EVALUATION OF NUTRITIONAL STATUS AND DIETARY MANAGEMENT OF IN-PATIENT DIABETICS IN UNIVERSITY OF NIGERIA TEACHING HOSPITAL ITUKU-OZALLA ENUGU STATE NIGERIA

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.

1.0       INTRODUCTION

1.1       Background of the Study

CHAPTER ONE

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  (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 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).

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.

1.2       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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