Diabetes Mellitus

ANSU Journal of Integrated Knowledge Vol. 3 No. 1

DIABETES MELLITUS AMONG NIGERIANS.A CHALLENGE TO PUBLIC HEALTH

OBASI STELLA CHINYELU Department of Human Kinetics

And Health Education Anambra State University, ULI&

AGBA PUONWU NOREEN EBELECHUKWU Department Of Nursing Science

Nnamdi Azikiwe University, Awka , Anambra State

AbstractDiabetes Mellitus (DM) a disorder of carbohydrate, fat and protein metabolism is characterized by high fasting sugar level above 126 mg/dl The two main types of the disorder are the insulin dependent (IDDM) or type 1 (TIDM) and the non insulin dependent (NIDDM) or type 2 (T2DM).The NIDDM is the most common form of DM affecting approximately 4% of the world's adult population. In Nigeria, the prevalence of DM was found to be in the range of 0.9 to 15% Type 2 DM is the most common type of DM accounting for about 90% of DM cases. The IDDM results from a Pancreatic deficiency in insulin production of related metabolic abnormality. However, the aetiology ofT2DM is unknown, but several studies indicated that the disease results from a combination of genetic susceptibility and external risk factors. The overall, aims of DM management is to achieve a fasting plasma glucose level of between 80 and 110 mg/dl normal weight (18-25kg), healthy diet and physical factivity. Exercise has been shown to be beneficial in the prevention and the onset of T2DM as well as decreased in intra-abdominal fat, enhanced insulin sensitivity and reduced free fatty acid level Both aerobic and resistance exercise training play important roles in the management ofT2DM and it has been shown that both forms of exercise were equally beneficial and the combination of both exercises was twice effective for improving glycaemia control. It was concluded that the major problems in DM management in Nigeria are the non availability of exercise training programme and non adherence to the prescribed lifestyle changes. It was recommended that comprehensive strategies for exercise recommendations should be

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INTRODUCTIONiabetes Mellitus (DM) is a m u l t i f a c t o r i a l a n d D heterogeneous disorder

with both genetic and environmental f a c t o r s c o n t r i b u t i n g t o i t s development (Hsieh, 2008). DM is a disorder of carbohydrate, fat and protein metabolism characterized by h i g h b l o o d s u g a r l e v e l s (Hyperglycemia) and presence of sugar hi the urine (glycosuria). It is characterized by a relative lack of or insensitivity to insulin or both (Cimbiz e t a l . , 2011) . The ch ron ic hyperglycemia of DM is associated with long-term damage, dysfunction, and failure of various organs, especially eyes, kidneys, nerves, heart and blood vessels . Therefore, diabetes leads to reducing patients' quality of life and life expectancy.The two main types of the disease are insulin-dependent diabetes mellitus (IDDM or type 1 (TIDM) and non- insulin dependent diabetes mellitus (NIDDM or type 2 [T2D]). IDDM or type 1 also referred to as juvenile onset diabetes results from a pancreatic deficiency in insulin production or related metabolic abnormalities. NIDDM or type 2 or maturity onset diabetes is usually associated with decreased cellular insulin sensitivity; Brooks. However, gestational diabetes mellitus (GDM) has also been recognized. GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Gestational diabetes complicates

2% to 5% of all pregnancies. In the majority of cases, glucose regulation will return to normal after delivery. However, women who have had gestat ional d iabetes are at increased risk of developing NIDDM later in life (Lalla and D* Ambrosio, 2001). It was estimated that in 2010 there were about 285 million people with type 2 diabetes making up about 90% of diabetes cases. Diabetese is common both in the developed and the developing world.

Diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes) is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. This is in contrast to diabetes mellitus type 1. in which there is an absolute insulin deficiency due to destruction of islet cells in the pancreas (Kumar et. al 2005) The classic symptoms are excess thirst, frequent urination, and constant hunger. Type 2 diabetes makes up about 90% of cases of diabetes with the other 10% due primarily to diabetes mellitus type 1 and gestational diabetes. Obesity is thought to be the primary cause of type 2 diabetes in people who are genetically predisposed to the disease. Type 2 diabetes is initially managed by increasing exercise and dietary modification. If blood glucose levels are not adequately lowered by


these measures, medications such as metformin or insulin may be needed. In those on insulin, there is typically the requirement to routinely check blood sugar levels. Rates of type 2 diabetes have increased markedly over the last 50 years in parallel with obesity: As of 2010 there are approximately 285 million people with the disease compared to around 30 million in 1985.(Smyth & H e r o n , 2 0 0 6 ) . L o n g - t e r m complications from high blood sugar can include heart disease, strokes, diabetic retinopathv where eyesight is affected, kidney failure which may require dialysis, and poor circulation in the limbs leading to amputations. The acu te comp l i ca t i on o f ketoacidosis. a feature of type 1 diabetes, is uncommon Fasanmade, Odeniyi,Ogbera.(2008) However, nonketotic hvperosmolar coma may occur.

