[Food intake, and anthropometrical and biological parameters in adult Tunisians during Ramadan]

We evaluated the effects of fasting during Ramadan on nutritional intake and plasma lipoproteins in 20 healthy adults of normal weight. A 5-day food questionnaire was completed for every participant. Clinical investigations, anthropometrical measurements and laboratory analysis were also undertaken. Body weight, blood pressure and blood glucose were not influenced by fasting but there were non-significant modifications in the plasma lipid fractions. The total cholesterol remained unchanged. Total daily energy intake was comparable before, during and after Ramadan despite the decrease in meal frequency during fasting. Thus fasting in Ramadan did not affect dietary intake, clinical, anthropometrical and most biological parameters

Waist circumference cut-off points for identification of abdominal obesity among the tunisian adult population

AIMS

Waist circumference (WC) is a convenient measure of abdominal adipose tissue. It itself is a cardiovascular disease (CVD) and diabetes-risk factor and is strongly linked to other CVD risk factors. There are, however, ethnic differences in the relationship of WC to the other risk factors. The aim of this study was to determine the optimal cut-off points of WC and body mass index (BMI) at which cardiovascular risk factors can be identified with maximum sensitivity and specificity in a representative sample of the Tunisian adult population and to investigate any correlation between WC and BMI.

METHODS

We used a sample of the Tunisian National Nutrition Survey, a cross-sectional population-based survey, conducted in 1996 on a large nationally representative sample, which included 3435 adults (1244 men and 2191 women) of 20 years or older. WC, BMI, blood pressure and fasting blood measurements (plasma glucose, total cholesterol, triglycerides) were recorded. Receiver operating characteristic (ROC) curve analysis was used to identify optimal cut-off values of WC and BMI to identify with maximum sensitivity and specificity the detection of high blood pressure, hyperglycaemia, high blood cholesterol and hypertriglyceridaemia.

RESULTS

ROC curve analysis suggested WC cut-off points of 85 cm in men and 85 cm in women for the optimum detection of high blood pressure, diabetes and dyslipidaemia. The optimum BMI cut-off points for predicting cardiovascular risk factors were 24 kg/m(2) in men and 27 kg/m(2) in women. The cut-off points recommended for the Caucasian population differ from those appropriate for the Tunisian population. The data show a continuous increase in odds ratios of each cardiovascular risk factor, with increasing level of WC and BMI. WC exceeding 85 cm in men and 79 cm in women correctly identified subjects with a BMI of >/=25 kg/m(2), sensitivity of >90% and specificity of >83%.

CONCLUSIONS

Based on the ROC analysis, we suggest a WC of 85 cm for both men and women as appropriate cut-off points to identify central obesity for the purposes of CVD and diabetes-risk detection among Tunisians. WCs of 85 cm in men and 79 cm in women were the most sensitive and specific to identify most subjects with a BMI >/=25 kg/m(2).

[Hypertension and insulin treatment in type 2 diabetes]

Insulin resistance and endogenous hyperinsulinemia are associated with blood hypertension.

OBJECTIVE

The aim of this analysis is to estimate the prevalence of blood hypertension one year after insulin treatment in type 2 diabetic patients.

MATERIAL

and methods: This is a retrospective clinical study of 178 type 2 diabetic patients (57 men and 121 women) insulin treated since at least one year. Mean age is 62 +/- 10 years and mean duration of diabetes is ten years. All patients had a clinical and biological control before treatment with insulin and at least three controls during the first year of insulin treatment (anthropometric measurements, blood pressure, fasting plasma glucose, HbA1C). WHO definition of hypertension is used (blood pressure >or=140 / 90 mmHg).

RESULTS

At baseline, 48% of patients have hypertension. After insulin treatment, the prevalence of hypertension significantly increase to 53% (94 / 178) three months later (p=0.008), to 54.5% (98 / 178) six months later (p=0.001) and to 55.6% (99 / 178) twelve months later. This increase in hypertension frequency is associated with a significant weight gain and a better blood glucose control.

