Acta Diabetol (2015) 52:365–371
DOI 10.1007/s00592-014-0653-4
ORIGINAL ARTICLE
Increased risk of severe diabetic ketoacidosis among Jewish
ultra-orthodox children
Noah Gruber • Brian Reichman • Liat Lerner-Geva
Orit Pinhas-Hamiel
Received: 5 July 2014 / Accepted: 8 September 2014 / Published online: 1 October 2014
Ó Springer-Verlag Italia 2014
Abstract
Aims Diabetic ketoacidosis (DKA) at diabetes diagnosis
is a dangerous yet potentially preventable condition. Young
age, low socioeconomic status, and low parental education
have been found to be associated with increased risk of
DKA. We aimed to evaluate the impact of religious affil-
iation on presentation with DKA at type 1 diabetes mellitus
(T1DM) diagnosis in Jewish children.
Methods The study comprised an analysis of medical
records of all consecutive patients with new-onset T1DM
who were admitted to one tertiary medical center from
January 2007 to January 2014. DKA was defined as venous
pH \7.3 or HCO3- \ 15 mmol/l, and severe DKA as pH
\7.1 or HCO3- \ 5 mmol/l.
Results Of 81 patients with new-onset T1DM (38
females, mean ± SD age at diagnosis 9.9 ± 4.2 years), 34
(42 %) presented with DKA: 21 of 60 (35 %) of patients
from secular families and 13 of 21 (62 %) from ultra-
orthodox families. Children from ultra-orthodox families
had a 3.5-fold increased risk of presenting with DKA than
children from secular families (95 % CI 1.2–10.1,
Managed by Antonio Secchi.
N. Gruber (&)
O. Pinhas-Hamiel
Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra
Children’s Hospital, Sheba Medical Center,
52621 Tel Hashomer, Ramat Gan, Israel
e-mail: noah.gruber@sheba.health.gov.il
N. Gruber
B. Reichman
L. Lerner-Geva
O. Pinhas-Hamiel
Sackler School of Medicine, Tel-Aviv University, Tel Aviv,
Israel
B. Reichman
L. Lerner-Geva
The Women and Children’s Health Research Unit, Gertner
Institute, Tel Hashomer, Israel
•
p = 0.02) and a 3.8-fold risk to be admitted with severe
DKA (95 % CI 1.1–12.6, p = 0.02). Other factors that
were found to be associated with an increased risk of DKA
were younger age, an absence of maternal academic edu-
cation, and residence in an area of low socioeconomic
status.
Conclusions DKA and severe DKA at diabetes diagnosis
were more common among religious ultra-orthodox than
among secular Jewish children. Awareness of the symp-
toms and dangers of DKA in new-onset T1DM should be
directed to particularly high-risk population groups.
Keywords Type 1 diabetes mellitus
Religion
Risk
factors
DKA
Ultra-orthodox
Jewish
Children
Abbreviations
DKA Diabetes ketoacidosis
T1DM Type 1 diabetes mellitus
T2DM Type 2 diabetes mellitus
MODY Maturity-onset diabetes of the young
SES Socioeconomic status
Introduction
The incidence of T1DM is rapidly increasing in children
and adolescents, with a reported increase of 3–15 %
annually [1–4]. Up to 80 % of children with new-onset
T1DM present with diabetic ketoacidosis (DKA) [5]. DKA
is the most common cause of hospitalization, cerebral
edema, and death in this population [6, 7]. In addition,
DKA at diagnosis has been associated with lower residual
beta cell function of the pancreas [8], worse glycemic
control [8, 9], and a lower rate of partial remission [10, 11].
123
366
A recent study has linked DKA at diagnosis to neurocog-
nitive impairment 6 months after the diagnosis [12].
Since DKA is a dangerous condition and potentially
preventable, the identification of risk factors associated
with its development is important. Risk factors that have
been identified include individual factors, family factors,
physician factors, disease factors, as well as a country’s
background incidence [13, 14]. A country’s background
incidence of T1DM is inversely associated with the pro-
portion of children who presents with DKA [5, 15], sug-
gesting that awareness to diabetes may contribute to the
prevention of DKA. This is also supported by a lower
incidence of DKA at presentation in children who have a
first-degree relative with T1DM [13, 16, 17]. Increased
awareness of diabetes in the general population and among
physicians may promote earlier diagnosis and decrease the
risk of DKA [17–20].
We observed that a large number of children who pre-
sented with DKA at our clinic were from ultra-orthodox
religious Jewish families. The objective of this study was to
evaluate the impact of religious affiliation on presentation
