Epidemiology of diabetic ketoacidosis in Arab patients with type 1 diabetes: a systematic review

Early Detection of Type 1 Diabetes in First-Degree Relatives in Saudi Arabia (VISION-T1D): Protocol for a Pilot Implementation Study

BACKGROUND

Type 1 diabetes (T1D) is a growing global health concern, with a notable rise in incidence in Saudi Arabia. Despite the potential benefits of early detection through screening programs, such initiatives are currently lacking in Saudi Arabia and other Arab countries.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and cost-effectiveness of a T1D-screening program targeting high-risk individuals, specifically children with a first-degree relative diagnosed with T1D.

METHODS

The VISION-T1D program is a prospective cohort study focused on the early detection of presymptomatic T1D by screening children aged 2-18 years. The primary screening method involves testing for islet autoantibodies, including insulin autoantibodies, glutamic acid decarboxylase autoantibodies, insulinoma associated-2 autoantibodies, and zinc transporter-8 autoantibodies. Optional genetic testing, including human leukocyte antigen phenotyping and the genetic risk score, is offered. Outcomes include the feasibility of the screening process, prevalence of early-stage T1D, psychological impacts, educational intervention effectiveness, progression rates to stage-3 T1D, and economic viability.

RESULTS

The VISION-T1D program began in May 2024. As of December 2024, a total of 176 families have been enrolled. Data collection will continue until April 2025, with final data analysis projected for mid-2025.

CONCLUSIONS

The VISION-T1D study provides a practical approach to T1D screening tailored to the health care landscape of Saudi Arabia. The insights gained from this pilot program will inform the development of a national, population-based screening initiative designed to reduce diabetic ketoacidosis at diagnosis, improve long-term outcomes, and alleviate the economic burden of T1D. The VISION-T1D initiative could also serve as a scalable and sustainable model that can be adopted internationally, contributing to global efforts to manage and prevent T1D.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06513247; https://clinicaltrials.gov/study/NCT06513247.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/70575.

Investigating the Association Between Family Socioeconomic Profile and Diabetes Control in Children: A Cross-Sectional Study From Sudan

AIMS

Diabetes mellitus is the most common endocrine disease in childhood which significantly impacts quality of life, morbidity and mortality. This study aimed to investigate the socioeconomic background of children with diabetes and their families and to assess its association with diabetes control.

METHODS

This cross-sectional study was conducted in Khartoum State, Sudan, in 2018, at three outpatient diabetes clinics, using standardised questionnaires. We included 138 diabetic children (T1D and T2D) aged 2-18 years using systematic random sampling. Descriptive statistics, economic indicator and inferential statistics were applied using SPSS version 20. An HbA1C level of > 7.0% was set as the cut-point for uncontrolled diabetes. A p-value of < 0.05 was considered statistically significant.

RESULTS

The mean age of the children was 11.1 (3.64) years. Over half of the respondents were not covered by any insurance scheme and 73% lived in urban areas. Mothers had a mean age of 37.3 (7.8), with one-fourth being illiterate, while fathers had a mean age of 45.4 (9.3). Twenty per cent of parents had higher education. Two-thirds of the participants had their HbA1C levels checked within the last 3 months. The prevalence of uncontrolled diabetes was 78.0%. No statistically significant association was found between HbA1C levels and families' socioeconomic, demographic or clinical characteristics (p > 0.05).

CONCLUSION

Neither children' nor parents' characteristics influenced HbA1C level. The high rate of uncontrolled diabetes (78.0%), and other countries showing better profiles of control, suggests the need for exploring other contributing factors. Insulin availability and lack of home glucose monitoring need to be considered. We recommend future prospective studies to consider these factors and use multiple HbA1C measures' average as a better indicator of diabetic control.

The Social and Financial Burden on Families of Type 1 Diabetic Pediatric Patients in Madinah Region, Saudi Arabia

INTRODUCTION

Caregivers and families play an essential role in managing and caring for type 1 diabetes mellitus (T1DM) pediatric patients. However, caregiving is usually associated with social and financial burdens. This study assesses the burden and underlying social and financial factors among Saudi caregivers of pediatric patients with T1DM.

METHODS

A cross-sectional study was conducted among caregivers and families of T1DM pediatric patients attending the Diabetic Center at King Fahad Hospital (KFH) and the Diabetic Center at King Salman Bin Abdulaziz Medical City (KSAMC) in Al-Madinah City, Kingdom of Saudi Arabia (KSA) from January 2024 to June 2024. The data collection was done using the Zarit Burden Questionnaire and the Caregiver Care Cost Assessment Questionnaire.

