Immunogenetic studies on malnutrition-modulated diabetes mellitus

Malnutrition-Modulated Diabetes Mellitus in Children, Rare Disease with Atypical Presentation: Case Report

AIM

Atypical diabetes is commonly reported in Africa. The objective of this case report is to highlight an unusual case of thin, severely hyperglycemic and ketone resistant teenager with history and signs of chronic under-nutrition to raise the awareness of clinicians on the existence of atypical phenotype of diabetes not fitting the current classification of diabetes.

CASE PRESENTATION

A 17-year-old male patient, known diabetic, was diagnosed in the health center as type1 diabetes for 8 months. He was on insulin for 3 months and discontinued for 5 months. He presented with polydipsia, polyuria, and weight loss since he discontinued the drug. On examination, he was severely wasted and underweight with unexplained bilateral parotid enlargement. On investigations;, he had hyperglycemic, glucosuria but no ketonuria. The patient was admitted with the diagnosis of type 1 diabetes and severe acute malnutrition. He started insulin (1IU/Kg/day) subcutaneously and nutritional management. On follow-up, RBS and FBS remained high and insulin was escalated to 3.32 IU/kg/day. Subsequently, serial RBS and FBS, the measurements were in the acceptable range and the patient was gaining weight. As the weight increases, his demand for insulin was decreased and the dose of insulin was de-escalated to 1.2 IU/Kg/day over 3 months. Finally, the patient was discharged with 1.2 IU/Kg/day with a weight of 44 kg over 4 months of hospital course with the diagnosis of malnutrition-modulated diabetes. Now, the patient is in diabetic clinic follow-up with good glycemic control.

CONCLUSION

Though there are unclear and uncertainties in malnutrition-modulated diabetes mellitus, clinicians need a high index of suspicion to reach the diagnosis especially in those countries where malnutrition is common. Early diagnosis and appropriate management of the patients demand are important in patient care and outcome.

Vitamin A: a missing link in diabetes?

Vitamin A has a critical role in embryonic development, immunity and the visual cycle. In recent years, evidence has demonstrated that vitamin A can also regulate metabolic pathways implicated in the pathogenesis of obesity and diabetes. This has increased interest in the possible antiobesity and antidiabetic properties of natural and synthetic vitamin A derivatives. However, whether vitamin A deficiency or aberrations in vitamin A metabolism contribute to the pathogenesis of diabetes is not known. This perspective article will review what is currently known and new data regarding the link between vitamin A and the clinical manifestations of common and atypical forms of diabetes.

Diabetes in rural individuals of different nutritional status and the alarming situation demands focus more on its under-nutrition association

OBJECTIVE

To study the relationship of nutritional-status with diabetes.

DESIGN

The socioeconomics/anthropometrics, blood-glucose/systemic-hypertension are evaluated in consecutively-selected diabetic-patients.

SETTING

Semi-urban/rural India.

SUBJECTS

Hyperglycaemic patients (total 90/male 37).

RESULTS

Blood-glucose (PP-mean ± SE) in individuals is overweight - 38.89% (226.94 ± 9.59), normal-weight - 50% (217.58 ± 1.34), underweight - 11.11% (305.50 ± 21.35) indicating most hyperglycaemia in undernourished-group (F = 6.357, p < 0.003). This group occupies higher glucose-groups in ≤140, 141-270, and ≥270 mg/dL. The blood-glucose negatively correlates with waist(r = -0.282; p < 0.01) and hip (r = -0.254; p < 0.05) circumference indicating the under-nutrition association with glucose-homeostasis (F = 7.6-8.2, p < 0.001). The higher glucose is noticed in more number of individuals in lower (<40 years) age-group (χ(2 )= 12.86; p < 0.002/ρ = -0.355; p < 0.001). The prevalence of hypertension is 28% (underweight = 20%, overweight = 27%, normal = 30%). The group of 141-270 mg/dL glucose has 45% and rest groups together have 23% hypertensive individuals relating directly, hypertension and diabetic-onset.

CONCLUSIONS

Diabetes, explored in <40 years group and even more in female should be extensively studied accounting WHO categorization (1985/TRS/727) of malnutrition related diabetes (MRDM). Further, different interactive risk-factors should be properly addressed and the global-malnutrition/gender-based inequities be eradicated.

HLA and disease

Association of HLA and diseases is well known. Several population studies are available suggesting evidence of association of HLAs in more than 40 diseases. HLA found across various populations vary widely. Some of the reasons attributed for such variation are occurrence of social stratification based on geography, language and religion, consequences of founder effect, racial admixture or selection pressure due to environmental factors. Hence certain HLA alleles that are predominantly associated with disease susceptibility or resistance in one population may or may not show any association in other populations for the same disease. Despite of these limitations, HLA associations are widely studied across the populations worldwide and are found to be important in prediction of disease susceptibility, resistance and of evolutionary maintenance of genetic diversity. This review consolidates the HLA data on some prominent autoimmune and infectious diseases among various ethnic groups and attempts to pinpoint differences in Indian and other population.

Low-carbohydrate–high-protein diets

Since the last meeting of the American Heart Association, a great deal of media attention has been focused on low-carbohydrate-high-protein diets (LC-HP) and their potential impact on the practice of cardiology. It has been suggested that these diets, which were introduced originally as weight-loss regimens, also have a significantly beneficial effect on a variety of cardiovascular risk factors. It is clear that people who consume such diets have a reduced intake of calories, resulting in a predictable degree of weight loss. These diets induce a moderate level of ketosis and, in some studies, have been shown to improve the lipid profile overall. There is also a reduction in the number of low-density lipoprotein particles. However, these trends also have been observed over periods of 24 weeks or less with low-calorie diets that already have an established record of safety and efficacy. Although there is a public perception that LC-HP diets have a near-perfect "success rate," the attrition rate on these diets varies from 20% to 43%, which is similar to other conventional weight-loss regimens. Additionally, from a nutritional standpoint, these diets are seriously deficient in several micronutrients and dietary fiber, thus creating a need for nutritional supplements. In contrast, the conventional weight-loss regimens have a favorable impact on serum lipids without the accompanying ketosis and have the potential to provide a nutritionally balanced diet without the need for supplements. Because of the nutritional deficiencies inherent in LC-HP diets and the absence of long-term data on their efficacy and safety, they cannot be recommended in place of currently advocated low-fat, low-calorie diets that have an established record of safety and efficacy.