Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion. Eur J Clin Nutr. 2010;64:1192-1198. [PMID: 20664624 DOI: 10.1038/ejcn.2010.143]

Socioeconomic gradient of lean diabetes in India: Evidence from National Family Health Survey, 2019-21

Diabetes is a global public health challenge, particularly in India, affecting millions. Among diabetic patients, lean type 2 diabetes is a severe subtype with higher microvascular complication risks. While studies on the prevalence, variations and risk factors of diabetes are increasingly available, there has been limited research on the prevalence, variations, and socioeconomic disparities of lean diabetes in India. This study used NFHS-5 microdata, and lean diabetes is defined as those with a BMI level of under 25 and random blood glucose levels of over 200 or under diabetic medication. Descriptive and multivariate analyses were conducted to understand lean diabetes variations and related factors. Socioeconomic disparities were measured using concentration curves and the concentration index. The study unveiled important insights into lean diabetes in India. 8.2% of men and 6.0% of women had elevated blood glucose levels, indicating a significant diabetes burden. Notably, 2.9% of men and 2.4% of women were diagnosed with lean diabetes. Among type 2 diabetics, 52.56% of males and 43.57% of females had lean type 2 diabetes. Lean diabetes prevalence varied from 11.6% in the poorest quintile to 1.1% in the richest. The odds of lean type 2 diabetes among those in the poorest quintile was 6.7 compared to the richest quintile. The concentration index of lean type 2 diabetes was -0.42 for men and -0.39 for women, suggesting a disproportionate impact on lower socioeconomic groups. This study advances our understanding of the complex interplay between socioeconomic factors and lean type 2 diabetes in India. To address the rising burden of lean diabetes among lower socioeconomic strata, policymakers and healthcare professionals must prioritise initiatives enhancing healthcare access, promoting healthy lifestyles, and ensuring effective diabetes management. By addressing socioeconomic disparities and implementing interventions for vulnerable populations, India can reduce diabetes-related mortality and enhance its citizens' overall health.

Phenotypic characterization of nonautoimmune diabetes in adult Ugandans with low body mass index

Background

Type 2 diabetes is common in relatively lean individuals in sub-Saharan Africa. It is unclear whether phenotypic differences exist between underweight and normal-weight African patients with type 2 diabetes. This study compared specific characteristics between underweight (body mass index <18.5 kg/m2) and normal-weight (body mass index of 18.5-24.9 kg/m2) adult Ugandans with new-onset nonautoimmune diabetes.

Methods

We collected the demographic, clinical, anthropometric, and metabolic characteristics of 160 participants with nonobese new-onset type 2 diabetes (defined as diabetes diagnosed <3 months, body mass index <25 kg/m2, and absence of islet-cell autoimmunity). These participants were categorized as underweight and normal weight, and their phenotypic characteristics were compared.

Results

Of the 160 participants with nonobese new-onset type 2 diabetes, 18 participants (11.3%) were underweight. Compared with those with normal weight, underweight participants presented with less co-existing hypertension (5.6% versus 28.2%, p = 0.04) and lower median visceral fat levels [2 (1-3) versus 6 (4-7), p < 0.001], as assessed by bioimpedance analysis. Pathophysiologically, they presented with a lower median 120-min post-glucose load C-peptide level [0.29 (0.13-0.58) versus 0.82 (0.39-1.50) nmol/l, p = 0.04] and a higher prevalence of insulin deficiency (66.7% versus 31.4%, p = 0.003).

Conclusion

This study demonstrates that nonautoimmune diabetes occurs in underweight individuals in sub-Saharan Africa and is characterized by the absence of visceral adiposity, reduced late-phase insulin secretion, and greater insulin deficiency. These findings necessitate further studies to inform how the prevention, identification, and management of diabetes in such individuals can be individualized.

Type 1 diabetes mellitus in the context of high levels of rural deprivation: differences in demographic and anthropometric characteristics between urban and rural cases in NW Ethiopia

Background

While there is increasing evidence for an altered clinical phenotype of Type 1 diabetes in several low-and middle-income countries, little is known about urban-rural differences and how the greater poverty of rural environments may alter the pattern of disease.

Objective

Investigation of urban-rural differences in demographic and anthropometric characteristics of type 1 diabetes in a resource-poor setting.

Research design and methods

Analysis of a unique case register, comprising all patients (rural and urban) presenting with Type 1 diabetes over a 20 yr. period in a poor, geographically defined area in northwest Ethiopia. The records included age, sex, place of residence, together with height and weight at the clinical onset.

Results

A total of 1682 new cases of Type 1 diabetes were registered with a mean age of onset of 31.2 (SD 13.4) yr. The patients were thin with 1/3 presenting with a body mass index (BMI) <17kg/m2. There was a striking male predominance of cases when clinical onset was between 20 and 35 yr., this was more marked in the very poor rural dwellers compared to the urban population. While most patients with Type 1 diabetes presented with low BMIs and reduced height, stunting preferentially affected rural men.

Conclusions

These data have led to the hypothesis that complex interactions among poor socioeconomic conditions in early life affect both pancreatic function and the development of autoimmunity and provide a possible explanation of the unusual phenotype of Type 1 diabetes in this very poor community.

Anthropometry, body composition and chronic disease risk factors among Zambian school-aged children who experienced severe malnutrition in early childhood

There is limited information as to whether people who experience severe acute malnutrition (SAM) as young children are at increased risk of overweight, high body fat and associated chronic diseases in later life. We followed up, when aged 7-12 years, 100 Zambian children who were hospitalised for SAM before age 2 years and eighty-five neighbourhood controls who had never experienced SAM. We conducted detailed anthropometry, body composition assessment by bioelectrical impedance and deuterium dilution (D2O) and measured blood lipids, Hb and HbA1c. Groups were compared by linear regression following multiple imputation for missing variables. Children with prior SAM were slightly smaller than controls, but differences, controlling for age, sex, socio-economic status and HIV exposure or infection, were significant only for hip circumference, suprailiac skinfold and fat-free mass index by D2O. Blood lipids and HbA1c did not differ between groups, but Hb was lower by 7·8 (95 % CI 0·8, 14·7) g/l and systolic blood pressure was 3·4 (95 % CI 0·4, 6·4) mmHg higher among the prior SAM group. Both anaemia and high HbA1c were common among both groups, indicating a population at risk for the double burden of over- and undernutrition and associated infectious and chronic diseases. The prior SAM children may have been at slightly greater risk than the controls; this was of little clinical significance at this young age, but the children should be followed when older and chronic diseases manifest.

An Atypical Form of Diabetes Among Individuals With Low BMI

OBJECTIVE

Diabetes among individuals with low BMI (<19 kg/m2) has been recognized for >60 years as a prevalent entity in low- and middle-income countries (LMICs) and was formally classified as "malnutrition-related diabetes mellitus" by the World Health Organization (WHO) in 1985. Since the WHO withdrew this category in 1999, our objective was to define the metabolic characteristics of these individuals to establish that this is a distinct form of diabetes.