RESULTS

The study surveyed 376 participants, primarily females (N = 285, 75.8%) and married (N = 317, 84.3%), with a majority aged between 18 and 47 years (N = 322, 85.6%). The burden experienced by families with T1DM pediatric patients was moderate, with a mean total burden level score of 27.8 ± 16.3. For those employed, most reported working as usual (N = 107, 81.1%), with most spending less than two hours on care weekly (N = 76, 57.6%). A significant association was found between the financial impact of caregiving on saving, spending, and general financial stress and social burden (p < 0.01).

CONCLUSION

The findings show a moderate burden faced by caretakers of T1DM pediatric patients, with a strong correlation between the financial impact of caregiving on saving, spending, and general financial stress and burden level. The findings also highlight the significant impact of caregiving on the financial stress and lifestyle changes that caregivers endure.

Exploring ketoacidosis frequency and risk factors in childhood-onset type 1 diabetes: an 8-year retrospective study (2011-2018) at a tertiary paediatric hospital in Tripoli, Libya

OBJECTIVES

Diabetic ketoacidosis (DKA) stands as a critical, acute complication of type 1 diabetes. Despite its severity, there exists a dearth of data concerning the frequency and prevalence of DKA at the onset of type 1 diabetes in Libyan children. This study aimed to ascertain the frequency of DKA during the initial presentation of type 1 diabetes among children aged 0.5-14 years admitted to Tripoli Children's Hospital between 2011 and 2018.

METHODS

Employing a retrospective approach, the study examined the proportion of children with newly diagnosed type 1 diabetes who presented with DKA. Data analysis included estimating DKA frequency concerning age at presentation, sex, and age groups. The comparative analysis involved assessing DKA frequency between 0.5 and <2 and 2-14 years age groups. Logistic regression analysis evaluated the impact of age group, sex, and family history of type 1 diabetes on DKA and severe DKA occurrence.

RESULTS

Among 497 children with newly diagnosed type 1 diabetes, 39.2 % presented with DKA, of these 44.5 % had severe DKA. Females exhibited a higher DKA rate than males (OR 1.63, 95 % CI 1.13-2.34, p=0.009). Very young children (0.5 to <2 years) presented with DKA more frequently than those aged 2-14 years (OR 4.73, 95 % CI 2.65-8.47, p<0.001), and they were more likely to present in severe DKA (63.9 vs. 39.1 %, [OR 7.26, 95 % CI 3.65-14.41, p<0.001]).

CONCLUSIONS

The frequency of DKA at type 1 diabetes onset among children admitted to Tripoli Children's Hospital is notably high, with nearly half of the DKA episodes categorized as severe. Very young children notably demonstrated a fivefold increase in the likelihood of presenting with DKA.

Prevalence and prognosis of fulminant type 1 diabetes mellitus in The Middle East: a comparative analysis in a 5-year nationwide cohort

PURPOSE

To analyze the prevalence and progression of fulminant type 1 diabetes (FT1D) in Qatar.

METHODS

This retrospective study analyzed consecutive index- diabetic ketoacidosis (DKA) admissions (2015-2020) among patients with new-onset T1D (NT1D) in Qatar.

RESULTS

Of the 242 patients, 2.5% fulfilled the FT1D diagnostic criteria. FT1D patients were younger (median-age 4-years vs.15-years in classic-T1D). Gender distribution in FT1D was equal, whereas the classic-T1D group showed a female predominance at 57.6% (n = 136). FT1D patients had a mean C-peptide of 0.11 ± 0.09 ng/ml, compared to 0.53 ± 0.45 ng/ml in classic-T1D. FT1D patients had a median length of stay (LOS) of 1 day (1-2.2) and a DKA duration of 11.25 h (11-15). The median (length of stay) LOS and DKA duration in classic-T1D patients were 2.5 days (1-3.9) and 15.4 h (11-23), respectively. The FT1D subset primarily consisted of moderate (83.3%) and severe 916.7%) DKA, whereas classic T1D had 25.4% mild, 60.6% moderate, and 14% severe DKA cases. FT1D was associated with a higher median white cell count (22.3 × 103/uL) at admission compared to classic T1D (10.6 × 103/uL). ICU admission was needed for 66.6% of FT1D patients, compared to 38.1% of classic-T1D patients. None of the patients in the FT1D group had mortality, while two died in the classic-T1D group.

