INTRODUCTION Mortality analysis based on a single cause of death is not, in most cases, fully informative. There are several more illuminating procedures using a multiple cause of death approach; these are little known and rarely used in Cuba. The simplest of these methods, while methodologically limited, consists of summing all deaths from a specific cause mentioned on death certificates, regardless of whether the cause is listed as underlying or contributing.

OBJECTIVE Using Cuban data, critically assess and implement two of the most recognized approaches to analyzing multiple causes of death.

METHODS Multiple causes of death in Cuba were assessed for the years 2005, 2010 and 2015, employing death records from the National Medical Records and Health Statistics Bureau of Cuba’s Ministry of Public Health. With the example of diabetes mellitus as underlying cause, we explored connections between underlying and associated (antecedent and contributing) causes on death certificates using two approaches from the international literature: the simple method and the cause-of-death association indicator.

RESULTS The study identified main trends in multiple causes of death identified in 2005, 2010 and 2015, overall and by age group and sex. We observed a trend to increasing mean number of causes of death per death certificate between 2005 and 2015. The number of causes reported showed no substantial differences by age group or sex. Diseases of the arteries, arterioles and capillaries were by far the most frequently associated with diabetes mellitus as underlying cause.

CONCLUSIONS The multiple causes of death approach affords more nuanced understanding of patterns of disease, comorbidity and death in the Cuban population. The indicators used fulfill different roles: the simple method brings to light the full range of ways in which a given cause contributes to mortality, and the cause-of-death association indicator enables exploration of links between different causes of death, not possible with the simple method.

KEYWORDS Mortality, multifactorial causality, causes of death, diabetes mellitus, Cuba

INTRODUCTION Shifts in diabetes onset to earlier ages, globally and in Cuba, signify greater risk of early complications and premature death, with consequent economic and social repercussions for families and health systems.

OBJECTIVE Describe the trend in diabetes burden in Cuban children and adolescents in the period 1990 to 2010, in terms of disability-adjusted life years.

METHODS A descriptive epidemiological study was conducted of diabetes burden in Cuba, analyzing the years 1990, 1995, 2000, 2005 and 2010 for the age group 0–19 years. Disability-adjusted life years were obtained from the sum of potential years of life lost plus years lived with disability. The first is calculated based on total deaths in the country in which diabetes was recorded as underlying cause; the second from the product of severity, as assigned to diabetes in similar studies, and incidence and average duration, provided by the DISMOD II program, which estimates six internally consistent epidemiological indicators.

RESULTS Mortality indicators improved, with a decrease in the rate of potential years of life lost in boys from 21.9/100,000 population in 1990 to 0 in 2010, and in girls from 38.8/100,000 in 1990 to 4.9/100,000 in 2010 (1% of disability-adjusted life years in girls in 2010, corresponding to one death). In contrast, years lived with disability increased by 134.5% in boys and 156.4% in girls. The net result was that disability-adjusted life years increased by >100% in both sexes (from 137.2 to 321.9/100,000 in boys and from 157.3 to 403.3/100,000 in girls, increases of 102.3% and 108.1%, respectively).

CONCLUSIONS Disability-adjusted life years lost for diabetes in Cuban children and adolescents have increased, due to disability, while mortality has decreased.

KEYWORDS Diabetes mellitus, childhood, adolescence, disability-adjusted life years, potential years of life lost, years lived with disability, Cuba

Se describe la creación, el desarrollo, la ampliación y la organización del Programa Nacional de Atención Integral a la Gestante con Diabetes, así como los cambios ocurridos en los servicios de salud desde 1959. Actualmente, el Programa se encuentra implementado en todo el país y es supervisado por un grupo de trabajo que aborda la salud reproductiva de la mujer con diabetes y su atención durante la gestación. Se destaca la importancia de la atención preconcepcional a la mujer con diabetes, la necesidad de generalizar el Programa a nivel nacional y de pesquisar la diabetes gestacional en la atención primaria de salud.