RESEARCH DESIGN AND METHODS

State-of-the-art metabolic studies were used to characterize Indian individuals with "low BMI diabetes" (LD) in whom all known forms of diabetes were excluded by immunogenetic analysis. They were compared with demographically matched groups: a group with type 1 diabetes (T1D), a group with type 2 diabetes (T2D), and a group without diabetes. Insulin secretion was assessed by C-peptide deconvolution. Hepatic and peripheral insulin sensitivity were analyzed with stepped hyperinsulinemic-euglycemic pancreatic clamp studies. Hepatic and myocellular lipid contents were assessed with 1H-nuclear magnetic resonance spectroscopy.

RESULTS

The total insulin secretory response was lower in the LD group in comparison with the lean group without diabetes and the T2D group. Endogenous glucose production was significantly lower in the LD group than the T2D group (mean ± SEM 0.50 ± 0.1 vs. 0.84 ± 0.1 mg/kg · min, respectively; P < 0.05). Glucose uptake was significantly higher in the LD group in comparison with the T2D group (10.1 ± 0.7 vs. 4.2 ± 0.5 mg/kg · min; P < 0.001). Visceral adipose tissue and hepatocellular lipids were significantly lower in LD than in T2D.

CONCLUSIONS

These studies are the first to demonstrate that LD individuals in LMICs have a unique metabolic profile, suggesting that this is a distinct entity that warrants further investigation.

Association of postnatal severe acute malnutrition with pancreatic exocrine and endocrine function in children and adults: a systematic review

Severe acute malnutrition may lead both concurrently and subsequently to malabsorption and impaired glucose metabolism from pancreatic dysfunction. We conducted a systematic review to investigate the associations of current and prior postnatal wasting malnutrition with pancreatic endocrine and exocrine functions in humans. We searched PubMed, Google Scholar, Web of Science and reference lists of retrieved articles, limited to articles in English published before 1 February 2022. We included sixty-eight articles, mostly cross-sectional or cohort studies from twenty-nine countries including 592 530 participants, of which 325 998 were from a single study. Many were small clinical studies from decades ago and rated poor quality. Exocrine pancreas function, indicated by duodenal fluid or serum enzymes, or faecal elastase, was generally impaired in malnutrition. Insulin production was usually low in malnourished children and adults. Glucose disappearance during oral and intravenous glucose tolerance tests was variable. Upon treatment of malnutrition, most abnormalities improved but frequently not to control levels. Famine survivors studied decades later showed ongoing impaired glucose tolerance with some evidence of sex differences. The similar findings from anorexia nervosa, famine survivors and poverty- or infection-associated malnutrition in low- and middle-income countries (LMIC) lend credence to results being due to malnutrition itself. Research using large, well-documented cohorts and considering sexes separately, is needed to improve prevention and treatment of exocrine and endocrine pancreas abnormalities in LMIC with a high burden of malnutrition and diabetes.

Impact of prenatal famine exposure on adulthood fasting blood glucose level

In the past decade, in low-income countries, there have been a rapid rise in prevalence of diabetes among adult population. Hence, understanding the context specific drivers of this change including the impacts of childhood nutrition adversaries on adult metabolic conditions is critical undertaking. This study investigates the potential effects of prenatal famine exposure to the Ethiopian great famine (1983–1985) on adulthood blood glucose level of survivors. A total of 441 adults (222 exposed and 219 controls) were included in the study. Self-reported place of birth and, date of birth and/or age were used to identify participants. A multivariable linear regression analysis was used to analyze the impact of prenatal famine exposure on the level of fasting blood glucose. In linear regression, unadjusted model (Model 1), fasting blood glucose level was increased by 4.13 (β = 4.13; 95% CI .41, 7.42) points in prenatal famine exposed groups, compared with non-exposed. Similarly, the positive association of prenatal famine exposure and fasting blood glucose level was maintained after adjusted for sex (Model 2) (β = . 4.08 95% CI .056, 7.50). Further adjusted for age, residence, educational status, wealth index and family size (Model 3) resulted in 4.10 (β = . 4.10 95% CI .45, 7.56) points increases in fasting blood glucose level. In model 4 adjusting for dietary pattern, physical activity level and family history of diabetes, alcohol and cigarette smoking resulted in 3.90 (β = 3.90, 95% CI 039, 7.52) points increase in fasting glucose level. In the he full adjusted model (Model 5) prenatal exposure to famine was resulted in 3.78 (β = 3.78, 95% CI .22, 7.34) increases in fasting blood glucose level after adjusted for BMI and waist to height ratio. There existed a positive association of prenatal famine exposure and adulthood blood glucose levels. In this population, establishing effective overweight/obesity prevention programs to minimize the co-impact of early famine exposure on blood glucose control are important.

The Incidence of Adult-Onset Type 1 Diabetes: A Systematic Review From 32 Countries and Regions

BACKGROUND

The epidemiology of adult-onset type 1 diabetes (T1D) incidence is not well-characterized due to the historic focus on T1D as a childhood-onset disease.

PURPOSE

We assess the incidence of adult-onset (≥20 years) T1D, by country, from available data.

DATA SOURCES

A systematic review of MEDLINE, Embase, and the gray literature, through 11 May 2021, was undertaken.

STUDY SELECTION

We included all population-based studies reporting on adult-onset T1D incidence and published from 1990 onward in English.

DATA EXTRACTION

With the search we identified 1,374 references of which 46 were included for data extraction. Estimates of annual T1D incidence were allocated into broad age categories (20-39, 40-59, ≥60, or ≥20 years) as appropriate.

DATA SYNTHESIS

Overall, we observed the following patterns: 1) there is a paucity of data, particularly in low- and middle-income countries; 2) the incidence of adult-onset T1D is lowest in Asian and highest in Nordic countries; 3) adult-onset T1D is higher in men versus women; 4) it is unclear whether adult-onset T1D incidence declines with increasing age; and 5) it is unclear whether incidence of adult-onset T1D has changed over time.

LIMITATIONS

Results are generalizable to high-income countries, and misclassification of diabetes type cannot be ruled out.

CONCLUSIONS

From available data, this systematic review suggests that the incidence of T1D in adulthood is substantial and highlights the pressing need to better distinguish T1D from T2D in adults so that we may better assess and respond to the true burden of T1D in adults.

High incidence of type 1 diabetes in adolescents and young adults in Eritrea

BACKGROUND

Eritrea has no data on type 1 diabetes incidence in children and youth; therefore, a study was undertaken to determine this in persons aged <25 years.

METHODS

Data were collected on new type 1 diabetes diagnoses during 2019, from district, provincial and national hospitals. Type 1 diabetes was diagnosed according to standard WHO criteria. No secondary ascertainment source was available. 95% confidence intervals were computed based on approximation to the Poisson distribution, and age and gender effects were analysed with Poisson regression.

