FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING HOSPITAL OSOGBO. BY FOLARANMI BASIRAT TEMITOPE

7/27/2019 FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVE

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FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETICPATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING

HOSPITAL OSOGBO.

BY

FOLARANMI BASIRAT TEMITOPEMATRIC NO: 082061

A RESEARCH SUBMITTED TO THE DEPARTMENT OF NURSING, COLLEGE OFHEALTH SCIENCES, LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY,

OSOGBO.

IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OFBACHELOR OF NURSING SCIENCE

(BNSC)

JANUARY, 2013.


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CERTIFICATION

This is to certify that Folaranmi Basirat Temitope, Matric No..carried out

this research under my supervisor.

B.L. AJIBADE _______________

(Rn, Ph,D, FWAN) Signature & Date

Supervisor

FOLARANMI BASIRAT TEMITOPE ________________

Student Signature & Date

Dr. W.A. TIJANI

RN, RPHN, BNSC, MSc, PhD, FWAC ____________________

HEAD OF DEPARTMENT Signature & Date


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DEDICATION

This study is dedicated to Almighty Allah and my beloved parent for their continual

love and encouragement towards the success of this research. I wish you long life and

prosperity (AMIN).


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ACKNOWLEDGEMENT

I give all glory and adoration to Almighty Allah, the lord of the world, the long of the

day of judgement, the most beneficent, the most merciful, for His guide and tutelage, over

me throughout my training in Nursing Department, Ladoke Akintola University of

Technology, Osogbo.

My unreserved thanks goes to my able, competent, enthusiastic, dynamic and

indefatigable supervisor, or B.L. Ajibade for devoting his precious time to read and make

necessary corrections before the final draft may God Almighty be with you in all your daily

endeavours.

I would like to commend the effort of my parents, late Chief Mr. Folaranmi and

Mrs. Folaranmi A.M for their parental support in making my dreams comes through. May

you live long (matter) to reap the fruit of your labour in peace and good health.Also, I equally extend my special thanks to the head of the department Dr. W.A.

Tijani and other lecturers in the department for their unflinching support during the court

of my study.

My profound gratitude goes to my loving, caring and understanding husband Mr

Omolola Adams Olatayo, for his support financially, spiritually and morally, may God

Almight continue to bless our union. My sincere apprication also go to my siblings,

friends, loved one and colleagues most importantly Shittu Adebowale for their moral

support and encouragement.

Conclusively, I also appreciate my respondents for taking time, to fill my

questionnaire, God bless you all.

Folaranmi B.T.


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ABSTRACT

This research work examined the factors influencing Compliance to dietary

regimen diabetes patient in Lautech Teaching Hospital Osogbo. The study was carried

out using descriptive design. A self designed questionnaire having three number of

section, section A is the demographic Data containing seven items, section B is the

knowledge on Diabetes and perception of dietary regimen containing Twenty-three items

and section family support which contains six items, was administered to one hundred

and nine (109) respondents that was chosen using purposive sampling technique. The

finding shows that gender and type of management were not significantly associated with

level of compliance to dietary regimen. Similarly it also revealed that educational status,

family support and socio-economics status were significant to compliance to dietary

regimen among, diabetes mellitus patient.

Sequel to the findings of this research, It was concluded that all efforts should be

made to address factors like level of education, family support and socio-economic status

etc, that influence the level of compliance of respondents toward there dietary the level of

compliance of respondents toward there dietary regimen.


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TABLE OF CONTENTS

FRONT PAGE i

CERTIFICATION ii

DEDICATION iii

ACKNOWLEDGEMENT iv

ABSTRACT v

TABLE OF CONTENT vi-ix

LIST OF TABLES

LIST OF FIGURES

CHAPTER ONE:

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY 1-2

1.2 STATEMENT OF PROBLEM 3

1.3 OBJECTIVE OF THE STUDY 3

1.4 SIGNIFICANCE OF PROBLEM 3-4

1.5 SCOPE OR DELIMITATION OF THE STUDY 4

1.6 DEFINITION OF TERMS 4-5


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CHAPTER TWO:

2.0 LITERATURE REVIEW

2.1 INTRODUCTION 6

2.2 CONCEPTUAL LITERATURE REVIEW 6-27

2.2.1 THE MEANING OF DIABETES MELLITUS 6-7

2.2.2 CAUSES OF DIABETES MELLITUS 7

2.2.3 PATHOPHYSIOLOGY OF DIABETES MELLITUS 7-9

2.2.4 SIGNS AND SYMPTOMS OF DIABETES MELLITUS 9-10

2.2.5 DIAGNOSIS OF DIABETES MELLITUS 10-12

2.2.6 CLASSIFICATION OF DIABETES MELLITUS 13-14

2.2.7 TREATMENT OF D.M 4-19

2.2.8 DIETARY MANAGEMENT OF D.M. 19-22

2.2.9 NUTRITIONAL CARE 22-24

2.2.10 COMPLICATIONS OF D.M 24-27

2.3 EMPERICAL LITERATURE REVIEW 27-36

2.3.1 EMPERICAL STUDIES COMPLIANCE BEHAVIOR 27

2.3.2 NON COMPLIANCE TO DIET REGIMEN 27-28

2.3.3 FACTOR WHICH AFFECT COMPLIANCE TO DIET 29-30

2.3.4 INFORMATION NEEDED TO MAZIMIZE COMPLIANCE 30-31

2.3.5 FACTOR CONTRIBUTING TO PATIENT NOT

COMPLYING TO EATING AND DRINKING IN HOSPITAL 31-35

2.3.6 FACTORS INFLUENCING COMPLIANCE

TO DIETARY REGIMEN 35-36

2.4 CONCEPTUAL MODEL 37-41

2.5 CONCEPTUAL FRAMEWORK 41

2.6 RESEARCH QUESTIONS 42

2.7 RESEARCH HYPOTHESIS 42


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CHAPTER THREE:

3.0 RESEARCH METHOLOGY

3.1 INTRODUCTION 43

3.2 RESEARCH DESIGN 43

3.3 RESEARCH SETTING 43

3.4 TARGET POPULATION 43-44

3.5 SAMPLE AND SAMPLING TECHNIQUE 44

3.6 PILOT STUDY 44-45

3.7 VALIDITY AND RELIABILITY OF THE INSTRUMENT 45

3.8 INSTRUMENT FOR DATA COLLECTION 45

3.9 TYPE OF DATA COLLECTION 45

3.10 LIMITATION OF THE STUDY 46

3.11 ETHICAL CONSIDERATION 46

3.12 ADMINISTRATION OF QUESTIONNAIRE 46

CHAPTER FOUR:

4.0 PRESENTATION OF RESULT

4.1 INTRODUCTION 47

4.2 PRESENTATION OF DATA IN TABULAR FORM 48-49

4.3 PRESENTATION OF DATA IN FIGURE 50-55

4.4 ANSWERING OF RESEARCH QUESTION 56

4.5 TESTING OF HYPOTHESIS 57-62

CHAPTER FIVE: DISCUSSION OF FINDINGS, SUMMARY, CONCLUSION AND RECOMMENDATION

5.0 INTRODUCTION 63

5.1 DISCUSSION OF FINDINGS 63-66

5.2 IMPLICATION FOR NURSES 66-68

5.3 SUMMARY 68-69


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5.4 CONCLUSION 69-70

5.5 RECOMMENDATION 70

REFERENCES 68

Appendixes

Apendix i: Appendix for analysis of data

Appendix ii: Letter of permission to collect data/information

Appendix iii: Questionnaire.

Table 2.1: Showing type of insulin

Table 2.2: Showing some common sources of dietary fibres

Table 2.3: Showing selected sample meals for exchange lists

Table 2.5: Conceptual framework

Table 4.10: Showing demographic characteristic of the respondents.

