Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (Riyadh cohort 2): a decade of an epidemic

Characteristics of Saudi patients with congestive heart failure and adherence to management guidelines in a tertiary hospital in Riyadh

BACKGROUND AND OBJECTIVES

There is limited data available on the characteristics of local Saudi patients diagnosed with congestive heart failure (CHF) and on their adherence to guidelines for managing the disease. This study aimed to fill this gap.

DESIGN AND SETTING

Retrospective study of patients treated at King Abdulaziz Medical City from 20022008.

SUBJECTS AND METHODS

The records were reviewed of subjects admitted secondary to heart failure (defined as systolic heart failure [ejection fraction < 55%] and/or heart failure with preserved ejection fraction diagnosed either clinically and/or by echocardiogram and/or cardiac catheterization) or who visited the outpatient department for the same complaint.

RESULTS

Of 392 CHF cases, the mean age was 67.8 (12.8) years and the majority were males (53.1%). Hypertension was the predominant comorbid illness, accounting for 84.9% of cases, followed by diabetes mellitus type 2 and hyperlipidemia. Almost three-fourths (73.7%) of the subjects had mild to severe left ventricular dysfunction, with 68.5% of the cases having right ischemic cardiomyopathy. Spironolactone, exercise and vaccination were the the least least adhered to recommendations (30.0%, 20.5% and 15.2%, respectively).

CONCLUSIONS

The study highlights the need for proper education of patients and caregivers to increase compliance to medications. Physicians are also encouraged to undergo continuing medical education and training courses to properly implement current recommendations in the management of heart failure. Further studies are needed on a larger scale in order to formulate an effective management scheme that will address the current challenges faced by both clinicians and CHF patients.

Causes of death certification of adults: an exploratory cross-sectional study at a university hospital in Riyadh, Saudi Arabia

BACKGROUND AND AIMS

Saudi Arabia has no precise data on causes of death. We sought to ascertain the commonest causes of death as stated in death certificates of adults and evaluate the completeness of death certificates at a teaching hospital in Riyadh.

DESIGN AND SETTINGS

A cross-sectional study carried out at King Khalid University Hospital in Riyadh, Saudi Arabia, during the year 2008.

METHODS

All death certificates that were issued in 2008 were reviewed and data were checked by two reviewers. Causes of death were coded according to specially-designed codes.

RESULTS

The mean (SD) age of death was 63.9 (20.7) years. More than 80% arrived alive at the hospital. Among the 410 certificates, 62.2% had the first reported cause of death being classified as "inappropriate" and this tended to be slightly, but significantly more frequent among women. The first most common appropriately reported cause of death was malignancy of any type (7.3%) followed by ischemic heart diseases (4.9%). Accidents and fractures were more common in the younger age groups and among men.

CONCLUSIONS

This is the first study that documents the possible gaps among healthcare professionals in Saudi Arabia in their understanding of death and its certification based on the clinical assessment of the deceased. The findings needs to be validated by similar studies from other health care sectors. It is clear, however, that proven educational, system-related and legal interventions to improve the accuracy of death certification are strongly needed if the health care priorities are to be properly identified.

Pre-existing diabetes mellitus and adverse pregnancy outcomes

Background

Pregnancies complicated by pre-existing diabetes mellitus (PDM) are associated with a high rate of adverse outcomes, including an increased miscarriage rate, preterm delivery, preeclampsia, perinatal mortality and congenital malformations; compared to the background population. The objectives of this study are to determine the prevalence of PDM and to investigate the maternal and the neonatal outcomes of women with PDM.

Methods

This is a retrospective cohort study for women who delivered in King Khalid University Hospital (KKUH) during the period of January 1^st to the 31^st of December 2008. The pregnancy outcomes of the women with PDM were compared to the outcomes of all non-diabetic women who delivered during the same study period.

Results

A total of 3157 deliveries met the inclusion criteria. Out of the study population 116 (3.7%) women had PDM. There were 66 (57%) women with type 1 diabetes mellitus (T1DM) and 50 (43%) women with type 2 diabetes mellitus (T2DM). Compared to non-diabetic women those with PDM were significantly older, of higher parity, and they had more previous miscarriages. Women with PDM were more likely to be delivered by emergency cesarean section (C/S), OR 2.67, 95% confidence intervals (CI) (1.63-4.32), P < 0.001, or elective C/S, OR 6.73, 95% CI (3.99-11.31), P < 0.001. The neonates of the mothers with PDM were significantly heavier, P < 0.001; and more frequently macrosomic; OR 3.97, 95% CI (2.03-7.65), P = 0.002. They more frequently have APGAR scores <7 in 5 minutes, OR 2.61, 95% CI (0.89-7.05), P 0.057 and more likely to be delivered at <37 gestation weeks, OR 2.24, 95% CI (1.37- 3.67), P 0.003. The stillbirth rate was 2.6 times more among the women with PDM; however the difference did not reach statistical significance, P 0.084.

