Trends of Diabetes in Children and Adolescents in Pediatric Endocrinology Clinic and Clinical Pediatric Diabetes Center at Al Baha Central Hospital in Saudi Arabia

Objectives. This study describes and compares the epidemiological criteria of children with diabetes from 2007 to 2014. Methods. A prospective study conducted with 372 children with diabetes mellitus. An access program was used for data collection, and SPSS 17 was used to analyses the results. Results. A total of 372 cases with diabetes were studied and were divided into three groups according age. The first age group was between one day and six years and comprised 128 (34.4%) patients. The second group aged 712 years of age comprised 174 (46.7%) patients. The third group aged 13-18 years of age comprised 58 (15.59%) patients. The average age was 8.32 years. Females constituted 52 % (194 cases) of all cases. T1DM constituted 95.4%, equal to 355 patients, T2DM constituted 1.88%, equal to seven cases. Monogenic diabetes affected three patients or 0.79%, with one case of monogenic neonatal diabetes confirmed by genetic study, and two other cases suspected to be MODY. The highest incidence was observed in the autumn months, with 105 children affected, constituting 27.8 % cases. The year 2012 had the highest incidence rate, with 59 children and adolescents affected at an incidence rate of 25.48 / 100000.Al-Baha region had the highest number of cases constituting 37.7 % of cases. Diabetic ketoacidosis was the first presentation and constituted 44.2% of cases. Conclusion. Diabetes in children is increasing significantly in recent years, requiring more detailed analysis of its epidemiological factors to find out any significant correlations which may help in its prevention. DOI : COMING SOON Ahmed H. Alghamdi, Majida N. Nasaif , Ali S. Dammas , Jameel M Alghamdi, Riyadh A Alghamdi 2 1. Faculty of Medicine, Albaha University, Kingdom of Saudi Arabia. 2. King Fahad Hospital, Albaha, Kingdom of Saudi Arabia Corresponding author: Ahmed Hassan Alghamdi ,assistant professor of pediatric, Department of Pediatrics / College of medicine ,Albaha university, Consultant of pediatric endocrinology ,King Fahad Hospital in Al-Baha, P.O. Box ;204, Al-Baha, Kingdom of Saudi Arabia, Telephone: 00966 -7 – 7254000 ,Ext3621, Fax: 00966 -7-7253152, Email: ahs1401@hotmail.com


Introduction
Many types of diabetes can affect children, the most common being type 1 diabetes mellitus (T1DM) which results from cellular-mediated autoimmune destruction of the B-cells of the pancreas.T1DM has multiple genetic predispositions and is also related to environmental factors that are poorly defined.The incidence of Type 1 diabetes has been increasing worldwide for decades at an average annual rate of 3% [1].It represents approximately 10% of all cases of diabetes, represents 90% of all diabetes affecting children and affects approximately 20 million people worldwide (American Diabetes Association, 2001) (11).
It is rare in the first few months of life, with rising incidence starting from nine months of age until puberty.There are two age groups in the occurrence of T1DM, the first occurring at five years of age and the second at puberty.A seasonal variation has also been seen worldwide with a reduction of incidence in warm summer months.
Although the genetic susceptibility to type 1 diabetes is inherited, only 12-15% of type1 diabetes occurs in families.Girls and boys are almost equally affected.There is no apparent correlation with the poor socioeconomic status.DKA occurs in 20-40% of children with new-onset diabetes [1].
T1DM is characterized by the presence of auto This study aims to describe some of the epidemiological criteria of diabetes and the trend of the disease in children followed in the Department of pediatrics at King Fahad Hospital (KFH) in the diabetes clinic and the diabetes pediatric clinic in Diabetic Center.

Research and Methods
Our study settings included The Pediatric Endocrinology Clinic in KFH in Al-Baha, a 400 bed capacity, and pediatric clinic in the Diabetes Center in AL -Baha region in Saudi Arabia.The inclusion criteria included all the children and adolescents with diabetes and followed in the above settings as out-patients.

Discussion
Our results from this study shows that T1DM is the most common type of diabetes in children and adolescence less than 18 years old.It is more common in females, as well as being more common in both sexes in ages between 7 and 12 years (second age group).
These data are inconsistent with Kulaylat and Narchi (11).As well controversy, in AL-Herbash study, who mentioned no differences between the sexes (7).Moreover, the results ofBell showed that males are more affected, in contrast to our results (6).In this study, the females were found to be more represented than males in the first presentation with ketoacidosis with a 1.49:1 female to male ratio, similar to the Habib study (4), who observed a 1.4: 1 female to male ratio.
The mean age at presentation with T1DM was 8.324 years ranging from one month old to 18 years old, CI 95% (7.91 to + 8.73).The first presentation was with DKA in 44.2% of cases which is similar to the Habib study (4).This is a high percentage compared with other international studies, for example the study by Arleta Rewers (14).
Our study shows bimodal peaks through the year, with the first from mid-summer to the beginning of winter, and the second in spring.This result contrasts with the results of the Lorenzi study (3).Moreover, Moltchanova and DiMe (13,27), showed a single peak, mainly in the winter months.In the USA, T1DM diagnosis is least in summer time (26), which supports exploring factors other than viral infection, which is common in winter that may affect the seasonal distribution of the disease in Al-Baha area.
The increasing annual percentage of new cases attending the diabetes clinics, especially in the last three years, may reflect the general trend of the disease in Al-Baha area which correlates with international trend, sin URODIAB study group (8), Furthermore, (DiaMond) Project Group (9), and Taplin, (10), mention in their conclusion similar incidencesin Switzerland Italy as we report in this study (28).
The   most hot area compared with others which have adopted weather .
Our study shows that nephropathy was the most prevalent chronic microvascular complications.This finding is in contrast the UKPDS study, which previously reported that retinopathy is the most common complication (20,21).In our study, the obesity rate was 12.4% (46cases) which is less than study by Sandu, who reported an obesity rate of 29.5% (22).Finally, our study shows that the percentage of patients on intensive regimen withHbA1C 7.5and less was higher than those with a conventional regimen and is similar to the comparable studies by SEARCH and DCCT (24and 25).

