|Year : 2016 | Volume
| Issue : 2 | Page : 85-88
Pattern of presentation of Type 1 diabetic patients in Kano, Nigeria
Umar Isa Umar
Department of Paediatrics, Paediatric Endocrinology Unit, Aminu Kano Teaching Hospital, Bayero University, Kano State, Nigeria
|Date of Web Publication||1-Aug-2016|
Umar Isa Umar
Department of Paediatrics, Paediatric Endocrinology Unit, Aminu Kano Teaching Hospital, Bayero University, P.M.B. 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Type 1 diabetes is the most common form of diabetes in children; its symptoms may be subtle and frequently misinterpreted. Presentation with diabetic ketoacidosis (DKA) may be associated with significant morbidity and mortality in the paediatric population. Objective: To examine the prevalence of Type 1 diabetes in children at the Aminu Kano Teaching Hospital, Kano. Design: Retrospective study of case files of children with diagnosis of Type 1 diabetes mellitus (T1DM). Patients and Methods: It was a retrospective review of case files of children younger than 18 years with diagnosis of T1DM over 4 years (January 1, 2012,–December 31, 2015). Results: A total of 7929 patients were seen during the study period, out of which 18 were diagnosed with T1DM, giving a case prevalence rate of 2.3/1000. Sixteen (89%) of the 18 patients were first presented with DKA. The mean age at presentation was 8 years, and there were more females 13/18 than males 5/18 among the subjects. The most prevalent presenting symptoms were dehydration 16 (89%), fever 14 (77.8), abdominal pain 12 (66.6%), polyuria and polydipsia 12 (66.6%). Two of the sixteen patients with DKA died with cerebral oedema during admission. Conclusion: DKA is the most common pattern of presentation of T1DM in our environment. This highlights the need for intensified efforts in education of health workers and the populace at large for quick presentation and prompt diagnosis and optimal management of childhood diabetes.
Keywords: Nigeria, patients, presentation, Type 1 diabetes
|How to cite this article:|
Umar UI. Pattern of presentation of Type 1 diabetic patients in Kano, Nigeria. Niger J Basic Clin Sci 2016;13:85-8
| Introduction|| |
Diabetes mellitus (DM) is a group of diseases characterised by high levels of glucose in the blood resulting from defects in insulin production, insulin action or both. Type 1 DM (T1DM) remains the most common form of diabetes in childhood and is caused by insulin deficiency, following autoimmune destruction of the insulin-producing pancreatic beta-cells. Although it commonly presents in childhood, one-fourth of cases are diagnosed in adults.,, Worldwide, DM is a major health problem and current studies have revealed a definite global increase in the incidence and prevalence of diabetes, with the World Health Organization (WHO) projecting that there will be almost 285 million cases in the year 2025. This increase is expected in both adult and childhood diabetes, including Type 1 and 2 diabetes. The WHO Diabetes Mondiale project group has reported a worldwide increase in the incidence and variation (over 400-fold) of Type 1 diabetes, with the highest occurring in Finland (over 45/100,000 children under the age of 15 years) and the lowest in parts of China and Fiji. In Africa, the incidence rate in children ranges from 1.5/100,000 in Tanzania to 10.1/100,000 in Sudan. However, the incidence and pattern of presentation in Nigeria are poorly documented. Regional variations exist in terms of prevalence and features of DM in children. A hospital prevalence of 1.6/1000 in Port Harcourt, South Nigeria, and 0.1/1000 in Abakaliki, South-east Nigeria, has been reported. In Sokoto, North-west Nigeria, a hospital prevalence rate of 0.33/1000 was reported by Ugege et al.
Childhood diabetes may present with polyuria, polydipsia and polyphagia, along with lassitude, nausea and blurred vision, all of which result from the hyperglycaemia itself. However, the onset of symptoms may be sudden and is not unusual for some patients to present with diabetic ketoacidosis (DKA), which may occur de novo or secondary to the stress of illness such as malaria, sepsis or surgery.
