Comparative incidence of Type I diabetes in children aged under 15 years from South Asian and White or Other ethnic backgrounds in Leicestershire, UK, 1989 to 1998

Prospects of Aloe vera and its Bioactive Compounds in Diabetes: Critical Review

Diabetes is a significant public health issue. The global diabetes epidemic has had a tremendous impact on India, and the disease burden has increased dramatically. Diabetes is quickly increasing in prevalence, especially in Indian cities, according to data. Therefore, an ideal drug is sought that has better safety and tolerability and the most effective control of diabetes. Many effective medications come from plant sources. Natural products like onion and garlic can effectively control diabetes. In this review, we should pay attention to Aloe vera and its bioactive compounds, that with the development of traditional medicine, Aloe vera can be used to treat various diseases. Some reports have questioned the safety and efficacy of Aloe vera or its compounds, especially at different doses, and some studies have shown no side effects. In this review we also focus on benefits on human health so that Aloe vera is part of the daily diet in many countries and appears to be non-toxic, it is necessary to investigate whether aloe vera dietary supplement can be a beneficial preventive or nutritional mitigation strategy to reduce the effects of diabetes. This review focuses on Aloe vera and its biologically active compounds that play a role in the treatment or prevention of this morbid disease: diabetes, including its underlying mechanism of blood sugar lowering properties, and herbal products that have been marketed for the treatment of diabetes or the therapeutic effect of diabetes.

The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing β-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Changing epidemiology of immune-mediated inflammatory diseases in immigrants: A systematic review of population-based studies

BACKGROUND

Immune-mediated inflammatory diseases (IMIDs) are systemic diseases of multifactorial etiology that share aberrant immune responses as the common final pathway. With rising globalization, their incidence is increasing in developing countries and among immigrants. Our primary objective was to systematically review the epidemiology of IMIDs in immigrants and conduct a meta-analysis to estimate the risk of IMIDs in immigrant populations according to their origin and destination countries.

METHODS

We systematically searched five biomedical databases and reviewed population-based studies, from inception through August 2018, that reported incidence or prevalence data of inflammatory bowel disease (IBD), multiple sclerosis (MS), type 1 diabetes (T1D), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS) or psoriasis and psoriatic arthritis (PPA) among immigrants and the host population.

RESULTS

The incidence and prevalence of IMIDs among immigrants differ from host populations, and evolve over subsequent generations. The risk of IBD among immigrants approximates that in hosts, especially among South Asians, with ulcerative colitis incidence changing prior to Crohn's disease incidence. MS risk is highest in Iranian immigrants, T1D in African immigrants and SLE in African and Iraqi immigrants. Data on other IMIDs are sparse. Significant heterogeneity between the studies precluded meta-analysis.

CONCLUSION

Based on our systematic review, the epidemiology of IMIDs among immigrants varies according to native and host countries, immigrant generation, and IMID type. The rapid evolution suggests a role for non-genetic factors and gene-environment interactions. Future studies should focus on these pattern shifts, given implications of rising global burden of IMIDs and immigration.

A stochastic epigenetic Mendelian oligogenic disease model for type 1 diabetes

The incidence of type 1 diabetes (T1D) and some other complex diseases is increasing. The cause has been attributed to an undefined changing environment. We examine the role of the environment (or any changing non-genetic mechanism) in causing the rising incidence, and find much evidence against it: 1) Dizygotic twin T1D concordance is the same as siblings of patients in general; 2) If the environment is responsible for both the discordance among identical twins of patients with T1D and its rising incidence, the twin concordance rate should be rising, but it is not; 3) Migrants from high-to low-incidence countries continue to have high-incidence children; 4) TID incidence among the offspring of two T1D parents is identical to the monozygotic twin rate. On the other hand, genetic association studies of T1D have revealed strong susceptibility in the major histocompatibility complex and many optional additive genes of small effect throughout the human genome increasing T1D risk. We have, from an analysis of previously published family studies, developed a stochastic epigenetic Mendelian oligogenic (SEMO) model consistent with published observations. The model posits a few required recessive causal genes with incomplete penetrance explaining virtually all of the puzzling features of T1D, including its rising incidence and the specific low T1D incidence rates among first-degree relatives of patients. Since historic selection against any causal gene could prevent T1D, we postulate that the rising incidence is because of increasing population mixing of parents from some previously isolated populations that had selected against different causal genes.