RESULTS

There were 532 new cases of type 1 diabetes. Mean ± standard deviation (range) age of diagnosis was 16.2 ± 5.7 (1.5-24.9) years, and peak age group was 15-19 years (n = 200, 37.6%), with mode at 18 years. Incidence <15 years was 11.5/100,000 individuals [9.9-13.2], with the highest incidence in the 10-14 years group (19.0/100,000 [15.5-23.1]). Incidence then peaked in the 15-19 years age group (50.2/100,000 [43.5-57.7]) and remained high in the 20-24 years group (46.2/100,000 [39.0-54.3]). There was a male:female ratio of 1.37 (p = 0.001). Two hundred and thirty-eight (44.7%) presented in diabetic ketoacidosis.

CONCLUSION

Type 1 diabetes incidence in Eritrea is moderate <15 years, and high 15-24 years. The 15-19 and 20-24 years rates appear to be the highest published to date. Given the study was only for one year, further confirmatory prospective information will clarify the situation and document trends. Assessment of the type 1 diabetes phenotypes that are occurring in Eritrea is also indicated.

Prior undernutrition and insulin production several years later in Tanzanian adults

BACKGROUND

The prevalence, pathology, and existence of malnutrition-associated diabetes remain uncertain, especially with respect to adult-acquired undernutrition.

OBJECTIVE

The aim was to investigate the association of prior undernutrition (low BMI, in kg/m2), acquired in adulthood and insulin during an oral glucose tolerance test (OGTT).

METHODS

We followed up 630 adults recruited 7-14 y previously for other studies. Plasma insulin was measured fasting and at 30 and 120 min during an OGTT. The main exposure was BMI measured 7-14 y prior. The main outcome of interest was plasma insulin, controlling for time during the OGTT using generalized estimating equations, and exploratory outcomes were early insulin response (relative change in insulin and glucose from 0-30 min) and relative insulin and glucose AUCs from 0 to 120 min. Current confounding factors were age, sex, BMI, HIV, socioeconomic status, and physical activity.

RESULTS

In unadjusted analyses, increasing severity of prior malnutrition was associated with lower insulin concentration. In multivariate adjusted analyses, only current BMI was a strong predictor of overall insulin concentration. Associations with prior BMI of insulin responses accounting for glucose were also seen in unadjusted but not adjusted analyses. For insulin concentration but not the outcomes accounting for glucose, there was a sex interaction with prior BMI such that only men had lower insulin if previously malnourished: insulin (pmol/L) at 120 min was 311 (95% CI: 272, 351) for prior BMI ≥18.5, 271 (95% CI: 221, 321) for prior BMI 17.0-18.5, and 237 (95% CI: 194, 297) for prior BMI <17.0; P = 0.03. HIV status showed limited and variable associations with insulin.

CONCLUSIONS

Insulin concentration, fasting and during an OGTT, was normalized in women more than in men several years after adult malnutrition. Chronic malnutrition, as indicated by low prior and current BMI, may contribute to diabetes through low insulin secretion.

Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review

INTRODUCTION

Child malnutrition (undernutrition) and adult non-communicable diseases (NCDs) are major global public health problems. While convincing evidence links prenatal malnutrition with increased risk of NCDs, less is known about the long-term sequelae of malnutrition in childhood. We therefore examined evidence of associations between postnatal malnutrition, encompassing documented severe childhood malnutrition in low/middle-income countries (LMICs) or famine exposure, and later-life cardiometabolic NCDs.

METHODS

Our peer-reviewed search strategy focused on 'severe childhood malnutrition', 'LMICs', 'famine', and 'cardiometabolic NCDs' to identify studies in Medline, Embase, Global Health, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. We synthesised results narratively and assessed study quality with the UK National Institute for Health and Care Excellence checklist.

RESULTS

We identified 57 studies of cardiometabolic NCD outcomes in survivors of documented severe childhood malnutrition in LMICs (n=14) and historical famines (n=43). Exposure to severe malnutrition or famine in childhood was consistently associated with increased risk of cardiovascular disease (7/8 studies), hypertension (8/11), impaired glucose metabolism (15/24) and metabolic syndrome (6/6) in later life. Evidence for effects on lipid metabolism (6/11 null, 5/11 mixed findings), obesity (3/13 null, 5/13 increased risk, 5/13 decreased risk) and other outcomes was less consistent. Sex-specific differences were observed in some cohorts, with women consistently at higher risk of glucose metabolism disorders and metabolic syndrome.

CONCLUSION

Severe malnutrition or famine during childhood is associated with increased risk of cardiometabolic NCDs, suggesting that developmental plasticity extends beyond prenatal life. Severe malnutrition in childhood thus has serious implications not only for acute morbidity and mortality but also for survivors' long-term health. Heterogeneity across studies, confounding by prenatal malnutrition, and age effects in famine studies preclude firm conclusions on causality. Research to improve understanding of mechanisms linking postnatal malnutrition and NCDs is needed to inform policy and programming to improve the lifelong health of severe malnutrition survivors.

Early and Long-term Consequences of Nutritional Stunting: From Childhood to Adulthood

Linear growth failure (stunting) in childhood is the most prevalent form of undernutrition globally. The debate continues as to whether children who become stunted before age 24 months can catch up in growth and cognitive functions later in their lives. The potentially irreparable physical and neurocognitive damage that accompanies stunted growth is a major obstacle to human development. This review aims at evaluation and summarizing the published research covering the different aspects of stunting from childhood to adulthood.

Hyperglycemic Crisis Characteristics and Outcome of Care in Adult Patients without and with a History of Diabetes in Tigrai, Ethiopia: Comparative Study

OBJECTIVE

To compare hyperglycemic crisis characteristics and outcomes of care in adult patients without and with a history of diabetes in Tigrai, Ethiopia.

METHODS

A retrospective record review of diabetes patients, 196 without and 393 with a history of diabetes who had been treated in the medical wards from September 1/2017 to August 31/2018, aged 18 years and above was included. An independent-samples t-test/Mann-Whitney tests, χ²-test, and logistic regression analysis were used to analyze the data using SPSS version 25.0.

RESULTS

Patients without history of diabetes were younger [43.9±12.6 vs 48.4±14.9], more rural residents [53.1% vs 30.3%], lower proportion of type 2 diabetes [38.3% vs 53.7%], hyperosmolar hyperglycemic state [15.8% vs 31.8%], with lower mortality rate [8.7% vs 15.5%] compared to with a history of diabetes. A higher mortality reported in rural residents [13.5% vs 3.3%; without vs 21.8% vs 12.8%; with history], and lower urine ketones [1.9± 1.3 vs 2.8± 1.1; without vs 1.6± 1.2 vs 2.2± 1.0; with a history] compared to their counterparts in both patients, respectively. Rural residents [AOR (95% CI); 3.1 (1.8, 5.4)]; medical history of stroke [AOR (95% CI); 2.7 (1.3, 5.6)]; type 2 diabetes [AOR (95% CI); 2.3 (1.1, 4.7)], hyperglycemic hyperosmolar state [AOR (95% CI); 2.4 (1.1, 5.4)]; and with a history of diabetes [AOR (95% CI); 2.0 (1.04, 3.8)] were significantly associated with mortality, but polydipsia [AOR (95% CI); 0.47 (0.27, 0.81)] was preventive.

