Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes?

Type 1 diabetes mellitus in the context of high levels of rural deprivation: differences in demographic and anthropometric characteristics between urban and rural cases in NW Ethiopia

Background

While there is increasing evidence for an altered clinical phenotype of Type 1 diabetes in several low-and middle-income countries, little is known about urban-rural differences and how the greater poverty of rural environments may alter the pattern of disease.

Objective

Investigation of urban-rural differences in demographic and anthropometric characteristics of type 1 diabetes in a resource-poor setting.

Research design and methods

Analysis of a unique case register, comprising all patients (rural and urban) presenting with Type 1 diabetes over a 20 yr. period in a poor, geographically defined area in northwest Ethiopia. The records included age, sex, place of residence, together with height and weight at the clinical onset.

Results

A total of 1682 new cases of Type 1 diabetes were registered with a mean age of onset of 31.2 (SD 13.4) yr. The patients were thin with 1/3 presenting with a body mass index (BMI) <17kg/m2. There was a striking male predominance of cases when clinical onset was between 20 and 35 yr., this was more marked in the very poor rural dwellers compared to the urban population. While most patients with Type 1 diabetes presented with low BMIs and reduced height, stunting preferentially affected rural men.

Conclusions

These data have led to the hypothesis that complex interactions among poor socioeconomic conditions in early life affect both pancreatic function and the development of autoimmunity and provide a possible explanation of the unusual phenotype of Type 1 diabetes in this very poor community.

Incidence, prevalence, and mortality of type 1 diabetes in children and youth in Burkina Faso 2013-2022

AIM

There are no data on type 1 diabetes (T1D) incidence and prevalence in Burkina Faso. We aimed to determine these in persons aged <25 years (y) since the implementation of Life for a Child (LFAC) program in 2013.

PATIENTS AND METHODS

Data were collected from the prospective program register. Diagnosis of T1D was clinical, based on presentation, abrupt onset of symptomatic hyperglycemia, need for insulin replacement therapy from diagnosis, and no suggestion of other diabetes types.

RESULTS

We diagnosed 312 cases of T1D <25y in 2013-2022. Male-to-female ratio was 1:1. T1D incidence <25y per 100,000 population/year increased from 0.08 (CI 95% 0.07-0.60) in 2013 to 0.34 (CI 95% 0.26-0.45) in 2022 (p=0.002). Incidence <15y/y rose from 0.04 (CI 95% 0.01-0.10) to 0.27 (CI 95% 0.18-0.38) per 100,000/year in 2013 and 2022, respectively (p < 0.002). Prevalence per 100,000 population <25y was 0.27 (CI 95% 0.19-0.37) in 2013 and rose to 1.76 (CI 95% 1.546-1.99) in 2022 (p<0.0001). Mortality rate was 20 (CI 95% 13-29.6) per 1,000-person y.

CONCLUSIONS

There is a low but sharply rising T1D incidence and prevalence rates in children and youth in Burkina Faso since LFAC program implementation. It is very likely this is partly due to improved case detection. Mortality remains substantial.

The phenotype of type 1 diabetes in sub-Saharan Africa

The phenotype of type 1 diabetes in Africa, especially sub-Saharan Africa, is poorly understood. Most previously conducted studies have suggested that type 1 diabetes may have a different phenotype from the classical form of the disease described in western literature. Making an accurate diagnosis of type 1 diabetes in Africa is challenging, given the predominance of atypical diabetes forms and limited resources. The peak age of onset of type 1 diabetes in sub-Saharan Africa seems to occur after 18-20 years. Multiple studies have reported lower rates of islet autoantibodies ranging from 20 to 60% amongst people with type 1 diabetes in African populations, lower than that reported in other populations. Some studies have reported much higher levels of retained endogenous insulin secretion than in type 1 diabetes elsewhere, with lower rates of type 1 diabetes genetic susceptibility and HLA haplotypes. The HLA DR3 appears to be the most predominant HLA haplotype amongst people with type 1 diabetes in sub-Saharan Africa than the HLA DR4 haplotype. Some type 1 diabetes studies in sub-Saharan Africa have been limited by small sample sizes and diverse methods employed. Robust studies close to diabetes onset are sparse. Large prospective studies with well-standardized methodologies in people at or close to diabetes diagnosis in different population groups will be paramount to provide further insight into the phenotype of type 1 diabetes in sub-Saharan Africa.

Current Knowledge on the Pathophysiology of Lean/Normal-Weight Type 2 Diabetes

Since early times, being overweight and obesity have been associated with impaired glucose metabolism and type 2 diabetes (T2D). Similarly, a less frequent adult-onset diabetes in low body mass index (BMI) people has been known for many decades. This form is mainly found in developing countries, whereby the largest increase in diabetes incidence is expected in coming years. The number of non-obese patients with T2D is also on the rise among non-white ethnic minorities living in high-income Western countries due to growing migratory flows. A great deal of energy has been spent on understanding the mechanisms that bind obesity to T2D. Conversely, the pathophysiologic features and factors driving the risk of T2D development in non-obese people are still much debated. To reduce the global burden of diabetes, we need to understand why not all obese people develop T2D and not all those with T2D are obese. Moreover, through both an effective prevention and the implementation of an individualized clinical management in all people with diabetes, it is hoped that this will help to reduce this global burden. The purpose of this review is to take stock of current knowledge about the pathophysiology of diabetes not associated to obesity and to highlight which aspects are worthy of future studies.

Perceived social supports and associated factors among diabetes mellitus patients

Purpose

The aim of this study was to assess the Perceived Social Supports and Associated Factors Among Diabetes Mellitus Patients.

Methods and materials

A facility-based cross-sectional study on 399 randomly selected adult diabetes patients was conducted at JUMC with data collection between August and September 2021.The data was collected using diabetic social support tool through face-to-face interviews and document review checklist. Logistic regression was used to determine factors associated with perceived social support in diabetes patients.

Result

Two hundred nineteen (54.9%) out of 399 diabetes patients reported a good level of perceived social support. Informational support was the most reported (55.4%), followed by emotional support (52.9%), companionship support (52.9%), and instrumental or tangible support (48.8%). Having a family history of diabetes (AOR = 1.90, CI: 1.09, 3.51) and presence of chronic comorbidities (AOR = 2.01; CI: 1.08, 3.75) were positively associated with social support. Whereas unemployment (AOR = 0.09, CI: 0.02, 0.38) was negatively associated with social support.

Conclusion and recommendations

One of every two diabetes patients got adequate level of social support. Health care system, along with other stakeholders could strengthen social support in line with diabetes patients' lifestyle.

Global incidence, prevalence, and mortality of type 1 diabetes in 2021 with projection to 2040: a modelling study

BACKGROUND

Accurate data on type 1 diabetes prevalence, incidence, associated mortality and life expectancy are crucial to inform public health policy, but these data are scarce. We therefore developed a model based on available data to estimate these values for 201 countries for the year 2021 and estimate the projected prevalent cases in 2040.

METHODS

We fitted a discrete-time illness-death model (Markov model) to data on type 1 diabetes incidence and type 1 diabetes-associated mortality to produce type 1 diabetes prevalence, incidence, associated mortality and life expectancy in all countries. Type 1 diabetes incidence and mortality data were available from 97 and 37 countries respectively. Diagnosis rates were estimated using data from an expert survey. Mortality was modelled using random-forest regression of published type 1 diabetes mortality data, and life expectancy was calculated accordingly using life tables. Estimates were validated against observed prevalence data for 15 countries. We also estimated missing prevalence (the number of additional people who would be alive with type 1 diabetes if their mortality matched general population rates).

FINDINGS

In 2021, there were about 8·4 (95% uncertainty interval 8·1-8·8) million individuals worldwide with type 1 diabetes: of these 1·5 million (18%) were younger than 20 years, 5·4 million (64%) were aged 20-59 years, and 1·6 million (19%) were aged 60 years or older. In that year there were 0·5 million new cases diagnosed (median age of onset 39 years), about 35 000 non-diagnosed individuals died within 12 months of symptomatic onset. One fifth (1·8 million) of individuals with type 1 diabetes were in low-income and lower-middle-income countries. Remaining life expectancy of a 10-year-old diagnosed with type 1 diabetes in 2021 ranged from a mean of 13 years in low-income countries to 65 years in high-income countries. Missing prevalent cases in 2021 were estimated at 3·7 million. In 2040, we predict an increase in prevalent cases to 13·5-17·4 million (60-107% higher than in 2021) with the largest relative increase versus 2021 in low-income and lower-middle-income countries.