Conclusion

PDM is associated with increased risk for C/S delivery, macrosomia, stillbirth, preterm delivery and low APGAR scores at 5 min.

Association of tobacco products use and diabetes mellitus-results of a national survey among adults in saudi arabia

OBJECTIVE

To compare the tobacco products use patterns of known diabetics and non diabetics.

MATERIAL AND METHODS

A community-based cross-sectional study using STEPwise approach among adults using a multistage, stratified, cluster random sample. Data was collected using a questionnaire which included sociodemographics; tobacco products use habits, history of diabetes, biochemical and anthropometric measurements.

RESULTS

Of the total of 4654 subjects who participated in the study, 1016 (21.8%) were ever smoked tobacco products users and 65 (1.4%) were ever smokeless tobacco products users. Known Diabetes prevalence was 15.3% (712 known diabetics). There were no significant differences in diabetic status and smokeless tobacco products use for both ever and current use. For smoked products diabetics are fewer in current smokers and more in ex smokers. Diabetics started smoking significantly older, smoked for longer duration and higher intensity than non diabetics.

CONCLUSION

Diabetes appears to be associated with smoked but not smokeless tobacco products use.

Association of body mass index, sagittal abdominal diameter and waist-hip ratio with cardiometabolic risk factors and adipocytokines in Arab children and adolescents

Background

Sagittal abdominal diameter (SAD) is a novel anthropometric measure hypothesized to be a surrogate measure of visceral abdominal obesity in adults. This study aims to determine whether SAD is superior to other anthropometric measures such as body mass index (BMI) and waist to hip ratio (WHR) in terms of association to cardiometabolic risk and circulating adipocytokine concentrations in a cohort of Saudi children and adolescents.

Methods

A total of 948 (495 boys and 453 girls) apparently healthy children with varying BMI, aged 10–17 years, were included in this cross sectional study. Fasting glucose, lipid profile, leptin, adiponectin, resistin, insulin, TNF-α and aPAI-1 were measured in serum and HOMA-IR was calculated. MetS components were defined according to the International Diabetes Federation (IDF) criteria.

Results

BMI was superior to SAD as well as WHR, and had the highest number of significant associations to MetS components and adipocytokines even after adjustment for age and gender, including blood pressure, lipids, glucose and leptin.

Conclusion

In conclusion, while SAD is significantly associated with components of MetS among children and adolescents, it is not superior to BMI. The use of SAD therefore may not be practical for use in the pediatric clinical setting. Follow-up studies are needed to determine whether SAD has clinical significance in terms of harder outcomes such as predicting diabetes mellitus or cardiovascular diseases.

Vitamin D supplementation as an adjuvant therapy for patients with T2DM: an 18-month prospective interventional study

Background

Vitamin D deficiency has been associated with impaired human insulin action, suggesting a role in the pathogenesis of diabetes mellitus type 2 (T2DM). In this prospective interventional study we investigated the effects of vitamin D3 supplementation on the metabolic profiles of Saudi T2DM subjects pre- and post-vitamin D supplementation over an 18-month period.

Methods

T2DM Saudi subjects (men, N = 34: Age: 56.6 ± 8.7 yr, BMI, 29.1 ± 3.3 kg/m²; women, N = 58: Age: 51.2 ± 10.6 yr, BMI 34.3 ± 4.9 kg/m²;) were recruited and given 2000 IU vitamin D3 daily for 18 months. Anthropometrics and fasting blood were collected (0, 6, 12, 18 months) to monitor serum 25-hydroxyvitamin D using specific ELISA, and to determine metabolic profiles by standard methods.

