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

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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="" kg="" m="" males="" of="" sup="" than="" that="">2
). The study also showed that the BMI of patients from rural areas


(23.70kg/m2) was significantly (p<0 .05="" kg="" lower="" m="" of="" sup="" than="" that="" the="" urban="">2
) 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.

TABLE OF CONTENTS

Title page
Abstract
Table of contents

CHAPTER ONE
1.0       INTRODUCTION
1.1       Background of the study
1.2       Statement of problems
1.3       General objective of the study
1.4       Specific objectives
1.5       Significance of the study

CHAPTER TWO
2.0       LITERATURE REVIEW
2.1       Definition and causes
2.1.1    Summary of causative and predisposing factor of diabetes
2.2       Prevention of diabetes
2.3       Prevalence of diabetes mellitus
2.4       Diagnostic criteria
2.5       Classification of diabetes mellitus
2.5.1    Type 2 diabetes mellitus
2.6       Complications of diabetes
2.7       Dietary misconception
2.8       Alcohol and diabetes mellitus
2.9       Smoking and diabetes
2.10     Diabetes and stress
2.11     Exercise and diabetes
2.12     Feeding of hospitalized patients and hospital induced malnutrition
2.13     Method of planning diets
2.14     Management of diabetes mellitus
2.14.1  Medical nutrition therapy for diabetics
2.14.2  Role of nutrition in management of obesity in diabetics

CHAPTER THREE
3.0       MATERIALS AND METHODS
3.1       Study area
3.2       Subject
3.3       Criteria for inclusion of subject in the study
3.4       Method of data collection and analysis

CHAPTER FOUR
RESULTS                  

CHAPTER FIVE
5.0       DISCUSSION, CONCLUSION AND RECOMMENDATION
5.2       Conclusion
5.3       Recommendation
References
Appendix: Questionnaire

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 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......

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