CONCLUSION

This is the first study establishing the existence of FT1D in ME, which presented distinctively from classic-T1D, exhibiting earlier age onset and higher critical care requirements. However, the clinical outcomes in patients with FT1D seem similar to classic T1D.

Incidence and predictors of mortality in children with diabetic ketoacidosis in the comprehensive specialized referral hospitals of West Amhara Region, Northwest Ethiopia: a retrospective follow-up study

Background

Diabetic ketoacidosis is one of the major life-threatening conditions associated with acute metabolic complications. It remains a major public health problem in developing countries such as Ethiopia.

Objective

To assess the incidence and prediction of mortality in children with diabetic ketoacidosis in West Amhara Region Comprehensive Specialized Referral Hospitals, Northwest Ethiopia, in 2022.

Methods

An institution-based retrospective follow-up study was conducted among 423 study participants with a confirmed diagnosis of diabetic ketoacidosis from 01/01/2017 to 31/12/2021. Data were entered, coded, cleaned, and checked using Epi-Data version 4.6 and exported to Stata version 14 for data analysis.

Results

A total of 401 child records were included in the final analysis and were followed for 3781 days during the study period. The overall mortality of children with diabetic ketoacidosis was 10.6 per 1000 person-days observed (95% CI: 7.8-14.4) during the entire follow-up period. Hypoglycemia (AHR=4.6; 95% CI: 2.13-10.1), rural residence (AHR=2.9; 95% CI=1.01-8.11), age younger than five (AHR=4.4; 95% CI=1.4-13.7) or between five and 10 (AHR=3.1; 95% CI=1.1-8.8), and female gender (AHR=2.6; 95% CI=1.1-5.8) were significant predictors of mortality.

Conclusions

The incidence rate of mortality in children with diabetic ketoacidosis was relatively high. Age, rural residence, female gender, and hypoglycemia were significantly predictive of mortality. Community education or mass campaigns about the signs and symptoms of diabetic ketoacidosis may reduce the mortality rate in children.

Epidemiological profile and diabetes control of Type 1 Diabetes Mellitus patients in Karbala Governorate, Iraq

Background: Type1 Diabetes Mellitus is a common chronic diseases among children, and associated with morbidity, mortality, and enormous healthcare expenditures. Objectives; to estimate the prevalence, incidence, and describe the epidemiological characteristics of Type 1 Diabetes Mellitus among children in Karbala governorate. Methods: A cross-sectional study was conducted among all children who attended the main DM center in Karbala Teaching Hospital for Children, Public Clinics, and Primary Health Care centers. Data was collected by structured questionnaire and biochemical and anthropometric measurements. The statistical analysis data entry was conducted using Statistical Package for Social Sciences. Results: Total number of Type 1 Diabetes Mellitus patients aged 0-15 years in Karbala in 2015 was 199; making 44.66/100 5. Fifty-four patients were newly diagnosed patients making an incidence of 12.11/100 5. There was nearly equal distribution among both sexes. Most of the cases were from urban areas and most of the patients had a Family history of Type 2 Diabetes Mellitus. Diabetic ketoacidosis was reported in 16.8% of the patients. Only 31.6% of patients had HbA1c < 7%. Half of the patients had a history of admission to the hospital for diabetes. Logistic regression analysis revealed that the only independent variables significantly correlated with poor glycemic control were lack of Self-Monitoring Blood Glucose, irregular visits to the Diabetic Center, and positive family history of diabetes. Conclusion: Only one-third of T1DM children in Karbala city had controlled blood sugar. Lack of regular blood glucose monitoring and irregular contact with health care providers were the main determinants of uncontrolled blood sugar.

Clinical and biochemical profile of childhood-adolescent-onset type 1 diabetes and adult-onset type 1 diabetes among Asian Indians

AIM

To compare the clinical and biochemical profile and prevalence of complications among childhood/adolescent-onset (CAO; onset of diabetes< 20 years of age) and adult-onset (AO; onset of diabetes- ≥ 20 years of age) type 1 diabetes (T1D), seen at a tertiary care diabetes center in south India.

METHOD

Data of 5578 individuals with T1D, diagnosed based on a history of diabetic ketoacidosis or ketonuria, fasting C-peptide < 0.3 pmol/mL and stimulated C-peptide values < 0.6 pmol/mL, and requirement of insulin right from the time of diagnosis, presenting to our center between 1991 and 2021, were retrieved from our electronic medical records. Retinopathy was assessed by retinal photography, chronic kidney disease (CKD) by urinary albumin excretion ≥ 30 µg/mg of creatinine and/or eGFR < 60 mL/min, and neuropathy by vibration perception threshold >= 20v on biothesiometry.

