Understanding Type 2 Diabetes Mellitus and the Knowledge Gaps among Future Health Care Professionals: Insights from Saudi Arabia

Background: Diabetes is a disorder of metabolism where the hormone insulin is deficient, ineffective or absent, resulting in abnormally high blood glucose levels and significant damage to the body's vascular system. The prevalence of type 1 diabetes for Unites States residents aged 0-19 years is 1.7 per 1000. Saudi Arabia is ranked the 7th globally in number of children with T1DM and the 5th regarding the incidence. The prevalence of type 1 diabetes mellitus in Saudi Arabian children and adolescents is 109.5 per 100,000. Diabetes mellitus (DM) is one of the most common chronic childhood diseases. Type 1 diabetes mellitus (T1DM) is the most common autoimmune endocrine disorder in childhood and adolescence1 with increasing incidence worldwide that varies according to race, country, and region. In the last decades, several studies reported a significant increase in T1DM cases in children up to 14 years old. Aim of the study: This study aimed to assess diabetes-related knowledge, attitudes and management practices among school teachers in order to determine their diabetes training needs and preparedness to provide adequate care for students with diabetes. Method: A cross sectional descriptive study was conducted at Taif primary schools teachers working in governmental schools in Saudi Arabia, in 2018. The researcher invited 411 teachers Systematic random by proportional allocated stratified technique to participate in the study. Results: Out of 411 teachers invited to participate in the study, returned completed questionnaire with a response rate of 100%. Their almost of the teachers (28.0%) were in the age group 45-50 years. All of them were males teachers (100.0%), the main source of information about DM cited by teachers was the mass media (67.9%) and Attitude of the teacher toward diabetes mellitus in the school children these study results show that is a significant relation between score and Attitude Negative where (93.2) where P-value=0.001. Conclusion: The results reveal that teachers have inadequate knowledge of some of the basic facts of diabetes and its treatment, a situation, which could have dangerous consequences for the child and complicate his or her schooling in a number of ways.coordinating these studies with the schools provided a way to reach a large number of teachers with a message for to prevent diabetes without singling any students out.

Diabetes medication pharmacology

Aim: The goal of this study is to explore the family physicians’ perspectives of the barriers in initiating insulin for adult patients with Type 2 diabetes mellitus (T2DM) in their primary health care settings. Background: Insulin therapy often becomes necessary when oral anti-hyperglycemic agents are not enough, no longer effective or even as an initial choice. Timely insulin initiation was noticed to be a clinical problem among people with type 2 diabetes mellitus (T2DM) registered in primary health care centers (PHCCs) of Tabouk Province, KSA. Tackling this inertia or insulinophobia is a challenge in order to delay or prevent serious complications of uncontrolled diabetes. Our study and many other studies indicated that this therapeutic inertia is inappropriately due to many patient, system and physician-related factors. The present study aimed to investigate physicians’ perspectives of barriers to insulin initiation for adults with T2DM registered in PHCCs, Tabouk Province - KSA and to identify opportunities for better outcomes. Materials and Methods: This is a cross sectional study where 102 primary health care physicians (PHCPs) (58 females and 44 males) from multi PHCCs in Tabouk Health Province – Kingdom of Saudi Arabia (KSA), responded correctly to online reliable self-administered questionnaire (Cronbach alpha of 0.77344) to address their perspectives of barriers to insulin initiation for adult patients with T2DM. All participants were physicians attending PHCCs with well-equipped diabetes care clinics. Data were collected during a period from 6th – 17th June 2021. Participants included 11 (10.8%) family medicine consultants, 14 (13.7%) family medicine specialists and 77 (75.5%) general physicians. Results: 68.6 of the study participants had barriers in initiating insulin for their patients with T2DM. A significant statistical disproportional correlation was found between the level of specialty and the rate of reporting barriers to insulin initiation (P<0.001). The top 10 listed barriers included the following: patients’ refusal to initiate insulin (71.4%), physicians’ fear of hypoglycemia (51.4%), inability of patients to perform home blood glucose monitoring (HMGM) (50%), physicians have no access to second opinion (44.3%), insufficient educational courses for physicians (37.1%), no family support for patients (34.3%), no clear MOH circular to support physicians’ initiation of insulin at PHCCs (28.6%) , insufficient hypoglycemic medications at PHCCs (25,7%), inability of patients to manage hypoglycemia (24.3%), and patients’ noncompliance to insulin regimen (24.3%). Conclusion: Despite the free of cost availability of all types of insulin, including the safest and peak less ultra-long (degludec) and long (Glargine), the availability of free of cost glucometers for all people with diabetes, the presence of a well-equipped diabetes clinic at every PHCC, the long list of guidelines and educational courses as well as an appointment system with electronic health information system (HIS), insulin inertia is a common problem among PHCPs working in Tabouk Health Region. Key words: Barriers, insulin initiation, insulin, primary health care, type 2 diabetes mellitus.

