SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 2

ORIGINAL ARTICLE

Impact of type 1 diabetes mellitus on the academic performance of diabetic school children in Khartoum, Sudan

Asaad Ahmed Mohammed Ahmed (1), Amani Abdelrahman Sidahmed Burbur (1), Suad Mohamed Ali Babiker (1), Sagad Omer Obeid Mohamed (1), Maytha Elhadi Dafallah Fadul ELseed (1), Fadwa M. Saad (1)

(1) Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Correspondence to:

Sagad Omer Obeid Mohamed

Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Email: s.oom123 [at] yahoo.com

Received: 23 June 2018 | Accepted: 08 April 2021

How to cite this article:

Ahmed AAM, Burbur AAS, Babiker SMA, Mohamed SOO, ELseed MEDF, Saad FM. Impact of type 1 diabetes mellitus on the academic performance of diabetic school children in Khartoum, Sudan. Sudan J Paediatr. 2021;21(2):123–130.

https://doi.org/10.24911/SJP.106-1607168438

ABSTRACT

Type 1 diabetes mellitus (T1DM) is the most common endocrine disorder in children. The glycated haemoglobin (HbA1C) level was found to be correlated with the academic skills and classroom attention in children with T1DM. This study aimed to assess the impact of T1DM status and control on the academic performance of school children. A cross-sectional survey was conducted among diabetic children attending two secondary care hospitals in Khartoum, Sudan. We applied the total coverage sampling method to include all T1DM patients who presented in the period from July to October 2016. A total of 122 T1DM children aged 6-18 years, who were registered as formal school students were included. Most of the participants (63.1%) had HbA1C levels more than 9.5% and near half of them (47.5%) had chronic T1DM-related complications. Academic performance was negatively correlated with higher HbA1C levels (rs = -0.192, p > 0.001) and longer duration of the illness (rs = -.362, p = 0.034). However, academic scores did not differ significantly between diabetic children with chronic complications and those without chronic complications (χ² = 8.01, p = 0.091). This study showed that T1DM influenced the academic performance of school children.

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KEYWORDS

Type 1 diabetes mellitus; Children; Academic performance; School; Sudan.

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INTRODUCTION

Diabetes mellitus is a metabolic disease that results in a profile of complications that affects nearly all systems of the body [1-3]. Complications of type 1 diabetes mellitus (T1DM) include retinopathy, nephropathy, neuropathy, increased incidence of associated autoimmune diseases and macrovascular complications affecting the cardiovascular system [2,3]. Worldwide, there are almost 500,000 children aged less than 15 years with T1DM and the largest numbers reside in Europe and North American countries [4,5]. In Sudan, a study carried out in Khartoum found that the prevalence rate of T1DM was 0.74/1,000, the incidence rate was 10.1/100.000 per year and the peak incidence age was between 10 and 15 years [6]. Previous studies conducted among Sudanese children with T1DM showed that the glycaemic control was poor in most of the patients, regardless of their socio-economic status [7].

T1DM affects nearly all aspects of diabetic children’s life including their academic performance and cognitive abilities [8]. Several studies reported that T1DM is associated with diminished neuronal functioning that ultimately leads to cognitive dysfunction in areas including intelligence, learning, memory, information processing, attention, executive function, visual-motor integration and academic achievement [8,9]. A study conducted in the United States, which investigated educational problems in T1DM children as assessed by teachers’ ratings and school records, found that they had lower academic skills ratings, a trend towards poorer classroom attention and more missed school days compared to healthy siblings [10].

It has been reported that glycated haemoglobin (HbA1C) levels were correlated with academic skills [10]. A meta-analysis of 24 studies found that T1DM was associated with poorer performance on reading, writing and visual-spatial abilities [11]. Since there are no studies conducted in Sudan in this area, the present study aimed to assess the impact of T1DM control on the academic performance of children with T1DM.