CONCLUSION

Insulin therapy may contribute to the development of blood hypertension. It promotes renal sodium retention and increases sympathetic nervous system activity. In the UKPDS intensive blood glucose control with insulin is not associated with an increase of macro vascular complications. These observational data suggest the need for further study of the relationship between exogenous insulin and hypertension.

[Prevalence of celiac disease serological markers in Tunisian type 1 diabetic adults]

OBJECTIVE

to evaluate the prevalence of celiac serological markers; anti-transglutaminase (ATGt), anti-endomysium (AE), anti-gliadin (AGD) and anti-reticulin (AR) antibodies; in type 1 diabetic Tunisian adults.

SUBJECTS AND METHODS

261 type 1 diabetic patients aged from 16 to 60 years were enrolled in this prospective study. IgG and IgA transglutaminase and gliadin were measured with ELISA. IgA AE were tested by indirect immunofluorescence using 2 substrates; monkey oesophagus and human umbilical cord. AR were detected by indirect immunofluorescence on rat liver, kidney and stomach. Sera IgA level was measured by turbidimetry.

RESULTS

83/261 of diabetics were positive for at least one antibody, 5.7% had ATGt-A, 3.4% AE on monkey esophagus, 3.1% AE on umbilical cordon, 18% AGD-A, 19.5% AGD-G and 3.1% AR. There was an excellent concordance between AE and ATGt (r = 0.9). Out of the 261 diabetics, 5 had an IgA deficiency and one of them has IgG AE and ATGt.

CONCLUSION

serological markers of celiac disease seem to be frequent in diabetics. Nevertheless, diagnosis must be confirmed by histological studies which allow us to know the real prevalence of celiac disease in diabetic adults.

The global diabetes pandemic: the Tunisian experience

OBJECTIVE

The prevalence of diabetes mellitus is known to be increasing rapidly worldwide, but few population-based surveys have been undertaken in Africa or the Middle East. The aims of this study are to report the prevalence of diabetes mellitus and impaired fasting glucose (IFG) in Tunisia, to compare the prevalence to previous studies and to analyse the relationship between diabetes and age, sex, area of residency and body mass index (BMI).

SUBJECTS AND SETTING

We have used data from the Tunisian National Nutrition Survey, a cross-sectional health study providing a large nationally representative sample of the Tunisian population including 3729 adults. We used the American Diabetes Association diagnostic criteria to determine the prevalence of diabetes mellitus and IFG.

RESULTS

The overall diabetes prevalence was 9.9% (9.5% in men and 10.1 in women) giving age-adjusted prevalence of diabetes of 8.5% (7.3% in men and 9.6% in women). Step-wise logistic regression showed age of more than 40 years, urban residency and high BMI to each be significantly and independently related to diabetes prevalence. The prevalence of diabetes mellitus has more than doubled in Tunisia over a 15-year period.

CONCLUSIONS

Our study has demonstrated a high prevalence of diabetes in the adult population with a wide difference among the rural and urban areas with an increased prevalence compared to previous studies. The results underline the need to increase public awareness and to emphasize the benefit of lifestyle modification in order to prevent type II diabetes.

[Hypertension in polycystic ovary syndrome]

Polycystic ovary syndrome (PCOS) is associated with multiple cardiovascular risk factors. The aims of this study are to investigate the prevalence of hypertension in a female population with PCOS and to correlate hypertension with her clinical and hormonal profile.

MATERIALS AND METHODS

it is a transversal study of 79 PCOS patients with mean age of 25 +/- 7 years (range 13-44). PCOS diagnosis is made by Rotterdam consensus criteria's (2003). WHO definition of hypertension is used (BP 140/90 mmHg). Blood pressure is measured three times in each patient. Ovarian echography and biochemical assays (GnRH test, androgens, cholesterol, triglycerides, and oral glucose tolerance test) are made before the 5th day of the menstrual cycle.

