Hyperglycemia effect on red blood cells indices.

OBJECTIVE: Hyperglycemia has an effect on all body tissues; one of them is the bone marrow. This effect is related to protein glycation and other chemical and physiological changes of red blood cells (RBCs). The aim of this study was to assess the effect of hyperglycemia on different RBCs indices along with evaluating these changes in the normal physiology and chronic diabetes complication pathology. PATIENTS AND METHODS: This is a cross-sectional hospital-based study of 1000 type 2 Saudi diabetic patients without any hematological diseases. Patients were fully evaluated clinically and biochemically with full blood hematological parameters assessment. The studied cohort matched the general characteristics of Saudi type 2 diabetic patients. RESULTS: This study shows that hyperglycemia increases the red blood cells count, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC). Red blood cell distribution width (RDW) was negatively correlated with poor glycemic control. Concurrently, the presence of micro and macroangiopathies with hyperglycemia shortens the lifespan of RBCs. CONCLUSIONS: We conclude that hyperglycemia has an imposing effect on RBCs count and its physiological function, which can be normalized effectively with good glycemic control.

Clinico-laboratory characteristics of diabetic keto acidosis in adults in a tertiary hospital in Saudi Arabia.

OBJECTIVE: The present study is undertaken to evaluate the magnitude of DKA in Saudi population with specific emphasis on clinical laboratory characteristics over 20 years. MATERIAL AND METHODS: A prospective analysis of hospital records of 240 episodes of DKA requiring inpatient admission from December 1985 to December 2005 in adult patients in a tertiary hospital was performed. Besides the demographic data of the patients, the clinico-laboratory parameters relevant to the diabetes and DKA status were thoroughly reviewed. RESULTS: 150 males and 90 females were admitted with DKA with a mean age of 21.77 +/- 7.2 years. 16.6% (n=40) were diagnosed to have DM for the first time and others had a mean duration of DM of 5.02 +/- 4.88 years with an average daily insulin requirement being 45.09 +/- 23.9 units. 80.4% of the DKA episodes occurred in intermediate, secondary school and University level students. The commonest precipitating factors were missed insulin doses (51.2%) and respiratory tract infections (22.5%). The mean duration of stay in the hospital was 6.56 +/- 3.4 days and there were no deaths reported because of DKA. The mean blood sugar on presentation was 23.49 +/- 8.3 mmol/L whereas the mean pH and bicarbonate levels on presentation were 7.21 +/- 0.1 and 14.7 +/- 4.3 meq/L respectively. Blood pH was found to be significantly lower in female patients. Among patients below 20 years of age, females have significantly lower bicarbonate levels (11.7 +/- 6.2). Among patients above 20 years of age females had significantly longer duration of diabetes (8.86 +/- 8.36 years; p < 0.04). CONCLUSIONS: By providing intensive education and increasing the awareness of DKA, a major reduction in morbidity and hospitalizations due to DKA may be expected.

Bioequivalence of Jusline following subcutaneous administration in healthy subjects.

OBJECTIVE: The aim of the current work is to evaluate the pharmacokinetic and pharmacodynamic profile of a new human insulin preparation (jusline) following subcutaneous administration in healthy subjects, and to compare this profile with Humulin insulin. METHODS: 20 healthy male subjects received a single dose of 0.2 U/kg of test (Jusline) or reference insulin (Humulin) during an euglycemic clamp keeping blood sugar constant (90 +/- 5 mg/dl) by changing the glucose infusion rate. Pharmacokinetic and pharmacodynamic measurements were taken from blood measurements of glucose, insulin, and C-peptide levels for tested insulin formulations. RESULTS: The mean values of the individual AUC ratios were well within the 90% confidence interval (100.5% for Regular, 101.9% for NPH, and 100.0% for Premixed Regular/NPH (30/70)). Similarly, Cmax and tmax were within the bioequivalence limit (80 - 125%). The maximum GIR were 10.20 mg/kg/min and 9.72 mg/kg/min for Jusline Regular and Humulin Regular, respectively. The maximum GIR were 7.09 mg/kg/min and 7.91 mg/kg/min for Jusline NPH and Humulin NPH, respectively. The maximum GIR and tGIRmax were 6.39 mg/kg/min and 6.63 mg/kg/ min for Jusline Premixed Regular/NPH (30/70) and Humulin Premixed Regular/NPH (30/70), respectively. Both insulin products produced similar suppression of endogenous C-peptide level (-29.76% to -50.22%). CONCLUSION: The present study demonstrated that after subcutaneous administration, there are no significant differences between Jusline and Humulin to promote peripheral glucose uptake.

