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Diabetes mellitus is a condition that results from the body’s ineffective use of insulin. Management of diabetes mellitus requires compliance to dietary regimen, lifestyle changes and drugs. This study assessed the level of adherence to diabetic dietary regimen among diabetic patients at Federal Medical Centre, Umuahia, Abia State. The following specific objectives guided the study; to determine the socio-demographic characteristics of the respondents; determine patients' knowledge of diabetic dietary regimen; assess the level of adherence to diabetic dietary regimen among diabetic patients in Federal Medical Centre Umuahia; determine the relationship between socio-demographic and economic factors with adherence; and assess barriers that influence adherence to recommended dietary regimen among diabetic patients Federal Medical Centre Umuahia. The study was a descriptive cross-sectional study. Purposive sampling technique was used to select a total of 110 diabetic patients in FMC Umuahia. Data on socio- demographic and economic characteristics, knowledge, adherence to dietary regimen and barriers to adherence were collected using well-structured and validated questionnaire. The IBM SPSS version 22.0 computer programme was used to analyze the data. Data obtained were described using frequency and percentage. Pearson correlation was used to analyze the relationship between socio-demographic/economic characteristics, knowledge and adherence to recommended dietary regimen. Significant relationship was judged at p ≤ 0.05. Result from the study showed that more than half (58.2%) of the respondents were female. Greater percentage (47.3%) of the respondents was above 60 years of age. More than half (52.7%) of the respondents had good knowledge about the recommended dietary practices. 49.10% of the respondents adhered to the recommended dietary regimen. Among the top most cited barrier was a financial constraint (43.6%). Other barriers cited in this study includes lack of information (23.6%), lack of quality food (10.9%), taste and preference (3.6%), poor self-control (7.3%) and lack of adequate food in the household (11.0%). Also, Most (60.0%) of the respondents were pre-hypertensive while 23.6%of them were hypertensive. Additionally, some (43.6%) of the respondents were overweight while 29.0% were obese.  There was a significant positive relationship between knowledge and adherence to recommended dietary practices and a negative relationship between age, educational qualification and adherence to recommended dietary regimen. There is therefore need to review and educate diabetic patients on a regular basis in order to reinforce the information and promote adherence to dietary regimen. 


LIST OF TABLES        ix
ABSTRACT                x

1.1 Background of the Study 1
1.2 Statement Of Problem 3
1.2 Objective of Study 4
1.3 Significance of the Study 5

2.1 Concept of Diabetes Mellitus 6
2.1.1 Classification of diabetes mellitus 6
2.2 Causes of Diabetes Mellitus 7
2.2.1 Causes of type 1 diabetes 7
2.2.2 Causes of type 2 diabetes 7
2.2.3 Causes of gestational diabetes 8
2.3 Symptoms of Diabetes Mellitus 11
2.4.1 Risk factors for type 1 diabetes 11
2.4.2 Risk factors for pre-diabetes and type 2 diabetes 12
2.4.3 Risk factors for gestational diabetes 13
2.5 Complications of Diabetes 13
2.6 Management of Diabetes Mellitus 15
2.7 Dietary Management of Diabetes Mellitus 22
2.7.1 Glycemic index: A key factor in choosing food type for diabetes. 23
2.7.2 Foods for the management of diabetes mellitus in Nigeria 24
2.8 Concept of Adherence 26
2.8.1 Implications for Practice of Adherence 27

3.1 Study Design 28
3.2 Study Area 28
3.3 Population of The Study 28
3.4 Sampling and Sampling Techniques 28
3.4.1 Sample size 28
3.4.2 Sampling technique 29
3.5 Preliminary Activities 30
3.5.1 Preliminary visit 30
3.5.2 Training of research assistants 30
3.5.3 Ethical approval 30
3.6 Data Collection 30
3.6.1. Questionnaire administration 30
3.7 Anthropometric Measurement and Index 31
3.7.1 Weight measurement 31
3.7.2 Height measurement 31
3.7.3 Body mass index (BMI) 32
3.8 Statistical Analysis 33

4.1 Awareness And Knowledge Of The Respondents Towards Recommend dietary practices for diabetes Mellitus managements 34
4.2.1 Level of Adherence to Recommended Dietary Regimen by the 
Respondents 39
4.2.2 Adherence to recommended dietary practices in management of diabetes 41
4.3 Factors Affecting Adherence to Dietary Recommendations 43
4.4 Socio Demographic/Economic Characteristics of the Respondents 45
4.5 Relationship Between Socio-Demographic/Economic Characteristics, Knowledge And Adherence To Recommended Dietary Regimen 48
4.6 Health Status and Diabetes Related Characteristics of the Respondents 50

