3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item An analysis of impaired fasting glucose and diabetes risk factors in Yaounde, Cameroon in 2007 for adults aged 25 years and above(2011-10-11) Kufe, Nyuyki ClementItem Investigation of the possible anti-diabetic activity of Icacina trichantha, Ananas cosmos and Uraria picta in a rat model(2011-04-08) Fatokun, Femi KayodeNatural remedies from medicinal plants are considered to be effective and safe alternative treatment for diabetes mellitus. The aim of this study was to demonstrate the hypoglycaemic and antidiabetic activity of the aqueous extract of Icacina tracantha (tuber) (fam Icacinaceae)Ananas cosmos (fam. Bromeliaceae)and Uraria picta (leaves) (fam leguminosae) on an animal model of insulin resistance, a condition which predisposes to type 2 diabetes. The plants have a long history of use as anti-diabetic agents in western Nigeria. Method: 120 male Sprague-Dawley rats were assigned into two major groups. One group was fed on normal rat chow with the other group fed on a high calorie diet for four months a period sufficient for the animals to be fed to attain insulin resistance. The animals were then randomly assigned into different groups (each containing 6 male rats). The plant crude extracts were made by weighing specific dried quantities of each plant, boiling in distilled water for about 2 hours, cooling overnight and separating solid from liquid by filtration. The solution was then poured into preweighed 250 ml beakers and allowed to dry in an oven at a temperature of 60oC. The dried, crude extracts were then weighed out and required doses prepared from the extracts. A non-treated group of animals was used as the control. The mixed dose of extract was administered at 300 mg/kg. Over a 3 week period, all the animals were orally dosed with the different doses of plant extracts daily while metformin was administered through the animals’ drinking water, blood was collected from the tail vein of each rat prior to dosing and thereafter weekly, plasma was preserved and 6 analysed for glucose, insulin, free fatty acid concentrations and calculation of HOMA values to determine insulin sensitivity. During this period, the animals were weighed weekly and food intake was measured every three days. An oral glucose tolerance test (OGTT) was performed after the dosing period and fasting, 0, 30, 60 and 120 minute blood samples were taken and assayed for glucose concentration. Animals were terminated and blood analysed. Statistical analysis: The results were tabulated as mean ± standard deviation and percentage median ± quartile range. The statistical analysis for other parameters was carried out via ANOVA (between groups) and Student’s paired T test (within groups). Only data from percentage median and quartile range was used because of the observed variation in glucose concentration between groups even at baseline values. Statistica software (StatSoft, Tulsa, OK, USA) was used for the analysis. Results: All plant extracts in the study showed differing concentration of significant difference in their effect on the plasma glucose, insulin and free fatty acid concentrations in the rat. The most significant effect was observed on the insulin concentration in the normal rat chow and high calorie diet fed animals. The plant extracts were observed to improve insulin sensitivity in most of the groups. This effect was more significant in the normal rat chow fed rats. The effect of the plant extracts on the weight, food consumed glucose and free fatty acid was minimal and in most of the groups was not significant. Conclusion: In conclusion, the results obtained suggest that the plant extracts may be used to improve insulin resistance in the management of diabetes mellitus.Item Factors influencing glycaemic control in diabetics at three community health centres in Johannesburg(2011-03-10) Timothy, Geraldine AntoinetteIntroduction: The complications associated with diabetes usually occur over a long period of time and are mainly influenced by poor glycaemic control. Diabetic complications impact on the individual, the healthcare delivery system, and also have high cost implications. A number of studies have shown the management of diabetes to be sub-optimal in primary health care settings. Barriers that impair a patients’ ability to achieve good glycaemic control can be looked at from a patient, health facility and health professional perspectives. Good glycaemic control will not only benefit the individual patient but will also have a positive financial impact on South Africa’s already overstretched healthcare budget. Methods: In this cross sectional analytical study set in three Community Health Centres (CHCs) in the Johannesburg Metropolitan Health District, 418 diabetic patients were selected. An HbA1c test was conducted for every patient and was used to classify patients into a well controlled glycaemic group (HbA1c < 7%) or a poorly controlled group (HbA1c ≥ 7%). Differences between the two groups in terms of their risk factors for poor glycaemic control were investigated. Patient related risk factors studied included, basic demographic, treatment related, clinical, behavioural and lifestyle characteristics. Healthcare professionals and facility managers were interviewed and patient records were reviewed to describe health system challenges to providing optimal care. Univariate and multivariate logistic regression models were used to determine patient related factors influencing