COMPLIANCE TO RECOMMENDED DIETARY PRACTICES AMONG PATIENTS WITH TYPE 2 DIABETES MELLITUS ATTENDING SELECTED HOSPITALS IN NAKURU COUNTY

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TABLE         OF          CONTENTS DECLARATION        ii

DEDICATION…………………………………………………………………………………………….. iii

ACKNOWLEDGEMENT……………………………………………………………………………. iv

TABLE OF CONTENTS………………………………………………………………………………. v

LIST OF TABLES……………………………………………………………………………………… viii

LIST OF FIGURES……………………………………………………………………………………… ix

OPERATIONAL DEFINITION OF TERMS………………………………………………… x

ABBREVIATIONS AND ACRONYMS……………………………………………………….. xi

ABSTRACT……………………………………………………………………………………………….. xii

CHAPTER ONE: INTRODUCTION…………………………………………………………….. 1

CHAPTER TWO: LITERATURE REVIEW………………………………………………… 9

2DM…………………………………………………………………………………………………….. 10

2DM…………………………………………………………………………………………………….. 11

CHAPTER THREE: MATERIALS AND METHODS………………………………… 14

CHAPTER FOUR: RESULTS…………………………………………………………………….. 23

dietary practices……………………………………………………………………………………… 34

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS      38

5.1.2      Level of compliance on dietary recommendations among Type 2 DM patients 42

REFERENCES…………………………………………………………………………………………… 51

APPENDICES…………………………………………………………………………………………….. 56

Appendix 1: Informed consent form………………………………………………………………… 56

Appendix 2; Patient Questionnaire…………………………………………………………………… 58

Appendix 3; Focused group discussion (FGD) guide…………………………………………… 63

Appendix 4; Key informant interviews guide…………………………………………………….. 64

Appendix 5: Map of Nakuru County………………………………………………………………… 65

Appendix 6: Work plan………………………………………………………………………………….. 66

Appendix 7: Approval of Research Proposal, Graduate School, Kenyatta University. 67

Appendix 8: Research authorization, National Commission for Science, Technology

and Innovation……………………………………………………………………………………….. 68

Appendix 9: Authority to Conduct Research, Department of Health Services, Nakuru  County Government…………………………………………………………………………………………… 69

Appendix 10: Research Authorization, Ministry of Education, Science and

Technology, Nakuru County…………………………………………………………………….. 70

Appendix 11: Research Authorization, Ministry of Interior and Coordination of

National Government, Nakuru County………………………………………………………. 71

LIST OF TABLES

Table 4.1: Social-Demographic Characteristics of the respondents……………………….. 23

Table 4.2: Health status and diabetes related Characteristics of the respondents……. 24

Table 4.3: Level of knowledge based on a series of Questions…………………………….. 25

Table 4.4: Comparative analysis of social demographic characteristics and health status in relation to level of knowledge on recommended dietary

practices in     management of type 2 DM…………………………………………. 27

Table 4.5: Compliance to recommended dietary practices in management of type 2 DM (self-reported)……………………………………………………………………………………………………. 29

Table 4.6: Compliance to recommended dietary practices, looking at nutrients

intake…………………………………………………………………………………………… 30

Figure 4.1: Number of meals consumed in a day (meal frequency)……………………….. 31

Table 4.7: Compliance to recommended dietary practices in management of type 2 DM (self-reported)-Stratified by age……………………………………………………………………………. 32

Table 4.8: Association of Social demographic Characteristics, Health status and Level of compliance to recommended dietary practices in management

of type 2 DM………………………………………………………………………………… 32

Figure 4.2: Association between age groups and compliance to recommended

dietary practices in management of DM2………………………………………….. 33

LIST OF FIGURES

Figure1.1: Conceptual Framework on factors that influence compliance to recommended dietary practices (as modified from Contento, 2008)……………………………………… 6

Figure 4.1:  Number of meals consumed in a day (meal frequency)………………………. 31

Table 4.8: Association of Social demographic Characteristics, Health

management of type 2 DM……………………………………………………………. 32

Figure 4.2: Association between age groups and compliance to recommended

dietary practices in management of DM2………………………………………… 33

Figure 4.3: Factors that prevent compliance to recommended dietary practices in management of DM2…………………………………………………………………………………………………… 35

Figure 4.4: Factors that facilitate compliance to recommended dietary practices in management of DM2…………………………………………………………………………………………………… 36

OPERATIONAL DEFINITION OF TERMS

Compliance:Was    the    extent   to   which    patients   adopted   the recommended dietary practices in management of type 2 diabetes mellitus.
Recommended: dietary practices:Was the meal composition, meal frequency and meal timings in management of type 2 DM
Meal composition:Meal composition referred to the choice of food by groups, for instance; cereals, tubers and roots, meats and pulses, vegetables, fruits and oils, among others. It also referred to the portion sizes of each food type in household measures and in grams.
  Frequency of meals:Frequency of meals in diabetes management was considered to be the number of meals a patient should/ actually consumes in a day. Main meals and snacks were regarded as individual meals.
Meal timings:Referred to consuming meals at almost exact time in a day e.g. taking breakfast at 7, most of the days
  24    Hour    Dietary Recall:Is a structured interview aimed to capture detailed information on all foods and beverages consumed by respondent in the past 24 hours