INTERPRETATION

The burden of type 1 diabetes in 2021 is vast and is expected to increase rapidly, especially in resource-limited countries. Most incident and prevalent cases are adults. The substantial missing prevalence highlights the premature mortality of type 1 diabetes and an opportunity to save and extend lives of people with type 1 diabetes. Our new model, which will be made publicly available as the Type 1 Diabetes Index model, will be an important tool to support health delivery, advocacy, and funding decisions for type 1 diabetes.

FUNDING

JDRF International.

An Atypical Form of Diabetes Among Individuals With Low BMI

OBJECTIVE

Diabetes among individuals with low BMI (<19 kg/m2) has been recognized for >60 years as a prevalent entity in low- and middle-income countries (LMICs) and was formally classified as "malnutrition-related diabetes mellitus" by the World Health Organization (WHO) in 1985. Since the WHO withdrew this category in 1999, our objective was to define the metabolic characteristics of these individuals to establish that this is a distinct form of diabetes.

RESEARCH DESIGN AND METHODS

State-of-the-art metabolic studies were used to characterize Indian individuals with "low BMI diabetes" (LD) in whom all known forms of diabetes were excluded by immunogenetic analysis. They were compared with demographically matched groups: a group with type 1 diabetes (T1D), a group with type 2 diabetes (T2D), and a group without diabetes. Insulin secretion was assessed by C-peptide deconvolution. Hepatic and peripheral insulin sensitivity were analyzed with stepped hyperinsulinemic-euglycemic pancreatic clamp studies. Hepatic and myocellular lipid contents were assessed with 1H-nuclear magnetic resonance spectroscopy.

RESULTS

The total insulin secretory response was lower in the LD group in comparison with the lean group without diabetes and the T2D group. Endogenous glucose production was significantly lower in the LD group than the T2D group (mean ± SEM 0.50 ± 0.1 vs. 0.84 ± 0.1 mg/kg · min, respectively; P < 0.05). Glucose uptake was significantly higher in the LD group in comparison with the T2D group (10.1 ± 0.7 vs. 4.2 ± 0.5 mg/kg · min; P < 0.001). Visceral adipose tissue and hepatocellular lipids were significantly lower in LD than in T2D.

CONCLUSIONS

These studies are the first to demonstrate that LD individuals in LMICs have a unique metabolic profile, suggesting that this is a distinct entity that warrants further investigation.

The Incidence of Adult-Onset Type 1 Diabetes: A Systematic Review From 32 Countries and Regions

BACKGROUND

The epidemiology of adult-onset type 1 diabetes (T1D) incidence is not well-characterized due to the historic focus on T1D as a childhood-onset disease.

PURPOSE

We assess the incidence of adult-onset (≥20 years) T1D, by country, from available data.

DATA SOURCES

A systematic review of MEDLINE, Embase, and the gray literature, through 11 May 2021, was undertaken.

STUDY SELECTION

We included all population-based studies reporting on adult-onset T1D incidence and published from 1990 onward in English.

DATA EXTRACTION

With the search we identified 1,374 references of which 46 were included for data extraction. Estimates of annual T1D incidence were allocated into broad age categories (20-39, 40-59, ≥60, or ≥20 years) as appropriate.

DATA SYNTHESIS

Overall, we observed the following patterns: 1) there is a paucity of data, particularly in low- and middle-income countries; 2) the incidence of adult-onset T1D is lowest in Asian and highest in Nordic countries; 3) adult-onset T1D is higher in men versus women; 4) it is unclear whether adult-onset T1D incidence declines with increasing age; and 5) it is unclear whether incidence of adult-onset T1D has changed over time.

LIMITATIONS

Results are generalizable to high-income countries, and misclassification of diabetes type cannot be ruled out.

CONCLUSIONS

From available data, this systematic review suggests that the incidence of T1D in adulthood is substantial and highlights the pressing need to better distinguish T1D from T2D in adults so that we may better assess and respond to the true burden of T1D in adults.

Maternal low protein diet and fetal programming of lean type 2 diabetes

Maternal nutrition is found to be the key factor that determines fetal health in utero and metabolic health during adulthood. Metabolic diseases have been primarily attributed to impaired maternal nutrition during pregnancy, and impaired nutrition has been an immense issue across the globe. In recent years, type 2 diabetes (T2D) has reached epidemic proportion and is a severe public health problem in many countries. Although plenty of research has already been conducted to tackle T2D which is associated with obesity, little is known regarding the etiology and pathophysiology of lean T2D, a variant of T2D. Recent studies have focused on the effects of epigenetic variation on the contribution of in utero origins of lean T2D, although other mechanisms might also contribute to the pathology. Observational studies in humans and experiments in animals strongly suggest an association between maternal low protein diet and lean T2D phenotype. In addition, clear sex-specific disease prevalence was observed in different studies. Consequently, more research is essential for the understanding of the etiology and pathophysiology of lean T2D, which might help to develop better disease prevention and treatment strategies. This review examines the role of protein insufficiency in the maternal diet as the central driver of the developmental programming of lean T2D.

Global estimates of incidence of type 1 diabetes in children and adolescents: Results from the International Diabetes Federation Atlas, 10th edition

BACKGROUND

Type 1 diabetes (T1D) incidence in children and adolescents varies widely, and is increasing in many nations. The 10th edition of the International Diabetes Federation Atlas estimated incident cases in 2021 for 215 countries/territories ("countries").

METHODS

Studies on T1D incidence for young people aged 0-19 years were sourced and graded using previously described methods. For countries without studies, data were extrapolated from similar nearby countries.

RESULTS

An estimated 108,300 children under 15 years will be diagnosed in 2021, a number rising to 149,500 when the age range extends to under 20 years. The ratio of incidence in 15-19 years compared to those aged 0-14 years was particularly high in some countries in sub-Saharan Africa, North Africa/Middle East, and in Mexico. Only 97 countries have their own incidence data, with extrapolation required for some very populous nations. Most data published were not recent, with 27 countries (28%) having data in which the last study year was 2015 or afterwards, and 26 (27%) having no data after 1999.

CONCLUSIONS

Many countries have recent data but there are large gaps globally. Such data are critical for allocation of resources, teaching, training, and advocacy. All countries are encouraged to collect and publish current data.

High incidence of type 1 diabetes in adolescents and young adults in Eritrea

BACKGROUND

Eritrea has no data on type 1 diabetes incidence in children and youth; therefore, a study was undertaken to determine this in persons aged <25 years.

METHODS

Data were collected on new type 1 diabetes diagnoses during 2019, from district, provincial and national hospitals. Type 1 diabetes was diagnosed according to standard WHO criteria. No secondary ascertainment source was available. 95% confidence intervals were computed based on approximation to the Poisson distribution, and age and gender effects were analysed with Poisson regression.

RESULTS

There were 532 new cases of type 1 diabetes. Mean ± standard deviation (range) age of diagnosis was 16.2 ± 5.7 (1.5-24.9) years, and peak age group was 15-19 years (n = 200, 37.6%), with mode at 18 years. Incidence <15 years was 11.5/100,000 individuals [9.9-13.2], with the highest incidence in the 10-14 years group (19.0/100,000 [15.5-23.1]). Incidence then peaked in the 15-19 years age group (50.2/100,000 [43.5-57.7]) and remained high in the 20-24 years group (46.2/100,000 [39.0-54.3]). There was a male:female ratio of 1.37 (p = 0.001). Two hundred and thirty-eight (44.7%) presented in diabetic ketoacidosis.