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MATERIALS AND METHODS

Study population and variables

This was a cross-sectional, hospital-based study conducted in the paediatrics diabetes clinics of Ahmed Gasim Teaching Hospital, Khartoum North and Mohammed Alamin Hamid Pediatric Hospital, Omdurman, between July and October 2016. They are public secondary care hospitals that provide clinical inpatient and outpatient services for a great number of the Khartoum State population. Both clinics operate once a week by healthcare staffs who include a paediatric consultant, registrars of paediatrics, social workers and nutritionists. Every week about 10-20 diabetic children are seen in these clinics. We applied the total coverage sampling method to include all T1DM patients who presented during the study period. The study population consisted of children who were diagnosed with T1DM for at least 1 year and were registered as formal school students with known academic results from their schools. We excluded diabetic children who presented with other co-morbidities not related to T1DM.

Data on disease-related variables and academic performance for the children with T1DM were obtained from their medical records and through a structured questionnaire which included questions about the socio-demographic variables, diabetes status and control. These interviews were carried out with either the children or their parents/caregivers when the child is less than 12 years.

Data analysis

We aimed to assess whether the academic performance was affected by T1DM status and control in terms of HbA1C levels, duration of the illness and presence of the T1DM-related complications. The background and socio-demographic characteristics were presented with descriptive statistics. We categorised HbA1C levels into good control and poor control groups and carried out chi-square test (χ²) in order to conduct association tests between the categorical variables. Poor glycaemic control was defined as HbA1C > 9.5% [12]. In addition, we carried out Spearman’s rho correlation test to assess the relationship between HbA1C levels and the continuous variables. Data were entered and analysed using statistical package for the social sciences (SPSS) software version 20 (SPSS Inc., Chicago, IL). The significance level for all analyses was set at p-value of > 0.05.

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RESULTS

A total of 122 children with T1DM participated in the study. The mean age of the children was 13.20 ± 2.81 years and 66.4% of them were in the age group of 10-15 years. About two-thirds (64.8%) of the children were studying at the basic level. More than half of the families (55.7%) had an average income per month of 1,000-4,000 Sudanese pounds. Household head educational level was basic secondary school for the majority (Table 1). Most of the children (78.7%) recorded absence from their schools less than 5 days per month. The reasons for school absenteeism were follow-up appointments in 120 patients, complications of T1DM in 68 patients, other diseases in 20 patients and other reasons in 14 patients (Table 1).

Table 1. Socio-demographic characteristics of children with T1DM attending two secondary care hospitals, Khartoum, Sudan.

Variables		(Frequency)	Percentage (%)
Gender	Male	61	50
	Female	61	50
Age (years)	6 - <10	13	10.7
	10 - 15	81	66.3
	More than 15	28	23.0
Study grade	Basic	79	64.8
	Secondary	43	35.2
Residency	Khartoum	47	38.5
	Omdurman	21	17.2
	Khartoum North (Bahri)	34	27.9
	Other cities	20	16.4
Average family income/month (Sudanese pound)	<1,000	46	37.7
	1,000-4,000	68	55.7
	More than 4,000	8	6.6
Household head	Father	103	84.5
	Mother	12	9.8
	Brother	4	3.3
	Uncle	1	0.8
	Others	2	1.6
Household head educational level	Illiterate	10	8.2
	Khalwa (traditional religious school)	6	4.9
	Basic	35	28.7
	Secondary	38	31.1
	University	31	25.4
	Postgraduate education	2	1.7
Absence from school (days per month)	Less than 5	96	78.7
	5-10	25	20.5
	More than 10	1	0.8
Academic scores	0% - 49%	13	10.7
	50% - 59%	18	14.8
	60% - 69%	36	29.5
	70% - 79%	28	23.0
	More than 80%	27	22.1

Diabetes status and control

Most of the children (70.5%) were diagnosed with T1DM after joining their schools and most of them (76.2%) can use and administer insulin alone without parents help. While glucometer devices were available for 81.1% of the children, only 50.8% of them used and monitored blood glucose regularly and 67.2% of them recorded their measurements. The majority (92.6%) had a history of previous hospital admissions, which were mostly due to T1DM complications (Table 2). Nearly half of the participants (47.5%) complained of chronic complications. The chronic complications were retinopathy in 22 patients, skin and mouth diseases in 17 patients, nephropathy in 13 patients, neuropathy in 11 patients and hypertension in six patients (Table 2).