PALABRAS CLAVE: Diabetes mellitus, diabetes en el embarazo, gestación en la mujer diabética, diabetes gestacional, atención preconcepcional, resultados de la gestación, complicaciones de la gestación, gestación de alto riesgo, atención prenatal, pesquisa, Cuba

Education at the community level is indispensable for control of chronic non-communicable diseases and comprehensive patient care, with diabetes mellitus a case in point. The need is even more pronounced for type 1 diabetes, affecting children and adolescents. Families of diabetic adolescents naturally worry about vulnerability to sexually transmitted diseases, which create risks for glycemic control and the adolescent’s health. We felt compelled to explore the issue of sexuality in diabetes education for adolescents, because education can do more than help maintain metabolic control; it can contribute to keeping diabetic children and adolescents on a healthy developmental curve, when combined with the other pillars of diabetes management. Accordingly, we carried out an educational intervention to increase type 1 diabetic adolescents’ knowledge of sexuality and sexually transmitted infections. Participants were 20 adolescents in Camagüey Province’s central clinic for type 1 diabetes patients. A six-session educational program was developed and implemented. Responses to a questionnaire before and after the program revealed that prior to the intervention only 3 of 20 participants (15%) demonstrated satisfactory knowledge of the material covered (≥70%), increasing to 20 (100%) after completion of the program.

KEYWORDS Sex education, adolescents, diabetes mellitus, sexually transmitted infections, Cuba

INTRODUCTION With 333 million cases worldwide predicted for 2015, type 2 diabetes mellitus presents an important global health challenge. Its rising tide calls for health policies emphasizing prevention at the primary care level, including public education as well as early risk identification and intervention.

OBJECTIVES Estimate risk of developing type 2 diabetes in persons with no known glucose abnormalities, registered in a primary care setting in Pinar del Río city, Cuba, using FINDRISK.

METHODS A descriptive, cross-sectional study applied FINDRISK to 620 persons aged ≥18 years randomly selected from a universe of 1058 patients with no known glucose abnormalities, registered in family-doctor-and-nurse office No. 23 in the Turcios Lima Teaching Polyclinic health area, Pinar del Río city.

RESULTS The study population was predominantly aged ≤45 years (53.5%) and 80.2% was overweight or obese. At least moderate risk of diabetes was found in 74.4% of the sample, and 10.5% was at very high risk, meaning an estimated 120 patients in the sample could be expected to develop type 2 diabetes within the next 10 years.

CONCLUSIONS Type 2 diabetes prevalence can be expected to increase substantially in this population over the next decade. We recommend design and timely implementation of intensive lifestyle change programs to eliminate or slow development of type 2 diabetes in at-risk individuals. We propose following cohorts identified by FINDRISK to assess its prognostic value in the Cuban population.

KEYWORDS Diabetes mellitus, risk factors, risk prediction, prevention, Cuba

Hyperglycemia characteristic of diabetes mellitus triggers pathological processes in fetal development of various structures such as the retina, peripheral nerves, renal glomerulus, and arterial and venous beds. Women with diabetes prior to conception have children with birth defects three to five times more frequently than women without diabetes. There is no specific pattern of birth defects, but the central nervous and cardiovascular systems are the most affected. Hyperglycemia leads to mitochrondrial superoxide radical production, which activates five metabolic pathways that mediate damage leading to diabetic embryopathy. Once oxidative stress is established, there is modification of gene expression controlling embryonic development in critical periods. Vitamin E application in animal models has greatly lowered occurrence of birth defects in embryonic and fetal stages, consistent with an etiologic role for oxidative stress in dysmorphogenesis. Effective metabolic control before and during pregnancy, achieved in Cuba by implementing programs for control of birth defects in children of diabetic pregnant women, has been found effective.

KEYWORDS Diabetes mellitus, hyperglycemia, oxidative stress, gene expression, glucose metabolism disorders, congenital abnormalities, birth defects, Cuba

Cardiovascular disease is the main cause of death for diabetics, and in many cases its presence is silent due to cardiac autonomic neuropathy. Thus, early diagnosis of coronary disease is essential, permitting proper risk stratification and appropriate therapy. This paper examines the usefulness of several noninvasive imaging techniques to study cardiovascular diseases in individuals with diabetes mellitus, with emphasis on nuclear cardiology, and proposes a diagnostic algorithm for detection of silent ischemia.

Keywords Myocardial perfusion scintigraphy, myocardial perfusion imaging, radionuclide imaging, diabetes mellitus, silent myocardial ischemia, Cuba

INTRODUCTION Diabetes in pregnancy threatens both maternal and neonatal health, with risks of lung immaturity, fetal macrosomia, dystocia and impaired maternal kidney function. Before insulin, diabetes resulted in maternal mortality rates of 30–50% and perinatal mortality rates of 50–60%. Global prevalence estimates vary by population, geographical area and diagnostic criteria. Diabetes accounts for some 90% of endocrine complications in pregnancy.