CONCLUSION

This finding suggests that rural residents, medical history of stroke, type 2 diabetes, hyperglycemic hyperosmolar state, and with a history of diabetes were independent predictors of mortality while polydipsia was preventive. Therefore, the need for more public health awareness campaigns, screening for people having known risk factors, and expansion of diabetes care services to the primary health care units is a fundamental measure.

Type 1 diabetes in Africa: an immunogenetic study in the Amhara of North-West Ethiopia

AIMS/HYPOTHESIS

We aimed to characterise the immunogenic background of insulin-dependent diabetes in a resource-poor rural African community. The study was initiated because reports of low autoantibody prevalence and phenotypic differences from European-origin cases with type 1 diabetes have raised doubts as to the role of autoimmunity in this and similar populations.

METHODS

A study of consecutive, unselected cases of recently diagnosed, insulin-dependent diabetes (n = 236, ≤35 years) and control participants (n = 200) was carried out in the ethnic Amhara of rural North-West Ethiopia. We assessed their demographic and socioeconomic characteristics, and measured non-fasting C-peptide, diabetes-associated autoantibodies and HLA-DRB1 alleles. Leveraging genome-wide genotyping, we performed both a principal component analysis and, given the relatively modest sample size, a provisional genome-wide association study. Type 1 diabetes genetic risk scores were calculated to compare their genetic background with known European type 1 diabetes determinants.

RESULTS

Patients presented with stunted growth and low BMI, and were insulin sensitive; only 15.3% had diabetes onset at ≤15 years. C-peptide levels were low but not absent. With clinical diabetes onset at ≤15, 16-25 and 26-35 years, 86.1%, 59.7% and 50.0% were autoantibody positive, respectively. Most had autoantibodies to GAD (GADA) as a single antibody; the prevalence of positivity for autoantibodies to IA-2 (IA-2A) and ZnT8 (ZnT8A) was low in all age groups. Principal component analysis showed that the Amhara genomes were distinct from modern European and other African genomes. HLA-DRB1*03:01 (p = 0.0014) and HLA-DRB1*04 (p = 0.0001) were positively associated with this form of diabetes, while HLA-DRB1*15 was protective (p < 0.0001). The mean type 1 diabetes genetic risk score (derived from European data) was higher in patients than control participants (p = 1.60 × 10-7). Interestingly, despite the modest sample size, autoantibody-positive patients revealed evidence of association with SNPs in the well-characterised MHC region, already known to explain half of type 1 diabetes heritability in Europeans.

CONCLUSIONS/INTERPRETATION

The majority of patients with insulin-dependent diabetes in rural North-West Ethiopia have the immunogenetic characteristics of autoimmune type 1 diabetes. Phenotypic differences between type 1 diabetes in rural North-West Ethiopia and the industrialised world remain unexplained.

Diabetes prevalence by HbA1c and oral glucose tolerance test among HIV-infected and uninfected Tanzanian adults

BACKGROUND

The burden of diabetes is increasing in sub-Saharan Africa, including among people living with HIV. We assessed the prevalence of diabetes and the roles of HIV, antiretroviral therapy (ART) and traditional risk factors among adults in Tanzania.

METHODS

We analysed diabetes-relevant baseline data from 1,947 adult participants in the CICADA study in Mwanza, Tanzania: 655 HIV-uninfected, 956 HIV-infected ART-naïve, and 336 HIV-infected persons on ART. WHO guidelines for haemoglobin A1c (HbA1c) and oral glucose tolerance test (OGTT) were used to define diabetes and prediabetes. Risk factors were evaluated using multinomial logistic regression analysis. Relative risk ratios (RRR) were generated comparing participants with diabetes and prediabetes against the reference of those with no diabetes.

RESULTS

Mean age was 41 (SD 12) years; 59% were women. The prevalence of diabetes was 13% by HbA1c and 6% by OGTT, with partial overlap among participants identified by the two tests. Relative to HIV-uninfected, HIV-infected ART-naïve persons had increased relative risks of diabetes (HbA1c: RRR = 1.95, 95% CI 1.25-3.03; OGTT: RRR = 1.90, 95% CI 0.96-3.73) and prediabetes (HbA1c: RRR = 2.89, 95% CI 1.93-4.34; OGTT: RRR = 1.61, 95% CI 1.22-2.13). HIV-infected participants on ART showed increased risk of prediabetes (RRR 1.80, 95% CI 1.09, 2.94) by HbA1c, but not diabetes. CD4 count < 200 cell/μL at recruitment increased risk and physical activity decreased risk of diabetes by both HbA1c and OGTT.

CONCLUSIONS

The prevalence of diabetes was high, especially among HIV-infected ART-naïve adults. Being more physically active was associated with lower risk of diabetes. HbA1c and OGTT identified different participants as having diabetes or prediabetes. Overall, the finding of high burden of diabetes among HIV-infected persons suggests that health systems should consider integrating diabetes screening and treatment in HIV clinics to optimize the care of HIV patients and improve their health outcomes.

Urban-Rural Differences in the Trends of Type 1 and Type 2 Diabetes Among Adults Who Received Medical Treatment from Public Hospitals in Resource-Poor Community Tigray, Ethiopia

OBJECTIVE

This study carried out to describe urban-rural differences in the trend of type 1 and type 2 diabetes among adults who have received medical treatment from public hospitals over the last five years.

METHODS

The trends of adult diabetes assessed from September 1, 2013, to August 31, 2018, using hospital-based retrospective medical records of 299,806 adult patients in the adult medical outpatient and emergency units. Data were collected using a uniform data abstraction format. An extended Mantel-Haenszel chi-square test of the linear trend used to examine the trend over time.

RESULTS

Of the total 299,806 adult patients, 3056 (1.02% (95% CI: 0.98-1.06)) patients were confirmed diabetes patients. The overall trend in the proportion of diabetes had increased from 6.8 to 14.3 per 1000 adult patients. The trend of type 1 diabetes increased for both urban from 1.0 to 2.2 per 1000 adult urban residents and rural from 1.2 to 2.6 per 1000 adult rural residents, with statistically a significant increase (χ²= 9.1, P=0.002) and (χ²=17.8, P<0.001) for linear trend, respectively. The trend of type 2 diabetes increased for both urban from 6.9 to 14.0 per 1000 adult urban residents and rural from 4.0 to 9.5 per 1000 adult rural residents, with a statistically significant increase (χ²=68.4, P<0.001) and (χ²=74.2, P<0.001) for linear trend, respectively. The higher increase in the proportion of both type 1 and type 2 diabetes observed among women patients.