RESULTS

12% of PCOS women have hypertension. Family history of hypertension is not a predictive factor of hypertension in our study. PCOS patients with hypertension are not significantly older than those without hypertension (28.4 +/- 6.5 vs. 25.2 +/- 7; p = 0.12). If compared to PCOS women without hypertension, those with hypertension have a significantly higher BMI (39.2 +/- 7 vs. 29.6; p = 0.0004). PCOS patients with and without hypertension do not differ significantly in their level of androgens and total cholesterol. Triglycerides level is higher in PCOS patients with hypertension (p = 0.06). In oral glucose tolerance test, areas under the curve of insulin and glucose are significantly higher in PCOS patients with hypertension (respectively p = 0.06 and 0.02). The area under the curve of LH during GnRH test is lower in PCOS patients with hypertension (p = 0.04).

Prevalence of metabolic abnormalities in the Tunisian adults: a population based study

AIMS

To estimate the prevalence of individual metabolic abnormalities and the cluster of metabolic abnormalities in a representative sample of the Tunisian adult population and to identify their relationship with gender, age and residency. The definition used is an adaptation of the NCEP ATP III definition, using total cholesterol>or=5.2 mmol/l instead of HDL-cholesterol.

MATERIALS AND METHODS

We used a sample of the Tunisian National Nutrition Survey (TNNS), a cross-sectional health survey conducted in 1996, to estimate the nutritional status of the population. The TNNS included 2 927 adults aged 20 years or older who had measurements of height, body weight, waist circumference, blood pressure, fasting plasma glucose, total cholesterol and triglycerides. The cluster of metabolic abnormalities was defined as the presence of three or more metabolic abnormalities.

RESULTS

The prevalence of abdominal obesity, hypertriglyceridemia, high total cholesterol, high blood pressure and high fasting plasma glucose was, respectively, 9%, 23%, 24%, 45% and 15% in men and 33%, 19%, 29%, 44% and 15% in women. The prevalence of the cluster was more frequent in women than in men (18% versus 13%, P<0.001) and in those living in urban communities (21% in women, 16% in men) rather than rural communities (11% in women, 8% in men) (P<0.001). The prevalence also increased significantly with age (P<0.001).

CONCLUSION

The cluster of metabolic abnormalities and its components are common in the Tunisian adult population and prevalence increases significantly with female sex, urban residency and age.

La pratique du jeûne du mois de Ramadan chez le diabétique de type 2

This study was designed to assess the effects of fasting during Ramadan on weight, blood pressure, metabolic control and plasma lipoproteins in diabetic patients. This study was conducted in December 2000 (Ramadan 1421) when the length of fasting was 12 hours a day. It included 38 type 2 diabetic patients (20 males and 18 females). Mean patient age was 51.410.5 years and mean body mass index (BMI) 28.94.7kg/m2. Three patients were treated with diet and 35 with oral hypoglycemic agents. Clinical and biochemical parameters were evaluated during three periods: three weeks before Ramadan (T0), at the fourth week of Ramadan (T1) and three weeks after the end of Ramadan (T2). During the month of Ramadan, a decrease in weight (0.52kg) and no change in blood pressure were observed. No metabolic complication occurred in our patients. A significant effect of Ramadan fasting was observed on glycemic control and lipoprotein levels. In patients whose fructosamine level before Ramadan was higher than 340micromol/l, plasma fasting glucose and serum fructosamine increased during Ramadan (p<0.003) and returned to initial levels at the end of Ramadan T2; in these patients also, a decrease of HDL-cholesterol (p<0.01) associated with an increase of LDL-cholesterol (p<0.003) were observed at T1 and disappeared at T2. But, in patients whose fructosamine level at T0 was lower than 340micromol/l, no effect on glycemic control and no significant effect on serum lipoprotein levels were found during Ramadan month. Ramadan fasting in type 2 diabetic patients seems to cause slight effects on glycemia and lipoprotein levels when previous metabolic control is quite good; but fasting induces more deterioration when previous control is poor.

Celiac disease in adult patients with type 1 diabetes mellitus in Tunisia

OBJECTIVE

Type1 diabetes mellitus may be associated with celiac disease. The prevalence of celiac disease as determined by screening among adult patients with type 1 diabetes is high with rates of 1.07.8% in Europe and U.S.A. The aims of the study are to determine the prevalence of celiac disease in adults with type 1 diabetes in Tunisia.