Fig. 4-10 - 4.19 Showing knowledge on D.M & perception towards Dietary Regimen

50 - 55

Fig. 4.10: What is diabetes mellitus? 50

Fig. 4.11: If it can be treated through which means

can it be treated? 50

Fig. 4.12: Which of the means of treatment are you using? 51

Fig. 4.13: Have you been coping with dietary regimen given to you in the hospital? 51

Fig. 4.14: How often do you check your weight? 52

Fig. 4.15: Diabetes diet are expensive? 53

Fig. 4.16: Diabetes diet are complex? 53

Fig. 4.17: Diabetes diet causes diarrhea? 54

Fig. 4.18: Management of D.M is a daily discipline? 54

Fig. 4.19: Is any of your family members staying with them? 55

CHAPTER ONE

1.0 INTRODUCTION


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1.1 Background of the Study

Diabetes Mellitus (DM) is derived from the Greek word Diabeinnein meaning To

pass through describing copious urination, and Mellitus from the latin word meaning

sweetened with honey These two word signify sweetened urine or sugar in urine.

Diabetes mellitus is a group of metabolic disease characterized by increased levels of

glucose in the blood (hyperglycaemia) resulting from defects in insulin secretion, insulin

action or both (American Diabetes Association (ADA, 2009). Normally, a certain amount

of glucose circulate in the blood. The major sources of this glucose are absorption of

ingested food in the gastro-intestinal tract and formation of glucose by the liver from

food substances.

According to the (world Health Organization (WHO, 2008) DM, is a disease that

occurs both in developed and developing countries. In developing countries like Nigeria

DM affects over 1.5million people and in developed countries life in the United States

more than 23 million people have diabetes mellitus, although about, one third of these

cases are undiagnosed. In developed Countries, most patients having DM are over

Sixty years of age but in developing Countries, diabetes mellitus is found to affect

people in their prime. The number of people newly diagnosed with DM increases by

about 1 million people per year (Centre for Disease Control and Prevention (CDC,

2008).By 2030, the number of cases is expected to exceed 30 million. (Centre for

Disease Control and Prevention (CDC, 2008).

In 2000, the world estimate of the prevalence of DM was 171 million people and

by 2030, this is expected to increase to more than 360 million. DM is especially

prevalent in the elderly, as many as 50% of people older than 65 years and older


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level of compliance to dietary regimen among diabetes patient in LAUTECH teaching

hospital Osogbo.

1.2 STATEMENT OF THE PROBLEM

It has been discovered that majority of D.M patient having being discharged,

within a short time they come back to the hospital either for problem or a

complication associated with DM, and it has been discovered that majority of the

D.M patient may either refuse to comply with the dietary regimen or find it difficult

to purchase or cook the prescribed dietary regimen therefore this research tried

to find our factors influencing level of compliance to dietary regimen.

1.3 OBJECTIVE OF THE STUDY

The objective of the study is to

1. Identify medical factors that are associated with compliance to dietary regimen.

2. Examine the factors that are associated with compliance along the gender

variables.

3. Examine the support of significant others towards compliances with dietary

regimen.

4. Identify the factors that are associated with compliance with dietary regiment

through the level of education.

5. Examine the influence of socio-economic status towards compliance to dietary

regimen.


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1.4 SIGNIFICANCE OF THE STUDY

1. The result of the research will be communicated to the LAUTECH Teaching

Hospital in order to have a policy on the compliance of client to dietary regimen

at the diabetic clinic.

2. It will reduce the alarming incidence of complications due to non-compliance to

dietary regimen.

3. It will enlighten diabetic client on the need for compliance to dietary regimen and

to improve their attendance at diabetic clinic.

4. The outcome of the study shall also contribute to existing knowledge in planning

nursing care and health education programmes for patients with diabetes

mellitus.

1.5 SCOPE OR DELIMITATION OF THE STUDY

This study is delimited to D.M patients attending out patient clinic and in patient

in Ladoke Akintola University Teaching Hospital, Osogbo, Osun State, before the

respondent was selected he or she will have come to the hospital twice and was

selected during the clinic. This research work will cover diabetic patients both male and

female between the age of twenty year and fifty year plus, whether they have formal

education or not.

1.6 DEFINATION OF TERMS

For the purpose of this study both operational and conceptional definitions have been

adopted.


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Compliance: This means that willingness to follow a prescribed course of treatment

(www.the free dictionary.com) retrieved 28/12/2012.

Gender: This is a state of being male or female (en.wikipedia.org/wiki/Gender) retrieved

28/12/2012.

Low-Income Earners: are those patients that are earning less than minimum wage of

the Country.

Attitude: It can be defined as a positive or negative evaluation of people, objects,

event, activities, ideas, or just about anything in your environment

(en.wikipedia.org/wiki/Attitude Retrieved 28/12/2012).

Diabetes Mellitus (D.M.) a disturbance in the oxidation and utilization of glucose, which

is secondary to a malfunction of the beta cells of pancreas, whose function is the

production and release of insulin. (Barbara 2009).

High Income Earners:According to this study they are those patients that their salaries

are scaled using the minimum wage of the Country.

Dietary Regimen: Are the selected types of foods that are prescribed to help the

treatment and management of DM.

Out Patients: This refers to clients who come from home to receive health education on

the new life style, nutrient and medical treatment suitable for the improvement of their

diseased condition.

Level of Education: This is the individuals academic qualification or attainment.

Family support: This is the assistance render by the family in terms of money,

following the patient to the hospital, given moral support and even social support.
http://www.the/http://www.the/


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CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction

This part of the research deals with the review of pertinent literature, towards this

end both empirical and conceptual literature review will be carried out.

2.2 Conceptual Literature Review

2.2.1 The Meaning of D.M.

DM is a group of metabolic disorder in which the body has a deficiency of and/or

a resistance to insulin (Jerreat 2003). It is the most common endocrine disorder and is

an insidious disease, with the risk of developing it increasing with age. It is a variable

disorder of carbohydrate metabolism caused by a combination of hereditary and

environmental factors and usually characterized by in adequate secretion or utilization

of insulin, by excessive urine production, by excessive amounts of sugar in the blood

and urine and by thirst, hunger and loss of weight (Merriam-webster, 2011, M-W. Com).

The term diabetes mellitus refers to a group of diseases that affect how the

body uses blood glucose, commonly called blood sugar Glucose, is vital to ones health

because its an important source of energy for the cells that make up the muscles and

tissues. Its the brains main source of fuel. If one has DM, no matter what type, it

means one have too much glucose in the blood, although the reasons may differ. Too

much glucose can lead to serious health problems.

Chronic DM conditions include type 1 DM and type 2 DM potentially reversible

diabetes conditions include prediabetes mellitus. When your blood sugar levels are


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higher than normal, but not high enough to be classified as DM and gestational

diabetes, which occurs during pregnancy (http//www. Mayo clinic. Com, retrieved March

30, 2012).

2.2.2 Causes of D.M.

Insulin plays a very important part in regulating how much glucose is available in

blood for energy and how much is stored away in the liver as glycogen insulin is an

hormone produced by special collection of cells in the pancreas known as islet of

langerhans. The islets of langerhans pour a lot of insulin into the blood stream after a

large quantities of insulin are necessary to store excessive glucose in the liver

(Hortwitz,2002).

2.2.3 Pathophysiology of D.M.

In DM something goes wrong. The islets of langerhans are damaged, not enough

insulin is produced and instead of excess glucose being stored in the liver, it simply,

accumulates in the blood stream, when the sugar in the blood rises above certain level

of threshold, the kidney-excretes the excess sugar in the urine. Hence large quantities

of urine are passed to get rid of the excess sugar. The excessive urination soon leads to

thirst, while the continuous drain of glucose from the body depletes the tissues of their

vital energy supplies.

In persons hereditarily disposed to DM persistent over eating and obesity coming

on in middle age may lead to the on set of DM, which may be precipitated by an

infection, an accident or by pregnancy.


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In children, the exact cause of DM (Juvenile DM) remain unknown realm for

medical scientists. The accurate and definite cause of the disease is still a mystery,

though there is an accepted beliefs on it that it is due to some risk factors. Juvenile

D.M. is basically a condition in which the bodys defence system attacks and damages

its very own cells called Auto immune response when such a problem takes place, the

vital cells in the pancreas that makes insulin cease to function resulting in the absence

of the hormone (insulin) in the body. Insulin is a very important part in the energy

processing in our body. It helps in the proper absorption of the sugar called glucose

into the different cells in our body.

Some experts have suggested that juvenile DM may be called by heredity.