The Role of Epigenetics in Type 1 Diabetes

PURPOSE OF REVIEW

Epigenetics is defined as mitotically heritable changes in gene expression that do not directly alter the DNA sequence. By implication, such epigenetic changes are non-genetically determined, although they can be affected by inherited genetic variation. Extensive evidence indicates that autoimmune diseases including type 1 diabetes are determined by the interaction of genetic and non-genetic factors. Much is known of the genetic causes of these diseases, but the non-genetic effects are less clear-cut. Further, it remains unclear how they interact to cause the destructive autoimmune process. This review identifies the key issues in the genetic/non-genetic interaction, examining the most recent evidence of the role of non-genetic effects in the disease process, including the impact of epigenetic effects on key pathways.

RECENT FINDINGS

Recent research indicates that these pathways likely involve immune effector cells both of the innate and adaptive immune response. Specifically, there is evidence of cell type-specific enrichment in altered DNA methylation, changes which were temporally stable and enriched at gene regulatory elements. Epigenomics remains in its infancy, and we anticipate further studies will define how the interaction of genetic and non-genetic effects induces tissue-specific destruction and enhances our ability to predict, and possibly even modify that process.

Environmental Risk Factors and Type 1 Diabetes: Past, Present, and Future

Type 1 diabetes is an autoimmune condition that results from the destruction of the insulin-producing beta cells of the pancreas. The excess morbidity and mortality resulting from its complications, coupled with its increasing incidence, emphasize the importance of better understanding the causes of this condition. Over the past several decades, a substantive amount of work has been done and, although many advances have occurred in identifying disease-susceptibility genes, there has been a lag in understanding the environmental triggers. Several putative environmental risk factors have been proposed, including infections, dietary factors, air pollution, vaccines, location of residence, family environment and stress. However, most of these factors have been inconclusive, thus supporting the need for further study into the causes of type 1 diabetes.

Ethnic differences in the incidence of type 1 diabetes in Norway: a register-based study using data from the period 2002-2009

BACKGROUND

Few studies have looked at variation in type 1 diabetes incidence between immigrant groups within a country.

OBJECTIVE

To investigate differences in incidence rates of childhood-onset type 1 diabetes between immigrant groups and ethnic Norwegians, and their contribution to the number of incident cases of type 1 diabetes in Norway.

SUBJECTS

The study includes 2221 individuals with newly onset type 1 diabetes diagnosed during 2002-2009 in children of 0-14 yr in Norway registered in the nationwide and population-based Norwegian Childhood Diabetes Registry.

METHODS

Incident cases were classified in seven groups based on country of maternal birth and three age groups. Statistics Norway provided the corresponding population sizes. Incidence rates were compared by Poisson regression.

RESULTS

The overall incidence rate was 34.0 cases per 100,000 person-years (95% CI: 32.6, 35.5). There were large variations in incidence across the immigrant groups (p < 0.001), ranging from 6.8 per 100,000 person-years (95% CI: 1.9-17.5) for South/East Asians to 26.0 cases per 100,000 person-years (95% CI: 11.9-49.3) for sub-Saharan Africans. The differences remained significant after adjusting for age and gender.

CONCLUSIONS

There are large variations in the rate of incidence of type 1 diabetes across the ethnic groups, and several immigrant groups have significantly lower incidence than ethnic Norwegians. Immigrant groups contributed ca. 5% of the total cases of type 1 diabetes and influence the overall incidence in Norway only to a small extent.

Type 1 Diabetes Among East African Immigrant and Nonimmigrant Black Youth in the U.S

Type 1 diabetes has not previously been described in East African immigrant youth in the United States. The purpose of this study was to compare East African immigrant and nonimmigrant Black youth with type 1 diabetes. Among other clinical and demographic differences, estimated prevalence of type 1 diabetes was nearly four times higher among East African youth in King County, Washington (6.20/1000, 95% confidence interval (CI) [4.49, 7.91] vs. 1.56/1000, 95% CI [1.03, 2.09]) compared to nonimmigrant Black youth. These observations are lost within the Black/African American race classification and additional work is needed to confirm and further explore these findings.

Asthma, type 1 and type 2 diabetes mellitus, and inflammatory bowel disease amongst South Asian immigrants to Canada and their children: a population-based cohort study

BACKGROUND

There is a high and rising rate of immune-mediated diseases in the Western world. Immigrants from South Asia have been reported to be at higher risk upon arrival to the West. We determined the risk of immune-mediated diseases in South Asian and other immigrants to Ontario, Canada, and their Ontario-born children.