RESULTS

Overall, 3559 (63.8%) of individuals with T1D, belonged to CAO group and 2019 (36.2%) to AO category. AO had higher prevalence of all microvascular complications compared to CAO at every diabetes duration interval, even after adjusting for A1c. Among the AO group, prevalence of retinopathy, CKD, and neuropathy was higher in the GAD negative group. Among CAO there were no differences between the GAD negative and GAD positive groups with respect to prevalence of complications of diabetes.

CONCLUSION

AO with T1D had higher prevalence of microvascular complications compared to CAO. Among AO, GAD negative individuals had higher percentage of retinopathy and CKD compared to GAD positive group.

Experiences and needs of Saudi mothers when a child or adolescent is diagnosed with type 1 diabetes mellitus: a qualitative study

Aim

To explore the experiences of Saudi mothers with children or adolescents who have Type 1 diabetes mellitus at time of diagnosis.

Background

The Kingdom of Saudi Arabia (KSA) has one of the highest incidence rates of Type 1 diabetes mellitus in children and adolescents in the world. Few studies have considered the most appropriate methods of support for parents in the KSA and none report the experiences of Saudi mothers.

Design

Phenomenological inquiry.

Method

Qualitative interviews were conducted with 11 Saudi mothers and data were analysed following Giorgi’s 5-step method.

Results

The lived experiences of Saudi mothers coalesced around three overarching themes and eight subthemes: 1. In the dark (mother’s instinct, challenges of diagnosis phase, cultural reflections); 2. Empowerment (methods of support, mother’s health and wellbeing); 3. Coping and acceptance (stigma and cultural perceptions, coping strategies, transformation and adaptation).

Conclusions

Effective interventions delivered in other countries to support mothers may be effective in the KSA. However, the central role that Saudi mothers play in the management of their child’s condition, and the place of Islam in Saudi society, indicate the need for customized methods of support that take into account psychosociocultural needs of both mother and child.

An Audit of Factors Impacting the Time to Resolution of the Metabolic Parameters in Diabetic Ketoacidosis Patients

INTRODUCTION

Diabetic ketoacidosis (DKA) is a major complication affecting patients with diabetes. It is often the first presentation of type I diabetes and can also occur due to a lack of compliance with insulin therapy or infection, among other causes. Hospitalizations for DKA have increased globally among patients with type I and type II diabetes, which poses a strain on health systems.

AIM

To determine the factors impacting the time to resolution of metabolic parameters in DKA patients.

METHODS

This retrospective study was performed by reviewing the clinical records of hospitalized DKA patients at King Fahad Specialist Hospital, a tertiary-level healthcare center in Buraidah, Al Qassim region, Saudi Arabia. The study included all DKA admissions that met the inclusion criteria between September 2019 and April 2022.

RESULTS

A total of 129 patients with a diagnosis of DKA from January 2019 to April 2022 were identified. Of these, 67 patients met the inclusion criteria. More females experienced DKA (56.7%), and the study population had an improvement rate of 97%. The mean length of stay (LOS) for patients with DKA was 73.19 hours, and the median time for DKA resolution was 15 hours (mean time 21.38 hours). The omission of insulin was the leading precipitating factor for DKA (43%) followed by infection (12%). A high serum bicarbonate (HCO3) level was identified as an independent predictor for a longer time to resolution. Patients with DKA who have high glucose levels on admission, higher body mass index (BMI), older age, and higher weight stayed in the hospital for extended periods. Conversely, patients with a higher serum potential of Hydrogen (pH) had a shorter LOS. Age was the only clinically independent predictor for a minimum LOS for DKA. Patients with comorbidities had a longer hospital LOS than patients without comorbidities; no such relationship has been reported in other studies. Patients in our study population had a longer time of resolution than observed in other studies, although no clear cause was identified.

CONCLUSION

This study contributes to our understanding of DKA in hospitalized patients in Saudi Arabia. This is the first study to link patients with DKA who have comorbidities to a longer hospital stay in the kingdom of Saudi Arabia. This study also identified multiple clinical and biochemical parameters related to the variability in LOS and time to resolution of DKA in hospitalized patients.

