Changing Diabetes In Children Research Articles

Competing Risks Model to Evaluate Dropout Dynamics Among the Type 1 Diabetes Patients Registered with the Changing Diabetes in Children (CDiC) Program

Understanding the survival dynamics of registered patients on a disease control program is a vital issue for the success of program objectives. Dropout of registered patients from such a program is a critical issue, hindering the effectiveness of the program. This study aimed to identify the risk factors of dropout of patients who were registered on the Changing Diabetes in Children (CDiC) program, taking a case of Uganda. Survival analysis was done by integrating competing risk of factors associated with attrition from the CDiC program. The data for the study was obtained from patients with type 1 diabetes mellitus (T1DM) registered during 2009-2018 at health units with specialized pediatric diabetes clinics from various regions in Uganda. The study considered follow-up data of 1132 children with T1DM. Our analysis revealed that the Body Mass Index (BMI) significantly influences dropout time, with patients classified as underweight showing higher hazards than those with normal BMI. Moreover, when considering competing risks, dropout hazards increased. Comparing the Cox model with the Fine and Gray model shows the latter exhibiting a smaller AIC value, which indicates its superiority in the time-to-dropout analysis. Thus, utilizing methods that integrate competing risks for CDiC dropout analysis is preferable and recommended for related studies. These findings provide actionable insights for enhancing CDiC program efficacy.

Seasonal Variation in the Diagnosis Onset of Type 1 Diabetes Mellitus in Children and Adolescents in Cameroon

Background: Although the seasonality of type 1 diabetes has been described in most regions of the world, there are few data from sub-Saharan Africa. The aim of this study was to determine if there is a seasonality in the occurrence of type 1 diabetes, based on the “Changing Diabetes in Children” (CDiC) registry where all cases of type 1 diabetes in children and adolescents in Cameroon are registered since 2010.

Newly Diagnosed Type 2 Diabetes in Children and Adolescents in Bangladesh- A Cross Sectional Study

Background: Type 2 diabetes (T2D) has become a serious health problem in children and adolescents as the prevalence of obesity is increasing. Objective: To observe the baseline clinical and laboratory findings and treatment modalities of children and adolescents with newly diagnosed T2D. Materials & Methods: This cross-sectional study was done from Jan- Dec.2017 in Changing Diabetes in Children (CDiC), Paediatric diabetes OPD clinic in BIRDEM among newly diagnosed T2D children and adolescents. Results: Among 68 patients majority were female (64.7%). Mean age was 13.1 ± 2.5 years. Ten patients were below 10 years. Most of the patients were from urban & semi urban area and high to middle socioeconomic status. Family history was present in 91.2% and 22.1 % mother had H/O GDM. Forty two patients (61.8%) had typical and 22 (32.3%) had atypical symptoms. Thirty seven children had acanthosis nigricans (54.4%). Majority were found overweight (53/68), and (12/68) were obese. Mean HbA1c was 10.2 ± 2.8. Life style modification was advised to all. Insulin was started along with metformin in patients with high HbA1c and 33.8% patients were given metformin only. While comparing, BMI was found high in basal and metformin group. Lower fasting blood glucose and HbA1c were observed in patients with metformin only. Conclusion: T2D is emerging in children and adolescents. The screening of children at high risk of T2D is essential for preventive and timely remedial measures. BANGLADESH J CHILD HEALTH 2022; VOL 46 (1) : 9-13

Type 1 diabetes in low and middle-income countries - Tanzania a streak of hope.

