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Diabetes mellitus has long been a concern of the World Health Organisation (WHO), and official relations were established between WHO and the International Diabetes Federation as early as 1957. The WHO Expert Committee on Diabetes Mellitus in 1985 produced important technical reports (2, 3) which have become international standard reference documents on public health aspects of diabetes.
A WHO Study Group on Prevention of Diabetes Mellitus met in Geneva from 16 to 20 November 1992 to review possibilities for the prevention of diabetes and its consequences, to consider the development of national prevention and control programmes and to identify areas where further research is needed. At the country level, WHO has provided technical support for epidemiological studies of diabetes in many of the WHO regions which fill important gaps in knowledge of diabetes and its risk factors in adult populations, as does the participation of a number of WHO Collaborating Centres for Diabetes in the WHO integrated programme for community health in noncommunicable diseases (INTERHEALTH).
Cooper RS. Rotimi CN. Kaufman JS. Owoaje EE. Fraser H. Forrester T. Wilks R. Riste LK. Cruickshank JK. Prevalence of NIDDM among populations of the African diaspora.
- OBJECTIVE: Rates of non-insulin-dependent diabetes mellitus have risen sharply in recent years among blacks in the U.S. and the U.K. Increases in risk have likewise been observed in the island nations of the Caribbean and in urban West Africa. To date, however, no systematic comparison of the geographic variation of NIDDM among black populations has been undertaken.
- RESEARCH DESIGN AND METHODS: In the course of an international collaborative study on cardiovascular disease, we used a standardized protocol to determine the rates of NIDDM and associated risk factors in populations of the African diaspora. Representative samples were drawn from sites in Nigeria, St. Lucia, Barbados, Jamaica, the United States, and the United Kingdom. A total of 4,823 individuals aged 25-74 years were recruited, all sites combined.
- RESULTS: In sharp contrast to a prevalence of 2% in Nigeria, age-adjusted prevalences of self-reported NIDDM were 9% in the Caribbean and 11% in the U.S. and the U.K. Mean BMI ranged from 22 kg/m2 among men in West Africa to 31 kg/m2 in women in the U.S Disease prevalence across sites was essentially collinear with obesity, pointing to site differences in the balance between energy intake and expenditure as the primary determinant of differential NIDDM risk among these populations.
- CONCLUSIONS: In ethnic groups sharing a common genetic ancestry, these comparative data demonstrate the determining influence of changes in living conditions on the population risk of NIDDM.
Diabetes Care 20(3):343-8, 1997 Mar.
Epidemiological aspects of diabetes
Diabetes is a worldwide public health problem made more acute in Africa by low socio-economic standards. Cases with an unusual clinical course are frequent and probably related to tropical diabetes, a syndrome that has not yet been precisely defined. This study reports the results of a prospective study carried out in Cameroon on 550 diabetic patients attending the Yaounde Central Hospital who were followed between December 1990 and July 1994. They were classified according to WHO criteria into 136 insulin-dependent diabetes mellitus (IDDM) (24.7%), 405 non-insulin- dependent diabetes mellitus (NIDDM) (73.7%) and 9 diabetes secondary to other diseases (1.6%). No cases of malnutrition-related diabetes mellitus (MRDM) were found, but 18 subjects were considered to have so-called "African diabetes". Investigation of the cohort showed epidemiological and clinical features markedly different from those of Caucasian diabetic subjects. The age of onset in IDDM occurred in all age groups, with a mean (+/- SD) close to that of NIDDM (40.9 +/- 4.8 years vs 49 +/- 10.9; P < 0.001). A clear male preponderance was found (M/F sex ratio = 1.63), as it has been reported in most studies from sub-Saharan Africa, in contrast with the slight female predominance noted in the Sahel and Saharan countries. An increased prevalence of young and non-obese NIDDM was also found. Seventy-nine NIDDM cases (19.5%) were detected in individuals under 40 years of age, including 31 with normal weight. Many atypical features were noted: IDDM in obese patients, NIDDM in ketotic subjects and patients with varying insulin requirements, all of which led to difficulties in classifying many diabetic patients according to current practices. All these uncommon features are concordant with the nature of tropical diabetes, including not only MRDM but also African diabetes which occurs in individuals older than MRDM patients who show no signs of malnutrition. Thus, tropical diabetes is apparently a syndrome with aetiological heterogeneity which requires further definition through clinical, genetic and immunological studies.
Ducorps M. Ndong W. Jupkwo B. Belmejdoub G. Poirier JM. Mayaudon H. Bauduceau B. Epidemiological aspects of diabetes in Cameroon: what is the role of tropical diabetes?.
Diabetes & Metabolism. 23(1):61-7, 1997 Feb.
Ethnic differences in the clinical and laboratory associations with retinopathy in adult onset diabetes: studies in patients of African, European and Indian origins.
Kalk WJ. Joannou J. Ntsepo S. Mahomed I. Mahanlal P. Becker PJ. Ethnic differences in the clinical and laboratory associations with retinopathy in adult onset diabetes: studies in patients of African, European and Indian origins.
- OBJECTIVE: To evaluate the prevalence of diabetic retinopathy (DR) and its associations in adult onset diabetic patients of African, European and Indian origins.
- DESIGN: The prevalence of retinopathy was determined by 60 degrees retinal photography in 507 consecutive out-patients. Clinical and laboratory associations were evaluated.
- SETTING: Diabetes clinic in a large community hospital.
- MAIN OUTCOME MEASURES: The associations between clinical and laboratory measurements with retinopathy.
