ABSTRACT
The study was carried out using randomized 121 in-patient diabetics in medical wards of University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla. The instrument for data collection was structured, validated pre-tested questionnaires, anthropometry and dietary study. Body mass index was calculated for each patient using weight and height measurements. The adequacy of nutrient intake was assessed by comparing the energy and nutrient intakes of patient with FAO/WHO requirements. The contribution of macronutrients (carbohydrate, protein and fat) to the total daily energy consumption was assessed using American Diabetes Association (ADA). Data collected were coded into the computer. Descriptive statistics such as frequencies, percentages, means and standard deviations were calculated. Mannwhitney’s and Kruskawalli’s tests were used to compare means. Results showed that the subjects were made up of 54.5% males and 45.5% females. The BMI of the females (27.55±6.61kg/m2) was significantly (p<0.05) higher than that of males (24.53±4.64kg/m2). The study also showed that the BMI of patients from rural areas (23.70kg/m2) was significantly (p<0.05) lower than that of the urban (26.81kg/m2) and suburban (26.20kg/m2). There was no significant difference (p>0.05) between the waist circumference of males (95.59±10.97cm) and females (88.41±13.24cm). The mean waist/hip ratios for male and female diabetics were 0.96±0.08 and 0.91±0.10 respectively. The overall mean daily intake of energy of both male and female diabetics was 99.32% of the prescribed energy level. The overall daily intake of energy for male diabetics was 75.50% while that of females was 96.06% of FAO/WHO requirement. The mean daily protein intake for males and females were 164.7% and 179.3% of FAO/WHO respectively. The mean daily intake of protein by patients was 77.90g which contributed 15.30% of the total daily energy intake. Carbohydrate was 281.44kg (1125.79kcal), contributing 52.7% of the total daily energy consumed. The mean daily fat intake of patients was 77.23g (695.07kcal), contributing 32.65%. The micronutrient intake of diabetics (male and female combined) was adequate for vitamin A, C, thiamine and calcium. The iron intake of the male diabetics was 156.02% of the FAO/WHO requirement while that of female diabetics was 80.80%. Other micronutrients such as niacin and riboflavin were less than 100% FAO/WHO requirement for both males and females (63.90% and 88.50%) and (39.62% and 52.91%) respectively. The overall dietary intake of the in-patient diabetics was adequate for energy and macronutrients for females, but close to adequate for the male diabetics. Intakes of micronutrient were adequate except for riboflavin and niacin.
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background
of the Study
Diabetes mellitus is a chronic condition that arises when the
pancreas fails to produce enough insulin or
when the body cannot use the insulin produced effectively (Alva, 2000). There
are currently an estimated 143 million people with diabetes worldwide and this
figure is estimated to rise to 300 million
by 2025 (Alva, 2000).
In the past, diabetes was considered a single condition. However, it is now clear that diabetes is a heterogeneous metabolic condition caused by many different mechanisms. Diabetes is now categorized based on differences in cause, natural history and clinical characteristics (Albert, 1998). There are two basic forms of diabetes: type 1 requiring insulin for survival and type 2 which may require insulin for metabolic control. Type 1 is more common in children and adolescents and accounts for between 10 – 15% of all diabetes (Alva, 2000). More than 90% of all people with diabetes have type 2 diabetes mellitus (www.ext.colastate).
Diabetes mellitus can lead
to long term complications many of which can be fatal,
if not prevented and all of which have the potential to reduce quality of life
for people with diabetes (JAMA, 2002). The underlying pathophysiology
and management of both forms are different, a common feature is development of
long-term micro and macro vascular complications such as retinopathy, nephropathy
macro vascular disease peripheral and autonomic neuropathy. These complications are
associated with increased morbidity and mortality (Diabetes Control and
Complications Trial, DCCT, 1993).
Diabetes management should consider nutrition, physical activity and pharmacologic therapies (www.ext.colastate).Globally, there is increasing use of complementary therapies by the general population and health professionals in management of diabetes mellitus (Dunning, 2002). Complementary therapies are known by varieties of terms such as “alternative”, “natural”, and “traditional”. Most importantly, although complementary therapies have common philosophical basis, they are very heterogeneous in their approach and each therapy is different from others (Wood-Hart, 2002). Diet and exercise are the first line of treatment for allpeople with diabetes (International Diabetes Federation, IDF, 2002). This research will place emphasis on dietary management of diabetics. Researchers have indicated that diet therapy is the corner stone of management in patients with diabetes, especially type 2 diabetes (Garg, 1996).
Diabetes
is a metabolic disorder so closely linked to what the person affected by the
condition eats and in what quantities. The relevance of the medical nutrition therapy
in diabetes management cannot be overemphasized.
Nutrition which is
important for optimal metabolic control becomes one of the most challenging therapeutic components both for people with
diabetes, who need to know what to eat and for their health care providers (Karmeen, 2002).
In recent years, increasing
interest was much more on diet and nutrition by many different interest groups in society.