Diabetic foot osteomyelitis: usefulness of erythrocyte sedimentation rate in its diagnosis.

BACKGROUND: Recently, ESR was reported to have a useful diagnostic value in detecting diabetic osteomyelitis. The test has been performed in a limited number of patients. This laboratory parameter is simple and could be routinely performed in developing countries where diabetes and its complication are increasingly being encountered. OBJECTIVE: To evaluate the reliability of erythrocyte sedimentation rate (ESR) in differentiating diabetic osteomyelitis from cellulitis, and to compare its diagnostic value with other hematological indices. METHODS: In a one-year prospective study, forty -three adult diabetic patients with foot ulcers were assessed at King Abdulaziz University Hospital Diabetes Center Riyadh from 1st January to 31st December 2005. ESR was compared with other hematological profiles in differentiating osteomyelitis from cellulitis. RESULTS: ESR, white blood cell count (WBC), platelet count, and red cell distribution width (RDW) were higher in patients with osteomyelitis than in patients with cellulitis (p<0.0001 for ESR; others p<0.05). In contrast, haematocrit and haemoglobin levels were lower in patients with osteomyelitis than in patients with cellulitis (p<0.0001). Overall, the efficiency of the haematological parameters in correctly diagnosing diabetic osteomyelitis from cellulitis was highest for ESR > 70 mm/hr (92%), followed by haematocrit < 36% (89%), haemoglobin < 12 g/dl (85%), platelet count > 400x10(9) (69%), RDW > 14.5 (65%), and WBC >11x10(9) (63%). CONCLUSION: It is concluded that of the haematological parameters, ESR has the best diagnostic discrimination between diabetic foot osteomyelitis from cellulitis. Further studies on larger population in this environment are however indicated.

Retinopathy as a predictor of other diabetic complications.

PURPOSE: Early predictors of diabetic complications may aid in the prevention and/or management of these complications. The aim of this cross-sectional study was to determine the predictive value of retinopathy for the presence of other diabetic complications. METHODS: The population studied comprised 648 patients with diabetes mellitus assessed by our service. There were 210 patients (32.4%) with insulin-dependent diabetes mellitus (IDDM), and 438 patients (67.6%) with non-insulin-dependent diabetes mellitus (NIDDM). RESULTS: Univariate analyses revealed that retinopathy significantly predicted the presence of neuropathy (odds ratio [OR] = 2.23; 95% confidence interval [CI] = 1.56-3.18; p < 0.001), nephropathy (OR = 5.68; 95% CI = 3.06-10.62; p < 0.001), and cerebrovascular disease (OR = 6.6; 95% CI = 1.16-67.21; p = 0.0239) in the total group. Similar associations were observed both in subjects with IDDM and NIDDM. The associations between retinopathy severity level and the prevalence rate of nephropathy were significant in the total group (p = 0.0001), in patients with IDDM (p = 0.0113), and in patients with NIDDM (p = 0.01). In patients with mild to moderate non-proliferative retinopathy (NPDR), nephropathy was present in 17.2% of patients with IDDM, and in 11.4% of patients with NIDDM. In patients with severe NPDR, nephropathy was present in 23.3% in patients with IDDM, and in 11.8% of patients with NIDDM. In patients with proliferative retinopathy (PDR), nephropathy was present in 50% in patients with IDDM, and in 45.5% in patients with NIDDM. In multivariate logistic regression analyses, nephropathy was the only significant complication to be independently associated with retinopathy in patients with IDDM (OR = 8.02; 95% CI = 1.95-33), and in patients with NIDDM (OR = 2.48; 95% CI = 1.02-6.03). CONCLUSIONS: Retinopathy, especially the presence of PDR, is an independent predictor for nephropathy. The predictive value of retinopathy for nephropathy is stronger in patients with IDDM than in those with NIDDM. Ophthalmologists should refer patients with retinopathy for regular medical evaluations.

Prevalence and determinants of smoking in three regions of Saudi Arabia.

