diabetes mellitus (NIDDM), is a multifactorial heterogeneous disorder characterized by chronic hyperglycemia as a result of two defects –insulin resistance (reduced insulin sensitivity) and β-cell dysfunction (impaired insulin secretion (World Health Organization (WHO), 1994).

Kashgari (2000) reported that type 2 diabetes mellitus starts much earlier many years before clinical diagnosis is made with a long period of insulin resistance and hyperglycemia. Ohwovoriole, Kuti ,Kabiawu., (1988) reported that diabetes mellitus affects about 1-7% of the Nigerian population and over 90% of these are non insulin dependent, about the ages of 45 years and above.

King, Rewers., (1993) reported that a person is diabetic if after 2 hours of drinking a solution with 75 grams of glucose, blood glucose of more than 200 milligrams per deciliter (200mg/100 dl) is obtained. Blood glucose of below 140mg/dl indicates normal blood glucose status. Between 140-200mg/dl is an impaired glucose tolerance. Impaired glucose tolerance is a risk factor for developing diabetes, and also increases the risk of getting myocardial infarction. Morbidity and mortality from cardiovascular disease are two to five times higher in patients with diabetes compared with non-diabetes (American Diabetes Assoiation, 1994).

Diet plays an important role in the management of acute and chronic diseases such as diabetes mellitus (Mann, 1980). An important factor in the success of diabetes treatment is to know what and how much to eat, which food components gives calories and which directly influences blood glucose level (Robinson, Fuller, Edmeades., 1988).

Lebovitz (1994) reported that type 2 diabetes treatment begins with diet control, exercise and weight reduction, although over time this treatment may not be adequate. People with type 2 diabetes typically work with a dietitian to formulate a diet plan that regulates blood sugar level, so that it does not rise swiftly after meal (Price, 1999).

A recommended meal is usually low in fat, provide moderate protein (10-20% of total calories), and contains a variety of carbohydrates and vegetables (Yamanouchi,Westen., 1995). Barnard. (1994) reported that regular exercise help body cells absorb glucose ,thirty minutes of exercise daily can be effective. Diet control and exercise may also play a role in weight reduction which appears to partially reverse the body inability to use insulin.

Harum (1993) reported that western diet leads to apparent occurrence of non-infectious chronic disease such as colon cancer, coronary heart disease, diabetes and obesity.

1.2       Statement of the problem

Increasing affluence, urbanization and changing food habits have lead to high incidence of diet-related non-communicable diseases including diabetes, obesity and hypertension (Standing committee on Nutrition,(SCN),2006).  Diabetes mellitus is becoming a major health problem in Nigeria with a high prevalence rate (The National Expert Committee on non-Communicable disease in Nigeria, 1992).Khare (1999) reported that though our understanding of diabetes has increased over time complication remain a problem. An individual who has diabetes is more likely to have obesity, hypertension, and coronary heart disease and stroke (Jervell, 1995).

More than 80% of people with diabetes mellitus die of cardiovascular disease. With diabetes the risk of death from heart disease in women doubles. (The Diabetes Control and Complication Trial Research Group (DCCTRG,1993). Arteriosclerosis tends to develop early in people with obesity who may also have hypertension. Atheroscleroic vascular disease especially coronary heart disease and stroke are the principal cause of death in about 70% of diabetic patients (ADA, 1994).

Morbidity and mortality from cardiovascular disease are two to five times higher in patients with diabetes compared with non diabetic.

The level of awareness is on the increase in the urban centers, however,   the level of ignorance in rural areas is still very high; compliance to controlled diet is very low, especially in developing countries where poverty level and ignorance of complications resulting from uncontrolled diabetes is very high (Erasmus, Ebonyi, Fakeye., 1988).

1.3    Objectives of the study

        General Objectives: To assess dietary management of diabetes and adequacy of diets served to patients in National Hospital, Abuja. 

       Specific Objectives:

        This study has three specific objectives:                           

1. To determine disease categories among patients.
2. To assess the nutritional status of the patients using anthropometry (BMI) and dietary studies.
3. To determine adequacy of diets served patients by comparing with doctors prescribed energy level and FAO/WHO requirements.      