According to scientists, people who have the genetic tendency to develop coxsackle,

rubella and mumps viruses may also develop juvenile D.M. This is because such

viruses can trigger the onset of the disease (www. What caused diabetes net reviewed

on March 30, 2012).

Some conditions that damage or destroy the pancreas such as pancreatutis, pancreatic

surgery or certain industrial chemicals can cause D.M.

Certain drugs can also cause temporary DM including corticosteroids, beta

blockers and phenytoin. Rare genetic disorders (Klinefelter syndrome, Huntingtons

cholera, wolfram syndrome, leprechaunism, Rabson-mendenhall syndrome, lipoatrophic

diabetes and others) and hormonal disorders (acromegally, cushing syndrome,

pheochromocytoma, hyperthyroidism, somatostatinoma, aldostaronoma) also increase

the risk for D.M (Alemzadeh & wyatt 2007).


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Carbohydrate foods are the main supplier of the blood sugar. If one eat more

carbohydrate foods, the blood glucose level will go up, the level of inflammation in the

body will go up too and inflammation is the cause of disease development including

damages to beta cells of the pancreas. When damages of the beta cells happen some

of the beta cells would die, others would try to work as hard they used to. However, the

number of healthy beta cells has decreased and those damaged ones cannot work in

their full capacity, thus damaged ones can not work in their full capacity, thus the

production of insulin has decreased too. Therefore the blood sugar level would stay

increased.

Excessive intake of carbohydrate foods also leads to gaining of weight (obesity)

which predisposes one to D.M. so eating too much carbohydrate foods, especially those

refined, processed foods including grains, grain products or flour products, starching

foods such as potato, sweet potato and sugary foods and beverages including fruit juice

with added sugars or high fructose corn syrup, sugars, cola are associated with the risk

of obesity. D.M. and other disease including cancers. (Robert 2011, www carbohydrate

can kill. Com. Reviewed March 30, 2012).

2.2.4 Signs and Symptoms of Diabetes Mellitus

The early symptoms of untreated diabetes are related to elevated blood sugar

levels and loss of glucose in the urine can cause increase urine out put and lead to

dehydration. Dehydration causes increased thirst and water consumption.

The inability of insulin to perform normally has effects on protein, fat and

carbohydrate metabolism. Insulin is an anabolic hormone, i.e, one that encourages,


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storage of fat and protein. A relative or absolute insulin deficiency eventually leads to

weight loss despite an increase in appetite. Some untreated diabetes mellitus patients

also complain of fatigue, nausea and vomiting patient with D.M. are prone to developing

infections of the bladder, skin and vaginal areas. Fluctuations in blood glucose levels

can lead to blurred vision to lethargy and coma.

When the blood sugar level rises above 160 to 180mgld glucose passes into the

urine when the level rises even higher, the kidneys excrete additional water to dilute the

large amounts of glucose lost. Because the kidneys produce excessive urine a person

with D.M. urinates large volumes frequently (polyuria). The excessive urination creates

abnormal thirst (polydipsia). Because excessive calories are lost in the urine, the

person loses weight, to compensate. The person often feels excessively hungry

(polyphagia) other symptoms include drowsiness, decreased endurance during

exercise.

In people with type 1 D.M. the symptoms begin abruptly and may progress

rapidly to a condition called diabetic keto acidosis. Despite high levels of sugar in the

blood, most cells cant use sugar without insulin thus, they turn to other sources of

energy far cells begin to break down, producing ketones, tonic chemical compounds

that can make the blood acidic (keto acidosis). The initial symptoms of diabetic keto

acidosis include excessive thirst and urination, weight loss nausea, vomiting, fatigue

and particularly in children abdominal pain. Breathing tends to become deep and rapid

as the body attempts to correct the bloods acidity. The persons breath smells like nail

polish remover, without treatment, diabetic keto acidosis can progress to come,

sometimes within a few hours.


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People with type II D.M. may not have any symptoms for years is or decades,

when insulin deficiency progresses, symptoms may develop, keto acidosis is rare. If the

blood sugar level becomes very high (often exceeding 1,00mg/dl) - usually as the result

of some super imposed stress such as an infection or drug the person may develop

severe dehydration, which may lead to mental confusion, drowsiness, seizures, and a

condition called non ketotic hyperglycaemic - hyperosmolar coma (Yin Yang 2002).

2.2.5 Diagnosis

The fact that insulin dependent diabetes mellitus (IDDM) is thought to result from

interaction between genetic and environmental factors has lead to research methods

directed at prevention, early diagnosis and early control of the disease. These methods

include the identification of generically susceptive and early intervention in newly

diagnosed person with D.M.

The use of fasting plasma glucose (FPG) only has been proposed for the

screening and diagnosis of diabetes, but its sensitivity has been reported to be

unsatisfactory. The use of HbA1C, alone or combined with FPG, has been suggested

for the screening of D.M. and impaired glucose tolerance (IGT) (Mannucci, 2003).

A fasting plasma glucose (FPG) test measures blood glucose in a person who

has not eaten anything for at least 8 hours. This test is used to detect diabetes and

prediabetes mellitus. An oral glucose tolerance test (OGIT): It measures blood glucose

after the person drinks a glucose - containing beverage. This test can be used to

diagnose diabetes and prediabetes mellitus.


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A random plasma glucose test, also called a casual plasma glucose test,

measures blood glucose without regard to when the person being tested last. This test,

along with an assessment of symptoms, is used to diagnose D.M. but not prediabetes

mellitus. Test result indicating that a person has D.M. should be confirmed with a

second test on a different day.

The FPG test is the preferred test for diagnosing D.M. because of its

convenience and low cost. How ever, it will miss some diabetes or prediabetes mellitus

that can be found with the OGTT. The FPG test is most reliable when done in the

morning. Result and their meaning are shown below.

Table 1: People with a fasting glucose level of 100 - 125 milligram per deciliter

(mg/dl) have a form of pre-diabetes mellitus called impaired fasting glucose (IFG).

Having IFG means a person has an increased risk of developing type 2 D.M. but does

not have it yet.

A level of 12.6mg/dl or above, confirmed by repeating the test on another day,

means a person has D.M.

Table 1 FPG Test

Plasma Glucose Result (mg/dl) Diagnosis 99mg/dl or below normal.

100 to 125mg/dl - pre-diabetes mellitus (impaired fasting glucose)

126mg/dl or above - D.M. confirmed by repeating the test on a different day.

OGTT (Oral glucose toletance test).

Research has shown that the OGTT is more sensitive than the FPG test for diagnosing

prediabetes mellitus, but it is less convenient to administer. The OGTT requires fasting


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for at least 8 hours before the test. The plasma glucose level is measured immediately

before and 2 hours after a person drinks a liquid containing 75grams of glucose

dissolved in water. Results and their meaning are shown in Table 2, if the blood

glucose level is between 140 and 199mg/dl 2 hours after drinking the liquid, the person

has a form of prediabetes mellitus called impaired glucose tolerance (IGT). Having IGT,

like having IFG, means a person has an increased risk of developing type 2 D.M. but

does not have it yet. A 2 hour glucose level of 200mg/dl or above, confirmed by

repeating the test on another day means a person has diabetes.

Table 2: OGTT

2 hours plasma glucose result (mg/dl) diagnosis 139mg/dl and below normal.

140 to 199mg/dl prediabetes mellitus (impaired glucose tolerance) 200mg/dl and

above D.M. confirmed by repeating the test on a different day.


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2.2.6 Classification

DM may first appear to any age, its prevalence rises dramatically in other

population from less than two cases per thousand children to almost two per hundred

adult in their sixties (Horwitz, 2002). The national commission on D.M. in United States

of America estimated that 16.5% of person aged 56 years and 26% of 85 years old are

diabetics (Horwitz, 2002)

Type 1 D.M. was previously called insulin dependent diabetes mellitus (IDDM) or

juvenile - onset diabetes mellitus. Type 1 D.M. develops when the body immune

system destroys pancreatic beta cells. The only cell in the body that make the

hormone insulin, that regulate blood glucose. This form of D.M. usually strikes

children and young adults, although disease onset can occur at any age. Type 1

D.M. may account for 5% to 10% of all diagnosed case of D.M. risk factor for type 1

D.M. may include auto immune, genetic and environmental factors.