CONCLUSION

The trend in the proportion of type 1 and type 2 diabetes increasing for both urban and rural residents, with a higher increase observed among women. These findings highlight health-care professionals and policymakers to design effective public health policies to treat each type of disease.

Atypical forms of diabetes mellitus in Africans and other non-European ethnic populations in low- and middle-income countries: a systematic literature review

BACKGROUND

Atypical presentations of diabetes mellitus (DM) have been reported in non-European ethnic populations under various names. It is unclear whether those names are used for the same or different clinical phenotypes. Unclear terminology may lead to inappropriate treatment and an underestimation of the burden caused by atypical diabetes phenotypes overlapping with classic types of diabetes. This review aimed to describe the terms used for atypical forms of diabetes and to investigate whether the terms are used for similar or different phenotypes.

METHODS

PubMed and Scopus were searched for relevant publications in French or English available before 15 September 2015 using the terms: "Atypical diabetes", "Malnutrition Related Diabetes Mellitus (MRDM)", "Fibro-calculus pancreatic diabetes (FCPD)", Protein deficient Pancreatic Diabetes (PDPD)", "African diabetes", "Ketosis prone-type 2 diabetes", "tropical diabetes", "Flatbush diabetes", "J-type diabetes". Titles, abstracts screening and quality assessment were performed by two independent authors. Observational studies addressing atypical diabetes in humans aged 14 years and above were included. One author extracted data from selected articles.

RESULTS

22 articles among 350 identified articles were retained for data extraction. Two atypical diabetes phenotypes were identified, each of them with a variety of names but similar definitions. One phenotype occurred in very thin people less than 30 years of age, typically from poor socio-economic backgrounds and requires insulin for life. It differs from type 1 diabetes in the tolerance of high blood glucose without ketosis in the absence of exogenous insulin. The second phenotype resembles type1 diabetes as it presents with ketosis at onset but responds well, as type2 diabetes, to oral hypoglycemic drugs after initial stabilization with insulin. It occurs in individuals who are usually over 30 years of age, with normal or overweight and absence of auto antibodies mainly found in type 1 diabetes.

CONCLUSION

The scarce existing literature used various terms for similar diabetes phenotypes. Agreement on nomenclature for the various forms of diabetes using the above reported characteristics are needed in populations where atypical forms of diabetes exist as well as better characterization of phenotypes and genotypes to inform evidence based treatment.

Non-communicable disease clinics in rural Ethiopia: why patients are lost to follow-up

Background

Providing medical care for non-communicable diseases (NCDs) in rural sub-Saharan Africa has proved to be difficult because of poor treatment adherence and frequent loss to follow-up (LTFU). The reasons for this are poorly understood.

Objective

To investigate LTFU among patients with two different but common NCDs who attended rural Ethiopian health centres.

Method

The study was based in five health centres in southern Ethiopia with established NCD clinics run by nurses and health officers. Patients with epilepsy or hypertension who were lost to follow-up and non-LTFU comparison patients were identified and traced; a questionnaire was administered enquiring about the reasons for LTFU.

Results

Of the 147 LTFU patients successfully located, 62 had died, moved away or were attending other medical facilities. The remaining 85 patients were compared with 211 non-LFTU patients. The major factors associated with LTFU were distance from the clinic, associated costs and a preference for traditional treatments, together with a misunderstanding of the nature of NCD management.

Conclusions

The delivery of affordable care closer to the patients' homes has the greatest potential to address the problem of LTFU. Also needed are increased levels of patient education and interaction with traditional healers to explain the nature of NCDs and the need for life-long management.

Rapid early increase in BMI is associated with impaired longitudinal growth in children with cystic fibrosis

BACKGROUND

We aimed to assess whether final height in children with cystic fibrosis (CF) is affected by body mass index (BMI), BMI increase, pulmonary function, and cystic fibrosis-related diabetes (CFRD).

STUDY DESIGN

A longitudinal, retrospective study was performed in a cohort of 57 patients with CF (30 boys, 27 girls) born between 1997 and 2001. Height and weight were recorded annually from ages 0.5 to 10 years and biannually up to the age of 18. Measurements were converted to height-for-age-adjusted-for-target-height (HFA-TH) and BMI-for-age z-scores. Analyses were performed using the independent t tests and the Pearson's correlation.

RESULTS

For both boys and girls, HFA-TH and BMI-for-age z-scores were significantly lower in the first year of life, these scores increased rapidly until the age of 11 and 8 years, respectively. In boys, HFA-TH z-scores declined during puberty, with subsequently significantly impaired final height (z-score, -0.56, n = 30, standard deviation [SD] = 0.81, P = 0.001). In girls, HFA-TH z-scores briefly declined after the age of 8 years, but then increased to a z-score of -0.21 (n = 27, SD = 0.87) at age 18, which is not significantly lower than the national average (P = 0.22). Pulmonary function and the presence of CFRD were not associated with final height. However, rapid BMI increase between ages 1 and 6 was negatively associated with final height in boys (n = 29, r =-0.420; P = 0.023) and girls (n = 25, r =-0.466; P = 0.019).

CONCLUSIONS

In boys and girls, early BMI increase was associated with impaired final height. We suggest that early childhood serves as a "window" in which nutritional variations may program subsequent growth. Further refinement of nutritional strategies could be needed.

Understanding the manifestation of diabetes in sub Saharan Africa to inform therapeutic approaches and preventive strategies: a narrative review

BACKGROUND

Globally, the burden of diabetes mellitus has increased to epidemic proportions. Estimates from the International Diabetes Federation predict that the greatest future increase in the prevalence of diabetes mellitus will occur in Africa.

METHODS

This article reviews literature on the manifestation of diabetes in adult patients in sub-Saharan Africa highlighting the distinct phenotypes, plausible explanations for this unique manifestation and the clinical significance of comprehensively defining and understanding the African diabetes phenotype.

RESULTS

There are few studies on the manifestation or phenotype of diabetes in Africa. The limited data available suggests that, compared to the Western world, the majority of patients with diabetes in Africa are young and relatively lean in body size. In addition, hyperglycaemia in most cases is characterised by a significantly blunted acute first phase of insulin secretion in response to an oral or intravenous glucose load and pancreatic beta cell secretory dysfunction, rather than peripheral insulin resistance predominates. Genetic and environmental factors like chronic infections/inflammation, early life malnutrition and epigenetic modifications are thought to contribute to these distinct differences in manifestation.

CONCLUSIONS

While published data is limited, there appears to be distinct phenotypes of diabetes in sub-Saharan Africa. Large and more detailed studies are needed especially among newly diagnosed patients to fully characterize diabetes in this region. This will further improve the understanding of manifestation of diabetes and guide the formulation of optimal therapeutic approaches and preventive strategies of the condition on the continent.

Impact of diabetes and sex in heart failure with reduced ejection fraction patients from the ASIAN-HF registry

AIMS

To examine sex differences in clinical characteristics, echocardiographic features, quality of life and 1-year death or heart failure (HF) hospitalization outcomes in patients with/without diabetes mellitus (DM).