ABBREVIATIONS AND ACRONYMS

ADAAmerican Diabetes Association
ANOVAAnalysis of Variance
BMIBody Mass Index
BPBlood Pressure
CDCCenter for Disease Control
CSOCivil Society Organizations
DKTDiabetes Knowledge Test
DMDiabetes Mellitus
FAOFood and Agriculture Organization
FBGFasting Blood Glucose
FGDFocused group Discussion
FNDFoods Nutrition and Dietetics
GAPGood, average or poor
GIGlycemic Index
IDDMInsulin Dependent Diabetes Mellitus
KIIKey Informant Interview
KU-ERCKenyatta University Ethics Review Committee
NACOSTINational Council of Science and Technology and Innovation
NIDDMNon-Insulin Dependent Diabetes Mellitus
OGTTOral Glucose Tolerance Test
RBGRandom Blood Glucose
SPSSStatistical Package for Social Sciences
SSASub Saharan Africa
Type 2 DMType two Diabetes Mellitus
UN-OHRLLS  The United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and the Small Island Developing States
WHO  World Health Organization

ABSTRACT

Type 2 Diabetes mellitus (formerly known as non-insulin-dependent or adult-onset diabetes mellitus) is a condition that results from the body’s ineffective use of insulin. Management of type 2 diabetes mellitus requires compliance to dietary regimen, lifestyle changes and drugs. The purpose of this study was to determine compliance to dietary recommendations among patients with type 2 diabetes mellitus attending selected hospitals in Nakuru County. Data was collected in 4 hospitals; 3 Sub-County Hospitals and Nakuru County Referral hospital using researcher administered questionnaires on a sample of 387 patients out of the targeted 403, which was calculated using Fisher et al as cited by Mugenda & Mugenda (2003). About 10% of the respondents were followed to their homes in order to administer a 24-hour dietary recall. Qualitative data was collected using focused group discussion (FGD) guides and key informant interviews (KII) guides on 4 FGD sites and 8 KII respondents respectively. Dietary intake data was analyzed using nutrisurvey software. The rest of the quantitative data was analyzed using Statistical Package for Social  Sciences (SPSS Version 21) computer software. Qualitative data from the key informant interviews and focused group discussions was studied and analyzed thematically using the common themes and based on objectives of the study. Mean age of the respondents was 58.5 years. Half (50.1%) of the respondents were farmers and 75.2% of the respondents had attained at least primary level education. The study recorded high level of knowledge on dietary recommendations in management of type 2 DM at 76.2%. There was a strong association between the level of knowledge on the recommended dietary practices in management of type 2 DM and level of formal education (P<0.001). Mean level of compliance to recommended dietary practices in management of type 2 DM as reported by respondents was 59.6% and using 24 hour recall it was 57.5%. The study found no association between compliance to recommended dietary practices in management of type 2 DM and sex (P=0.938), age (0.914), or level of formal education (0.779). The study accepted the null hypothesis that compliance to recommended dietary practices among patients with type 2 DM was not influenced by the level of knowledge on the recommendations (P=0.872). Respondents reported financial constraints (47%) as a major hindrance to compliance to recommended dietary practices. Some of the facilitators to compliance were adequate finances and government support to diabetes care. Other facilitators included availability of a variety of food as well as family support. Diabetes is expensive to manage and it is even more expensive with the complications that accompany prolonged undiagnosed DM or long standing poorly managed DM. There is therefore need for government of Kenya, donors and other implementing partners to come up with ways that will ease the burden of diabetes mellitus care.

CHAPTER ONE: INTRODUCTION

                    Background to the study

Diabetes mellitus is increasing rapidly. In 1980, prevalence of diabetes mellitus globally was 4.7% and has since risen to 8.5% in 2014 (WHO, 2017). Olokoba et al. (2012) estimated that the number of adults with diabetes in the world would rise from 135 million in 1995 to 300 million in the year 2025. Global mortality attributable to diabetes in 2000 was estimated at 2.9 million deaths, equivalent to 5.2% of all deaths (Roglic et al., 2005). The study also revealed that the mortalities were higher in 35–64 years old people with 6–27% of deaths attributable to diabetes. Type 2 diabetes mellitus accounts for over 90% of diabetes in Sub-Saharan Africa (Hall et al., 2011 and mortality attributable to diabetes in 2010 was 6% (Mbanya et al., 2010). Christensen et al. (2009) recorded a 4.2% prevalence of type 2 DM in Kenya; with a high prevalence being recorded in urban areas (12.2% in urban areas & 2.2% in rural areas). About 1% deaths in Kenya were attributable to diabetes (WHO, 2014).  Nakuru County had a higher prevalence of DM (6.6%) than the national prevalence (4.2%) (Mathenge et al., 2010).