CONCLUSION

Type 1 diabetes incidence in Eritrea is moderate <15 years, and high 15-24 years. The 15-19 and 20-24 years rates appear to be the highest published to date. Given the study was only for one year, further confirmatory prospective information will clarify the situation and document trends. Assessment of the type 1 diabetes phenotypes that are occurring in Eritrea is also indicated.

Rapid increases in observed incidence and prevalence of Type 1 diabetes in children and youth in Mali, 2007-2016

AIMS

Determine incidence, prevalence and mortality of Type 1 diabetes (T1D) in children and youth <25 years (y) in Mali during the first 10 years of the Santé Diabète/Life for a Child program.

METHODS

Data were collected from the prospective program register. Diagnosis of T1D was clinical, based on presentation, clinical features, immediate requirement for insulin, and no suggestion of other diabetes types.

RESULTS

Total of 460 cases were diagnosed with T1D <25 years in 2007-2016. Male-to-female ratio was 1.04:1. Peak age at onset was 15-16 years (range 1.1-24 years). T1D incidence <25 years per 100,000 population/year increased from 0.12 in 2007 to 0.74 in 2016 (an 18% annualized increase, p < 0.001). Incidence peaked at 0.80 in 2014, the year after an education campaign was conducted. Incidence <15 years rose from 0.12 to 0.35 per 100,000/year in 2007 and 2016, respectively, (14% annualized increase, p < 0.001). There was a steep, consistent increase in prevalence (per 100,000) from 0.43 in 2007 to 2.90 in 2016 (p < 0.001). Prevalence <15 years was 0.34/100,000 in 2007 and 1.02/100,000 by 2016 (p < 0.001). Overall crude mortality rate was 30.0/1000 patient years, equating to a standardized mortality rate of 9.0, with vital status known for 99.8% of cases.

CONCLUSION

Known incidence and prevalence of diabetes in Mali increased rapidly from 2007 to 2016, contemporaneous with the introduction and development of the Santé Diabète/Life for a Child program. Improved diagnosis and care resulting in lower mortality are likely contributors. True incidence may still be underestimated, with some cases still dying undiagnosed and full study ascertainment being uncertain.

Type 1 diabetes in Africa: an immunogenetic study in the Amhara of North-West Ethiopia

AIMS/HYPOTHESIS

We aimed to characterise the immunogenic background of insulin-dependent diabetes in a resource-poor rural African community. The study was initiated because reports of low autoantibody prevalence and phenotypic differences from European-origin cases with type 1 diabetes have raised doubts as to the role of autoimmunity in this and similar populations.

METHODS

A study of consecutive, unselected cases of recently diagnosed, insulin-dependent diabetes (n = 236, ≤35 years) and control participants (n = 200) was carried out in the ethnic Amhara of rural North-West Ethiopia. We assessed their demographic and socioeconomic characteristics, and measured non-fasting C-peptide, diabetes-associated autoantibodies and HLA-DRB1 alleles. Leveraging genome-wide genotyping, we performed both a principal component analysis and, given the relatively modest sample size, a provisional genome-wide association study. Type 1 diabetes genetic risk scores were calculated to compare their genetic background with known European type 1 diabetes determinants.

RESULTS

Patients presented with stunted growth and low BMI, and were insulin sensitive; only 15.3% had diabetes onset at ≤15 years. C-peptide levels were low but not absent. With clinical diabetes onset at ≤15, 16-25 and 26-35 years, 86.1%, 59.7% and 50.0% were autoantibody positive, respectively. Most had autoantibodies to GAD (GADA) as a single antibody; the prevalence of positivity for autoantibodies to IA-2 (IA-2A) and ZnT8 (ZnT8A) was low in all age groups. Principal component analysis showed that the Amhara genomes were distinct from modern European and other African genomes. HLA-DRB1*03:01 (p = 0.0014) and HLA-DRB1*04 (p = 0.0001) were positively associated with this form of diabetes, while HLA-DRB1*15 was protective (p < 0.0001). The mean type 1 diabetes genetic risk score (derived from European data) was higher in patients than control participants (p = 1.60 × 10-7). Interestingly, despite the modest sample size, autoantibody-positive patients revealed evidence of association with SNPs in the well-characterised MHC region, already known to explain half of type 1 diabetes heritability in Europeans.

CONCLUSIONS/INTERPRETATION

The majority of patients with insulin-dependent diabetes in rural North-West Ethiopia have the immunogenetic characteristics of autoimmune type 1 diabetes. Phenotypic differences between type 1 diabetes in rural North-West Ethiopia and the industrialised world remain unexplained.

Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial

INTRODUCTION

Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement.

METHODS AND ANALYSIS

This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants.

ETHICS AND DISSEMINATION

This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PACTR201905538846394; pre-results.

Association Between the Level of Reported Good Medication Adherence and the Geographic Location of a Patient's Residence and Presence of a Glucometer Among Adult Patients with Diabetes in Ethiopia: A Systematic and Meta-Analysis

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Seven thousand seven hundred fifty-six participants were included for the final analysis.

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Reported good medication adherence among adult diabetic patients in Ethiopia was 68.59%.

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Reported good medication adherence among adult diabetic patients in regions was 67.81%.

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Reported good medication adherence among adult diabetic patients in Addis Ababa was 70.37%.

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Presence of glucometer at home has positive association with reported good medication adherence among adult diabetic patients.

Background

Diabetes mellitus (DM) is a major public health problem worldwide that was estimated to have affected the lives of 425 million people globally in 2017. The prevalence and mortality rates of DM have increased rapidly in low- and middle-income countries with an estimated 2.6 million cases of DM occurring in Ethiopia alone in 2015.

Objective

Considering that Ethiopia is undergoing an epidemiological transition, it is increasingly important to understand the significant influence DM has on Ethiopians annually. A systematic review and meta-analysis of the existing studies were conducted to better understand the factors that are associated with DM medication adherence across Ethiopia and to elucidate areas for further studies.

Methods

Studies were retrieved through search engines in Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, PubMed, Google Scholar, Web of Science, Science Direct, and Scopus. The Newcastle–Ottawa Scale for cross-sectional studies was used to assess the critical appraisal of the included studies. Random effects model was used to estimate the association between the level of medication adherence and the geographic location of a patient's residence and presence of a glucometer at 95% CI with its respective odds ratio. Meta-regression was also used to identify the potential source of heterogeneity. Beggs and Egger tests were performed to determine publication bias. Subgroup analyses, based on the study area, were also performed.

Results

A total of 1046 articles were identified through searching, of which 19 articles representing 7756 participants were included for the final analysis stage. Reported good medication adherence among patients with diabetes in Ethiopia was 68.59% (95% CI, 62.00%–75.18%). Subgroup analysis was performed, and the pooled estimate of reported good medication adherence among these patients in regions outside Addis Ababa was 67.81% (95% CI, 59.96%–75.65%), whereas in Addis Ababa it was 70.37% (95% CI, 57.51%–83.23%). Patients who used a glucometer at home had an odds ratio of 2.12 (95% CI, 1.42–3.16) and thus reported good adherence. We found no statistically significant association between the geographic location of a patient's residence and a good level of reported medication adherence (odds ratio, 1.81; 95% CI, 0.78–4.21).

Conclusions

Most adult patients with diabetes in these studies had a good level of reported DM medication adherence. Having a glucometer was significantly associated with reported increased medication adherence. Our findings suggest the need for interventions to improve diabetes medication adherence.

Diabetic health literacy and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of a university hospital in Ethiopia

BACKGROUND

Despite how much effect of low health literacy is on diabetic treatment cannot be accurate, it has an impact on controlling blood glucose level. Less is known about diabetic health literacy in Ethiopian diabetic patients which can affect patient medication adherence, self-care, and glycemic control.

OBJECTIVE

This study was aimed to assess the diabetic health literacy level and its association with glycemic control among adult patients with type 2 diabetes mellitus attending the outpatient clinic of University of Gondar Comprehensive Specialized Hospital (UOGCSH): Northwest Ethiopia.

