1.0: INTRODUCTION.

1.1 Background

Diabetes is one of the major global public health problems. According to the Centre for Diabetes and Endocrinology (CDE), the pervasiveness of diabetes is projected to increase from 420 million people in 2017 to 630 million people by 2045 (Distiller et al., 2010 ). The focus should be geared in channeling investment that aims to modify factors that are related to diet, physical activity, and weight. Diet has been proven to be the principal contributor to diseases and mortality worldwide bestowing to the Global Burden of Disease Study carried out in 188 countries (Who et al., 2003).

The subject of this research proposal is Diabetes Mellitus which is a non- communicable disease that has become a significant challenge globally (Arredondo 2013). Statistic by American diabetes association has it that in 2015, 30.3 million Americans, which is equitable to 9.4% of the population, had diabetes (William et al., 2012). The writer says that type 2 diabetes is of great concern because of its high mortality as opposed to type 1. This mandate is achieved by keeping glycaemic control as close to normal as possible. According to Global Diabetes Community UK, for healthy individuals, normal blood sugar levels are as follows between 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting and up to 7.8 mmol/L (140 mg/dL) 2 hours after eating (Inzucchi et al., 2012). The writer further notes that for people with diabetes, blood sugar level targets are as follows: Before meals: 4 to 7 mmol/L for people with type 1 or type 2 diabetes. After meals: under nine mmol/L for people with type 1 diabetes and under 8.5mmol/L for people with type 2 diabetes. According to the Global Burden of Disease, many factors contribute to the interruption of glycaemic control in people with diabetes. However, nutritional management and anti-diabetic medication are essential ways of preventing complications and monitoring prognosis.

ABSTRACT

To manage to control type 2 diabetes, one needs to factor in the significance of dietary need.  Progress has been noted in coming up with well-formulated nutritional evidence in the recent past. However, questions have been raised in regards to calorie diet for glycaemic control among hospitalized clients with type 2 diabetes. As a result of this, the paper is going to focus on providing evidence about the 1800 calorie diet nutrition as well as a diet for glycaemic control for type 2 diabetes patients. The study will produce results based on group nutritional therapy as well as identifying the difference between dietary treatment and a standard 1,800 calorie diet. Respondents with an HbAlc of 7% or higher were selected purposively, and it included adults and teens admitted to the Princess Alexandra Hospital aged 16 and above. Results show that optimal glycaemic control is necessary for the prevention of preventable complications and the progression of complications in people with diabetes.

A study conducted by national institute of health state that Foods type to be eaten by type 2 diabetic patients includes complex carbohydrates such as whole wheat, quinoa, oatmeal, fruits, vegetables, and lentils (Dyson et al., 2011). The study further states that a person with diabetes on a 1,800 calorie diet should get 45%-50% of these calories from carbohydrates. Personal interest in diabetes care, at my present institution of employment, has been the catalyst for my advocating for preventing complications of diabetes. NIH further notes that type 2 diabetes patient should consume around 45 to 60 grams of carbohydrates per meal. This study no doubt is timely since it will present new knowledge to clients and team of persons providing care while influencing policy in the care and management of clients with diabetes locally, regionally and internationally. The opportunity for conducting this research study, in diabetes, was granted by the professions of the Diabetes Master’s program of Kings College London, class of 2017- 2019

1.2 Problem statement

According to ADA diabetes was recorded to be the seventh chief cause of death in the United States in 2015 centered on the 79,535 death certificates in which diabetes was listed as the primary cause of death(Distiller et al., 2010).  ADA in a statement said that in 2015, diabetes was a cause of death in a total of 252,806 certificates. Dietary is fundamental in controlling and regulating type two diabetes. However, the notion of being placed on a monitored diet for a prolonged lifelong state like diabetes is sufficient to put many people off. Reason being it is hard to know what to eat and when to eat it as well as to maintain an optimal eating pattern. Due to this, the study is trying to focus on the effects of implementing nutritional therapy with less than 1,800 calories diet versus 1,800 standard calorie diet for glycaemic control in hospitalized clients with type two diabetes. The result from the study will serve the purpose of stipulating a clear pathway to be followed by a group of people with type 2 diabetes when it comes to proper dietary.

 

 

1.3 Objectives of the study

1.3.1 General objective

The general objective of the study is to compare the effect of low calories versus high calories diet on glycaemic control in patients with type 2 diabetes.

 

1.3.2 Specific objectives

The objectives of this study include:

• To establishing relevant knowledge on low carbs concerning nutritional therapy

 

• To identify the difference between individualized nutritional therapy and a standard 1,800 calorie diet.

 

• To assess the impact of different dietary in relational to the blood glucose level.

 

 

 

 

 

 

 

 

 

 

 

 

 

2.0: RESEARCH METHODOLOGY.