METHODS AND RESULTS

Utilizing the Asian Sudden Cardiac Death in HF (ASIAN-HF) registry, 5255 patients (mean age 59.6 ± 13.1, 78% men) with symptomatic HF with reduced ejection fraction (HFrEF) were stratified by DM status to address the research aims. Despite similar prevalence of DM between Asian men (43%) and women (42%), the odds of DM increased at lower body mass index in women vs. men (≥ 23 vs. ≥ 27.5 kg/m² , P_interaction  = 0.014). DM was more strongly related to chronic kidney disease in women vs. men [adjusted odds ratio (OR) 1.85, 95% confidence interval (CI) 1.33-2.57 vs. OR 1.32, 95% CI 1.11-1.56, P_interaction  = 0.009]. Sex also modified the relationship between DM and left ventricular geometry (P_interaction  = 0.003), whereby DM was associated with a more concentric left ventricular geometry in women than men. Women had lower quality of life than men (P < 0.001), in both DM and non-DM groups. DM was associated with worse composite outcomes at 1 year in women vs. men [hazard ratio (HR) 1.79, 95% CI 1.24-2.60 vs. HR 1.32, 95% CI 1.12-1.56; P_interaction  = 0.005).

CONCLUSIONS

Asian women with HFrEF were more likely to have DM despite a lean body mass index, a greater burden of chronic kidney disease and more concentric left ventricular geometry, compared to men. Furthermore, DM confers worse quality of life, irrespective of sex, and a greater risk of adverse outcomes in women than men. These data underscore the need for sex-specific approaches to diabetes in patients with HF.

Nurse-Led Diabetes Self-Management Education Improves Clinical Parameters in Ethiopia

Background: Unlike in developed countries, the clinical effectiveness of diabetes self-management education (DSME) is not well-studied in the African context. Thus, this study sought to determine effects of DSME on clinical outcomes among type 2 diabetic (T2DM) patients in Ethiopia.

Methods: Before-and-after controlled study design was employed, with random assignment of 116 T2DM adult patients to a nurse-led DSME group and 104 to a treatment-as-usual (comparison) group. A nurse-led DSME with six sessions supported with illustrative pictures handbooks and fliers was customized to local conditions and delivered by trained nurses over 9 months. Our primary outcome was a change in the proportion of people with target glycated hemoglobin (HbA1c ≤ 7%). We used chi-square test and mixed model analysis.

Results: Seventy-eight (67%) and 64 (62%) participants assigned to intervention and comparison, respectively completed the study, and included in the final analysis. Mean HbA1c was significantly reduced by 2.88% within the intervention group and by 2.57% within the comparison group. However, change in the proportion of participants with target HbA1c and end-line mean HbA1c difference between the groups were not significant. Adjusted end-line fasting blood sugar (FBS), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were significantly lower in the intervention group, by 27 ± 9 mg/dL, 12 ± 3, and 8 ± 2 mmHg, respectively.

Conclusion: After 9 months of nurse-led DSME, HbA1c was significantly reduced within both groups but there was no significant difference in HbA1c between groups. The intervention also showed some clinically significant effects on blood pressure and FBS.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03185689, retrospectively registered on June 14, 2017 on ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT03185689.

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries

Background

Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases.

Methods

We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs.

Results

Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings.

Conclusions

Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population.

Systematic review registration number

Prospero: CRD42015020169.

Type 1 Diabetes in a Resource-Poor Setting: Malnutrition Related, Malnutrition Modified, or Just Diabetes?

PURPOSE OF REVIEW

Very little is known about the occurrence of type 1 diabetes (T1DM) in resource-poor countries and particularly in their rural hinterlands.

RECENT FINDINGS

Studies of the epidemiology of T1DM in Ethiopia and similar countries in sub-Saharan Africa show that the pattern of presenting disease differs substantially from that in the West. Typically, the peak age of onset of the disease is more than a decade later with a male excess and a low prevalence of indicators of islet-cell autoimmunity. It is also associated with markers of undernutrition. These findings raise the question as to whether the principal form of T1DM seen in these resource-poor communities has a different pathogenesis. Whether the disease is a direct result of malnutrition or whether malnutrition may modify the expression of islet-cell autoimmunity is unclear. However, the poor prognosis in these settings underlines the urgent need for detailed clinical and epidemiological studies.

High rates of ocular complications in a cohort of Haitian children and adolescents with diabetes

BACKGROUND

Ophthalmic complications of pediatric diabetes are rare, and rates are unknown in Haitian youth.

OBJECTIVES

To determine the prevalence and predictors of diabetic retinopathy (DR) and cataracts in a cohort of Haitian youth with insulin-treated diabetes.

METHODS

We performed a cross-sectional retrospective review of pediatric patients with diabetes from a pediatric chronic disease center in Haiti, from December 1, 2012 to November 1, 2016. Data collection included demographic and anthropometric information, total daily insulin dose and result of eye examination by a local ophthalmologist.

RESULTS

Of 67 patients (54% female, mean age at diagnosis 14.6 ± 3.9 years, mean diabetes duration 3.3 ± 3.0 years, mean HbA1c 84 ± 22 mmol/mol (9.8% ± 2.0%), mean current insulin requirement 0.49 ± 0.28 IU/kg/day), DR was diagnosed in 10/57 (18%) and cataracts in 10/62 (16%), at a mean age of 19.0 ± 4.3 and 19.1 ± 3.3 years, respectively. Diabetes duration was 4.9 ± 5.4 and 3.0 ± 1.5 years at the time of diagnosis of DR and cataracts, respectively. Age at complication, insulin requirement, sex, body mass index, family history, mean HbA1c and diabetes duration were not significant predictors of an ocular complication.

CONCLUSIONS

In this cohort of Haitian youth, DR and cataracts occur prematurely. Low-insulin requirements years after diagnosis, possibly allowing for prolonged undetected hyperglycemia prediagnosis, may explain complication risk. The phenotypes of diabetes in pediatric populations of African ancestry may be distinct. Ophthalmologic evaluation should possibly start at diagnosis, and screening guidelines may need to be adapted.

High attainment of optimal nutritional and growth status observed among Greek pediatric cystic fibrosis patients: results from the GreeCF study

BACKGROUND

Pediatric cystic fibrosis (CF) patients suffer high rates of undernutrition, subject to several parameters. We aimed to assess growth and nutritional status of Greek children and adolescents with CF.

METHODS

Eighty-four patients (35 boys) formed the sample. Anthropometrics and FEV1 were measured, growth and weight status were assessed. Body mass index (BMI), arm circumference (MUAC), fat (MUAFA) and muscle (MUAMA) were calculated.

