Hussein Saadi

Randomized Controlled Trial (RCT) of Vitamin D Supplementation in Pregnancy in a Population With Endemic Vitamin D Deficiency

BACKGROUND Vitamin D (vD) deficiency in pregnancy is a global health problem and the amount of vD supplementation to prevent vD deficiency is controversial. OBJECTIVE The objective of the study was to determine effectiveness and safety of prenatal 2000 IU and 4000 IU/d compared with 400 IU/d vD3 supplementation in a randomized controlled trial in population in which vD deficiency is endemic. DESIGN/METHODS Arab women were randomized at 12-16 weeks of gestation to 400, 2000, and 4000 IU/d vD3, which were continued to delivery. Serum 25-hydroxyvitamin D [25(OH)D] concentrations were measured during pregnancy and at delivery. The primary outcome was the maternal and cord blood 25(OH)D, and the secondary outcomes were the achievement of sufficient serum 25(OH)D of 32 ng/mL or greater (≥80 nmol/L) at delivery. SETTING The locations were primary care and tertiary perinatal care centers. RESULTS Of 192 enrolled, 162 (84%) continued to delivery. Mean serum 25(OH)D of 8.2 ng/mL (20.5 nmol/L) at enrollment was low. Mean serum 25(OH)D concentrations at delivery and in cord blood were significantly higher in the 2000 and 4000 IU than the 400 IU/d group (P < .001) and was highest in the 4000 IU/d group. The percent who achieved 25(OH)D greater than 32 ng/mL and greater than 20 ng/mL concentrations in mothers and infants was highest in 4000 IU/d group. Safety measurements were similar by group and no adverse event related to vD supplementation. CONCLUSIONS Vitamin D supplementation of 2000 and 4000 IU/d appeared safe in pregnancy, and 4000 IU/d was most effective in optimizing serum 25(OH)D concentrations in mothers and their infants. These findings could apply to other populations in which vD deficiency is endemic.

Predictors and relationships of serum 25 hydroxyvitamin D concentration with bone turnover markers, bone mineral density, and vitamin D receptor genotype in Emirati women

OBJECTIVES To determine factors influencing serum 25 hydroxyvitamin D (25OHD) concentration and relationships between serum 25OHD concentration, bone turnover markers, bone mineral density (BMD), and vitamin D receptor (VDR) genotype in Emirati women. METHODS Serum 25OHD, parathyroid hormone (PTH), osteocalcin (OC), vitamin D binding protein (VDBP), and urinary deoxypyrdinoline (UDPD) concentrations and VDR genotype were determined in Emirati women volunteers who were participating in a study aiming at establishing a reference database for BMD. RESULTS Serum 25OHD concentration in the 259 women volunteers was 25.3 +/- 10.8 nmol/l (mean +/- SD), and all had vitamin D deficiency (25OHD <80 nmol/l). Mean serum 25OHD was highest in April (29.2 +/- 13.0 nmol/l), which marks the end of the short and cooler winter season, and lowest in August (18.2 +/- 5.9 nmol/l). No significant difference in 25OHD concentration was noted among Emirati women wearing different dress styles, but the mean serum 25OHD was significantly lower in comparison with non-Arab Caucasian women volunteers who dressed in a Western style (P < 0.001). Serum 25OHD correlated positively with age (r = 0.2), number of pregnancies (r = 0.16), dietary vitamin D intake (r = 0.15), serum calcium (r = 0.14), phosphorus (r = 0.14), VDBP (r = 0.15), and urinary calcium/creatinine (r = 0.2), and inversely with PTH (r = -0.22), OC (r = -0.13), and UDPD/creatinine (r = -0.15); P < 0.05 for all correlations. Multiple linear regression analysis showed that age, dietary vitamin D intake, multivitamin intake, and cooler season were independent positive predictors of serum 25OHD concentration (R(2) = 0.18). The frequencies of VDR genotypes were 36% GG, 44.1% AG, and 19.9% AA. Allele frequencies were 58% for G allele and 42% for A allele and were in Hardy-Weinberg equilibrium (x(2) = 1.44; P > 0.1). There was no statistically significant influence of VDR genotype on bone turnover or BMD. CONCLUSIONS Vitamin D deficiency is highly prevalent in Emirati women and appears largely attributable to insufficient sunlight exposure. It is associated with increased bone turnover. VDR genotype does not appear to influence bone turnover markers or BMD in Emirati women.