This study aims to examine the prevalence and clinical presentation of Type 1 diabetes in children at the Aminu Kano Teaching Hospital (AKTH) over a 4-year period.
| Patients and Methods|| |
The study involved a retrospective review of case note of all children diagnosed and managed as cases of DM in the Paediatric Department of AKTH between January 2012 and December 2015. Ethical approval was obtained from the Ethical and Research Committee of the hospital, and the study was performed according to the Declaration of Helsinki. Childhood diabetes was diagnosed by the presence of symptoms of diabetes and a random blood glucose (>11.1 mmol/L) or fasting plasma glucose >7.0 mmol/ L. DKA was diagnosed by significant hyperglycaemia (>14 mmol/L), ketonuria, serum bicarbonate <15 mmol/L and DKA-associated clinical signs (e.g., dehydration, Kussmaul respiration, etc.). Patients with DKA were managed according to the departmental protocol of DKA management. Data retrieved from the case notes include age, sex, presenting symptoms, duration of symptoms prior to presentation and outcome of hospitalisation. The results of random plasma glucose, serum electrolytes and urinalysis were also recorded. The data were entered into SPSS version 20.0. IBM Corp., Armonk, NY, USA and a descriptive analysis was done.
| Results|| |
Eighteen cases of childhood DM were seen out of 7929 admissions during the 4 years period, indicating a hospital prevalence of 2.3/1000 per year. The study subjects were between the ages of 15 months and 13 years, with a mean (±standard deviation) age of 8 ± 3.388 years. There were more females 13/18 than males 5/18 among the subjects [Table 1]. A family history of diabetes was found in three of the children. The majority presented with dehydration, abdominal pain, polydipsia and polyuria. Other presenting features are shown in [Table 2]. [Table 3] shows the indications for admissions; 16 of the 18 had DKA (89%), septicaemia was the precipitating factor in 6 of 16 patients with DKA and 2 of the 16 patients died with cerebral oedema during admission. [Figure 1] shows the prevalence of DKA in this study compared with the prevalence in some developed and developing countries.
|Table 2: Common presenting clinical features in patients with diabetes mellitus|
Click here to view
|Table 3: Indication for admission, outcome and precipitating factor for diabetic ketoacidosis|
Click here to view
|Figure 1: Diabetic ketoacidosis as a presenting diagnosis at Aminu Kano Teaching Hospital, Kano, Nigeria, compared with other developed and developing countries|
Click here to view
| Discussion|| |
The purpose of this study was to examine the prevalence and pattern of presentation of Type 1 diabetes in children in Kano. The present study found a prevalence of Type 1 diabetes of 2.3/1000 in AKTH, which is lower than the 10.1/1000 reported by John et al. in a similar hospital-based study in Jos, North Central Nigeria. Our finding is however higher than what was reported by Afoke et al. of 0.33/1000 of T1DM among children in Ishiellu, South-eastern Nigeria, and Ugege et al. in Sokoto, North-western Nigeria, who also reported the prevalence of 0.33/1000 among children. This low prevalence is also in keeping with the few epidemiological studies on T1DM in African children, for instance, Tanzania was estimated to have a prevalence of 1.5/100,000. This low prevalence had been postulated to be due to reduced genetic susceptibility to DM among black African; a finding also observed among Afro-Americans., The other contributory factor could be the high mortality among African children with T1DM; in rural Mozambique, life expectancy was reported to be as low as 0.6 years.
The study found a female preponderance, with 13 (72.2%) females versus 5 (27.8%) males; such a female preponderance was observed in Abakaliki by Ibekwe, with a male: female ratio of 1:1.2 and also in the series conducted by Salman et al. in Riyadh, Saudi Arabia, wherein 53.6% of patients were female. On the contrary, some studies reported male preponderance; Abdullah  also in Saudi Arabia found a male preponderance, with a male: female ratio of 1.3:1; this ratio is similar to the ratios observed in the UK.
The most prevalent presenting features were dehydration, polyuria and polydipsia, and 89% of the patients presented in DKA in this study. Similarly, local studies in Nigeria; Abakaliki (88%), Sokoto (62.5%), Jos (75%) and some studies from other developing countries such as South Africa (69.8%), Tanzania (90%) and Congo (90%) have reported high frequencies of DKA. This similarity may be explained by the possible low level of awareness of signs and symptoms of diabetes in children among parents coupled with inter-current infections, poverty, in addition to poor health services with late diagnosis and poor management. On the contrary, countries with a higher level of awareness among parents, in addition to good and affordable health services with early diagnosis observed lower frequencies of DKA; 14% in Sweden  and 26% in the USA. This is not surprising as there is robust evidence for a similar relationship between life expectancy and gross domestic product (GDP), and poorer countries account for the largest share of the global burden of disease. Several ecological studies have also shown that the Type 1 diabetes incidence rates correlate strongly with indicators of national prosperity such as GDP and low infant mortality.,
In most subjects, the apparent trigger for DKA was infection. This ranged from urinary tract infection, malaria to septicaemia and bronchopneumonia. Infections have been documented as a precipitating factor for DKA., Other documented precipitating factors include newly diagnosed diabetes, poor insulin administration and stressful conditions. The outcome of subjects was good among those admitted as 16/18 were discharged to follow-up, two died from DKA with cerebral oedema.