Conclusion
In conclusion, the present study demonstrates the epidemiological features of T1DM.The principal focus of this study was to identify similarities with international.Although DKA is more prevalent at the first presentation in our study, this can be combined IA-2 and IA-2β], and islet cell antibody.The other common form of diabetes is T2DM, which mainly affects pubertal obese adolescents.The incidence of T2DM is increasing due to the increasing incidence of obesity in children, and now constitutes approximately 10% of all cases of diabetes in children.In addition to obesity, T2DM is associated with a family history of type 2 diabetes in first-or second-degree relative, race/ethnicity (e.g., Native American, African American, Hispanic/Latino, Asian American, and Pacific Islander), signs of insulin resistance or conditions associated with insulin resistance (e.g., a canthosis nigricans, hypertension, dyslipidemia, poly cystic ovarian syndrome (PCOS) , or small for gestational-age birth weight), and a maternal history of diabetes or gestational diabetic mellitus (GDM) during the child's gestation.The third type of diabetes is monogenic diabetes, which is increasingly being discovered because of the advances in genetic sciences, and now constitutes 1 -2 % of all diabetes in children.Monogenic diabetes is of two types: (1) Neonatal diabetes, which mainly affects infants below one year of age due to genetic mutations that impair insulin synthesis or excretion, and(2) Maturity onset diabetes of the young (MODY).

Figure IV :
Figure IV: T1DM and associated celiac disease according to sex

Figure VIII :
Figure VIII: Types of treatment regimens within a unified framework to answer scientific and clinical questions of diabetes in children.This study should be extended to involve all of the patients in other regional hospitals to give a better understand the epidemiology.Other factors, such as association with viral infection, vaccination history and vitamin D deficiency, could be included in this extension.Moreover, prevention of diabetic ketoacidosis and a reduction of its frequency among patients should be a goal in managing children with diabetes.This may in the future identify an effective treatment approach from the beginning before treatment even starts.Rising standards of medical information and general awareness of diabetes can contribute to this which may support the diagnosis of diabetes.

CC-license DOI : 10.14302/issn.2474-3585.jpmc-16-1281
patients were divided into three age groups: one month to six years of age, from seven to 12 years of age and from 13 to 18 years of age.(Note the age groups divided to this according to difference normal hormonal physiological change and category of international insulin dose etc).ResultsA total of 372 diabetic children and adolescents aged one month to 18 years were studied.The mean of age was 8.32 years, and the CI was 95% (+7.91 to + 8.73) with p value < 0.001.The diabetic center and the pediatric clinic were the main source of the target population.Therefore, the incidence rate and prevalence represent the incidence rate and the prevalence in the Al -Baha area.The average incidence rate was 8.6/100000, among a total population of 231,474 children and adolescents aged18 years and younger.The highest incidence rate was 59 children in 2012, and it was 25.48/100000, the lowest incidence rate was in 1996 and 1999, when one patient was affected, constituting 0.3%, as shown in figure I.The highest incidence was in autumn, and constituted 27.8 % of all cases (105cases), while winter surprisingly had the lowest incidence i.e 19.6 % of all cases (75cases).In this correlation with age, the first age group was the most affected from 1996 until 2004, after which the second age group presented as the most prevalent age group, as shown in figure I .Females were slightly more affected than males, constituting 52 % cases(194).Furthermore, in correlation to age groups, both females and males were more affected in the second was less than five years, and in 49.6% (184 cases) was more than five years.The remaining 2.1 %( eight cases) were of unknown duration.Correlating the duration of diabetes with the most prevalent chronic complications of diabetes (diabetic nephropathy) showed an incidence Freely Available Online www.openaccesspub.org|JPMC CC-license DOI : 10.14302/issn.2474-3585.jpmc-16-1281Vol-1Issue 3 Pg.no.-12FigureI: Cases distribution according to years and sex Freely Available Online www.openaccesspub.org| JPMC CC-license DOI : 10.14302/issn.2474-3585.jpmc-16-1281Vol-1 Issue 3 Pg.no.-13 of 17.02% (32 cases) in those who had diabetes for more than five years.40.5 % (30cases) had DKA, with a significant p value 0.048, the correlation is significant at the 0.05 level (1tailed), as shown in table II.Consanguinity was present in 39.7% (148) of cases .Regarding family history of T1DM,41.1% (153cases) had positive family history of T1DM, p value 0.03,< 0.05.Regarding the family history of autoimmune diseases (thyroid diseases, celiac and adrenal),8.8%(55cases).A duodenal biopsy was performed in six patients who had celiac disease, which was positive in three girls and one boy, as shown in figure IV.Correlations were significant for all apart from obesity and overweight at the 0.01 level.36.95% of patients were obese or overweight, with non-significant p value of 0.4.Freely Available Online www.openaccesspub.org| JPMC CC-license DOI : 10.14302/issn.2474-3585.jpmc-16-1281Vol-1 Issue 3 Pg.no.-14 Figure II.Cases distribution according to diabetes types and age groups Figure III: Cases distribution according to 1 st presentation and age groups Freely Available Online www.openaccesspub.org| JPMC CC-license DOI : 10.14302/issn.2474-3585.jpmc-16-1281Vol-1 Issue 3 Pg.no.-15 presentation & mother education st Correlation between 1

Table I :
DKA as FIRST PRESENTATION correlated with MOTHER EDUCATION