Adherence as a Predictor of Glycemic Control Among Adolescents With Type 1 Diabetes: A Retrospective Study Using Real-World Evidence

PURPOSE

Metabolic control among adolescents with type 1 diabetes mellitus (T1DM) is generally poor. Nonadherence is a contributor to this poor glycemic control, leading to adverse outcomes. The findings of studies reporting the association between adherence and glycemic control are conflicting. This study aimed to assess the level of adherence among adolescents with T1DM and its relationship with glycemic control.

METHODS

This was a retrospective, cross-sectional study that was conducted at Sidra Medicine, a state-of-the-art tertiary health care facility for women and children in Qatar. Mean blood or interstitial glucose monitoring frequency (BGMF) was used to assess adherence level among adolescents with T1DM, whereas glycemic control was assessed via documented glycated hemoglobin A_1c (HbA_1c). Adolescents who had a mean BGMF of ≥4 checks per day were considered adherent, and those who had an HbA_1c level of <7% were considered as having controlled diabetes. Correlational and logistic regression analyses were performed to assess the relationship between adherence and glycemic control, incorporating other covariates into the model.

FINDINGS

The rate of adherence among adolescents with T1DM in Qatar was 40.9%. Adherent adolescents had significantly lower median HbA_1c levels compared with nonadherent adolescents (9.0% vs. 9.7%; P = 0.002). A significant negative correlation was found between BGMF and HbA_1c level (correlation coefficient r_s = -0.325; P < .001). Approximately 97% of nonadherent adolescents compared with 87% of adherent adolescents had suboptimal diabetes control (HbA_1c ≥7%) (P = .016). Furthermore, nonadherent adolescents were 78% less likely to have controlled diabetes compared with adherent adolescents (adjusted odds ratio = 0.221; 95% CI, 0.063-0.778; P = 0.019). The combined effect of the determinants of glycemic control among adolescents with T1DM that were included in the multiple regression model was able to explain approximately 9% of the variances in glycemic control (Cox and Snell R² = 0.092).

IMPLICATIONS

The current findings suggest that nonadherence was highly prevalent among adolescents with T1DM and was a significant independent predictor of glycemic control, explaining 9% of the variability. This finding warrants further exploration of other possible predictors of poor glycemic control among the adolescent population. Comprehensive interventions, including educational, technological, and health service delivery aspects, aimed at improving adherence and ultimately optimizing glycemic control are warranted in adolescents with T1DM.

Burden of type 1 diabetes mellitus in the North Africa and Middle East Region, 1990-2019; findings from the global burden of disease study

AIMS

We aimed to report the burden of type 1 diabetes mellitus (T1DM) in the North Africa and Middle East region and its 21 countries from 1990 to 2019.

METHODS

Information related to incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and years lived with disability (YLDs) of T1DM was acquired from the 2019 Global Burden of Disease study. The burden was estimated by sex, age groups, and socio-demographic index (SDI) in 21 countries.

RESULTS

Over the past 30 years, regional incidence, prevalence, mortality, and DALYs of T1DM increase by 188.7%, 304.8%, 43.7%, and 71.6%, respectively. While the age-standardized incidence and prevalence rates increased by 84% and 91%, the mortality and DALYs rates decreased by 34% and 13%. During these years, the contribution of YLDs to total DALYs increased considerably (from 17% to 42%). The highest increase in the incidence and prevalence rates occurred in high SDI countries. Moreover, the Mortality to Incidence Ratio (MIR) decreased in the region countries.

CONCLUSIONS

Despite progress made in diabetes care, there is a persistently increasing burden of T1DM in the region countries. This indicates that T1DM is still one of the major health challenges in the region countries, especially in high SDI Arab countries.

Base excess measured at hospital admission is useful for predicting diabetic ketoacidosis severity and resolution time in adult patients

BACKGROUND AND AIMS

This study aimed to identify the biochemical factors measured at hospital admission that could predict diabetes ketoacidosis (DKA) resolution time in adult patients.

MATERIALS AND METHODS

This retrospective study included 79 patients >18 years of age. Multivariate analyses were performed to determine which variables might predict DKA resolution time. Biochemical parameters between the two DKA resolution time groups were compared.

RESULTS

Using multiple linear regression models, acidosis time was found to decrease by 29 h if the pH value increased by one unit, 0.64 h if the base excess (BE) value increased by 1 mmol, and 1.09 h if the bicarbonate (HCO3^-) value increased by 1 mmol. The biochemical parameters that differed between the two groups were pH, HCO3^-, and BE. Patients with delayed resolution of DKA had a blood pH of 7.1 (±0.18), HCO3^- of 5.1 mmol (2.9-11.6 mmol), and BE of -21.5 mmol (-28.2 to -14.4 mmol) at hospital admission.

