Childhood obesity in Tunisia: Prevalence and risk factors.

INTRODUCTION: Obesity in children is currently a major public health problem in Tunisia. AIM: To determine the prevalence of obesity among pre-schoolchildren in the city of Bardo and to identify risk factors. METHODS: We carried a cross-sectional study of 220 children between 4 and 6 years of age, recruited from kindergartens in the city of Bardo. Children with endocrinal, tumoral or genetic diseases causing secondary obesity, children on corticosteroids and children with two illiterate parents were not included. The weight status of the children was defined according to the curves of the international obesity task force. A parent is considered obese if his BMI>30 Kg/m². RESULTS: The average age was 4.65±0.77 years. A female predominance was noted (55.9% girls and 44.1% boys). The average BMI of the children was 16.93±2.46 kg/m². The prevalence of overweight among all children was 10.9% and that of obesity was 11.4%. The frequency of overweight (including obesity) was 22.3%. In multivariate analysis, factors independently related to childhood obesity were child age, child medical history and hospitalization, parental obesity, parental dyslipidemia, snack type and snacking. CONCLUSIONS: Overweight is common in pre-school children. It should be detected at an early age, especially if risk factors are present.

Audit of glycemic control of diabetic patients on insulin analogues: about 2915 insured persons of the CNAM (Tunisia).

BACKGROUND: Insulin analogues are increasingly prescribed in Tunisia. These molecules, covered by the National Health Insurance Fund (CNAM) in Tunisia under certain conditions, have an important and constantly increasing cost. AIM: To audit the diabetes control among insured in the Northern district of the CNAM (Tunisia), treated with insulin analogues in 2019 and to assess factors associated with good glycemic control. METHODS: Retrospective observational study including patients with diabetes who applied for renewal of insulin analogues between March and April 2019 in the northern district of the CNAM. RESULTS: Our study included 2915 diabetic insured. The sex ratio was 1.08. The mean age was 56.5 ±18.56 years. More than half of the diabetic insured were followed by a specialist physician (44% by endocrinologists, 7% by internists, 6% by nutritionists and 4% by other specialists). The average duration of treatment with insulin analogues was 5 years ± 1.41. Almost three quarters (74%) of the diabetic insured were type 2 diabetics. The mean daily dose of rapid-acting, short-acting and premixed insulin analogues were 30±15.49 IU/d, 38±18.36 IU/d and 65±19.38 IU/d respectively. HbA1c targets were achieved in 8% of the diabetic insured. In univariate analysis, the variables significantly associated with diabetes balance were follow-up by a physician specializing in endocrinology (OR=3.14, 95% CI [0.98-10.08]), internal medicine (OR=5.06, 95% CI [1.49-17.21]) or nutrition (OR=2.06, 95% CI [0.54-7.77]), type 1 diabetes (OR=1.67, 95% CI [1.26-2.22]) and basal insulin therapy regimen (OR=1.88, 95% CI [1.39-2.54]). In multivariate analysis, the independent and significant factors associated with glycemic control were type 1 diabetes (ORa=1.81, 95% CI [1.37-2.39]) and basal insulin therapy regimen (ORa= 1.77, 95% CI [1.30-2.40]). CONCLUSION: This study showed that the majority of diabetic insured on insulin analogues had a poor controlled diabetes. Type 1 diabetes and basal insulin therapy regimen were the two factors associated with good glycemic control after multivariate analysis. A review of criteria for reimbursement of insulin analogues by the National Health Insurance Fund is necessary in order to rationalize the expenses related to these molecules.

Impact of the COVID-19 Pandemic on Clinical Practice, Medical Education, and Research: An International Survey.

OBJECTIVES: Because of the mandatory sanitary measures established during the Covid-19 Pandemic, we have proposed to describe the new clinical, educative, and research practices of an international sample of doctors. METHODS: We have used an online electronic survey of a convenient sample of doctors from 40 countries using a multiple-choice online questionnaire, including three domains.  424 out of 456 respondents provided adequate responses. RESULTS: Most respondents were from medical (51.5%) and surgical (11.8%) specialties. Over half of the respondents practiced in academic centers and one fifth in the private sector. Coronavirus pandemic induced frequent changes in practice, such as seeing fewer patients in clinics than usual (34.9%) and utilization of telemedicine (31.3%). A significant disruption in medical education activities and residents' training was observed, resulting in the cancellation of many activities such as grand rounds, departmental and multidisciplinary meetings, and case conferences with over-reliance on virtual and on-demand educational sessions. The residents' supervision and support were significantly reduced. Almost 16% of respondents were involved in research work on coronavirus pandemic while a third continued their usual research activity, but half were not involved in any research at the time of the survey. CONCLUSIONS: The COVID19 pandemic has promoted new practices in the field as the recourse to telemedicine, virtual conferences, and thematic researches on COVID-19. The unexpected situation has opened new prospects for future doctors' preparation for these new means of practice and learning of medicine.