In several of the Low and Middle Income countries , many patients with Type 1 diabetes (T1D) are most probably not diagnosed at all which may contribute to their low incidence. As an example of a country with low income and poor resources, we have chosen to study T1D in children/young people in Tanzania. Analyses of casebooks and statistics at several Tanzanian hospitals treating young patients with insulin dependent diabetes, usually Type 1 diabetes, and collection of information from different organisations such a Tanzanian Diabetes Association, Life for a Child, Changing Diabetes in Children and World Diabetes Foundation. The incidence in several areas is low. However, a lot of data are often missing at studied clinics and therefore the incidence might be higher, and with increased awareness in recent years the number of patients has increased many-folds. Most patients present with typical symptoms and signs of T1D, and a high proportion with plausible ketoacidosis , although this proportion has decreased from about 90% to about 40% in recent decades. Many patients have poor blood glucose control, and complications often develop already after short diabetes duration. In recent years resources have increased, awareness has increased and diabetes clinics started where staff has got training. There are problems with diabetes care in Tanzania but several facts give hope for the future.

Nutritional Status of Underprivileged Indian Children and Youth with Type-1 Diabetes - A Multicentre Study.

India has the highest number of prevalent type-1 diabetes (T1D) cases in the under-20-year age population. Data on the anthropometry of underprivileged Indian children with T1D are scarce. In economically disadvantaged countries like India, poor growth in patients with T1D is a major concern due to limited accessibility and affordability. Besides, due to the double burden of malnutrition, the prevalence of obesity is increasing mirroring the global trends, which may lead to the development of insulin resistance. This study aims to assess the prevalence of malnutrition in Indian children and youth with T1D and to identify the determinants of short stature. A registry-based cross-sectional analysis of data collected from various centres across India enrolled in the Changing Diabetes in Children (CDiC) programme. We observed that 6.4% were undernourished (3.4% severe undernutrition) and 17.7% (overweight 13.2%) had combined overweight/obesity. 21.2% of participants had short stature (adjusted for mid-parental height) with 7.4% cases of familial short stature. Longer duration of illness and insulin requirement were significant positive predictors of short stature while glycaemic control, insulin regimen and mid-parental height did not have a significant relationship with short stature. Participants on basal-bolus regimen had significantly higher insulin requirements and better glycaemic control than the ones on mixed-split regimen. We report that around one-fifth of children and youth with T1D were overweight/obese and around a fourth were stunted, especially those with longer duration of diabetes and higher insulin requirements. Close monitoring of anthropometric parameters is necessary for all children with T1D to optimize growth and nutrition.

Survival of children and youth with type 1 diabetes mellitus in Tanzania.

Survival from type 1 diabetes Mellitus is low in lower-income countries with underdeveloped health systems. Support programs from partners like life for a child (LFAC) and changing diabetes in children (CDiC) were implemented in Tanzania in 2005 to provide diabetes care to children and youth. No evaluation of survival has been done since their implementation. To assess the survival of children and youth living with diabetes mellitus (CYLDM) in Tanzania. A retrospective data collection from 39 clinics of CYLDM was done by extracting data from the diabetes registry between 1991 and 2019. Three cohort were analyzed (1) Cohort 1991-2004 (pre-implementation), (2) Cohort 2005-2010 (during implementation), and (3) 2011-2019 (after the implementation of LFAC/CDiC). Data were analyzed using STATA-version 14. A total of 3822 data of CYLDM were extracted, mean age at diagnosis was 13.8 (±5) years. Approximately fifty-one percent (50.8%) were male. The total observation time was 28 years, and the Median duration of diabetes of 5 (IQR2, 8) years. Total death was 95 (3%), with a mean age at death of 17.7 (SD 4.7) years. The last cohort (2011-2019) had more diagnosis 2353 (72.7%), as compared to the <2005 cohort with only 163(5%). The survival improved from 59% before 2005 to 69% in the last cohort (2011-2019). The implemented programs have facilitated the diagnosis and retention of CYLDM in the health care system. In doing so, it has also increased the survival probability in Tanzania compared to the early 90s.

Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: the case study of the changing diabetes in children program in Cameroon

Brief Summary: Despite provision of free insulin by the Changing Diabetes in Children (CDiC) program, mortality remains high in children and adolescents with type 1 diabetes (T1D) in Cameroon, in particular in rural settings and in families with no formal education.