- RESULTS: African patients (A) had shorter duration of diabetes (P < 0.001), higher HbA1 levels (P < 0.01) compared to those of Europeans (E) and Indian (I) extraction. A also had lower C-peptide levels (median 0.57 nmol L-1; vs. E. 0.81 nmol L-1 and I, 0.93 nmol L-1) (P < 0.001). The prevalences of retinopathy at diagnosis (21-25%) and overall were similar (A 37%, E 41%, I 37%). Severe DR was more frequent in the Africans (52%, P < 0.0001) and Indians (41%, P = 0.03) compared to the Europeans (26%). In Africans DR was significantly associated only with duration of diabetes (P < 0.0001) and macro-albuminuria (P = 0.01); in I it was also associated with systolic BP (P = 0.03); in E also with lower C-peptide levels (P = 0.0002), worse glycaemic control and greater use of insulin (P < 0.0001). In patients with DR insulin was used less frequently in A (35%) than in E patients (62%) (P = 0.001).
- CONCLUSIONS: In South Africa, the African population with adult onset diabetes has the highest prevalence of severe retinopathy, probably the result of very poor glycaemic control attributable to more severe insulinopenia and infrequent insulin treatment. Visual loss from diabetic retinopathy is likely to be considerable in Africans.
Journal of Internal Medicine. 241(1):31-7, 1997 Jan.
Diabetes mellitus as a cause of death in Sub-Saharan Africa
The aim of this study was to determine the contribution of diabetes mellitus to all-cause mortality and diabetes mortality rates in adults 15 years and above living in one urban and two rural areas of Tanzania (Dar es Salaam, Hai and Morogoro Rural Districts). The threesurveillance populations comprised 307,912 persons. Prospective monitoring of all deaths between 1 June 1992 and 31 May 1995 was carried out. Cause of death was determined by verbal 'autopsy' conducted with relatives of the deceased. In total, 4299 deaths were recorded in children (aged < 15 years) and 8054 in adults. In children there were no reported deaths associated with diabetes (due to or in children with diabetes). The adult male mortality rates associated with diabetes were 34, 30, and 15 per 100,000 per year in Dar es Salaam, Hai and Morogoro Rural Districts respectively. The figures in women were 21, 18, and 4 per 100,000 per year, respectively. The percentages of all adult male deaths associated with diabetes were 2.6%, 2.1% and 0.7% respectively. In women the percentages were 1.7%, 1.8%, and 0.2% respectively. Acute metabolic complications, infection, and stroke each accounted for approximately 30% of all diabetic deaths. Thus diabetes mortality rates varied between the three surveillance areas, being lowest in the poorest rural area. Rates were higher in men in all areas. While care is required in the comparison of mortality rates between countries, it was noteworthy that Tanzania, a country with a low diabetes prevalence, had diabetes mortality rates which were higher than or comparable to rates in Mauritius and the United States. Most patients died from preventable causes, indicating a need for improved case-management of diabetic emergencies as well as better detection and treatment of hypertension.
McLarty DG. Unwin N. Kitange HM. Alberti KG. Diabetes mellitus as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania. The Adult Morbidity and Mortality Project.
Diabetic Medicine. 13(11):990-4, 1996 Nov.
Clinical experience with adolescent diabetes
Diabetes mellitus presenting in adolescents age 10 to 20 years accounts for less than 5% of all diabetes in tropical African countries. Consequently, inadequate attention is paid to the medical and psychosocial problems attendant on adolescent diabetes in those countries. This article highlights our clinical experience in the management of 30 adolescent diabetic subjects who presented consecutively in the diabetic clinic of a major Nigerian teaching hospital. In these patients, adolescent diabetes appeared heterogeneous, comprising classical insulin-dependent diabetes mellitus (IDDM) in approximately 80%; the remaining fraction (20%) was contributed variably by malnutrition-related diabetes (MRDM) and an "atypical" form of IDDM. The most common medical complications were recurrent hypoglycemia, ketoacidosis, and infections. About 80% of the patients were poor, and up to two thirds had to withdraw from school or trade because of recurrent illness. One third of the girls had a history of unwanted pregnancies. Almost all (93%) had a history of general rebelliousness and clinic truancy. Therefore, the high prevalence of acute metabolic decompensation may be related to the increased frequency of psychosocial problems, especially poverty, in these patients. It is suggested that agencies in tropical Africa increase welfare facilities for adolescent chronic disease, and also establish and encourage clinics dedicated to adolescent diabetes care.
Akanji AO. Clinical experience with adolescent diabetes in a Nigerian teaching hospital.
Journal of the National Medical Association. 88(2):101-5, 1996 Feb.
Mortality and outcome of insulin-dependent diabetes
Sixty-four insulin-dependent (Type 1) diabetic patients (IDDM) in Soweto, South Africa were followed over a 10-year period. Patients were assessed in 1982 and again in 1992. There were 10 deaths (16%), half of which were due to renal failure. Ketoacidosis, hypoglycaemia, and sepsis accounted for the rest. At the 10-year follow-up mean age (+/- SD) was 32.4 +/- 5.0 years and diabetes duration 13.6 +/- 2.6 years. Retinopathy affected 52%, peripheral neuropathy 42%, and nephropathy 28% (all significantly increased from the 1982 assessment). Microalbuminuria and autonomic neuropathy were also common. Serum cholesterol was over 6.5 mmol l-1 in 19%, hypertension affected 22%, and 28% were cigarette smokers; though no patient had evidence of macroangiopathy. We conclude that IDDM in South Africa is associated with excess mortality, a significant proportion of which is related to nephropathy. Diabetes of long duration is now not uncommon in South Africa, and although diabetic complications frequently occur, most patients have good life quality and freedom from large vessel disease.
Gill GV. Huddle KR. Rolfe M. Mortality and outcome of insulin-dependent diabetes in Soweto, South Africa.
Diabetic Medicine. 12(6):546-50, 1995 Jun.
