Evaluation of Nutritional Status and Dietary Management of Diabetic Patient in Imo State University Teaching Hospital (Imsuth) Orlu
CHAPTER ONE
Objective of the study
The general objective of the study is to evaluate the dietary management of in-patient diabetics in IMSUTH Orlu, Imo State, Nigeria
Specific objectives
The specific objectives of the study are to:
- determine the nutritional status of patients using anthropometry, biochemical and dietary studies.
- assess energy and nutrient composition of hospital diets served to patients on admission.
- determine carbohydrate distribution in daily meals.
- determine proportion of carbohydrate, protein and fat in daily diet.
CHAPTER TWO
LITERATURE REVIEW
Definition and Causes
Diabetes is a chronic condition characterized by hyperglycemia. It is caused by deficient insulin production, resistance to insulin action or a combination of both (Alberti KGmm and Zimmet 1998). Knowledge of the relationship between glucose, insulin and counter-regulatory hormones and glucose homeostasis is important in understanding these defects and how they result in abnormal glucose and fat metabolism (Atkinson and Maclareen, 1994). Type 1 and type 2 diabetes are at least partly inherited. Type 1 diabetes appears to be triggered by infection, stress, or environmental factors, example exposure to a causative agent.
There is a genetic element in the susceptibility of individuals to some of these triggers which has been traced to particular 11LA genotypes (that is genetic “self identifiers used by the immune system). Even in those who have inherited the susceptibility, type 1 diabetes Mellitus seems to require an environmental trigger.
There is an even stronger inheritance pattern for type 2 diabetes, those with type 2 ancestors or relatives have very much higher chances of developing type 2 diabetes. It is also often connected to obesity, which is found in approximately 85% of patients diagnosed with type 2 diabetes. Inheriting a tendency towards obesity seems also to contribute. Age is also thought to be a contributory factor, as most type 2 patients develop theirs at old age. Symptoms of diabetes mellitus include – polydipsia, polyuria, polyphagia, weight loss, blurred vision and weakness (Wardlaw, 1996).
Summary of causative and predisposing factor of diabetes
Type 2 diabetes has increased especially in areas that have seen major changes in eating patterns, increase in overweight and obesity (SCN, 2006). The evidence for a relationship between excessive weight gain, a high waist-to hip ratio and development of type 2 diabetes is strong. The waist circumference is a stronger predictor of risk for type 2 diabetes than BM1 (WHO/FAO, 2003). The risk of diabetes was associated with increasing age, BMI and systolic and diastolic blood pressure. The highest diabetes prevalence (13.6 percent) was found in the 64 + age group. A national study of non-communicable disease in Nigeria showed that 2.8 percent of the population had diabetes Federal Ministry of Health and Social Services (MOHSS, 1997). The prevalence was higher in females and those with increasing age. Children born to women who had gestational diabetes are more likely to develop obesity in childhood and are, therefore, at increased risk for developing type 2 diabetes at an early age (WHO/FAO, 2003) There is association between intrauterine growth retardation and low birth weight and development of insulin resistance (SCN, 2006). It is thought that this may have been advantageous for surviving famine but with increased energy intakes and decreased physical activity this is rather enhancing insulin resistance and type 2 diabetes. The rapid post-natal catch up growth is also associated with an increased risk of type 2 diabetes in adulthood.
There is also some evidence of the role of genetic and immunological factors in the pathogenesis of diabetes. African-Americans with West African origins were found to be less sensitive to insulin and, as a result, more susceptible to type 2 diabetes. Studies from five West African Communities in Nigeria and Ghana have identified genes within populations that are susceptible to diabetes (Rotimi et al., 2001).
The convincing evidence of factors that may increase the risk of diabetes in individual are: over weight, abdominal obesity, physical inactivity and maternal diabetes. The probable evidence are excessive consumption of saturated fat and intra uterine growth retardation (SCN, 2006). The association between excessive weight gain resulting in obesity is convincing and voluntary weight loss and physical activity have been shown to reduce the risk of progression from impaired glucose tolerance to type 2 diabetes. Off spring born to mothers with diabetes have a three times higher risk of developing type 2 diabetes in later life. High intake of saturated fats is linked with a high risk of impaired glucose tolerance.