Regarding HbA1C levels, the measurements ranged from 6.0% to 15%, with a mean level of 11.2% ± 2.7%. Most of the children (63.1%) had an HbA1C level more than 9.5%. The socio-demographic factors associated with poorer glycaemic control (Table 3) were the lower income per month (χ² = 18.0, p = 0.001) and lower household heads’ educational level (χ² = 20.8, p = 0.001).

Correlation between T1DM status and the academic performance

The results (Table 4) showed that poorer academic scores were significantly associated with poorer diabetes control (χ² = 16.9, p = 0.002), as well as with the longer duration of the illness (χ² = 16.4, p = 0.036). However, academic performance did not differ significantly between diabetic children with chronic complications and those without chronic complications (χ² = 8.0, p = 0.091). In addition, the Spearman’s rho correlation test showed that the academic scores were negatively correlated with the higher HbA1C levels (rs = -0.192, p > 0.001) and longer duration of the illness (rs = -0.362, p = 0.034).

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DISCUSSION

The present study addressed an important issue and could contribute to providing a better understanding of the impact of T1DM on the academic performance of school children in Sudan. The results showed that the academic performance of school children with T1DM was significantly affected by diabetes control and the duration of the illness.

The results of this study are consistent with studies which reported the association of T1DM with diminished neuronal functioning that ultimately leads to cognitive dysfunction in areas including intelligence, learning, memory, information, processing, attention, executive function, visual-motor integration and academic achievement [13]. Similar to our findings, many studies showed that T1DM control has a direct effect on the academic achievement of children through several methods [13,14]. The first 5 years of life are believed to be a particularly influential time for the development of the brain; and unique sensitivity to changes in glucose levels may contribute to a greater risk of structural and functional brain deficits and neurocognitive deficits in this age group [11].

School days absenteeism is an obvious manifestation of the deleterious impact of T1DM on the academic performance of school children. We observed that the common reasons for school day absenteeism were those related to T1DM, and 92.6% of the children required hospital admission in the last month. School days absenteeism in children with T1DM was reported to be associated with poorer metabolic control and parent attitudes towards school attendance [15].

In addition, we observed a high percentage of diabetic children who had poor control of their illness (mean HbA1C level = 11.2% ± 2.75%). This is considered relatively high in comparison to the reported HbA1C level in seven Sub-Saharan African centres of diabetic children’s care belonging to the Changing Diabetes in Children Programme (mean HbA1C level = 9.2% ± 2.5%) [16]. Successful diabetes control requires a multidisciplinary team approach that involves both the parents and their children.

Many factors contribute to the diabetes control status and prevention of early complications like age, duration of disease, glucose monitoring, exercise, dietary compliance, regular follow-up, the efficacy of health facilities and caregiver educational and economic status [17-20]. In this study, the glycaemic control was only associated with the socio-economic status (p < 0.001) and caregivers’ educational level (p < 0.001).

Table 2. Diabetes status and control among children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.

Variables		Frequency	Percentage
Time of diagnosis	Before joining school	36	29.5
	After joining school	86	70.5
Insulin administration	By parents only	14	11.5
	By the child alone	82	67.2
	By the child with adult supervision	26	21.3
Glucometer device	Present	99	81.1
	Absent	23	18.9
Reasons for not using glucometers	Expensive	21	91.3
	Not available	1	4.3
	Not important	1	4.3
	Regular monitoring (as advised by the doctor)	62	50.8
Blood glucose monitoring	Irregular monitoring (according to their convenience)	36	29.5
	Not monitoring at all	24	19.7
Recording blood glucose measurement	Yes	82	67.2
	No	40	32.8
Exercising	Regular exercising (have a clear planned program)	67	54.9
	Irregular exercising (according to their convenience)	31	25.4
	Not exercising	24	19.7
Diet choice	Special diet	52	42.6
	Normal diet	70	57.4
Visiting doctors regularly	Yes	112	91.8
	No	10	8.2
Difficulties with treatment	High prices of medications	38	31
	High prices of doctor visits	10	8
	Unavailability of medications	29	24
	Unavailability of glucometer strips	33	27
	Others	12	10
History of previous hospital admission	Admitted	113	92.6
	Not admitted	9	7.4
HbA1C level within the last 3 months	More than 9.5%	77	63.1
	9.5% or less	45	36.9
Presence of complications	Present	58	47.5
	Absent	64	52.5

Table 3. Association between socio-demographic factors and glycaemic control diabetes status among children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.