The global epidemic of type 2 diabetes mellitus (T2DM) has substantial implications for cardiovascular disease–related morbidity and mortality.1 The prevalence of T2DM in patients with heart failure (HF) is high, with strong and independent association between T2DM and incident HF observed in multiple prospective studies and in randomized-controlled clinical trials. In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), which enrolled subject’s ≥55 years of age with hypertension and ≥1 risk factor, patients with T2DM had a 2-fold risk for HF hospitalization or death after adjustment for other risk factors (RR, 1.95). The association with T2DM was independent of coronary artery disease and at least equivalent in magnitude and greater than that for electrocardiographic left ventricular (LV) hypertrophy.2 All measures of glycemia including fasting, postprandial, measures of insulin resistance, and hemoglobin A1c (HbA1c) have been associated with risk of developing HF, with the association extending to both HF with preserved ejection fraction and to HF with reduced ejection fraction.3,4 A substantial body of evidence from preclinical studies, endomyocardial biopsies in humans and more recently with cardiac MRI, support increased myocardial stiffness in T2DM related to alteration in extracellular matrix. There are multiple proximate mediators that have been hypothesized to play a role including advanced glycation end product deposition and reactive oxygen species that may increase myocardial stiffness during diastole, by cross-linking collagen or by enhancing collagen formation.5,6 Another pernicious proximal mediator is the elevation in postprandial lipids, such as remnant lipoproteins, characteristic of atherogenic dyslipidemia, a highly prevalent abnormality in T2DM, that may result in direct myocellular deposition of lipid, leading to microcirculatory dysfunction, alteration in substrate use and mitochondrial dysfunction.7,8 Indeed, positron emission tomography studies show reduced myocardial glucose uptake in favor of fatty acid …

Background: Patients with Coronary Heart Disease (CHD) or Tuberculosis (TB) are more likely to have Type 2 Diabetes Mellitus (T2DM). Insulin Resistance (IR) in patients with normal glucose may also be a risk factor for these conditions. Methods: This thesis explored whether T2DM and IR are risk factors for TB enrolled patients receiving TB treatment in the previous year and controls. In addition, the thesis explores whether T2DM and IR are risk factors for CHD among patients with stable CHD and controls. The studies were based in Saudi Arabia and used cross sectional surveys and case controls design. Controls were asymptomatic adults attending the TB clinics for labour reasons. All participants were screened for fasting plasma glucose (FPG), insulin, glycated haemoglobin (HbA1c) and lipids. We assessed the severity of the clinical presentation of TB among patients with T2DM, IR and normal glucose. Finally, we described the quality of life of patients with CHD among patients with T2DM, IR and normal glucose. Results: One hundred seventy-five adults with pulmonary TB and 140 controls were recruited (36.6% and 40.7% female and 63.4% and 59.3% male, respectively). Twenty-nine per cent of TB cases had T2DM and 22% normoglycemic IR. 3.3% of patients were unaware of their T2DM diagnosis. TB was associated with prediabetes (AOR 5.112, p = 0.032), low level of risky HDL Cholesterol (AOR 0.316, p = 0.001) and non-Saudi nationalities (AOR 4.018, p ˂ 0.001). Former TB cases were more likely to eat fast foods (1 – 2 times/week, AOR 2.857 and 2 – 3 times/month, AOR 3.126, p = 0.026, respectively) and to have a fair or poor diet (AOR 13.518, and AOR 37.766, respectively) (p ˂ 0.001). Three hundred twenty-five patients with stable CHD and were recruited (29.2% and 39.9% female and 70.8% and 60.1% male, respectively). Of these 65% had T2DM and 31.3% normoglycemic IR. Almost 6% of patients were unaware of their T2DM status. CHD were more likely to have T2DM (AOR 4.974, p = 0.034), high FPG (AOR 5.034, p = 0.021), to be male (AOR 9.950, p ˂ 0.001), aged above 50 years old (p ˂ 0.015), Saudi (AOR 6.879, p = 0.002), to have primary education (AOR 20.315, p = 0.004), hypertension (AOR 5.920, p = 0.003) and to take lipid lowering medications (AOR 24.516, p ˂ 0.001) than controls. Cases were more likely to have high WHR (AOR 33.997, p ˂ 0.001) and diastolic BP (AOR 1.080, p = 0.004) than controls. CHD-IR cases had lower quality of life and satisfaction scores with bodily appearance (p = 0.003), overall perception of satisfaction with themselves (p = 0.041) and score in the psychological domains (p = 0.006) than controls. Patients with CHD and T2DM had lower overall scores for quality of life (p = 0.002), satisfaction with bodily appearance (p = 0.012), overall perception of satisfaction with themselves (p = 0.015), with access to health services (p = 0.049) and satisfaction score with transport (p = 0.027) than controls. Conclusion: TB was more prevalent among non-Saudi nationals and males. Patients with TB were more likely to have T2DM, and to be prediabetic, but not more likely to have IR than controls. More efforts are required to upscale the detection of T2DM among TB patients. Patients with CHD were more likely to be male and to have T2DM and IR than controls. Patients with CHD and IR had a lower quality of life than controls. More efforts are required to upscale the management of T2DM and IR among CHD patients.

Double trouble: T2DM genetic risk factors play a causal role in CAD.

Objectives:To determine the association between sociodemographic, clinical, and health literacy and the presence of depressed mood and their relationships to diabetes self-management among type 2 diabetes mellitus (T2DM) patients in Saudi Arabia.Methods:A total of 352 T2DM patients from 2 public tertiary hospitals in Saudi Arabia participated in this descriptive cross-sectional study between December 2016 and February 2017. All respondents answered a 4-part questionnaire, which includes demographic data, Diabetes Self-Management Questionnaire (DSMQ), 36-item test based Short Test of Functional Health Literacy in Adults, and a 2-item Patient Health Questionnaire (PHQ-2). The Chi-square test and logistic regression analysis were conducted to determine the relationship and significant predictors for self-management among T2DM patients.Results:The analysis showed that majority of the participants had low to marginal functional health literacy. The overall DSM-16 score was good, indicating more effective self-care, while 20% of the participants had a score of 2 or more in the PHQ-2 indicating presence of depressed mood. No significant association was found between DSM and health literacy among the study participants while age, gender, educational level, employment status, and level of the depressive symptom were significantly associated with differences in the level of functional literacy of the participants.Conclusion:The study shows that nearly half of the T2DM patients that exhibited low level of functional health literacy had low diabetes self-management. Our findings also show that gender significantly affects diabetes self-management in which odds are a lot higher among females than males with diabetes self-management. This study underscores the importance of proper counselling and education about diabetes control on both patients and family members.

