Background
Diabetes mellitus (DM) is a worldwide health challenge and is present in every country. As
insulin is an important regulator of growth hormone-related factors, specifically insulin-like
growth factor (IGF-1) and insulin-like growth factor binding protein (IGFBP-3), disorders of
insulin production can result in poor growth. The decrease of insulin level in blood causes
decrease of production of IGF by the liver and decrease of IGFBP, which will result in poor
response to the growth hormone and poor growth. Malnutrition adds to the difficulty of diabetes
management, making appropriate insulin dosing more difficult and also contributing to decreased
IGF-1 production and poor growth. In Rwanda the prevalence of malnutrition under 5 years was
reported in the last DHS (demographic household survey) to be around 38%i
. Research done
among diabetic children concluded that the abnormalities in growth associated with DM are due
to reduced insulin use and are reversible with adequate insulin therapy [9,10]. A diabetic child
who is on appropriate treatment should have no impairment of growth. In this study, we assessed
the prevalence of stunting among a population of pediatric patients with diabetes. We examined
the distribution of glycated hemoglobin as a measurement of glycemic control among this
population and assess whether there was a correlation between the degree of stunting and the
glycemic control.
Method
This was a descriptive cross-sectional study done from September to December 2015 in
Rwanda.136 children and adolescents from 23 districts of Rwanda were included. Patients aged
1 to 18 years old and followed by Rwanda Diabetes Association through the project “Life for a
Child” were enrolled in the study. A written consent was obtained from participants and parents.
The study was approved by UR IRB and RDA ethic committee.
The weight was measured using digital scale. Standing height was measured without shoes, or, if
a child was unable to stand, the length was measured with a horizontal stadiometer. Weight and
height were plotted to WHO growth charts as weight for age and height for age. Stunting was
defined as height for age below -2 SD. Glycated hemoglobin, (HbA1c), was measured by a
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trained laboratory technician using a “Siemens DCA Vantage machine”. The previous HbA1c
were obtained from patient files. Interviews were used to code demographic and socio-economic
condition and access to and affordability of food, as well as clinical data. Data entry was done in
Epidata and analyzed by Stata 13.
Result
136 children and adolescents were enrolled in the study aged 2 to 18 years old with a mean age
of 15.5. In this group, 39.7% were male and 60.3% were female.
The prevalence of stunting was 30.9% among this population. The mean HbA1c was 9.7%, 28%
were well controlled with an HBA1c <7.5, whereas 41.2% had a poor glycemic control with
HbA1c of 10% or above with 24 (17.6%) having HbA1c >14%. Those with lower socioeconomic
status were better controlled. Total daily dose of insulin ranged from 0.4 to 1.7
IU/kg/day with a mean total daily dose of 0.8 IU/kg/day.
Regarding availability of meals, 4.4% report that they are able to have only one meal per day.
When parents were asked about their impressions of the nutrition their children / adolescent
received on a daily basis 34.6% admitted that the nutrition was not adequate, usually because of
poverty.
There was no association found between glycemic control and stunting. There was no association
found between stunting and duration of diabetes, age, parents being alive or not. Lack of
parental education to the secondary school level was associated with stunting. Districts Huye
(south) and Rusizi (south-west) were the first and second most affected district with respect to
stunting. Children who were not properly fed, according to the parent or the adolescent himself,
were likely to be stunted.
Conclusion
The prevalence of stunting among children and adolescent with diabetes mellitus type 1 was
high. There was no association between stunting and glycemic control, but there was an
association between stunting and poor socio-economic condition. One third of participants were
estimating their nutrition as inadequate
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because of affordability. While the study did not find an association between growth stunting and
level of glycemic control, it did find a high rate of poorly controlled diabetes in this population
with only one quarter being well-controlled based on HbA1c.