OBJECTIVES Determine diabetes mellitus prevalence in pregnancy and characterize the population of diabetic women who gave birth in the Isle of Youth Special Municipality in 2008.

METHODS A descriptive retrospective study was carried out from January to December 2008. Clinical records were reviewed of 180 diabetic women who gave birth on the Isle of Youth in 2008, their diagnosis based on WHO criteria modified by municipal health authorities. Study variables were: maternal age, nutritional status, glucose tolerance, gestational age at diagnosis, history of diabetes, and pregnancy outcome; as well as risk factors such as diabetes family history, pregnancy weight gain and comorbidities.

RESULTS Overall prevalence (pregestational and gestational diabetes) among these cases was 17.3%; highest in the group aged ≥35 years. Gestational diabetes was more frequent (96.1% of cases) than pre-gestational diabetes. Multiparity (62.1%), a first-degree family history of diabetes mellitus (26.1%), excess weight before pregnancy (50%) and adequate weight gain during pregnancy (54.4%) were the most frequent conditions found. Among gestational diabetics, diabetes was most frequently detected at 20–28 weeks gestation (31.8%). Fetal macrosomia appeared in 4.4% of cases and a high percentage of deliveries were by Cesarean section (30%). There were no low Apgar scores or congenital abnormalities among neonates.

CONCLUSIONS Despite using modified, more inclusive, WHO diagnostic criteria, the clinical and demographic characteristics of the population studied were comparable to those in other studies of diabetes in pregnancy, except for the low frequency of fetal macrosomia and absence of birth defects present in our study.

KEYWORDS diabetes mellitus, pregnancy, risk factors, diabetes, gestational

Introduction Obesity is a social disease constituting a global pandemic. It is present in 90% of diabetic and 65% of hypertensive patients. It is associated with cardiometabolic syndrome and with damaging physiopathological mechanisms, particularly for the vascular system and the kidneys. On Cuba’s Isle of Youth, a community-based epidemiological study of chronic kidney disease (CKD), hypertension (HTN), diabetes mellitus (DM) and cardio-cerebral vascular disease was carried out in total population, including an examination of common risk factors.

Objective Based on the Isle of Youth Study (ISYS) data, determine prevalence of obesity and overweight, and their association with CKD, HTN, DM, and shared risk factors for all these conditions in total population of the Isle of Youth, Cuba.

Methods Phase 1: Population diagnosis (November 2004-April 2006): 96.6% of the Isle of Youth’s total population (80,117) was studied, including all ages and both sexes. Information was offered to the public, and written informed consent obtained. Screening was conducted by participant questionnaire including risk factors, physical measurements (weight, height, blood pressure and body mass index), and a single first-morning urine sample to determine the presence of vascular-renal damage markers – proteinuria and hematuria (Combur 10 Test, Roche), and microalbuminuria (Micral Test, Roche). When results were positive, serum creatinine was determined and glomerular filtration rate (GFR) estimated with Modification of Diet in Renal Disease (MDRD) formula for adults and Schwartz formula for children <15 years. Data obtained were analyzed to determine association of participants’ nutritional status with prevalence of chronic kidney disease, hypertension and diabetes mellitus, as well as a set of common risk factors.

Results Population <20 years: Obesity prevalence 3.2%; positive urine markers in 56.9% of obese and 8.9% of non-obese participants; positive albuminuria in 38% of obese and 3% of non-obese. Obese participants were found to be hyperfiltrating. DM prevalence was 9.5% in obese and 1.1% in non-obese participants. Population ≥20 years: Overweight, 31.3%; obese, 13.4%. Positive markers in normal-weight, overweight and obese individuals were 18.3%, 21.2% and 32.7%, respectively; microalbuminuria values increased with weight. Obese individuals were found to be hyperfiltrating. HTN prevalence in normal-weight, overweight and obese individuals was 18.3%, 31.5%, and 51.0% respectively; DM rates were 2.8%, 5.2% y 11.3%, respectively.

Conclusion In Cuba, obesity poses significant risk for vascular and renal damage and should be the focus of increased prevention efforts.

Keywords Vascular diseases, chronic kidney disease, CKD, chronic kidney insufficiency, hypertension, diabetes mellitus, risk factors, obesity, overweight, body mass index, glomerular filtration rate