glycaemic control. Results: Of 394 patients with a measurable outcome (HbA1c), only 62 (15.7%) had well controlled diabetes. The mean HbA1c was similar across the three CHCs studied (p=0.464). Good glycaemic control was significantly associated with unemployment, shorter duration since diabetes diagnosis, treatment with oral medication alone and normal LDL-cholesterol levels (p<0.05). On multivariate analysis significant predictors of good glycaemic control were found to be a shorter duration since diabetes diagnosis, treatment with oral medication alone, being male, and those who were unemployed. Numerous challenges to providing optimal diabetes care were reported by health professionals including high patient to staff ratios, lack of working equipment as well as a need to improve diabetes management skills. Record review revealed that only a limited number of patients (16%) had ever had HbA1c testing. Conclusions: The majority (84.2%) of patients attending the selected facilities for diabetes care had poor glycaemic control. Management of diabetes in these CHCs is suboptimal. Patients with a shorter duration of diabetes, those who were male, Black African, unemployed and treated with oral medication alone were more likely to have good glycaemic control. Although the study concludes that patient related factors are at the forefront in terms of factors influencing glycaemic control, improved strategies in all spheres can only improve diabetes management at the CHCs.Item Insulin to carbohydrate ratios with increasing carbohydrate loads(2011-01-28) Marran, Kerry JoanBackground: To reduce the risks and prevent progression of diabetic complications average blood glucose and glucose variability need to be kept as close to the non diabetic range as possible. Post prandial glucose excursions contribute significantly to average blood glucose and to glycemic variability. Dietary carbohydrate is the primary determinant of meal related blood glucose excursions. Carbohydrate counting is a method of insulin dosing that matches carbohydrate load to insulin dose using a fixed ratio. Many patients and current insulin pumps, calculate insulin delivery for meals based upon a linear carbohydrate to insulin relationship. Hypothesis: A non-linear relationship exists between the amount of carbohydrate consumed and the insulin required to cover it. Rather, an exponential increase in insulin is needed to cover an increasing load of carbohydrate. Aim: To document blood glucose exposure, as measured by AUC, in response to increasing carbohydrate loads on fixed carbohydrate to insulin ratios. Sample and Methods: 5 Type-1 diabetic adolescents and young adults on insulin pump therapy with good control were recruited. Morning basal rates and carbohydrate to insulin ratios were optimized prior to the study start. A Medtronic glucose sensor was worn by each participant for 5 days on which standardized meals of increasing carbohydrate content were consumed. After the 5 days the glucose sensors were downloaded and the glucose area under the curve was analyzed for each carbohydrate load for each participant. Results: Only subjects with 5 days of complete recordings covering the test meals were included for analysis, resulting in 5 complete analyses. Sensor failure and hypoglycaemic v episodes prior to test meals accounted for failures. Increasing carbohydrate loads on a fixed carbohydrate to insulin ratio resulted in increasing glucose area under the curve (AUC).The log (Average AUC) was linear confirming that this relationship is exponential. An Analysis of Covariance performed on the log (AUC) data confirmed a highly significant exponential relationship (p<0.0001) although no significant differences were found between the profiles of the 5 individuals. Late post prandial hypoglycaemia followed carbohydrate loads greater than 60 grams and this was often followed by rebound hyperglycaemia that lasted more than 6 hours. Conclusion: A non linear relationship exists between carbohydrates consumed and the insulin required to cover them when using premeal bolus insulin. This has implications for control of postprandial blood sugars, especially when consuming large carbohydrate loads. Because of the late post prandial hypoglycaemia that follows the larger doses of insulin used with larger amounts of carbohydrate it is not possible to simply increase the amount of the insulin bolus using an exponential formula. Further studies need to be done looking at the optimal ratios of insulin needed for increasing carbohydrate loads, the duration and type of boluses needed to cover these high carbohydrate loads and the possibility of changing the linear equation used in current insulin pumps to one that would better cover the increase in post prandial glucose load with large carbohydrate meals.Item New onset diabetes post renal transplantation(2009-02-12T11:43:48Z) Harrichund, PretisshaABSTRACT Diabetes mellitus is a major cause of morbidity and mortality and is the leading cause of end-stage renal disease worldwide. New onset diabetes post renal transplantation is associated with reduced graft function, decreased patient survival and increased risk of graft loss. The immunosuppressive regimes used and dosage of corticosteroid therapy appear to impact on the incidence of new onset diabetes post renal transplantation. The objectives of this study were: to ascertain the prevalence of new onset diabetes post transplantation; to determine the association between new onset diabetes with immunosuppressive regimens and ethnicity; and to assess outcomes in terms of morbidity and mortality. The study design consisted of a retrospective analysis of 398 patient files transplanted between 01/07/1994 and 30/06/2004. Information retrieved from the files consisted of patient demographics ( age, race, gender ), weight, date of onset of diabetes, immunosuppressive regimens used, infections, cardiovascular and overall morbidity and mortality. The diagnosis of diabetes was based on the American Diabetes Association (ADA) criteria or the requirement for anti-diabetic agents. Results obtained showed that 15.58% (62/398) of patients became diabetic. The mean time to onset of diabetes was 22.9 months ( range 1 week to 100 months ). 