CHAPTER THREE
MATERIALS AND METHODS
Study area
The study was conducted in medical, surgical, antenatal, post-natal and paediatric wards of the Imo State University Teaching Hospital (IMSUTH) Orlu, Imo State of Nigeria. This hospital was selected because of the number of diabetics being attended to in the institution. IMSUTH provides in-patient and out-patient services to its clients through highly trained and qualified staff in its employment. It provides adequate clinical materials for services and training as well as equipment for research. It also provides teaching facilities for the training of medical students, resident doctors, student nurses, dietetic interns, pupil pharmacists and laboratory technology students. There is 24 hour accident and emergency services. It is a referral tertiary health institution. Diabetics are admitted to the various wards through the accident and emergency unit and through the consulting clinics by the physicians.
CHAPTER FOUR
RESULTS
Socioeconomic characteristic of the patients
Table 1 presents the percentage distribution of socio-economic characteristics of female and male in-patient diabetics. A total of 54.5% of the subjects were males and 45.5% were females. Less than 40% of the subjects (38.02%) were within the age range of 61 years and above. Another 29% were within the age range of 51 to 60 years. As many as 46% of the hospitalized diabetics live in the urban areas and 32% live in the sub-urban areas. A total of 41.22% had primary education. About 32.72%of the subjects were in other occupation and 23.63% were petty traders.
CHAPTER FOUR
RESULTS
Socioeconomic characteristic of the patients
Table 1 presents the percentage distribution of socio-economic characteristics of female and male in-patient diabetics. A total of 54.5% of the subjects were males and 45.5% were females. Less than 40% of the subjects (38.02%) were within the age range of 61 years and above. Another 29% were within the age range of 51 to 60 years. As many as 46% of the hospitalized diabetics live in the urban areas and 32% live in the sub-urban areas. A total of 41.22% had primary education. About 32.72%of the subjects were in other occupation and 23.63% were petty traders.
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATION
The higher percentage of male subjects (54.4) in this study is contrary to many previous reports (Federal Ministry of Health, 1992, Ngwu and Okoli, 2008, Ogbonna et al., 2008, Sczrvieni et al., 2003). The higher percentage of male in this study could be attributed to the Nigerian cultural practices. The males are much more respected in the families and in the societies as regards health care. This belief that the males after the females have grown and gotten married, the males would remain to maintain and keep the families’ heritage, had adversely affected the care and support for girls and women in living with diabetes.
The much more males in this study could also be attributed to the fact that the females in most cases are not economically empowered as such have less access to health care. Corbett (2009) in his poverty research reported that in developing countries there are fewer employment opportunities especially for women. This adversely affects women’s capability to provide health care for themselves.
Dorseen (2009) observed that women in developing countries are often denied their right and optimum attention with regards to good health care. The women, on the other hand, with the little fund at their disposal channel all toward the entire family’s welfare to compromise their health care. The higher percentage of the subjects that clustered within 61 and above, and 51 to 60 years ranges were earlier observed by many (Ngwu and Okolie, 2008; Anderson 2003; Nelson et al., 1994). The National Health and Nutrition Examination Survey (NHNES 1988-1994), and other authors mentioned above indicated that type 2 diabetes increased with increase in age. The results of this study showed that subjects within the age of 10-40 years was 14.05% of the study population. This observation is similar to that of Nelson et al., (1994). They observed that type 1 diabetes accounts for 10-15% of person with diabetes mellitus that manifests prior to the age of 40 years.
In the present study, the larger percentage of the subjects lived in the urban area. This result accords those of many (Colagiuri et al., 2002, Ramaiya 2004). Colagiuri et al. (2002) reported that the prevalence of diabetes is double in urban area when compared with rural if the difference between obesity and age was excluded. Apart from age and obesity differences, differences in diet, physical activity and stress or a combination of these precipitated the rural and urban differences in prevalence of diabetes. Ramaiya (2004) observed that migrations from rural to urban in most African countries precipitated most of the negative lifestyle changes in many communities. The regular physical exercise and traditional diets peculiar to rural life were displaced with sedentary behaviour and consumption of refined sugar convenience foods among the poor urban dwellers. These changes in lifestyle predispose many urban dwellers to obesity. The ruralites on the other hand engage in all day farming and walk difficult terrain to access their farm and what they eat.