The finding of a higher frequency of DKA in lower socioeconomic countries may be explained by differing levels of disease awareness and healthcare provision, suggesting a considerable need to decrease the excessive morbidity, mortality and healthcare expenditure associated with DKA in these countries. This can be achieved through community intervention by improving awareness of childhood diabetes among school children, parents and health-care providers. Better disease recognition through improved awareness of diabetes is also supported by the findings that children from families with higher parental education are less likely to present in DKA and having the first-degree relative with diabetes is associated with an up to 6-fold decreased risk of DKA at diagnosis.
| Conclusion|| |
A relatively low prevalence of T1DM in children was found which is in keeping with other studies performed in other areas of Africa. However, this finding may not be true reflection of the actual population prevalence on account of this being a hospital-based retrospective data, with all its limitations. The diagnosis of T1DM may have been missed in the hospital, or children may have already died before they reached the hospital. However, a significant strength of this study was that it was performed over a relatively long period and examined all admissions to the paediatric ward.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organisation. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia: Report of a WHO/IDF Consultation. Geneva, Switzerland: World Health Organisation; 2006.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014;37 Suppl 1:S81-90.
Lipton RB, Drum M, Burnet D, Rich B, Cooper A, Baumann E, et al.
Obesity at the onset of diabetes in an ethnically diverse population of children: What does it mean for epidemiologists and clinicians? Pediatrics 2005;115:e553-60.
Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, et al.
Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective. J Pediatr 2000;136:664-72.
Duncan GE. Prevalence of diabetes and impaired fasting glucose levels among US adolescents: National Health and Nutrition Examination Survey, 1999-2002. Arch Pediatr Adolesc Med 2006;160:523-8.
Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: Estimates and projections to the year 2010. Diabet Med 1997;14 Suppl 5:S1-85.
Silink M. Childhood diabetes: A global perspective. Horm Res 2002;57 Suppl 1:1-5.
WHO multinational project for childhood diabetes. WHO Diamond Project Group. Diabetes Care 1990;13:1062-8.
Majaliwa ES, Elusiyan BE, Adesiyun OO, Laigong P, Adeniran AK, Kandi CM, et al.
Type 1 diabetes mellitus in the African population: Epidemiology and management challenges. Acta Biomed 2008;79:255-9.
Opara PI, Anochie IC, Eke FU. Childhood diabetes mellitus in Port-Harcourt: Any change in prevalence and outcome? Port Harcourt Med J 2008;21:126-9.
Ibekwe MU, Ibekwe RC. Pattern of Type 1 Diabetes Mellitus in Abakaliki, Southeastern, Nigeria. Pediatric Oncall. [serial online] 2011. Available from: http://www.pediatriconcall.com
. [Last accessed on 2012 Aug 25].
Ugege O, Ibitoye PK, Jiya NM. Childhood diabetes mellitus in Sokoto, North-Western Nigeria: A ten-year review. Sahel Med J 2013;16:97-101.
Ayoola OO. Recent advances in childhood diabetes mellitus. Ann Ib Postgrad Med 2008;6:9-20.
John C, Abok II, Yilgwan C. Clinical profile of childhood type 1 diabetes in Jos, Nigeria. Afr J Diabetes Med 2013;21:148-51.
Afoke AO, Ejeh NM, Nwonu EN, Okafor CO, Udeh NJ, Ludvigsson J. Prevalence and clinical picture of IDDM in Nigerian Igbo schoolchildren. Diabetes Care 1992;15:1310-2.
Mac Donald MJ. Lower frequency of diabetes among hospitalized Negro than white children: Theoretical implications. Acta Genet Med Gemellol (Roma) 1975;24:119-26.
Dunston GM, Henry LW, Christian J, Ofosu MD, Callender CO. HLA-DR3, DQ heterogeneity in American blacks is associated with susceptibility and resistance to insulin dependent diabetes mellitus. Transplant Proc 1989;21(1 Pt 1):653-5.
Beran D, Yudkin JS, de Courten M. Access to care for patients with insulin-requiring diabetes in developing countries: Case studies of Mozambique and Zambia. Diabetes Care 2005;28:2136-40.
Salman H, Abanamy A, Ghassan B, Khalil M. Insulin-dependent diabetes mellitus in children: Familial and clinical patterns in Riyadh. Ann Saudi Med 1991;11:302-6.
Abdullah MA. Epidemiology of type I diabetes mellitus among Arab children. Saudi Med J 2005;26:911-7.