Assessment of oral health status among uncontrolled diabetic mellitus patients in Tunisia.

AIM: To assess oral health status of Tunisian diabetic mellitus patients. METHODS: We carried a cross-sectional study among 100 uncontrolled diabetic mellitus patients. An oral health survey was developed to collect their socio-demographic characteristics and to assess their oral health behavior. Each patient benefited of an oral examination. Clinical and biological data were collected from medical file of patients. RESULTS: In terms of number of brushings, 44% of diabetic mellitus patients brushed their teeth at least twice a day, 25% brushed once a day, 10% occasionally and 21% did not used to brush their teeth. The last visit to a dentist dated since less than a year ago for 48% of participants and 8% reported that they hadn't never visit a dentist. Oral hygiene and the rate of dental consultation were correlated with gender but not with glycemic control. Only 17% had complete dentition, 75% were partially dentate and 8% were completely edentulous. More than half of the diabetics had at least 5 missing teeth. About 67% had had experienced tooth decay. The presence of tooth decay was not correlated with glycated hemoglobin (HbA1c). The examining dentist estimated that nine out of ten patients required dental care. CONCLUSION: The oral health status of diabetic mellitus patients in Tunisia was bad. The need for dental care was real and high but often overlooked. The establishment of a national oral health care policy seems to be a national priority today.

[Effect of protein restriction on renal function and nutritional status of type 1 diabetes at the stage of renal impairment]. / Effet de la restriction protéique sur la fonction rénale et l'état nutritionnel de diabétiques type 1 au stade d'insuffisance rénale modérée.

BACKGROUND: In an effort to slow the deterioration of renal function, several authors have recommended in the diabetic stage renal disease with moderate renal impairment decreased protein intake to 0.7 or 0.3 g / kg / day associated with energy intake of at least 30 to 35 kcal / kg / day. However, in clinical practice this proved difficult to achieve without exposing patients to the risk of under nutrition. AIM: To evaluate the effects of a protein restricted diet on the development of diabetic nephropathy and the nutritional status of diabetic patients with renal impairment at the stage of moderate renal impairment compared with those of a group of diabetics with the same characteristics put under basal diabetic diet. METHODS: Prospective study of 57 diabetic patients in moderate stage renal disease of middle age (32 ± 0.6 years) followed at the National Institute of Nutrition of Tunis in 2010. Our patients were separated into two groups (group A comprising 30 patients, put on diabetic diet basal and group B comprising 27 patients used in protein-deficient diet: 0.6 to 0.7 g / kg /d). We followed the evolution of certain parameters: glomerular filtration rate (GFR), serum albumin, albuminuria, nutritional risk index (NRI) and we analyzed dietary intake at D0, D90 and D180. RESULTS: Renal function in patients in group B improved as demonstrated by the trend towards higher GFR. It increased from day 0 to day 90 and at day 180. In parallel, there was a beneficial effect on albuminuria which was reduced from 380 ± 56 mg/24h on day 0, to 322 ± 50mg/24h at day J90 and 302 ± 16 mg/24h at day 180. In group A, the opposite phenomena occurred. The patients in Group B have also reduced their overall caloric intake to less than 1800 kcal / day making sure that the balance of their diet quality could no longer be assured the result has a tendency to under nutrition noted more frequently in the latter group (NRI0 = 97.90%, NRI 90= 90.10% , NRI180=90,0%). In the literature these results were found by several studies. CONCLUSION: The protein-deficient diet (0.6 to 0.7 g/ kg /d) must be integrated into the overall care of diabetic renal insufficiency with moderate renal impairment but requires rigorous repeated dietary interviews and customized to avoid malnutrition can result.

[Multiple medication use in diabetic patients aged]. / Le polymédication chez le diabétique âgé.

BACKGROUND: Multiple medication use is especially common in those with diabetes aged due to multiple illnesses, certain chronic diseases and disabling of the growing demand for care, treatment advances, but also some over-prescription. AIMS: To assess the achievement of treatment goals in a population of older diabetics, to analyze drug consumption and to derive a practical driving prevention. METHODS: This descriptive retrospective study was interested in 600 cases of diabetic patients older than 60 years, recruited from the diabetes followed at the National Institute of Nutrition and Health Unit in Tunis Sidi Hassine involving three local clinics to during the years 2009-2010. RESULTS: The average age of the study population was 70 ± 0.5 years with extremes from 65 to 92 years. In our study, 91% of patients between 2 and 5 chronic diseases and the majority of subjects suffering from disabilities. The number of drugs prescribed in our subjects (all dosage forms combined) varies between 1 and 4,with a peak of interest to patients treated with 2-4 drugs, encountered in 91% of cases.The similarity of shapes and colors of certain drugs often confusing. CONCLUSION: Multiple medication use is common in older diabetic subjects. Hence the need for good coordination between prescribers to prevent abuse and ensure the correct therapeutic education of patients and their families.