Type 2 D.M. was previously called non-insulin dependent diabetes mellitus (NIDDM)

or adult onset diabetes mellitus. Type 2 diabetes mellitus may account for about

90% to 95% of all diagnosed cases of D.M. It usually begins as insulin resistance, a

disorder in which the cells do not use insulin properly. As the need for insulin rises,

the pancreas gradually loses its ability to produce insulin. Type 2 D.M. is associated

with older age, obesity, family history of D.M., history of gestational diabetes

mellitus, impaired glucose metabolism, physical in activity and race/ethnicity. African

Americans, is Hispanic/latino americans and some Asian Americans and native

hawarians or other pacific islanders are at particularly high risk for type 2 D.M. Type

2 D.M. is increasingly being diagnosed in children and adolescents.


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Latent Auto immune Diabetes in Adults (LADA).

It is a type 1 diabetes mellitus diagnosed in adults over 30 years, sometime

known as type 1.5 D.M. LADA is often misdiagnosed as type 2 D.M. because of age,

however people with LADA do not have insulin resistance like those with type 2 D.M., a

gradual increase in insulin requirements, positive antibodies and decreasing ability to

make insulin as indicated by a low C-peptide. A fourth and very rare form of D.M. called

monogenic D.M. is also sometimes mistakes for type 1 D.M. but typically strikes new

borns.

Gestational D.M. is a form of glucose intolerance that is diagnosed in some women

during pregnancy. Gestational D.M. occurs more frequently among African

Americans, Hispanic/latino Americans and American Indians. It is also more

common among obese women and women with a family history of D.M. during

pregnancy, gestation diabetes mellitus requires treatment to normalize maternal

blood glucose levels to avoid complications in the infant. After pregnancy 5% to

10% of women with gestational D.M. are found to have type 2. D.M. women who

have had gestational D.M. have a 20% to 50% chance of developing D.M. in the

next 5 - 10 years.

Other specific types of D.M. result from specific genetic conditions (such as maturity

on set D.M. of youth), surgery, drugs malnutrition, infections and other illnesses such

types of D.M. may account for 1% to 5% of all diagnosed cases of D.M.

2.2.7 Treatment of D.M.


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The objective of the treatment is to help the patient to live a comfortable and useful life

for as long as possible D.M. is a chronic disease which cannot be cured except in very

specific situations. Management concentrates on keeping blood sugar level as close to

normal (euglycemia) as possible without causing hypoglyceamia. This can usually be

accomplished with diet, exercise and use of appropriate medications (insulin in the case

of type 1 d.M. oral medications as well as possible insulin in type 2 D.M.)

Patient education

Understanding the participation is vital since the complications of D.M. are far less

common and less severe In people who have well managed blood sugar levels.

Attention is also paid to other health problems that may accelerate the deleterious

effects of D.M. These include smoking, elevated cholesterol levels, obesity high blood

pressure and lack of regular exercise.

Life Style

There are roles for patient education, deistic support, sensible exercise, with the goal of

keeping both short term and long term blood glucose levels within acceptable bounds.

In addition given the associated higher risk of cardio vascular disease. Lifestyle

modifications are recommended to control blood pressure.

Medications

Oral medications (Anti-diabetic medications) met form in is generally recommended as

a first line treatment for type 2 D.M. as there is good evidence that it decreases

mortality.

Routine use of aspirin however has not been found to improve outcomes in

uncomplicated D.M.


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Insulin - Insulin therapy

Type 1 D.M. is typically treated with a combinations of regular and NPH insulin (Neutral

protamine Hagedorn/Aumulin N) or synthetic insulin analogs. When insulin is used in

type 1 D.M. a long acting formulation is usually added initially while continuing oral

medications. Dosage of insulin are then increased to effect (Rother 2007).

Transplantation: In recent years, researchers have focused increasing attention on

transplantation for people with type 1 D.M. current procedures include.

pancreas transplantation - pancreas transplants have been performed since the late

1960s. Most are done in conjunction with or after a kidney transplant. Kidney failure is

one of the most common complications of D.M. and receiving a new pancreas when you

receive a new kidney may actually improve kidney survival.

Furthermore, after a successful pancreas transplant many people with D.M. may no

longer need to use insulin, Unfortunately, pancreas transplants arent always

successful. The persons body may reject the new organ days or even years after the

transplant, which means the person will need to take immune suppressive drugs the

rest of his/her life. These drugs are costly and can have serious side effect including a

high risk of infection and organ injury. Because the side effects can be more dangerous

to ones health than the D.M. transplantation is not always advisable unless the person

is experiencing serious complications.

islet cell transplantation - pancreas contains about 1 million islet cells, 75 percent to 80

percent of which produce insulin. The beta cells that produce insulin reside in the islets.

Although still considered an experimental procedure, transplanting these cells may offer


28/98

a less inuasive, less expensive and less risky options than a pancreas transplant for

people with D.M. (Mayo 2012).

Treatment modalities for older patients

Treatment modalities available for older person with D.M. are not different from

those used in younger patients. However a number of special consideration arise in

their application to the elderly. For instance the person already being treated with

insulin may as he grows older finds that stiffening joints make it difficult to fill the syringe

accurately or warning visual acquity leads to insulin does errors. (Horwitz, 2002). If

appetite decreases or the patient become too frail to eat regularly, glucose control may

change even mild degree of senile dementia may lead to poor compliance by a

previously consecutive patient or leading to increasing errors in diet or medications.

Therapuetic modalities include diet, exercise, hypoglyceamic drugs (insulin or oral

agents) and patient education (Horwitz, 2002).

Moreover, the initial manifestation in other patients are more subtle, a

symptomatically and vague constitutional symptoms (loss of energy, fatigue) which

make diagnosis and treatment difficult (Horwitz, 2002). A particular severe consequence

of this may be non-ketotic hyperosmolar coma, which has high mortality rate if not

promptly and effectively treated. In the absence of this life threatening presentation.

However patients sometime do not accept the need for treatment. Insulin is destroyed

by the gastric juice hence it cannot be given by mouth but has to be administered

through subcutaneous injection, clear insulin known as soluble insulin, when injected


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leads to a fall in the blood sugar but it is short acting, that is why the use of intermediate

and long acting insulin is included in the treatment.

TABLE 2.1: SHOWING TYPE OF INSULINE

TYPES OF

INSULINE

ONSET OF

ACTION (HRS)

PEAK OF ACTION DURATION OF

ACTION (HPS)

Short acting or

regular acting

30 mins-1 hour 2-5hours 5-8hours

Intermediate Acting

(NPH) N

1-2 hours 4-12 hours 18-24 hours

Long Acting

(ultralented) (u)

30mins - 3hours 10-20hours 30-36 hours

Rapid Acting 15-30minutes 30-90minutes 3-5 hours

Pre-mixed

(Humulin 70/30)

3.0 minutes 2-4hours 14-24 hours

Rapid-Acting insulin covers insulin needs for meals eaten at the same time as the

injection. This type of insulin is used with longer acting insulin.

Short-Acting insulin covers insulin needs for meals eaten with 30-60 minutes.

Intermediate-Acting insulin covers insulin needs for about half the day or overnight.

This type of insulin is often combined with rapid or short acting insulin.

Long-acting insulin covers insulin needs for about one full day. This type of insulin is

often combined, when needed, with rapid or short acting insulin.

Pre insulins these products are generally taken twice a day before meal time. They

are combination of specific proportions of intermediate-acting and short acting insulin in


30/98

one bottle or insulin pen (the numbers following the brand name indicate the percentage

of each type of insulin) (Brunilda 2011).

NOTE: Insulin reacts differently in individuals and the above chart is intended only as a

general guideline based upon. Insulin manufacturer, information. The peak and

duration of insulin is affected by many things including individual response, time of the

day, exercise, stress, sickness and content of a meal (high-fat means can lead to

hypoglycemica).

Diabetes Needing Tablet

Many adult patient who develop D.M. can be controlled with out resort to insulin.

If they are overweight the weight need to be reduced through reduction in the caloric

intake. This is referring to non-insulin dependent diabetes mellitus (NFDDM). Several

types of sulphonylurea tablets are in common use to bring down the blood sugar. These

compounds stimulate the pancreas to produce more insulin. Tolbutamide and glipizide

have a short duration of action and are normally taken twice a day. Chloropropamide

and tolazamide has a longer action and once a day is effective.