Type 2 diabetes mellitus (T2DM) in children and adolescents is becoming an increasingly important public health concern throughout the world (1–17). Because of the relatively recent recognition of the problem in this age group, many children with new onset T2DM may be misclassified as having T1DM. Conversely, as the population becomes heavier, overweight adolescents with autoimmune diabetes may be misdiagnosed as having T2DM. T2DM is often associated with risk factors for cardiovascular disease that may already be present at the time of diagnosis, making normalization of blood glucose levels and diagnosis and treatment of hypertension and dyslipidemia important (18). T2DM occurs when insulin secretion is inadequate to meet the increased demand posed by insulin resistance (19). Thus, T2DM is commonly associated with other features of the insulin resistance syndrome [hyperlipidemia, hypertension, acanthosis nigricans, ovarian hyperandrogenism, non-alcoholic fatty liver disease (NAFLD)] (20). Insulin secretion depends on disease status and duration, and can vary from delayed but markedly elevated in response to a glucose challenge, to absolutely diminished (19). Adults with symptoms have 50% reduction at the time of diagnosis, and may become insulin dependent within a few years (21). T2DM occurs: in youth most often during the second decade of life, with a mean age of diagnosis of ∼13.5 years. This coincides with the peak of physiologic pubertal insulin resistance, which may lead to onset of overt diabetes in previously compensated adolescents. in all races, but at a much greater prevalence in those of non-white European descent, e.g. those of black African descent, native North American, Hispanic (especially Mexican)-American, Asian, South Asian (Indian Peninsula), and Native Pacific islanders. The SEARCH for Diabetes in Youth population-based study found the proportion of physician diagnosed T2DM among 10–19-year-olds to vary greatly by ethnicity in the US: 6% for non-Hispanic whites, 22% for Hispanics, 33% for blacks, 40% for Asians/Pacific Islanders, and 76% for Native Americans (8). In Hong Kong > 90% of young onset diabetes is T2DM (10), in Taiwan 50% (11) and nearly 60% in Japan (Ogawa et al. personal communication). in > 75% of cases in youth in the USA there is a first or second-degree relative with T2DM. in youth in the USA and Europe with body mass index (BMI) above 85th percentile for age and sex. In Japan, however, ∼30% of T2DM are not obese (17), in Asian Indian urban children, half of those with T2DM had normal weight (< 120% ideal for height) (12), and half of Taiwanese children with T2DM were not obese (11). in some asymptomatic individuals in high-risk populations during medical, school, or sports examinations (22,23). in the presence of ketosis/ketoacidosis, one third or more of newly diagnosed patients (24). This presentation is responsible for misclassification of T2DM patients as T1DM. occasionally with severe dehydration (hyperosmolar hyperglycemic coma, hypokalemia) at presentation, which can be fatal (24,25) with a sex ratio (male:female) that varies from 1: 4–1:6 in native North Americans to 1:1 in Asians and Libyan Arabs without associated HLA specificities. without associated islet cell autoimmunity (see autoimmunity T2DM). The pathophysiology of autoimmune 'T2DM' is unclear. It most likely represents autoimmune T1DM in overweight or obese individuals with underlying insulin resistance. It has been postulated that obesity and insulin resistance may promote an inflammatory response to antigen exposure caused by apoptosis of beta cells (26). Youth and adults in US and Europe who are clinically diagnosed with T2DM are found to have T1DM-associated auto-antibodies in 15–40% of cases, including many who are not receiving insulin one year after diagnosis (27–30). Antibody positive young adult individuals with the T2DM phenotype are significantly less overweight and younger than antibody negative patients (21, 27). Hemoglobin (HbA1c) concentrations are significantly higher in young adults with T2DM who are antibody positive compared with those who are antibody negative (27). ß-cell function is significantly less in antibody positive individuals, the most dramatic difference being reported in younger adult patients (25–34 years), resulting in more rapid development of insulin dependence, usually by 3 years duration (27, 30). The presence of islet cell antibodies (ICA) and glutamic acid decarboxylase antibodies in adults with clinically typical T2DM has been referred to as latent autoimmune diabetes of adults (27, 31). Neither the autoimmunity nor the diabetes is latent, however (26). Atypical diabetes mellitus (ADM) occurs throughout childhood, but rarely begins past age 40. It has only been described in young people of African descent. There is a strong family history in multiple generations with an autosomal dominant pattern of inheritance, but an abnormal sex ratio (M : F = 1 : 3). ADM is not associated with HLA specificities and islet autoimmunity does not occur. Ketosis or ketoacidosis is typical at onset. Insulin secretion is present but diminished and without long-term deterioration of function. Interestingly, insulin is often not required for survival after treatment of acute metabolic deterioration, although diabetes control may be poor and ketoacidosis may recur without insulin, e.g. with illness or pregnancy. ADM is not associated with obesity beyond that in the general population and it is not associated with insulin resistance. Monogenic diabetes (formerly referred to as maturity onset diabetes of the young or MODY) For more in depth information see the ISPAD Clinical Consensus Guidelines for Monogenic Diabetes (34). Identified in families with multigenerational diabetes; including asymptomatic individuals identified through testing of family members. Monogenic diabetes is not associated with obesity beyond that in the general population and it is not associated with insulin resistance The clinician is obliged to weigh the evidence in each individual patient to distinguish between T1DM and T2DM. The reasons for this conundrum are: with increasing obesity in childhood, as many as 15–25% of newly diagnosed T1DM (or monogenic diabetes) patients may be obese. the significant number of pediatric patients with T2DM demonstrating ketonuria or ketoacidosis at diagnosis (2). T2DM is common in the general adult population, with a random family history of ∼15% or greater in minority populations, reducing the specificity of a positive family history. positive family history for T2DM is increased for patients with T1DM as much as threefold over the non-diabetic population and T1DM is more frequent in relatives of patients with T2DM (35, 36). There is considerable overlap in insulin or C-peptide measurements between T1DM, T2DM and MODY at onset of diabetes and over the first year or so. This overlap is due to the recovery phase of autoimmune-mediated T1DM (the honeymoon) and degree of glucotoxicity/lipotoxicity impairing insulin secretion at the time of testing in both T1DM and T2DM. In addition the insulin resistance of obesity raises residual C-peptide levels in obese adolescents with T1DM. Such measurements are thus relatively valueless in the acute phase. [The role of C peptide may be more helpful in established diabetes as persistent elevation of C-peptide above the level of normal would be unusual in T1DM after 12–24 months.] The criteria and classification of diabetes are presented in greater detail in the ISPAD Clinical Practice Consensus Guidelines: Definition, Epidemiology, Diagnosis and Classification of Diabetes (37) Diagnostic criteria for diabetes are based on BG measurements and the presence or absence of symptoms (E) (38,39). Three ways to diagnose diabetes are possible and each, in the absence of unequivocal hyperglycemia, must be confirmed, on a subsequent day, by any one of the three methods given below. Diabetes is diagnosed when: A fasting plasma glucose (FPG) is ≥ 7.0 mmol/l (126 mg/dl) or The post challenge plasma glucose is > 11.1 mmol/l (200 mg.dl) performed as