Results

In all subjects there was a significant increase in mean 25-hydroxyvitamin D levels from baseline (32.2 ± 1.5 nmol/L) to 18 months (54.7 ± 1.5 nmol/L; p  < 0.001), as well as serum calcium (baseline = 2.3 ± 0.23 mmol/L vs. 18 months = 2.6 ± 0.1 mmol/L; p = 0.003). A significant decrease in LDL- (baseline = 4.4 ± 0.8 mmol/L vs. 18 months = 3.6 ± 0.8 mmol/L, p  < 0.001] and total cholesterol (baseline = 5.4 ± 0.2 mmol/L vs. 18 months = 4.9 ± 0.3 mmol/L, p < 0.001) were noted, as well as a significant improvement in HOMA-β function ( p  = 0.002). Majority of the improvements elicited were more prominent in women than men.

Conclusion

In the Saudi T2DM population receiving oral Vitamin D3 supplementation (2000 IU/day), circulating 25-hydroxyvitamin D levels remained below normal 18 months after the onset of treatment. Yet, this “suboptimal” supplementation significantly improved lipid profile with a favorable change in HDL/LDL ratio, and HOMA-β function, which were more pronounced in T2DM females.

Vitamin D deficiency and calcium intake in reference to increased body mass index in children and adolescents

Vitamin D deficiency has been linked to several chronic diseases in adults. Studies focusing on children and adolescents, however, are limited. In this randomized cross-sectional study, we aimed to determine the prevalence of vitamin D deficiency and its relationship with childhood obesity and dietary calcium intake among a population of healthy urban Saudi children and adolescents. To achieve this, 331 randomly selected Saudi children (53.8% females and 46.2% males) aged 6-17 years were included. Demographic, medical, and dietary information were collected; anthropometrics were measured. Levels of serum fasting glucose, lipid profile, 25(OH) D, and for albumin corrected calcium were analyzed. Vitamin D deficiency was noted in all subjects, with girls having significantly lower vitamin D levels than boys. Mean calcium intake was found to be 60% of the required dietary allowance (RDA), while the mean vitamin D intake was 23% of RDA. Vitamin D status and calcium intake were comparable in both normal and overweight/obese children and adolescents. Vitamin D status was highest among children who had calcium intake >800 mg/day. In adolescents there was insignificant but decreasing trend in BMI, which was observed to be highest among those whose calcium intake was <250 mg/day and lowest among those taking >800 mg/day.

CONCLUSION

results from this study suggest the importance of vitamin D fortification and increased dietary calcium in the Saudi diet to meet RDA requirements and avoid onset of vitamin D deficiency-related diseases in Saudi children and adolescents.

Circulating leukocyte telomere length is highly heritable among families of Arab descent

Background

Telomere length, an indicator of ageing and longevity, has been correlated with several biomarkers of cardiometabolic disease in both Arab children and adults. It is not known, however, whether or not telomere length is a highly conserved inheritable trait in this homogeneous cohort, where age-related diseases are highly prevalent. As such, the aim of this study was to address the inheritability of telomere length in Saudi families and the impact of cardiometabolic disease biomarkers on telomere length.

Methods

A total of 119 randomly selected Saudi families (123 adults and 131 children) were included in this cross-sectional study. Anthropometrics were obtained and fasting blood samples were taken for routine analyses of fasting glucose and lipid profile. Leukocyte telomere length was determined using quantitative real time PCR.

Results

Telomere length was highly heritable as assessed by a parent-offspring regression [h2 = 0.64 (p = 0.0006)]. Telomere length was modestly associated with BMI (R² 0.07; p-value 0.0087), total cholesterol (R² 0.08; p-value 0.0033), and LDL-cholesterol (R² 0.15; p-value 3 x 10^-5) after adjustments for gender, age and age within generation.

Conclusion

The high heritability of telomere length in Arab families, and the associations of telomere length with various cardiometabolic parameters suggest heritable genetic fetal and/or epigenetic influences on the early predisposition of Arab children to age-related diseases and accelerated ageing.

The future of health care delivery and the experience of a tertiary care center in Saudi Arabia

Five major technological changes will herald a new era in health care delivery around the World: digitalization of the personal health record, sharing of health care digital data across different platforms, applications and institutions, delivery of patient services via the internet, use of the digital media and social networking as a medium for education and preventive medicine and introduction of smart applications as counselors to prevent medical errors. The implications of such changes are huge. Saudi Arabia is not isolated from such important developments. This article explores the future of health care delivery with a special focus on the experience of a tertiary care center in Saudi Arabia that has led the wave in such changes regionally.