Association of TCF7L2 polymorphism with diabetes mellitus, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects

AIMS The prevalence of type 2 diabetes mellitus (DM) among Emirati subjects is one of the highest in the world. This has been attributed to rising prevalence of obesity acting on genetically susceptible individuals. We analyzed the associations between TCF7L2 polymorphism and DM, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects. METHODS We genotyped the two TCF7L2 single nucleotide polymorphisms (SNPs) rs12255372 and rs7903146 in 368 adult subjects. Homeostatic model assessment (HOMA) was used to assess beta cell function (HOMA2-%B) and insulin resistance (HOMA2-IR). The SNP genotypes were analyzed against disease stage [normal glucose=0 (n=188), pre-diabetes=1 (n=85), and DM=2 (n=95)] and against clinical and biochemical measures. Age and sex were included as covariates in all association analyses. Additional adjustments were made for body mass index (BMI) and waist circumference in several analyses. RESULTS Diabetes disease stage was marginally significantly associated with the frequency of the T variant at rs12255372 (p=0.057; adjusted p=0.017) but not at rs7903146 (p=0.5; adjusted p=0.2). Comparison between subjects with normal glucose and the combined DM/pre-diabetes showed a significant association with rs12255372 (OR 1.47, CI 1.04-2.08; p=0.03) but not with rs7903146 (OR 1.16, CI 0.81-1.64; p=0.4). We found no association with metabolic syndrome, or with insulin and glucose levels, HOMA2-%B or HOMA2-IR. The age-standardized prevalence rate for metabolic syndrome was 43.9% in men and 42.1% in women. CONCLUSION These data suggest that TCF7L2 variants are associated with increased risk for DM in Emirati subjects. We also demonstrate a high prevalence of the metabolic syndrome in this population.

Assessment of dietary practice among diabetic patients in the United arab emirates.

OBJECTIVES The aim of this study was to assess dietary practices and risk profile (hypertension, obesity, lipid profile and glycemic control) among people with diabetes in Al-Ain District, United Arab Emirates (UAE). METHODS During 2006, we performed a cross-sectional study of diabetic patients attending diabetic outpatient clinics at Tawam Hospital and primary health care centers in Al-Ain District. Subjects completed an interviewer-administered questionnaire, blood pressure, body mass index, percentage body fat and abdominal circumference were measured and recorded and the most recent HbA1c levels and fasting lipid profile were identified. RESULTS A sample of 409 diabetic patients was recruited, 50% of whom were illiterate. Only 24% read food labeling. 76% reported being unable to distinguish clearly between low and high carbohydrate index food items and no one reported counting calorie intake. 46% reported that they had never been seen by dietician since their diagnosis. Their overall risk profile, notably body weight, lipid profile and blood pressure, was very unfavorable; more than half of the study sample had uncontrolled hypertension and uncontrolled lipid profile and the majority was overweight (36%) or obese (45%). Abdominal obesity was particularly common (59%). Only 31% had an HbA1c of less than 7%. CONCLUSIONS The dietary practices of diabetic patients in the UAE are inadequate and need improvement.