Glibenclamide has an intermediate strength of action, all these tablets are well

tolerated by the patients. Unfortunately they became ineffective if the diet is not adhere

to and they often give rise to increase in weight if the patients over eats. Since the

development of insulin, oral agent and to some extent also antibiotics, there has been a

considerable improvement in the survival rate and general prognosis for D.M. must

accept a major role in the management of his diseased condition. His education must

be updated continuously since D.M. is a long life disease.


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2.2.8 Dietary Management of D.M.

A proper dietary management is the first and perhaps the most essential part of

D.M. treatment. There is a list of dietary dos and donts that are associated with D.M.

In fact the dietary restrictions are so severe that it may lead to mental trauma. In the

patient, and make the disease much more insufferable. Yet dietary management is

extremely necessary for people who wish to keep their disease to a controllable level

and to lead a longer life. The purpose of dietary management is to attain or maintain

ideal body weight and ensure normal growth when insulin is given or taken special

consideration must be given to ensure adequate carbohydrate intake to correspond to

the time when the insulin is most effective and less carbohydrate when insulin is least

effective (Smeltzer & Bare 2002).

Although diet cannot cure D.M. but at least it can be brought in control. Diet will

help to monitor the level of the blood sugar. The following are some suggestions to

make a health diet for controlling D.M. All bitter vegetables are excellent in reducing the

blood sugar level. One must consume one bitter vegetable in every meal one take. One

can choose between the vegetables such as bitter leave, bitter gourd and bitter variety

of drumstick.

Sour foods containing high vitamin C in them are good for D.M. the Indian goose

berry, popularly known as the Amalaki and a prime component of the Amalaki and a

prime component of the Ayurvedic Triphala powder is very good in dissolving excess

fats in the body and in bringing the blood sugar level down. Reduction of the total fat in


32/98

take can be promoted/achieved by avoiding frying foods, instead try other options such

as baking, roasting, steaming, grilling which requires little or no oil.

Red meats contain more fatty acids than white meats. Avoiding mutton pork and

beef, but chicken and sea food are okay. The diabetic diet has traditionally been low in

carbohydrate content. However recent studies have shown that the diet may be

liberalized in this respect provided that complex carbohydrate are given (Smith, 2003)

when given in amounts corresponding to 50g starch beans, in particular, raise the blood

glucose level to only a small extent and less than various other food stuff tested (Smith,

2003) various vegetable provided about 50% of the plant fibre on diet, the content of

insulin required by the patients was clearly reduced to maintain unchanged or even

improve control.

This appeared that a diet rich in plant fibre and complex carbohydrate has

definite advantage for diabetic patient. Recently studies clearly indicated that different

sources of complex carbohydrate diet markedly different post prandial glucose and

insulin response both in normal subjects and in subjects with impaired glucose

tolerance (Smith, 2003)

In conclusion, treatment of D.M. with certain dietary fibre improve the diabetic

control and also may be beneficial by virtue of the lipid reduction achieved (Smith,

2003). The diabetic diet is still in its developing stage. The function of different fibre

fraction is not well known (Phillipson, 2003). It is wise to increase fibre food than to use

supplements or fibre medications with a high fibre diet the diabetic patients can

eventually decrease their insulin or tablet medication. Dietary fibre is defined as the

substance in the cell wall, vegetable passing undigested through the upper part of the


33/98

intestinal tracts no degradation taking place before they reach caecum (Phillipson,

2003). These are various type of fibre with different physiologic effect as it is shown

below.

TABLE 2.2: SOME COMMON SOURCES OF DIETARY FIBRES

Fibre fraction sources

Cellulose Bran, whole meal bread, dry beans nuts,

and beefs

Hemi cellulose Bran, whole meal, bread, raddish, beefs

Pectin Bran Citrus fruits, apple, grapes, berries

Lignin Bran, whole meal flour and nuts.

Adapted from (Phillipson, 2003) cellulose is made up of glucose units only, hemi

cellulose also contains pentose while pectin, contains uronic acids. The fourth dietary

fibre, lignin is not a carbohydrate in the cell wall (Phillipson, 2003).

Insulin, diet and exercise are the so called corner stones in joshns triad, which

make up the means for good treatment in D.M. (holm & Strom bald, 2003). A diabetic

diet must be sufficient in quantity to enable the patient to undertake his activities, to

satisfy his appetite and to maintain his weight at a proper level A girl of slight physique

learning a sedentary life may require a diet of 200chlories (8000kilo joules) a man doing

a heavy labouring job may need 2,800chlories (11,500kj) or more. The diet must

contain an adequate amount of protein (at least 75%) and carbohydrate (at least 180g).

It must contain fruits and vegetables with a high fibre content, the meal must also be

spaced during the day, with snacks in between meals, meals must be taken at regular

times, as delayed meals may lead to hypoglycaemia attack. Compliance is best if diet


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is planned after a careful history to determine patients usual eating habits reduction of

simple sugars may be the only change gradually rate than giving the patient a whole

new diet at all once. It may be desirable to restrict fat consumption and emphasize

polysaturated fats (Hortwitz, 2002).

2.2.9 Nutritional Care

Nutrition, meal planning and weight control are the foundation of D.M.

management. The most important objectives in the dietary and nutritional management

of D.M. are control of total caloric in take to attain or maintain a reasonable body weight,

control of blood glucose levels and normalization of lipids and blood pressure to prevent

heart diseases. Success in the area alone is often associated with reversal of

hyperglycaemia in type 2 D.M. However, achieving these goals is not always easy.

Because medical nutrition therapy (MNT, Nutritional management) of D,M. is complex.

A registered dietitian who understands D.M. management has the major responsibility

for designing and teaching this aspect of the therapeutic plan. Nurses and all other

members of the health care team must be knowledgeable about nutritional therapy and

supportive of patients who need to implement nutritional and lifestyle changes nutritional

management of D.M. include the following goals American Diabetes Association (ADA,

2008b).

1. To achieve and maintain

Blood glucose levels in the normal range or as close to normal as is safely

possible.

A lipid and lipo protein profile that reduces the risk for vascular disease.


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Blood pressure level in the normal range or as close to normal as is safely

possible.

2. To prevent, or at least slow, the rate of development of the chronic

complications of D.M. by modifying nutrient intake and lifestyle.

3. To address individual nutritional needs, taking into account personal and

cultural preferences and willingness to change.

4. To maintain the pleasure of eating by only limiting food choices when

indicated by scientific evidence.

For obese patients with D.M. (especially those with type 2 D.M.), weight loss is the key

to treatment.

(It is also a major factor in preventing D.M.). In general, over weight is considered to be

a body mass Index (BMI) of 25 to 29, obesity is defined as 20% above ideal body

weight or a BMI equal to or greater than 30 (National Institute of health 2000). BMI is a

weight to height ratio calculated by dividing body weight (in kilograms) by the square of

the height (in metres).

Obese patients who have type 2 D.M. and who require insulin or oral agents to

control blood glucose levels may be able to reduce or eliminate the need for medication

through weight loss. A weight loss as small as 5% to 10% of total weight may

significantly improve blood glucose levels (ADA, 2009b). For obese patients with D.M.

who do not take insulin or sulfonylureas, consistent meal content or timing is important

but not as critical. Rather, decreasing the overall caloric intake assumes more

importance. However, meals should not be skipped spacing food intake throughout the

day places more manageable demands on the pancreas.


36/98

Consistently following a meal plan is one of the most challenging aspects of D.M.

management. It may be more realistic to restrict calories only moderately. For patients

who have lost weight, maintaining the weight loss may be difficult. To help these

patients in corporate new dietary habits into their lifestyles, diet education, behavioural

therapy, group support and on going nutrition counseling are encouraged (Smeltzer &

Bare, 2010).