METHODS

348 consecutive adult patients with type1 diabetes were investigated prospectively and screened for celiac disease. The mean age was 28.45+/-10.74 years old. There were 176 females and 172 males. For the screening of celiac disease, we used immunoglobulin A (IgA) anti-endomysium (EMA) antibodies determined by an indirect immunofluorescence method. Anti-transglutaminase (tTG) antibodies were determined by an ELISA method. Those patients with positive results for anti EMA and or tTG were proposed for duodenal biopsy.

RESULTS

14 patients were positive for anti EMA and had high or a weak positive level of tTG antibodies. One patient from this group was already known to have celiac disease. Only 8 patients consented to biopsy and morphological changes were consistent with celiac disease in all cases. Prevalence of biopsy-proven celiac disease was 2.3% (95% CI=1.0-4.5%).

CONCLUSION

The present study confirms that celiac disease of adults is prevalent in type 1 diabetic patients in Tunisia. Serological screening for celiac disease in type 1 diabetes is important because many patients are asymptomatic and most are detected by the screening.

Prévalence et aspects cliniques des mycoses superficielles chez le diabétique tunisien en milieu hospitalier

OBJECTIVES

The prevalence of mycotic infection seems to be higher among diabetic patients than in the non-diabetic population. The aims of this study were to determine the frequency of mycosis and to compare clinical and fungal results.

PATIENTS AND METHODS

This transversal study included 307 type 1 and 2 diabetic patients admitted between January 1998 and January 2000. A dermatologist examined all patients. The mean age was 44 +/- 17 years and the duration of diabetes 8 +/- 6 years. Patients with suspected lesions underwent mycological examination.

RESULTS

Clinical signs of presumed fungal infection were found in 61% of patients, but mycosis was confirmed only in 30%. Fungal foot infection accounted 38% of the patients, mostly due to dermatophytes (94%). The commonest localizations of dermatophytes were interdigital (60%) followed by onychomycosis (30%). The main fungal agent was Trichophyton rubrum. The main risk factors for fungal infections were the age of patients (P = 0.0003) and duration of diabetes (P < 0.05). Interdigital foot localization of dermatophytes was correlated to age (P < 0.0001) and to the male gender (P < 0.01). The frequency of dermatophytes in nails was higher in type 2 diabetic patients (P < 0.01). Vulvovaginal candidosis and interdigital dermatophytes were more frequent in obese than in non-obese patients. The accuracy and specificity of direct examination were respectively 85% and 79%.

CONCLUSION

The high frequency of mycosis in diabetic patients at hospital is demonstrated. The main risk factors were age, male gender and obesity.

[Cortisol rhythm during the month of Ramadan]

We studied the nyctohemeral cortisol secretion rhythm and the cortisol response to 1-24 corticotropin during Ramadan in 11 healthy, male volunteers aged 20-35 years. Their response to 250 mg 1-24 corticotropin was investigated 2 weeks before Ramadan by testing daily at 08:00 and 20:00 hours. After 16-22 days of fasting, their cortisol levels were measured at 08:00 hours and their response to 1-24 corticotropin at 20:00 hours. Before Ramadan, the baseline cortisol level was significantly higher at 08:00 hours than at 20:00 hours and the cortisol response to 1-24 corticotropin was also higher at 08:00 hours but this difference was not significant. During Ramadan, the cortisol level at 08:00 hours was lower than at the same time before Ramadan; the level at 20:00 hours was slightly higher than at the same time before Ramadan. There was no significant difference between the cortisol response to 1-24 corticotropin at 20:00 hours during Ramadan and the responses before Ramadan at 20:00 hours and 08:00 hours.

[Metabolic effects of the month of Ramadan fasting on type 2 diabetes]

We assessed the effects of Ramadan fasting on metabolic control, particularly change of HDL-cholesterol in 25 type 2 diabetic patients treated with diet or oral agents, with good metabolic control. Clinical and biochemical parameters and food intake were evaluated 3 weeks before Ramadan, in the fourth week of Ramadan and 3 weeks after Ramadan.There were no changes in body weight and blood pressure nor any metabolic complications. The mean plasma fasting glucose, serum fructosamin and haemoglobin A1c did not change. We found a negative relation between cholesterol intake during Ramadan and the change of HDL-cholesterol. When cholesterol intake was lower than 400 mg/day, plasma HDL-cholesterol increased by 13% at the end of Ramadan and by 23% 3 weeks after Ramadan.