with DKA at T1DM diagnosis in Jewish children and to
assess the risk factors for presenting with DKA among
ultra-orthodox and secular Jewish children.
Patients and methods
The study comprised an analysis of medical and laboratory
records from patients admitted to the tertiary medical
center—the Edmond and Lily Safra Children’s Hospital,
Tel Hashomer, Israel, from January 2007 until January
2014. The study was approved by the Institutional Review
Board.
Inclusion criteria were age 6 months to 18 years and
presentation to the hospital with new-onset T1DM.
Exclusion criteria were neonatal diabetes, type 2 diabetes
mellitus (T2DM), and maturity-onset diabetes of the young
(MODY). The patients diagnosed with T2DM were all
adolescents (mean age at diagnosis—16 years), obese
(mean BMI above 97th percentile), had a family history of
T2DM, did not present with DKA, lacked markers of islet
autoimmunity, and had high C-peptide levels. The children
diagnosed with MODY had either genetic diagnosis or
incidental mild hyperglycemia, a family history of diabe-
tes, and none of them were treated with insulin. We also
excluded children with first-degree relatives with T1DM,
since previous studies have shown this to be a protective
factor for presenting with DKA [13, 16, 21]. In addition,
we excluded families that did not define themselves as
either secular or as ultra-orthodox religious affiliation.
Data related to individual, family, and disease factors
were extracted from patients’ medical records. The
123
Acta Diabetol (2015) 52:365–371
individual factors included date of diagnosis, age at diag-
nosis, and sex. Family factors included religious affiliation
(secular or ultra-orthodox Jews) according to their self-
definition, total number of children, maternal education
(classified as either non-academic or academic), and the
socioeconomic status (SES) of their geographical residen-
tial area. The mainstream religious affiliation among the
Jews in Israel is secular, and significant differences exist in
the lifestyles of the secular and orthodox communities. The
secular population lives according to Western lifestyle
characteristics and are free to choose their actions
according to their own will, whereas the ultra-orthodox
Jews choose appropriate and meaningful actions according
to strict oral and written religious Jewish laws [22]. The
Orthodox Jewish community in Israel accounts for 10 % of
the population in Israel and is segregated by choice from
the secular mainstream in terms of educational framework,
social and cultural life, and geographically. They typically
do not view television or movies or read secular newspa-
pers and books. Religious studies are a lifelong obligation,
and in most ultra-orthodox Jewish households, the fathers
pursue religious studies. They do not have a formal high
education degree, and the mothers are the main wage
earners. Most of the families are large with more children
than the average family in Israel.
SES was classified using the Israel Index of Deprivation
2008, as published by the Central Bureau of Statistics
(CBS) in Israel [23]. This is based on household census
data reflecting eight aspects of material and social depri-
vation, dividing Israel into twenty clusters (scored 1–20, 1
being the lowest) by residential address. Scores are derived
from units covering a small geographical area, each
reflecting the unique socioeconomic parameters. Low SES
was defined as allocation to a cluster B10 and high SES as
allocation to a cluster [10.
The disease factors comprised severity of acidosis as
measured by pH and bicarbonate levels, and HbA1c level
at diagnosis. The criterion for diagnosis of DKA was
venous pH \ 7.3 or HCO3- \ 15 mEq/l, according to the
American Diabetes Association, the Pediatric Endocrine
Society, and the European Endocrine Society [24–26]. The
severity of DKA was defined by the degree of acidosis:
mild, venous pH 7.2–7.3 or HCO3- 10–15 mmol/l; mod-
erate, pH 7.1–7.2 or HCO3- 5–10 mmol/l; and severe,
pH \ 7.1 or HCO3- \ 5 mmol/l.
Statistical analysis
Univariate analysis was performed using the Pearson’s chi-
square test or Fisher’s exact test. Groups were compared
according to categorical variables. Two-sample T tests
were used to compare variables that follow a normal dis-
tribution and two-sample Wilcoxon tests to compare the
Acta Diabetol (2015) 52:365–371 367