METHODS

A cross-sectional study was employed at the outpatient clinic of the University of Gondar Comprehensive Specialized Hospital from May, 1 -May 30, 2019. The comprehensive 15-items diabetic health literacy questions with a 5-point Likert scale used to measure diabetic health literacy. The mean score calculated and switched to the percentage (5 points as 100%) to determine the level of diabetic health literacy. Morisky Green Levine Scale 4 item adherence assessment tool was used to assess the diabetic patient's level of adherence. Binary and multivariable logistic regression analysis was used to assess the association between sociodemographic, clinical variables, diabetic-related literacy, and glycemic control. Independent samples t-test and One-way ANOVA test was employed to compare the mean literacy score difference in different groups.

RESULT

400 respondents were included in the study. Of all the respondents, 17.3%, 26.3%, and 56.5% had low, medium and high diabetic-related health literacy, respectively. The proportions of patients with low, medium and high adherence to medication were 9.8%, 56.3%, and 34% respectively. Patients with high diabetes literacy are 1.85 times more likely to achieve target glycemic control than lower diabetic literacy patients with 95% CI Adjusted Odds Ratio (AOR). 1.85(1.09-3.40). While patients with good adherence 1.61 times more likely to achieve target glycemic control than patients with low adherence; 95% CI AOR 1.61(1.04-4.79). Diabetic patients with morbidity have 67% less likelihood to achieve the target glycemic control; 95% CI AOR 0.33(0.15-0.73).

CONCLUSION

Adequate diabetic health literacy and better glycemic control are highly correlated. Adjusting all variables; younger age, high diabetic health literacy and good adherence are associated with achieving the target glycemic control.

Prevalence and incidence of type 1 diabetes in the world: a systematic review and meta-analysis

Background: Diabetes is referred to a group of diseases characterized by high glucose levels in blood. It is caused by a deficiency in the production or function of insulin or both, which can occur because of different reasons, resulting in protein and lipid metabolic disorders. The aim of this study was to systematically review the prevalence and incidence of type 1 diabetes in the world. Methods: A systematic search of resources was conducted to investigate the prevalence and incidence of type 1 diabetes in the world. The databases of Medline (via PubMed and Ovid),ProQuest, Scopus, and Web of Science from January 1980 to September 2019 were searched to locate English articles. The located articles were screened in multiple levels of title, abstract,and full-text and final studies that met the inclusion criteria were retrieved and included in the study. Results: From 1202 located articles, 193 studies were included in this systematic review. The results of meta-analysis showed that the incidence of type 1 diabetes was 15 per 100,000 people and the prevalence was 9.5% (95% CI: 0.07 to 0.12) in the world, which was statistically significant. Conclusion: According to the results, the incidence and prevalence of type 1 diabetes are increasing in the world. As a result, insulin will be difficult to access and afford, especially in underdeveloped and developing countries.

Correlating the global increase in type 1 diabetes incidence across age groups with national economic prosperity: A systematic review

BACKGROUND

The global epidemiology of type 1 diabetes (T1D) is not yet well known, as no precise data are available from many countries. T1D is, however, characterized by an important variation in incidences among countries and a dramatic increase of these incidences during the last decades, predominantly in younger children. In the United States and Europe, the increase has been associated with the gross domestic product (GDP) per capita. In our previous systematic review, geographical variation of incidence was correlated with socio-economic factors.

AIM

To investigate variation in the incidence of T1D in age categories and search to what extent these variations correlated with the GDP per capita.

METHODS

A systematic review was performed to retrieve information about the global incidence of T1D among those younger than 14 years of age. The study was carried out according to the PRISMA recommendations. For the analysis, the incidence was organized in the periods: 1975-1999 and 2000-2017. We searched the incidence of T1D in the age-groups 0-4, 5-9 and 10-14. We compared the incidences in countries for which information was available for the two periods. We obtained the GDP from the World Bank. We analysed the relationship between the incidence of T1D with the GDP in countries reporting data at the national level.

RESULTS

We retrieved information for 84 out of 194 countries around the world. We found a wide geographic variation in the incidence of T1D and a worldwide increase during the two periods. The largest contribution to this increase was observed in the youngest group of children with T1D, with a relative increase of almost double when comparing the two periods (P value = 2.5 × e^-5). Twenty-six countries had information on the incidence of T1D at the national level for the two periods. There was a positive correlation between GDP and the incidence of T1D in both periods (Spearman correlation = 0.52 from 1975-1999 and Spearman correlation = 0.53 from 2000-2017).

CONCLUSION

The incidence increase was higher in the youngest group (0-4 years of age), and the highest incidences of T1D were found in wealthier countries.

Type-1 diabetes onset age and sex differences between Ghanaian and German urban populations

Highlights Type 1 diabetes onset age in Kumasi/Ghana has a peak at around 17 to 20 years, whereas the peak is at 11 to 12 years in North Rhine-Westphalia, Germany. Higher proportions of females were found in the type 1 diabetes cohort from Ghana, and males were more frequent in the German cohort.

A hidden face of migration: Diabetic ketoacidosis in a severely malnourished refugee

Besides violence, the risk of under nutrition and infection, migrant children with noncommunicable chronic diseases face serious challenges in the management of their conditions. Management of diabetic ketoacidosis in a severely malnourished patient includes careful hydration, therapeutic feeding, and monitoring.

Worldwide estimates of incidence, prevalence and mortality of type 1 diabetes in children and adolescents: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIMS

This article describes the methods, results and limitations of the International Diabetes Federation (IDF) Diabetes Atlas 9th edition estimates of worldwide numbers of cases of type 1 diabetes in children and adolescents.

METHODS

Most information in the published literature is in the form of incidence rates derived from registers of newly-diagnosed cases. After systematic review of the published literature and recent conference abstracts, identified studies were quality graded. If no study was available, extrapolation was used to assign a country the rate from an adjacent country with similar characteristics. Estimates of incident cases were obtained by applying incidence rates to United Nations 2019 population estimates. Estimates of prevalent cases were derived from incidence rates after making allowance for higher mortality rates in less-developed countries.

RESULTS

Incidence rates were available for 45% of countries (ranging from 6% in the sub-Saharan Africa region to 77% in the European region). Worldwide annual incidence estimates were 98,200 (128,900) new cases in the under 15 year (under 20 year) age-groups. Corresponding prevalence estimates were 600,900 (1,110,100) existing cases. Compared with estimates in earlier Atlas editions, numbers have increased in most IDF regions, reflecting incidence rate increases, but prevalence estimates have decreased in sub-Saharan Africa because allowance has been made for increased mortality in those with diabetes.

CONCLUSIONS

Worldwide estimates of numbers of children and adolescents with type 1 diabetes continue to increase.

Ability of verbal autopsy data to detect deaths due to uncontrolled hyperglycaemia: testing existing methods and development and validation of a novel weighted score

OBJECTIVES

Verbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4).

SETTING

This study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi.

PARTICIPANTS

All deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga.

RESULTS

Of the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen's kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%.

CONCLUSION

Our results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist.

An Evaluation of the Delivery of Medicines Using Drones

This study tests the impact of drone transportation on the quality of a medicine. Modelling the critical process parameters of drone flight, the effects of temperature and vibration on insulin were investigated using the pharmacopoeia methods. The medicine, Actrapid, (3.5 mg/mL of insulin), was flown by a quad-rotor drone. Insulin stored between −20 and 40 °C for 30 mins, and subjected to vibration (0–40 Hz, 25 °C, 30 mins) passed the pharmacopeia tests. Dynamic light scattering identified the active tetrameric and hexameric forms of insulin post testing. Vibration frequencies during drone flight were between 0.1 and 3.4 Hz. There was no evidence of visible insulin aggregates following the drone transportation. The differences in UV absorbance readings between flown Actrapid and controls were insignificant (p = 0.89). No adverse impact of drone transport on insulin was observed. This study provides supporting evidence that drone transportation of medicinal products containing insulin is feasible. The authors recommend that when considering the drone delivery of medicines five tests need to be applied. These tests must determine the safe flight time and range, the quality of the medicine post flight, the onboard conditions experienced by the medicine, the security of the drone supply chain and the effect of drone failure on both the medicine and the environment.

Retrospective assessment of the quality of diabetes care in a rural diabetes clinic in Western Kenya

BACKGROUND

Sub-Saharan Africa continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care. We assessed the quality of diabetes care in a rural diabetes clinic in western Kenya.