[Cortisol rhythm during Ramadan]

Nous avons étudié le rythme nycthéméral de sécrétion du cortisol et la réponse du cortisol à la 1-24 corticotropine pendant le ramadan chez 11 sujets volontaires sains, de sexe masculin, âgés de 20 à 35 ans. Ceux-ci ont d’abord été explorés deux semaines avant le ramadan par deux tests à 250 mg de 1-24 corticotropine pratiqués l’un à 8 h et l’autre à 20 h, puis après 16 à 22 jours de jeûne, par un dosage de la cortisolémie à 8 h et un test à la 1-24 corticotropine à 20 h. Avant le ramadan, le taux de cortisol de base était significativement plus élevé à 8 h qu’à 20 h et la réponse du cortisol à la 1-24 corticotropine était également plus élevée à 8 h qu’à 20 h mais cette différence était non significative. Pendant le ramadan, le taux de cortisol à 8 h s’abaisse par rapport à sa valeur à la même heure avant le ramadan ; le taux de 20 h s’élève légèrement par rapport à sa valeur à la même heure avant le ramadan. La réponse du cortisol à la 1-24 corticotropine à 20 h pendant le ramadan ne présente pas de différence significative avec les réponses avant le ramadan à 20 h et à 8 h

[Metabolic effects of Ramadan fasting on type 2 diabetes]

Nous avons analysé les effets métaboliques, en particulier les variations du cholestérol HDL, du jeûne du mois de ramadan chez 25 diabétiques de type 2 bien équilibrés traités par le régime ou les antidiabétiques oraux. Nos patients ont été évalués trois semaines avant le ramadan, durant la quatrième semaine du mois de ramadan et trois semaines aprés le mois de ramadan. Cette évaluation a comporté une enquête clinique, une enquête nutritionnelle et des analyses biologiques. Le jeûne du mois de ramadan n’a pas eu d’influence sur le poids, la tension artérielle, la glycémie, la fructosamine et l’hémoglobine A1c. Nous avons trouvé une relation négative entre les variations du cholestérol HDL et la consommation alimentaire de cholestérol. Le cholestérol HDL a augmenté de 13 % à la fin du jeûne et de 23 % trois semaines après la fin du jeûne chez les diabétiques ayant eu une consommation alimentaire de cholestérol inférieure à 400 mg/j

Efficacy and safety of bromocriptine in the treatment of macroprolactinomas

To assess the effectiveness of bromocriptine (BRC) as primary therapy in reducing the size of PRL-secreting macroadenomas with extra-sellar extension, we conducted a multicenter study in 29 patients without prior radiotherapy. Clinical presentation, response to medical treatment and long term follow-up of 29 patients with macroprolactinoma (pituitary mass more than 10 mm in diameter) were analysed. There were 19 women for 10 men. Mean age was 33 years. An hypogonadism was present in 94% of women vs 57% for men. Headaches and or visual abnormalities were present in 68% of women vs 90% of men. The mean basal serum prolactin level before treatment was 1 501 ng/ml: 202 ng/ml for women (range: 70-478 ng/ml) and 3 870 ng/ml for men (range: 100-20 476 ng/ml) and was correlated to tumoral size. 25 patients were treated with BRC as primary therapy with a mean dose of 9,7 mg/day (13 mg/day in men and 8 mg/day in women). BRC no malized serum PRL levels in all men and in 17/19 women over a mean period of 6 months, ranging from 3 to 72 months in both sexes. Tumor size was reduced by more than 50% in 18/29 patients (62%) with secondary empty sella in 5 patients and by less than 50% in 11 patients. Visual field improved in most of the patients in whom it was initially abnormal. Reduction in size was quite fast in most of patients but slower in some of them. The cumulative radiological response to BRC increased with time. Therefore, it appears that prolonged medical therapy is effective and safe in macroprolactinomas.

