13J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 13–16 Original ISSN 2413-0516 Introduction Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases of childhood.1 Its incidence is rising world- wide,2 with reported increases of 2–5 percent per year in the Middle East.3 In Iraq, the incidence of T1DM in Basra City is 5–9.99/100,000 per year and was increasing between 2012 and 2016.4 Similarly, in Al-Nassiryah City the incidence was also increasing in the last 5 years,5 and with the existence of only a few national/regional diabetes registries available to support diabetes research, provide reliable data, and help cope with the widespread threat of this disease, there is a need for establish- ing a population-based Arab diabetes registry.6 Most children with T1DM grow normally, however, poor glycemic con- trol can result in poor linear growth, poor weight gain, and/ or delayed skeletal development. Conversely, treatment with excessive insulin and/or excessive caloric intake can lead to excessive weight gain. And if obesity develops, this can lead to insulin resistance, which complicates diabetes management.7 Purpose of the Study To estimate the prevalence of T1DM in primary school chil- dren in Baghdad City, and to evaluate its effect on growth of those children. Material and Methods This is a comparative cross-sectional study that was conducted in primary schools in catchment area of 12 primary health care centers (PHCCs) in Al-Karkh side of Baghdad City, selected by multistage cluster sampling (Fig. 1), during the period of Feb 15, 2018–May 1, 2018. The study population included all primary school students in the selected PHCCs (all T1DM students in these schools and an equal number of children from the same class and same gender who were T1DM- free were included). Research was done in Al-Karkh side of Baghdad/Iraq in 141 school in the territory of the following PHCCs: Name of PHCCs: Number of schools which covered by local PHCC: (Al Khadhraa PHCC: 8, Al Jamieaa PHCC: 17, The martyr Saif Zakie PHCC: 16, Al Gazalia the first PHCC: 8, Al Dakhilia PHCC: 17, Al Mansoor exemplary PHCC: 14, Martyrs of Alchalijia PHCC: 4, Al Yarmouk PHCC: 13, Al Huriya exemplary PHCC: 12, Al Jawadin exemplary PHCC: 9, Al Zahraa exemplary PHCC: 7, The new Iraq PHCC: 16). School children with any other chronic disease or comorbid- ities were excluded from the anthropometric measures only. Data Collection Tools Two different types of questionnaires had been used. The first questionnaire was filled by the researcher through direct inter- view with the primary school teachers. It included questions to gather information on certain student variables, and the anthropometrics’ measures; the Centers for Disease Control Epidemiological profile of type 1 diabetes among primary school children in Baghdad, Iraq Sarah Hayder Zalzala,a Faris H. Al-Lami,b Khalid Saeed Fahadc aAl-Karkh Directorate of Health, Ministry of Health, Baghdad, Iraq. bCommunity and Family Medicine Department, College of Medicine, Baghdad University, Baghdad, Iraq. cDepartment of Internal Medicine, College of Medicine, Al-Nahrain University, Baghdad, Iraq. Correspondence to: Sarah Hayder Zalzala (email: sarahhaider1988@gmail.com). (Submitted: 23 November 2019 – Revised version received: 02 December 2019 – Accepted: 12 January 2020 – Published online: 26 February 2020) Objectives To estimate the prevalence of type 1 diabetes mellitus in primary school children in Baghdad City, and to evaluate its effect on growth of those children. Methods This comparative cross-sectional study was conducted in a sample of primary schools in Baghdad city selected by multistage cluster sampling. All primary school students in the selected schools were included. For every diabetic child, we selected a child from the same class who is free from diabetes. Information on disease variables were obtained through sending questionnaire to the children’s parents. The Centers for Disease Control and Prevention growth charts were used. Results The total number of primary school students in the selected 141 schools was 69,115; 110 of them had T1DM (159/100,000). Female to male ratio was 1.3:1. Obesity and underweight were significantly lower in diabetics than non-diabetic children (P=0.03). Conclusion The prevalence of type 1 diabetes mellitus was 159 per 100,000, which was approximate to the prevalence in Saudi Arabia, less than that in Al-Kuwait, but higher than that in Turkey. Percentage of underweight and obesity were lower in the diabetics while overweight percentage was slightly higher compared to the non-diabetics. Keywords type 1 diabetes, primary school children, prevalence, obesity, underweight Fig. 1 Multistage cluster sampling. 