Advantage of HbA1c assay by HPLC D-10 versus cobas integra 400 in a population carrier for HbS and HbC.

BACKGROUND: Several studies demonstrate significant bias in analytical methods used to measure glycohemoglobin. The clinical importance of that fact is evident when HbA1c overestimation leads to aggressive glucose management, resulting in more frequent hypoglycaemic episodes. Our study was aimed to compare two automated instruments (Integra 400 and D-10) in the evaluation of HbA1c in the Tunisian population. METHODS: Samples of 205 Tunisian diabetic patients were collected. The HbA1c assay was done simultaneously with a first generation immunoturbidimetric assay on an INTEGRA 400 (ROCHE) and using ionic exchange high pressure liquid chromatography (HPLC) on a D-10 system (BIO-RAD). RESULTS: Correlation is determined by linear regression analysis: D-10 = 0.921*(Integra 400) +1.125; coefficient of correlation (r) = 0.946. This r increases to 0.973 when samples of carriers for HbS and HbC (n = 9) are filtered out. For the carrier patients, significant differences in the percentage of HbA1c were observed relating to the methodology used. CONCLUSIONS: Laboratories must be aware of hemoglobin variant interferences on their methods of assessment of glycated hemoglobin. Using ion-exchange HPLC to control glycated hemoglobin seems to be essential to prevent mis-management in diabetic patients and to permit the diagnosis of the presence of HbS in patients.

[What is has the artificial sweeteners in indication the food of our diabetics?]. / Quelle place ont les édulcorants dansl'alimentation de nos diabétiques?

BACKGROUND: Artificial Sweeteners are food additives increasingly developed by the food industry. AIM: Study of the consumption of sweeteners in diabetic patients. METHODS: This prospective cross study performed using a questionnaire to 100 patients recruited at random outpatients of the National Institute of Nutrition. Data on the BMI,the blood sugar were found in clinical records. RESULTS: 94% of diabetics have at least heard of sweeteners and 50% use it regularly. Sweetener table are the most consumed sweeteners, in order of frequency Saccharin, Sucralose and Aspartame, used to sweeten coffee and tea. The trade products "light" are consumed by 29% of patients. Yet consumers have no real information on these products. There was no statistically significant correlation between the consumption of sweeteners and BMI, balance and diabetes evolution. A statistically significant correlation was found between consumption and socio-economic and cultural development of patients. CONCLUSION: The education of diabetic patients should include information of patients on these sweeteners, their interest, their against-indications and adverse reactions.

Generalized allergy due to zinc in insulin treated with zinc-free insulin.

Allergy to insulin became a rare complication due to the introduction of recombinant human insulin preparations. Nevertheless, allergic reactions to components of such preparations can occur. We report a case of a 61-year-old man with an atopic background and affected by diabetes mellitus type 2 since 27 years, who experienced generalized allergy to insulin at the moment of switching oral anti-diabetics to insulin. Prick tests revealed an allergy specifically to zinc, and the patient was treated with zinc-free glulisine insulin. After 8 months of such treatment, patient's glucose is stable and he never experienced allergic reactions to insulin injections. Even insulin allergy due specifically to zinc is rare, such complication must be assessed especially in a patient suffering from multiple allergies.

[Association of type 1 diabetes and celiac disease: features of this double pathology]. / Association diabète de type 1 et maladie coeliaque: le vécu de cette double pathologie.

BACKGROUND: the association of diabetes type 1 and celiac disease seems to pose many problems diagnostic, therapeutic and psychological. Aim of our work is to study in eight patients with type 1 diabetes associated with celiac disease their daily experience and the constraints that this pathological association imposes. METHODS: This cross-sectional study involved eight patients with type 1 diabetes and celiac disease known for at least 1 year. All patients were given a thorough interrogation specifying the regular monitoring of the two diseases and the quality of the observance of the diabetic dietary and gluten-free diet, as well as an assessment of impact of diabetes. RESULTS: the caloric intake in relation to the recommendations is very insufficient. Taking snack is not respected. There is also the consumption of certain foods containing gluten masked and regular consumption of sucrose by our patients despite a long-term evolution of diabetes (19 +/- 6 years) and celiac disease (11 +/- 7.8 years). Half of patients have degenerative complications of diabetes. CONCLUSION: In light of these results, a frequent evaluation of nutrition education in these patients and a psychological care seems necessary.

[Diabetes mellitus of elderly patients: therapeutic recommendations]. / Le diabete du sujet age: actualites therapeutiques et recommandations.

In the elderly diabetic patient, therapeutic decision is very delicate because of the psycho social pathological ground at this age. The emergence of new concepts of ageing and frailty made it possible to re-examine the plasma glucose goals and to build strategies of prevention and treatment adapted to the clinical and biological profiles of elderly subjects.