BMI values for both the males and the females were comparable to that reported earlier by many (Bakari et al., 2005; Uloko and Brodo; 2008). The proportion of females with abnormal BMI in this study (77.8%) was similar to that of Uloko and Borodo (2008) (77.8% and 74.4%). The higher proportion of obese and overweight subjects observed both in the urban and the suburban areas in the present study accords those of many (Colagiuri et al., 2002, Ramaiya, 2004). They reported that the major difference between the urban and the rural body weight was change in lifestyle. This study equally showed that there were more overweight and obese subjects within these age ranges (41-50, 51-60 and 61 and above years). This is similar to the findings of Zuo and Hui (2008) who observed that diabetes and metabolic syndrome were highly prevalent in the middle ages and the elderly. Iwuala et al., (2008) reported that in both genders the increases in age increased the mean anthropometric indices (Body Mass Index, waist circumference and waist/hip ratio). The observed mean waist circumference of both male and female subjects (95.59±10.7) and 88.40±13.44 cm respectively was similar to that of Uloko and Brodo (2008) 95.61±11.99 and 92.30±12.14 cm each).
The 64.84% value for central obesity of the female subjects showed they had abnormal waist circumference. This value was very slightly different from that of Akindale et al. (2008). About 61% of their female subjects had abnormal waist circumference. There were preponderance of female subjects (74.07% with abnormal waist/hip ratio. This was comparable to the value of Uloko and Brodo (2008). About 88.8% of their female subjects had abnormal waist/hip ratio. These anthropometric indices strongly indicated that the female diabetics are more obese and had higher abdominal adiposity than the males.
Schulze et al. (2006) indicated in their study that anthropometric measurements that describe central fat distribution are superior in predicting type 2 diabetes mellitus as against measurements of the general adiposity. They observed that among men and women waist circumference appears to be of a better predictor of diabetes than any other single direct measure.
The mean values for lipid profile of the subjects in this study were similar to that of Bello-Sani and Anumah (2006). They reported that dyslipidemia does exist in type 2 diabetics and they are always at risk of macrovascular complications. The abnormalities of lipid profile in diabetics include elevated total cholesterol, triglyceride, Low density lipoprotein (LDL), very low density lipoprotein (VLDL) and reduced high density lipoprotein (HDL).
The high percentage (73.63%) of the subjects that had abnormal triglyceride is in line with the report of Betterisdge (1999). He indicated that the apparent lipid abnormality in type 2 diabetic patients was increased total serum triglycerides. He further observed that the frequency of hypertriglyceridemia was increased two-to-three folds in type 2 diabetic patients as against that of the non-diabetics. Post-prandial triglycerides metabolism was also abnormal in type 2 diabetics and the abnormalities was demonstrated even in individuals whose fasting triglyceride levels were usually within defined normal range (Betteridge, 1999).
The slightly lower energy composition of the hospital diets of the patients as against that of FAO/WHO value was to reduce weight of obese diabetics. That Pi-Sunyer (1996) reported that weight loss decreases morbidity in diabetics supports the observation in the present study. The higher fat intake of the patients against those of FAO/WHO and ADA values was attributed to added fat during preparation of some of the diabetic foods such as “akara balls” and okpa”.
The percentage protein intake of diabetic in this study was higher than the FAO/WHO requirement. It is worthy to note here that 85% of the protein were sourced from legumes. When excess protein is ingested, only the extra calories are retained and stored while excess nitrogen is excreted. The excess amino acids are transaminated so that the nitrogenous portion of the molecule can be used as a calorie source, example pyruvate derived from alanine. The unneeded nitrogen is converted to urea and excreted in the urine. Alpers 1991, observed that not all sources of protein are utilized equally well. Egg protein, the standard against which other sources of protein are, often compared, is utilized for growth in animals with 85 to 90% efficiency. The efficiency of utilization of plant protein is between 50 – 80%. This is because they are more poorly hydrolyzed by pancreatic amino acid content is lower. As a result the bioavailability of ingested protein varies according to the source of protein.