This is because research has shown that different risk factors for coronary
heart disease and its incidence can be reduced in diabetics by non-pharmacological means (Nydal
et al., 1993). Physicians and clinical scientists have devoted greater
attention to dietary prevention and treatment.
Suitable diet, with or
without pharmacological treatment, can reduce the amount of abdominal fat and
at the same time lower blood glucose level, blood pressure and serum lipids (Seidell et al., 1991). The advantages of dietary treatment are
clear. Today, the focus in managing diabetes is not on weight loss but on
efforts people with diabetes make to adapt, behavioural changes (eating pattern
and physical exercise) that lead to improved blood glucose, blood lipid and
blood pressure control.
Medical
Nutrition Therapy (MNT) is very much like medication of which diabetes treatment
regimens, nutrition recommendations are not the same for all people. They are
tailored to the needs of each individual. Nutrition management should be based
upon individual nutritional assessment.
Currently,
nutrition counselling sessions do not focus so much on the composition and
nutritional values of various foods. They rather focus on the difficulties (if
any) encountered by the diabetic in making the right food choice, the impact
this has on diabetes control and ways in which poor food habits can be
modified. What counts is solving any existing nutrition-related problems,
setting specific goals and understanding if the diabetic was ready to change
and to what extent.
Any adequate meal plan is good as long as it meets the patient’s goals. The optimal meal plan for a specific person should be set up after a thorough assessment of the person’s lifestyle, usual food intake, metabolic and personal goals as well as the willingness to achieve these. Franz et al. (2002) in their evidence based recommendations indicated that the best available mode of management of diabetes, is to take into account individual circumstances, preferences, cultural and ethnic preferences as well as the person with diabetes should be involved in the decision making process. A diabetic meal plan can be established in many different ways. It could be based on food pyramids, a plate divided into quarters, a traditional food exchange system, carbohydrate counting at a basic, intermediate or advanced level, a set of weekly menu, or list of general dietary guideline (www.ext.colastate).
As with
diabetes treatment regimens, the effectiveness of any meal plan can be assessed
by the results of blood glucose, blood lipid and blood pressure. Medical nutrition therapy, medication and
physical activity can jointly assist people with diabetes to achieve their
blood glucose goals, eating well and being active were found to be more
effective than medication. Recent diabetes prevention programme showed that
participants who followed a reduced-energy, low fat diet combined with 150
minutes of physical activity per week had 58% decreased risk of developing type
two diabetes (Karmeen, 2002). The current nutrition therapy and education focus
on problem solving skills and flexible meal planning based on informed choices.
The responsibility of
developing and implementing nutrition care plan is shared by all members of the
health care team. Generally, the greater the participation of team members the
more realistic and attainable the health care plan would be. In a hospital setting, the physician decides
if a patient should be on prescribed diet, prescribes and writes diet order in medical record and gets the patients
referred to a Dietitian (Eschleman, 1996). The Dietitian determines nutrient
requirement and translates the Physician’s diet order into foods or feedings. In the light of the complexity of nutrition
issues, it is recommended that a registered Dietitian, knowledgeable and
skilled in implementing nutrition therapy into diabetes management and
education, be the team member to provide medical nutrition therapy (ADA, 2002).
Medical
nutrition therapy, which has its integral part in dietary management, is one of
the five pillars for treatment of diabetes. However, in clinical practice,
nutritional recommendations that have little or no supporting evidence have
been and are still being given to persons with diabetes. The thrust of this
work is to study the dietary management of in-patient diabetics in the University of Nigeria
Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria.
- Statement
of problem
There
is an increase in the prevalence of diagnosed and undiagnosed diabetes mellitus
in most developed and developing countries. Nigeria is not an exception. This
increase can be attributed to increasing affluence and urbanization. This has
shifted peoples dietary habit from consumption of natural foods, to consumption
of refined foods, especially among the urban dwellers. The shift from intensive agrarian life to a
more sedentary urban life is an important factor. This precipitates obesity,
the major cause of type 2 diabetes mellitus (Dunning, 2004; Popkin, 2004).
The growing
concern over diabetes stems in large part from the recognition of its
complications. There are many half-truths, exaggerations and distortions
surrounding diabetes; such as diabetes caused by the retribution of gods
(Gilmore, 2004). Gilmore further observed that due to half-truths about
diabetes a person may have type 2 diabetes for months or years prior to
diagnosis. As a result, serious
complications, such asneuropathy, retinopathy, kidney failure and
cardiovascular disease might be diagnosed. Ngwu (2004) affirmed this
observation. She reported that diabetics
in Nigeria
have various perceptions about the causes of diabetes. Some attribute diabetes
to witchcrafts, heredity, diets etc and others are ignorant of the causes as
such did not realize that they have diabetes until its complications set in. The major problem with diabetics is non-compliance
to dietary regimen despite series of counselling by Dietitians and other
healthcare professionals. Approximately,
20% of people with diabetes in India
do not comply with recommendations made by their health carers due to
indifferent attitude to their treatment regimen (Shobhana, 1999).