Blood pressure changes in diabetes
Little is known of the natural history of blood pressure (BP) levels in diabetic patients from sub-Saharan Africa. BP levels were therefore recorded in such patients in Dar es Salaam, Tanzania, over 2, 5, and 7 years. Hypertension was found in 5% of insulin-treated diabetes mellitus (IDDM) and 29.2%of non-insulin-dependent diabetes mellitus (NIDDM) patients at presentation with diabetes. Hypertension developed in a further 2 IDDM (3.7%) and 27 NIDDM (15.6%) patients at 2 years, and in 3 IDDM (13.0%) and 9 NIDDM (9.8%) patients at 5 years. Seven NIDDM (18.4%) patients had developed hypertension by 7 years. In NIDDM patients with normal BP initially, the mean systolic BP rose from 131 to 141 mmHg (P < 0.001) 2 years later (n = 146); from 131 to 138 mmHg (P <0.001) for those followed for 5 years (n = 82); and from 131 to 138 mmHg (P <0.05) for those followed for 7 years (n = 31). The mean diastolic BP was 83 mmHg initially and 84 mmHg (NS) for those followed for 2 years (n = 146). There was no observed rise in mean diastolic BP at 5 or 7 years of follow-up. In IDDM patients without hypertension, only the systolic BP rose significantly by 5 years, from 124 to 132 mmHg (P < 0.001; n= 20). These changes were independent of age, sex, body mass index, and proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)
Mugusi F. Ramaiya KL. Chale S. Swai AB. McLarty DG. Alberti KG. Blood pressure changes in diabetes in urban Tanzania.
Acta Diabetologica. 32(1):28-31, 1995 Mar.
Thyroid and diabetes
It is generally believed that autoimmune disorders are uncommon in Africans. Some workers have argued that insulin-dependent diabetes mellitus (IDDM) is rare in Africa on account of this reduced proneness to autoimmunity. However, it is undetermined whether or not Africans with IDDM have increased prevalence of thyroid dysfunction and autoimmunity, two phenomena strongly associated with Caucasian IDDM. We determined thyroid function and the prevalence of thyroid autoimmunity in IDDM Africans. The results are compared with those of a nondiabetic group and a group with non-insulin-dependent diabetes mellitus (NIDDM). Thyroid hormone levels were significantly lower in IDDM patients than in the control population and the NIDDM population. Subclinical hypothyroidism was present in 21% of the 28 IDDM patients. One patient was hypothyroid and another hyperthyroid. Of the 60 NIDDM patients, 5 (8.3%) had subclinical hypothyroidism. Forty-six percent of the IDDM patients had significant levels of serum thyroid autoantibodies (TAAB). This was significantly higher than the 1.4% and 1.7%, respectively, in the controls and NIDDMs. Presence of TAAB in the patients was strongly associated with thyroid dysfunction, female preponderance, and duration of diabetes mellitus. Thyroid dysfunction and autoimmunity are common in Nigerians clinically diagnosed as IDDM, and have prevalence rates comparable to other populations but higher than rates previously reported from some other African groups. The increased prevalence of thyroid autoimmunity in the IDDM supports the view that these patients are true IDDMs rather than variants NIDDM or malnutrition-related diabetes mellitus (MRDM) as has been suggested by some workers.
Cardoso C. Ohwovoriole AE. KuKu SF. A study of thyroid function and prevalence of thyroid autoantibodies in an African diabetic population.
Journal of Diabetes & its Complications. 9(1):37-41, 1995 Jan-Mar.
Third World & Diabetes
Since 1988, the World Health Organization has been collecting standardized information on the prevalence of diabetes mellitus and impaired glucose tolerance in adult communities worldwide. Within the age range 30 to 64 years, diabetes and impaired glucose tolerance were found to be absent or rare in some traditional communities in Melanesia, East Africa, and South America. In communities of European origin, the prevalences of diabetes and impaired glucose tolerance were in the range of 3% to 10% and 3% to 15%, respectively, but migrant Indian, Chinese, and Hispanic American groups were at higher risk (15% to 20%). The highest risk was found among the Pima Indians of Arizona and the urbanized Micronesians of Nauru, where up to half of the population aged 30 to 64 years had diabetes. The prevalence of total glucose intolerance (diabetes and impaired glucose tolerance combined) was greater than 10% in almost all populations, and was within the 11% to 20% range for European and US white populations. However, the prevalence of total glucose intolerance reached almost 30% in Arab Omanis and US blacks and affected one third of all adult Chinese Mauritians, migrant Indians, urban Micronesians, and lower-income urban US Hispanics. In Nauruans and Pima Indians, approximately two thirds of all adults aged 30 to 64 years were affected. These results lead to three important conclusions. (1) An apparent epidemic of diabetes has occurred--or is occurring--in adults through the world. (2) This trend appears to be strongly related to life-style and socioeconomic change.(ABSTRACT TRUNCATED AT 250 WORDS)
King H. Rewers M. Diabetes in adults is now a Third World problem. World Health Organization Ad Hoc Diabetes Reporting Group.
Ethnicity & Disease. 3 Suppl:S67-74, 1993.
Hypertension in Africa
Hypertension is the commonest cardiovascular disease in Africans occurring in more than 15% of the adult population in some studies. It occurs in the lower as much as in the higher socio-economic groups. Recent studies have confirmed earlier findings that essential hypertension in Africans is characterised by volume loading, low plasma renin activity, high salt taste threshold, high urinary sodium and low potassium excretion and high plasma aldosterone. The commonest complication of hypertension in Africans is congestive cardiac failure followed by cerebrovascular accidents. Coronary heart disease is rare. Even in the absence of overt heart failure and compounding factors like obesity, alcoholism, cigarette smoking, diabetes mellitus and myocarditis, evidence of abnormal left ventricular morphology and function is often present in newly diagnosed patients with moderate or severe hypertension. Response to monotherapy with beta-blockers or ACE inhibitors is usually poor but is good with thiazide diuretics or calcium channel blockers. The diuretics are an essential component of a two or three drug regime containing other classes of antihypertensive drugs. Cost of drugs is the most important determinant of compliance with drug treatment and consequently the likelihood of progression of the diseases to more severe forms in long term follow-up. [References: 25]
Salako LA. Hypertension in Africa and effectiveness of its management with various classes of antihypertensive drugs and in different socio-economic and cultural environments. [Review] [25 refs]
Clinical & Experimental Hypertension. 15(6):997-1004, 1993 Nov.