T2DM or NIDDM is the most common form of diabetes, affecting approximately 4% of world's adult population. NIDDM results from the contr ibut ion of many genes i n t e r a c t i n g w i t h d i f f e r e n t environmental factors, which produce wide variation in the clinical courses. The dramatic worldwide prevalence of NIDDM over the past decades may have resulted from the relatively recent changes in diet, life style and physical activities (Hsieh et al., 2008). Traditionally considered a disease of adults, type 2 diabetes is

increasingly diagnosed in children in parallel to rising obesity rates due to alterations in dietary patterns as well as in life styles during childhood (Steinberger, Moran, Hong, Jacobs and Sinaiko, 2001.).Type 2 diabetes is a complex metabolic disorder characterized by hyperglycemia and associated with a relative deficiency of insulin secretion, along with a reduced response of target tissues to insulin (insulin resistance). Its metabolic a n d c l i n i c a l f e a t u r e s a r e heterogeneous; people with type 2 diabetes range from those of normal weight or underweight with a predominant deficiency of insulin secretion (in whom slowly evolving type 1 d iabetes should be considered) to the more common obese person; with substantial insulin resistance (Shaw and Chishohn, 2003).

Epidemiology of Diabetes MellitusGlobally in 2003 it was estimated that there were 150 million people with type 2 diabetes (Green, Hirsch and Pramming, 2003) . The incidence varies substantially in different parts of the world, almost certainly because of environmental and lifestyle factors, though these are not known in detail. It is calculated that worldwide there are about 150 million people with diabetes, and that this number will


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rise to 300 million by 2025 (Zimme, AIbeti and shaw,2001).Diabetes mellitus (DM) is a chronic metabolic disorder that is estimated to affect, 4% of the world's population. A doubling of this figure is expected in the near future, especially in the African and Asian continents (Engelgau, Narayan, Saaddine and Vinicor. 2003). Gross underreporting of DM occurs in African countries. Over a decade ago, the prevalence of DM in Nigeria w a s 2 .2 % ( A k i n k u g b e a n d Akinyanju, 1997). Isolated reports from some regions of Nigeria have found prevalence rates to range from 0.9-15% (Okeoghene, Chinenye, Onyckwerc & Fasanmade, 2007. In Nigeria, the national prevalence of DM was estimated to be 6.8% in adu l t o l de r t han 40 yea rs (Abubakaria and Bhopalb, 2008). Crude prevalence rates of 7.7 and 5.7% were, estimated for males and females in Port Harcourt, southern part of Nigeria (Nyenwe, Odia, Thekwaba, Ojule and Babatunde, 2003). A study of the prevalence of DM in Nigeria showed that T2DM is the most common type of DM accounting for about 90% of cases (Familoni, Olatunde and Raimi, 2008; 2011), Sixty two percent of persons with T2DM in the northern part of Nigeria were estimated to be hypertensive (Bello-Sani and Anumah, 2009). In 2004, heart

disease was noted on 68 percent of DM-related death among people aged 65 years or older (NIHP, 2011).

Aetiology and Risk factors for Type 2 Diabetes MellitusThe etiology of type 2 diabetes mellitus is unknown, but several studies indicate that the disease results from a combination of genetic susceptibility and external risk factors (DeFronzo and Ferrannini, 1 9 9 1 ) . A c c o r d i n g t o t h i s multifactorial model, genetically predisposed subjects will not necessarily develop overt disease unless they are also exposed to particular environmental factors. Important risk factors for the development of type 2 diabetes mellitus, apart from obesity, include a family history of diabetes, increased age, hypertension, lack of physical exercise, and ethnic background (DeFronzo and Ferrannini, 1991). Diabetes mellitus may be caused by other conditions. Secondary diabetes may occur in patients taking glucocorticoids or when patients have conditions that antagonize the actions of insulin (eg, Gushing syndrome, acromegaly). The major risk factors for T2DM are the following: Age more than 45 years (though, as noted above, type 2 diabetes mellitus is occurring with increasing frequency in young individuals) (US


