Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion

Abstract

Background/Objectives: Most insulin-requiring diabetes patients in Ethiopia have an atypical form of the disease, which resembles previous descriptions of malnutrition-related diabetes. As so little is known about its aetiology, we have carried out a case-control study to evaluate its social and nutritional determinants. Subjects/Methods: Men and women with insulin-requiring diabetes (n ¼ 107), aged 18-40 years, were recruited in two centres, Gondar and Jimma, 750 km northwest and 330 km southwest of the capital, Addis Ababa, respectively. Controls of similar age and sex (n ¼ 110) were recruited from patients attending other hospital clinics. Results: Diabetes was strongly associated with subsistence farming, odds ratio ¼ 3.5 (95% confidence interval: 1.5-7.8) and illiteracy/low levels of education, odds ratio ¼ 4.0 (2.0-8.0). Diabetes was also linked with a history of childhood malnutrition, odds ratio ¼ 5.5 (1.0-29.0) the mother's death during childhood, odds ratio ¼ 3.9 (1.0-14.8), and markers of poverty including poorer access to sanitation (P ¼ 0.004), clean water (P ¼ 0.009), greater overcrowding (P ¼ 0.04), increased distance from the clinic (P ¼ 0.01) and having fewer possessions (P ¼ 0.01). Compared with controls, people with diabetes had low mid upper arm circumference, body mass index (BMI) and fat/lean body mass (Po0.01). In addition, men with the disease tended to be shorter, were lighter (P ¼ 0.001), with reduced sitting height (P ¼ 0.015) and reduced biacromial (P ¼ 0.003) and bitrochanteric (P ¼ 0.008) diameters. Conclusions: Insulin-requiring diabetes in Ethiopia is strongly linked with poor education and markers of poverty. Men with the disease have associated disproportionate skeletal growth. These findings point towards a nutritional aetiology for this condition although the nature of the nutritional deficiency and its timing during growth and development remains obscure.

2. Non-Traditional Forms of Diabetes Worldwide: Implications for Translational Investigation

“…Alemu and colleagues have described the phenotype of most insulinrequiring patients in two regions of Ethiopia as follows: lean, poor, peak age at diagnosis approximately 25 years, male preponderance, and no clinical evidence of structural pancreatic abnormalities. This phenotype resembles previous descriptions of the KRDY form of malnutrition-associated diabetes rather than classic "type 1" diabetes (5,23).…”

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia

“…We have previously reported from two centres in western Ethiopia where, although the incidence of T1DM was higher in the urban centres, the total number of cases in the surrounding rural areas was greater by a factor of two because of the great excess in the population A c c e p t e d M a n u s c r i p t numbers of the rural dwellers [9,11]. The T1DM phenotype in many developing countries differs from westernised societies.…”

“…As in other countries of sub-Saharan Africa, the maximum incidence of T1DM occurs in the 15-34 age group with a peak at the age of 25-29 years, and little diagnosed in the pre-pubertal period [9]. The typical patient presenting with severe symptoms requiring insulin treatment in rural Ethiopia is a young adult who is extremely poor, with evidence of chronic protein-calorie malnutrition, and skeletal disproportions that suggest nutritional problems dating from early childhood; there is a marked male preponderance in rural dwellers [9,11]. Therefore, the urban and rural groups in this audit were representative of their parent groups with respect to relative numbers and sex differences.…”

“…This report is on 544 T1DM patients who were screened and who represent approximately 80% of all rural T1DM and 80% of all urban T1DM cases followed up on a regular basis at the rural and urban clinics, respectively. They are also representative of their parent groups with respect to age and sex ratio; there is a welldocumented preponderance of males, especially in the rural group [9,11].…”

Diabetes in Africa - Puzzles and challenges

“…However, recent work for Ethiopia has strongly supported the existence of MRDM in a famine area in the north of the country. [1718] Though an association with malnutrition appears established, the true cause of MRDM remains unknown. As Tom Johnson (a well-known Kenyan diabetologist) observed over 20 years ago, MRDM is “a syndrome seeking clarity.”[19]…”