METHODS

Population-based cohorts of patients with asthma, type 1 diabetes (T1DM), type 2 diabetes (T2DM), and inflammatory bowel disease (IBD) were derived from health administrative data. We determined the standardized incidence, and the adjusted risk of these diseases in immigrants from South Asia, immigrants from other regions, compared with non-immigrant residents of Ontario. The risk of these diseases in the Ontario-born children of immigrants were compared to the children of non-immigrants.

RESULTS

Compared to non-immigrants, adults from South Asia had higher risk of asthma (IRR 1.56, 95%CI 1.51-1.61) and T2DM (IRR 2.59, 95%CI 2.53-2.65). Adults from South Asia had lower incidence of IBD than non-immigrants (IRR 0.32, 95%CI 0.22-0.49), as did immigrants from other regions (IRR 0.29, 95%CI 0.20-0.42). Compared to non-immigrant children, the incidence of asthma (IRR 0.66, 95%CI 0.62-0.71) and IBD (IRR 0.47, 95%CI 0.33-0.67) was low amongst immigrant children from South Asia. However, the risk in Ontario-born children of South Asian immigrants relative to the children of non-immigrants was higher for asthma (IRR 1.75, 95%CI 1.69-1.81) and less attenuated for IBD (IRR 0.90, 95%CI 0.65-1.22).

CONCLUSION

Early-life environmental exposures may trigger a genetic predisposition to the development of asthma and IBD in South Asian immigrants and their Canada-born children.

Beyond genetics. Influence of dietary factors and gut microbiota on type 1 diabetes

Type 1 diabetes (T1D) is an autoimmune disease ultimately leading to destruction of insulin secreting β-cells in the pancreas. Genetic susceptibility plays an important role in T1D etiology, but even mono-zygotic twins only have a concordance rate of around 50%, underlining that other factors than purely genetic are involved in disease development. Here we review the influence of dietary and environmental factors on T1D development in humans as well as animal models. Even though data are still inconclusive, there are strong indications that gut microbiota dysbiosis plays an important role in T1D development and evidence from animal models suggests that gut microbiota manipulation might prove valuable in future prevention of T1D in genetically susceptible individuals.

DNA methylation impairs TLR9 induced Foxp3 expression by attenuating IRF-7 binding activity in fulminant type 1 diabetes

Fulminant type 1 diabetes (FT1D) is an extremely aggressive disease characterized by the abrupt onset of insulin-deficient hyperglycemia. However, the precise mechanisms underlying disease etiology almost remain unclear. As mice deficient in regulatory T cells (Tregs) are prone to the development of an FT1D-like phenotype, we thus investigated whether FT1D patients manifest Treg deficiency and explored the related mechanisms. We first noted a significant reduction for Foxp3 and CTLA4 expression levels in PBMCs of FT1D patients. IRF-7 was found to selectively bind to the Foxp3 promoter, and by which it promotes Foxp3 transcription. Therefore, ectopic IRF-7 expression significantly promoted Foxp3 and CTLA4 expression in PBMCs, while knockdown of IRF-7 manifested opposite effect. Importantly, stimulation of PBMCs with CpG ODN, a ligand for TLR9, significantly induced Foxp3 expression, demonstrating that TLR9 signaling positively regulates Treg development. However, knockdown of IRF-7 expression almost completely diminished the enhancing effect of TLR9 signaling on Foxp3 expression, suggesting that IRF-7 is a downstream molecule of TLR9 signaling and is essential for TLR9 induced Treg generation. Of interestingly note, the Foxp3 promoter in FT1D patients was hypermethylated, indicating that DNA methylation could be a causative factor responsible for the reduced Foxp3 expression in FT1D patients. Indeed, our mechanistic studies revealed that DNA methylation blocked IRF-7 binding to the Foxp3 promoter. Together, our data support the notion that environmental insults in genetic predisposed subjects trigger Foxp3 promoter hypermethylation, which then prevents IRF-7 binding to the Foxp3 promoter and impairs Treg development/functionality contributing to the pathogenesis of FT1D.

