The Transcultural Diabetes Nutrition Algorithm: A Middle Eastern Version.

Diabetes prevalence is on the rise in the Middle East. In countries of the Gulf region-Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates-prevalence rates are among the highest in the world. Further, Egypt now ranks as one of the top 10 countries in the world for high number of people with diabetes. Medical nutrition therapy is key to optimal management of diabetes. Patient adherence to nutritional guidance depends on advice that is tailored to regional foods and cultural practices. In 2012, international experts created a transcultural Diabetes Nutrition Algorithm (tDNA) for broad applicability. The objective of this current project was to adapt the algorithm and supportive materials to the Middle East region. A Task Force of regional and global experts in the fields of diabetes, obesity, and metabolic disorders met to achieve consensus on Middle East-specific adaptations to the tDNA. Recommendations, position statements, figures, and tables are presented here, representing conclusions of the tDNA-Middle Eastern (tDNA-ME) Task Force. Educational materials can be used to help healthcare professionals optimize nutritional care for patients with type 2 diabetes. The tDNA-ME version provides evidence-based guidance on how to meet patients' nutritional needs while following customs of people living in the Middle Eastern region.

Mechanisms of action of metformin with special reference to cardiovascular protection.

Management guidelines continue to identify metformin as initial pharmacologic antidiabetic therapy of choice for people with type 2 diabetes without contraindications, despite recent randomized trials that have demonstrated significant improvements in cardiovascular outcomes with newer classes of antidiabetic therapies. The purpose of this review is to summarize the current state of knowledge of metformin's therapeutic actions on blood glucose and cardiovascular clinical evidence and to consider the mechanisms that underlie them. The effects of metformin on glycaemia occur mainly in the liver, but metformin-stimulated glucose disposal by the gut has emerged as an increasingly import site of action of metformin. Additionally, metformin induces increased secretion of GLP-1 from intestinal L-cells. Clinical cardiovascular protection with metformin is supported by three randomized outcomes trials (in newly diagnosed and late stage insulin-treated type 2 diabetes patients) and a wealth of observational data. Initial evidence suggests that cotreatment with metformin may enhance the impact of newer incretin-based therapies on cardiovascular outcomes, an important observation as metformin can be combined with any other antidiabetic agent. Multiple potential mechanisms support the concept of cardiovascular protection with metformin beyond those provided by reduced blood glucose, including weight loss, improvements in haemostatic function, reduced inflammation, and oxidative stress, and inhibition of key steps in the process of atherosclerosis. Accordingly, metformin remains well placed to support improvements in cardiovascular outcomes, from diagnosis and throughout the course of type 2 diabetes, even in this new age of improved outcomes in type 2 diabetes.

Prediabetes management in the Middle East, Africa and Russia: Current status and call for action.

Most data on the burden of diabetes and prediabetes are from countries where local infrastructure can support reliable estimates of the burden of non-communicable diseases. Countries in the Middle East and Africa, together with Russia, have a total population of almost 2 billion, but have been relatively overlooked by authors in this field. We reviewed the prevalence and drivers of prediabetes and diabetes across this large region. A large, and variable, burden of dysglycaemia exists, especially in Middle Eastern and North African countries, associated with high levels of obesity and sedentariness, with a generally lower prevalence in most other parts of Africa. The design and size of studies are highly variable, and more research to quantify the scale of the problem is needed. Local barriers to care relating to issues concerned with gender, consanguinity, lack of understanding of diabetes, lack of understanding of obesity as a health issue, and limited resource at a national level for tracking and intervention for diabetes and other non-communicable diseases. Lifestyle interventions with proven local cost-effectiveness, enhanced access to pharmacologic intervention, and societal interventions to promote better diet and more activity will be an important element in strategies to combat these adverse trends.

Sexual dysfunction among Jordanian men with diabetes.