Gonadal dysfunction and infertility in kidney transplant patients receiving sirolimus

Sirolimus is an immunosupressor of the mammalian target of rapamycin inhibitors (mTOR-I) group. Recent studies have emphasized a potential impact of sirolimus on male gonadal function. We report our clinical experience with sirolimus-induced gonadal dysfunction and infertility in both male and female kidney transplant patients. Of the 170 kidney transplant patients, nine (5.3%) patients (six males and three females) were receiving sirolimus. Follow-up data for two male patients were not available. The one unmarried female patient developed amenorrhea post-transplantation and had resumption of her menstrual cycles after discontinuation of sirolimus. The remaining six married patients (four males and two females), who all had fathered or conceived children in the pre-transplantation period, developed gonadal dysfunction and infertility on average 5–12 months after transplantation. Sirolimus was discontinued in all four male patients with full recovery of the oligo/azospermia and restoration of fertility. Both married female patients developed amenorrhea post-transplantation. Sirolimus was discontinued in one female patient with resumption of her menstrual cycles. In this small population of patients treated with sirolimus, the prevalence rate of reversible gonadal dysfunction and infertility was significant in both males and females. Infertility secondary to sirolimus is under-diagnosed and should be studied further.

A clinical trial of chronic care diabetic clinics in general practice in the United Arab Emirates: a preliminary analysis.

Control of diabetes mellitus is a high priority for primary health care systems. One innovative method of diabetes care delivery is the use of structured diabetes care in primary care. This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care. There is limited experience with this model in non-Western settings. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf. The study design used was a controlled before-after methodology. Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls. A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics, a diabetic flow chart, and educational programs for clinic nurses and doctors and patients. The study intervention took place over a period of 18 months with three diabetic outcomes (fasting blood glucose, blood pressure and cholesterol) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period. Knowledge and satisfaction questionnaires were also administered to intervention and control subjects at the end of the study. In this study, 219 subjects were enrolled (130 males and 89 females). They had a mean age of 51.6 years and a mean of 3.1 years of formal education. Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics. Subjects had diabetes for a mean of 7.8 ± 4.8 years and the majority was treated with pharmacological therapy. Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age (p = 0.01) and a trend for more males (p = 0.06) in the intervention clinics. There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied (fasting blood glucose, blood pressure and cholesterol) both in comparison to the control group before and after and within the intervention group. However most changes noted were in the expected direction of improvement; six of the seven guidelines were statistically improved in the intervention group when compared with the control group. Within the intervention group, adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement (fasting blood glucose measurements (p = 0.07) and urine determinations for protein (p = 0.07)). Knowledge questionnaire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group. The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care. The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement. The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries.

Physical Activity and Reported Barriers to Activity Among Type 2 Diabetic Patients in the United Arab Emirates

OBJECTIVES This study was designed to assess the physical activity practice among type 2 diabetic patients in the United Arab Emirates (UAE). METHODS This is a cross-sectional study of type 2 diabetic patients who participated in the outpatient clinics in Al-Ain District, during 2006. The patients completed an interviewer-administered questionnaire, and measurements of blood pressure, body mass index, body fat, abdominal circumference, glycemic control (HbA1c), and fasting lipid profile. RESULTS Of the 390 patients recruited, only 25% reported an increase in their physical activity levels following the diagnosis of diabetes, and only 3% reported physical activity levels that meet the recommended guidelines. More than half of the study subjects had uncontrolled hypertension (53%) and unacceptable lipid profiles; 71% had a high low-density lipoprotein (LDL), 73% had low high-density lipoprotein (HDL), and 59% had hypertriglyceridemia. Forty-four percent were obese and a further 34% were overweight. Abdominal obesity was also common (59%). Only 32% had an acceptable glycemic control. CONCLUSIONS The physical activity practice of type 2 diabetic patients in the UAE is largely inadequate to meet the recommended level necessary to prevent or ameliorate diabetic complications. Interventions aiming at overcoming the barriers to physical activity are urgently needed.

Cushing's syndrome caused by unsupervised use of ocular glucocorticoids.

