ASSESSMENT OF DIABETES MANAGEMENT  REGIMENS AND EFFECT OF  DIABETES   EDUCATIONAL   INTERVENTION   AMONG   DIABETICS ATTENDING  NNAMDI  AZIKIWE  UNIVERSITY  TEACHING  HOSPITAL NNEWI ANAMBRA STATE, NIGERIA

ABSTRACT

This  study  investigated  diabetes  management  regimens  and  effect  of   diabetes educational intervention on diabetics attending Nnamdi Azikiwe University Teaching Hospital(NAUTH), Nnewi. A total of 146 diabetics were interviewed with structured questionnaire to obtain information on their lifestyles, diabetes management, diabetes knowledge   and   compliance   to   management   regimens.   Diabetes   educational intervention materials were developed to educate the subjects on 3 crucial areas of diabetes  management-  diet,  exercise  and  drug.  A sub-sample  of 33 subjects  with uncontrolled diabetes (fasting blood sugar >160 mg/dl) was followed up for 3 months to assess the immediate effect of the intervention on blood-sugar. Post intervention questionnaire   interview  was  repeated  on  the  subjects  after  two  years  of  the intervention  to assess  the long term effect  of the intervention.  The subjects  were predominantly  non- insulin  dependent  (type  2) diabetics  (96%) and a few  insulin dependent (type1) diabetics (4%); 62 % females and 38% males. Majority (75.7%) of the subjects used drugs and diets for diabetes management,  7%  used  drugs alone,

0.7% used diet alone and 16.6% used liquid extract of bitter and pumpkin leaves in addition  to  drug  and  diet.  Fifty  seven  percent  of  the  subjects  had  poor  diabetes knowledge while 43% had good diabetes knowledge. Similarly, 53% and 47% of the subjects had poor and good nutrition knowledge respectively.  Diabetes knowledge had  significant   (p<05)  effect  on  diabetes  control.  The   subjects  restricted  the consumption of some carbohydrate foods like rice (10%) and garri (2%) and increased the  consumption  of  unripe  plantain  (78%).  Consumption  of  legumes  was  high; cowpea and its products ranked highest (82%) followed by bread fruit pottage (27%). Fruits mostly consumed were  garden eggs (56%), avocado pear (27%), firm-ripped pawpaw (14%) and orange (9%). There was marked decrease in the intake of alcohol (17%) and cigarette  (23%).  Sixty-three  percent (63%)  of the subjects were either inactive  or  maintaining  light physical  activity in their daily life, while 37% were active.  Controlled  diabetes  (Fasting  blood  sugar  <  160  mg/dl)  was  significantly (p<0.05) higher among active subjects. The educational intervention had significant (p<0.05)  effect  on the blood-sugar  levels  of the subjects  within  3  months  of the intervention. There were positive lifestyle changes on the diabetics two years after the intervention. Diabetes knowledge significantly (p<0.05) improved from 43% to 57%. More  subjects  became  more  active,  blood  sugar  control  significantly  (p<0.05) improved  from  59%  to  63%.  Rigidity  and  monotony  in  their  food  consumption pattern became less and there was more diversification in their food selection.

INTRODUCTION

1.1      Background to the Study

Diabetes Mellitus is a group of multi-system endocrine disorder characterized by a raised blood glucose concentration due to defects in insulin secretion or action or both  (Chuwhak,  Peupet  &  Ohwovoriole,  2002;  Mathur,  2006).  Diabetes  occurs throughout the world. Mokdad, Ford & Bowman  (2000) observed that an epidemic of diabetes   mellitus   was  occurring   worldwide   and   warned   that  communities   in developing countries were now at greatest risk of the disease. Obesity and physical inactivity  comprise  an important  worldwide  epidemic  that has been linked  to the increased prevalence of diabetes and the  metabolic syndrome (Carlos, 2008). It has been projected that by the year 2025 the current incidence of diabetes worldwide will double, with an inevitable and  profound impact on global health care systems and budget (Williams, 2004). Lifestyles in resource poor countries are changing, putting population at much  higher risk of diabetes. Nwosu (2000) noted an increase in the incidence of diabetes mellitus among Nigerians and observed that diabetes constitutes

10% of patients seen by General Practitioners in Anambra State of Nigeria.

