LIFE STYLE MODIFICATIONS AND GLYCAEMIC CONTROL AMONG PATIENTS ATTENDING DIABETIC CLINICS IN TEACHING HOSPITALS IN ENUGU STATE

CHAPTER ONE
INTRODUCTION
Background to the Study
Diabetes mellitus (DM) is one of the common conditions seen in primary health care. Chinenye, Uloko, Ogbera, Ofoegbu, Fasamande and Ogbu (2008) stated that DM is the commonest endocrine-metabolic disorder in Nigeria as well as in other parts of the world. It is a challenging chronic disease which affects vast population worldwide with life threatening complications such as nephropathy, retinopathy, foot ulcers and shortening of life span. In Sub-Saharan Africa, proportions of patients with diabetic complications ranged from 7-63% for retinopathy, 27-66% for neuropathy and 10-83% for micro-albuminuria. Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis, thus it has a double disease burden and increased economic cost (Hall, Thomsen, Herriksen & Lohse, 2011).
World Health Organisation (WHO, 2008) reported that diabetes is a growing epidemic which threatens to overwhelm health services and undermine economies especially in the developing countries. It affects currently 250 million people worldwide and WHO predicted a worldwide rise in its prevalence which will affect over 380 million people by 2025. The major part of this numerical increase will occur in developing countries. India has around 40 million adult diabetics, America; 25.8 million, China; 90 million, Africa; 14.7 million with the urban/rural ratio as 1%: 5-7%, Nigeria has 3 million which is the largest number, followed by South Africa; 1.9 million (International Diabetes Federation Atlas, 2012).
The expansion of the disease is based on lifestyle related factors such as diet choices (high fat and more refined carbohydrate diet), ageing of the population, physical inactivity, smoking, alcohol consumption, genetic predisposition, obesity, stress and urbanization in developing countries (Indian Medical Association, 2009). These risk factors are modifiable, as Chege (2010) posited, except, ageing and genetic predisposition. Esene (2010) opined that the progression of the disease is more flagrant in developing countries particularly Sub-Saharan African region due to the ageing of the population and rapid urbanization with the adoption of “western lifestyles”. There is abandonment of the healthier traditional lifestyles in developing countries. The traditional lifestyle was characterised by regular and rigorous physical activities accompanied by sustenance on high fibre, whole grain, vegetables and fruits which limit the development of the disease. (Maina, Ndegwam, Njenga & Muchem, 2011).
John (2007) noted that DM is associated with long-term complications which threaten life and quality of life and requires a life time of special self-management behaviour and appropriate education to prevent the complications. Therefore the patient and family have a central role to play in diabetes management. Vance, Harold and Cherne (2008) observed that conventional treatments are not satisfactory; insulin injections to replace the deficient body insulin do not prevent the various complications from developing. The tight control over blood glucose levels only delays the onset and progression of symptoms/complications but does not prevent them.  They further revealed that there is evidence that protecting the cells against the adverse effects of unstable serum glucose can reduce the complications, for instance, weight reduction and exercise improve tissue sensitivity to insulin and allow its proper use by the cells.
According to Woolley (2012) life style changes tend to lower blood glucose level and are more powerful than medications with many health benefits and they can eliminate or reduce the need for medications and their side effects. Lifestyle modifications include meal habits, exercise, alcohol reduction, smoking cessation, stress reduction, weight reduction, eye care, blood glucose monitoring, ophthalmic and dental care, lipid level, foot care and medication adherence. Moore (2011) opined that despite the increase in the number of diabetics, many of them do not want to change their lifestyles, they know the changes they should make for their health yet they fail to do so. It is observed that some diabetics do not have the will power to adhere to these changes.
In Nigeria, patients may not have adequate knowledge of the disease, treatment modalities and the inherent dangers of non compliance with the lifestyle modifications. It is observed that many diabetics are often admitted in University of Nigeria Teaching Hospital (UNTH) Ituku, for one complication or another. John (2007) stated that most hospitals in Nigeria do not give patients written guide for effective self care. Though some patients may be literate, they tend to forget oral instructions and end up being often admitted in the hospitals for complications. The developed countries have a good diabetic education programme which includes the treating physician, a diabetic patient nurse, a diabetic patient counsellor and a dietician which are lacking in a developing country. (Prably & Ramas, 2011). They also asserted that DM is a chronic condition but people with the disease can lead a full life while keeping their disease under control. The emphasis is on the control of the condition through life style modifications which are essential component of any diabetes management plan.  Apeh (2012) observed that Nigerians are at risk of having diabetes and its complications because of their lifestyles and nonchalant attitude towards comprehensive and routine medical checkups. It is against this background that this study intends to assess life style modifications among diabetic patients in UNTH, Ituku and Enugu State Teaching Hospital.
 