described by the World Health Organization (39), using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. or Symptoms of diabetes and a casual plasma glucose ≥ 200 mg/dl (11.1 mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. Diabetes in children, including T2DM, usually presents with characteristic symptoms such as polyuria, polydipsia, blurring of vision, and weight loss, in association with glycosuria and, in some cases, ketonuria. In its most severe form, ketoacidosis or hyperglycemic hyperosmolar state may develop and lead to stupor, coma, and in absence of effective treatment, death. The diagnosis is usually confirmed quickly in symptomatic individuals by measurement of a marked elevation of the blood glucose level. In this situation, if ketones are present in the blood or urine, treatment is urgent. Waiting another day to confirm the hyperglycemia may be dangerous in allowing ketoacidosis or hyperosmolarity to evolve. In the absence of symptoms or presence of mild symptoms of diabetes, hyperglycemia detected incidentally or under conditions of acute infective, traumatic, circulatory, or other stress may be transitory and should not in itself be regarded as diagnostic of diabetes. The diagnosis of diabetes, in the absence of symptoms, should not be based on a single plasma glucose concentration. Diagnosis may require continued observation with fasting and/or 2-h postprandial BG levels and/or an oral glucose tolerance test (OGTT). An OGTT should not be performed if diabetes can be diagnosed using fasting, random, or postprandial criteria, as excessive hyperglycemia can result using a fasting OGTT in these circumstances. (E). If doubt remains, periodic re-testing should be undertaken until the diagnosis is established or refuted. There are individuals whose glucose levels do not meet the criteria for diabetes, but are too high to be considered normal. Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) are intermediate stages in the natural history of disordered carbohydrate metabolism between normal glucose homeostasis and diabetes (E). IFG and IGT are not interchangeable and represent different abnormalities of glucose regulation. IFG is a measure of disturbed carbohydrate metabolism in the basal state, while IGT is a dynamic measure of carbohydrate intolerance after a standardized glucose load. Patients with IFG and/or IGT are now referred to as having 'pre-diabetes', indicating the relatively high risk for development of diabetes in these patients (38). IFG and IGT may be associated with the metabolic syndrome (MS), which includes obesity (especially abdominal or visceral obesity), dyslipidemia of the high-triglyceride and/or low-high density lipoprotein type, and hypertension. Individuals who meet the criteria for IGT or IFG may be euglycemic in their daily lives as shown by normal or near-normal glycated hemoglobin levels, and those with IGT may manifest hyperglycemia only when challenged with an OGTT. FPG < 5.6 mmol/L (100 mg/dL)= normal fasting glucose. FPG 5.6–6.9 mmol/L (100–125 mg/dL)= IFG. FPG ≥ 7.0 mmol/L (126 mg/dL)= provisional diagnosis of diabetes (the diagnosis must be confirmed, as described above under 'Diagnostic criteria for type 2 diabetes'). The corresponding categories for IGT when the OGTT is used are as follows: 2-h postload glucose < 7.8 mmol/l (140 mg/dl)= normal glucose tolerance. 2-h postload glucose 7.8–11.1 mmol/l (140–199 mg/ dl)= IGT. 2-h postload glucose > 11.1 mmol/l (200 mg/dl)= provisional diagnosis of diabetes (the diagnosis must be confirmed with additional testing, as described above). After the diagnosis of diabetes is established, autoantibody testing should be considered when diagnosing and treating T2DM. Diabetes autoantibody testing should be considered in all pediatric patients with the clinical diagnosis of T2DM because of the high frequency of islet cell autoimmunity in otherwise "typical" T2DM. Antibodies will indicate an earlier need for insulin as well as the need to monitor for thyroid autoimmunity and to consider other autoimmune disorders associated with T1DM. (E) Diabetes autoantibody testing also should be considered in overweight/obese children > 13 years of age with a clinical picture of T1DM (weight loss, ketosis/ketoacidosis), some of whom may have T2DM (E) Insulin resistance is an impaired response to the physiologic effects of insulin, including effects on glucose, lipid, and protein metabolism, and on vascular endothelial function. Insulin resistance occurs in most tissues including liver, muscle, and fat tissue and is influenced by sex, age, race/ethnicity, stage of sexual maturation, and total adiposity. While visceral adiposity is important in insulin resistance in adults, the specific contribution of visceral adiposity to insulin resistance in the pediatric population remains uncertain. Several events in development may be associated with increased risk for the insulin resistance syndrome. These include premature adrenarche in girls (pubic hair appearing before the age of 8 years) and being born small for gestational age. Girls with a history of premature adrenarche are at increased risk for ovarian hyperandrogenism and PCOS and thus, insulin resistance (40). Children born small for gestational age are at increased risk for insulin resistance related to decreased intrauterine growth (41) and also at increased risk for premature adrenarche. Diabetes is only one manifestation of the insulin resistance syndrome or the MS (22, 42–50). Other associations include: Obesity: Obesity has deleterious associations with morbidity and cardiovascular risk independent of effects related to insulin resistance and diabetes (51–54). Nephropathy: Albuminuria (either micro- or macro- ) is present at the time of diagnosis in a substantial number of adolescents with T2DM and prevalence increases with duration of diabetes (24). Proteinuria and focal segmental glomerular sclerosis have also been reported in African-American adolescents with severe obesity, in the absence of diabetes (55). Hypertension; Hypertension is estimated to account for 35–75% of diabetes complications, both microvascular and macrovascular (56). Diabetes or impaired glucose tolerance doubles the risk of developing hypertension (57). In addition, there is a possible genetic predisposition to hypertension in T2DM related to the associated angiotensin converting enzyme genotype (58). Hypertension in T2DM is due to volume expansion and increased vascular resistance (59) related to reduced (NO)-mediated vasodilatation and increased activity of the renin-angiotensin system. Dyslipidemia: Hypertriglyceridemia and decreased high-density lipoprotein cholesterol are the hallmarks of T2DM dyslipidemia. Additional findings include elevated very low-density lipoprotein (VLDL), elevated LDL-c, elevated lipoprotein(a), and increased small dense LDL particles. Decreased lipoprotein lipase activity, increased lipoprotein glycation and increased lipoprotein oxidation render the lipoproteins more atherogenic. (60,61) Ovarian hyperandrogenism and premature adrenarche (62): PCOS is being increasingly recognized in adolescents as part of the insulin resistance syndrome. Adolescents with PCOS have ∼40% reduction in insulin-stimulated glucose disposal compared to body composition matched non-hyperandrogenic control subjects (59). Decreasing insulin resistance may improve ovarian function and increase fertility. NAFLD: Hepatic steatosis is present in 25–45% of adolescents with T2DM and more advanced forms of NAFLD, such as non-alcoholic steatohepatitis, are increasingly common and associated with progression to cirrhosis (24, 64). NAFLD now represents the most common cause of cirrhosis in children and the most common reason for liver transplantation in adults in the US. Systemic inflammation: elevated C-reactive protein, inflammatory cytokines and white blood cell counts in obese adolescents have been associated with increased risk for cardiovascular disease in adults (54). Additional health problems related to obesity include Obstructive sleep apnea (OSA) with associated pulmonary hypertension (65), orthopedic problems resulting in diminishing physical activity (66,67), pancreatitis, cholecystitis and pseudotumor cerebri. In adults, there is a strong association between level of hyperglycemia and increased risk of macrovascular disease. Hyperglycemia, dyslipidemia, and hypertension are contributors to the acceleration of atherosclerosis in T2DM, along with oxidative stress, glycation of vascular proteins, and abnormalities of platelet function and coagulation. Defective endothelium dependent vasodilatation is an additional factor accelerating atherosclerosis in T2DM. It is an early sign of increased risk for cardiovascular disease, and predictive of cardiovascular events (68) (B) and occurs in obese children relative to their level of obesity and degree of insulin resistance (69) (B). Co-morbidities characteristic of the insulin resistance syndrome are commonly seen at diagnosis or appear early in the course of T2DM and should be tested for sooner than in T1DM, where these disorders are complications of the diabetes rather than co-morbid conditions (70, 71) (B). A more complete discussion of testing for complications/co-morbidities is presented in the ISPAD Clinical Practice Guidelines for microvascular and macrovascular complications (72). Either micro- or macro-albuminuria, may be present at the time of diagnosis and albuminuria should be evaluated at diagnosis and annually thereafter (55, 72)(E). Likewise, hypertension may be present at, or prior to diagnosis of diabetes and each individual should be evaluated at every visit for hypertension. Dyslipidemia is more common in type 2 diabetes and in family members, (60,61) and should be screened for when metabolic stability is achieved. Evaluation for NAFLD should be done at diagnosis and annually thereafter (24)(E). Inquiries about puberty, menstrual irregularities and obstructive sleep apnea should be made at diagnosis and regularly thereafter (65)(E). Additional information is available in the ISPAD Clinical Practice Guidelines on complications. (72). Dyslipidemia, hypertension and albuminuria are more common in type 2 diabetes compared to type 1 diabetes and may be present at diagnosis and should be assessed after blood glucose control has been optimized. Confirmed hypertension (BP> 95% for age, gender and height) or albuminuria should be treated with an ACE inhibitor or, if not tolerated, an angiotensin receptor blocker (E). Combination therapy may be required if hypertension or albuminuria does not normalize on single agent treatment (E). Side effects are cough, hyperkalemia, headache and impotence (73). In addition, major congenital malformations have been reported with first trimester exposure to ACE inhibitors but not with other antihypertensive agents in non-diabetic women (74). Testing for dyslipidemia should be performed soon after diagnosis when BG control has been achieved and annually thereafter. (60,61) E Goal is LDL-C < 2.6 mmol (100 mg/dl) (68). If LDL-C is borderline (2.6-3.4 mmol;100–129 mg/ dl), or elevated (≥ 3.4 mmol; 130 mg/dl), repeat lipid profile should be performed in 6 months and dietary intervention to decrease total and saturated fat initiated. If LDL-C remains elevated after 3-6 months of attempting to optimize blood glucose control and diet, pharmacotherapy is warranted (72). Statin therapy has been shown to be safe and effective in children as in adults and should be the first pharmacologic intervention (72) although long term safety data are not available. Special attention should be paid to symptoms associated with muscles and connective tissues, as there is an increased risk of rhabdomyolysis The of T2DM in children and adolescents has required that with the of T1DM in children and adolescents the between the treatment of these T1DM is throughout the population to T2DM in North and Europe those with e.g. levels, less less well This has not been described for Asian T2DM. age. T1DM occurs throughout childhood, when is T2DM occurs in when family of families with a with T1DM have family with the disease, while 75% or more of families of the with T2DM have such The of these family to control weight and is with complications in the family and a of and in the treatment In most T1DM, beyond insulin and glucose is only for those individuals who are overweight and In all youth with T2DM, the is on and on glucose and effects of have the of T1DM and blood glucose insulin In in with an that dense increasingly and have to the of T2DM in children and its in of of including hypertension, dyslipidemia, and in the of complications may require more control in insulin T2DM than in T1DM, and attention to as by the Diabetes (21). also the ISPAD Clinical Practice Guidelines for diabetes and family for youth with type 2 diabetes is as important as it is in type 1 diabetes. and for T2DM will on and in insulin therapy and may not be required in T2DM will a greater on dietary and physical activity than is required for T1DM. should be given by with and of the and of youth with T2DM should be in a and age Because the of youth with T2DM are the ISPAD Guidelines for are to the of youth and families with T2DM The family will need to the of treatment of T2DM and to the of the required to T2DM should that the in the diagnosis type 1 type in a minority of patients can be and for the youth and The can be by the of blood glucose metabolism using therapy is to the metabolic of the specific of the of diabetes. is the of treatment of T2DM The family and should the of obesity and T2DM. must have an of the health and of the to an effective should be made in small and with the that these need to be The patient and family should be to monitor the and of and physical in any a and is for The and treatment for T2DM should include a and/or to a with and in of children with is should be to family and should be to all The family should be to dietary with including for weight reduced total and saturated fat increased and increased physical activity specific dietary are given in the ISPAD Guidelines for dietary should include: on and in of these and and for can result in substantial weight and is one of the most important for weight loss. and for the family and for the patient in an age including about dietary and activity related to and activity by of and using for that should be on in one with other activity as a family and should be in a or and not from a or of high density and in the the of and control of positive of or weight reduction in high and for and activity as for of and activity and for and should be for each patient and family that are to family and and should be to all A family or should be identified who is available to in physical activity with the may be to patients and family members. to with the dietary and is important to the of the should include: and an daily is to the of increased at reducing such as the and the time in related may be the most effective activity to be as a This should include daily to be more such as using of or to and to and and (E). for to and physical activity, including increases in daily (E). of blood glucose should be performed of should be and include a of fasting and postprandial glucose have been fasting a and daily post after the are while the within the (E). If the impaired glucose tolerance more frequent testing should be for of acute illness or when symptoms of or patients should more frequent testing and be in with their diabetes for (E). Patients on insulin or need to monitor for asymptomatic (E). should be at a year and if insulin is being used or metabolic control is should be continued in addition to pharmacologic therapy The of pharmacologic therapy is to decrease insulin resistance, increase insulin or to postprandial glucose The first used should be It has the over of reduction in without the risk of weight is decreased or remains and LDL-C and levels decrease during for type 2 diabetes in children and adolescents. of with over 3 months the need to a or insulin or in with a or a inhibitor Patients for should be on the effects of diabetes and oral agents on and oral agent should be used during pregnancy.