Table 2.3: below give selected sample means from exchange lists

Exchange Sample lunch 1 Sample lunch 2 Sample lunch 3

2 starch 2 slices bread Hamburger bun 1 cup cooked pasta3 meat 2 0z sliced turkey and

1 oz low fat cheese

3 oz lean beef

patty

3 oz boiled stirimp

1 vegetable Lettuce,Tomato,onion Green salad cup plum

tomatoes

1 fat 1 teaspoon

mayornaise

1 teaspoon salad

dressing

1 teaspoon olive oil

1 fruit 1 medium apple 1 cup water

melon

1 cup fresh stew

barriers

Free items

(optional)

Un sweetened iced

tea mustard, pickle,

hot pepper

Diet soda. 1

teaspoon, eat

sup,pickle onions

Ice water with

lemon, garlic basil.

2.2.10 Complications of D.M.

All forms of D.M. increase the risk of long term complications. These typically develop

after many years (10-20 years), but may be the first symptom in those who have

otherwise not received a diagnosis before that time (1) Diabetic ketoacidosis (DKA) is

an acute and dangerous complication that is always a medical emergency. Low insulin


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level cause the liver to turn this ketone for five (i.e. ketosis) ketorne bodies are

intermediate substance in the metabolic sequence. This is normal when periodic but

can become a serious problem if sustained elevated blood level of ketone bodies

decrease the bloods ph, leading to DKA on presentation to the hospital. The patient

with DKA is typically dehydrated, and breath rapidly and deeply, Abdomina pain is

common and may be severe when DKA is severe it can lead to lethargy, hypotension,

shock, brain oedema and death. Urine analysis will reveal significant level of ketone

bodies (which have exceeded their renal threshold blood levels to appear in the urine,

often before other over symptoms).

2.2.11 Hyperglycemia Hyperosomolar States (HHSS)

Non ketotic hyperosmolar coma/hyperosmolar non ketotic state (HNS) is an

acute complication sharing many symptoms with DKA, but an entirely different origin

and different treatment. A person with very high (usually considered to be above

300mg/dl (16mmol/l) blood glucose levels, water is osmotically drawn out of cells into

the blood and the kidney eventually begin to dump glucose into the urine.

This result in loss of water and an increase in blood osmolarity. If fluid is not

replaced (by mouth or intravenously) the osmotic effect of high glucose levels,

combined with the loss of water will eventually lead to dehydration, electrolyte

imbalance are also common and are always dangerous.

Hypoglycemia, or abnormally low blood glucose, is an acute complication of several

D.M. treatment. It is rare otherwise, either in diabetic or non-diabetic patients.

Patient may become agitated, sweaty, weak and have many symptoms of


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sympathetic activation of the autonomic nervous system resulting in feelings a kin to

dread and immbolized panic.

Diabetic coma is a medical emergency in which a person with D.M. is comatose

(unconscious) because of one of the acute complications of D.M. e.g. severe

diabetic hypoglycemia, diabetic keto acidosis the advanced form, and hyperosmolar

non ketotic come. The major long term complications relate to damage blood

vessels D.M. doubles the risk of cardiovascular disease. The main macro vascular

diseases (related to atherosclerosis of large arteries).

Arteriosclerosis: Hardening of the arteries which leads to poor blood supply to the

feet. A minor injury to toe may not heal on time and is prone to infection and

eventually may also lead to gangrene with consequent amputation of the whole leg.

Stroke and peripheral vascular disease, angina pectoris and myocardial

infarction are complication that are related to or due to damages to the vessel.

Macrovascular disease leads to cardiovascular disease to which accelerated

atherosclerosis is a contributor.

Coronary artery disease leading to angina or myocardial infarction (heart

attack).

Diabetic myonecrosis (muscle wasting)

Peripheral vascular disease, which contributes to intermiltent elaudication

(exertion related leg and foot pain) as well as diabetic foot.

Stroke (mainly the ischemic type)

D.M. also causes micro vascular complications damages to the small blood vessels.


39/98

Diabetic retinopathy! Which affects blood vessel formation in the retina of the

eye, can lead to visual symptoms, reduced vision and potentially blindness. Diabetic

nephropathy, the impact of D.M. on the kidneys can lead to scarring changes in the

kidney tissue, loss of small or progressively chronic kidney disease requiring dialysis.

Diabetic neuropathy:Is the impact of diabetes on the nervous system, most commonly

causing numbness, tingling and pain in the feet and also increasing the risk of skin

damage due to altered Sensation. Together with vascular disease in the legs.

Neuropathy contributes to the risk of skin damage due to altered sensation. Together

with vascular disease in the legs. Neuropathy contributes to the risk of D.M. related to

foot problem (such as diabetic foot ulcers) that can be difficult to treat and occasionally

require amputation.

Respiratory infections: The immune response is impaired in individuals with D.M.

cellular studies have shown that hyperglyemia both reduces the function, of immune

cells and increases inflammation. The vascular effects of D.M. also tends to alter lung

function, all of which leads to an increase in susceptibility to respiratory infections such

as pneumonia and influenza.

Periodontal disease: D.M associated with periodontal disease (gum disease) and may

make D.M. more difficult to treat. Gum disease is frequently related to bacterial

infection by organisms such as porphyromonas gingivalis and actinobacillus and

actinomycetem comitans. (Nathan & Mealey, 2006).

2.3 Empirical Literature Review

2.3.1 Emperical Studies of Compliance Behaviour


40/98

Compliance as related to diet: Can be defined as the extent to which a patients

behaviour coincides with dietary advice (Wilkinson, 2008). Further in his studies

reported that about 6-20% of patients fail to redeem their prescription and 30-35% delay

or omit doses. Poor compliance may produce adverse effect on the quantity of medical

care, may waste resources. Firstly, it interfered with therapeutic efforts by reducing the

benefits of the preventive or curative services offered.

Secondly non-compliance to dietary regimen may cause unnecessary diagnostic

and treatment procedures, thus generating further costs.

2.3.2 Non Compliance to diet regimen

Non compliance is defined as behaviour of person and/or care giver that fails to

coincide with a health promoting or therapeutic plan agreed upon by the person (and/or

family and/or community) and health care professional, what is important in the

definition is that the patient for some reason (which will become the related factors)

doesnt follow it, making it behavioural issues.Factors affecting compliance, including

the nurse/patient relationship, has allowed the evolution of concordance.

Concordance views the patient as being the equal of the equal of the health care

provider and as having a right to make informed decision. In a condition such as D.M.

which has many potential long term complications, it is vital that concordance is

embraced in the health care system. In order to improve care. D.M. is a life long disease

condition that has a complex treatment, and requires behaviour changes on the part of

the patient. If patient do not comply to the course of treatment and adjustment in the

behavioural changes thus leads to complication from poorly controlled D.M.


41/98

Hence the holistic approach to the care of the control of D.M. is vital and will

actually have a direct impact on the prevention of complication D.M.Rate of non-

compliance vary with estimates ranging from 50% to 80%. Greater compliance may be

associated with a decreased probability of diabetic complications. Non-compliance

imposes an immense financial burden on modern health care systems. Such as the

National Health Services (NHS), as well as imposing personal cost on the individual

patient low compliance can have detrimental effects on medical research trials, reducing

the value and the usefulness of studies.

Compliance can also be defined as the extent to which a patients behavour in

terms of taking medication, following diets or implementing life style changes coincides

with medical or health advice (Vermeire, 2011).


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2.3.3 Factors which Affect Compliance to Diet

Factors which decrease compliance from the perspective of health care

providers, therapeutic compliance is a major effect on treatment outcomes and direct

Clinical consequences non-compliance is directly associated with poor treatment

outcomes in patients with D.M.Poor compliance with dietary therapy is the most

important reason for poorly controlled blood sugar level (Hajjar & Kotchen, 2008).

The financial cost: Therapeutic non compliance has been associated with

excess urgent care visits, hospitalizations and higher treatment costs;

(Bond, Hussar & Suarstad, 2011). Some other factors that affect the

compliance to diet regimen are patient centered factors, demographic

factors, age, ethnicity, gender, education, marriage status, psychosocial

factors, beliefs, motivation, attitude patient-prescriber relationship, health

literacy, patient knowledge, physical difficulties, tobacco smoking or

alcohol intake, forgetfulness, History of good compliance.

Therapy - related factors: Preparation complexity, Duration of the

preparation of the diets, degree of behavioral change required, taste of the

diet quantity of food to be taken lack of accessibility.

Social and economic factors: Inability to take time off work, cost and

income, social support, disease factors, disease symptoms and severity of

the disease (wal, wong, check, tan, chua, mak, Aung & Lims 2008).