Coronary heart disease risk factors
Kitange HM. Swai AB. Masuki G. Kilima PM. Alberti KG. McLarty DG. Coronary heart disease risk factors in sub-Saharan Africa: studies in Tanzanian adolescents.
- STUDY OBJECTIVE--To assess the level of cardiovascular risk factors in young people in sub-Saharan Africa living in rural and urban settings.
- DESIGN--Cross sectional survey of the population aged 15 to 19 years.
- SETTING--Eight rural Tanzanian villages in three regions, and two districts in Dar es Salaam.
- PARTICIPANTS--664 males and 803 females in rural villages and 85 males and 121 females in the city. Response rates for total population were 74% to 94% in the rural areas and 60% in the city.
- MEASUREMENTS AND RESULTS--Measurements included blood pressure, body mass index, serum lipids, and blood glucose concentrations (fasting and two hours after 75 g glucose). Blood pressure was slightly but significantly higher in young women than in young men (115/67 mmHg versus 113/65 mmHg) and increased significantly with age. Only 0.4% subjects had blood pressure greater than 140 and/or 90 mmHg. There were no urban-rural differences. Body mass index was higher in females (mean (SD) 20.3 (2.8) kg/m2) than males (18.5 (2.1)). Overweight was found in only 0.6% at age 15 years but 5.4% at age 19 years. Serum cholesterol concentrations were low at 3.5 mmol/l in males and 3.7 mmol/l in females. Only 7% had values above 5.2 mmol/l. The highest concentrations were found in the city and in Kilimanjaro, the most prosperous rural region. Serum triglycerides were 1.0 (0.5) mmol/l in males and 1.1 (0.5) mmol/l in females, and were highest in the city dwellers. Diabetes was rare (0.28% males, 0.12% females) but impaired glucose tolerance was present in 4.7% and 4.1% respectively. Drinking alcohol was equally prevalent in males and females, reaching 30% at age 19 years. Only 0.4% of females smoked compared with 7.3% of males. Smoking was commoner in rural areas that in the city.
- CONCLUSIONS--Several risk factors for cardiovascular disease were found in Tanzanian adolescents, but levels were much lower than in studies reported from developed nations. The challenge is to maintain these low levels as the population becomes more urbanised and more affluent.
Journal of Epidemiology & Community Health. 47(4):303-7, 1993 Aug.
Age of onset and sex distribution Type I (insulin-dependent) diabetes mellitus
(IDDM) appears to be rare in indigenous African populations, but little detailed information has been published. We have therefore analysed the age of onset of diabetes in 176 African patients with IDDM (age of onset < 35 years), and in 149 consecutive white patients of European extraction for comparison. In the Africans the peak age of onset occurred at 22-23 years (median 22 years) with an earlier peak from 14 to 17 years. In the Whites, the peak was found at 12-13 years (median 12 years). In only 7% of Africans did diabetes start under the age of 12 years. There was a slight female preponderance in the Africans, especially at the ages of greatest incident (20-25 years)-F:M 1.55:1. When patients with duration of diabetes less than 5 years only were analysed (the period during which early mortality among African patients was greatly reduced) the patterns of age distribution were similar to the total respective groups. Apeak incidence in the winter months was noted.
Kalk WJ. Huddle KR. Raal FJ. The age of onset and sex distribution of insulin-dependent diabetes mellitus in Africans in South Africa.
Postgraduate Medical Journal. 69(813):552-6, 1993 Jul.
Management of childhood obesity
Evaluation of obese children and adolescents in the pediatric office or clinic should include baseline assessment of weight for height and body fatness; rule out endocrine and genetic causes of obesity; and evaluate other health-risk factors, such as those for cardiovascular disease, cancer, diabetes, and hypertension. Treatment of obesity is most successful if realistic goals are set; a balanced low-fat/high-fiber diet is stressed; a safe rate of weight loss of 1 to 2 pounds per week is achieved through a moderate reduction of caloric intake (approximately 20-25% decrease); increased physical activity is stressed as much as diet; parental support is strong; and behavior therapy is provided during the course of treatment to help both child and parent achieve the diet, exercise, and behavior goals. [References: 40]
Williams CL. Campanaro LA. Squillace M. Bollella M. Management of childhood obesity in pediatric practice. [Review]
Annals of the New York Academy of Sciences. 817:225-40, 1997 May 28.
Diabetes and seizures in children
Severe partial seizures may be the presenting feature of nonketotic hyperglycemia in older adults, but cases in children are rare. We report three teenagers with well-controlled epilepsy who suddenly developed intractable partial seizures poorly responsive to anticonvulsants. Blood glucose levels were measured only after several days of hospitalization for frequent seizures when mild polyuria and polydipsia were first noted. Glucose levels were high with mild ketosis and acidosis in one patient and no ketosis in two. With institution of insulin, there was prompt cessation of seizures. The patients were diagnosed as having type I insulin-dependent diabetes mellitus and require ongoing insulin treatment. Hyperglycemia should be considered in children with epilepsy who develop intractable seizures.
Whiting S. Camfield P. Arab D. Salisbury S. Insulin-dependent diabetes mellitus presenting in children as frequent, medically unresponsive, partial seizures.
Journal of Child Neurology. 12(3):178-80, 1997 Apr.
Onset of type I diabetes in a child
A 12 yr-old child without any past medical history of diseases was admitted to hospital for sopor and polyuria. At admission he was markedly dehydrated. Blood glucose was 72 mmol/l, sodium 154 mmol/l, osmolarity 381 mOsm/Kg, urinary ketons were negative. He was rehydrated with hypotonic saline and treated with insulin. The osmolality and sodium initially increased to 176 mmol/l and 408 mOsm/Kg respectively and progressively decreased to normal levels. Serum transaminases increased to GOT 336 and GPT 209 U/l in the first days of treatment and normalized after 15 days. The anti-islet antibodies were positive. The non ketotic hyperosmolar coma and Type I diabetes is rare in children but this possibility must be kept in mind especially when some familial or psychological problems are present as in our case.