20.21% Black patients (p=0.100), 9.42% White, 12.5% Coloured and 12% Indian patients became diabetic. Treatment with Cyclosporine( CyA) had an incidence of diabetes of 14.44%, Tacrolimus 20.25% p = 0.228, Rapamune 11.36% and Mycophenolate Mofetil 11.97%. Infections occurred in 96.77% of diabetic patients, p = <0.0001. Cardiovascular morbidity and mortality was 11.29%, p = 0.82. Overall mortality was 79.3% in the diabetic group p = 0.237, HR 1.45. In conclusion, the incidence of new onset diabetes is significant as it confers a higher risk of infections and overall mortality. Black patients are more affected, with an increased risk for those treated with Tacrolimus.Item Service provision for diabetes and hypertension at the primary level in the Johannesburg metropolitan area(2008-10-01T12:15:08Z) Smith, Chad HamiltonExecutive Summary Non-communicable disease currently accounts for 59% of global deaths and 46% of the global burden of disease. In 2000, 38% of all male deaths and 43% of all female deaths, in South Africa, were due to non-communicable disease. Like all health systems, the South African health system is not adequately equipped to deal with these types of diseases. The burden of chronic disease will grow over time due to factors such as urbanisation and associated behaviours regarding food consumption and physical activity. The World Health Organisation has developed the Innovative Care for Chronic Conditions (ICCC) framework for resource-constrained settings. The ICCC framework is structured into three levels: macro (positive policy environment), meso (community and health care organisation) and micro (health care interactions) levels. Using diabetes and hypertension as examples of chronic disease, this research drew upon portions of this framework to examine service provision for chronic diseases in the Gauteng Province. The overall aim of the study was to document the resources available to manage chronic disease in the Gauteng Province by investigating primary health care clinics, community organisations, and provincial and district support. The objectives were to describe the following: health services offered by primary health care clinics in the city of iv Johannesburg for the management of patients with diabetes and hypertension; the role of district and provincial management in chronic disease care; and the role of community based organisations within the city of Johannesburg in promoting good health, preventing chronic illness, and providing curative and rehabilitative services. The micro level is represented by primary health care (PHC) clinics, the meso level is represented by community-based organisations (CBOs), and the macro level is represented by provincial and regional managers. This is a qualitative, cross-sectional descriptive study. The study population is PHC clinics, associated CBOs, and managers operating in Metropolitan Johannesburg, which is managed by the provincial government. One Gauteng province sub-district was selected by simple random sampling from a list of sub-districts containing at least five provincial PHC clinics. The selected sub-district was located in Soweto and the four PHC clinics and two community health centres were included in the study. Snowball sampling was used to select the CBOs after contacting the PHC clinics. Chronic disease managers at the regional and provincial level were also selected for the study. Data was collected entirely through interviews. One key respondent was selected at each site after contacting the site via telephone. The interview was in-depth and guided by a pre-determined list of questions. The issues probed included topics common to all three levels such as: challenges in chronic disease management, goals for chronic disease management, financial and human resource issues and patient information. Interviews were tape recorded, transcribed and analysed thematically. Ethics approval for the study was obtained from the University of the Witwatersrand’s Human Research Ethics Committee and authorisation to conduct the research was acquired from the Gauteng Provincial Department of Health. A total of 13 people were interviewed. At the micro level (PHC clinics), health care workers believed there was an adequate skill mix for chronic disease care but felt unsupported and understaffed. They did not feel motivated by the incentives currently offered. No health information was maintained at the clinic and all patient information was kept on cards. These cards were used to track patients’ progress, clinic attendance and compliance. The only information collected, and sent for analysis, was a patient headcount. Clinics primarily focused on curative treatment. Patients were deemed to be ‘controlled’ or ‘uncontrolled’ based