METHODS

To provide a comprehensive assessment, a set of clinical outcomes, process, and structure metrics were evaluated to assess the quality of diabetes care provided in the outpatient clinic at Webuye District Hospital. The primary clinical outcome measures were the change in HbA1c and point of care blood glucose. In assessing process metrics, the primary measure was the percentage of patients who were lost to follow up. The structure metrics were assessed by evaluating different facets of the operation of the clinic and their accordance with the International Diabetes Federation (IDF) guidelines.

RESULTS

A total of 524 patients were enrolled into the diabetes clinic during the predefined period of evaluation. The overall clinic population demonstrated a statistically significant reduction in HbA1c and point of care blood glucose at all time points of evaluation after baseline. Patients had a mean baseline HbA1C of 10.2% which decreased to 8.4% amongst the patients who remained in care after 18 months. In terms of process measures, 38 patients (7.3%) were characterized as being lost to follow up as they missed clinic visits for more than 6 months. Through the assessment of structural metrics, the clinic met at least the minimal standards of care for 14 out of the 19 domains recommended by the IDF.

CONCLUSION

This analysis illustrates the gains made in various elements of diabetes care quality which can be used by other programs to guide diabetes care scale up across the region.

Correlation between Serum Lipid Profile with Anthropometric and Clinical Variables in Patients with Type 2 Diabetes Mellitus

Background

The problem of dyslipidemia is high in patients with diabetes mellitus. There is ample evidence that abnormalities in lipid metabolism are important risk factors for increased incidence of diabetes associated complications. The most important risk indicators for these complications are lipid profile abnormalities. Therefore, the aim of this study was to assess the correlation between serum lipid profile with anthropometric and clinical variables among type 2 diabetes mellitus patients.

Methods

A comparative cross sectional study was conducted at University of Gondar Hospital from February to April in 2015. A total of 296 participants (148 case and 148 healthy controls) were selected using systematic random sampling technique. Socio-demographic characteristics and clinical data were collected using pretested structured questionnaire incorporating the WHO Stepwise approach. Fasting venous blood sample was collected for blood sugar; lipid profile investigations and the blood levels were determined by Bio Systems A25 Chemistry Analyzer (Costa Brava, Spain). Independent sample t-test and Man Whitney U test were used to compare means. P-value < 0.05 was considered statistically significant.

Results

Overall, T2DM patients had significantly higher total cholesterol ([205.4±50.9vs184.9±44.1]mg/dl), low density lipoprotein ([113.1±43.2vs100.1±36.4] mg/dl) and triacylglycerol ([189.22± 100.9 vs 115.13±59.2] mg/dl), and significant decline of high density lipoprotein cholesterol ([56.5±20.4vs62.1±13] mg/dl) as compared to healthy controls, respectively. Triacylglycerolemia was significantly associated with the risk of cardiovascular disease (AOR: 1.015; 95%CI: 1.010–1.021). Evident correlation was observed between anthropometric and clinical variables with lipid profile.

Conclusion

Higher serum levels of fasting blood sugar, total cholesterol, low density lipoprotein cholesterol, and triacylglycerol and lower levels of high density lipoprotein cholesterol are found in type 2 diabetes mellitus patients. Thus, DM patients are more prone to dyslipidemia which is an important risk factor for atherosclerosis and coronary heart disease.

Type 1 Diabetes in a Resource-Poor Setting: Malnutrition Related, Malnutrition Modified, or Just Diabetes?

PURPOSE OF REVIEW

Very little is known about the occurrence of type 1 diabetes (T1DM) in resource-poor countries and particularly in their rural hinterlands.

RECENT FINDINGS

Studies of the epidemiology of T1DM in Ethiopia and similar countries in sub-Saharan Africa show that the pattern of presenting disease differs substantially from that in the West. Typically, the peak age of onset of the disease is more than a decade later with a male excess and a low prevalence of indicators of islet-cell autoimmunity. It is also associated with markers of undernutrition. These findings raise the question as to whether the principal form of T1DM seen in these resource-poor communities has a different pathogenesis. Whether the disease is a direct result of malnutrition or whether malnutrition may modify the expression of islet-cell autoimmunity is unclear. However, the poor prognosis in these settings underlines the urgent need for detailed clinical and epidemiological studies.

High rates of ocular complications in a cohort of Haitian children and adolescents with diabetes

BACKGROUND

Ophthalmic complications of pediatric diabetes are rare, and rates are unknown in Haitian youth.

OBJECTIVES

To determine the prevalence and predictors of diabetic retinopathy (DR) and cataracts in a cohort of Haitian youth with insulin-treated diabetes.

METHODS

We performed a cross-sectional retrospective review of pediatric patients with diabetes from a pediatric chronic disease center in Haiti, from December 1, 2012 to November 1, 2016. Data collection included demographic and anthropometric information, total daily insulin dose and result of eye examination by a local ophthalmologist.

RESULTS

Of 67 patients (54% female, mean age at diagnosis 14.6 ± 3.9 years, mean diabetes duration 3.3 ± 3.0 years, mean HbA1c 84 ± 22 mmol/mol (9.8% ± 2.0%), mean current insulin requirement 0.49 ± 0.28 IU/kg/day), DR was diagnosed in 10/57 (18%) and cataracts in 10/62 (16%), at a mean age of 19.0 ± 4.3 and 19.1 ± 3.3 years, respectively. Diabetes duration was 4.9 ± 5.4 and 3.0 ± 1.5 years at the time of diagnosis of DR and cataracts, respectively. Age at complication, insulin requirement, sex, body mass index, family history, mean HbA1c and diabetes duration were not significant predictors of an ocular complication.

CONCLUSIONS

In this cohort of Haitian youth, DR and cataracts occur prematurely. Low-insulin requirements years after diagnosis, possibly allowing for prolonged undetected hyperglycemia prediagnosis, may explain complication risk. The phenotypes of diabetes in pediatric populations of African ancestry may be distinct. Ophthalmologic evaluation should possibly start at diagnosis, and screening guidelines may need to be adapted.

Immigration to Israel during childhood is associated with diabetes at adolescence: a study of 2.7 million adolescents

AIMS/HYPOTHESIS

Immigration studies can shed light on diabetes pathogenesis and risk factors. To this end, we investigated the association between age at immigration and diabetes occurrence at adolescence among immigrants to Israel.

METHODS

We analysed cross-sectional data on 2,721,767 Jewish adolescents assessed for mandatory military service at approximately 17 years of age between 1967 and 2014. The study population comprised 430,176 immigrants with origins in Ethiopia, former USSR, Middle East and North Africa (ME/NA) and western countries. ORs for diabetes were calculated for men and women, grouped according to age at immigration, with Israel-born participants as controls. Unadjusted and fully adjusted models were made to account for possible confounders. Additionally, the study population was stratified by origin and each immigrant group was referenced to Israel-born participants of the same origin.

RESULTS

There was a graded decrease in OR for diabetes across the study groups in the fully adjusted model. Immigrants arriving at age 0-5 years had comparable OR for diabetes to the Israeli-born reference group; those arriving at age 6-11 years had an OR of 0.82 (95% CI 0.70, 0.97; p = 0.017) and recent immigrants, arriving at age 12-19 years, had the lowest OR of 0.65 (95% CI 0.54, 0.77; p < 0.0001). When age at immigration was treated as a continuous variable, there was an adjusted risk for occurrence of diabetes of 0.97 (95% CI 0.96, 0.99; p = 0.001) for every year increment. The lower risk for diabetes among recent immigrants persisted in the unadjusted model and persisted when the study sample was stratified by sex and origin, except for immigrants arriving from ME/NA. Notably, Ethiopians born in Israel had a sixfold higher diabetes crude prevalence than Ethiopian immigrants arriving after the age of 5 years.

CONCLUSIONS/INTERPRETATION

Immigrants of different ethnic groups arriving earlier in childhood lose their protection against diabetes at adolescence, relative to children born in Israel. This is perhaps due to environmental and lifestyle changes, especially those beginning at an early age.