OBJECTIVES: To study the prevalence and determinants of cigarette smoking among Saudi nationals in three regions of Saudi Arabia. PARTICIPANTS: A sample of 8310 individuals aged 15 years and above from both sexes, randomly selected from the three regions, using a stratified cluster sampling technique. DESIGN: A cross-sectional, household, community-based survey. Using a predesigned and tested questionnaire, the participants were interviewed by primary care physicians. The interview covered personal, social, and educational characteristics of the respondents, and also included questions about their smoking status, duration of smoking, and daily cigarette consumption. MAIN OUTCOME MEASURES: Association between current smoking and sociodemographic variables, in univariate and multivariate analysis. Degree of interaction between the different determinants of cigarette smoking. RESULTS: The overall prevalence of current smoking was 21.1% for males and 0.9% for females. Most smokers (78%) were young to middle-aged (21-50 years old). Smoking prevalence was higher among married people, among uneducated people, and among those in certain occupations: manual workers, businessmen, army officers, and office workers. CONCLUSIONS: Cigarette smoking is an important public health problem in Saudi Arabia. A more intense and comprehensive tobacco control effort is needed.

Risk factors for diabetic retinopathy among Saudi diabetics.

PURPOSE: To describe the incidence of, and risk factors associated with, diabetic retinopathy in diabetic persons assessed at a Saudi diabetes centre. METHODS: Five hundred and two patients with diabetes mellitus assessed by our service were studied. There were 174 patients (34.7%) with insulin-dependent diabetes mellitus (IDDM) and 328 patients (65.3%) with non-insulin-dependent diabetes mellitus (NIDDM). RESULTS: The incidence of retinopathy was 157/502 (31.3%). The incidence was 42.5% in patients with IDDM and 25.3% in those with NIDDM. By logistic regression analysis, it was shown that old age (>60 years), insulin use, long duration of diabetes (>10 years), poor diabetes control, and the presence of nephropathy were significantly associated with the incidence of retinopathy. On the basis of the magnitudes of the regression coefficients in the hazard function, long duration of diabetes was the most important independent risk factor for the development of retinopathy; the presence of nephropathy, age >60 years, poor diabetes control, and use of insulin were less important (regression coefficients: 1.9, 1.71, 1.331, 0.8508 and 0.6178, respectively). The incidence of macular oedema was significantly associated with the presence of hypertension and high cholesterol levels in patients with IDDM. Polycotomous regression analysis showed that the presence of nephropathy was the only factor significantly associated with the severity of retinopathy. CONCLUSIONS: The significant associations with poor control and duration of diabetes provide further strong evidence for the benefits of optimal glycaemic control. Other potentially modifiable risk factors for retinopathy may be important, including elevated blood pressure and serum cholesterol.

Pattern and factors associated with glycemic control of Saudi diabetic patients.

BACKGROUND: The pattern and factors which can be associated with the glycemic control of Saudi adult diabetic patients were examined in this study. PATIENTS AND METHODS: Confirmed diabetic patients from all regions of Saudi Arabia constituted the study population. Random blood glucose <10 mmol/L and >10 mmol/L was used to categorize patients into good and poor glycemic control patients, respectively. RESULTS: There were 613 confirmed non-insulin dependent diabetic patients (NIDDM), 50% with good glycemic control. Patients with poor glycemic control were significantly older than patients with good glycemic control (51.5 vs. 47 years, P=0.0001). The insulin-treated diabetic population amounted to 13%, compared with 43% and 44% for oral agent and diet, respectively. The rate of insulin users among poor glycemic control diabetic population was 18%, compared with 50% for oral agents. There was a significant relationship between glycemic control and age, and treatment modalities of DM. Subjects who had good glycemic control of DM were younger and following a diet regimen, while those who had poor glycemic control were older and on insulin treatment. Multivariate analysis comprising 415 individuals was conducted to find out the factors that can potentially influence, or may be associated with, the control of DM. CONCLUSION: The association of insulin therapy with poor glycemic control is not a cause-effect relationship. Insulin therapy in our study population is underutilized, given the high rate of poor glycemic control and high rate of relative occurrence of complication among the Saudi diabetic population. There is a need to address the importance of maintaining good glycemic control, and the reason for the low rate of insulin users. Close periodic monitoring of glycemic control, utilizing laboratories and home glucose monitoring devices, is required. Effective implementation of these measures, in addition to diabetes education, will have an impact on the future outcome of the Saudi diabetic population.

Population-based epidemiological study on characteristics of risk factors of hypercholesterolemia in Saudi Arabia.

