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