Islet cell-associated autoantibodies in Ethiopians with diabetes mellitus

BACKGROUND & AIMS

Our understanding of the role of autoimmunity in the pathogenesis of diabetes in African populations is limited. This study aims to evaluate the prevalence of 4 different islet cell-associated antibodies in Ethiopian patients with diabetes and non-diabetic controls.

METHODS

A total of 187 subjects from a diabetic clinic at an Ethiopian hospital were evaluated in a cross-sectional study. Fifty-five patients had type 1 diabetes mellitus (T1DM), 86 had type 2 diabetes mellitus (T2DM) and 46 were non-diabetic controls. Islet cell-associated antibodies were measured using 4 different assays for antibodies against islet cells (ICA), glutamic acid decarboxylase (GADA), insulin (IAA) and the protein tyrosine phosphatase-like IA-2 (IA-2A).

RESULTS

Comparing the antibody positivity in subjects with T1DM versus T2DM, the results were as follows: 29% versus 3.5% for GADA; 21% versus 2.7% for ICA; 27% versus 16% for IAA. In the control group, the only positive result was for IAA at 2%. IA-2A was absent in all groups. The combi-assay for GADA and IA-2A detected all GADA-positive subjects. T2DM patients who were GADA positive had lower BMI, lower C-peptide levels and all of them were on insulin therapy.

CONCLUSIONS

Compared to Caucasians, Ethiopians with T1DM have less prevalence of islet cell-associated antibodies, but the rates are higher than in T2DM. GADA is present in Ethiopians, whereas IA-2A seems to be absent. GADA positivity in T2DM correlates with clinical features of T1DM, indicating the existence in Ethiopia of the subgroup, latent autoimmune diabetes in adults.

Childhood diabetes in Africa

PURPOSE OF REVIEW

This review summarizes the current state of diabetes in African children.

RECENT FINDINGS

Type 1 diabetes is the most common form of pediatric diabetes in Africa. Significant improvements have been achieved over the last 6 years, including the training of more than 60 pediatric endocrinologists who are now practicing in 14 African nations, greater training of other healthcare providers, increased availability of insulin through the efforts of philanthropic organizations and industry, modestly better availability of testing supplies, and the introduction of patient education materials in native languages. However, there is still a long way to go before the standard-of-care available to children in resource-rich nations is available to children with diabetes in Africa.

SUMMARY

Here, we review the known epidemiology, pathophysiology, complications, and treatment of diabetes in children in Africa.

Neglected chronic disease: The WHO framework on non-communicable diseases and implications for the global poor

The current global framework on noncommunicable disease (NCD), as exemplified by the WHO Action Plan of 2012, neglects the needs of the global poor. The current framework is rooted in an outdated pseudo-evolutionary theory of epidemiologic transition, which weds NCDs to modernity, and relies on global aggregate data. It is oriented around a simplistic causal model of behaviour, risk and disease, which implicitly locates 'risk' within individuals, conveniently drawing attention away from important global drivers of the NCD epidemic. In fact, the epidemiologic realities of the bottom billion reveal a burden of neglected chronic diseases that are associated with 'alternative' environmental and infectious risks that are largely structurally determined. In addition, the vertical orientation of the framework fails to centralise health systems and delivery issues that are essential to chronic disease prevention and treatment. A new framework oriented around a global health equity perspective would be able to correct some of the failures of the current model by bringing the needs of the global poor to the forefront, and centralising health systems and delivery. In addition, core social science concepts such as Bordieu's habitus may be useful to re-conceptualising strategies that may address both behavioural and structural determinants of health.

Diabetes Mellitus in Outpatients in Debre Berhan Referral Hospital, Ethiopia

INTRODUCTION

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Most people with diabetes live in low- and middle-income countries and these will experience the greatest increase in cases of diabetes over the next 22 years.

OBJECTIVE

To assess the prevalence and associated factors of diabetes mellitus among outpatients of Debre Berhan Referral Hospital.

METHODS AND MATERIALS

A cross-sectional study was conducted from April to June 2015 among 385 patients. Random quota sampling technique was used to get individual patients and risk factors assessment. Patients diabetes status was ascertained by World Health Organization Diabetes Mellitus Diagnostic Criteria. The collected data were entered, cleaned, and analyzed and Chi-square test was applied to test any association between dependent and independent variable. Result. Out of the total 385 study patients, 368 have participated in the study yielding a response rate of 95.3%. Concerning clinical presentation of diabetes mellitus, 13.3% of patients reported thirst, 14.4% of patients declared polyurea, and 14.9% of patients ascertained unexplained weight loss. The statistically significant associated factors of diabetes mellitus were hypertensive history, obesity, the number of parities, and smoking history.

CONCLUSION

The prevalence of diabetes mellitus among outpatients in Debre Berhan Referral Hospital was 0.34% and several clinical and behavioral factors contribute to the occurrence of diabetes mellitus which impose initiation of preventive, promotive, and curative strategies.

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia

AIM

To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications.

METHODS

A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded.

RESULTS/CONCLUSIONS

Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p<0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed.

Lean diabetes mellitus: An emerging entity in the era of obesity

Much has been published on the characteristics of type 2 diabetes mellitus and its association with the epidemic of obesity. But relatively little is known about the incidence of lean diabetes, progression of disease and fate of the patients with low-normal body mass index (< 25). Studies in developing countries have shown that the clinical characteristics of these patients include history of childhood malnutrition, poor socioeconomic status, relatively early age of onset and absence of ketosis on withdrawal of insulin. In the United States, recent studies showed that the lean, normal weight diabetes is not rare especially among minority populations. They showed that these patients are mainly males, have higher prevalence of insulin use indicating rapid beta cell failure. They might have increased total, cardiovascular and non cardiovascular mortality when compared to obese diabetic patients. In this review, the epidemiologic and clinical features of lean diabetes are presented. The potential causal mechanisms of this emerging diabetes type that may include genetic, autoimmune, acquired and behavioral factors are discussed. The need for studies to further elucidate the causation as well as specific prevention and treatment of lean diabetes is emphasized.

David Barker, Buruli ulcer and the epidemiology of a neglected tropical disease

In 1969, David Barker, his wife and four children moved to Uganda to work at Makerere Medical School in the capital Kampala. During the 1960s, Makerere had become a research and teaching centre with an international reputation based on the work of Trowell, Burkitt, Hutt and many others who had pioneered studies explaining the disease patterns in the West Nile area on the basis of the local climate, nutrition and lifestyle. David Barker was funded by the Medical Research Council to carry out research on a poorly understood disease, Buruli ulcer, joining Scottish surgeon Wilson Carswell, who was later to achieve fame as the role model for Dr Garrigan in Giles Foden's novel The Last King of Scotland.

Dietary patterns and physical inactivity, two contributing factors to the double burden of malnutrition among adults in Burkina Faso, West Africa

A population-based cross-sectional study was carried out in the northern neighbourhoods of Ouagadougou (Burkina Faso), to examine the relationship of nutritional deficiencies and cardiometabolic risk factors (CMRF) with lifestyle in adults. We randomly selected 330 households stratified by income tertile. In each income stratum, 110 individuals aged 25-60 years and having lived in Ouagadougou for at least 6 months were randomly selected. We performed anthropometric, dietary intake and physical activity measurements, and blood sample collection. Cluster analysis of dietary intake identified two dietary patterns: 'urban' (29 % of subjects) and 'traditional' (71 %). The 'urban' cluster exhibited a higher intake of fat and sugar, whereas a higher intake of plant protein, complex carbohydrate and fibre was observed in the 'traditional' pattern. Female sex, low income and lack of education were associated with the 'traditional' cluster, as well as Fe and vitamin A deficiency. CMRF prevalence (abdominal obesity, hypertension, hyperglycaemia, dyslipidaemia) was similar in both clusters. Subjects in the 'traditional' cluster spent more time in physical activity and had less sedentary time than those in the 'urban' cluster. 'Traditional' dietary pattern, low income, female sex and sedentary time were significant contributing factors to the double burden of malnutrition. The rapid nutrition transition is reflected in this co-occurrence of CMRF and nutritional deficiencies. This stresses the need for prevention strategies addressing both ends of the nutrition spectrum.