Basso A. Dalla Paola L. Erle G. Nacamulli D. Armanini D. Hyperosmolar nonketotic coma at the onset of type I diabetes in a child.
Journal of Endocrinological Investigation. 20(4):237-9, 1997 Apr.
Gastrointestinal symptoms and diabetes in children
Because it may be difficult to evaluate gastrointestinal diseases in children with insulin-dependent diabetes mellitus (IDDM), this report highlights several clinical features unique to diabetes and emphasizes the relationship between gastrointestinal pathology and glycemic control. Two children with IDDM are described whose hyperglycemia, ketosis, and abdominal pain were the presenting features of H. pylori-positive duodenal ulcer disease and acute appendicitis, respectively. A third nondiabetic child developed persistent postprandial hyperglycemia as the initial manifestation of dumping syndrome. These patients illustrate the relationship between glycemic control and gastrointestinal pathology in children with diabetes and the effects of gastrointestinal dysfunction on glucose regulation in nondiabetic children. In children with IDDM, gastrointestinal pathology can be confused with ketoacidosis and complicate diabetes control and management. Early recognition and treatment of the underlying gastrointestinal disease often improves glycemic control. Furthermore, severe gastrointestinal dysfunction in nondiabetic children may deleteriously influence glycemic regulation and may be confused with childhood diabetes.
Vogiatzi MG. Gunn SK. Sherman LD. Copeland KC. Gastrointestinal symptoms and diabetes mellitus in children and adolescents [see comments].
Clinical Pediatrics. 35(7):343-7, 1996 Jul.
Hyperinsulinism in infants and children
Hyperinsulinism is the most common cause of hypoglycemia in early infancy. Congenital hyperinsulinism, formerly termed nesidioblastosis, is usually caused by genetic defects in beta-cell regulation, including a severe recessive disorder of the sulfonylurea receptor, a milder dominant form of hyperinsulinism, and a syndrome of hyperinsulinism plus hyperammonemia. Transient neonatal hyperinsulinism may be associated with perinatal asphyxia or small-for-dates birthweight and maternal diabetes. To prevent permanent brain damage from hypoglycemia, the treatment of infants with hyperinsulinism must be prompt and aggressive. A combination of medical therapy with diazoxide or octreotide, a long-acting somatostatin analog, and surgical 95% subtotal pancreatectomy may be required. [References: 34]
Stanley CA. Hyperinsulinism in infants and children. [Review] [34 refs]
Pediatric Clinics of North America. 44(2):363-74, 1997 Apr.
Paediatric obesity
Pediatric obesity is a chronic and growing problem for which new ideas about the biologic basis of obesity offer hope for effective solutions. Prevalence of pediatric and adult obesity is increasing despite a bewildering array of treatment programs and severe psychosocial and economic costs. The definition of obesity as an increase in fat mass, not just an increase in body weight, has profound influence on the understanding and treatment of obesity. In principle, body weight is determined by a balance between energy expenditure and energy intake, but this observation does not by itself explain obesity. There is surprisingly little evidence that the obese overeat and only some evidence that the obese are more sedentary. Understanding of the biologic basis of obesity has grown rapidly in the last few years, especially with the identification of a novel endocrine pathway involving the adipose tissue secreted hormone leptin and the leptin receptor that is expressed in the hypothalamus. Plasma leptin levels are strongly correlated with body fat mass and are regulated by feeding and fasting, insulin, glucocorticoids, and other factors, consistent with the hypothesis that leptin is involved in body weight regulation and may even be a satiety factor (Fig. 2, Table 1). Leptin injections have been shown to reduce body weight of primates, although human clinical trials will not be reported until summer 1997. So many peptides influencing feeding have been described that one or more may have therapeutic potential (Fig. 2, Table 1). Although the complexity of pathways regulating body weight homeostasis slowed the pace of understanding underlying mechanisms, these complexities now offer many possibilities for novel therapeutic interventions (Fig. 2). Obesity is a major risk factor for insulin resistance and diabetes, hypertension, cancer, gallbladder disease, and atherosclerosis. In particular, adults who were obese as children have increased mortality independent of adult weight. Thus, prevention programs for children and adolescents will have long-term benefits. Treatment programs focus on modification of energy intake and expenditure through decreased calorie intake and exercise programs. Behavior-modification programs have been developed to increase effectiveness of these intake and exercise programs. These programs can produce short-term weight loss. Long-term losses are more modest but achieved more successfully in children than in adults. Several drug therapies for obesity treatment recently have been approved for adults that produce sustained 5% to 10% weight losses but experience with their use in children is limited. Identification of the biochemical pathways causing obesity by genetic approaches could provide the theoretic foundation for novel, safe, and effective obesity treatments. The cloning of leptin in 1994 has already led to testing the efficacy of leptin in clinical trials that are now underway. Although novel treatments of obesity are being developed as a result of the new biology of obesity, prevention of obesity remains an important goal. [References: 157]
Schonfeld-Warden N. Warden CH. Pediatric obesity. An overview of etiology and treatment. [Review]
Pediatric Clinics of North America. 44(2):339-61, 1997 Apr.