OBJECTIVES: To study the characteristics of risk factors for hypercholesterolemia among the Saudi population. DESIGN: Population-based cross-sectional national epidemiological randomized household survey. SUBJECT: 4548 Saudi subjects, aged 15 years and above. Sample was representative and in accordance with the national population distribution with respect to age, gender, regional and residency, urban vs. rural, population distribution. MEASUREMENT: Height and weight with calculation of body mass index, blood samples were drawn and assayed for glucose and total cholesterol concentration. Hypercholesterolemia (HC) was defined: borderline high HC (5.2-6.2 mmol l-1) and high HC (> 6.2 mmol l-1). Univariate, multivariate, simple logistic, multiple logistic, odd ratio and chi-square were employed in the statistical analysis. RESULTS: The risk of developing HC increased with age by 2% and 1% for each year increase in age for borderline high HC and high HC. The risk of developing HC was significantly higher among female subjects. There was no significant relation between the spectrum of BMI group, underweight to obesity, with risk of developing borderline high or high HC. There was a significant increase in the risk of developing HC among residents of urban communities. There was no significant regional variation for risk of borderline high HC, however, there was a significant increase in the risk of developing high HC among residents of Central and Eastern regions, compared with other regions. CONCLUSION: The characteristics of risk factors for HC among the Saudi population differ in many respects from other populations. Overweight and obesity are not significant risk factors for HC. Rural communities are more at risk of HC than urban communities. The population of the Eastern and Central regions were at significantly higher risk of developing HC. The relatively recent urbanization may account for the low prevalence of HC. It may partially explain the dissociation between obesity and HC. Food habits, both in quantity and quality in rural communities in genetically predisposed homogenous populations may account for the increase in the prevalence of HC in rural communities. There is a need to propagate information about the potential health hazard of obesity and HC among Saudi communities, at large, and specifically in the Eastern and Central regions. There is a need to study the food patterns of rural communities which may explain partially the relative increase in the prevalence of HC in rural communities.

Overweight and obesity in Saudi Arabian adult population, role of socio-demographic variables.

The objectives of this Community-based National Epidemiological Household Survey, conducted between 1990-1993, were to estimate the prevalence of overweight and obesity in Saudi Arabia and to examine its association with the socio-demographic characteristics of the adult population. A sample of Saudis 20 years and over was selected using a multistage stratified cluster sampling technique with probability proportionate to size. The selected subjects were requested to visit primary health care centers in their localities. Physicians in these clinics took measurements of heights and weights and collected other relevant data. Obesity was measured by the Body Mass Index, using the Quetelet Index. The results showed the sample of 10,651 subjects of which 50.8% were males, had a mean age of 35.8 years (SD = 14.27 years). The prevalence of overweight was 31.2% (95% confidence interval: 30.3%, 32.1%); 33.1% for males and 29.4% for females. For obesity, the overall prevalence was 22.1%; males 17.8% and females 26.6%. The study design suggested that these estimates could be closer to the true values. The multiple logistic regression analysis showed that age, residential area, region, income, gender, and education are statistically significant predictors of obesity. The prevalence of obesity was higher in females than males, lower in subjects living in rural areas with traditional lifestyles than those in more urbanized environments, and increased with increasing age. The observed prevalence and pattern of overweight and obesity with age and gender is similar to those observed in the Arab community and some Western nations. There is a need for increased physical activity and better nutrition education programs to reduce the extent of obesity and to prevent the serious health consequences, especially, in the middle age group.

High prevalence of overweight and obesity in Saudi Arabia.

OBJECTIVES: To study the pattern of body weight distribution and the prevalence of overweight and obesity in Saudi Arabia. DESIGN: Cross-sectional national epidemiological household survey. SUBJECT: 13,177 Saudi subjects, over the age of 15 years. The sample was adjusted for gender, age, regional and residency population distribution. The range and mean of age was similar for male and female subjects (15-95 years, 33 years). MEASUREMENT: questionnaire, describing the social, educational and financial status. Measurement of height, weight and calculation of body mass index (BMI). WHO classification was used for defining overweight (BMI 25-30) and obesity (BMI > 30). RESULTS: The mean BMI for female subjects was significantly higher than for male subjects, whether for all subjects or subjects of any given age group. There was a progressive increase of BMI for male and female subjects with age, reaching maximum at the 5th decade. The prevalence of overweight among male subjects was significantly higher than for female subjects (29% vs 27%). The prevalence of obesity among female subjects was significantly higher than for male subjects (24% vs 16%). There was a gender variation within each region with respect to the prevalence of overweight with higher prevalence of overweight among male subjects, throughout all the regions, except the Southern region, none of the differences, however, reached significance levels. The prevalence of obesity was significantly higher among female subjects, throughout all the regions. Overweight and obesity were more prevalent among illiterate, high-income subjects who were residing in urban communities. CONCLUSION: This epidemiological household survey has shown high prevalence of overweight and obesity among Saudi subjects. The prevalence of obesity among female Saudi subjects was among the highest reported, whether, when using the WHO criteria or the 85th percentile of US subject aged 20-29 years. The increase of prevalence of such conditions among high income subjects would reflect the perception of fatness as sign of affluence among those subjects. As the prevalence of obesity increases with age and considering that the majority of Saudi population are less than 30 years old at the present time, then, one would expect the magnitude of obesity to be even bigger in the near future. There is a need to establish programs for promoting awareness among the population of the health hazards and means of control of obesity.