 

2.1 Study Area

The study is being carried out in The Princess Alexandra Hospital which is located in Anguilla in the Caribbean. It is a public district general hospital with a bed space of 36 and a total number of nine doctors. Regardless of its small size, the hospital delivers routine surgical and medical care with a 24hour emergency room. The hospital has a well-equipped obstetric unit.

2.2 Research Design

Data was collected through Clinical trials by searching online medical databases such as on PubMed, EMBASE and Cochrane library. Keywords used to conduct the search were: “type 2 diabetes”,“diabetes mellitus”, “and mortality”, “sudden death”; “hypoglycaemia, hypoglycaemic. The study restricted the search to randomized clinical trials (RCTs), systematic reviews and meta-analyses of RCTs.

 

2.3 Study selection

We included RCTs in comparing nutritional therapy for 1800 calories verse a glycaemic control on T2D patients aged 18 to 70 years. RCTs with a comparison control group that compost of usual care was included. Routine care includes typical diabetes dietary treatment; for instance, those that are recommended by the American Diabetes Association or carbohydrate exchange–type diets. The study excluded patients who are over the age of 70. This was mainly to reduce exposing a patient to the risk of hypoglycemia. RCTs of diabetes prevention or RCTs in populations at risk for type 2 diabetes were excluded too. RCTs that targeted multiple chronic diseases, gestational diabetes, or type 1 diabetes was also eliminated in the study.

 

2.4Statistical Analysis.

 

The sample size was selected with the aim to provide a statistical power of 80%. This will be used to distinguish a 1% difference in HbA1c values between the groups mean, 6.5% verse 7.5% with a standard deviation of 1.40%. Statistical Package for Social Science (SPSS) version 12.01 (Chicago USA) will be used to perform an analysis. The result will be expressed as mean and standard deviation (SD). Students paired t-test and at least one-sample t-test will be used on data analysis. Statistical significance will be set at p<0.05.

 

2.4Research Significance

The subject matter of this research study is of importance to the Princess Alexandra Hospital which needs addressing and was identified by stakeholders of the hospital as such. An observation was made that there is a lack of glycaemic control despite medical intervention in hospitalized clients with diabetes particularly type 2 which make up more than 90% of all diabetes cases admitted to the hospital.  This is evident by glucometer test done at various times, pre meals and post meals, audited for the period January to December 2015 – 2018, are never healthy or near normal. Hyperglycaemia is very prevalent among hospitalized clients with type 2 diabetes.  This prompted other observations of:

 

• a standard calorie diet which may be considered large meals for all clients with diabetes

 

• a frequent serving of meals as evident by three main meals and three snacks in between meals (appendix 1)

 

A stakeholders meeting was held on 9^th January 2019, comprising of heads of departments including representation from the nutrition department, pharmacy, nursing department, and specialist physician. The main agenda was to discuss the problems associated with Hyperglycaemia. The nutritionist lamented the fact that there is no policy to guide nutritional therapy. Therefore, an 1800 calorie diet adopted by the American Diabetes Association is used for all patients with diabetes. The audience agreed that roles had to be defined and enacted to obtain better outcomes of the hospitalized clients.  Therefore, the response to writing this diabetes proposal for the hospital was received with approval and encouragement.

 

 

2.5 Validity and Ethical Consideration

A research study requires validity through approval granted by authentic source, therefore, to meet the validity needs, the research committee of Anguilla was contacted in November 2018 informing them of the intended research proposal and possible future research.  Considering the study will involve patients in the clinical setting, a medical ethical committee shall be approached as well as the hospital administration to grant ethical approval for the study.  These necessary measures are also crucial so that the results can be published for the benefit of reaching even larger populations who may have a similar need to use these findings.

 

2.6 Time Events of Study

Period: 2019 (January to December)              Activities

0-3 months (January to March) Stakeholder orientation, the establishment of protocols and training

3-4 months (March to April)                           Pilot test of the proposed system

5-11 months (May to November)                   Data entry and analyses of observations made about meals served and glucose level

12 month (December)                                     Preparation and submission of finding

3.0 Strengths and Limitations

3.1Strengths

The strengths of this study include the following:

• It is easier to secure ethical approval for small studies
• The research can be done within the time frame, as well as data collection analysis and reporting.
• The research monitors would not become overwhelmed, and funding becomes less of a challenge

3.2 Limitations

Ideally, a study with a small sample should also be done in other similar centers; however, geographically it is not possible since there is only one hospital on the island.

4.0 Reference

 

Arredondo A (February 2013) Am J Public Health. Diabetes: A Global Challenge With High Economic Burden for Public Health Systems and Society. 103(2): e1-e2 retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3558753/  January 16, 2019

Distiller, L. A., Brown, M. A., Joffe, B. I., & Kramer, B. D. (2010). Striving for the impossible dream: a community‐based multi‐practice collaborative model of diabetes management. Diabetic Medicine, 27(2), 197-202.