Diabetes in the young - a global view and worldwide estimates of numbers of children with type 1 diabetes

This paper describes the methodology, results and limitations of the 2013 International Diabetes Federation (IDF) Atlas (6th edition) estimates of the worldwide numbers of prevalent cases of type 1 diabetes in children (<15 years). The majority of relevant information in the published literature is in the form of incidence rates derived from registers of newly diagnosed cases. Studies were graded on quality criteria and, if no information was available in the published literature, extrapolation was used to assign a country the rate from an adjacent country with similar characteristics. Prevalence rates were then derived from these incidence rates and applied to United Nations 2012 Revision population estimates for 2013 for each country to obtain estimates of the number of prevalent cases. Data availability was highest for the countries in Europe (76%) and lowest for the countries in sub-Saharan Africa (8%). The prevalence estimates indicate that there are almost 500,000 children aged under 15 years with type 1 diabetes worldwide, the largest numbers being in Europe (129,000) and North America (108,700). Countries with the highest estimated numbers of new cases annually were the United States (13,000), India (10,900) and Brazil (5000). Compared with the prevalence estimates made in previous editions of the IDF Diabetes Atlas, the numbers have increased in most of the IDF Regions, often reflecting the incidence rate increases that have been well-documented in many countries. Monogenic diabetes is increasingly being recognised among those with clinical features of type 1 or type 2 diabetes as genetic studies become available, but population-based data on incidence and prevalence show wide variation due to lack of standardisation in the studies. Similarly, studies on type 2 diabetes in childhood suggest increased incidence and prevalence in many countries, especially in Indigenous peoples and ethnic minorities, but detailed population-based studies remain limited.

Diabetic ketoacidosis: an overlooked child killer in sub-Saharan Africa?

The true incidence of diabetic ketoacidosis (DKA) in sub-Saharan Africa is unknown but unlike in the Western countries, DKA is also uniquely frequent among type 2 diabetes patients of African origin. Increased hyperglycaemia and hepatic ketogenesis lead to osmotic diuresis, dehydration and tissue hypoxia. Acute complications of DKA include cerebral oedema, which may be compounded by malnutrition, parasitic and microbial infections with rampant tuberculosis and HIV. Overlapping symptoms of these conditions and misdiagnosis of DKA contribute to increased morbidity and mortality. Inability of the patients to afford insulin treatment leads to poor glycemic control as some patients seek alternative treatment from traditional healers or use herbal remedies further complicating the disease process. Standard treatment guidelines for DKA currently used may not be ideal as they are adapted from those of the developed world. Children presenting with suspected DKA should be screened for comorbidities which may complicate fluid and electrolyte replacement therapy protocol. Patient rehabilitation should take into account concurrent treatment for infectious conditions to avoid possible life-threatening drug interactions. We recommend that health systems in sub-Saharan Africa leverage the Expanded Immunization Programme or TB/HIV/AIDS programmes, which are fairly well entrenched to support diabetes services.

Prevalence of food insecurity in patients with diabetes in western Kenya

AIMS

To determine the characteristics of patients with diabetes who reported food insecurity at three diabetes clinics in western Kenya.

METHODS

This study includes routinely collected demographic data at the first presentation of patients with diabetes at clinics in western Kenya from 1 January 2006 to 24 September 2011. A validated questionnaire was used to assess food insecurity with descriptive and comparative statistics being used to analyse the food-secure and food-insecure populations.

RESULTS

The number of patients presenting to these clinics who were food-secure and those who were food-insecure was 1179 (68.0%) and 554 (32.0%), respectively. Comparative analysis shows a statistically significant difference in weight, BMI, the presence of a caretaker, and use of insulin between the two groups. These variables were lower in the food-insecure group. The overall assessment of the clinic population revealed an abnormally high mean HbA1c concentration of 81 mmol/mol (9.6%).

CONCLUSIONS

Despite the widely recognized contribution of caloric over-nutrition to the development of diabetes, this study highlights the high prevalence of food insecurity amongst patients with diabetes in rural, resource-constrained settings. Other factors, such as the lower prevalence of obesity, poor glucose control, challenges in the use of insulin because of the risk of hypoglycaemia, and varying subtypes of diabetes in this population, point to the need for additional research in understanding the aetiology, pathophysiology and optimum management of this condition, as well as understanding the effects of enhancing food security.

Current clinical status, glucose control, and complication rates of children and youth with type 1 diabetes in Rwanda

OBJECTIVE

To describe the clinical status of youth and adolescents (≤ 25 yr) in the Rwanda Life For A Child (LFAC) program who had their first HbA1c measure in 2009 or 2010, and to identify factors which may relate to glycemic control (HbA1c) and complication status.

RESEARCH DESIGN AND METHODS

Data were collected from June 2009 to November 2010 for the LFAC program in Rwanda and comprise clinical data from when participants' first HbA1c reading was obtained.

RESULTS

From June 2009 to November 2010, 286 youth aged ≤25 yr had their first HbA1c. Mean age, duration, and age at diagnosis were 18.6 ± 4.5 yr, 3.4 ± 3.1 yr and 15.1 ± 4.8 yr, respectively. Mean HbA1c was 11.2 ± 2.7% with 15.7% (n = 45) having HbA1c <8%, while 30.8% (n = 88) had HbA1c >14%. Five (2.1%) had either abnormal tuning fork vibratory sensation or monofilament response, 21% (n = 31) had microalbuminuria (MA, A/C ratio >30 mg/g) and 5% (n = 7) had nephropathy (A/C ratio >300 mg/g). Diabetes duration and insulin dose/kg were positively associated with higher HbA1c, while residing in the southern province was associated with lower HbA1c. Duration, diastolic blood pressure, and HbA1c were positively associated with developing MA, while age was protective.

CONCLUSIONS

These data from the LFAC program for 2009-2010 show that there is a urgent need for dramatically improved care, as many patients have greatly elevated HbA1c measures, often >14%. We have identified correlates of better control (e.g., living in the Southern province) and MA (e.g., diastolic blood pressure), which provide potential avenues to improved quality of care.

Addison's disease symptoms--a cross sectional study in urban South Africa

Background

Addison’s disease is a potentially life-threatening disorder, and prompt diagnosis, and introduction of steroid replacement has resulted in near normal life-expectancy. There are limited data describing the clinical presentation of Addison’s disease in South Africa. It is hypothesised that patients may present in advanced state of ill-health, compared to Western countries.

Patients

A national database of patients was compiled from primary care, referral centres and private practices. 148 patients were enrolled (97 white, 34 mixed ancestry, 5 Asian and 12 black).

Methods

Demographic and clinical data were elicited using questionnaires. Biochemical data were obtained from folder reviews and laboratory archived results.

Results

The majority of the cohort was women (62%). The median and inter-quartile age range (IQR) of patients at enrolment was 46.0 (32.0–61.0) years, with a wide range from 2.8–88.0 years. The median and IQR age at initial diagnosis was 34.0 (20.0–45.0) years (range 0.02–77.0) years, indicating that at the time of enrolment, the patients, on average, were diagnosed with Addison’s disease 12 years previously. Hyperpigmentation was observed in 76%, nausea and vomiting occurred in more than 40%, and weight loss was noted in 25%. Loss of consciousness as a presenting feature was recorded in 20%. with a 95% confidence interval [CI] of (14–28%) and shock occurred in 5% CI (1.5–8.5%). Case-finding was recorded at 3.1 per million.

Conclusions

The usual constellation of hyperpigmentation, nausea, vomiting and weight loss suggests Addison’s disease, but a significant proportion present with an advanced state of ill-health and Addisonian crises. A lower prevalence rate, compared to Western countries is suggested.

The double burden of malnutrition and cardiometabolic risk widens the gender and socio-economic health gap: a study among adults in Burkina Faso (West Africa)

OBJECTIVE

To document the double burden of malnutrition and cardiometabolic risk factors (CMRF) in adults and its occurrence according to different sociodemographic parameters.