[Circadian rhythm of cortisol and its responsiveness to ACTH during Ramadan]

Changes in the nyctemeral pattern observed during Ramadan include diurnal fasting from sunrise to sunset and delayed and shortened periods of sleep. The purpose of the present study was to investigate the possible effect of these changes on the circadian rhythm of cortisol and its response to exogenous ACTH.

SUBJECTS AND METHODS

Eleven healthy male volunteers aged 20 to 35 years were studied for two weeks prior to Ramadan. Two short ACTH stimulation tests (250 microg ACTH 1-24 intravenously) at 8 a.m. and 8 p.m. An average 17 days after the beginning of the month of Ramadan, basal cortisol was measured at 8 a.m. and a short stimulation test was performed at 8 p.m.

RESULTS

Before Ramadan, cortisol level was higher at 8 a.m. (749.5 +/- 207 nmol/l) than at 8 p.m. (195.18 +/- 79 nmol/l, p<0.001) and the incremental cortisol response to exo genous ACTH was higher at 8 a.m. (peak at 1.167 +/- 46 nmol/l) than at 8 p.m. (peak at 950 nmol/l) (NS). During Ramadan, morning cortisol level (646.3 81 nmol/l) was lower than before Ramadan (NS). The 8 p.m. cortisol level (319 193 nmol/l) increased slightly during Ramadan (p=0.08) but remained lower than the morning level during Ramadan (p=0.001) and before Ramadan (p<0.001). There was not significant difference between cortisol responsiveness to exogenous ACTH at 8 p.m. during Ramadan (peak at 1.102 51 nmol) and at 8 a.m. and 8 p.m. during Ramadan.

DISCUSSION

Changes in eating and sleeping schedule was found to reduce morning cortisol level and raise the evening cortisol level. Adrenal sensitiveness to corticotropin stimulation did not appear to be impaired during Ramadan.

[Food intake, and anthropometrical and biological parameters in adult Tunisians during fasting at Ramadan]

We evaluated the effects of fasting during Ramadan on nutritional intake and plasma lipoproteins in 20 healthy adults of normal weight. A 5-day food questionnaire was completed for every participant. Clinical investigations, anthropometrical measurements and laboratory analysis were also undertaken. Body weight, blood pressure and blood glucose were not influenced by fasting but there were non-significant modifications in the plasma lipid fractions. The total cholesterol remained unchanged. Total daily energy intake was comparable before, during and after Ramadan despite the decrease in meal frequency during fasting. Thus fasting in Ramadan did not affect dietary intake, clinical, anthropometrical and most biological parameters.

Diabetic pregnancy in over 35 years old women

87 pregnancies in diabetic women older than 35 years at time of conception were studied. 3% were insulin-dependent diabetes mellitus (IDDM), 52% non insulin-dependent diabetes mellitus (NIDDM) and 45% gestational diabetes mellitus (GDM). Mean age was 38 +/- 3 years; BMI was 33.2 +/- 7.0 kg/m2; gestation rate was 5 +/- 3 and number of alive children was 2 +/- 2. Only 3% of pregnancies were planned. Mean time of reference to diabetic care unit was 17 +/- 10 weeks. 95% of the women required human insulin. Mean total daily insulin dose was 0.49 +/- 0.28 UI/kg/d, increasing with gestational age. Mean fasting glycemia was 6.85 +/- 1.93 mmol/l and mean post-prandial glycemia was 8.29 +/- 2.52 mmol/l. Mean time of delivery was 38 +/- 2.1 weeks (less than 37 weeks in 9%). Cesarean section was performed in 44% of 34 cases. Death in utero occurred in 11% of 54 cases, postnatal death in 4%, congenital malformations in 4%, macrosomia in 40%. 9% of infants received intensive neonatal care. No difference was found between NIDDM and GDM about outcome of pregnancy. These results underlined importance of early screening for GDM as most cases seem to be undiagnosed pregravid diabetes mellitus (DM).