The epidemiology of type 1 diabetes in children

Type 1 diabetes is one of the most common chronic diseases of childhood and adolescence. Multiple registries have assessed its epidemiology and have noted a steady increase in incidence of the disease. This article addresses the epidemiology of type 1 diabetes in children aged 0 to 19 years, by reviewing the available, current data from both US and international registries. The prevalence and incidence data by race, ethnicity, age of onset, sex, season of onset, and temporal trends of the disease are presented. Multiple risk factors have been implicated for the increasing incidence in type 1 diabetes, and these genetic and environmental risk factors are discussed.

Being born in Sweden increases the risk for type 1 diabetes - a study of migration of children to Sweden as a natural experiment

AIM

To investigate whether the age of first exposure to a high-incidence country like Sweden determines the risk of T1DM in children with an origin in a low incidence region of the world.

METHODS

Register study in a Swedish study population in the age 6-25 years in three categories of residents with an origin in low incidence regions of T1DM (Eastern Europe, East Asia, South Asia and Latin America); 24,252 international adoptees; 47,986 immigrants and 40,971 Swedish-born with two foreign-born parents and a comparison group of 1,770,092 children with Swedish-born parents. Retrieval of a prescription of insulin during 2006 was used as an indicator of T1DM and analysed with logistic regression.

RESULTS

The odds ratios (OR) for T1DM were lower than the Swedish majority population for residents with an origin in the four low incidence regions. Being Swedish-born implied a higher risk for T1DM in the four low incidence study groups compared with the internationally adopted with an OR of 1.68 (CI 1.03-2.73).

CONCLUSIONS

Being born in Sweden increases the risk for T1DM in children with an origin in low incidence countries. This may imply that exposures in utero or very early infancy are important risk factors for T1DM.

Incidence rate trends in childhood type 1 diabetes in Yorkshire, UK 1978-2007: effects of deprivation and age at diagnosis in the South Asian and non-South Asian populations

AIMS

Incidence of Type 1 diabetes in children is increasing worldwide. Earlier studies suggest that UK south Asian immigrants develop similar rates to the overall UK population, although incidence is lower in their country of origin. This study examines incidence rate trends of childhood Type 1 diabetes in Yorkshire 1978-2007, focusing on differences between south Asians and non-south Asians.

METHODS

Data from the population-based Yorkshire Register of Diabetes in Children and Young People were used to estimate incidence (per 100,000 childhood population < 15 years per year) of Type 1 diabetes, stratified by sex, age and ethnicity validated using two name-recognition programs. Age-sex standardized rates were calculated for 1978-2007 and assessed by ethnic-group and deprivation for 1990-2007. We used Poisson regression to assess incidence trends and predict rates until 2020.

RESULTS

From 1978-2007, 3912 children were diagnosed. Overall incidence was 18.1 per 100,000 childhood population (< 15 years) per year (95% CI17.6-18.7) and increased significantly over time: 13.2 (1978-1987) to 17.3 (1988-1997) to 24.2 (1998-2007). Average annual percentage change was 2.8% (2.5-3.2). Incidence for non-south Asians (21.5; 20.7-22.4) was significantly higher than for south Asians (14.7; 12.4-17.1). Average annual percentage change increased significantly over 18 years (1990-2007) in non-south Asians (3.4%; 2.7-4.2) compared with a non-significant rise of 1.5% (-1.5 to 4.6) in south Asians. Deprivation score did not affect overall incidence.

CONCLUSIONS

Type 1 diabetes incidence rose almost uniformly for non-south Asians, but not for south Asians, contrary to previous studies. Overall rates are predicted to rise by 52% from 2007 to 2020 to 39.0 per 100,000 per year.

Prevention of type 1 diabetes

Prevention of loss of b cells in type 1 diabetes is a major goal of current research. Knowledge of the genetic susceptibility, increasing ability to predict who may be at risk, recognition of the potential clinical impact of residual insulin secretion after diagnosis, and development of new immunomodulatory agents have supported an increasing number of clinical trials to prevent b-cell loss. Interventions can be targeted at 3 stages: before the development of autoimmunity (primary prevention), after autoimmunity is recognized (secondary prevention), or after diagnosis when significant numbers of b cells remain (tertiary prevention). Thus far, several agents show promise when given shortly after diagnosis, but no interventions before diagnosis have shown benefit. Knowledge in this area has grown quickly in recent years and will continue to grow rapidly with several international collaborative efforts underway.