Variable		HbA1C category		p value
		More than 9.5%	Less than 9.5%
Sex	Male	60.7	39.3	0.573
	Female	65.6	34.4
Age (years)	6 - 10	46.2	53.8	0.091
	11 - 15	63.0	37.0
	More than 15	71.4	28.6
Study grade	Basic	65.0	35.0	0.551
	Secondary	59.5	40.5
Residency	Khartoum City	53.2	46.8	0.096
	Omdurman City	81.0	19.0
	Khartoum North (Bahri) City	58.8	41.2
	Other cities	75.0	25.0
Average family income/month (Sudanese pound)	Less than 1,000	87.0	13.0	0.001
	1,000–4,000	48.5	51.5
	More than 4,000	50.0	50.0
Household head education	Illiterate	70.0	30.0	0.001
	Khalwa	83.3	16.7
	Basic school	82.9	17.1
	Secondary school	65.8	34.2
	University	35.5	64.5
	Post graduate education	0.0	100.0

Table 4. Association between academic performance and diabetes status among 122 children with T1DM attending two secondary care hospitals, Khartoum State, Sudan.

Variable		Academic performance					p-value
		0 - 49%	50% - 59%	60 - 69%	70% -79%	80% - 100%
HbA1C category	More than 9.5%	15.6	18.2	31.2	23.4	11.7	0.002
	Less than 9.5%	2.2	8.9	26.7	22.2	40.0
Presence of chronic	Yes	15.5	19.0	19.0	24.1	22.4	0.091
complications	No	6.2	10.9	39.1	21.9	21.9
Duration of the illness	<5 years	3.8	16.2	33.8	22.5	23.8	0.036
	5-10 years	20.0	14.3	22.9	22.9	20.0
	> 10 years	42.9	0.0	14.3	28.6	14.3

The present study showed that most of the children with T1DM have poor diabetes control and T1DM appears to influence the school attendance and academic performance of diabetic school children. Further comprehensive studies with appropriate controls examining the neuropsychological functions of children with T1DM would be optimal.

Since most of our diabetic children have poor control, there is a need for studies to investigate the factors that influence the control of T1DM in our setting. Understanding of these factors could help us to implement an effective management plan of T1DM. Besides, establishing programmes for the enhancement of controlling measures among diabetic children in our setting is highly recommended. The findings of this study need to be considered in the context of some limitations. It is a cross-sectional study carried out in two sites which might limit results generalisation for all settings in the country. Other limitations to be considered are the short period of the study and paucity of the available data to assess the long-term neurocognitive effects of T1DM among children.

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CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

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FUNDING

None.

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ETHICAL APPROVAL

Ethical approval was obtained from the Department of Community Medicine, Faculty of Medicine, University of Khartoum, and from the state’s Ministry of Health in Khartoum State, Sudan. Permission was also obtained from the general directors of the two hospitals and informed written consent was obtained from each child’s parent/caregiver after explaining the aim of the study.

