Current status of diabetes management, glycemic control and complications in children and adolescents with diabetes in Egypt. Where do we stand now? And where do we go from here?

The potential Association of Bisphenol A exposure and type 1 diabetes mellitus among Dakahlia Governorate's children sample, Egypt

Background

Bisphenol A (BPA) is an endocrine disrupter affecting glucose homeostasis.

Objectives

This study aimed to investigate BPA's relationship with Type 1 Diabetes Mellitus (T1DM) in Dakahlia Governorate's children, in Egypt.

Subjects materials and methods

The study had two parts: clinical and experimental. Clinical Study was conducted on 200 children, equally divided into control and T1DM groups. They underwent: demographic data, height, weight, body mass index, glycosylated HbA1C, random blood glucose, and urinary BPA measurements. Experimental Study was conducted on 60 adult albino rats. Rats were randomly divided into three equal groups: control group: received 0.5 mL of pure olive oil, group 1: received 20 mg/kg/day BPA, and group 2: received 100 mg/kg/day BPA orally for 6 weeks. Fasting and two hours postprandial glucose levels were measured at the beginning and end of the study. Histopathological examination and imaging study of the pancreas were done.

Results

In clinical study: HbA1C and random blood glucose levels in diabetic children showed a significant increase compared to control. Children in control group showed controlled HbA1C, while the T1DM group showed 86% with poor diabetic control. There was a significant increase in BPA level in the T1DM group compared to the control. Rats that received BPA showed a marked increase in fasting and two hours postprandial glucose levels, histopathological changes in the pancreas with more changes determined in the high dose group, and a significant decrease in the islets of Langerhans diameters with group 2 more affected.

Conclusion

So, BPA exposure could be considered a risk factor for T1DM in children.

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.

Comparison of regular with NPH insulin vs. premix insulin in children and adolescents with type 1 diabetes in a resources-limited setting: a retrospective data analysis

OBJECTIVES

Few studies addressed the efficacy of human insulin regimens (mostly premix insulin) used in many low-and-middle income countries on glycemic control of children and adolescents with diabetes. The aim of this study was to assess the efficacy of the premix insulin on the glycated hemoglobin (HbA_1c) in comparison to the regular with NPH insulin scheme.

METHODS

A retrospective study was carried out from January 2020 to September 2022 on patients with type 1 diabetes aged below 18 years followed in Burkina Life For A Child program. They were categorized into three groups, on regular with NPH insulin (Group A), on premix insulin (Group B) and on regular with premix insulin (Group C). Outcome was analyzed based on HbA_1c level.

RESULTS

Sixty-eight patients with a mean age of 15.38 ± 2.26 years and the sex ratio (M/W) 0.94 were studied. There were 14 in Group A, 20 in Group B, and 34 patients in Group C. The mean HbA_1c value in the corresponding insulin regimen was 12.8 ± 1.39%, 9.87 ± 2.18%, and 10.66 ± 2.1%, respectively. Glycemic control was better in Groups B and C than Group A (p<0.05) but there was no difference between groups B and C.

CONCLUSIONS

Our results indicate that the use of premix insulin gives a better glycemic control than NPH insulin. However, further prospective study of these insulin regimens with a strengthening education strategy and glycemic control by continuous glucose monitoring and HbA_1c is required to corroborate these preliminary findings.

Prevalence of diabetic retinopathy in the Eastern Mediterranean Region: a systematic review and meta-analysis

Objectives

Individual studies in the Eastern Mediterranean Region (EMR) have shown the high prevalence of diabetic retinopathy. We conducted a meta-analysis to yield an estimate of the prevalence of diabetic (type 1 and 2) retinopathy in the EMR. Additionally, we explored its potential modulators.

Methods

Two-step screening of relevant articles published from 1 January 2000 to 13 December 2019 was carried out. An estimation of summary proportions, subgroup analysis, meta-regression, and publication bias assessment were performed.