CHAPTER TWO

LITERATURE REVIEW

2.1 Definition

Diabetes mellitus is defined as a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances in carbohydrates, protein and fat metabolism resulting from defects on insulin secretion, insulin action or both (Albert et al., 1992). Krolewski, Warrm,Christlie. (1985) reported that insulin enhances the entry of glucose into the tissue cells, where it is metabolized to produce energy. Excess cellular glucose is stored as glycogen which may be catabolised in time of need. However, the presence of excess glucose circulating in the blood results in potential complications. Diabetes is the commonest endocrine disorder seen in the hospital medical clinics.

2.2 Brief history of diabetes mellitus

Diabetes mellitus is becoming a major health problem in Nigeria with a prevalence of 1.4-2.7%. Diabetes causes prolonged ill health, imposes morbidity and mortality risks, and necessitates a change in lifestyle, with a meticulous daily routine and long term self care. However few sufferers are aware of the devastating effects of diabetes (Adetuyibi, 1976). Diabetes mellitus is increasingly being recognized as a major public health problem in developed countries. The discovery of insulin in 20^th century by Banting, Bast, Macleod and Collip revolutionized the treatment of diabetes. Although our understanding of diabetes has increased over time, complications remain a problem (Stephens, 1996).

Okesina,Omotobo,Gadzama,Ogunrimola.(1995) reported that the onset of diabetes complications was often preceded by a period of deprivation particularly loss of emotional support and unconscious conflict, there is additional burden of frustration and anxiety surrounding potential diabetes complications. Diabetes mellitus is no longer considered to be one disease but is believed to be a group of diseases differing in etiology, biochemical features and natural history. Diabetes mellitus is generally characterized by a relative lack of insulin, but the acute insulin deprivation often occurring in the ketosis prone type of diabetes. Any absence of insulin not only inhibits the use of glucose by muscles and adipose tissue, but also sets into motion a sequence of events that without effective intervention will result in coma and death of affected patients; the effects of diabetes mellitus include long term damage, dysfunction and failure of various organs. . (Charney, 1993).

Diabetes may present with characteristic symptoms such as:

 Excessive thirst (polydipsia): A person with diabetes develops high blood sugar levels; the body tries to counteract this by sending a signal to the brain to dilute the blood which translates into thirst. The body encourages more water consumption to dilute the high blood sugar level back to normal levels and to compensate for the water lost by excessive urination.

 Excessive urination ( polyuria): The body tries to get rid of the extra sugar in the blood by passing it in the urine, this can also lead to dehydration because excreting the sugar carries a large amount of water out  of the body along with it.

Excessive eating (polyphagia): There is excessive blood sugar level in the system and to stabilize this the body will secret more insulin and this hormone stimulate hunger, this causes the individual to eat excessively.

Unexplained weight loss: People with diabetes are unable to process many of the calories in the food they eat, this leads to loss of weight even with the excessive eating. Losing sugar and water in the urine and the accompanying dehydration also contribute to weight loss.

Fatigue: The body is inefficient and sometimes unable to use glucose for fuel, the body switches over to metabolizing the fat, partially or completely as a fuel sources. This process requires the body to use more energy and this leads feeling fatigued.

   In its most severe forms ketoacidosis or a non ketotic hyperosmolar state may develop and lead to stupor, coma and in the absence of effective treatment death follows. The long term effect of diabetes include progressive development of the specific complications of retinopathy with potential blindness, neuropathy with risk of foot ulcers, amputation, charcot joints, and features of autonomic dysfunction, including sexual dysfunction. People with diabetes mellitus are also at risk of cardiovascular, peripheral vascular and cerebrovascular diseases, increase incidence of atherosclerotic cardiovascular disease hypertension and abnormalities of lipoprotein metabolism. (Mykkanen,Darton,Nishida,James.1993).   

Silverstein,Connor,Wingard.(1989) reported that insulin has a variety of actions on metabolism, most of which have the effect of lowering blood glucose; such actions include decreasing hepatic glucose output, while increasing glucose oxidation, glycogen deposition, lipogensis, protein synthesis, and cell replication. In the absence of insulin, all the hormones favoring catabolism and the raising of blood glucose operate with opposition. In diabetes, however, the responses are much more violet than those occurring in the body’s adaptation of fasting or starvation, during which the purpose is maintenance of a blood glucose level sufficient to meet the crucial demands of the central nervous system and red blood cupules. The unrestrained action of the catabolic hormones in the absence of insulin along with a dramatically decreased use of glucose caused by an insulin lack, results in aberration in metabolism. Not only is carbohydrates, fat and protein metabolism affected but water and electrolyte imbalance occurs.