OBJECTIVE: To estimate the prevalence and severity of erectile dysfunction (ED) and its correlations among Jordanian men with diabetes. METHODS: We conducted this study at the National Center for Diabetes, Endocrinology and Genetics, Amman, Jordan, between January and August 2004. The study included 988 married diabetic men. Patients were interviewed by one of our medical staff based on a health care questionnaire and an Arabic translation of the 15-item International Index of Erectile Function. Scores of the questions in each of the 5 sexual function domains were summed up. Dysfunction was categorized as absent, mild, moderate or severe. RESULTS: The overall prevalence of ED was 62%; and we found that 30.3% had severe ED. The prevalence increased with age from 26.5% (13 out of 49) of patients <40 years of age to 91% (87 out of 96) in the age group > or = 70 years. Severity of ED increased with age as well. Multivariate logistic regression analysis identified age, glycemic control, hypertension, coronary artery disease, retinopathy and neuropathy as independent risk factors of ED. Among patients with ED, 7% reported having treatment for ED. CONCLUSION: Prevalence of ED among Jordanian diabetic patients is high. It increases with age and poor glycemic control. Other independent risk factors include: hypertension, coronary artery disease, retinopathy and neuropathy.

Sleepwalking associated with hyperthyroidism.

OBJECTIVE: To report several cases of hyperthyroidism in patients presenting with the unusual symptom of sleepwalking and to discuss the possible pathophysiologic basis for this novel association. METHODS: After encountering and reporting the first case of new-onset somnambulism in a patient presenting with thyrotoxicosis at our institution, we routinely inquired about the sleep history of patients with thyrotoxicosis, questioning both the patients and family members when applicable. Those patients who actually had sleepwalking episodes coinciding with the onset of thyrotoxicosis underwent close follow-up, and the relationship between the sleepwalking and the results of thyroid function tests was analyzed. In addition, we reviewed the literature on psychiatric disorders and sleep problems, and the pathophysiologic rationale for a cause-and-effect relationship is discussed. RESULTS: We collected 8 cases of patients with new-onset sleepwalking episodes that coincided with the start of thyrotoxicosis. The disappearance of the sleepwalking with successful achievement of euthyroidism supports a cause-and-effect relationship. This hypothesis is further supported by the absence of a family history, the adult onset, and the relapse of sleepwalking in 2 of the patients when their thyrotoxicosis became poorly controlled as a result of noncompliance with medications and its subsequent disappearance with reachievement of euthyroidism. Of note, such a presentation was seen only in patients with thyrotoxicosis caused by diffuse toxic goiter or Graves' disease and never in patients with other causes of thyrotoxicosis. CONCLUSION: New-onset sleepwalking could be caused by thyrotoxicosis or, more specifically, by thyrotoxicosis resulting from diffuse toxic goiter. The mechanism is hypothesized to be related to the combination of prolongation of non-rapid eye movement sleep and the associated fatigue. Specific inquiry about this unusual presentation of thyrotoxicosis is encouraged, and more studies are needed to confirm and evaluate its extent.

Clinical and inheritance profiles of Kallmann syndrome in Jordan.

BACKGROUND: Proper management of patients with Kallmann syndrome (KS) allows them to attain a normal reproductive health. The purpose of this study is to demonstrate the presentation modalities, phenotypes and the modes of inheritance among 32 patients with Kallmann syndrome in Jordan. Recognition of the syndrome allows for prompt proper management and provision of genetic counselling. SUBJECTS: Over a period of five years (1999-2004), the clinical and inheritance profiles of 26 male and 6 female patients with Kallmann syndrome from 12 families were evaluated at the National Center for Diabetes, Endocrinology and Genetics in Jordan. RESULTS: The patients belonged to twelve Jordanian and Palestinian families and their age at presentation ranged from 4 - 46 years. Nine boys aged 4-14 years presented with cryptorchidism and microphallus, all other males presented with delayed puberty, hypogonadism and/or infertility. The main presentation among six female patients was primary amenorrhea. Intrafamilial variability in clinical phenotype was specifically evident for renal abnormalities and sensorineural hearing impairment. Familial KS was diagnosed in 27 patients belonging to five families with the X-linked mode of inheritance and two families with the autosomal recessive mode of inheritance. CONCLUSIONS: (1) the majority of cases in this study represented the X-linked form of KS, which might point to a high prevalence of Kal 1 gene in the population. (2) Genetic counselling helps these families to reach a diagnosis at an early age and to decide about their reproductive options. (3) Children presenting with cryptorchidism and microphallus in our population should be investigated for KS.

Radiological findings in Wolfram syndrome.