Non Compliance Due to Finance

From the investigation clinical exposure and experience affect the role of finance

in the compliance to diet and during treatment regimen of D.M. can not be over


43/98

emphasized. Many patients, who are well educated and known the implication of non-

compliance to treatment are being in capacitated to produce expensive drugs (both oral

agents and insulin, as well as expensive therapeutic diet that D.M. involved).

Therefore when patient cannot afford their medical care due to the high cost of

treatment and cost of special diet is affecting compliance to such treatment. The

economic barriers to medical care are the primary factors. There are so many cases in

which the relative affordability of treatment affects degrees of compliance in patients

who are able to pay at least some of their medical expenses.

There is no doubt that illness imposes a burden on our, resources in two ways.

First resources are used up to prevent diagnosis and treat disease. These costs which

include expenses of hospital care, consultations with physician , Nursing care rendered,

drug diet, etc. are called direct economics costs. Secondly resources are lost because

those afflicted by illness cannot take part in the production of goods and services,

included in these indirect economic costs to the production cost due to short term illness

permanent disability and death prior to retirement age. Smith (2012) state that failure to

adhere to treatment instruction has been estimated to be reason for 25% of all

Australians hospitals administration leading to avoidable examples

In conclusion, the investigation has been able to discuss D.M. extensively in this

review in terms of its meaning, causes clinical manifestation, diagnosis, types or

classification, treatment modalities in both IDDM and NIDDM, dietary management,

exercise, complication and the meaning of compliance and non compliance as it affect

D.M. factors which decreased it. Compliance factors which affects, its compliance, its

non-compliance to drug and diet.


44/98

2.3.4 Information Needed to Maximize Compliance

For the successful attempts to improve patient compliance depend upon a set of

key factors. These include realistic assessment of patients knowledge and

understanding of the regimen, clear and effective communication between health

professionals and their patients and the nurturance of trust in the therapeutic

relationship.

Patients must be given the opportunity to tell the story of their unique illness

experiences. Knowing the patient as a person allows the health professional to

understand element that are crucial to the patients compliance, beliefs, attitudes,

subjective norms, cultural context, social supports and emotional health challenges,

particularly depression, physician - patient partnership are essential when choosing

among various therapeutic options to maximize compliance.

Mutal collaboration fosters greater patient satisfaction, reduces the risks of non

adherence, and improves patients health care outcomes.

The advice given to patients by their health care professionals to cure or control

diseased condition is too often misunderstood, carried out incorrectly, forgotten or even

completely ignored so this can be avoid by given the patient adequate, understand and

using appropriate language the patient can understand when caring for them (Dimateo

2008).

2.3.5 Factors Contributing to patient Not Complying to Eating and Drinking in

Hospital


45/98

Problems with ordering of food is the first factor, patients should be given a choice of

meals few when a special diet as the case in D.M. patient, they should be allowed to

choose from their local diets that are not control indicated to their ailment in correct

proportion.

Communication must be effective between the Nursing staff, catering staff and the

patients. In some hospital, the distribution and collection of meals is shared by Nursing

staff. For instance nurse may dish out the mutals and the catering staff may clear them

away. Problem may arise because there is no system for monitoring and reporting

whether food has been eaten, to the Nursing staff. For the out patient, the close

relatives and friends should be educated on how to comply with the dietary, regimen for

the majority of people the general appearance of a meal is important and contributes to

whether or not a person will eat it. People who are ill often experience a loss of

appetite, so the appearance of meals takes on great significance. A lack of variety of

food on the menu can also have effect on patients. Unfortunately for developing

Countries like Nigeria, not many people will be able to afford varieties because of the

poor economic situation.

Food should be contently prepared and appropriate to patients needs. The available

food may be unsuitable for patients with specify dietary requirement. For example,

people from minority ethnic group may not be catered for and the Vegetarian.

Moreover, a Yoruba man, in Nigeria for example may find himself being hospitalized in

a hospital in a far Northern part of the Country or far Eastern part of the Country there is

no doubt that such a patient will be confronted with problem of non-compliance with his

diet. Therefore, patients should be asked about their personal dietary needs before


46/98

admission so that his/her special diet will be tailored towards his food preference and

this will enhance dietary compliance.

It is often suggested that hospitals should serve meals at times of the day which

reflect the normal eating time of the majority of people instead of being dictated by the

need of the catering and Nursing staffs, some hospitals give a wide gap before serving

another meal. This wide gap is frequently a cause for compliant among many patients,

eating environment in which meals are served plays an important role in whether or not

patients eat their meals wherever possible, patient should be given the choice of eating

in a designated dining area. Some people may be embarrassed about their eating

habits and may want to eat alone. Other group of people may not feel able to socialize

at meal time e.g. depressed patients and alternate place is suggested for these type of

patients.

Dietary recommendations for the management of D.M. have changed over the

past 16 years. There is now a reduced emphasis on the importance of carbohydrate in

the diet.

Non Compliance Due to Finance

From the investigation clinical exposure and experience affect the role of finance

in the compliance to diet and during treatment regimen of D.M. can not be over

emphasized. Many patients, who are well educated and known the implication of non-

compliance to treatment are being in capacitated to produce expensive drugs (both oral

agents and insulin, as well as expensive therapeutic diet that D.M. involved).

Therefore when patient cannot afford their medical care due to the high cost of

treatment and cost of special diet is affecting compliance to such treatment. The


47/98

economic barriers to medical care are the primary factors. There are so many cases in

which the relative affordability of treatment affects degrees of compliance in patients

who are able to pay at least some of their medical expenses.

There is no doubt that illness imposes a burden on our, resources in two ways.

First resources are used up to prevent diagnosis and treat disease. These costs which

include expenses of hospital care, consultations with physician, Nursing care rendered,

drug diet, etc. are called direct economics costs. Secondly resources are lost because

those afflicted by illness cannot take part in the production of goods and services,

included in these indirect economic costs to the production cost due to short term illness

permanent disability and death prior to retirement age. Smith (2012) state that failure to

adhere to treatment instruction has been estimated to be reason for 25% of all

Australians hospitals administration leading to avoidable examples.

A cross sectional study was conducted and multistage stratified random sample

method was used for the selection of 600 diabetic patients. Data were collected by

means of an interviewing questionnaire, an observation checks list, review of

prescriptions and laboratory investigations. A scoring system was made for a diabetic

patient is knowledge and skills, patients compliance, doctor - patient relationship, and

glyemic control. Result showed that about 57% always took their medication as

prescribed by doctor and on time, only 2.2% always complied with dietary regimen,

while no one reported regular compliance with exercise regimen. Complications of the

regimen were the exercise regimen. A complication of the regimen was the commonest

cause (63.3%) of non compliance. A highly statistically significant difference was found

between compliance with all regimens and patients knowledge of diabetes. The scores


48/98

for doctor patient relationship were all unsatisfactory results of glycosylated hemogloblin

(HbAIc) revealed that metabolic control of four - fifth of the patients was satisfactory,

12% had fair and 8% had poor metabolic control.

The personal and socio-demographic characteristics of the sample of 600

diabetic patients indicated that men represented 48.3% of the sample while women

formed 51.7%; the men to women ratio being 1:11. The age of diabetic patients ranged

from 25 to 81years, with a mean age 47.688+11.94 years. Marriage patients comprised

83.0% and 10.8% were single. About one-third (34.5%) of diabetic patients were

illiterate and 42.2% were manual workers.

An analysis of result revealed that about two third (64.3%) of the sample got their

knowledge from physicians, 19.3% from nurses, 18.7% from relative and 4.8% from

other diabetic patients. Most patients gave more than one cause for non-compliance.

About two third of patients (63.3%) said that the non-compliance was because they did

not understand the drugs lack of knowledge about drugs was mentioned by 51.3%

whereas the reason were financial for 27% of the patient www. Tochi. Nmmh - gov >

journal list > J family common med > 11.17(3)l 01/09/12.

2.3.6 Factors influencing compliance to dietary regimen

patient satisfaction to the service given to them, diet and drug supervision by Nurses

and Physicians, patients expectations, been met, physicians accept patients family

agrees with physician degree of disability, adapted from nursing times, 2003 (by

Barbara).