on their ability to return to the clinic for monthly check-ups and consistently achieve acceptable clinical indicators such as blood pressure and/or blood glucose level. Medical doctors, the only health care workers permitted to initiate insulin therapy, are present only at the community health centres. Patients at PHC clinics must therefore receive referrals and travel to CHC to receive such treatment. PHC sisters did not express an interest in being able to begin insulin therapy, suggesting it is too dangerous and should only be performed by a medical doctor. Five CBO representatives were interviewed. Only two community-based organisations could be identified as having dealt specifically with chronic disease. Both of which focused on diabetes but were inclusive of hypertension due to the number of patients with both conditions. These organisations operated with no budget, paid staff or dedicated office space. They maintained close relationships with clinic staff and ran support groups at the clinic, many times with the help of sisters at the clinic. The other CBOs included in the study were home-based care in nature and dealt primarily with HIV/AIDS. They began treating these chronic disease patients when they realised the stigma of HIV/AIDS was ultimately affecting their outreach. In contrast to the two chronic disease CBOs, the AIDS related organisations all received government training and funding, which included stipends. It was felt that the government training did not provide enough information regarding noncommunicable chronic disease such as hypertension, and instead focused almost exclusively on HIV/AIDS. A monthly meeting was held for all Soweto-based CBOs to discuss issues and receive information from government representatives. There exist dedicated chronic disease programme managers at both regional (covering two districts) and provincial levels. Both levels support one another as they work with the PHC clinics in managing chronic disease. Managers felt free to communicate ‘upwards’ from region to province and province to the national level on an as-needed basis. With respect to PHC services, they saw their role largely as conduits. They provided guidelines to the clinics that were created at the national level and then subsequently monitored their guideline implementation by conducting random site visits. Managers felt that health care worker support was to be accomplished at the clinic level, rather than being their personal responsibility. Chronic disease services, in the study area, held the primarily focus on curative care rather than on health promotion, prevention and early diagnosis through screening. Nearly all patient education was delivered to individuals who had already developed one or more chronic conditions. Community-based organisations motivated those with chronic disease to adhere to treatment protocols, make positive lifestyle choices, and provide patients with a forum to discuss their conditions and learn from one another. They also worked with the government to implement awareness campaigns each month. These campaigns included the community and provided education to those whom had not yet developed a chronic disease. All three levels of the ICCC are functional and communicate with each other, though to varying degrees. While communication between levels is present, there exists a top-down management style where workers feel unsupported. The government is heavily involved in all three levels of chronic disease management. They train and pay PHC clinic staff and CBO workers. The government produces and disseminates all guidelines and protocols and monitor their implementation. The government accomplishes all these tasks while collecting only monthly patient headcounts from each clinic. Patients retain all clinical data and managers see no need to collect any data other than a monthly headcount from each clinic. Nurses are unable to initiate insulin therapy and are unhappy with the current incentive program. There are only two CBOs dedicated to chronic disease, all the rest focus primarily on HIV/AIDS. CBO workers do not feel there is enough training regarding chronic diseases. Each level cite various challenges to successfully managing chronic disease. These include, but are not limited to, low patient compliance, finances, lack of family support, and human resource issues. The research applied only a portion of the ICCC framework to one group of government clinics - provincial PHC clinics and CHCs. Examining a larger number of clinics and managers and applying a greater portion of the ICCC framework would be valuable further research. The following recommendations are a partial list of those generated by this research: • Increase the amount of chronic disease information presented in the mandatory government training of all CBO health care workers. • Construct a comprehensive list of all CBOs that includes: contact information, where they operate, services provided, current client addresses, etc. This will strengthen their ability to partner with one another and reduce overlap in patient care. • Educate patients better regarding how insulin works. This will decrease the usage of herbal medicines that mask health problems and lessen patients’ fear of insulin. • PHC nurses could be trained and permitted to administer and/or initiate insulin therapy. • Enable managers to realise they can affect change in clinic staff, rather than feeling this responsibility belongs solely to the clinic manager.