Results

One hundred nine articles were included in the meta-analysis, involving 280,566 patients. The prevalence of diabetic retinopathy was 31% (95% confidence interval [CI] = 28, 33). The highest and lowest diabetic retinopathy prevalence rates were observed in low human development index (HDI) countries (63.6; 95% CI = 52.4, 74.0) and very high HDI countries 22.6 (95% CI = 20.5, 24.7), respectively.

Conclusions

The prevalence of diabetic retinopathy is high in the EMR. Our results provide important information for diverse healthcare surveillance systems in the EMR to implement the modifiable risk factors, diabetes screening to decrease undiagnosed diabetes, early detection of retinopathy, and proper diabetes care to decrease untreated diabetes.

Glycemic control among children with type 1 diabetes mellitus and its determinants in a resource-limited setting

OBJECTIVES

Glycemic control is an important parameter that can predict long-term complications of diabetes mellitus. It can be affected by many factors. Hence, identifying those factors for improving disease outcomes is essential. The purpose of this study was to assess glycemic control in children who were treated with a conventional insulin regimen and to identify its associated factors.

METHODS

A retrospective cohort study was conducted among children with type one diabetes mellitus (T1DM) who had follow-up from November 2015 to November 2020 at the pediatric endocrinology clinic of St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia. Glycemic control was assessed by measuring glycosylated hemoglobin (HbA_1C) and children who had HbA_1C within three to six months of the data collection were recruited.

RESULTS

A total of 106 children with TIDM who were on conventional insulin therapy were included in this study. Their median age at diagnosis was nine years, 47.2% were females, and 57.5% were from urban areas. The average HbA_1c of the children was 9.7%. The majority (85.2%) of the children had poor glycemic control (>7.5%). Younger age, longer disease duration, and urban residence were found to be significant predictors of good glycemic control.

CONCLUSIONS

A significant majority of children with T1DM had poor glycemic control. This calls for the need to create access to intensive diabetes care by health authorities and stakeholders to prevent the long-term complications of T1DM.

A systematic review of the prevalence, risk factors and screening tools for autonomic and diabetic peripheral neuropathy in children, adolescents and young adults with type 1 diabetes

AIMS

We aimed to estimate the prevalence of Diabetic peripheral neuropathy (DPN) and Cardiac autonomic neuropathy (CAN) in youth with type 1 diabetes; identify key risk factors; identify the most useful tests for the diagnostic evaluation of DPN and CAN; identify key treatment options for DPN and CAN.

METHODS

A systematic search was performed including studies published in the last 15 years. PICO framework was used in the selection process and evidence was assessed using the GRADE system.

RESULTS

A total of 758 studies were identified and a final number of 49 studies were included in this systematic review. According to moderate-high level quality studies, the prevalence of probable DPN, ranged between 13.5 and 62%; subclinical DPN between 22 and 88%; confirmed DPN between 2.6 and 11%. The Michigan Neuropathy Screening Instrument was the tool with higher sensitivity and specificity for detecting DPN, which needs to be confirmed by nerve conduction velocity. The prevalence of CAN was 4-39%. Specific treatment options for DPN or CAN in patients younger than 25 years are not available. Key risk factors for DPN and CAN are hyperglycemia/HbA1c, age, diabetes duration, the presence of other microvascular complications, waist/height ratio, lipid profile and blood pressure. For CAN, additional risk factors were cigarette smoking, BMI and total daily insulin.

CONCLUSIONS

Prevalence of neuropathy in youth with type 1 diabetes varies depending on different screening methods and characteristics of the study populations. However, the assessed studies confirmed a relatively high prevalence of subclinical neuropathy, reiterating the importance of early identification of risk factors to prevent this complication.

New glycemic metrics and traditional clinical and laboratory profiles of children and adolescents with type 1 diabetes mellitus in an outpatient follow-up

INTRODUCTION

This study evaluated the demographic, clinical, and laboratory data - including traditional (as glycated hemoglobin, HbA1c) and new glycemic metrics (as time in range, TiR) - and the complications present in children and adolescents (CA) in outpatient follow-up, as well as their possible associations.