CONCLUSIONS

Lower pH, HCO3^-, and BE values at hospital admission may predict longer DKA resolution times in adult patients. In addition, BE may predict DKA severity.

Efficacy and Safety of SGLT2 Inhibitors as Adjunctive Treatment in Type 1 Diabetes in a Tertiary Care Center in Saudi Arabia

Background  Adjunctive treatment with sodium-glucose co-transporters 2 inhibitors (SGLT2- I) has been successfully used in patients with type 1 diabetes mellitus (T1DM) in recent years to improve glycemic control and reduce body weight without increasing the risk of hypoglycemia; however, there is a scarcity of evidence for real-world experience in their use in T1DM Saudi patients. The purpose of this study was to evaluate the efficacy and safety of empagliflozin as off-label adjunctive therapy in Saudi patients with T1DM. Methods  This study was a retrospective study for T1DM patients, who were prescribed empagliflozin as an adjunctive therapy. Baseline characteristics including age, changes in HbA1c, body weight, total daily insulin dose, lipid profile, and well as side effects such as urinary tract infections (UTIs) and diabetes ketoacidosis (DKA) were evaluated before and after initiation empagliflozin in 37 T1DM patients. Results  The mean age was 25.8 ± 8.0 years, mean weight was 75.3 ± 14.8 kg, mean body mass index (BMI) was 28.1 ± 6.7 kg/m 2 , mean duration of diabetes was 10.1 ± 6.5 years, and mean HbA1c was 9.4 ± 1.4%. After a mean follow-up duration of 15.8 ± 6.0 months, the mean reduction in the HbA1c% from baseline was 0.82% ( p  = 0.001) and mean weight reduction from baseline was 1.7 kg ( p  = 0.097). The total daily insulin dose was decreased by 2.9 units. UTIs and DKA episodes were reported among 2.7% and 10.8% of the participants, respectively. Conclusion  Empagliflozin in combination with insulin in overweight Saudi T1DM subjects resulted in a significant improvement in glycemic control, mild non-significant reduction in body weight, and a small but statistically significant reduction in the total daily insulin dose with a slight increase in the risk of DKA and UTIs. Further larger prospective studies are needed for better evaluation of the efficacy and safety of these agents in Saudi T1DM patients.

Lifetime risk and health-care burden of diabetic ketoacidosis: A population-based study

OBJECTIVE

Diabetic ketoacidosis (DKA) is a life-threatening complication of both type 1 and type 2 diabetes. We aimed to assess population-based rates, trends and outcomes of patients with DKA.

DESIGN AND METHODS

This is a nationwide cohort study using hospital discharge claims data from 2010 to 2018 in Switzerland. Incidence rates and in-hospital outcomes of DKA were analyzed throughout lifetime for children (0-9 years), adolescents (10-19 years), and adults (20-29, 30-59, and 60-90 years). Analyses were stratified for type of diabetes mellitus and sex.

RESULTS

In total, 5,544 hospitalizations with DKA were identified, of whom 3,847 were seen in patients with type 1 diabetes and 1,697 in type 2 diabetes. Incidence rates of DKA among patients with type 1 diabetes were highest during adolescence with 17.67 (girls) and 13.87 (boys) events per 100,000 person-years (incidence rate difference [IRD]: -3.80 [95% CI, -5.59 to -2.02]) and decreased with age in both sexes thereafter. Incidence rates of DKA in patients with type 2 diabetes were low up to an age of 40 years and rose to 5.26 (females) and 6.82 (males) per 100,000 person-years in adults aged 60-90 years. Diabetic ketoacidosis was associated with relevant health-care burden independent of age, sex, or type of diabetes. The population-based incidence rate of DKA increased over time from 7.22 per 100,000 person-years in 2010 to 9.49 per 100,000 person-years in 2018.

CONCLUSIONS

In type 1 diabetes highest incidence rates of DKA hospitalizations were observed among adolescent females. In comparison, in patients with type 2 diabetes the risk for DKA steadily increased with age with higher rates in adult males. Over the 9 year study period, incidence rates of DKA were increasing irrespective of type of diabetes. DKA was associated with a high burden of disease reflected by high rates of intensive care unit admission, prolonged hospital stay and high mortality rates, especially in elderly.