49/98

2.3.61 Information needed to maximize compliance

Food that the patient can avoid.

Some drugs react with certain foods and may make a patient feel III or pose a

potential danger. The patient must know and understand the reason why these

foods should be avoided.

The kind of food they should be eating should be explain to them, hell them the

component and the importance of the food to there health. The mode of

preparation.

The kind of language that will be understood by the patient should be used

during health education or explanation to aid effective communication.

If the patient is unable to read the information and instructions on the label, it

must be explained to the patient and his understanding of the instruction must be

assessed list of food should be given to them and it should be made available in

different languages they can understand and it should include food they can be eaten

and those they should avoid. The reason for the avoidance should be stated and the

complication of non-avoidance or adherence to the diet should be explained to them.

Clients should be taught the means of preparation of the food and the places

where the can get the food items and the diet regimen should be

communicated to them.

For the successful attempts to improve patient compliance depend upon a set of key

factors. These include realistic assessment of patients knowledge and understanding of

the regimen, clear and effective communication between health professionals and their

patients and the nurturance of trust in the therapeutic relationship. Patients must be


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given the opportunity to tell the story of their unique illness experiences. Knowing the

patient as a person allows the health professional to understand element that are crucial

to the patients compliance, beliefs, attitudes, subjective norms, cultural context, social

supports and emotional health challenges, particularly depression, physician patient

partnership are essential when choosing among various therapeutic options to

maximize compliance.

Mutual collaboration fosters greater patient satisfaction, reduces the risks of non-

adherence, and improves patients health care outcomes. The advice given to patients

by their health care professionals to cure or control diseased condition is too often

misunderstood, carried out incorrectly, forgotten or even completely ignored so this can

be avoid by given the patient adequate, understand and using appropriate language the

patient can understand when caring for them (Dimateo 2004).

In conclusion, the investigation has been able to discuss D.M. extensively in this

review in terms of its meaning, causes clinical manifestation, diagnosis, types or




non-compliance to drug and diet. Information needed to maximize compliance.

2.4 Conceptual Model

The theoretical framework for this study shall be behavior models by (Jacqueline

Dunbar 2007). Management of diabetes typically requires the patient to make frequent

alterations in her or his diet, physical activity level, glucose measurement. Schedule and


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medication administration. To encourage these changes or behaviour and to instruct

patients on how to do so safely, the clinician must have a sound understanding of the

relationship between the treatment elements and the clinical outcome they produce. In

addition, most people with diabetes also have other conditions that require specific

management regimens. Minimizing the patients self care burden by integrating the

regimens can be a challenge for the diabetes educator.

2.41 Common Element In Behaviour Change Models

There are only a few effective strategies for promoting and sustaining behaviour

change in people who have diabetes mellitus and con-comitant chronic conditions.

These strategies usually basic education (to address low health literacy), help with

setting goals, engendering a sense of control (self-efficacy), arranging for professional

or social support and providing feed back. All successful models begin with clearly

defining the desired change or behaviour, establishing a baseline and encouraging the

patient to self monitor her or his progress. In most cases multiple interventions are

necessary and only modest changes in behaviour can be espected.

2.42 Specifying the Behaviour

Instructing someone to increase exercise or take your medication and to work

toward clinical goals such as lower your cholesterol are unlikely to be helpful. Patients

are unlikely to change unless they are given aspeutic description of the behaviour to be

undertaken. For example, saying walk at your normal pace for 30 minutes five days a

week, either for 30 minutes at one time or for 15 minutes twice a day gives patients a


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concrete goal on that clinicians then can use to monitor behaviour and evaluate its

contribution to clinical outcomes.

2.43 Encouraging Self-monitoring

In all models of behaviour charge assessment is critical. It is important for the

clinician to understand the patients existing behaviour and to establish the baseline

behaviour. Its not enough for the patient to know what to do and intends to do it, what

matters is what the patient does how often, and under what conditions. Its crucial for

the clinician to understand the circumstances (environmental, social, financial and

attitudinal) that help or hinder the patient in making changes. For example, the patient

may not have the financial resources to join a health club and may live in a

neighborhood that is unsafe for outside exercise or even walking on the other hand, the

patient may live a 10 minutes bus ride form a community center with a gym where she

or he can begin using an exercise bike. Understanding these circumstances can help

the clinician and patient plan for behavior change.

Because memory for the specific details of behavior (what, when, how and under

what circumstances) tends to be poor. Some form of recorded self monitoring is

needed. For example, the patient may keep a daily or complete a daily checklist of

activities. Self monitoring is very useful, but its requires the patient to recognize and

record her or his behavior.

2.44 Help with setting goals


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Research suggests that setting specific goals leads to greater behavior change than

having vague or no goals. The patient must be interested in achieving the goal and it

should not conflict with other goal. The patient must be interested in achieving the goal

and its should not conflict with other goals. In complex situations such as a regimen

designed to treat multiple conditions, including D.M. It is important that there be sub

goals, a strategic plan for moving toward them and regular feed back on performance.

Goals should be challenging but attainable, taking into account the persons ability and

perceived sell efficiency.

2.45 Engendering self-efficacy is critical for successful behavior change.

According to Bandura (2002) Perceived self, efficacy is defined as peoples

judgments of their capabilities to organize and execute courses of action required to

attain designated types of performances. It is not concern with the skills one has self-

efficacy theory suggests that goals should be attainable in the near future, because

immediate success can provide motivation and enhance efficacy. Indeed, the strongest

influence on self-efficacy is mastery. Successfully completing easy tax does not

strengthen efficacy on the other hand failure can harm it.

2.46 Developing knowledge

To change behavior, the patient must understand what to do and how to do it.

The patient needs enough knowledge to adjust the treatment or prevention regimen in

response to changing circumstances. Learning relies heavily on the educators ability to

adapt teaching strategies to the individual and on the patients ability to process


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information. Because poor glycemic control and cognitive dysfunction are associated, it

is among the numerous tactors that can affect the ability of the patient with D.M. to

process information. Health literacy the ability to apply skills such as reading and

interpreting medication labels to functioning effectively as patient also contributes to the

patients ability to comprehend and apply knowledge to modifying behavior. Patients

with poor health literacy often do not understand dosing instructions and are not able to

interpret a blood glucose value.

Instructional strategies can make it easier for the patient to change her or his

behavior perhaps the most important strategy is to teach only a small amount at time

just enough to support behavior change. The instructor should focus on the behavior

and how to carry it out correctly, rather than on the reason for the change language

should be simple group information into categories has been shown to increase recall.

For example lets talk about self monitoring of what you eat. First well review what

goes into a food diary, next well talk about when to do the recording. Then well

discuss how to review the diary to identify problem areas.

2.47 Giving Feed Back

Allow patients the opportunity to demonstrate their understanding and then give

them feed back on their progress. Feed back may consist of verbal comments,

modeling, or demonstration or chart or other graphics, such as a checklist for

medication wage.Bandura (2002) noted that the type of feed back that is best varies

according to the stage of behavior change initially, feed back should support the

patients capabilities, as skills develop, feed back should be informative, with the


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educator advising the patient in a way that enhances suggested that feed back focus on

the individual comparing the patients current performance to her or his past behavior

rather than to that of other patients.

In conclusion, the investigation has been able to discuss D.M. extensively in

this review in terms of its meaning, causes clinical manifestation, diagnosis, types or




non-compliance to drug and diet. Information needed to maximize compliance.

2.5 Conceptual framework

Dependent Variables

2.51 Application of the framework

Dietary regimen amongdiabetic patient

Dietary regimen amongdiabetic patient

Cultural belief, level of education,employment status, cultural belief,

family support, socio economicStatus, etc.

Intervening/extraneous variables


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As earlier discussed Jacqueiline Dunbar Model said that management of

diabetes typically requires the patient to make frequent alternations in his or her diet,

physical activity level, glucose measurement, Schedule and medication administration.

However, various factors like unemployment status (finance) attitude of the care givers,

cultural belief, family support, socio - economic status, level of education, contribute to

the poor compliance of diabetic patient to dietary regimen a

Documents

FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING HOSPITAL OSOGBO. BY FOLARANMI BASIRAT TEMITOPE