Insulin Past, Present, and Future: 100 Years from Leonard Thompson

Before the discovery of insulin and the critical role of the pancreas vis-à-vis diabetes mellitus pathophysiology, childhood diabetes or what we now call type 1 or autoimmune diabetes mellitus was almost universally fatal. In limited-resource countries (LRC) around the world, this remains sadly true because of the expense and unavailability of medical care, medical information, and/or medications. In 1889, Minkowski and Mering identified the pancreas as the likely source of the problem in pancreatectomized dog experiments, and Langerhans, working with Virchow, identified the islands of pancreatic tissue now named after Langerhans as the likely source of the problem. Prior to that, Cawley, Boucherdat, Zuelzer, Gley, de Meyer, Schafer, Scott, Kleiner, and Paulescu all worked on this problem with varying results until Banting, Best, MacLeod, and Collip in Toronto in 1921 successfully treated pancreatectomized dogs with an alcohol-based pancreatic extract and then were the first to do the same with children and adults with diabetes, starting with Leonard Thompson in early 1922. Urinary and blood glucose levels were reduced, and clinical symptoms decreased concurrently. The magnificent medical historical work by Professor Michael Bliss, also from Toronto, as well as an excellent US NPR Television documentary, describes the trials and tribulations of this event that culminated in the “fastest Nobel Prize” awarded. Progressive biopharmaceutical advances have modified insulin from pigs and cows and then genetically engineered insulin to work much faster and also much slower to provide more modernized ways of providing insulin. Insulin pens then replaced vial and syringe administration, and then insulin pumps coupled with continuous blood glucose sensors have made delivery more physiologic in addition to more attention paid to nutrition advice, education, and psychosocial support around the world. Programs to assist delivery of expensive insulin to LRC administered by Insulin for Life, Life for a Child (LFAC), Changing Diabetes in Children (CDIC) coupled with support by ISPAD (International Society for Pediatric and Adolescent Diabetes) have continued to make such advances available thorough wonderful philanthropy in insulin manufacturers and manufacturers of blood glucose monitoring equipment and insulin pump/sensor suppliers.

Assessment of Insulin Therapy in 281 Children and Adolescents with Type 1 Diabetes in Senegal

Introduction: In Senegal, with the CDIC “Changing Diabetes In children” project, insulin has been made free. The objective of this study was to evaluate the accessibility and modalities of insulin therapy in the management of type 1 diabetes. Methodology: This was a retrospective study including patients followed for type 1 diabetes (T1DM) in hospital between April 2018 and December 2020. Results: 281 patients were included. The mean age was 14.22 years. The mean age at diagnosis was 11.28 years. Ketoacidosis was the main mode of discovery of diabetes at 51.6%. Premix and rapid insulins were most commonly used at 84.7% and 82.9% respectively, most often in combination. The most commonly used treatment regimen was three injections/day in 82.5% of cases. The average daily insulin dose was 0.62 IU/Kg/dr. Of the patients, 219 (78%) were self-monitoring of blood glucose. The average number of blood glucose checks was 1.78 per day. 76 patients (27%) went days without an insulin injection and up to 7 days in 51% of cases. The main reasons were forgetfulness, therapeutic errors and stock-outs. Hypoglycaemia was observed in 14.2%. The average glycated haemoglobin was 10%. Conclusion: Despite the efforts made, there are still challenges to improve access to insulin. The reinforcement of therapeutic education on insulin therapy is essential for a better quality of life of diabetic children and adolescents.

Improving access to diabetes care for children: An evaluation of the changing diabetes in children project in Kenya and Bangladesh.