variables that did not follow a normal distribution. Multi-
variable logistic regression was applied to data to identify
the significant independent predictors of DKA by consid-
ering candidate variables with p values \0.05 in the uni-
variate analysis. Statistical analysis was performed by SAS
version 9.2 (SAS Institute Inc., Cary, NC).
Results
A total of 105 children presented at our medical center with
new-onset T1DM during the study period. One was
excluded from the study due to neonatal diabetes, 4 due to
T2DM, 4 due to MODY, 6 due to having a first-degree
relative with T1DM, and 9 who did not identify themselves
affiliating with either secular or ultra-orthodox. The study
population comprised 81 patients with new-onset T1DM.
The mean age at diagnosis was 9.9 ± 4.2 years. Thirty-
four patients (42 %) presented with DKA. There were no
fatal cases in our cohort. Characteristics of the cohort
according to presentation with or without DKA are shown
in Table 1. Age at diagnosis of T1DM was 1.8 years
younger in the DKA group (8.8 ± 4.4 vs. 10.6 ± 4,
p = 0.06). Compared to those without DKA, patients who
presented with DKA were more often from families living
in low SES areas (61 vs. 34 %, respectively, p = 0.03),
and children of mothers without an academic education (53
vs. 32 %, respectively, p = 0.06). Twenty-one patients
(26 %) were from ultra-orthodox families and 60 (74 %)
from secular families. Children from ultra-orthodox fami-
lies presented more often with DKA than did those from
secular families (62 vs. 35 %, respectively, p = 0.03,
Fig. 1). Fourteen patients (41 %) presented with severe
DKA. Children from ultra-orthodox families had a 3.8-fold
(95 % CI 1.1–12.6, p = 0.02) increased risk of presenting
with severe DKA than did children from secular families.
The characteristics of children from religious ultra-
orthodox compared with secular families are presented in
Table 2. A higher proportion of ultra-orthodox families had
more than three children (p \ 0.0001), resided in an area of
lower SES score (p \ 0.0001), and had mothers without an
academic education (p = 0.001).
We present three models of multivariable analyses.
Factors associated with increased risk of presenting with
DKA in the univariate analysis (younger age, low SES, low
maternal education and ultra-orthodox religious affiliation)
were further analyzed in the multivariable analyses. The
number of children in a family was not included in the
multivariable models, since 100 % of the ultra-orthodox
families, compared with only 12 % of the secular families,
had more than three.
In the multivariable logistic regression analyses
(Table 3), both religious affiliation and age were inde-
pendent determinants of DKA at T1DM diagnosis. Chil-
dren from ultra-orthodox families had a 3.5-fold increased
risk of presenting with DKA than did children from secular