Diabetes mellitus is recognized as type 1 or insulin dependent diabetes and type 2 or adult onset diabetes. In type 1 diabetes, the insulin production from the pancreas is virtually  absent,  patients  must be managed  with exogenous  insulin  in addition  to dietary manipulation in an attempt to regulate blood glucose  level.  Type 2 diabetic patients may produce insulin that would be insufficient and ineffective in regulating blood glucose level, management could thus be with hypoglycemic drugs and/or diet. American Diabetes Association (ADA) opined that dietary management is crucial for all types of diabetes. The basic nutritional requirement of diabetic patient is the same as  those  of  a  non-diabetic.  However,  the  regimentation  of  food  intake  is  the

cornerstone  of diabetic  therapy.  Timing  of food intake,  the caloric  value  of  food ingested, the proportions and quality of carbohydrate, fat and protein are all-important aspect of the diet (ADA, 2004). The major principle is to reduce hyperglycemia, avoid hypoglycemia, and maintain appropriate weight. In an attempt to lower blood glucose, the patient should avoid easily absorbable simple carbohydrates  and highly processed and refined foods. The levels of energy recommendation for a patient depends on the age, body weight and activity.  During the National African Congress in 1994, the reconstruction and development programme in South Africa had specifically targeted diabetes as one of the chronic diseases in need of special attention.

The  increasing  prevalence  worldwide  of  diabetes  is  associated  with  levels   of modernization  (Popkin,  1999).  Apart from genetic implications,  diabetes  has  been associated with changes in lifestyle such as migration from rural to urban  settings, over-eating, sedentary habits, a change to high-fat diets, consumption of refined sugar with lower fibre diet, smoking, social and economic stress ( ADA, 2004).

Certainly, strategies on diabetes management need to focus on dietary and physical activity behavior. Evidence of successful control and prevention of  type 2 diabetes was  previously  published  from  the Finish  Diabetes  Prevention  Study  (Lindstrom, Louheranta  & Mannelin,  2003). In the study, 522 middle  aged (40-65 years) over

weight  individuals  (BMI  >  25  kg/m2)  with  impaired  glucose  tolerance  were  put

through  an  intervention  programme  consisting  of  weight  loss,  reduced  total  and saturated fat intake, increased dietary fibre and physical activity. Another study has demonstrated that behavioral interventions are more successful if they adopt ideas of informed choice and the acquisition of skills for self-management (Conor, 2003).

If  diabetes-associated   morbidity  and  mortality  are  to  be  reduced,   establishing sustainable  mechanisms  to achieve  good diabetic care is essential.  Diet therapy is

known  to be  a primary  therapy  in the  management  of  type  2 diabetes  and  vital injunctive in type 1 diabetes. This is because the type of food consumed by the patient plays a fundamental role in their glycaemic control (Rekha, 2000; ADA, 2004). It is imperative therefore that dieticians counsel diabetic patients appropriately, according to their social circumstances.  This requires time to  educate patients on the use of household measures and to point out the quantity of cheap but appropriate foods that are available locally.

1.2    Statement of the Problem

The  increasing  prevalence  of  diabetes  mellitus  around  the  world  appears  so dramatic  as  to  have  been  characterized  as  an  epidemic  (Mokdad  et  al.,  2000). Diabetes mellitus 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.

The  cardiovascular  complications  of  diabetes,  which  is  also  a  leading  cause  of blindness, amputation and kidney failure, account for much of the social and financial burden of the disease (Williams, 2004). The prediction that diabetes  incidence will double by the year 2025 indicates a parallel risk in cardiovascular related illness and death,  an inevitable and profound impact on global health-care system and a rise in co- morbid diseases. The burden on the health-care system and budget are enormous. An expenditure of up to 13% of the world’s health-care budget is on diabetes care and high  prevalence  countries  may  be  spending  up  to  40%  of  their  budget  annually (International Diabetes Federation, 2003). It is important to note that these estimates of a burden on national health-care are for type 2 diabetes only and do not, as yet, estimates the  additional burden of cardiovascular disease associated with metabolic syndrome where clinical diabetes is not yet present.