The males and females in this study had calcium higher than hundred percent. Alpers et al 1991 noted that because the absorption of calcium is not very efficient that amount ingested must exceed the actual requirement. They further noted that vegetable calcium are complexed with organic anions like phytates and oxalates. These organic anions in vegetables are not digested and are poorly absorbed. In this study the in-patient diabetics consumed more of vegetable calcium than animal calcium. The bioavailability is therefore questionable.
The adequacy of vitamins A, C, B (thiamin) in the therapeutic diet is very promising. Vitamins A and C are antioxidants that prevent the reaction of free radicals in the cells. Vitamin A is a good immune builder while vitamin C is very effective wound healer, these facts contribute positively to the management of diabetes mellitus. Thiamine is essential for production of energy, proper metabolism of carbohydrates and proper nerve cell function. Vitamin C on the other hand enhances inorganic iron absorption and transfer of iron from transferrin to ferrintin. It functions as antioxidant for vitamins A and E. It plays an important role in recycling and re-empowering Vitamin E anti oxidant role. Vitamin C slows the conversion of glucose to sorbitol, (factor in development of diabetes foot ulcer), which can cause free radical damage. The combination of antioxidant role of vitamin A and C have a great therapeutic promise in tackling oxidative stress which is a major factor in the etiology of diabetic complication.
On the other hand, there were lower niacin and riboflavin content of the therapeutic diet of diabetics. Riboflavin (Vitamin B2) is important for both lipid and protein metabolism. Alphabetic (2009) noted that conditions that place stress in the body, example diabetes increase requirement for riboflavin. Niacin (B3) on the other hand is important in maintaining the function of beta pancreatic cells that secrete insulin and promote glucose metabolism. Vega (2002) reported that niacin raises blood glucose levels when consumed in large quantities. High levels worsen glycaemic control in patients with diabetes. The implication is that moderate doses of niacin are better for management of diabetes mellitus. Moderate niacin intake increases HDL cholesterol and reduces triglycerides in type 2 diabetics. The low iron content of the therapeutic diet (females) in this study calls for increase in the intake of foods that are high in iron, like beef, poultry and other animal products, which are equally good sources of riboflavin and niacin.
Conclusion
- Diabetes mellitus is a major public health problem that requires proper medical and dietary management to control high blood glucose and its complications.
- Adequate dietary management is the hub to providing adequate care to diabetics.
- Diabetes occurs much more in males than in females 54.5% vs 45.5% and more at the age of 61 years and above. The females had higher BMI than the males.
- The subjects had higher triglyceride and LDL values (73.3% and 44.4% respectively). These higher percentages with abnormal lipid profile are likely to be more prone to cardiovascular diseases.
- Therapeutic diets were adequate in macronutrients except for slightly excess fat as against the RDI value. The distribution of macronutrient in terms of percentage as found in this study is in line with the recommended levels. The effort to relate dietary management to insulin dosage failed due to irregular meal times.
Recommendation
Combinations of intensive nutrition education, medical nutrition therapy, prescribed medication and counselling are key to successful management of diabetes mellitus.
The obese diabetics must reduce weight and adiposity to be successful in the management of their diabetes, as most of the patients with diabetes are either overweight or obese.
Late arrivals of meals especially breakfast should be avoided to enable food intake to be matched with the anticipated rise and fall of insulin.
Food high in soluble fiber is a relatively cheap and effective way to lower both cholesterol and triglyceride levels that are associated with increased heart diseases in diabetes and are therefore recommended.
Food preparation methods that would help reduce the amount of fat in the diet of hospitalized patients should be encouraged.
Increased intake of fish, meat and poultry should be encouraged to enable patients meet their recommended intakes for B vitamins and iron.
It would be helpful, as a follow up of this study if research were carried out on evaluation of energy and nutrient intakes of diabetics in other tertiary and secondary health institution where diabetics are cared for, for comparison.
Continuous nutrition monitoring is needed to assess the adherence of diabetics to their prescribed dietary regime.
Health care providers and the general public should be sensitized to the relevance of adequate nutritional care for people living with diabetes mellitus through workshops, lectures, seminars and interactive sessions.
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