OBJECTIVE: To determine the precise radiologic findings in Wolfram syndrome (WFS) patients using objective techniques in order to better define the reference population for the clinical evaluation. METHODS: Sixteen patients (6 males and 10 females) with WFS found in 4 families were included in this study. Fourteen patients with WFS-2 came from 3 families while 2 patients with WFS-1 from one family. All patients were studied at Jordan University Hospital, Amman, Jordan, from January 2001 through to January 2003 by definite radiologic techniques as part of a thorough clinical comprehensive assessment. These include intravenous urography, abdominal and pelvic ultrasonography, barium meal, upper gastrointestinal endoscopy and magnetic resonance imaging with and without contrast to the brain and the pituitary glands. RESULTS: Five of the female patients had a small uterus. Spina bifida was found in 7, hydronephrosis in 9 and hydroureter in 5 patients. Peptic ulcer was detected in 10 out of 14 available patients and helicobacter pylori in 7 out of 16 patients. Atrophy was detected in all brains, 9 brain stems, 12 cerebellums and 14 optic tracts of all patients. The size of the pituitary glands was variable CONCLUSION: The particular radiologic assessment of patients with WFS proofed that, urinary tract dilatation was detected in WFS-1 and WFS-2 patients though all WFS-2 patients have no diabetes insipidus. Peptic ulcer was frequently higher in WFS-2 patients. No significant radiologic difference was found between patients with WFS-1 and WFS-2.

Spontaneous ovarian hyperstimulation syndrome caused by hypothyroidism in an adult.

A 22-year-old patient presented with abdominal pain and massive ovarian enlargement secondary to severe long standing hypothyroidism, mimicking an ovarian cancer. Treatment with L-thyroxin caused marked regression of the tumor.

Prevalence and predictors of diabetic foot syndrome in type 2 diabetes mellitus in Jordan.

OBJECTIVE: To detect feet changes and to identify risk factors leading to amputation among type 2 diabetics. METHODS: A total of 1142 patients with type 2 diabetes mellitus; 595 males (52%), and 547 females (48%) were seen between January and December 2001 at the National Center for Diabetes, Endocrinology, and Genetics (NCDG) Amman, Jordan. The mean age was 56.1 years (SD=10.2) and the mean duration of diabetes was 9 years (SD=7.1). All patients had a complete medical assessment including history, physical examination, glycosylated hemoglobin (HbA1c) (the mean of the last 4 readings) and microalbuminuria. Statistical analysis were performed to identify significant risk factors leading to amputation using Epi info, version 6 software. RESULTS: Mean HbA1c was 7.4% (SD=1.4). The prevalence of hypertension was 52%, retinopathy 45% and microalbuminuria 33%. Impaired vibration, position and protective sense were found in 19%, 13%, and 18%. The prevalence of all amputations was 5%. The following were strong predictors of amputation; duration of diabetes (P= 0.04), smoking (P=0.01), microalbuminuria (P=0.02), retinopathy (P=0.008), legs hair loss (P=0.003), neurological deficit (P=0.0001), ulceration (P=0.00001) absent dorsalis pedis (P=0.0006) and insulin therapy (P=0.0001). The rate of amputation was directly proportional to high HbA1c >= 8% (P=0.01). Age and gender were not found to have an impact on prevalence of amputation. CONCLUSION: Prevalence of amputation correlates with duration of diabetes, poor glycemic control, smoking, neurological impairment, peripheral vascular disease and microalbuminuria.

Wolfram syndrome: identification of a phenotypic and genotypic variant from Jordan.

Wolfram syndrome is an autosomal recessive disorder with probable locus heterogeneity. Only insulin-dependent diabetes mellitus and progressive optic-nerve atrophy are necessary to make the diagnosis, but associated findings include diabetes insipidus, sensorineural hearing loss, ataxia, peripheral neuropathy, urinary-tract atony, and psychiatric illnesses. We performed clinical and molecular studies on four consanguineous families with 16 affected individuals. We point out a new phenotypic variant with absent diabetes insipidus, presence of peptic ulcer disease and bleeding tendency secondary to a platelet aggregation defect. The same phenotypic variant turned out to be a genotypic variant with linkage to a second Wolfram syndrome locus (WFS2) on chromosome 4q22-24.