14 Original Epidemiological profile of type 1 diabetes among primary school children Sarah Hayder Zalzala et al. J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 13–16 and Prevention (CDC) growth charts were used.8The second questionnaire is translated to Arabic language and was sent to parents of the diabetic group only, to gather information about disease variables: Clinical presentation for DM (classic new onset of chronic polydipsia, polyuria, and weight loss); diabetic ketoacidosis; or asymptomatic incidental discovery,9 the duration of DM in year(s), the age at onset of diabetes (early onset diabetes has been variously defined as occurring any- where from age 4 to age 7 years,10 blood glucose monitoring (less than four, four, or more than four times per day) and whether a glucometer in the house was available or not, family history of T1DM, the no. of follow up visit(s) for PHCC, Diabetic cen- ter or private doctor in the last 6 months (routine follow-up should be performed at least four times a year,11 number of ER visits and hospital admission in the last 6 months, and the value of the last HbA1C test for each child were all inquired. The statistical software (Statistical Package for the Social Science, release 11.0 for Windows; SPSS; Chicago, IL) was used for data entry and analysis. Descriptive statistics were used to summarize subject characteristics and questionnaire results. Chi-square test of independence was used to test qual- itative and frequency data. P-value of <0.05 was considered significant. A written informed consent was obtained from parents of each enrolled student. All personal information was kept anonymous. Administrative approval was granted from research committee in Ministry of Health, Iraq. Result The total number of primary school students in the selected 141 schools was 69,115; 110 of them had T1DM. The highest prevalence of diabetes was in Al Mansoor exemplary PHCC (338 per 100,000) while the overall prevalence of diabetes was 159 per 100,000. The proportion of female was slightly more than male with female to male ratio of 1.3:1, diabetics’ age ranged 6–14 years old. The distribution of the diabetics according to age, sex, and disease variables is shown in Table 1. The distribution of the study group according to anthropo- metric measures is shown in Table 2. Table 1. Variables No. (n=105) Percentage (%) Age (year) 6-8 23 21.9 9-11 56 53.3 ≥12 26 24.8 Sex male 46 43.8 female 59 56.2 Clinical presentation for DM Classic new onset 52 62.7 Diabetic ketoacidosis 15 18.1 incidental discovery 16 19.2 Duration of DM (years) <3 44 53.0 3-6 30 36.2 ≥7 9 10.8 Age at onset of diabetes (years) <7 53 63.9 ≥7 30 36.1 The availability of glucometer in the house Yes 73 88.0 no 10 12.0 Blood glucose monitoring (No. of times per day) <4 56 67.5 ≥4 27 32.5 Table 2. Distribution of study group by anthropometric measures. Variable Diabetics Nondiabetics Chi square P value BMI percentile No.(n=102) Percentage (%) No.(n=105) Percentage (%) <5 2 2.0 9 8.6 8.929 0.030 ≥5 and <85 76 74.5 66 62.9 ≥85 and<95 17 16.6 14 13.3 ≥95 7 6.9 16 15.2 Weight for age percentile <5 5 4.9 2 1.9 3.243 0.198≥5 and ≤ 95 91 89.2 91 86.7 > 95 6 5.9 12 11.4 Height for age (percentile) <5 10 9.8 2 1.9 5.931 0.052≥5 and ≤ 95 89 87.2 100 95.2 > 95 3 3.0 3 2.9 15 Original Epidemiological profile of type 1 diabetes among primary school childrenSarah Hayder Zalzala et al. J Contemp Med Sci | Vol. 6, No. 1, January–February 2020: 13–16 The majority of patients (62.7%) were diagnosed by clas- sic symptoms of diabetes. The mean for duration of DM was 3.9 ±2.4 (SD) years and 63.9% have DM before the age of 7 years. Around 10% of children didn’t have follow-up visit at all, 50% of them had at least one hospital admission and fre- quent attacks of hypoglycemia in the last 6 months. Only 1 of them had documented HbA1c value which was 13%. Among the reminder 90% whom had gone for follow-up visit, 14.5% had 1 visit, 13.3% had 2 visits and 62.6% had >2 visits per 6 months. According to where they went for follow-up, 75.9% visited a private doctor and only 54.2% of children had docu- mented HbA1c result. Discussion The prevalence of T1DM has been reported to vary greatly among different countries, within countries, and among dif- ferent ethnic populations.12 Recently, a study reported that the prevalence and incidence of T1DM were found to be variable among the Arabs.6 This study showed that preva- lence of diabetes in primary school children in Baghdad was 159 per 100,000, which was higher than Basrah where prev- alence rate was 87 per 100,000,4 despite the age group sam- ple was much wider than this study (all ≤40 years old), but these findings were based on a retrospective data analysis of electronic archives for patients with T1DM registered in Faiha Specialized Diabetes, Endocrine, and Metabolism Center, which is a tertiary referring Center in Basrah. The prevalence of T1DM was 269.9 per 100,000 among 6–18-year-old Kuwaiti children,13 while it was 109 per 100,000 in Saudi Arabian chil- dren (7–12 