 Hyperglycemia, the hallmark of diabetes which is due to decrease glucose and increase hepatic glucose output, results in an osmotic diuresis that proves fatal if uninterrupted. The water and electrolytes lost through these diuresis lead to dehydration compounded by increased insensible water loss due to the hyperpnea of metabolism acidosis. Metabolic acidosis results from the excessive ketogenesis occurring in the liver. (Khare,Chitakala., 1999). Klein (1995) reported that peripheral circulatory failure, a consequence of severe hem concentration leads to tissue hypoxia with a consequent shift of the tissue to anaerobic metabolism. Anabolic metabolism raises the concentration of lactic acid in the blood thereby worsening the metabolism acidosis. El-Hazim’s (1996) reported that ketonuria  with glucosuria associated with acidosis causes an excessive loss of sodium (Na+) from the body, loss of this extra cellular cation  further compromises the body water balance. A net loss of potassium (K+) the chief intracellular cation, accompanies increase protein catabolism and cellular dehydration both of which characterized uncontrolled diabetes. Diabetes mellitus is a vivid example negative example that emphasizes the integration of metabolism and the importance of metabolic regulation (homeostasis) to continuance of life. Hypoglycerima, or low blood sugar, occurs from time to time in most individuals with diabetes. It results from taking too much diabetes medications or insulin (sometimes called insulin reaction), missing a meal, doing more exercise than usual, drinking too much alcohol, or taking medications for other conditions. It is very important to recognize hypoglycemia and be prepared to treat it at all times. Headache, feeling dizzy, poor concentration, tremors of hands, and sweating are common symptoms of hypoglycemia, it can lead to fainting or seizure (Casparie.,1985)    

2.3 Classification:

The Expert Committee On The Diagnosis and Classification of Diabetes Mellitus (2003). The new classification system identifies four types of diabetes mellitus: type 1, type 2, other specific type and   neonatal diabetes.

Type 1 Diabetes- insulin dependent diabetes mellitus (IDDM):

Oldrizzi et al., (1994) reported that insulin-dependent diabetes mellitus or type 1 (IDDM) and non insulin dependent diabetes mellitus or type 2 (NIDDM) are the most known. Diabetes is a life long metabolic disease irrespective of the age at onset. Type1 diabetes is almost invariably the type among children and adolescence, the incidence is increasing in developed countries but in Africa the incidence is the subject of debate .Type 1 diabetes is usually characterised by the presence of anti-GAD, islet cell or insulin antibodies which identify the autoimmune processes that lead to beta cell destruction, individual with type 1 may be metabolically normal before the disease is clinical manifested , but the process of beta cell destruction can be detected.(Valle,Western,Shah. 1997).

Other specific type are diabetes of various known etiologies ,this include persons with genetic defects of beta cell function or with defects of insulin action, persons with disease of the pancreas, such as pancreatitis or cystic fibrosis, persons with dysfunction associated with other endocrinopathies for example acromegaly and persons with pancreatic dysfunction caused by drugs, chemicals or infections.(The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus,2003).

Type 2 Diabetes- non insulin dependent diabetes mellitus (NIDDM):      

Type2 diabetes is a multifactor heterogeneous disorder characterized by chronic hyperglycemia as a result of a dynamic interaction between defect insulin secretion and insulin action (WHO, 1999). Fabiyi, Kolawole, Adefehinit, Ikem. (2002) reported that diabetes mellitus affects about 1-7% of the Nigerian population and over 90% of this are non insulin dependent diabetes mellitus (NIDDM). Diabetes is increasing in frequency, and the type2 syndrome is strongly associated with obesity, the problem is increasing in Africa with increasing urbanization and westernization.