Statement of Problem
DM is a chronic disease with significant personal and social implications. It is a global public health challenge associated with high morbidity and premature death due to its complications. WHO/International Diabetes Federation (IDF) (2011) and American Diabetes Association (2010b) asserted that the complications of DM can greatly be delayed or decreased with effective  glycaemic control which can be achieved through lifestyle changes. It is of great concern to note that many diabetic patients have elevated glycaemia which makes them vulnerable to the complications though they receive treatment for their conditions. Young (2011) and Bagnasco, DiGioma, DaRino, Mora, Castinia, Turci, Rocco and Sasso (2013) observed that many patients in America and Italy respectively have continous high blood glucose levels though they receive treatment. Most Nigerians living with DM have sub-optimal glycaemic control, are hypertensive, not meeting the WHO and IDF blood pressure and lipid targets. The short term outcome of the diagnosis of DM for a patient in Nigeria is death. The essential medicines, diagnostic and monitoring technologies and education required are cost-effective, but tragically inaccessible to many. (Diabetes Association of Nigeria, 2011).
Bagnasco et al (2013) emphasized that behaviour change is a key component in diabetes self-care management which enables the patients to become empowered through a sound understanding of the disease and self-care management in order to take charge of their disease and achieve metabolic control. Despite the benefits of diabetes self-care, many patients seem to find it difficult to make the necessary changes and thus have diabetes complications such as gangrenous foot ulcers and amputations. John (2007) posited that many patients do not understand the relationship between poor glycaemic control and complications of DM. They may attribute it to witchcraft attack and resort to traditional medicine.
The patients are often not motivated or knowledgeable enough to make substantial behaviour change on their own. Maina et al (2011) observed that the health care providers do not have the necessary time and resources to engage their patients in an intensive life style modification programme. The researcher observed that some young diabetics have long stay hospitalizations and drop out of school eventually and resort to street begging, many die prematurely due to the complications. This is a big problem because it could have been prevented with sound health education, supervision by health care providers and support of key family members which will make them competent in self-care management.  The researcher deemed it necessary then to assess whether the patients have a practical understanding of diabetes self care management, the requisite skills and if actually they practice the self care activities.
 
Purpose of the Study
The purpose of the study is to assess life style modifications among diabetic patients in order to achieve better glycaemic control.
 
Objectives of the Study
The specific objectives are to:

1. determine the modifications the diabetic patients made in their exercise, diet and drug regimen.
2. determine the self-management approaches used by the diabetic patients as a result of their conditions.
3. assess the weight and blood pressure of the diabetic patients in relation to their life style modifications.

 
Research Questions

1. How do diabetic patients keep to their exercise, diet and drug regimen?
2. What are the self-management approaches used by the diabetic patients as a result of their condition?
3. What are the weight and blood pressure values of the subjects in relation to their life style modifications?

Null Hypotheses

1. Ho1:     There will be no significant relationship between the patients’ life style          modification on exercise, diet and drug regimen and their glycaemic control.
2. Ho2:     There will be no significant relationship between the patients’ educational level and self-management approaches.

 
Significance of the Study  
The findings from the study will be beneficial to the diabetic patients. The individual modifications made by the diabetic patients will be revealed thus serving as a baseline for future health education and counseling. The self care activities which are wrongly practiced will be corrected through health education. The findings if published and made available could assist the nurses to tailor the plan of care to each individual client needs, also help them to channel their health education towards more specific areas that need attention.
The dietician can also through the findings design nutrition education to assist the patients to meet up with the dietary modification. The physical therapist can also be made aware of areas in exercise that need emphasis which can help the diabetic patients achieve optimal glycaemic control. When effective life style modifications are achieved by the patients, there will be a more sustained glycaemic control, thus reducing complication and mortality that can result from poor control of diabetes.
Patients will furthermore function optimally thereby reducing the socio-economic burden on their families and the society at large, a healthier person will lead to better productivity and a healthier nation. Finally, the resources used by the individual, hospital management and the society at large for handling complications can be re-channeled into other more productive ventures.  The findings would provide a reliable resource material for students and others for further studies.
 
Scope of Study
 
The study is delimited to all adult type II diabetic patients who attend clinics at UNTH, Ituku/Ozalla and Enugu State University Teaching Hospital (ESUTH). It is also delimited to the life style modifications and glycaemic control among the patients.
 
Operational definition of Terms

1. Life Style Modification: Refers to the changes or adjustment in the daily self-care activities of the diabetic patients with regards to diet, stress control, exercise, smoking cessation, weight, blood pressure and lipid control, foot, dental and ophthalmic care.
2. Glycaemic control: Ability of the client to maintain his/her fasting blood glucose level at 70 -120 mg/decilitre through life style modifications measured at 2 points of 2-4 weeks intervals.
3. Self–management approaches: In this study, means what the diabetic patients do about their feet, ophthalmic and dental self-care as well as their stress control measures and follow-up.