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
INTRODUCTION
1.1 Background to 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.
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. 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 all people 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).
- 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 as neuropathy, 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.
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