Background: Due to rising rates of morbidity and mortality associated with type 2 diabetes mellitus (T2DM), Saudi Arabia is ranked second in the Middle East and seventh overall among nations with the greatest incidence of diabetes mellitus (DM). Significant sleep abnormalities have been linked to difficulties in managing blood sugar levels, suggesting a link between sleep disorders and diabetes. This study aimed to find out how common sleep disturbances were among patients with T2DM in Makkah, Saudi Arabia.Methods: This descriptive cross-sectional study was conducted between June and August 2022 in Makkah City, Saudi Arabia. Patients with T2DM who visited primary healthcare facilities in Makkah during the study's duration were included in the study. To evaluate sleep quality, the Pittsburgh Sleep Quality Index in Arabic was employed. Patients who met the inclusion criteria were given an interview questionnaire to fill out.Results: In total, 355 patients with T2DM were enrolled in this study. The patients' median age was 49.24 years. Other than DM, a majority of them (58.9%) had chronic illnesses, with hypertension (64.5%) and cardiovascular disease (65.5%) as the most prevalent comorbidities. Only 22% of the patients had controlled diabetes. Of the individuals who had sleep disorders, 63.7% stated having poor sleep quality.Conclusion: Sleep problems are a common occurrence in patients with T2DM. Additionally, compared to people with other chronic disorders, people with endocrine diseases had poorer sleep quality. Hence, the duration of diabetes has an impact on sleep quality.