Type 2 diabetes mellitus is the most common type, is characterized by disorders of insulin resistance and insulin secretion either of which may be the predominant feature. The important point here is that insulin secretion, has not ceased when the disease develops but may be inadequate for the purpose for which it is being secreted, there is unusually too much carbohydrates to be metabolized. The development of type 2 diabetes passes through several stages in its natural history, the most important of this is impaired glucose tolerance (IGT) and this stage is a marker for identifying those at risk of developing diabetes. Patients with this marker are usually hypertensive. Type 2 diabetes must be viewed primarily as a long term complication of obesity; its development is accelerated by hypertension and this leads to onset of other chronic non communicable diseases. (Unwin, Sobugwi, Alberti., 2001).Rosenbloom, Douse, Finish, Sergeantson, King(1999), reported that obesity is now recognized as the most important factor in primary and secondary prevention intervention in type 2 diabetes. Cross-sectional studies in population of Pacific Islanders, Urban African population and African American implicate obesity as the driving force of the current type 2 diabetes epidemic. In urban Africa there is an increasing emergence of non communicable diseases (NCDs) as common causes of morbidity and mortality in adults.

 Pregestational and Gestational Diabetes: Metabolic changes- normal pregnancy is characterized by increasing insulin resistance which is probably due to human placental lactogen, a growth hormone like protein secreted by the placenta. During late pregnancy, fasting glucose level falls because of increase glucose consumption of the placenta and fetus (Schwartz, 1986). Freinkel, Henry, David, (1985) reported that gestational diabetes most often appears during the third trimester a period of maximum insulin resistance, and ketoacidosis may be seen in particularly in patients with insulin dependent diabetes mellitus who do not increase their insulin dose appropriately. Gestational diabetes typically ceases after delivery, women who have gestational diabetes are more likely than other women to develop type 2 diabetes later in life. The incidence of major congenital malfunctions is increased approximately fourfold among infants of women with pregestational diabetes, resulting in the birth of infants with central nervous system, cardiac renal, skeletal and other malfunctions.

The diet needs of women with pregestational diabetes at latter half of the pregnancy should be consuming 35kilocalories per kilogram of her ideal prepregnant body weight each day, or approximately 2200-2400calories per day. A weight gain of 24-28 pounds is recommended for most patients, however for obese patients with non-insulin dependent diabetes the preferred daily dietary intake is 25kilocalories per kilogram of ideal prepregnancy body weight or approximately 1600-1800calories per day. The calories should be derived as follows approximately 50% from complex carbohydrate, 30% from fats, and 20% from proteins. Patients will require three meals and up to three snacks each day. A bedtime snack is particularly important to decrease the risk of nocturnal hypoglycemia. (Gabbe, 1985).

 Neonatal diabetes:

  Diabetes mellitus affects the newborn infants in one or two ways, either as neonatal diabetes or as the infants of the diabetic mother. Classic neonatal diabetes is defined as hyperglycemia occurring within the first six weeks of life in terms of infants. The endocrine pancreas in the neonate is unable to regulate insulin in relation to blood glucose concentration with the same level of tight control seen in the older child and adult. (Aynsley, Green, Hawdon.,1997). Hyperglycemia is a common finding in the extremely premature neonate, especially during the first day of life. Premature neonates have difficulty maintaining normal blood glucose levels. Neonatal diabetes maybe transient or permanent, the permanent variety has been reported in a new born infant with trisomy 21 (Down syndrome) where  it is thought to be due  to selective B cell defects with undetectable C-peptide levels, but normal and cell function (Shehadeh, Gershoni, Etzioni, 1998). Hoveyda, Shield, Garret. (1999) reported that three cases of neonatal diabetes, cerebellar hypoplasia lagenesis, and dysmorphism occurring within a highly consanguineous family. An autosomal recessive pattern of inheritance was suggested, rarely, pancreas agenesis may be the cause of permanent neonatal diabetes with associated mal-absorption.

The syndrome of transient diabetes in the newborn has its onset in the first week of life and persists from several weeks to months before resolving spontaneously. It is an uncommon diagnosis that is utilized when other reasons for hyperglycaemia cannot be determined. It occurs most often in infants who are small for gestational age and is characterized by hyperglycaemia and pronounced glycosuria, resulting in severe dehydration and at time metabolic acidosis, but with only minimal or absent ketonaemuria or ketonuria. Insulin responses to glucose or tolbulamide are low or absent, but basal plasma insulin concentrations are normal. After spontaneous recovery, the insulin responses to these same stimuli are brisk and normal, implying a functional delay in beta cell maturation with spontaneous resolution (moniac, Howard.,Roche, Waxwell.(1999).