5.1 Conclusion 52
5.2 Recommendations 52


Tables Pages
4.1a: Awareness of the respondents towards recommended dietary practices for diabetes mellitus management 35

4.1b: Knowledge of recommended dietary practices necessary in management of diabetes mellitus 36

4.1c: knowledge of the respondents towards recommended dietary practices 38

4.2a: Level of adherence to recommended dietary regimen by the respondents 40

4.2b: Adherence to recommended dietary practices in management of DM (self-reported) 42

4.3: Factors that prevent adherence to dietary recommendation 44

4.4: Socio demographic/economic characteristics of the respondents 46

4.5: Relationship between socio-demographic/economic characteristics, knowledge and adherence to recommended dietary regimen 49

4.6: Health status and diabetes related Characteristics of the respondents 51


1.1. Background of the Study

Diabetes mellitus is one of the chronic diseases that require long-term therapies and daily self-management. Diabetes is one of the most rapidly increasing non communicable diseases and an important public health problem all over the world (Guariguata et al., 2014).  It is now regarded as a global epidemic and more than 230 million people worldwide are living with diabetes (Silinik, 2007). This number is expected to rise to a staggering 350 million (6.3% of the world population) within 20 years (Silinik, 2007). 

In United States, more than 13.8 million Americans have diabetes and Type 2 diabetes accounts for 90% to 95% of the diagnosed cases with 800,000 new cases reported each year (Silinik, 2007). In Australia, chronic diseases like diabetes now contribute to over 70% of the disease burden, and this is expected to increase to 80% by 2020 (Jordan & Osborne, 2006). China with its large population of 1.3 billion has 30 million diabetic adults, while India has 35.5 million (Jordan & Osborne, 2006).

The global burden of diabetes is rising dramatically worldwide and an estimated 422 million adults are currently living with diabetes mellitus (Hanson et al., 2012; WHO, 2016). As such, a previous estimate that the diabetes prevalence would increase from 171 to 276 million between 2000 and 2030 has already been exceeded. 

A more recent estimate suggests that the prevalence will reach 642 million people in 2040 (IDF, 2017). The rate at which diabetes is now increasing, especially in developing countries, and with its long and short term complications, there is urgent need for diabetic patients to adhere and maintain the American Diabetic Associations Clinical Practice recommendations of tight plasma glucose control of 80 – 120 mg/dl for fasting glucose measurement, eat as recommended, perform other self-care activities, and go for checkup as necessary (Motilch, 2005/2006). Some studies (Kolyango, 2008; Rubin & Peyrot, 2005; Dey et al., 2008) have recorded prevalence of non-adherence to various aspects of diabetes treatment. 

Diabetes is one of the chronic illnesses for which self-management plays a central role in care. Management of the disorder creates a great physical, psychological and socioeconomic burden on families and society, thus, prevention with diet and lifestyle modifications should be prioritized (Bisiriyu, 2010). Glycemic control is achieved by undertaking and sustaining a complex array of self-care behaviors, including four main domains: taking medications, sustaining appropriate dietary practice, engaging in regular exercise and self-monitoring of blood glucose levels (Lanting, 2008; Nelson, 2007). 

To optimize their health, individuals with diabetes may be advised regarding diet and exercise, frequent medical examinations, annual specialized examinations of their eyes and feet, and, for many, prescribed multiple oral or injected medications every day. Until there is a cure for diabetes, these behaviors must be sustained for a lifetime (Schechter, & Walker, 2002). Of the preferred life style modifications for diabetes management, dietary modification is considered to be one of the cornerstones of diabetes care. Appropriate dietary practices emphasizes the intake of less fat, more fiber, less sodium and more foods that have health-promoting properties such as fish, soy products, fruits and vegetable (Ekore, 2008; ADA, 2007). Improvement of dietary practice alone can reduce glycosylated hemoglobin (HbA1c) by an absolute 1 to 2% with the greatest impact at the initial stages of diabetes; and its effects are apparent after 6 to 12 weeks of initiation (Ekore, 2002). 