Cahill GF Jr., McDevitt HO. Insulin-dependent diabetes mellitus: The initial lesion. N Engl J Med 1981;304:1454-65.
Reddy Y, Ganie Y, Pillay K. Characteristics of children presenting with newly diagnosed type 1 diabetes. S Afr J Child Health 2013;7:46-8.
Majaliwa ES, Munubhi E, Ramaiya K, Mpembeni R, Sanyiwa A, Mohn A, et al.
Survey on acute and chronic complications in children and adolescents with type 1 diabetes at Muhimbili National Hospital in Dar es Salaam, Tanzania. Diabetes Care 2007;30:2187-92.
Otieno CF, Kayima JK, Omonge EO, Oyoo GO. Diabetic ketoacidosis: Risk factors, mechanisms and management strategies in sub-Saharan Africa: A review. East Afr Med J 2005;82 12 Suppl: S197-203.
Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden – A 2-year paediatric population study. Diabet Med 2007;24:1080-5.
Bui H, To T, Stein R, Fung K, Daneman D. Is diabetic ketoacidosis at disease onset a
result of missed diagnosis? J Pediatr 2010;156:472-7.
Swift R. The relationship between health and GDP in OECD countries in the very long run. Health Econ 2011;20:306-22.
World Health Organization World Health Statistics 2007: Ten Statistical Highlights in Global Public Health. Available from
. [Last accessed on 2016 Jan 11].
Patterson CC, Dahlquist G, Soltész G, Green A; EURODIAB ACE Study Group. Europe and Diabetes. Is childhood-onset type I diabetes a wealth-related disease? An ecological analysis of European incidence rates. Diabetologia 2001;44 Suppl 3:B9-16.
Haynes A, Bulsara MK, Bower C, Codde JP, Jones TW, Davis EA. Independent effects of socioeconomic status and place of residence on the incidence of childhood type 1 diabetes in Western Australia. Pediatr Diabetes 2006;7:94-100.
Syed M, Khawaja FB, Saleem T, Khalid U, Rashid A, Humayun KN. Clinical profile and outcomes of paediatric patients with diabetic ketoacidosis at a tertiary care hospital in Pakistan. J Pak Med Assoc 2011;61:1082-7.
Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al.
Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care 2003;26 Suppl 1:S109-17.
Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ 2011;343:d4092.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future
| ||Brian Godman,Debashis Basu,Yogan Pillay,Paulo H. R. F. Almeida,Julius C. Mwita,Godfrey Mutashambara Rwegerera,Bene D Anand Paramadhas,Celda Tiroyakgosi,Okwen Patrick,Loveline Lum Niba,Israel Sefah,Margaret Oluka,Anastasia N Guantai,Dan Kibuule,Francis Kalemeera,Mwangana Mubita,Joseph Fadare,Olayinka O. Ogunleye,Enos M Rampamba,Jeffrey Wing,Debjani Mueller,Abubakr Alfadl,Adefolarin A Amu,Zinhle Matsebula,Aubrey C. Kalungia,Trust Zaranyika,Nyasha Masuka,Janney Wale,Ruaraidh Hill,Amanj Kurdi,Angela Timoney,Stephen Campbell,Johanna C Meyer |
| ||Hospital Practice. 2020; : 1 |
|[Pubmed] | [DOI]|
A Ten-Year Review of the Pattern and Outcome of Childhood Diabetes in Two State Teaching Hospitals in South-West Nigeria
| ||Isaac Oludare Oluwayemi,Olusola Adetunji Oyedeji,Emmanuel Oluwatosin Adeniji,Adebukola Bidemi Ajite,Adefunke Olarinre Babatola,Adewuyi Temidayo Adeniyi,Ezra Olatunde Ogundare,Oladele Simeon Olatunya,Temitope Opeyemi Ayeni,Ayotunde Emmanuel Ajibola |
| ||Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2020; Volume 13: 4051 |
|[Pubmed] | [DOI]|
||Type 1 diabetes mellitus in Gabon. A study of epidemiological aspects
| ||Armelle Pambou Damiens,Patrice Serge Ganga –Zandzou,Pierrette Ntyonga-Pono,Simon Kayemba-Kayćs,Eudine Tsoucka-Ibounde,Eric Baye,Peggy Biloghe,Chantal Kakou |
| ||International Journal of Pediatrics and Adolescent Medicine. 2019; |
|[Pubmed] | [DOI]|
||Childhood diabetes mellitus in a rural tertiary hospital in North-West Nigeria
| ||UmmaAbdullahi Idris |
| ||CHRISMED Journal of Health and Research. 2018; 5(2): 123 |
|[Pubmed] | [DOI]|