Preventing insulin-dependent diabetes
It has been postulated that treatment with nicotinamide may prevent or delay the onset of insulin dependent diabetes mellitus. We report the findings of a population based diabetes prevention trial which tests this hypothesis. 33,658 school children aged 5-7.9 years were randomly selected (by school) from a total population of 81,993 of such children in the Auckland (New Zealand) region. They were offered testing for islet cell antibodies. 20,195 (60%) consented to testing. Of these 185 had islet cell antibodies and met the criteria for treatment with nicotinamide. 173 received this treatment. The study population has an average follow up time of 7.1 years. The diabetes incidence of the untested controls was: 16.07 (12.4-20.5 95% CI) /100,000 person years at risk; in the group who were tested and treated when deemed appropriate: 7.14 (3.1-14.1 95% CI); and in the group offered testing but who did not consent ("refusers'): 18.48 (10.1-31.0 95% CI). The tested group had a rate of diabetes of 41% (20-85 95% CI) of the other groups combined after an age adjustment, which is significant (p = 0.008). The tested group combined with the "refuser' group (i.e. "intention to treat') also has a lower incidence than the control group (p = 0.12). Nicotinamide has a protective effect against the development of insulin dependent diabetes in this setting but the size of the effect has a wide confidence interval. Further follow up may define the magnitude of the protective effect within narrower limits.
Elliott RB. Pilcher CC. Fergusson DM. Stewart AW. A population based strategy to prevent insulin-dependent diabetes using nicotinamide.
Journal of Pediatric Endocrinology & Metabolism. 9(5):501-9, 1996 Sep-Oct.
Coping with medical adjustment and treatment responsibility
Youngsters with diabetes face numerous, daily challenges associated with their treatment. Previous research has examined coping in relation to global medical adjustment. However, the role that coping with diabetes-specific stressors plays in adherence to different treatment components, and child responsibility for these components, is not well understood. The present study examined the contribution of coping strategies to medical adjustment (i.e., metabolic control, treatment adherence) and level of child responsibility for treatment among children (n = 27) and adolescents (n = 29) with diabetes. Youngsters reported coping strategies in response to three diabetes-related situations (social, diet, fingerprick). Coping strategies accounted for a significant proportion of the variance in predicting most adjustment and responsibility variables, above and beyond the effects of relevant background variables (i.e., age, duration of diabetes, diabetes knowledge). Higher levels of approach-coping strategies related to better adherence to diet. Higher levels of avoidance-coping strategies related to poorer metabolic control and adherence to fingerpricks and higher levels of child responsibility for diet. These findings suggest that the role that coping strategies play in youngsters' medical adjustment is best understood within the context of diabetes-specific situations.
Reid GJ. Dubow EF. Carey TC. Dura JR. Contribution of coping to medical adjustment and treatment responsibility among children and adolescents with diabetes.
Journal of Developmental & Behavioral Pediatrics. 15(5):327-35, 1994 Oct.
FCCYD predominantly serves children from the entire state of Florida. Children are referred to the camp by pediatricians, endocrinologists, diabetes educators, Children's Medical Services offices, school nurses, the American Diabetes Association and other nonprofit organizations. Parents also call the camp themselves in an effort to obtain FCCYD's services. There is a $400 fee per camper but almost two thirds of those attending receive partial or full scholarships. The State of Florida Childrens' Medical Services provides funds for their patients that become campers. The camp also coordinates the distribution of scholarship funds from service and charitable organizations (Rotary, Kiwanas, United Way).
FCCYD holds five sessions of camp annually each designed for a particular age group (two "main camp" sessions, one for children 6 - 11, and one for 11 - 14 year olds, and three smaller "traveling camp" sessions for children over 15). These overnight camping sessions run 6 to 10 days in length. Main camp sessions accept up to 155 campers. At the main camp, medical care is provided by three physicians and three nurses. The smaller "traveling camp" sessions accept 15 to 35 campers depending on location, and consist of specialized camping adventures for teenagers. Traveling camp sessions are medically attended by one or two physicians and nurses. Presently, there are six day bike, environmental and sports camps for this 15-18 age group.
Physicians do an initial medical screening of all campers including taking history, heights and weights, and evaluation of their insulin dosages and any other pertinent medical conditions. Thereafter, daily rounds are made on each camper and adjustments and medical care provided on an individual basis. At the end of each session, parents are advised of their child's progress and suggestions for "at home" treatment are made. The child's daily medical record (chart) is immediately sent to their individual referring physician. Referrals to other agencies are made as necessary.
The medical aid and education provided for the youngsters are designed to help the child to adjust to their life-long disease. Each person with Type I insulin dependent diabetes must receive multiple daily injections of insulin, and they must monitor their blood sugar level at least three times per day by pricking their finger for a blood sample and reading the glucose level on a meter. Further, they may need to test their urine for ketone levels. Children at camp also learn to draw and inject their own insulin. People with diabetes must modify their diet to the demands of the disease and should increase their exercise level.
At the camps, counselors and medical staff help the children to learn these skills which they will need to practise for the rest of their lives. Registered dieticians give instruction in nutrition and diet and supervise our menus and food preparation. Certified diabetes educators (CDEs) teach self-monitoring, insulin adjustment, and the signs and symptoms of high and low blood sugar. At the end of the camp session this information is also provided to parents in an effort to have proper care and diabetes management continue in the home setting.
In addition to the medical care given at camp the children have an opportunity to be seen by our psychology staff. This psychological support staff assists counselors and medical staff in dealing with children's behavior. They are trained to deal with the psychological adjustments which the children need to make in learning to live with a chronic disease. They also conduct discussions and instruction on the changes occurring in the children's bodies because of their disease and how that will affect them psychologically and socially as they grow older. They conduct discussions on an age appropriate level with the youngsters and answer their questions and concerns in an effort to have them accept their disease and follow good diabetes management. Further, the psychology staff works with parents and the children's referring counselors and physicians on any individual psycho-social problems they are having. Individual counseling may be done at camp as necessary, evaluations made and post-camp referrals suggested.
The greatest social benefit to these children is the ability to interact with other youngsters with the same chronic illness. These children are often the only ones at their school who have diabetes. They often feel that they have done something "bad" and that is why they have diabetes. They feel alone and "different" from their peers.
Interaction at the camp with over 100 other youngsters who have diabetes helps them to realize that they are not alone; they are not being "punished"; and they can handle the medical and psychological demands that their disease puts upon them. By having counselors and staff who also have diabetes present, the children learn that they can have full lives, relatively free of complications and can do what other youngsters can do - as long as they practice the good diabetes management that the medical staff teaches. By being able to share this time with other children like themselves, they are better able to adjust to and accept their disease.