Most times, dietary misconceptions acquired from
non-professionals adversely affect diabetics. Diabetics sometimes become too
rigid in food selection. This precipitates loss of
appetite due to monotonous food habit. The poor food habit in turn causes under nutrition, starvation and frequent hypoglycemic attacks (MacDonald, 1998). Diabetics, sometimes consume more
carbohydrate per meal to attain consumption of low glycaemic foods. This is one
of the major hindrances to attain diabetic control. Non-compliance to dietary
regimen is a major hindrance to good blood glucose controls. This is because
dietary control remains the corner stone for diabetes management. Moreso, the
health care givers are not left out in the dilemma of how best to feed
diabetics (Karmeen, 2004). Children with diabetes who like any other child
require more energy and nutrients for growth are subjected to energy restricted
meal plan (Karmeen, 2004). The failure to individualize diet for diabetics to
their cultural, sociological and economic backgrounds pose enormous problems.
The degree of family support can also be a problem, for example, some families
and friends offer tempting foods as such patients consume more food in presence
of friends than in their absence.
Stigmatization associated with
diabetes always scare some diabetics away from access to health care
facilities. Shobhana (2005) indicated that in a society in which arranged
marriages are common, the negative impact of this social stigma is rampant,
particularly in girls who developed type 1 diabetes. There girls are considered ineligible for
marriage. Furthermore, most of the
diabetics resorted to use of traditional medicine as a source of a permanent
cure. These precipitated increased risk of developing diabetic complications.
The interest in nutrition
assessment of diabetics has increased considerably over the last decades. Malnutrition was documented in hospitalized
patients. It was shown to be associated
with an increased prevalence of complications as well as high mortality among
hospitalized patients (Bani and Al-Kanhal, 1998). Precise information on
frequency and severity of malnutrition in hospital patients is difficult to
obtain. This is because physicians and dietitians do not recognize the need to
evaluate nutritional status of virtually every patient with chronic and acute
illness. Furthermore, some signs and symptoms of
malnutrition are often non specific. They appear during advanced stages of
nutritional depletion which pose difficulty in diagnosis (Gibson, 1990).
In many chronic diseases, such as
hypertension, diabetes, obesity, atherosclerotic heart and cerebral vascular
diseases, metabolic bone disease and alcoholism, deteriorated nutritional
status may contribute to aetiology of disease process. They might also prevent
effective recovery unless it is corrected in the course of a therapeutic
regimen (Halpern, 1979). Protein-energy malnutrition produces progressive
weight loss, weakness and apathy. This combination precipitates worse
malnutrition and disease conditions.
The social consequences of
malnutrition are equally important in these days of increasing concern with the
cost of medical care delivery systems. Delayed responses to various therapies,
precipitates malnutrition that increases the need for critical care facilities
and special nursing care. It increases stay duration in hospital and
convalescence in most instances. These special needs and long duration required
for the treatment of malnutrition produce stress on patient’s family,
environment and delay patients to return to normal work (Halpern, 1979).
There are, however, a few
documented evidence of the incidence of malnutrition among hospitalized adult
population. Bani and Al-Kanhal (1998) reported in
their study of malnutrition in hospitalized patients the following:-
- Malnutrition
seems consistently present, despite considerable differences in the types of
hospitals studied, socio-economic backgrounds of the patients and despite the
medical specialty under which the patient was admitted.
- Early
diagnosis and treatment of malnutrition may decrease the length of stay and
cost incurred by the hospitals.
- The over-riding cause of
malnutrition in hospitalized patients is restricted low food intakes. Food refusal by patients might be another
factor. It was estimated that the average plate waste in Saudi hospitals was
40% of the meal cost/subject/ day (A1- Shoshan, 1992).
Consequent
to the above points, it is imperative to assess dietary management of
in-patient diabetics in UNTH Ituku-Ozalla.
1.3 General objective of the study
The
general objective of the study is to evaluate the dietary management of
in-patient diabetics in U.N.T.H. Ituku-Ozalla, Enugu State, Nigeria.
1.4 Specific
objectives
The specific objectives
of the study are to:-
1.4.1 determine the nutritional status of patients
using anthropometry, biochemical and dietary studies.
1.4.2 assess energy and nutrient composition of
hospital diets served to patients on admission.
1.4.3 determine carbohydrate distribution in daily meals.
1.4.4 determine proportion of carbohydrate, protein
and fat in daily diet.
1.5 Significance of the study
The results of the study:
1.5.1 will highlight nutritional status of the patients.
1.5.2 will indicate the adequacy or otherwise of the
hospital diet served to patients.
1.5.3 will provide useful information and tool to
stake holders (Dietitians Health Workers, Ministry of
Health, Nigerian Government) to draw up appropriate dietary guidelines for
diabetics.
1.5.4 It is hoped that the information gathered from this work would enhance the living conditions of diabetics.
EVALUATION OF NUTRITIONAL STATUS AND DIETARY MANAGEMENT OF IN-PATIENT DIABETICS IN UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ITUKU-OZALLA, ENUGU STATE, NIGERIA