National Library of Health [USNLH] and National Institute of Health [NIH], 2011) weight greater than 120% of desirable body weight (Rosenbloom et al., 1999; American Diabetes Association. Family history of type 2 diabetes in a first-degree relative (eg, parent or sibling) (USNLH and NIH, 2011) Race and Ethnicity (Hispanic, Native American, African American, Asian American, or Pacific Islander descent) (USNLH and NIH, 2011) History or previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) (USNLH and NIH, 2011). Hypertension (> 140/90 mm Hg) or dyslipidemia (high-density lipoprotein [HDL] cholesterol level < 40 mg/dL or triglyceride level >150 mg/dL). History of gestational diabetes mellitus or of delivering a baby with a birth weight of >9 Ib (USNLH and NIH, 2011) Polycystic ovarian syndrome (which results in insulin resistance) (USNLH and NIH,2011)The genetics of type 2 diabetes are complex and not completely understood. Evidence supports the involvement of multiple genes in pancreatic beta-cell failure and insulin resistance.Some forms of diabetes, however, have a clear association with genetic defects. The syndrome previously

known as Maturity Onset Diabetes of Youth (MODY) has now been reclassified as a variety of defects in beta-cell function. These defects account for 1-5% of individuals with type 2 diabetes who present at a young age and have mild disease. The trait is autosomal (chromosome other than the one that determines sex) dominant and can be screened for in commercial laboratories.

Complications of type 2Diabetes MellitusAfter many years, diabetes can lead to serious problems with the eyes, kidneys, nerves, heart, blood vessels, and other areas in the body. There is no doubt that duration and degree of hyperglycemia play a major role in the development of complications (Gale and Anderson, 2005). In general, complications include: Kidney disease and kidney failure (diabetic nephropathy) Nerve damage (diabetic neuripathy), which causes pain and numbness in the feet, as well as a number of other problems with the stomach and intestines, heart, and other body organs. Eye disease (diabetic retinopathy), Cataracts. Damage to blood vessels that supply the legs and feet (peripheral vascular disease)Foot sores or ulcers, which can result in amputation Glaucoma H i g h b l o o d p r e s s u r e H i g h cholesterol Macular edema Stroke Worsening of eyesight or even blindness Other complications


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include: Erecti le dysfunction Infections of the skin, female genital tract, and urinary tract .Abundant evidence shows that patients with type 1 diabetes or type 2 diabetes are a high r isk for several cardiovascular disorders: coronary heart disease, stroke, peripheral arterial disease, cardiomyopathy, and congestive heart failure. Cardiovascular complications are not the leading causes of diabetes-related morbidity and mortality.T2DM is the sixth-leading cause of death (Simpson et al., 2003), with m o s t d e a t h s a t t r i b u t e d t o cardiovascular disease (CVD; nearly 70%) and with ischemic heart disease being responsible for nearly 50% of these deaths. These c o m p l i c a t i o n s a r e d u e t o atherosclerotic vascular disease but also reflect a susceptibility of patients with T2DM to heart failure (Nichols et al., 2004; perhaps mediated by direct effects on the myocardium.

General Management of Type 2 Diabetes MellitusManagement of type 2 diabetes focuses on lifestyle interventions, lowering other cardiovascular risk factors, and maintaining blood glucose levels in the normal range(Ripsm) Self-monitoring of blood glucose for people with newly diagnosed type 2 diabetes was

recommended by the Brit ish National Health Service in 2008, however the benefi t of self monitoring in those not using multi-dose insulin is questionable. Managing other cardiovascular risk factors, such as hypertension, high cholesterol, and microalbuminuria, improves a person's life expectancy. I n t e n s i v e b l o o d p r e s s u r e management (less than 130/80 mmHg) as opposed to standard blood pressure management (less than 140-160/85-100 mmHg) results in a slight decrease in stroke risk but no effect on overall risk of death. (McBrien et a!2012)Intensive blood sugar lowering (HbAi