The changing diabetes in children (CDiC) project is a public-private partnership implemented by Novo Nordisk, to improve access to diabetes care for children with type 1 diabetes. This paper outlines the findings from an evaluation of CDiC in Bangladesh and Kenya, assessing whether CDiC has achieved its objectives in each of six core program components. The Rapid Assessment Protocol for Insulin Access (RAPIA) framework was used to analyze the path of insulin provision and the healthcare infrastructure in place for diagnosis and treatment of diabetes. The RAPIA facilitates a mixed-methods approach to multiple levels of data collection and systems analysis. Information is collected through questionnaires, in-depth interviews and focus group discussions, site visits, and document reviews, engaging a wide range of stakeholders (N=127). All transcripts were analyzed thematically. The CDiC scheme provides a stable supply of free insulin to children in implementing facilities in Kenya and Bangladesh, and offers a comprehensive package of pediatric diabetes care. However, some elements of the CDiC program were not functioning as originally intended. Transitions away from donor funding and toward government ownership are a particular concern, as patients may incur additional treatment costs, while services offered may be reduced. Additionally, despite subsidized treatment costs, indirect costs remain a substantial barrier to care. Public-private partnerships such as the CDiC program can improve access to life-saving medicines. However, our analysis found several limitations, including concerns over the sustainability of the project in both countries. Any program reliant on external funding and delivered in a high-turnover staffing environment will be vulnerable to sustainability concerns.

Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: The case study of the Changing Diabetes in Children program in Cameroon.

Type 1 diabetes in Africa has been associated with high mortality attributed mainly to poor insulin access. Free insulin provision programs for people with type 1 diabetes have been introduced across Africa recently. We aimed to determine the mortality rate and associated factors in a cohort of children and adolescents with type 1 diabetes who receive free insulin treatment in sub-Saharan Africa. We conducted a retrospective analysis using the Changing Diabetes in Children (CDiC) medical records in Cameroon between 2011 and 2015. The overall mortality rate was 33.0 per 1000 person-years (95% CI 25.2-43.2). Most deaths (71.7%) occurred outside of the hospital setting, and the cause of death was known only in 13/53 (24.5%). Mortality was substantially higher in CDiC participants followed up in regional clinics compared to the main urban CDiC clinic in Yaounde; 41 per 1000 years (95% CI 30.8-56.0) versus 17.5 per 1000 years (95% CI 9.4-32.5), and in those with no formal education compared to those who had some level of education; 68.0 per 1000 years (95% CI 45.1-102.2) versus 23.6 per 1000 years (95% CI 16.5-33.8). In Cox proportional multivariable analysis, urban place of care (HR=0.23, 95% CI 0.09-0.57; p= 0.002) and formal education (HR=0.42, 95% CI 0.22-0.79; p= 0.007) were independently associated with mortality. Despite free insulin provision, mortality remains high in children and adolescents with type 1 diabetes in Cameroon and is substantially higher in rural settings and those with no formal education.

Use of telemedicine for the management of type 1 diabetes in children and adolescents in Bangladesh during the COVID-19 pandemic

Background: Telemedicine has been an option for healthcare during the COVID-19 pandemic time. According to the COVID-19 forum on the International Society for Pediatric and Adolescent Diabetes, telemedicine is now the reality for all pediatric diabetes centers around the globe. We report here the analysis of telemedicine care provided to children and adolescents with type 1 diabetes by our diabetes team during the first phase of lockdown in Bangladesh. Materials and Methods: The Diabetic Association of Bangladesh (BADAS) is providing a highly structured and organized system of diabetes care as an extended arm of the government. Since the lockdown, diabetes care for children was started through telemedicine by the diabetes team in our center. Results: We analyzed our phone calls, text messages from March 26 to April 30, 2020. During lockdown, more than 645 calls, including text messages and WhatsApp messages, were received. A total of 235 patients were given advice over the phone in 1 month. Fifty-two percent of phone calls were from the capital city Dhaka and rest from other districts of Bangladesh. While analyzing the problems, three of our patients noticed mild fever, but there was no history of contact with infected persons, and they recovered within 2–3 days. No laboratory test was done for the confirmation of COVID-19. Most of the patients developed hyperglycemia during this period. None of them required hospital admission during this month. Free insulin from CDiC (Changing Diabetes in Children) and LFAC (Life for a Child) programs was sent to the BADAS centers in different districts through courier service even during the lockdown. So, there was no patient without access to insulin during pandemic time. Conclusion: Telemedicine service has been found to be a useful medium for the care of children with diabetes in Bangladesh during COVID-19 crisis. In the future, telemedicine service could be a solution for routine care of diabetic children who are unable or unwilling to travel long distances to a clinic.