COVID-19 Precautionary Measures and Type 1 Diabetes Patients in Saudi Arabia

AIM

To minimize the spread of COVID-19, the Kingdom of Saudi Arabia (KSA) enforced a nationwide lockdown. We aimed to explore whether the manner in which Saudi patients with type 1 diabetes (T1D) manage their disease has changed during this unparalleled lockdown.

METHODS

An online survey exploring the effect of lockdown on T1D outcomes was distributed among T1D patients residing in KSA during lockdown.

RESULTS

A total of 1010 patients responded to the survey. Around 40% reported communicating with their physicians during lockdown. Age, level of education, residence, previous visits to diabetes education clinics, last HbA1c value, and average monthly income were all significantly associated with communication with the treating physician (p = 0.008, p < 0.001, p < 0.001, p = 0.002, p < 0.001, and p < 0.001, respectively). Age, level of education, and average monthly income were significantly associated with experiencing severe hypoglycemia (p = 0.036, p = 0.03, and p < 0.001, respectively), while average monthly income and level of education were significantly associated with experiencing diabetic ketoacidosis (DKA) (p < 0.001 and p = 0.0039, respectively); during lockdown. Patients who communicated with their physicians reported lower rates of severe hypoglycemia compared to those who did not (25.2% vs 30.7%, respectively).

CONCLUSION

Age and level of education were significantly associated with communication with the treating physician, and experiencing severe hypoglycemia and DKA; in patients with T1D during the lockdown period in Saudi Arabia. Keeping two-way virtual communication channels between physicians and their T1D patients should be encouraged.

Frequency of Diabetic Ketoacidosis in Patients with Type 1 Diabetes Using FreeStyle Libre: A Retrospective Chart Review

INTRODUCTION

Diabetic ketoacidosis (DKA) is an acute complication associated with poorly managed or undiagnosed diabetes. DKA is associated with significant morbidity, mortality, and healthcare costs, but can be prevented with appropriate management of diabetes. The FreeStyle Libre is flash glucose monitoring device that measures glucose levels in the interstitial subcutaneous tissue and has been shown to reduce HbA1c, time in hypoglycemia and hyperglycemia, as well as improve health-related quality of life.

METHODS

A retrospective chart review of patients with type 1 diabetes mellitus (T1DM) and recurrent DKA and who initiated FreeStyle Libre (Abbott Diabetes Care, Alameda, CA, USA) was conducted. DKA frequency and severity, glycated hemoglobin (HbA1c), and frequency of blood glucose monitoring were compared between the 2-year period before FreeStyle Libre initiation and the 2-year period after FreeStyle Libre initiation.

RESULTS

A total of 47 patients with T1DM with recurrent DKA were included. FreeStyle Libre was associated with a reduction in the frequency of DKA events, with a mean of 0.2 (standard deviation [SD] 0.4) events per person during the 2 years after FreeStyle Libre initiation versus 2.9 (SD 0.9) during the 2 years before FreeStyle Libre initiation. Severity of DKA events was also reduced, with fewer severe (before mean 0.3 [SD 0.5] versus after 0.0 [SD 0.0]; p < 0.001) DKA events. A reduction in HbA1c (mean 7.4% [SD 0.5] after versus 9.9% [SD 1.2] before [p < 0.001]) and an increase in frequency of blood glucose testing (mean 8.1 scans/day [SD 1.7] after versus 2.2 finger-pricks/day [SD 0.7] at before [p < 0.001]) were also observed.

CONCLUSION

FreeStyle Libre is associated with a reduction in the frequency and severity of DKA events, reduction in HbA1c, and increase in frequency of blood glucose testing in patients with T1DM and recurrent DKA. The use of such a glucose monitoring tool can help to reduce the burden of morbidity, mortality, and healthcare costs associated with complications of diabetes.

Barriers to Diabetes Adherence: Translation and Cultural Adaptation of the Instrument Into Arabic Context

OBJECTIVES

Barriers to Diabetes Adherence (BDA) instrument is a measure developed in English to assess barriers to adherence in adolescents with type 1 diabetes (T1DM). The main objectives of the present study were to translate and culturally adapt the BDA tool into Arabic for the assessment of barriers to adherence in adolescents with T1DM in Arabic-speaking populations.

METHODS

The International Society for Pharmacoeconomics and Outcomes Research guidelines for the translation and cultural adaptation of patient-reported outcome measures were used for the process. Permission to use the instrument was obtained from the developers. This was followed by 2 forward translations of the tool into Arabic. The 2 Arabic versions were combined into a reconciled Arabic version that was then back-translated into English. This was then tested against the original tool. The resultant Arabic version underwent a cognitive debriefing process to assess its comprehension and appropriateness among potential users, and this resulted in further refinements, leading to the final Arabic version of the tool.