PDB112 EXPERIENCES OF PATIENTS WITH TYPE 2 DIABETES MELLITUS PATIENTS IN THE KINGDOM OF SAUDI ARABIA

The studies on the risk of tuberculosis (TB) in patients with type 1 diabetes mellitus (T1DM) alone are limited. We examined this relationship using a population-based retrospective cohort study. From claims data of the National Health Insurance system of Taiwan, we identified 5195 patients with T1DM newly diagnosed from 2002 to 2011 and 20,780 randomly selected controls without T1DM, frequency matched by age, sex, and year of diagnosis. Both cohorts were followed up until the end of 2011 to evaluate the risk of TB. The overall incidence of TB was 4.07-fold higher in the T1DM cohort than in the control cohort (1.18 vs 0.29 per 1000 person-years, P < 0.001). Compared with the controls, the Cox model estimated adjusted hazard ratios (HRs) of TB in patients with T1DM were greater in men than in women (4.62 vs 3.59) and in adults than in children (4.06 vs 3.37), but not significant. The adjusted HR was much greater for those with comorbidities than those without comorbidities (14.6 vs 1.62, P < 0.001). Compared with the controls, the patients with T1DM were also more likely to develop TB with multiple emergency room visits (adjusted HR: 116.1, 95% confidence interval [CI] = 43.8–307.4) or hospitalizations (adjusted HR: 86.5, 95% CI = 33.7–222.4). Patients with T1DM are at elevated risks of developing TB with much higher HRs for those with comorbidities, within the first year of diagnosis, and with frequent emergency cares or hospitalizations.

The association between 25-hydroxy-vitamin D [25(OH)D] levels and glycemic control in pediatric patients with type 1 diabetes mellitus (T1DM) is unclear. In this study, we aimed to investigate the association between 25(OH)D levels and glycemic control in Saudi pediatric patients' with T1DM in a region that is sunny year-round. A retrospective study was conducted in the Pediatric Department of King Saud Hospital in Unaizah, Saudi Arabia. A total of 218 children with T1DM were enrolled in the study and grouped according to their glycated hemoglobin (HbA1C) levels into the controlled T1DM (HbA1C ≤ 7.5%) and the uncontrolled T1DM (HbA1C > 7.5%). Their 25(OH)D levels and thyroid function were measured using standard methods. Of the 218 children in this study, 182 (83.5%) had uncontrolled T1DM, while only 36 (16.5%) had controlled T1DM. The median (interquartile range) of 25(OH)D levels was significantly lower in the uncontrolled T1DM group compared with the controlled group [45.4 (31.2-59.7) nmol/L vs. 56.1 (37.5-77.6) nmol/L; p = 0.007], respectively. Vitamin D deficiency (<50.0 nmol/L) and insufficiency (50-74 nmol/L) were detected in 55.0% and 31.1% of all the enrolled children, respectively. Vitamin D deficiency was detected in 86.6% of the uncontrolled T1DM patients and in 16.5% of the controlled T1DM patients (p = 0.012). The multivariable analysis showed that both vitamin D deficiency [adjusted odds ratio (aOR) = 2.92, p = 0.048] and insufficiency [aOR = 3.17, p = 0.042] were risk factors for uncontrolled diabetes. Vitamin D deficiency was highly prevalent in the studied group. Both vitamin D deficiency and insufficiency are associated with uncontrolled T1DM. Further study is needed.

The association of type 2 diabetes mellitus and hypertension is so high that it cannot be explained on the basis of diabetic nephropathy. This phenomenon has been attributed to a condition known as metabolic syndrome. Depression may be another aspect of metabolic syndrome. We conducted a cross-control study with 110 patients with type 2 diabetes mellitus (DM) and 110 control subjects of comparable age and sex. We determined the time since diagnosis of diabetes, the presence of hypertension (HT), coronary heart disease, cerebrovascular insufficiency, and depression, and took several anthropometric measurements, including height, weight, body mass index (BMI) waist circumference (WC), waist-to-hip circumference ratio (WHR), triceps skin fold thickness (TSFT), mid-upper arm circumference (MUAC), and mid-upper arm muscle area (MAMA). We also investigated depression in metabolic syndrome by comparing patients with type 2 diabetes alone and with type 2 diabetes and hypertension who attended a diabetes clinic. The prevalence of depression in hypertensive diabetics was 57% whereas in diabetics alone it was 40% (X2=4.3, P is less than 0.05). Likewise, combined hypertension and depression was more common among diabetics than controls (66% vs 25% respectively P is less than 0.01). The presence of combined hypertension and type 2 diabetes should alert the clinician to look for other features of the metabolic syndrome and for associated depression, which should be treated in most cases by pharmacotherapy.