METHODS

This retrospective observational study's data were compiled from the CA's medical records with T1DM (n = 78) being followed up at the Pediatric Endocrinology Service of the Federal University of Uberlândia.

RESULTS

The average participants' age was 10.2 years (1-16), most of them (55%) being male, with a diagnosis time of 4.5 years (1-13), and a body mass index of 18 kg/m2. The group had HbA1c levels of 9.6% and an estimated average glycemia of 229.5 ± 103 mg/dL. TiR was 25% (7-54%); the short- (CV%) and medium-term (ΔHbA1c) glycemic variability was 45.7% and 1.5%, respectively. Approximately 10% had diabetes ketoacidosis in the last year of follow-up, about 6% had chronic complications, such as nephropathy or retinopathy, and 20% had some other associated autoimmune disease. 49% of the participants reported regular physical activity.

CONCLUSION

The high values of HbA1c and glycemic variability amplitude, short TiR, and the early presence of chronic complications reveal that the treatment did not reach its goal in this population. Better education of patients and their families about the disease and greater adherence to intensive insulin treatment can optimize the control of diabetes in pediatric patients.

Diabetic Microvascular Complications Among Children and Adolescents in Northwestern Tanzania: A Cross-Sectional Study

Background

Africa is experiencing a rapid increase in morbidity and mortality related to diabetes mellitus (DM). Contemporary data are needed to guide efforts to improve prevention and treatment for microvascular complications in children and adolescents in Africa. This study was conducted to assess prevalence of diabetic microvascular complications in northwestern Tanzania, including nephropathy, retinopathy, and neuropathy, as well as associated risk factors.

Objectives

1) To determine the prevalence of microvascular complications and the overlap of nephropathy, retinopathy and neuropathy and 2) to determine factors associated with the development of microvascular complications.

Methods

This cross-sectional study included 155 children and adolescents with DM consecutively attending all three health centers providing diabetes care for children in the Mwanza region of Tanzania. Participants were examined for microvascular complications and possible risk factors.

Results

Fifty-one of 155 participants (age: 5-19 years) had diabetic nephropathy (32.9%), 16 had diabetic retinopathy (10.3%), and 21 had diabetic neuropathy (13.6%). Risk factors for development of a microvascular complication included age, duration of DM, and poor glycemic control. Of the participants, 107 had poor levels of glycemic control (69%) with HbA1C levels >10%.

Conclusion

The prevalence of microvascular complications, especially that of nephropathy, was disturbingly high. Risk factors for microvascular complications were similar to other studies from Africa and included poor glycemic control, older age, and longer duration of DM. Innovative, locally appropriate systems for optimizing glycemic control are urgently needed.

Early Diabetic Nephropathy and Retinopathy in Patients with Type 1 Diabetes Mellitus Attending Sudan Childhood Diabetes Centre

OBJECTIVE

Data on microvascular complications in children and adolescents with type 1 diabetes mellitus (T1DM) in Sudan are scarce. This study was aimed at determining the prevalence of diabetic nephropathy (DN) and retinopathy (DR) and their relationship to certain risk factors in children with T1DM attending the Sudan Childhood Diabetes Centre. Design and Methods. A clinic-based cross-sectional study of 100 patients with T1DM aged 10-18 years. Patients with disease duration exceeding 5 years if the onset of diabetes was prepubertal and 2 years if it was postpubertal were included. Relevant sociodemographic, clinical, and biochemical information was obtained. Blood pressure was measured. The patients were screened for DN and DR using urinary microalbumin estimation and fundus photography, respectively.

RESULTS

The frequency of microalbuminuria and diabetic retinopathy was 36% and 33%, respectively. Eleven percent had both retinopathy and microalbuminuria. Seven percent of the patients were found to be hypertensive. Patients with diabetic retinopathy had significantly higher HbA1c levels (p = 0.009) and longer diabetes duration (p = 0.02) than patients without retinopathy. Logistic regression showed that high HbA1c (odds ratio (OR) 0.83, confidence interval (CI) 0.68-1.00, p = 0.04), but not age, duration, ethnic group, BMI, blood pressure, and presence of nephropathy, was an independent risk factor for retinopathy. Likewise, high blood pressure (OR 6.89, CI 1.17-40.52, p = 0.03), but not age, duration, ethnic group, BMI, HbA1c, and presence of retinopathy, was a predictor for nephropathy.