Young people with type 1 diabetes on insulin pump therapy could fast safely during COVID-19 pandemic Ramadan: A telemonitoring experience in Bangladesh.

Our aim was to report our telemedicine experience with type 1 diabetes patients using insulin pumps who fasted for Ramadan 2020 during the COVID‐19 pandemic. The routine diabetes outpatient care in our Changing Diabetes in Children (CDiC) Pediatric Diabetes Center at the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders hospital was closed, as there was a lockdown from 26 March in Bangladesh. The diabetes team in our center started telemedicine care for routine follow up of patients. Nine patients who wished to fast for Ramadan contacted our diabetes team over the phone. The mean age was 19.3 ± 5.0 years, and five (55.6%) were female. Most of the patients fasted >20 days. Hyperglycemia and mild hypoglycemia were common complications during fasting. There was no episode of severe hypoglycemia or diabetic ketoacidosis, and none of the patients required admission. During the COVID‐19 crisis in Bangladesh, patients with type 1 diabetes using an insulin pump could fast safely for Ramadan with the support of the telemedicine service by the diabetes team.

Incidence, prevalence and clinical manifestations at onset of juvenile diabetes in Tanzania

Better knowledge on incidence, prevalence and clinical manifestations is needed for planning diabetes care in Sub Saharan Africa. AimsTo find a crude incidence/prevalence of diabetes in children and young adults in a low resource setting, classify the diabetes and audit the health record keeping. MethodsA retrospective observational study based on medical recordings 2010–2016. Target population was children and adolescent registered in Changing Diabetes in Children (CDiC) or Life for a Child (LFAC) programs for children with T1DM and diagnosed at 5 diabetes clinics in three geographical regions of Tanzania. 604 patients’ files were available from five hospitals. Results336/604 files covered patients <15 years of age at diagnosis. The prevalence of diabetes <15 years of age ranged from 10.1 to 11.9 per 100,000 children and the annual incidence 1.8–1.9/100,000 children, with peak incidence at 10–14 years. A lot of data were missing. The great majority of the patients presented with typical signs and symptoms of T1D, 83.7% with plausible ketoacidosis (DKA). ConclusionsDiabetes incidence and prevalence is still low. T1D seems to dominate with very high frequency of DKA at diagnosis. Increased awareness of diabetes both in health care and community is needed.

Fibrocalculous pancreatic diabetes in Bangladeshi children and adolescents—a not so rare form of secondary diabetes