Table 1 Characteristics of children according to their presentation with diabetic ketoacidosis at diabetes diagnosis
Factor Specific factors Study cohort With DKA at Without DKA at p value
categories n = 81 diagnosis n = 34 diagnosis n = 47
n (%) n (%) n (%)

Individual Sex Female 38 (47 %) 16 (42 %) 22 (58 %) 0.9

factors Male 43 (53 %) 18 (42 %) 25 (58 %)
Age (years) (mean ± SD) 9.9 ± 4.2 8.8 ± 4.4 10.6 ± 4 0.06
Family factors Religious affiliation Secular 60 (74 %) 21 (35 %) 39 (65 %) 0.03
Ultra-orthodox 21 (26 %) 13 (62 %) 8 (38 %)
Total number of children B3 children 53 (65 %) 19 (64 %) 34 (36 %) 0.12
[3 children 28 (35 %) 15 (46 %) 13 (54 %)
Maternal education Non academic 40 (49 %) 21 (53 %) 19 (47 %) 0.06
Academic 41 (51 %) 13 (32 %) 28 (68 %)
Socioeconomic status score Low 23 (28 %) 14 (61 %) 9 (39 %) 0.03
High 58 (72 %) 20 (34 %) 38 (66 %)
Disease factors pH (mean ± SD) 7.27 ± 0.15 7.12 ± 0.12 7.37 ± 0.02 \0.0001
HCO3- (mmol/l) (mean ± SD) 16 ± 6.9 9.4 ± 5 20.6 ± 3.4 \0.0001
Severity of DKA Mild 12 (35 %)
Moderate 8 (24 %)
Severe 14 (41 %)
HbA1C % (mmol/mol) 11.9 ± 2.4 11.9 ± 1.8 11.8 ± 2.8 0.9
(mean ± SD) (107 ± 26) (107 ± 19) (105 ± 31)

123
368 Acta Diabetol (2015) 52:365–371

100% Discussion
Distribution of Severity of
90%
23%
80%
70%
43% This study showed that children with new-onset T1DM
from ultra-orthodox Jewish religious families, compared to
DKA (%)

60%
50%
24%
40%
30%
20%
33%
10%
0%
Secular Ultra-Orthodox
Religious Affiliation
Severe DKA Moderate DKA
Fig. 1 Distribution of severity of diabetic ketoacidosis according to
religious affiliation. Black bars severe DKA, stripe bars moderate
DKA, white bars mild DKA
families (95 % CI 1.2–10.1, p = 0.02). A decrease of
1 year of age was associated with a 13 % increased risk of
presenting with DKA (OR 1.13, 95 % CI 1.02–1.28,
p = 0.04). In a second model, we assessed maternal edu-
cation as a determinant of DKA. Compared to secular
families with maternal academic education, secular fami-
lies without maternal academic education had a 1.8-fold
increased risk to present with DKA (95 % CI 0.6–5.4,
p = 0.3), whereas ultra-orthodox families had a 4.3-fold
increased risk (95 % CI 1.3–14, p = 0.01). In the third
model, compared to secular families with high SES scores,
secular families with low SES scores had a 3.1-fold (95 %
CI 0.5–19.7, p = 0.2) increased risk, and ultra-orthodox
families had a 3.8-fold (95 % CI 1.3–11.3, p = 0.01)
increased risk of presenting with DKA.
23%
secular families, were at increased risk of presenting with
DKA and with severe DKA. The rate of DKA at diagnosis
54% of T1DM was 42 %, similar to the rate that was recently
reported in another study conducted in Israel [27]. A sys-
tematic review that assessed 65 cohorts in 31 countries
reported great geographical variation in rates of DKA at
diagnosis, from 12.8 to 80 %. DKA frequency was found to
Mild DKA be inversely associated with a country’s gross domestic
product, latitude, and background incidence of T1DM [5].
The association of younger age with DKA presentation
is consistent with previous studies [13, 14, 16, 17, 21, 28].
The diagnosis of diabetes in young children can be difficult
and perplexing. The classic symptoms of diabetes may be
subtle. De-compensation, due to dehydration and acidosis,
develops more rapidly in young children. Moreover, b cell
destruction may be more aggressive in young children,
with a shorter preclinical phase [13]. A study that evaluated
whether DKA is a missed diagnosis among young children
diagnosed with diabetes found that the most common
diagnoses in the month prior to T1DM onset were upper
respiratory tract infection, diarrhea/gastroenteritis, and
serous otitis media [28].
Ethnicity has been reported to be a risk factor for
developing DKA. Increased rates of DKA have been shown
in Hispanics [14] and African Americans in the USA [13,
14, 21], in Asian children in the UK [29], and in South
Asian, African, and East European children in the UK [30].
In Israel, higher rates of DKA have been reported in ethnic

Table 2 Characteristics of children according to the religious affiliation of their families

Factor categories Specific factors Secular n = 60 Ultra-orthodox n = 21 p value
n (%) n (%)