Effective management of type 2 diabetes mellitus requires that patients learn and practice new and complex behaviors like blood glucose monitoring, taking medications (some self-injecting), keeping track of meal times, diet and exercise, besides dealing with their routine work, social and family life (Kapur et al., 2008). Compliance to these new practices is important. Dietary modification is one of the major aspects in management of type 2 diabetes mellitus (Ministry of Public Health and Sanitation, 2010). A patient should consume high-fiber foods, low glycemic index (GI) with caloric restrictions. This includes consuming more fruits and vegetables,

nuts and whole grains, and choosing unsaturated vegetable oil as opposed to saturated animal based fats. World Health Organization (WHO) recommends 30g fiber intake in a day for good health while higher fiber content is recommended for diabetic patients (Joshi, et.al., 1991). A diet plan for patients with type 2 DM also includes avoiding alcohol and limiting consumption of snacks that are high in fat, sugar or salt. These snacks may include potato chips, cakes, biscuits, soda and among others (American Diabetes Association, 2015). Portion sizes as well as meal times should also be observed. The diet plan is normally individualized. Management of type 2 DM also involves lifestyle modifications and adherence to medication. Delamater (2006) in his study on improving adherence noted that diabetes mellitus care regimen is complex; however, there are patients with good diabetes self-care behaviors who always manage to attain excellent glycemic control.

Compliance to recommended lifestyle changes improves glucose levels, and leads to decreased blood pressure and corrects lipid abnormalities which are factors associated with complications of diabetes (Ganiyu et al., 2013). The same study also reported 63% rate of adherence to dietary regimen. Patient’s knowledge on diabetes mellitus is vital in proper management of DM. Patients with adequate understanding and knowledge of their medication have better gycemic control (McPherson et al., 2008). However studies have shown that knowledge is not always translated into practice. A study by Saleh et al. (2012) reported high levels of nutritional knowledge on management of DM but adherence to these guidelines was very low; for instance, only a third of the respondents partially followed the rules of measuring food before eating. This study

therefore set out to determine compliance to recommended dietary practices among patients with type 2 diabetes mellitus, attending selected hospitals in Nakuru County.

                    Problem statement

Prevalence of DM in Nakuru County is 6.6% (Mathenge, et al. 2010), which is a higher prevalence than the national level 4.2% (Christensen et al. 2009). Diabetes Mellitus (DM) is a chronic disorder that is not curable. Diabetes Mellitus (DM) relies heavily on proper management which includes hypoglycemic drugs/insulin injections and lifestyle changes. Diabetes complications are common and they are the major causes of morbidity and mortality among patients with DM. Managing diabetes complications is almost triple the annual cost of managing diabetes (Bate & Jerums, 2003). Compliance to diabetic regimen (diet, exercise, drugs and other self-care) prevents/ delays the onset of diabetes complications (Bate & Jerums, 2003). Compliance to dietary recommendations also improves glucose levels, reduces obesity and leads to decreased BP and other complications of DM (Ganiyu et al., 2013). Compliance to dietary regimen in management of DM in Nigeria was 63% (Ganiyu, 2013). Patients attending hospitals in Nakuru County recorded high DM complications and frequent hospitalization attributable to poor management of DM. However there was limited literature on compliance to recommended dietary practices among patients with type 2 DM attending hospitals in Nakuru County.

                    Justification

Compliance to dietary recommendations is one of the important factors in management of type 2 DM. It improves blood glucose control, reduces incidences of hyperglycemia and hypoglycemia and other complications of DM (Ganiyu et al., 2013). Researches and literature on compliance to dietary recommendations on DM in Kenya and factors affecting compliance is limited. The study sought to establish compliance to recommended dietary practices among patients with type 2 DM. The study also helped establish factors that affect compliance.

                    Research Questions

  1. What is the level of knowledge of the recommended dietary practices in management of type 2 DM among diabetic patients attending selected hospitals in Nakuru County?
  2. What is the level of compliance to recommended dietary practices among patients with type 2 DM attending selected hospitals in Nakuru County?
  3. Which factors influence compliance to recommended dietary practices among patients with type 2 DM attending selected hospitals in Nakuru County?

                    Null Hypothesis

H0: Compliance to recommended dietary practices among patients with type 2 DM is not influenced by the level of knowledge on the dietary recommendations.

                    Objectives

                    Main Objective

To establish compliance to recommended dietary practices among patients with type 2 diabetes mellitus, attending selected hospitals in Nakuru County.

                    Specific Objectives

  1. To establish the level of knowledge of the recommended dietary practices in management of type 2 DM among diabetic patients attending selected hospitals in Nakuru County.
  2. To establish the level of compliance to recommended dietary practices among patients with type 2 DM attending selected hospitals in Nakuru County.
  3. To establish factors that influence compliance to recommended dietary practices among patients with type 2 DM attending selected hospitals in Nakuru County.