Variants of endothelial nitric oxide synthase gene are associated with components of metabolic syndrome in an Arab population

Genetics plays a crucial role in the development of metabolic syndrome (MetS). Here we examined the association between endothelial nitric oxide synthase (eNOS) gene polymorphisms and MetS in a Saudi Arabian cohort to extend the understanding of the genetic basis of MetS in diverse ethnic populations. Anthropometric, clinical and biochemical parameters as well as genotyping for 894G>T, -786T>C variants of eNOS gene by PCR-RFLP and 4a/b by direct PCR were performed in 886 Saudi Arabians (477 MetS and 409 Non-MetS). The genotype distribution (TT, p=0.001; TC, p=0.001; TC+CC, p=0.001) and allele (T, p=0.007; C, p=0.007) frequency of the -786T>C SNP were significantly different between Non-MetS and MetS subjects which remained significant after Bonferroni correction. Moreover: 1) the GT and GT+TT genotypes of the 894G>T SNP were associated with elevated blood pressure (p=0.017, and p=0.022, respectively); 2) the ab variant of 4a/b polymorphism was associated with decreased HDL levels (p= 0.044); and 3) the TC+CC genotype and C allele of the -786T>C SNP were associated with increased fasting glucose levels (p=0.039, and p=0.028, respectively). Also, G-a-C was identified as the risk haplotype for MetS susceptibility (p=0.034). The results suggest a significant association of 894G>T, 4a/b and -786T>C polymorphisms with MetS and its components is present in an Arab population. A genetic predisposition to develop abnormal metabolic phenotypes, consistent with an increased prevalence of metabolic phenotypes can be detected in this ethnic group.

Adiponectin gene polymorphisms (T45G and G276T), adiponectin levels and risk for metabolic diseases in an Arab population

In this study we examined the association of adiponectin gene variants with circulating adiponectin, and known metabolic diseases in 298 healthy controls and 297 Saudi subjects with type 2 diabetes mellitus (T2DM). Anthropometric and biochemical parameters were measured by standard procedures. Genotyping of T45G and G276T single nucleotide polymorphisms of adiponectin gene was carried out by PCR-RFLP analysis. No significant differences in the genotype distribution of T45G and G276T polymorphism were found between control and diabetic subjects. Neither SNP conferred an association with T2DM, obesity, hypertension or dyslipidemia. Despite a marked decrease in patients as opposed to controls, adiponectin levels were not different according to genotypes of T45G and G276T polymorphisms in control and patients. Thus, neither adiponectin SNPs independently conferred increased T2DM risk nor in other metabolic conditions considered such as obesity, hypertension or dyslipidemia. These findings support the existence of population based differences in the association of adiponectin gene variants with metabolic phenotypes and emphasize the importance of studying multiple polymorphisms, sufficient enough to identify the adiponectin gene as a genetic marker for several non-chronic communicable diseases.

Overweight, air and noise pollution: Universal risk factors for pediatric pre-hypertension

Pediatric pre-hypertension (pre-HTN) has a complex multifactorial etiology. Although most cases are secondary to other disorders, a substantial number of children and adolescents have primary or essential HTN and pre-HTN. The gene-gene and gene-environment interactions should be considered in this context. The strong relationship of pre-HTN with environmental factors such as air pollution, noise pollution and passive smoking and obesity suggest that its prevalence will be escalating.Exposure to ambient particulate matters may increase blood pressure (BP) within hours to days. The underlying biologic pathways include autonomic nervous system imbalance and arterial vascular dysfunction or vasoconstriction because of systemic oxidative stress and inflammation. Likewise, tobacco smoke exposure of pregnant mothers increases systolic BP of their offspring in early infancy. Parental smoking also independently affects systolic BP among healthy preschool children. Noise exposure, notably in night, is associated with catecholamine secretion, increased BP and a pre-HTN state even in pre-school age children.Excess weight is associated with dysfunction of the adipose tissue, consisting of enlarged hypertrophied adipocytes, increased infiltration by macrophages and variations in secretion of adipokines and free fatty acids. These changes would result in chronic vascular inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone system and sympathetic response, and ultimately to pre-HTN from childhood.Prevention and control of the modifiable risk factors of pre-HTN from prenatal period can have long-term health impact on primordial and primary prevention of chronic non-communicable diseases. This review presents a general view on the diagnosis, prevalence and etiology of pre-HTN along with practical measures for its prevention and control.