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes with classic triad of abdominal pain, pancreatic calculi, and diabetes. This study was undertaken to identify the clinical characteristics in newly diagnosed children and adolescents with FCPD and compare them with children with Type 1 diabetes (T1D). The study was carried out at the Changing Diabetes in Children (CDiC) Diabetes Clinic of tertiary care hospital, BIRDEM in Bangladesh. All patients underwent abdominal X-rays and careful analysis of history of abdominal pain to differentiate the two diagnoses. Pancreatic auto antibodies were not available. Four hundred twenty-nine patients were aged under 18 years at diabetes presentation: 106 (25%) fulfilled the criteria for FCPD and 323 (75%) for T1D. When comparing FCPD with T1D at diagnosis, it was found that they were older (median age 14.0 [IQR 12.0–15.0] years vs 12.0 [IQR 10.0–14.0] years (p < .0001)). Few had a positive family history of diabetes (31% vs 48% (p = .002)). DKA was less common (4 vs 12% (p = .020)). HbA1c was higher (13.6 ± 4.2% (125 ± 22) vs 12.1 ± 3.4% (109 ± 14) (p = .001)). More FCPD patients had atypical symptoms compared to T1D (25 vs 14%, (p = .010)). The median duration of symptoms was significantly longer (3.0[1.0–6.0] vs 1.0[1.0–2.0] months (p = .0001)). Cataracts were more common in FCPD (9 vs 3% (p = .010)). The median dose of insulin was higher in FCPD patients than T1D (1.41[0.91–2.03] vs 1.02[0.78–1.48] (p = .0001)). In addition to pancreatic calcification, FCPD showed atypical symptoms with longer prodrome and higher HbA1c than T1D.

Best practices from changing diabetes® in children India

AbstractIt is estimated that India alone has 70,200 cases of T1DM, with an annual increase rate of 3–5%.2 Despite being the most common chronic disease in children and adolescents, T1DM does not receive the attention it requires. Many children die of undiagnosed diabetes or shortly after diagnosis because of poor blood sugar control. Everyone with type 1 diabetes requires insulin from the beginning.3 Continuous management, comorbidities, and chronic complications place a heavy psychological and economic burden on the whole family. Challenges in India are at many levels, right from diagnosis, health-care delivery, availability of trained physicians, infrastructure, insulin, and monitoring and providing psychosocial support. The Changing Diabetes® in Children (CDIC) Programme is a part of Novo Nordisk's Access to Diabetes Care strategy and builds on the undefined cornerstones in the right to health. With an aim to improve the health condition and quality of life of the children with diabetes, this program was started in 2009. Globally, the program is operational in nine underdeveloped and developing countries including India and there are a total of &gt;14,000 children under the care of the CDiC Programme. This global program was launched in India in 2011 by late former President Dr. APJ Abdul Kalam through Novo Nordisk Education Foundation. It has a pan-India footprint with 21 established centers in government hospitals and specialized clinics and &gt;4000 registered children. Apart from providing essential care which includes free doctor consultations, providing insulin, and monitoring insulin, CDiC is also working in other key areas in type 1 management, namely, (1) diabetes education–with specially designed diabetes education tools, for children, parents, siblings, and other caregivers, (2) awareness and capacity building–advertorial series for general public and special accredited trainings for doctors and other health-care professionals, and (3) communication for all stakeholders–periodic CDiC newsletters and Mishti Guardian.

Creativity and diabetes education: Essentiality, impact and way forward

The changing diabetes in children (CDiC) program is a unique program aimed at children suffering from type 1 diabetes. The whole focus of CDiC is to provide comprehensive care including diabetes education. Various innovative and creative diabetes educational materials have been developed, which makes learning fun. Lot of diabetes camps are held at CDiC, focusing on diabetes education, experience sharing and fun activities. CDiC faces many challenges in an effort to cater to the needs of most deserving children with type 1 diabetes mellitus (T1DM) throughout the country, to provide comprehensive care including self-sufficiency, to serve children for as long as possible and to ultimately have better outcomes for all children with T1DM. The CDiC program aims to make the child more positive, secure and hopeful and initiate and strive for comprehensive diabetes care for the economically underprivileged children with T1DM.

Treatment essentials and training for health care providers.

The lack of awareness among health care providers (HCPs) is one of the biggest challenges for the management of patients with type 1 diabetes mellitus (T1DM) in India. Major challenges faced by HCPs include lack of awareness about the disease among general physicians and inadequately trained staff to deal with children with T1DM. The changing diabetes in children (CDiC) program is helping in overcoming these barriers faced by HCPs. CDiC provides treatment, monitoring tools, and education to children affected with T1DM and has been instrumental is developing various education and awareness tools.