DESIGN

Population-based cross-sectional observational study. We first randomly selected 330 households stratified by tertile of the income levels proxy as low, middle and high income.

SETTING

Northern district of Ouagadougou, the capital city of Burkina Faso.

SUBJECTS

In each income stratum, 110 individuals aged 25-60 years and who had lived permanently in Ouagadougou for at least 6 months were randomly selected, followed with collection of anthropometric, socio-economic and clinical data, and blood samples.

RESULTS

The overall obesity/overweight prevalence was 24.2 % and it was twice as high in women as in men (34.1 % v. 15.5 %, P < 0.001). Hypertension, hyperglycaemia and low HDL cholesterol prevalence was 21.9 %, 22.3 % and 30.0 %, respectively, without gender difference. The prevalence of the metabolic syndrome was 10.3 %. Iron depletion and vitamin A deficiency affected 15.7 % and 25.7 % of participants, respectively, with higher rates in women. Coexistence of at least one nutritional deficiency and one CMRF was observed in 23.5 % of participants, and this 'double burden' was significantly higher in women than in men (30.4 % v. 16.1 %, P = 0.008) and in the low income group.

CONCLUSIONS

CMRF are becoming a leading nutritional problem in adults of Ouagadougou, while nutritional deficiencies persist. The double nutritional burden exacerbates health inequities and calls for action addressing both malnutrition and nutrition-related chronic diseases.

The quality of care provided to patients with chronic non-communicable diseases: a retrospective multi-setup study in jimma zone, southwest ethiopia

Background

Chronic Non-Communicable Diseases are among the major causes of morbidity and mortality worldwide. However, access to and quality of health care for patients is very low in developing countries including Ethiopia. Hospitals and Health Centers are the main sources of health care for such patients in Ethiopia. In this study we assessed the quality of care patients with Chronic Non-Communicable Diseases received in hospital and health center setups.

Methods

A retrospective multi-setup study was conducted in Jimma University Specialized Hospital and four Health Centers in Jimma Zone from February to March 2010. A total of 52 process indicators of quality covering three disease conditions: Diabetes, Hypertension and Epilepsy were measured by reviewing randomly selected medical records. Quality of care was measured as a proportion of recommended components of care actually provided to patients. And also outcome and structural measures were assessed to supplement process measures of quality.

Results

Six hundred seventy four medical records were reviewed. Recommended care components were actually provided to patients in 35.1% (95% CI:34.1%, 36.0%), 38.5% (95% CI:37.5%, 39.5%) and 60.1% (95% CI:59.3%, 61.0%) of times on which patients were eligible, among patients with Diabetes, Hypertension and Epilepsy, respectively. After case mix adjustment, it was found that 45.9% (95% CI:45.4%, 46.5%) of recommended components of care was actually provided to patients. This was 45.1% (95% CI:44.4%, 45.8%) in the hospital and 30.5% (95% CI:29.7%, 31.3%) in the health centers. Among patients for whom outcome data was available, optimal level of disease control was achieved only for 47 (30.5%), 40 (38.5%) and 193 (52.9%) of patients with Diabetes, Hypertension and Epilepsy, respectively.

Conclusion

The quality of care provided to patients with Chronic Non-Communicable Diseases is very low in both settings though it is relatively better in Jimma University Specialized Hospital. Therefore, a continuous process of quality improvement is recommended in both settings.

Epidemiology, complications and management of diabetes in Ethiopia: a systematic review

Non-communicable diseases are becoming major problems of public health importance in most developing countries as a result of the effects of globalization and epidemiologic transition; however, there is little evidence regarding diabetes and other non-communicable diseases in these countries. The aim of this study was to conduct a systematic review of the literature on the magnitude of diabetes, the relationship between malnutrition and diabetes, diabetic complications, and the management of diabetes in Ethiopia. Relevant studies and other evidence were identified by searches in the Embase from 1970 to December 2011 and by reviewing the reference lists from retrieved articles. Relevant articles from non-indexed local journals were also included. Data were extracted and summarized using the major themes of the systematic review. Although the prevalence of diabetes in Ethiopia is estimated to be 2% nationally, evidence suggests that it prevalence could be >5% in those older than 40 years of age in some settings. Studies in the 1980s and 1990s have reported conflicting evidence regarding malnutrition-related diabetes; however, more recent studies are reconfirming a strong association between malnutrition and diabetes. There is remarkable prevalence of both acute and chronic complications in diabetic cases in Ethiopia. In addition to this, more than one-third, but only less than half, of diabetic patients in Ethiopia receive standard diabetes care. The results of this study indicate that, in response to the emergence of diabetes and other non-communicable diseases, effective and efficient prevention and control strategies should be designed and implemented in Ethiopia.

Functional and structural adaptations in the pancreatic α-cell and changes in glucagon signaling during protein malnutrition

Chronic malnutrition leads to multiple changes in β-cell function and peripheral insulin actions to adapt glucose homeostasis to these restricted conditions. However, despite glucose homeostasis also depends on glucagon effects, the role of α-cells in malnutrition is largely unknown. Here, we studied α-cell function and hepatic glucagon signaling in mice fed with low-protein (LP) or normal-protein diet for 8 wk after weaning. Using confocal microscopy, we found that inhibition of Ca²⁺ signaling by glucose was impaired in α-cells of LP mice. Consistent with these findings, the ability of glucose to inhibit glucagon release in isolated islets was also diminished in LP mice. This altered secretion was not related with changes in either glucagon gene expression or glucagon content. A morphometric analysis showed that α-cell mass was significantly increased in malnourished animals, aspect that was probably related with their enhanced plasma glucagon levels. When we analyzed the hepatic function, we observed that the phosphorylation of protein kinase A and cAMP response-binding element protein in response to fasting or exogenous glucagon was impaired in LP mice. Additionally, the up-regulated gene expression in response to fasting observed in the hepatic glucagon receptor as well as several key hepatic enzymes, such as peroxisome proliferator-activated receptor γ, glucose-6-phosphatase, and phosphoenolpyruvate carboxykinase, was altered in malnourished animals. Finally, liver glycogen mobilization in response to fasting and the ability of exogenous glucagon to raise plasma glucose levels were lower in LP mice. Therefore, chronic protein malnutrition leads to several alterations in both the α-cell function and hepatic glucagon signaling.

Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review

Background

Diabetes prevalence is increasing globally, and Sub-Saharan Africa is no exception. With diverse health challenges, health authorities in Sub-Saharan Africa and international donors need robust data on the epidemiology and impact of diabetes in order to plan and prioritise their health programmes. This paper aims to provide a comprehensive and up-to-date review of the epidemiological trends and public health implications of diabetes in Sub-Saharan Africa.

Methods

We conducted a systematic literature review of papers published on diabetes in Sub-Saharan Africa 1999-March 2011, providing data on diabetes prevalence, outcomes (chronic complications, infections, and mortality), access to diagnosis and care and economic impact.

Results

Type 2 diabetes accounts for well over 90% of diabetes in Sub-Saharan Africa, and population prevalence proportions ranged from 1% in rural Uganda to 12% in urban Kenya. Reported type 1 diabetes prevalence was low and ranged from 4 per 100,000 in Mozambique to 12 per 100,000 in Zambia. Gestational diabetes prevalence varied from 0% in Tanzania to 9% in Ethiopia. Proportions of patients with diabetic complications ranged from 7-63% for retinopathy, 27-66% for neuropathy, and 10-83% for microalbuminuria. Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis. Meanwhile, antiviral treatment for HIV increases the risk of obesity and insulin resistance. Five-year mortality proportions of patients with diabetes varied from 4-57%. Screening studies identified high proportions (> 40%) with previously undiagnosed diabetes, and low levels of adequate glucose control among previously diagnosed diabetics. Barriers to accessing diagnosis and treatment included a lack of diagnostic tools and glucose monitoring equipment and high cost of diabetes treatment. The total annual cost of diabetes in the region was estimated at US$67.03 billion, or US$8836 per diabetic patient.

Conclusion

Diabetes exerts a significant burden in the region, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high mortality and prevalence of complications observed. The significant interactions between diabetes and important infectious diseases highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.