Individual factors Sex Female 29 (48 %) 9 (43 %) 0.6

Male 31 (52 %) 12 (57 %)
Age (years) (mean ± SD) 9.8 ± 4.2 10.3 ± 4.3 0.6
Family factors Total number of children B3 children 53 (88 %) 0 (0 %) \0.0001
[3 children 7 (12 %) 21 (100 %)
Maternal education Non academic 21 (40 %) 17 (81 %) 0.001
Academic 32 (60 %) 4 (19 %)
Socioeconomic status score Low 6 (10 %) 17 (81 %) \0.0001
High 54 (90 %) 4 (19 %)
Disease factors DKA With DKA 21 (35 %) 13 (62 %) 0.03
Without DKA 39 (65 %) 8 (38 %)
pH (mean ± SD) 7.29 ± 0.13 7.20 ± 0.17 0.02
HCO3- (mmol/l) (mean ± SD) 17.18 ± 6.6 12.72 ± 6.9 0.01
Severe DKA 7/60 (12 %) 7/21 (33 %) 0.02
HbA1C % (mmol/mol) (mean ± SD) 11.8 ± 2.5 (105 ± 28) 12.1 ± 2.3 (109 ± 25) 0.6

123
Acta Diabetol (2015) 52:365–371 369

Table 3 Multivariable analyses for factors associated with diabetic ketoacidosis presentation at diagnosis
Models Factors Study DKA OR (95 % CI) p value
cohort n = 34
n = 81 n (%)

Model 1 Age (years) 9.9 ± 4.2 8.8 ± 4.4 1.13 0.04

(1.02–1.28)
Religious affiliation Secular 60 21 (35 %) Reference 1 0.02
Ultra-orthodox 21 13 (62 %) 3.5 (1.2–10.1)
Model 2 Religious affiliation and maternal education Secular, academic 37 11 (30 %) Reference 1
Secular, non- 23 10 (44 %) 1.8 (0.6–5.4) 0.3
academic
Ultra-orthodox 21 13 (62 %) 4.3 (1.3–14) 0.01
Model 3 Religious affiliation and socioeconomic status (SES) Secular, high SES 54 17 (31 %) Reference 1
Secular, low SES 6 4 (67 %) 3.1 (0.5–19.7) 0.2
Ultra-orthodox 21 13 (62 %) 3.8 (1.3–11.3) 0.01