Prevalence of hypercholesterolemia in Saudi Arabia, epidemiological study.

The objective of this study was to look at the pattern of serum total cholesterol concentration (TCC) distribution and the prevalence of hypercholesterolemia (HC) in Saudi Arabia. A cross-sectional national epidemiological household survey was carried out, consisting of 4539 Saudi subjects, over the age of 15 years. The sample was adjusted for gender, age, regional and residency, and urban versus rural population distribution. The following details were taken for each subject: height, weight, calculation of body mass index (BMI) and random blood samples for total cholesterol measurements. It was found that the mean TCC for all female subjects was significantly higher than for male subjects (4.24 versus 4 mmol/l). The mean TCC of female subjects, aged 40-59 years was higher, but not significantly so, than for male subjects (4.5 versus 4.4 mmol/l). There was a progressive increase in TCC with age, reaching a maximum at the fifth and sixth decades for male and female subjects, respectively. There was a progressive increase in mean TCC with increasing BMI values for male and female subjects with higher values of mean TCC for female subjects for any given BMI value. The prevalence of HC, 5.2-6.2 mmol/l was 9% and 11% for all male and female subjects, respectively (P = 0.74), whereas the prevalence of HC, > 6.2 mmol/l was 7% and 8% for male and female subjects, respectively (P = 0.52). The prevalence of HC 5.2-6.2 mmol/l for subjects aged 40-59 years was 14% and 10% for male and female subjects, respectively (P = 0.67), whereas the prevalence of HC > 6.2 mmol/l was 9% and 11% for male and female subjects, respectively (P = 0.6). There was a progressive increase in the prevalence of HC with age for male and female subjects. The prevalence of HC > 5.2 mmol/l increased with increasing BMI values. The prevalence of HC of female subjects was significantly higher than for male subjects among normal weight groups. The prevalence of HC (> 6.2 mmol/l) for female subjects was higher, however, not significant than for male subjects among overweight and obese groups. The prevalence of HC, whether for male or female subjects, was higher among diabetics when compared with non-diabetic subjects. The prevalence of HC (> 6.2 mmol/l) among male subjects was higher for smokers when compared with non-smokers. It was concluded that Saudi subjects have lower prevalence of HC than the European and American populations. This can partially be explained by the younger nature of the population. The prevalence of HC is likely to increase in the near future with the increasing percentage of the aged population in the community, and with the effects of a longer exposure to the acquired western life-style and nutritional habits, which is showing an impact with the increase in the prevalence of obesity. The cause of coronary heart disease is multifactorial, HC being one of the main contributors. Therefore, there is a need to study, in detail, the prevalence of other risk factors, such as: obesity, smoking, hypertension etc. There is a need to promote health awareness among the population with an emphasis on controlling weight and carrying out periodic cholesterol measurements.

Phenytoin-induced insulin insensitivity.

Phenytoin is known to induce hyperglycaemia. The mechanism has generally been considered primarily an inhibition of insulin release. We have recently treated a patient who became hyperglycaemic on phenytoin and whose markedly increased insulin requirements suggested an insulin resistant state. Reduction of the phenytoin dose resulted in amelioration of the hyperglycaemia. In vitro studies of phenytoin in a primary culture system of adipocytes that allowed assessment of both insulin receptor binding and post-binding function showed a 57% reduction in maximum [14C]3-0-methylglucose transport in the presence of phenytoin while having no effect on maximum insulin binding. These results suggest that phenytoin administration can result in insulin insensitivity by inducing a post-binding defect in insulin action.