During the overnight camping stay, besides medical care the children also receive all room and board and use of recreational facilities and instruction. FCCYD does not own its own campground but rents camping facilities. Since 1990 FCCYD has held its sessions at Camp Winona, a YMCA campground located in DeLeon Springs, FL. Most of our campers would never be able to attend a camp since most camps are not able to provide the medical care necessary. Since all children can attend regardless of their family's ability to pay any fees, youngsters who might not otherwise learn how to swim, sail, canoe, play field sports,learn about nature, do arts and crafts programs, camp outdoors etc. have the opportunity to do so. The recreational program is supervised by a volunteer recreation staff headed by a physical education teacher.
The Florida Camp for Children and Youth with Diabetes was incorporated in 1970 with the purpose of providing youngsters with Type I insulin dependent diabetes a setting where they can obtain good medical care, instruction in diabetes management, independence and confidence in handling their disease - and have a fun recreational camping experience regardless of their background or family's financial situation. Our programs have grown to include weekends for newly diagnosed children and their families and weekends for teenage campers. The overnight camp and all our year round events and programs have grown from serving a few dozen children our first year to serving almost 500 children and their families each year from every part of the state of Florida. All of the medical and psychological staff and counselors are volunteers who contribute their time and talents to the care of these youngsters with diabetes.
Submitted by: Leonard Rhine, Ph.D., Health Sciences Centre Library of the University of Florida, USA (Waterfront Director)
Experience has shown that, compared with communicable diseases and hypertension, diabetes is still a new disease for an African, when first diagnosed. Patients are shocked and frightened at the prospect of being an invalid for life, or of being out of job, if employed. In order to motivate the patients and restore confidence in their ability to lead a normal life, an outline of what diabetes is and the importance of dietary management must be explained, both to the patients and to their families.
Dietary Advice:
Dietary advice should be in terms of basic
guidelines and tailored to every individual's
specific needs. The advice must consider the
following aspects.
Dietary modification should be based on what the patient is already eating at the time. Furthermore, the diet recommended should fit in with the family meals. Most African families eat out of one plate and often the meal consists of one staple dish and a relish of meat, fish or green leafy vegetables (5) Hence a detailed history of the existing dietary habits of the patient must be taken.
Underweight diabetics are advised to eat more, and more frequently, than they are doing. Specific foods to which they may have easy access should be suggested.
Overweight diabetics are asked to cut down on their food and alcohol intake and to increase their physical activity. At least 50% of patients adhere to their diet for the first 6 months, and some weight loss is seen in obese diabetics attending the diabetic clinic in Dar es Salaam(3).
It has also been suggested that the type of carbohydrate to be used should be specified and the method of preparation of the food should be taken into consideration with relation to blood glucose fluctuations(17,18). Further research is needed before any concrete conclusions can be drawn.
Data collected on the number of persons in charge of institutional feeding reveal that there is 1 dietitian to every 613 institutions and 1 nutritionist per 284 institutions in the countries within Eastern, Central and Southern Africa(ECSA)[19]. These institutions include boarding and non-boarding schools and day-care centres, all of which are not hospital-based, and there are 82 nutritionist within ECSA]. Furthermore, there are many nutritional problems associated with communicable diseases in Africa. This makes it difficult for the very few dietitians to work closely with non-communicable diseases.
Food served to hospitalized patients, for example, in Tanzania is of poor quality and does not often suit those patients on therapeutic diets. Hospital dietitians have no authority over the hospital catering, which falls under a catering officer not always suitably qualified for the job[20]. Hospital in which dietitians work in the diabetic clinic therefore aim to give dietary instructions to follow at home. In other situations, the actual role of the dietitian is not fully understood. Another aspect is that nearly all dieticians are trained in the more developed western countries, where management is better structured. They find it difficult sometimes to function efficiently in the less organized institutions of their countries.. Hence they are underutilised.
Taking all these factors into account, it appears that in the absence of adequate dietetic personnel-which will remain the case for some years to come- medical or nursing personnel (as is already being done in some countries) must make an effort to devote enough time to provide basic and simple dietetic instructions for the patients. If a specific nurse or medical assistant can be allocated for the task, there is no reason why, in an illiterate or a literate patient, advice to limit starches or to substitute saccharine or another sweetener for sugar, should not be adopted. Experience indicates that this exactly what the patient will always remember. A more detailed diet need not be recommended provided the advice is backed up by explanation of why sugar should be avoided, what starches are, which other foods contain carbohydrate, why eat at regular intervals, why the total intake per day should be constant, and why daily injections of insulin are necessary. A diet sheet with lists of commonly consumed starch food exchanges by domestic measures, all fruit available and practical guidelines, all written in the patient's native tongue, may be given out. Even illiterate patients would find it useful, as their children at home or neighbours can probably read and explain.
The compliance cannot be expected to be 100%, but at least with regular supervision and recall of dietary instructions given at certain intervals, The patient would become confident and be able to enjoy a normal life.
Egypt has long been a battleground for progressive and reactionary forces in relation to the campaign to stop FGM. In September 1994, during the United Nations International Conference on population and Development which was held in Cairo, a Cable News Network (CNN) broadcast from Egypt of a young girl screaming as a barber cut her clitoris prompted an international outcry. Then the Minister of Health Ali Abdel Fattah subsequently stated that FGM should be banned and that those who perform it should be punished. Yet one month later, apparently under pressure from Islamists, the Minister issued a directive permitting public hospitals in Egypt to perform FGM, effectively overturning a ban which had been in place since 1959. After a national and international campaign of protest, in October 1995 this directive was rescinded and replaced by a new directive instructing public hospitals not to perform FGM and stating that the role of medical personnel would be limited to providing counselling and guidance t limit the practice. In rescinding the directive, which he did in accordance with the recommendations of an advisory committee comprised of religious and medical authorities, Minister Ali Abdel Fattah made reference to the physical and psychological harm caused by FGM. His successor, the present Health Minister Ismail Sallam, extended the scope of the directive in July 1996 to cover private as well as public hospitals, banning any licensed medical professional from performing FGM.