Environmental factors associated with childhood-onset type 1 diabetes mellitus: an exploration of the hygiene and overload hypotheses

OBJECTIVE

To assess the relationship between selected maternal and infant characteristics and risk of type 1 diabetes mellitus, specifically characteristics identified from birth records that may pertain to the hygiene or overload hypotheses.

DESIGN

Population-based case-control study.

SETTING

Washington State from 1987 to 2005.

PARTICIPANTS

All children younger than 19 years hospitalized for type 1 diabetes (International Classification of Diseases, Ninth Revision codes 250.x1 and 250.x3) identified (n=1852) from hospital discharge data and linked with their birth certificates. Controls (n=7408) were randomly selected from birth records, frequency matched on year of birth.

MAIN EXPOSURES

Maternal factors included age, race, educational attainment, marital status, use of Medicaid insurance, body mass index, prepregnancy weight, prior births, timing and adequacy of prenatal care, and cesarean delivery. Infant factors included birth weight, size for gestational age, and gestational age.

MAIN OUTCOME MEASURE

The main outcome was first hospitalization for type 1 diabetes mellitus; adjusted odds ratios were estimated for the association of selected maternal and infant characteristics with type 1 diabetes.

RESULTS

Consistent with the hygiene hypothesis, type 1 diabetes was negatively associated with having older siblings (for >or=3 siblings, odds ratio [OR], 0.56; 95% confidence interval [CI], 0.45-0.70) and with indicators of lower economic status or care access, such as an unmarried mother (OR, 0.79; 95% CI, 0.69-0.91), inadequate prenatal care (OR, 0.53; 95% CI, 0.40-0.71), or Medicaid insurance (OR, 0.67; 95% CI, 0.58-0.77). Related to the overload hypothesis, maternal body mass index of 30 or higher (OR, 1.29; 95% CI, 1.01-1.64) was associated with increased risk of diabetes.

CONCLUSION

Environmental factors related to decreased antigenic stimulation in early life and maternal obesity may be associated with type 1 diabetes.

Defining and analyzing geoepidemiology and human autoimmunity

Autoimmune diseases cumulatively affect 5-10% of the industrial world population and are a significant cause of morbidity and mortality. In recent decades rates are rising worldwide, and autoimmunity can no longer be associated solely with the more developed "Western" countries. Geoepidemiology of autoimmune diseases portrays the burden of these illnesses across various regions and ethnic populations. Furthermore, Geoepidemiology may yield important clues to the genetic and triggering environmental mechanisms of autoimmunity. In this review we compiled and discuss in depth abundant geoepidemiological data pertaining to four major autoimmune conditions, namely type-1 diabetes mellitus, multiple sclerosis, autoimmune thyroid disease, and inflammatory bowel disease. The following key results manifested in this review: 1) Ethno-geographic gradients in autoimmune disease risk are attributable to a complex interplay of genetic and environmental pressures. 2) Industrial regions, particularly Northern Europe and North America, still exhibit the highest rates for most autoimmune diseases. 3) Methods particularly useful in demonstrating the significant influence of genetic and environmental factors include comparative ethnic differences studies, migration studies, and recognition of 'hotspots'. 4) Key environmental determinants of geographical differences include diminished ultraviolet radiation exposure, Western or affluence-related lifestyle, infection exposure, environmental pollutants, nutritional factors and disease-specific precipitants (e.g., iodine exposure).

Prevention of type 1 diabetes

Prevention of loss of beta cells in type 1 diabetes is a major goal of current research. Knowledge of the genetic susceptibility, increasing ability to predict who may be at risk, recognition of the potential clinical impact of residual insulin secretion after diagnosis, and development of new immunomodulatory agents have supported an increasing number of clinical trials to prevent beta-cell loss. Interventions can be targeted at 3 stages: before the development of autoimmunity (primary prevention), after autoimmunity is recognized (secondary prevention), or after diagnosis when significant numbers of beta cells remain (tertiary prevention). Thus far, several agents show promise when given shortly after diagnosis, but no interventions before diagnosis have shown benefit. Knowledge in this area has grown quickly in recent years and will continue to grow rapidly with several international collaborative efforts underway.