The  Nigerian  diabetics,  unlike  their  counterparts  in  developed  countries,   have extremely limited chances for achieving self-care living with diabetes because of their limited knowledge of nutrition (Osisianya, Delda, Ogbonnaya &  Ogundana, 2006). The study reported a low nutrition knowledge among the diabetics and suggested that adequate nutrition education should be employed in diabetic counseling. Everybody claims  to  know  about  nutrition.  In  the  face  of  nutritional  ignorance,  myths  and quackery gained stronghold. To maximize the effect of chronic disease management programmes, patients must be empowered to self-help, a policy that has been shown to improve diabetic care (ADA, 2004).

ADA  (2004)  observed  that  drastic  change  from  the  traditional  diet  that consists of high fibre, high carbohydrate, low animal protein, generous vegetable and low saturated fat to the so-called western diet, with low fibre, high protein and high fat content has been implicated as one of the causative factors for the development of diabetes  mellitus.  Although  allopathic  drugs  for  management of this  disorder  are available in the market but the high cost and the need for prolonged use (Balkrishnan, 2004) have influenced the desire for alternative medicine. Coincidentally,  intensive promotion  of  herbal  medicine  through  exhibition,  print  and  electronic  media  has greatly increased the awareness  of medicinal potential of  some local and common herbs, vegetables, fruits and spices even among the highly educated. The Diabetes  Control  and Complication  Trial (DCCT,  1993)  demonstrated that  intensive  blood  sugar  control  delays  the onset  and  slows  the  progression  of diabetic complication. ADA (2004) advised that good diabetic management is more than blood sugar control and maintained that diabetic management with drugs only could not tackle some of the risk factors like obesity, hypertension and serum lipid level.  Most diabetics  skip the  numerous  locally available  high fibre foods due to ignorance.  Studies  have  reported  improvement  in  blood  sugar  level  of  diabetic patients  using  high  fibre  diets  (Osisanya  et  al.,  2006;  ADA,  2004;    Tumilehto, Lindstrom & Eriksson, 2001). Strategies on diabetes management need to focus on dietary  and physical  activity  behavior.   The role  of  professional  nutritionist  is to positively guide the public on scientifically proven sound nutrition messages. There is therefore  need  to investigate  the  lifestyles  and  various  management  combinations used by diabetics in Anambra State in order to plan effective intervention measures.

1.3   Objective of Study

General  Objective:  The general  objective  of the study is to assess the  diabetic’s lifestyles and management regimens and effect of diabetes educational intervention on diabetes care.

Specific Objectives:

The specific objectives of this study were as follows: to

1.   assess the diabetes knowledge of the subjects.

2.   determine the diabetic’s compliance to management regimen.

3.   determine the lifestyle factors affecting diabetes control

4.   develop appropriate diabetes educational intervention.

5.   assess the immediate effect of intervention on the blood glucose.

6.   assess the impact of the intervention on target population two years following the intervention.

1.4    Significance of the study

In order to reduce  diabetes-associated  morbidity  and mortality,  an  evidence-based study of this kind is essential  to establish factors militating  against good diabetes control and to institute measures to enhance good diabetes care. Living with diabetes requires knowledge and experience. Diabetes management is not only an element of treatment but also a preventive treatment in itself for maintaining  normal-glycemia (Tumilehto et al., 2001), hence the importance of investigating the various diabetes management regimens among diabetic patients in our locality. The present study will be beneficial  in that it will  highlight  the major  problems  militating  against  good diabetes  control  as well as the factors  facilitating  good  diabetes  control  and then institute diabetes educational intervention to enhance good diabetes care.

Highlighting  the  major  problems  militating  against  good  diabetic  control  will guide the researcher on the area to emphasize in the educational intervention in order to enhance good diabetes care which will in turn enable the diabetics to:

–         Maintain a good glycaemic control

–          Prevent  diabetic complications  which are caused  by “swings”  in the  blood glucose levels.

–         Correct misinformation on diabetic management that abounds in our society

–          Provide  a  positive  guide  to  the  diabetics  and  the  public  at  large   on scientifically proven sound nutrition message.

1.5   Definition of Key Terms

Gylycaemic   control:  means  maintaining  as  near  normal  blood  glucose   level as possible (80 – 110 mg/d1)

Lifestyle behavior: means such habits as physical activity, drinking habits, smoking habits   and   eating   habits   including   meal   combinations   and   feeding   pattern. Management protocol:   means treatment guidelines that is suitable and socially acceptable

Diabetic complications: any additional development of ill-health as a result of the diabetes state, e.g. neuropathy,  retinopathy,  liver diseases,  cardiovascular  diseases, and others.

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