Although Islam is often referred to in debates concerning FGM, there is no mention of the practice in the Quran. Mohammed Al Tantawi, when he was Grand Mufti of Egypt, issued a fatwa (religious opinion) in which he stated that the Quran contained nothing on female circumcision and that as the hadith (the sayings of the Prophet Mohammed) were weak on this subject, one should defer to the opinion of doctors. Mohammed Al Tantawi now serves as the sheikh of Al Azhar, widely considered to be the leading Islamic University in the world. The World Health Organisation has expressed unequivocal opposition to the medicalisation of FGM in any setting.
It is estimated that more than 100 million girls and women around the world have undergone female genital mutilation. FGM takes place in different forms in different countries: the partial or total removal of the clitoris (clitoridectomy), the removal of the entire clitoris and the cutting of the labia minora (excision), or in its most extreme from the removal of all external genitalia and the stitching together of the two sides of the vulva, leaving only a very small vaginal opening (infibulation). In Egypt, a 1995 Demographic Health Survey of more than 14,000 married Egyptian women between the ages of 14 and 49 found that 97% had been subjected t genital mutilation. In Egypt, the practice takes the form of clitoridectomy or excision. According to the Egyptian Organization for Human Rights, almost 3,600 girls everyday are subjected to FGM. Dozens of FGM-related deaths have been reported by the press. In mid-October 1996, two young girls aged three and four reportedly bled to death in the small Egyptian town of Armant after a doctor tried to circumcise them at their homes.
An extreme form of many traditional practices used around the world to deny women independence and equality, FGM is defended in the cultures where it is practised as a rite of passage and a social prerequisite of marriage, and it is used to control women's sexuality by safeguarding virginity and suppressing sexual desire. But women and men who come from cultures which practice FGM are increasingly giving voice to the devastating harm inflicted by FGM, and movements for its eradication are growing. The Cairo Family Planning Association initiated the campaign against FGM in Egypt in 1980, by organizing a ground-breaking seminar entitled "Bodily Mutilation of Young Females" which was held in Cairo. Since 1994, an increasing number of non-governmental organizations, including human rights and feminist organizations, have joined together in their efforts to eradicate FGM in Egypt working through the national FGM Task Force.
Equality Now issued its first Women's Action on Egypt in March 1995, in consultation with the FGM Task Force, calling on then Minister of Health Ali Abdel Fattah to revoke the directive of October 1994 which medicalised FGM. Members of Equality Now's Women's Action Network appealed to the Minister from countries around the world including Austria, Canada, Kenya, Peru, the United States and Zaire. He responded to these letters acknowledging the "unacceptable disastrous repercussions on female child health" created by FGM and identifying efforts to combat the practice as one of his first priorities. In light of recent developments in Egypt, the dialogue should continue.
In her presentation, Dr. Kaseba revealed that unplanned pregnancies occur among adolescents aged from as young as 10 and 19 years. To address this problem, she recommended that appropriate information be made available to educate teenagers about sex. It was further observed that the "Sugar Daddy Syndrome" is contributing to the worsening of the situation.
When such unplanned pregnancies occur, chances such children sometimes seek illegal abortions or if they keep decide to go through with the pregnancies, they are at risk of complications associated with early pregnancies because their bodies may not be ready for the function.
It is affirmed medically that young women under 18 have more complications in pregnancy and delivery than older women. Their babies are more likely to be premature and under-weight. It is therefore unsafe for teens to get involved in early sex, and under age women need appropriate information before, during and after pregnancy.
The crux of the matter is who should provide
such information?
NGO's, schools, colleges, churches, parents and
more importantly peer to peer groups can play a
vital role in awareness campaigns which teach
that early pregnancy is dangerous for health.
The girls themselves should also start practising
how to say no to sex. In fact both girls and boys
should be encouraged to concentrate on their
studies and whatever they are doing because sex
should come much later when they marry.
Early pregnancy was also attributed to lack of
knowledge about sexuality. An enquiry was made
about the position of UTH and government on
abortion.
The presenter lamented that it is not easy for one to access medical assistance within a few days because one would need to apply, then a panel of two or three medical practitioners assess the case, after which the successful applicant is admitted and operated on.
It was confirmed that most abortion laws in Southern Africa are very restrictive, focussing mainly on saving the life of the woman. The requirement of a committee's sitting an approving reduces women's access to safe and legal services. These restrictive laws foster the practice of clandestine, poorly performed abortions.
Dr. Kasonde used statistics to illustrate the situation. Among 13,000 women that she studied at UTH in 1996 who were pregnant 2,536 were teens representing 4%, alarmingly enough 0.3% of 12 - 19 year old girls had 4th pregnancy. In her findings she discovered that 2 of 15 year old girls had already 3 pregnancies each. By age 30, such teens would be grandmothers! The study further revealed that 144 had eclampsia, 123 had still born babies, 564 flat babies; 29.6% babies born by such children mothers were underweight, weighing below 1.3kg.
The research stated that maternal deaths in Caesarian operations and other complications were frequently associated with teenage pregnancies. Part of the problem was attributed to attitudes by staff at UTH which is characterized by unfriendliness and unnecessary bureaucracy, while parents are blamed for issuing too many "don'ts" than "dos" without offering specific reasons. Society does not approve of teenage pregnancy, and children who fail to proceed for further studies resort to sex as an occupation.
Lack of information about safe sex, inadequate access to qualified medical practitioner services, prohibitive costs and other factors referred to above were summed up as contributory factors to teenage pregnancies. Hats off to the Zambia Medical Association for organising this informative discussion.
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Last updated June 28, 1997