CONCLUSION

High prevalence of incipient DN and early stages of DR were observed in this study. Longer diabetes duration and higher HbA1c were associated with the presence of diabetic retinopathy. High blood pressure was a risk factor for DN. So regular screening for these complications and optimization of glycemic control are needed.

Glycemic control and correlates in a group of sub Saharan type 1 diabetes adolescents

OBJECTIVES

This study aims to describe the prevalence of glycemic control and related factors in a population of Sub-Saharan African T1D patients. We carried out a cross-sectional study including children and adolescents from seven different centers of the Changing Diabetes in Children (CDiC) program. All children enrolled in the program where recruited after parental consent. Diabetes history, daily practice anthropometrics parameters and HbA1c were assessed for each participant.

RESULTS

We enrolled 95 children adolescents, aged from 06 to 19 years. The mean HbA1c was 9.2 ± 2.5% and 67.4% of participant had poor glycemic control. There was an association between study level of the patients (p = 0.03), healthy eating habits (p < 0.001), diabetes duration (p < 0.001) and level of glycemic control on univariate analysis. On multivariate analysis, diabetes diagnosed for more than 2 years was associated to a good control compared to those with diagnosis that is more recent. Glycemic control of adolescents with type1 diabetes remain very poor in Cameroon despite the implementation of free diabetes care through the program CDiC.

Glycemic control and correlates in a group of sub Saharan type 1 diabetes adolescents

Objectives

This study aims to describe the prevalence of glycemic control and related factors in a population of Sub-Saharan African T1D patients. We carried out a cross-sectional study including children and adolescents from seven different centers of the Changing Diabetes in Children (CDiC) program. All children enrolled in the program where recruited after parental consent. Diabetes history, daily practice anthropometrics parameters and HbA1c were assessed for each participant.

Results

We enrolled 95 children adolescents, aged from 06 to 19 years. The mean HbA1c was 9.2 ± 2.5% and 67.4% of participant had poor glycemic control. There was an association between study level of the patients (p = 0.03), healthy eating habits (p < 0.001), diabetes duration (p < 0.001) and level of glycemic control on univariate analysis. On multivariate analysis, diabetes diagnosed for more than 2 years was associated to a good control compared to those with diagnosis that is more recent. Glycemic control of adolescents with type1 diabetes remain very poor in Cameroon despite the implementation of free diabetes care through the program CDiC.

Neuropathy of type 1 diabetes in the Arab world: A systematic review and meta-analysis

AIMS

Although type 1 diabetes (T1D) is a common disease in the Arab nations, there is no data available on the prevalence of peripheral neuropathy (PN) among T1D subjects in Arab countries. The aim of this study is to analyze the prevalence of PN in T1D subjects via published literature and to draw attention to the dearth of the published work in this serious complication of T1D.

METHODS

A meta-analysis was performed on studies representing different Arab countries with a total number of 2243 T1D subjects.

RESULTS

The pooled prevalence of PN among T1D subjects in the Arab region was estimated as 18% with 95% confidence intervals (CI): 0.09-0.34. The PN prevalence was significantly higher in the >16-yr age group, with 59.1% (95% CI: 0.45-0.72) compared to 9.5% (95% CI: 0.05-0.19) in the <16-yr age group. Furthermore, the PN prevalence was significantly higher in the group with more than 10-yr T1D, 35% (95% CI: 0.15-0.62) than in the group with less than 10-yr T1D, 9.4% (95% CI: 0.04-0.21).

CONCLUSION

In Arab countries, PN is common in adults and children with T1D, but prevalence varies widely. Older age Arab people (>16years) with T1D are affected more with PN than younger age Arab people (<16years). PN is more frequently present in Arab subjects with a longer duration of T1D diabetes than in those with shorter duration.

