ANSU Journal of Integrated Knowledge Vol. 3 No.

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

Abstract

Diabetes 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/dlf normal weight (18-25kg), healthy diet and physical
activity. 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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227

INTRODUCTION
iabetes Mellitus (DM) is a
multifactorial and
heterogeneous disorder
with both genetic and environmental
factors contributing to its
development (Hsieh, 2008). DM is a
disorder of carbohydrate, fat and
protein metabolism characterized by
high blood sugar levels
(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 . , 2 0 11 ) . T h e c h r o n i c
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
gestational diabetes 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

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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 &
Heron,2006). Long-term
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 acute complication of
ketoacidosis. a feature of type 1
diabetes, is uncommon Fasanmade,
Odeniyi,Ogbera.(2008) However,
nonketotic hvperosmolar coma may
occur.

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
and clinical features are
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 diabetes should be
considered) to the more common
obese person; with substantial
insulin resistance (Shaw and
Chishohn, 2003).

T2DM or NIDDM is the most

common form of diabetes, affecting
approximately 4% of world's adult
population. NIDDM results from the
co n tri b u ti o n o f ma n y g e n e s
interacting with different
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

Epidemiology of Diabetes
Mellitus
Globally 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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229

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
was 2.2% (Akinkugbe and
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
adult older than 40 years
(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 Mellitus
The 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,
1991). According to this
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

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230

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
Mellitus
After 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
High blood pressure High
cholesterol Macular edema Stroke
Worsening of eyesight or even
blindness Other complications

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include: Erectile 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 risk for several
cardiovascular disorders: coronary
heart disease, stroke, peripheral
arterial disease, cardiomyopathy,
and congestive heart failure.
Cardiovascular complications are
not the leading causes of diabetesrelated morbidity and mortality.
T2DM is the sixth-leading cause of
death (Simpson et al., 2003), with
most deaths attributed to
cardiovascular disease (CVD; nearly
70%) and with ischemic heart
disease being responsible for nearly
50% of these deaths. These
complications are due to
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 Mellitus
Management 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 British

National Health Service in 2008,
however the benefit of self
monitoring in those not using multidose insulin is questionable.
Managing other cardiovascular risk
factors, such as hypertension, high
cholesterol, and microalbuminuria,
improves a person's life expectancy.
Intensive blood pressure
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 c <6%) as
opposed to standard blood sugar
lowering (HbAjc of7-7.9%) does not
appear to change mortality. The goal
of treatment is typically an HbAic of
less than 7% or a fasting glucose of
less than 6.7 mmol/L (120 mg/dL)
however these goals may be
changed after professional clinical
consultation, taking into account
particular risks ofhypoglycemia and
life expectancy.(Vijan 2010) It is
recommended that all people with
type 2 diabetes get regular
ophthalmology examination.
Treating gum disease in those with
diabetes may result in a small
improvement in blood sugar levels.
The overall aim of diabetes
management is to achieve as near
.normal metabolic control as is
practicable through a broad based

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intervention with lifestyle

modifications as the building block.
However, the goals of diabetes
management are: relief of
symptoms, achievement of
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
development of chronic
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 MeUitus
Exercise 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 insulin sensitivity
(Helmrich, Ragland and
Paffenberger, 1994). Decreased
intra-abdominal fat, an increase in
insulin-sensitive glucose
transporters (GLXJT-4) in muscle,
enhanced blood flow to insulinsensitive 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
p r e s c r i p t i o n o ff e r s a n i d e a l

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opportunity to account for both

cardiac and noncardiac
considerations hi T2DM. to reduce
cardiovascular risk, it is
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.
Conclusion
T2DM 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
interacting with different
environmental factors, which
produce wide variation in the clinical
courses. Abundant literature
supports the beneficial effects of diet
and exercise recommendations for
improving and maintaining
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 comorbidities of type 2 diabetes such
as hypertension and cardiovascular
disease. Prescribed lifestyle
changes are the cornerstones in the
management of types 2 diabetes
and therefore, helps in preventing
and/or delaying diabetic
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.
Recommendations
Based 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 total populace. Dietary
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

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encouraged as adjunctive therapy

for people with type 2 diabetes. This
recommendation must be
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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