i n t e r v e n t i o n w i t h l i f e s t y l e modifications as the building block. However, the goals of diabetes managemen t a re : r e l i e f o f s ymp toms , ach ievemen t o f prescribed normal physical activity and healthy diets, achievement and/or maintenance of normal body weight (between 18-25 kg/m ), little or no glycosuria, fasting plasma glucose of 80 -110 mg/dl (Davidson, 2005).Pharmaceutical intervention for glycemic control has shown beneficial results for microvascular complications in patients with T2DM; however, whether this therapy has beneficial effects on macrovascular complications and cardiovascular events remains unclear, with recent work suggesting some benefit (Holman, Paul, Bethel, Matthews and Neil, 2008), although previous studies report conflicting results. In addition to drug therapy, diet and behavioral modification-induced weight loss has been associated with a decrease in insulin resistance.Dietary management is considered to be one of the cornerstones of diabetes care and is based on the principle of healthy eating in the context of social, cultural and psychological influences on food choices. Along with increasing levels of physical activity, it should be the first step in the management of newly diagnosed patients with type 2 diabetes. The goals of dietary management of diabetic patients are (Kaukua et al., 2003): To help achieve and maintain good

glucose, Upid, and blood pressure control; To prevent or slow the rate of d e v e l o p m e n t o f c h r o n i c complications of diabetes; To address individual nutrition needs with respect to cultural preferences and willingness to change; To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.

Exercise Management of Type 2 Diabetes MeUitusExercise has been shown to be beneficial in the prevention of the onset of type 2 diabetes mellitus as well as in the improvement of glucose control as a result of enhanced insul in sensi t iv i ty ( H e l m r i c h , R a g l a n d a n d Paffenberger, 1994). Decreased intra-abdominal fat, an increase in i n s u l i n - s e n s i t i v e g l u c o s e transporters (GLXJT-4) in muscle, enhanced blood flow to insulin-sensitive tissues, and reduced free fatty acid levels appear to be the mechanisms by which exercise restores insulin sensitivity (Erisonn, 1991).

Marwick et al. (2009) concluded that exercise training in patients with T2DM is feasible, well tolerated, and beneficial. Individual exercise prescr ipt ion offers an ideal


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opportunity to account for both c a r d i a c a n d n o n c a r d i a c considerations hi T2DM. to reduce c a r d i o v a s c u l a r r i s k , i t i s recommended that patients with T2DM accumulate a minimum of 150 minutes per week of at least moderate-intensity and/or 90 minutes per week of at least vigorous-intensity cardiorespiratory exercise. In addition, resistance training should be encouraged.ConclusionT2DM is the most common form of diabetes, affecting approximately 4% of world's adult population with prevalence range in Nigeria between 0.9-15 percent. NIDDM results from the contribution of many genes i n t e r a c t i n g w i t h d i f f e r e n t environmental factors, which produce wide variation in the clinical courses. Abundant l i terature supports the beneficial effects of diet and exercise recommendations for i m p r o v i n g a n d m a i n t a i n i n g glycaemic level for people with diagnosed type 2 diabetes mellitus. Type 2 DM is preventable by adopting a healthy diet and increasing physical activity. The management of type 2 diabetes should begin with an individualized regimen of diet, exercise, and medical counseling targeted to reduce body weight. The primary goal of this approach is to achieve and maintain ideal glycaemic

control, while secondary benefits include Weight loss and reduction in risk factors for common co-morbidities of type 2 diabetes such as hypertension and cardiovascular disease. Prescribed l i festyle changes are the cornerstones in the management of types 2 diabetes and therefore, helps in preventing a n d / o r d e l a y i n g d i a b e t i c complications by improving and maintaining glycaemic control. Hence, strategies for lifestyle changes for people with type 2 diabetes must be incorporated. Non availability of exercise training programme and non adherence to the prescribed lifestyle changes is a major problem in the management of DM in Nigeria.

RecommendationsBased on the findings, the following recommendations are made:1. Information on diet and exercise benefits on diabetes mellitus should be provided to diabetic patients and the to ta l populace. Die tary information must take into account locally available food and exercise preference must also be taken into consideration.2. Comprehensive strategies for exercise recommendations should be incorporated as part of total primary health care for people with type 2 diabetes in Nigeria.3. Healthy eating habits and gentle aerobic exercise should be


encouraged as adjunctive therapy for people with type 2 diabetes. This r e c o m m e n d a t i o n m u s t b e incorporated as part of a total diabetes care and must be adapted to individual ability, needs and limitations.4. The health educators, exercise physiologist and the physician must interpret (preferably in patient's language), for each diabetic patient, the short and long-term benefits of exercise recommendations.5. The federal and state government of Nigeria through their ministries and agencies concern should make available opportunity and avenue for exercise and related programmes and facilities for diabetes patients in geriatrics nursing homes, hospital and health institutions of learning in Nigeria.

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