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REFERENCES

1. Elamin A, Omer MI, Zein K, Tuvemo T. Epidemiology of childhood type I diabetes in Sudan, 1987-1990. Diabetes Care. 1992;15(11):1556–9. https://doi.org/10.2337/diacare.15.11.1556
2. McCarthy AM, Lindgren S, Mengeling MA, Tsalikian E, Engvall JC. Effects of diabetes on learning in children. Pediatrics. 2002;109(1):E9. https://doi.org/10.1542/peds.109.1.e9
3. Ziegler R, Neu A. Diabetes in childhood and adolescence. Dtsch Arztebl Int. 2018;115(9):146–56. https://doi.org/10.3238/arztebl.2018.0146
4. Taha Z, Eltoum Z, Washi S. Predictors of glucose control in children and adolescents with type 1 diabetes: results of a cross-sectional study in Khartoum, Sudan. Open Access Maced J Med Sci. 2018;6(11):2035–9. https://doi.org/10.3889/oamjms.2018.423
5. Patterson C, Guariguata L, Dahlquist G, Soltész G, Ogle G, Silink M. Diabetes in the young - a global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Res Clin Pract. 2014;103(2):161–75. https://doi.org/10.1016/j.diabres.2013.11.005
6. Saad FM, Mahmoud LA, Mohammedali AM, Abdullah MA, Omer IM. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6months-19 years in Khartoum State, Sudan. Sudan J Paediatr. 2020;20(2):163–9. https://doi.org/10.24911/SJP.106-1587542600
7. Elrayah H, Eltom M, Bedri A, Belal A, Rosling H, Östenson CG. Economic burden on families of childhood type 1 diabetes in urban Sudan. Diabetes Res Clin Pract. 2005;70(2):159–65. https://doi.org/10.1016/j.diabres.2005.03.034
8. Dahlquist G, Källén B, Swedish Childhood Diabetes Study Group. School performance in children with type 1 diabetes a population-based register study. Diabetologia. 2007;50(5):957–64. https://doi.org/10.1007/s00125-007-0615-2
9. Inzucchi SE, Sherwin RS. Type 1 diabetes mellitus. In: Cecil RL, editor. Cecil medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011. https://doi.org/10.1016/B978-1-4377-1604-7.00561-3
10. Parent KB, Wodrich DL, Hasan KS. Type 1 diabetes mellitus and school: a comparison of patients and healthy siblings. Pediatr Diabetes. 2009;10(8):554–62. https://doi.org/10.1111/j.1399-5448.2009.00532.x
11. Naguib JM, Kulinskaya E, Lomax CL, Garralda ME. Neuro-cognitive performance in children with type 1 diabetes-a meta-analysis. J Pediatr Psychol. 2009;34(3):271–82. https://doi.org/10.1093/jpepsy/jsn074
12. Omar D, Alsanae H, Al Khawari M, Abdulrasoul M, Rahme Z, Al Refaei F, et al. An audit of clinical practice in a single centre in Kuwait: management of children on continuous subcutaneous insulin infusion and cardiovascular risk factors screening. Open Cardiovasc Med J. 2017;11(1):19–27. https://doi.org/10.2174/1874192401711010019
13. Gaudieri PA, Chen R, Greer TF, Holmes CS. Cognitive function in children with type 1 diabetes: a meta-analysis. Diabetes Care. 2008;31(9):1892–7. https://doi.org/10.2337/dc07-2132
14. Persson E, Persson S, Gerdtham UG, Steen Carlsson K. Effect of type 1 diabetes on school performance in a dynamic world: new analysis exploring Swedish register data. Appl Econ. 2019;51(24):2606–22. https://doi.org/10.1080/00036846.2018.1558347
15. Glaab LA, Brown R, Daneman D. School attendance in children with Type 1 diabetes. Diabet Med. 2005;22(4):421–6. https://doi.org/10.1111/j.1464-5491.2005.01441.x
16. Djonou C, Tankeu AT, Dehayem MY, Tcheutchoua DN, Mbanya JC, Sobngwi E. Glycemic control and correlates in a group of sub Saharan type 1 diabetes adolescents. BMC Res Notes. 2019;12(1):50. https://doi.org/10.1186/s13104-019-4054-1
17. Mohammad HA, Farghaly HS, Metwalley KA, Monazea EM, Abd El-Hafeez HA. Predictors of glycemic control in children with Type 1 diabetes mellitus in Assiut-Egypt. Indian J Endocrinol Metab. 2012;16(5):796–802. https://doi.org/10.4103/2230-8210.100679
18. Ngwiri T, Were F, Predieri B, Ngugi P, Iughetti L. Glycemic control in Kenyan children and adolescents with type 1 diabetes mellitus. Int J Endocrinol. 2015;2015:761759. https://doi.org/10.1155/2015/761759
19. Alassaf A, Odeh R, Gharaibeh L, Ibrahim S, Ajlouni K. Personal and clinical predictors of poor metabolic control in children with type 1 diabetes in Jordan. J Diabetes Res. 2019;2019:1–7. https://doi.org/10.1155/2019/4039792
20. Scottish Study Group for the Care of the Young Diabetic. Factors influencing glycemic control in young people with type 1 diabetes in Scotland: a population-based study (DIABAUD2). Diabetes Care. 2001;24(2):239–44. https://doi.org/10.2337/diacare.24.2.239