RESULTS

In the total sample, 6.0% of the patients were underweight, 4.8% stunted, 8.3% wasted and 17.9% in nutritional failure, whereas 59.5% attained the ideal BMI for CF. FEV1 positively associated with BMI (B=0.03, p≤0.003), weight (B=0.03, p≤0.003) and MUAMA z-scores (B=0.04, p≤0.005). Meconium ileus negatively associated with FEV1 (B=-14.17, p≤0.003) and stature (B=-0.65, p≤0.043). Pancreatic insufficiency negatively influenced MUAC and MUAFA z-scores (p≤0.05 for both).

CONCLUSIONS

The examined CF patients appear to be thriving. Unlike published research, the participants' sex, gene mutation and acquisition of pathogens did not affect growth.

Dysglycemia associations with adipose tissue among HIV-infected patients after 2 years of antiretroviral therapy in Mwanza: a follow-up cross-sectional study

BACKGROUND

Data on the burden of dysglycemia among HIV-infected patients on antiretroviral therapy (ART) in Africa are limited. We determined the prevalence of pre-diabetes and diabetes among HIV-infected patients who started ART when malnourished 2 to 3 years previously and investigated the association of dysglycemia with body composition.

METHODS

Malnourished (body mass index (BMI) < 18.5 kg/m2) HIV-infected patients who were enrolled in the Nutritional Support for Africans Starting Antiretroviral Therapy (NUSTART) trial from 2011 to 2013 were followed-up from March to August 2015. Anthropometric, fat mass and fat-free mass by bioelectrical impedance, and C-reactive protein (CRP) data were collected at baseline and follow-up. At follow-up, we defined fasting glucose of 6.1-6.9 mmol/L as impaired fasting glucose (IFG) and 2-h oral glucose tolerance test (OGTT) glucose of ≥7.8 to <11.1 mmol/L as impaired glucose tolerance (IGT). Both of these were considered pre-diabetes. Fasting glucose of ≥7.0 mmol/L or impaired glucose tolerance of ≥11.1 mmol/L was defined as diabetes mellitus. The relation of pre-diabetes and diabetes with body composition was assessed using logistic regression.

RESULTS

Two hundred seventy-three (57%) of 478 patients who were alive at trial conclusion were followed-up. The mean age was 41.5 (SD 9.8) years and 65.2% (178) were females. The mean follow-up BMI was 19.9 (SD 2.8) kg/m2, 12 (4.4%) were either overweight or obese, and 61 (22.3%) patients had pre-diabetes or diabetes. In multiple regression, upper tertiles of baseline hip circumference (OR: 0.41, 95% CI: 0.2, 0.8) and fat mass index (OR: 0.20 (0.1, 0.5), and upper tertiles of follow-up waist circumference (OR: 0.22 (0.1, 0.5), BMI (OR: 0.32 (0.1, 0.7), fat mass index (OR: 0.19 (0.1, 0.5) and the middle tertile of follow-up fat-free mass (OR: 0.36, 95% CI: 0.1, 0.8) were associated with lower risk of pre-diabetes and diabetes (P < 0.05 for all). Baseline and follow-up CRP were not predictors.

CONCLUSIONS

Low rather than high measures of adipose tissue were associated with increased risk of pre-diabetes and diabetes. Additional studies are needed to further investigate the role of body composition and control of glucose metabolism in the pathogenesis of diabetes among persons living with HIV in Africa.

High Prevalence of Autoimmune Diabetes and Poor Glycaemic Control among Adults in Madagascar: A Brief Report from a Humanitarian Health Campaign in Ambanja

Madagascar is a geographically isolated country considered a biodiversity hotspot with unique genomics. Both the low-income and the geographical isolation represent risk factors for the development of diabetes. During a humanitarian health campaign conducted in Ambanja, a rural city in the northern part of Madagascar, we identified 42 adult subjects with diabetes and compared their features to 24 randomly enrolled healthy controls. 42.9% (n = 18) of diabetic subjects showed HbA1c values ≥ 9.0%. Unexpectedly, waist circumference and BMI were similar in people with diabetes and controls. Different from the healthy controls, diabetic subjects showed a low prevalence of obesity (5.7% versus 30%, p = 0.02). Accordingly, we found a high prevalence of autoimmune diabetes as 12% of people with diabetes showed positivity for the autoantibody against glutamic acid decarboxylase. Diabetic subjects with positive autoantibody had higher HbA1c values (11.3 ± 4.1% versus 8.3 ± 2.6%, p = 0.03) compared to diabetic subjects with negative autoantibody. In conclusion, here we describe the presence of diabetes and its features in a rural area of Northern Madagascar, documenting poor glycaemic control and a high prevalence of autoimmune diabetes. These data highlight that the diabetes epidemic involves every corner of the world possibly with different patterns and features.

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia

AIM

To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications.

METHODS

A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded.

RESULTS/CONCLUSIONS

Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p<0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed.

Lean diabetes mellitus: An emerging entity in the era of obesity

Much has been published on the characteristics of type 2 diabetes mellitus and its association with the epidemic of obesity. But relatively little is known about the incidence of lean diabetes, progression of disease and fate of the patients with low-normal body mass index (< 25). Studies in developing countries have shown that the clinical characteristics of these patients include history of childhood malnutrition, poor socioeconomic status, relatively early age of onset and absence of ketosis on withdrawal of insulin. In the United States, recent studies showed that the lean, normal weight diabetes is not rare especially among minority populations. They showed that these patients are mainly males, have higher prevalence of insulin use indicating rapid beta cell failure. They might have increased total, cardiovascular and non cardiovascular mortality when compared to obese diabetic patients. In this review, the epidemiologic and clinical features of lean diabetes are presented. The potential causal mechanisms of this emerging diabetes type that may include genetic, autoimmune, acquired and behavioral factors are discussed. The need for studies to further elucidate the causation as well as specific prevention and treatment of lean diabetes is emphasized.

David Barker, Buruli ulcer and the epidemiology of a neglected tropical disease

In 1969, David Barker, his wife and four children moved to Uganda to work at Makerere Medical School in the capital Kampala. During the 1960s, Makerere had become a research and teaching centre with an international reputation based on the work of Trowell, Burkitt, Hutt and many others who had pioneered studies explaining the disease patterns in the West Nile area on the basis of the local climate, nutrition and lifestyle. David Barker was funded by the Medical Research Council to carry out research on a poorly understood disease, Buruli ulcer, joining Scottish surgeon Wilson Carswell, who was later to achieve fame as the role model for Dr Garrigan in Giles Foden's novel The Last King of Scotland.

Lower waist circumference in mildly-stunted adolescents is associated with elevated insulin concentration

OBJECTIVE

Augmented waist circumference (WC) is associated with non-communicable diseases and could represent a valuable marker in screening for metabolic dysfunctions in subjects with insufficient linear growth. The objective of the present study was to determine whether biochemical and hemodynamic parameters and waist circumference vary between mildly-stunted and non-stunted adolescents from impoverished communities of São Paulo, Brazil.