years old)14 which is approximate to our results. Lower prevalence found in children who lived in the Nile Delta region of Egypt (26.8 per 100,000)15 and school children living in Istanbul, Turkey, (67 per 100,000).16 These variations might be due to the variation in the incidence of T1DM as it varied based upon geography, age, gender, family history, and ethnicity.7 When people relocate from a region of low to high incidence, their risk of developing T1DM also increases, sug- gesting a causative role for environmental factor(s). However, wide variations in incidence occur between neighboring areas of similar latitude, suggesting the presence of other contrib- uting risk factors and demonstrating the complexity of the pathogenesis of T1DM.7 A study found that there is consid- erable variation among Arab countries, which could not be explained on genetic or climatic variations alone, other envi- ronmental factors particularly nutritional ones including high intake of dairy products and vitamin D deficiency are possibly operating.17 The proportion of female was slightly more than male, which agreed with two studies as prevalence for T1DM slightly favors females in Australia,18 and Japan,19 but disagree with another study which slightly favors males in the USA,20 and it was near parity in North-West England.21 The lifetime risk of developing T1DM is significantly increased in close rel- atives of a patient with T1DM.22 In this study, around 30.1% of diabetics had family history of T1DM (aunts and uncles were included), as they found that 10%–20% of newly diagnosed childhood cases of T1DM have an affected first-degree rela- tive,2 and familial history was more than 20% when account- ing for the extended family history.23 The higher percentage of underweight in the non-diabetics group might be due to the primary cause of poor weight gain in school-aged children and adolescents which is inadequate dietary intake relative to typical metabolic and growth needs.24 Children may ingest too much juice or other non-nutritious liquid, resulting in satia- tion and decreased appetite for higher caloric density or more nutritious solid foods,25, 26 while these beverages might be more restricted in the diabetics, and these results is approximate to Turkish study as they found that rates of overweight and obesity were 21.2% and 14.6% (35.8% combined), using the WHO growth curve,27 compared to 13.3% and 15.2% (28.5% combined) in this study. About 2% of diabetics were under- weight, 74% normal, 16.6% overweight and 6.9% obese, which agreed with a Canadian study as they found that Children with T1DM are more overweight, but not more obese.28 An Australasian study showed that the prevalence of being over- weight was 19% and of obesity was 6%,29 and another study where none of the study subjects were underweight, 69% were within the normal weight range.30 The challenges for main- taining healthy weight associated with T1DM include weight gain as the result of supra-physiological insulin doses, and overeating to avoid or treat hypoglycemia.29 Another study showed that pre‐ and post‐onset body mass index in children with T1DM were both well above the population mean, were closely correlated with each other and (inversely) with age at onset.31 Proper attention to diet is a major factor in minimiz- ing hypoglycemia and weight gain while achieving glycemic control.32 The majority of patients were diagnosed by classic symptoms of diabetes which agreed with another Iraqi study.33 Although routine follow-up should be performed at least four times a year,11 about 10% of parents didn’t go for follow-up visit at all, 50% of those had at least one hospital admission and frequent attacks of hypoglycemia in the last 6 months and only 1 of them had documented HbA1c value which was 13%. Cardwell et al found that patients attending less than four dia- betes clinics in the last year had a significantly higher HbA1c level compared to those attending exactly four clinics level.34 Acknowledgments Authors would like to express deepest thanks for all the staff in the selected Primary Health Care Centers and Primary Schools for their generous help and support during the time of this project, especially to: Dr. Zainab, Al Dakhilia PHCC. Mrs. Shatha, Al Jawadin exemplary PHCC. I would like to apologize gratefully to all those people who helped me to complete my work without being able to mention them by names. Conflicts of Interest Disclosure: None References 1. Levitsky LL, Misra M, Wolfsdorf J, Hoppin A. Management of type 1 diabetes mellitus in children and adolescents. Complications and screening in children and adolescents with type. 2011;1. 2. Tuomilehto J. The emerging global epidemic of type 1 diabetes. Curr. Diab. 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This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. dx.doi.org/10.22317/jcms.02202003