Dyson, P. A., Kelly, T., Deakin, T., Duncan, A., Frost, G., Harrison, Z., …& Oliver, L. (2011). Diabetes UK evidence‐based nutrition guidelines for the prevention and management of diabetes. Diabetic Medicine, 28(11), 1282-1288.

Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., …& Matthews, D. R. (2012). Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55(6), 1577-1596.

Morris S. F &Rosett J.W.  Clinical Diabetes (Jan 2010).  Medical Nutrition Therapy: A Key to Diabetes Management and Prevention.  Retrieved from: http://clinical.diabetesjournals.org/content/28/1/12January 16 2019

Who, J., & Consultation, F. E. (2003). Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser, 916(i-viii).

William H.H. & Paul Z (May 2012) American Diabetes Association. Type 2 Diabetes: An Epidemic Requiring Global Attention and Urgent Action. Retrieved from:http://care.diabetesjournals.org/content/35/5/943   January 16, 2019

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix 1

 

Princess Alexandra Hospital Standard Diet Schedule

 

Standard Diets: Normal Diet

Description /Indication of the Diet

This diet is indicated for persons who do not require any modification of the menu. Regularly scheduled meals are planned according to the daily food guide to provide the nutrients needed by the average healthy adult (see appendix a). The diet should be well balanced and appealing in color, texture, and flavor to stimulate the appetite; as well as high in fiber and low in fat.

 

Caloric distribution

This section contains the total energy (caloric) needed for the diet daily.It also identifies the number of nutrients supplying power,and food portions required to form each of the six food groups.

Food	Amount	Exchange	Carbohydrate 55%=316g	Protein 15%=87g	Fat 30%=77g	Calories 2300Keal
Milk	2 cups	4	24	16	16	304
Fruits	Varies	3	30	–	–	120
Vegetable	1 cup	2	14	4	–	72
Legumes	½ cup	1	14	4	–	72
Sugar	12tsp	12	60	–	–	240
Staples cereals/provision	Varies	10	150	20	–	680
Meat	6oz.	6	–	42	30	438
Fats/oil	6tsp	6	–	–	30	270
Total						2196

 

Meal plan
A suggested distribution of the total daily food intake into meal types and times served. A list of foods allowed or forbidden may also be given depending on the kind of diet.

Main Meals	Snack
Breakfast	Midmorning
Lunch	Mid-afternoon
Supper	Night

 

 

Standard Diets: Low Sodium

 

Description /Indication of the diet

The level of sodium restriction needed in the menu to enhance the effectiveness of antihypertensive medication is a mild restriction of 2g sodium. Hence; terms such as low salt, salt-free or low sodium used to order diets it will be considered as 2g sodium-restricted diet. Salt substitutes will not be used since it may be contraindicated in renal compilations .restricting sodium in the diet help loss of body water by reducing the sodium content in body tissues this may be requester in, congestive heart failure, hypertension, renal disease. The diet may be frequently accompanied by a high or low potassium diet prescription (see appendix B)

 

Caloric Distribution

food groups.

Food	Amount	Exchange	Carbohydrate 55%=316g	Protein 15%=87g	Fat 30%=77g	Calories 2300Keal
Milk	2 cups	4	24	16	16	304
Fruits	Varies	3	30	–	–	120
Vegetable	1 cup	2	14	4	–	72
Legumes	½ cup	1	14	4	–	72
Sugar	12 Tsp	12	60	–	–	240
Staples cereals/provision	Varies	10	150	20	–	680
Meat	6oz.	6	–	42	30	438
Fats/oil	6tsp	6	–	–	30	270
Total						2276

 

 

Meal plan
A suggested distribution of the total daily food intake into meal types and times served. A list of foods allowed or forbidden may also be given depending on the kind of diet.

Main Meals	Snack
Breakfast	Midmorning
Lunch	Mid-afternoon
Supper	Night

 

Standard Diet: Diabetic

 

Description /Indication of the Diet

The diabetic diet is a nutritionally balanced diet which aims to maintain the patient at a desirable weight and keep blood sugar within reasonable limits; using methods such as restriction of concerted sweet, decrease in fat intake increase in complex carbohydrates and fiber, regularity and consistency in timing of meals daily.

 

Caloric Distribution

food groups.

Food	Amount	Exchange	Carbohydrate 55%=247.5g	Protein 15%=67.5g	Fat 30%=60g	Calories 1800Keal
Milk	2 cups	4	24	16	8	224
Fruits	Varies	3	30	–	–	120
Vegetable	1 cup	2	14	4	–	72
Legumes	½ cup	1	14	4	–	72
Sugar				–	–
Staples cereals/provision	Varies	10	150	20	–	680
Meat	6oz.	6	–	42	30	438
Fats/oil	4tsp	4	–	–	20	180
Total						1786

 

 

Meal plan

Main Meals	Snack
Breakfast	Midmorning
Lunch	Mid-afternoon
Supper	Night

 

 
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