Patients with diabetes need nutrition recommendations that are supported by scientific evidence and that can be easily understood and translated into everyday life. To achieve positive outcomes, a coordinated team effort that provides continued education and support is essential (Franz, 2003). Adherence has been defined as the active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result (Delamater, 2007). Implicit in the concept of adherence is choice and mutuality in goal setting, treatment planning, and implementation of the regimen. Patients internalize treatment recommendations and then either adhere to these internal guidelines or do not adhere. Issues about adherence became a topic of considerable research by multidisciplinary teams beginning in the 1970s when studies showed that as many as 50% of patients diagnosed with hypertension were not taking sufficient amounts of their antihypertensive medications and that non-adherence was common particularly with long term treatments for conditions such as diabetes, asthma, hypertension and HIV/AIDS (Morisky, 2009). Regimen adherence problems are common in individuals with diabetes, making glycemic control difficult to attain. If diabetic management goals are to be achieved, all factors and circumstances that predispose or contribute to patients’ non-adherence to regimen should be part of the health care givers concern. This underscores the need to investigate the obstacles to non-adherence to diabetes dietary regimen.  

1.2 Statement of the Problem 

Diabetes is considered to be one of the most psychologically and behaviorally demanding of the chronic diseases (Delamater, 2007). It requires frequent self- care and lifestyle modifications, which principally includes dietary modifications (Morisky, 2009). Studies have emphasized the importance of achieving optimal glucose control through strict adherence to diet and exercise in order to minimize serious long-term complications. These complications affect the patient's quality of life, increase mortality, morbidity and economic cost to society. It is imperative that patients adhere to their prescribed regimens to minimize the burden of the disease on the health systems (Blanca et al., 2001). 
During my industrial training and clinical practice at Federal Medical Centre Umuahia, Abia state, I observed that some diabetic patients find it difficult to adhere to their dietary regimen.

Non-adherence in chronic diseases has been described as taking less than 80% of the prescribed treatment (Delamater, 2007). Previous studies have found adherence to diabetes treatment generally to be sub-optimal ranging from 23 to 77% (Rubin & Peyrot, 2005; Delamater, 2007; Harris, 2001). In addition, these studies have generated varied results of the factors associated with non-adherence to diabetes treatment. Most of the studies, however, were carried out in developed countries, leaving a gap in knowledge about the prevalence and factors that may be associated with adherence to diabetic treatment in Nigeria, a developing country. 

Dietary adherence has always been a problem for both diabetics and physician. Diabetics find it difficult to adhere to their diet due to poor understanding of the principles, strategies and method of diet therapy. Failure to individualize the diet to the patient's cultural, sociological and economic background also poses a problem. Patients also express strong feeling of Independence and therefore do not like to be told what to eat and what not to eat. Some feel it is too expensive to buy some foods. The level of family support can also be a problem. Deficiencies in patients' education and follow up can be a problem, poor relationship of patient and health workers can also be a problem. Diabetes is a disease that affects major organs in the body, resulting in complications that can be life threatening such as; neuropathy, erectile dysfunction, nephropathy, retinopathy, ischemic heart diseases, stroke, peripheral vascular diseases, with associated reduced life expectancy and diminished quality of life.

In view of the need to prevent or delay the development of diabetes complications, it is reasoned that diabetic patients would be empowered to manage their illness better, and there is a need to be help identify and manage factors that contribute to non-adherence to dietary regimen as compliance is a crucial component of chronic illness self-management. The obstacles associated with adherence in resource limited settings should be determined so as to lower the impact of the disease that is on the increase in the health systems, which are already overburdened with communicable diseases. Hence, the need for this study.

1.3 Objective of Study
The main objective of the study is to assess the level of adherence to diabetic dietary regimen among diabetic patients at Federal Medical Centre, Umuahia. Specific objectives were to;

i. determine the socio-demographic characteristics of the respondents;

ii. determine patients' knowledge of diabetic dietary regimen;

iii. assess the level of adherence to diabetic dietary regimen among diabetic patients in Federal Medical Centre Umuahia;

iv. determine the relationship between socio-demographic and economic factors with adherence; and

v. assess barriers that influence adherence to recommended dietary regimen among diabetic patients Federal Medical Centre Umuahia.

1.4 Significance of the Study

Identifying factors in adherence will lead to finding more efficient and effective ways of enhancing patients’ adherence. It will also help healthcare providers compare their perceived factors related to patients live experiences thus enhancing patient/provider communication and better therapeutic relationship that aids adherence.  The information from this research will be of great help to the public especially diabetic patients. It will help them know the factors associated with adherence to know how to avert them and it will also serve as a reference for further studies.

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