Epidemiology of type 1 diabetes and what animal models teach us about the role of viruses in disease mechanisms

There is a consensus among epidemiologists that the worldwide incidence rate of type 1 diabetes has been rising in recent decades. The cause of this rise is unknown, but epidemiological studies suggest the involvement of environmental factors, and viral infections in particular. Data demonstrating a cause-and-effect relationship between microbial infections and type 1 diabetes and how viruses may cause disease in humans are currently lacking. However, new evidence from animal models supports the hypothesis that viruses induce disease via mechanisms linked with innate immune upregulation. In the BioBreeding Diabetes Resistant rat, infection with a parvovirus induces islet destruction via upregulation of the toll-like receptor 9 (TLR9) signaling pathway. Data from mouse models of diabetes implicate TLR2, TLR3, and TLR7 in the disease process. Understanding the link between environmental agents and innate immune pathways involved in early stages of diabetes may advance the design of immune interventions to prevent disease in genetically susceptible individuals.

A low incidence of Type 1 diabetes between 1977 and 2001 in south-eastern Sweden in areas with high population density and which are more deprived

AIMS

To explore how socioeconomic factors and population density may contribute to the geographical variation of incidence of Type 1 diabetes in children in south-eastern Sweden.

METHOD

All children diagnosed with Type 1 diabetes in south-eastern Sweden during 1977-2001 were defined geographically to their place of residence and were allocated x and y coordinates in the national grid. The population at risk and socioeconomic data were aggregated in 82,000 200-m squares and geocoded likewise. A socioeconomic index was calculated using a signed chi(2) method. Rural-urban gradients were defined by overlay analysis in a geographic information system.

RESULTS

The incidence during the past 25 years has been rising steadily, particularly in the last 6 years. The incidence was highest in areas with a high proportion of small families, of families with a high family income and better education, and this was found both at the time of diagnosis and at the time of birth. In the rural-urban analysis, the lowest incidence was found in the urban area with > 20,000 inhabitants, where there was also a higher frequency of deprivation.

CONCLUSIONS

Our findings indicate that geographical variations in incidence rates of Type 1 diabetes in children are associated with socioeconomic factors and population density, although other contributing factors remain to be explained.

Teaching children with diabetes about adequate dietary choices

Recent recommendations by the American Diabetes Association suggest that children with type 1 diabetes should follow the recommendations for age, sex and body size of the general population. In the case of being overweight or obese, weight-control strategies should be applied. Adherence to recommendations should be pursued by continuous nutritional education that should start at the onset of diabetes and maintained by means of nutritional counselling to the family. The second main target of nutritional intervention is to encourage a reproducible daily meal plan that can be maintained by acquiring good habits when making nutritional choices. Finally, children and parents should be taught how to count carbohydrates, which would help them manage exceptions in their daily meal plan. Specifically, nutritional recommendations for children with diabetes focus on limiting the intake of foods of animal origin (red meat, cheese, cold cuts), moderating fat intake and promoting the intake of foods that naturally contain fibre (mainly vegetables, legumes, fruit). There are two at-risk periods in the lives of children when nutritional education procedures as well as diabetes care in general are less likely to be effective: early years of life and adolescence. In the case of very young children, new behavioural-based intervention strategies to help parents improve mealtimes could be useful in teaching diabetic children to learn to follow a structured eating schedule, which is desirable for long-lasting efficacy in diabetes care. In adolescents, eating disorders and insulin misuse for weight control purposes are concrete and difficult problems to deal with. A good balance between eating for pleasure and maintaining one's health is a challenge for anyone. Appropriate nutritional education helps children with diabetes to find this balance and enjoy a better quality of life.

Parental country of birth is a major determinant of childhood type 1 diabetes in Sweden

OBJECTIVE

To test the hypothesis that the risk of childhood diabetes type 1 increases with migration from a low to a high incidence region.

METHODS

Register study of a national cohort of 783 547 children born between 1987 and 1993 who remained in Sweden in 2002, including 3225 children with childhood type 1 diabetes identified in hospital discharge data. Logistic regression analysis was used to test the hypotheses.

RESULTS

Offspring of two parents born in very low (Asia excluding Middle East and Latin America) and low (southern and eastern Europe and the Middle East) incidence regions had the lowest adjusted odds ratios (ORs) of childhood type 1 diabetes; 0.21 (0.11-0.41) and 0.37 (0.29-0.48), respectively, compared with the Swedish majority population. When one parent was born in a low incidence country and one parent was Swedish born, the adjusted ORs increased but remained lower than the Swedish majority population.

CONCLUSIONS

Parental country of birth is an important determinant of childhood type 1 in Sweden. Heritable factors seem most likely to explain this pattern.