Serum Levels of Neuron-Specific Enolase in Children With Diabetic Ketoacidosis

Neuron-specific enolase is a sensitive marker of neuronal damage in various neurologic disorders. This study aimed to measure serum neuron-specific enolase levels at different time points and severities of diabetic ketoacidosis. This study included 90 children (age 9.2 ± 3.4 years) with diabetic ketoacidosis. Neuron-specific enolase was measured at 3 time points (baseline and after 12 and 24 hours of starting treatment). Among patients, 74.4% had diagnosis of new diabetes, 60% had Glasgow Coma Scale score <15, and 75.6% had moderate/severe diabetic ketoacidosis. Compared with controls (n = 30), children with diabetic ketoacidosis had higher neuron-specific enolase levels at the 3 time points ( P = .0001). In multiple regression analysis, the factors associated with higher neuron-specific enolase levels were younger age, higher glucose, lower pH, and bicarbonate values. This study indicates that serum neuron-specific enolase is elevated in diabetic ketoacidosis and correlated with the severity of hyperglycemia, ketosis, and acidosis. This study indicates that diabetic ketoacidosis may cause neuronal injury from which the patients recovered partially but not completely.

Electrophysiologic pattern and prevalence of subclinical peripheral neuropathy in children and adolescents with type I diabetes mellitus in Iran

OBJECTIVES

To evaluate electrophysiologic pattern of subclinical diabetic peripheral neuropathy (DPN) in children and adolescents with type 1 diabetes mellitus (T1DM) based on nerve conduction study.

METHODS

In this cross sectional study, 40 children and adolescents (62.5% female with mean age of 12.73 ± 0.43 years) with T1DM for at least 5 years attending the Pediatrics Clinics. Tabriz University of Medical Sciences, Tabriz, Iran, between 2014 and 2015 were recruited. Demographic and laboratory findings were recorded and all patients underwent clinical neurological examination and electrophysiologic studies.

RESULTS

According to electrophysiologic studies, DPN was found in 57.5% of patients including early stage of neuropathy (15%), mild sensory axonal neuropathy (25%), mild sensory motor axonal neuropathy (10%), and moderate sensory motor axonal neuropathy (7.5%). Age, duration of diabetes, fasting blood sugar, and glycosylated hemoglobin levels had no significant difference between patients with and without DPN. Reduced deep tendon reflexes were observed in the upper limb (30%) and lower limb (47.5%) of patients, which were both significantly higher in DPN patients (upper limb [p=0.03] and lower limb [p=0.04]). The most frequent electrophysiologic findings were unobtainable H-reflex, low amplitude sural, and median sensory responses.

CONCLUSION

Subclinical DPN is a common complication found in children and adolescents with TIDM and peripheral sensory axonal neuropathy is the most frequent type. Nerve conduction study is recommended for early detection of DPN and prevention of its progress.

Childhood diabetes in Africa

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

AIMS

Diabetic ketoacidosis (DKA) is an acute and risky complication of type 1 diabetes. The aim of this study is to build the overall rate of DKA in Arab patients with type 1 diabetes in the 22 Arab nations. This is expected to tailor the healthcare approaches in Arab countries where attention is needed to save lives from the devastating consequences of DKA.

METHODS

The study here is a quantitative analysis of the articles indexed in four different scientific literature databases: Web of Science, PubMed, Science Direct and Scopus, from inception to June 2015. Arab patients with type 1 diabetes who presented with DKA have been captured. Key information was possible to extract for patients belong to only 12 Arab countries out of the 22 Arab patients.

RESULTS

Twenty-nine studies in 12 different Arab countries captured 4,688 type 1 diabetes patients with overall rates of 46.7% patients presented with DKA, ranging from a low of 17% in Egypt to a high of 100% in Morocco, Algeria and Tunisia.

CONCLUSION

This is the first descriptive quantitative study to determine the overall DKA rate in 46 years of studies in the Arab world of patients with type 1 diabetes; DKA rates were found to range from 17% to 100% with overall rate of 46.7%.