OBJECTIVE To report a case of Cushings syndrome in an adult patient caused by prolonged and unsupervised use of glucocorticoid ocular drops. METHODS We present the clinical and laboratory findings and describe the clinical course of our patient. RESULTS A 33-year-old man with extensive ophthalmologic complaints and procedures, who had used glucocorticoid ocular drops for an extended period, was referred to the endocrinologist for new onset of type 2 diabetes mellitus. Clinically, the patient appeared cushingoid with a buffalo hump, thin skin, bruises, and purple striae, and his blood pressure was 130/90 mm Hg. Laboratory evaluation revealed a very low serum cortisol level with a concomitantly low-normal level of adrenocorticotropic hormone (corticotropin). In addition, the response to a corticotropin stimulation test was abnormal, an indication of suppression of the adrenal glands. After the patient discontinued the use of the glucocorticoid eyedrops, his cushingoid features gradually faded, and his blood pressure and serum glucose levels normalized. CONCLUSION Prolonged unsupervised use of glucocorticoid ocular drops may result in Cushings syndrome and its numerous associated complications. Physicians and pharmacists should be aware of this possibility and must educate patients about the potentially serious adverse effects of such use.

Prevalence of Undiagnosed Diabetes and Quality of Care in Diabetic Patients Followed at Primary and Tertiary Clinics in Abu Dhabi, United Arab Emirates

AIMS To investigate the prevalence of undiagnosed type 2 diabetes (T2D) at primary health care (PHC) clinics, and to assess the quality of care of diabetic patients followed at a tertiary hospital diabetes center in Abu Dhabi, United Arab Emirates (UAE). METHODS Between May 2009 and October 2010, adult patients attending two PHC clinics, and adult diabetic patients attending the diabetes center, were invited to participate in the study. After overnight fast, participants returned for interview and laboratory tests. Undiagnosed T2D was defined by FPG ≥ 7.0 mmol/l or HbA1c ≥ 6.5%. Quality of care was assessed by reported care practices and achievement of internationally recognized targets. RESULTS Out of 239 patients at PHC clinics without history of T2D, 14.6% had undiagnosed T2D, and 31% had increased risk of diabetes (FPG 5.6-7.0 mmol/l or HbA1c 5.7-6.5%). The independent predictors of undiagnosed T2D were age (adjusted OR per year 1.07, 95% CI 1.04-1.11, p < 0.001) and BMI ≥ 25 (adjusted OR 4.2, 95% CI 0.91-19.7, p = 0.033). Amongst all 275 diagnosed T2D patients, including those attending PHC clinics and those followed at the diabetes center, it was found that 40.1% followed dietary recommendations, 12% reported visiting a diabetes educator, 28.2% walked for exercise, and 13.5% attained recognized targets of HbA1c < 7%, blood pressure < 130/80 mmHg, and LDL cholesterol < 2.6 mmol/l. CONCLUSIONS Almost half of the adult patients attending PHC clinics had undiagnosed T2D, or increased diabetes risk. Care practices, and achievement of treatment targets, were suboptimal.

Screening strategy for type 2 diabetes in the United Arab Emirates.

The prevalence of type 2 diabetes mellitus (DM) among Emirati nationals is one of the highest in the world. The recently released United Arab Emirates National DM guidelines call for screening all adults aged 30 years and more. The authors explored the need for such a modification of current American Diabetes Association (ADA) guidelines. They also considered the prevalence rates for undiagnosed DM based on oral glucose tolerance test (OGTT) versus glycohemoglobin (HbA 1c) ≥ 6.5% in a population-based sample of 296 adult Emirati participants. In the low-risk ADA category, defined by age <45 years and BMI <25, only 1 of 68 (1.5%) participants was diagnosed with DM. The overall rate of DM based on HbA1c was lower than that based on OGTT (10.1% versus 14.2%; P < .05). The authors conclude that the ADA guidelines are adequate for screening in this high-risk population. They also find high discordance between HbA1c and OGTT.