METHODS

The cross-sectional study involved 206 subjects, aged between 9 and 19 years and living in impoverished areas of São Paulo, Brazil. The sample population was divided according to height-for-age Z-score (HAZ) into stunted (-1 > HAZ ≥ -2) and non-stunted (HAZ ≥ -1) groups, and was sub-divided according to gender. Logistic regression analysis was employed to compare individuals with elevated (> 75th percentile) insulin concentrations. The receiver operating characteristic curves were constructed to determine WC cut-off points that could be used to identify stunted and non-stunted individuals with elevated insulin concentrations.

RESULTS

WC cut-off points of 58.25cm and 67.2cm allowed for correct classification of 90.7% of stunted and 88.7% of non-stunted individuals in the studied population. While the sensitivity of the model was high for stunted and non-stunted subjects (98.8% and 97.2%, respectively), the specificity was modest (57.1% and 41.2%, respectively).

CONCLUSION

The results presented herein suggest that an increase in plasma insulin is one of the primary metabolic modifications in stunted individuals, and that this alteration could be identified at a lower WC cut-off point than in non-stunted counterparts.

Glucose metabolism in adult survivors of severe acute malnutrition

CONTEXT AND OBJECTIVES

The clinical syndromes of severe acute malnutrition may have early life origins because children with marasmus have lower birth weight than those with kwashiorkor. We hypothesized that resultant metabolic effects may persist into adulthood. We investigated whether marasmus survivors (MS) are more insulin resistant and glucose intolerant than kwashiorkor survivors (KS).

RESEARCH DESIGN AND SETTING

This was a case-control study in Jamaican adults.

SUBJECTS

We performed oral glucose tolerance tests on 191 adults (aged 17-50 y; 52% male; body mass index 24.2 ± 5.5 kg/m(2)). There were 43 MS; 38 KS; 70 age-, sex-, and body mass index-matched community controls; and 40 age- and birth weight-matched controls.

MEASUREMENTS

We measured insulin sensitivity with the whole-body insulin sensitivity index, and β-cell function with the insulinogenic index and the oral disposition index.

RESULTS

Fasting glucose was comparable across groups, but glucose intolerance was significantly more common in MS (19%) than in KS (3%), community controls (11%), and birth weight-matched controls (10%). The whole-body insulin sensitivity index was lower in MS than KS (P = .06) but similar between MS and controls. The insulinogenic index and oral disposition index were lower in MS compared with all three groups (P < .01).

CONCLUSIONS

Marasmus survivors tend to be less insulin sensitive, but have significantly lower insulin secretion and are more glucose intolerant compared with kwashiorkor survivors and controls. This suggests that poor nutrition in early life causes β-cell dysfunction, which may predispose to the development of diabetes.

MicroRNAs with Specific Roles in Diabetes and Psychiatric Diseases

Diabetes mellitus is one of the most cited non communicable diseases and the most common metabolic disorder. Epigenetics represents the field of study of heritable changes in gene expression which are not directly related to DNA. Epigenetics is concerned, alongside histone modifications, short interfering RNAs etc., with microRNAs (miRNAs) as well. These are small noncoding RNAs, 21 to 23 nucleotides in length, which either inhibit translation or affect mRNA stability and degradation. At present, there are dozens of miRNAs which have been proven to be involved in the animal and human pathology of diabetes (type 1 or 2). This review focuses on the miRNAs which have been identified as playing a role in both psychiatric diseases and diabetes.

Better nutritional status in early childhood is associated with improved clinical outcomes and survival in patients with cystic fibrosis

OBJECTIVES

To evaluate the relationship between nutritional status early in life and the timing and velocity of height growth, lung function, complications of cystic fibrosis, and survival.

STUDY DESIGN

Prospective, observational study using data from the Cystic Fibrosis Foundation Registry (US) for patients born between 1989 and 1992 (n = 3142).

RESULTS

Weight-for-age percentile (WAP) at 4 years of age was positively associated with height-for-age percentiles throughout childhood. Age 4 years WAP >10% was associated with better lung function from 6-18 years of age. In boys and girls with current WAP >50%, peak pubertal height velocities approximated but remained lower than that of the healthy reference population. By age 18 years, patients with an age 4 years WAP >50% suffered fewer acute pulmonary exacerbations, spent fewer days in the hospital, and had lower rates of impaired glucose tolerance or diabetes. Patients attaining higher age 4 years WAP and height-for-age percentiles had a survival advantage throughout childhood.

CONCLUSION

For the population studied, greater weight at age 4 years is associated with greater height, better pulmonary function, fewer complications of cystic fibrosis, and better survival through age 18 years. Furthermore, greater weight-for-age in the peripubertal period is associated on average with improved tempo and timing of pubertal height growth.

Epilepsy, poverty and early under-nutrition in rural Ethiopia

PURPOSE

The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition.

METHODS

Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes.

RESULTS

Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037).

CONCLUSION

Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy.

Epidemiology, complications and management of diabetes in Ethiopia: a systematic review

Non-communicable diseases are becoming major problems of public health importance in most developing countries as a result of the effects of globalization and epidemiologic transition; however, there is little evidence regarding diabetes and other non-communicable diseases in these countries. The aim of this study was to conduct a systematic review of the literature on the magnitude of diabetes, the relationship between malnutrition and diabetes, diabetic complications, and the management of diabetes in Ethiopia. Relevant studies and other evidence were identified by searches in the Embase from 1970 to December 2011 and by reviewing the reference lists from retrieved articles. Relevant articles from non-indexed local journals were also included. Data were extracted and summarized using the major themes of the systematic review. Although the prevalence of diabetes in Ethiopia is estimated to be 2% nationally, evidence suggests that it prevalence could be >5% in those older than 40 years of age in some settings. Studies in the 1980s and 1990s have reported conflicting evidence regarding malnutrition-related diabetes; however, more recent studies are reconfirming a strong association between malnutrition and diabetes. There is remarkable prevalence of both acute and chronic complications in diabetic cases in Ethiopia. In addition to this, more than one-third, but only less than half, of diabetic patients in Ethiopia receive standard diabetes care. The results of this study indicate that, in response to the emergence of diabetes and other non-communicable diseases, effective and efficient prevention and control strategies should be designed and implemented in Ethiopia.

Long-lasting effects of undernutrition

Undernutrition is one of the most important public health problems, affecting more than 900 million individuals around the World. It is responsible for the highest mortality rate in children and has long-lasting physiologic effects, including an increased susceptibility to fat accumulation mostly in the central region of the body, lower fat oxidation, lower resting and postprandial energy expenditure, insulin resistance in adulthood, hypertension, dyslipidaemia and a reduced capacity for manual work, among other impairments. Marked changes in the function of the autonomic nervous system have been described in undernourished experimental animals. Some of these effects seem to be epigenetic, passing on to the next generation. Undernutrition in children has been linked to poor mental development and school achievement as well as behavioural abnormalities. However, there is still a debate in the literature regarding whether some of these effects are permanent or reversible. Stunted children who had experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted. Children treated before 6 years of age in day-hospitals and who recovered in weight and height have normal body compositions, bone mineral densities and insulin production and sensitivity.