Type 1 diabetes

Type 1 diabetes accounts for only about 5-10% of all cases of diabetes; however, its incidence continues to increase worldwide and it has serious short-term and long-term implications. The disorder has a strong genetic component, inherited mainly through the HLA complex, but the factors that trigger onset of clinical disease remain largely unknown. Management of type 1 diabetes is best undertaken in the context of a multidisciplinary health team and requires continuing attention to many aspects, including insulin administration, blood glucose monitoring, meal planning, and screening for comorbid conditions and diabetes-related complications. These complications consist of microvascular and macrovascular disease, which account for the major morbidity and mortality associated with type 1 diabetes. Newer treatment approaches have facilitated improved outcomes in terms of both glycaemic control and reduced risks for development of complications. Nonetheless, major challenges remain in the development of approaches to the prevention and management of type 1 diabetes and its complications.

Educating families from ethnic minorities in type 1 diabetes-experiences from a Danish intervention study

Ethnic minorities may constitute vulnerable groups within Western health care systems as their ability to master severe chronic diseases could be affected by barriers such as different culture and health/illness beliefs, communication problems and limited educational background. An intervention focusing on immigrant families with children with type 1 diabetes is described. The intervention included the development of adapted educational material and guidelines, and a subsequent re-education of children, adolescents and parents from 37 families. The study demonstrated that it was possible to improve health outcome. During the study, the knowledge of diabetes increased, but with considerable differences between the families. HbA(1c) also decreased significantly during the intervention, but increased during follow-up. The paper discusses possible explanations and suggestions for optimising education and calls for new projects where ethnic minorities are active participants in the development of appropriate educational programs and material.

Younger age at diagnosis of type 1 diabetes mellitus in children of immigrated families born in Italy

The aim of this study was to evaluate the age of immigrants' children at diagnosis of Type 1 diabetes (T1DM) according to their country of birth. Immigration from developing countries to a westernised area causes rapid changes in the environmental conditions, and we investigated whether the location of birth, either inside or outside Italy, is associated with age at diagnosis of diabetes. Out of a prevalent hospital-based cohort of 5718 T1DM children cared for in 2002 in 47 Italian Pediatric Diabetes Units, we recruited 195 children (M: 97) of immigrants from developing countries--119 were born in Italy and 76 outside the European Union. Children with only one immigrant parent (no. 42) were also included. Age at diagnosis of T1DM, and other variables were compared with those of Italian children. Children of immigrated families born in Italy developed T1DM at a median age of 4.0 yr (IQR 2.2-6.9), whereas those born in developing countries and that had immigrated to Italy after birth developed T1DM at a median age of 7.9 yr (IQR 5.1-10.7, p < 0.001). Among the children born in Italy, 77 had parents who were both immigrants and the children's median age at diagnosis was 3.8 yr (IQR 2.1-6.3); 42 had only one immigrant parent and, when it was the father (no. = 23), median age was even younger (2.9 yr, IQR 2.0-8.2). Ten children had immigrated in their first yr of life and their median age was 9.1 yr (IQR 5.0-10.6). The median age of the Italian children was 6.6 yr (IQR 3.6-9.5). Results show that the outbreak of T1DM is earlier in immigrants' children born in Italy than in original countries.

Etiology and outcome of childhood and adolescent diabetes mellitus in North India

The etiology of childhood onset diabetes mellitus (DM) varies between regions and races, and its long-term outcome is affected by social and economic factors. There are scant data on the etiology of childhood DM and outcome of multidisciplinary team management from developing countries. We retrospectively analyzed case records of 160 predominantly middle socio-economic group patients with onset of DM < or =18 years of age for etiology and features at presentation. In addition, we prospectively studied acute and chronic complications and metabolic control in a subset of 67 patients. Type 1 DM comprised 81%, type 2 DM 8%, and fibrocalculous pancreatic DM 9% of patients. Mean HbA1c was 8.0+/-1.5%. Retinopathy was present in 22% and nephropathy in 18% of those with DM duration > or =5 years (mean age 21.2+/-6.8 years, mean duration 10.2+/-4.6 years). The frequency of ketoacidosis and severe hypoglycemia was 5.0 and 3.3 episodes per 100 patient years. Mortality was 7% over 823 person years of follow up. We conclude that fairly good metabolic control is achievable in a middle socio-economic population in India, with the assistance of a diabetes education program. The frequency of microvascular complications is comparable to that in the literature. However, mortality remains unacceptably high.