BackgroundHypertension (HTN) and type 2 diabetes mellitus (T2DM) are interconnected metabolic disorders with escalating global incidence and prevalence. However, no longitudinal studies have specifically examined the incidence of HTN and T2DM in the same study population. This study aimed to elucidate the association between HTN and T2DM and ascertain their respective roles in the development of each other.MethodsThis retrospective cohort study encompassed 809 Saudi patients from primary healthcare centers in Al Madinah Al Munawarah, Saudi Arabia. The sample was stratified into three cohorts: 226 patients with HTN but without T2DM, 274 patients with T2DM but without HTN, and 309 patients devoid of both T2DM and HTN. Over a retrospective follow-up period of approximately 5 years, incidence density rates (IDR) were computed for HTN in the T2DM cohort, T2DM in the HTN cohort, and both HTN and T2DM in the control cohort. Multiple logistic regression analysis was employed to identify predictors of HTN and T2DM.ResultsThe IDR of T2DM among patients with HTN stood at 73.9 (95% confidence interval [CI] 56, 92) per 1000 person-years, in contrast to 33.9 (95% CI 24, 44) per 1000 person-years in the control cohort (adjusted odds ratio [OR] = 7.1, 95%CI 3.55, 14.13). Conversely, the IDR of HTN among patients with type-2 T2DM was 55.9 (95% CI 42, 70) per 1000 person-years, while in the control cohort, it was 20.8 (95% CI 13, 28) per 1000 person-years (adjusted OR = 5.8, 95% CI 3.11, 11.09). Significant predictors of HTN in the logistic regression model encompassed age, smoking status, family history of HTN, T2DM status, and body mass index (BMI). Similarly, significant predictors of T2DM in the logistic regression model included age, sex, family history of T2DM, HTN, and BMI.ConclusionThis study unveils HTN and T2DM as mutually significant risk factors. The IDR of each condition in the presence of the other significantly exceeded that among individuals devoid of HTN or T2DM.

The treatment for patients with type 2 diabetes mellitus (T2DM) follows a stepwise progression. As a treatment loses its effectiveness, it is typically replaced with a more complex and frequently more costly treatment. Eventually this progression leads to the use of basal insulin typically with concomitant treatments (e.g., metformin, a GLP-1 RA [glucagon-like peptide-1 receptor agonist], a TZD [thiazolidinedione] or a DPP-4i [dipeptidyl peptidase 4 inhibitor]) and, ultimately, to basal-bolus insulin in some forms. As the cost of oral antidiabetics (OADs) and noninsulin injectables have approached, and in some cases exceeded, the cost of insulin, we reexamined the placement of insulin in T2DM treatment progression. Our hypothesis was that earlier use of insulin produces clinical and cost benefits due to its superior efficacy and treatment scalability at an acceptable cost when considered over a 5-year period. To (a) estimate clinical and payer cost outcomes of initiating insulin treatment for patients with T2DM earlier in their treatment progression and (b) estimate clinical and payer cost outcomes resulting from delays in escalating treatment for T2DM when indicated by patient hemoglobin A1c levels. We developed a Monte Carlo microsimulation model to estimate patients reaching target A1c, diabetes-related complications, mortality, and associated costs under various treatment strategies for newly diagnosed patients with T2DM. Treatment efficacies were modeled from results of randomized clinical trials, including the time and rate of A1c drift. A typical treatment progression was selected based on the American Diabetes Association and the European Association for the Study of Diabetes guidelines as the standard of care (SOC). Two treatment approaches were evaluated: two-stage insulin (basal plus antidiabetics followed by biphasic plus metformin) and single-stage insulin (biphasic plus metformin). For each approach, we analyzed multiple strategies. For each analysis, treatment steps were sequentially and cumulatively removed from the SOC until only the insulin steps remained. Delays in escalating treatment were evaluated by increasing the minimum time on a treatment within each strategy. The analysis time frame was 5 years. Relative to SOC, the two-stage insulin approach resulted in 0.10% to 1.79% more patients achieving target A1c (<7.0%), at incremental costs of $95 to $3,267. (The ranges are due to the different strategies within the approach.) With the single-stage approach, 0.50% to 2.63% more patients achieved the target A1c compared with SOC at an incremental cost of -$1,642 to $1,177. Major diabetes-related complications were reduced by 0.38% to 17.46% using the two-stage approach and 0.72% to 25.92% using the single-stage approach. Severe hypoglycemia increased by 17.97% to 60.43% using the two-stage approach and 6.44% to 68.87% using the single-stage approach. In the base case scenario, the minimum time on a specific treatment was 3 months. When the minimum time on each treatment was increased to 12 months (i.e., delayed), patients reaching A1c targets were reduced by 57%, complications increased by 13% to 76%, and mortality increased by 8% over 5 years when compared with the base case for the SOC. However, severe hypoglycemic events were reduced by 83%. As insulin was advanced earlier in therapy in the two-stage and single-stage approaches, patients reaching their A1c targets increased, severe hypoglycemic events increased, and diabetes-related complications and mortality decreased. Cost savings were estimated for 3 (of 4) strategies in the single-stage approach. Delays in treatment escalation substantially reduced patients reaching target A1c levels and increased the occurrence of major nonhypoglycemic diabetic complications. With the exception of substantial increases in severe hypoglycemic events, earlier use of insulin mitigates the clinical consequences of these delays.