RESULTS

The translation and cognitive debriefing processes revealed issues related to the cultural or conceptual equivalence of the tool that were addressed and resolved by rewording, restructuring, or addition or elimination of words or phrases that in certain circumstances necessitated communications with the developers for further clarifications of the intended meaning of relevant items. This process generated an easy, comprehensive, clear, and culturally acceptable tool as proven by the cognitive debriefing and clinical review processes.

CONCLUSION

A culturally acceptable Arabic translation of the BDA tool was developed to be used in adolescent Arabic population with T1DM.

Incidence, prevalence and clinical manifestations at onset of juvenile diabetes in Tanzania

Better knowledge on incidence, prevalence and clinical manifestations is needed for planning diabetes care in Sub Saharan Africa.

AIMS

To find a crude incidence/prevalence of diabetes in children and young adults in a low resource setting, classify the diabetes and audit the health record keeping.

METHODS

A retrospective observational study based on medical recordings 2010-2016. Target population was children and adolescent registered in Changing Diabetes in Children (CDiC) or Life for a Child (LFAC) programs for children with T1DM and diagnosed at 5 diabetes clinics in three geographical regions of Tanzania. 604 patients' files were available from five hospitals.

RESULTS

336/604 files covered patients <15 years of age at diagnosis. The prevalence of diabetes <15 years of age ranged from 10.1 to 11.9 per 100,000 children and the annual incidence 1.8-1.9/100,000 children, with peak incidence at 10-14 years. A lot of data were missing. The great majority of the patients presented with typical signs and symptoms of T1D, 83.7% with plausible ketoacidosis (DKA).

CONCLUSIONS

Diabetes incidence and prevalence is still low. T1D seems to dominate with very high frequency of DKA at diagnosis. Increased awareness of diabetes both in health care and community is needed.

Ischaemic Haemorrhagic Stroke in a Child with New Onset Type 1 Diabetes Mellitus

Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient’s with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.

Type 1 Diabetes Mellitus in Saudi Arabia: A Soaring Epidemic

Type 1 diabetes mellitus (T1DM) is quite prevalent in the world, with a proportion of 1 in every 300 persons and steadily rising frequency of incidence of about 3% every year. More alarmingly, the incidence of T1DM among infants is also increasing, with children as young as 6 months succumbing to it, instead of that at a rather established vulnerable age of around seven and near puberty, when the hormones antagonize the action of insulin. These reports pose a unique challenge of developing efficient T1DM management system for the young children. The Kingdom of Saudi Arabia (KSA) is the largest country in the Middle East that occupies approximately four-fifths of the Arabian Peninsula supporting a population of more than 33.3 million people, of whom 26% are under the age of 14 years. As per the Diabetes Atlas (8th edition), 35,000 children and adolescents in Saudi Arabia suffer from T1DM, which makes Saudi Arabia rank the 8th in terms of numbers of TIDM patients and 4th country in the world in terms of the incidence rate (33.5 per 100,000 individuals) of TIDM. However, in comparison with that in the developed countries, the number of research interventions on the prevalence, incidence, and the sociodemographic aspects of T1DM is woefully inadequate. In this review we discuss different aspects of T1DM in Saudi Arabia drawing on the published literature currently available.

Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review

OBJECTIVES

To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration).

DESIGN

Systematic literature review (SLR).

DATA SOURCES

Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016).

STUDY SELECTION

Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised.

RESULTS

Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0-56 per 1000 person-years (PYs), with one outlying study reporting an incidence of 263 per 1000 PYs. Eleven studies reported prevalence with a range of 0-128 per 1000 people. Prevalence of DKA decreased with increasing age. Subgroup analyses were performed using data from no more than two studies per subgroup. There was a higher prevalence of DKA reported in women, non-whites and patients treated with insulin injections compared with men, whites and patients using continuous subcutaneous insulin infusion pumps, respectively.

CONCLUSIONS

To our knowledge, this is the first SLR on the epidemiology of DKA in T1D adults. Despite an increasing prevalence of T1D in recent years, DKA in adults has been poorly characterised. In an era when the benefit-risk profiles of new antidiabetic therapies are being evaluated, including the potential risk of DKA, there is a clear need to better elucidate the expected rate of DKA among T1D adults.