minorities, such as Ethiopians [16] and Bedouins [31]. The
International Diabetes Federation (IDF) and the Interna-
tional Society for Pediatric and Adolescent Diabetes
(ISPAD) [32] state that knowledge of a family’s cultural
and religious beliefs can be critical to providing care.
This study is the first to identify ultra-orthodox religious
Jewish children as a group at risk of presenting with DKA.
The ultra-orthodox currently comprise approximately 10 %
of Jews in the world today [23]. The largest ultra-orthodox
communities are in Israel and in the USA, and smaller
communities are located in England, Canada, France, Bel-
gium, and Australia [33]. The members of the ultra-orthodox
community, similar to other collectivist societies, reside pri-
marily in their own neighborhoods [34]. They usually reject
modern lifestyle, and their interaction with secular society in
general is limited. It should be noted that the predominant
ultra-orthodox city of Bnei Brak is located in the proximity of
the study center, which may explain the high proportion of
ultra-orthodox patients in our cohort. This, however, does not
explain the higher rate of DKA. While the ultra-orthodox
children comprised 26 % of the children in this study, they
accounted for 50 % of those with severe DKA.
The elevated rate of DKA among the ultra-orthodox
children in our population may be the result of a lower
awareness of the disease due to their isolated lifestyle. The
ultra-orthodox segregate themselves by choice from mod-
ern living, including exposure to information from televi-
sion, internet, and newspapers [35]. In addition, they tend
to be discrete regarding health-related issues. Suppression
of medical information was shown, for example, for self-
reported mammography, where women within the ultra-
orthodox community more often failed to report having had
a mammogram, despite indications in the medical records
that they had [36]. Both the lower exposure to modern
communication networks and the extreme privacy regard-
ing their health, together with cultural barriers, may
contribute to the lower awareness of the disease and its
symptoms within this community. A recent study on the
Amish population in the Midwest of the USA, which is a
closed and traditional society, reported higher rates of
advanced stage of cancer at diagnosis and lower screening
rates compared to non-Amish patients [37].
We found the lack of maternal academic education to be
associated with an increased risk of DKA, concurring with
other studies [13, 38–40]. Fewer ultra-orthodox than sec-
ular mothers had an academic education. It is important to
add that perhaps the different lifestyle of the ultra-orthodox
community leads the women to seek jobs rather than to
achieve an academic education. The increased risk of DKA
was fourfold among the ultra-orthodox compared to the
secular academically educated mothers.
In the present study, residing in an area with a low SES
score was associated with an increased risk of DKA. More
of the ultra-orthodox than secular families reside in such
areas; the increased risk of DKA was almost fourfold for
children of these families compared to children from sec-
ular families and from those residing in high SES areas.
These findings concur with other studies that have found
associations between low socioeconomic status and the risk
of DKA at diabetes diagnosis [14, 38]. Most of the ultra-
orthodox population in Israel resides in areas of low
socioeconomic status, and family incomes are about half of
those of the average Israeli family [23]. Low SES is shown
to increase the risk of various diseases. For example, a
particularly high rate of invasive meningococcal disease
was reported within the low socioeconomic Arab and
Jewish ultra-orthodox communities in Jerusalem [41].
Establishing a diabetes awareness program specifically
in high-risk communities, through the relevant communi-
cation networks, could potentially reduce the incidence of
DKA at T1DM onset. Several publications have suggested
intervention programs aimed to reduce the rates of DKA at

123
370
diabetes diagnosis. During an 8-year period, posters with
practical messages were provided pediatricians in Italy,
together with equipment for the measurement of both
glycosuria and blood glucose levels, and information cards
listing guidelines for the early diagnosis of diabetes to be
distributed to patients. DKA was successfully reduced after
this campaign [20]. Similarly, a campaign in Australia,
comprising posters, radio, and newspaper promotions, and
the provision of blood glucose testing equipment to
healthcare providers also reported a significant decrease in
DKA at diagnosis [19]. A national diabetes awareness
program in Turkey also contributed to the reduction in the
rate of DKA [18]. There is a great importance to identi-
fying specific populations at increased risk to present with
DKA at T1DM onset.
A limitation of the current study is that we did not study
the impact of physician factors on delayed diagnosis and
the development of DKA. A Canadian study found that
84 % of children had been seen in primary care before the
diagnosis of T1DM [13].
In conclusion, this study identified the closed commu-
nity of ultra-orthodox Jewish children, as well as young
age, low socioeconomic status, and non-academic maternal
education as risk factors for the presentation of DKA at
T1DM diagnosis. Awareness of the symptoms and dangers
of DKA in new-onset T1DM should be directed to par-
ticularly high-risk population groups.
Acknowledgments We thank Dana Hadar, MSc, The Women and
Children’s Health Research Unit, Gertner Institute, Tel Hashomer,
Israel, affiliated to Sackler School of Medicine, Tel-Aviv University
for a statistical assistance, and to Valentina Boyko, MSc, The Women
and Children’s Health Research Unit, Gertner Institute, Tel Hasho-
mer, Israel, affiliated to Sackler School of Medicine, Tel-Aviv Uni-
versity for a thorough statistical analysis. We thank Cindy Cohen,
MA, for an editorial assistance.
Conflict of interest The authors declare no conflict of interest.
Ethical standard All procedures were in accordance with the eth-
ical standards of the responsible committee on human experimenta-
tion (institutional and national) and with the Helsinki Declaration of
1975, as revised in 2008.
Human and animal rights disclosure This article does not contain
any studies with human or animal subjects performed by any of the
authors.
Informed consent disclosure Due to the retrospective nature of the
analysis, informed consent was not obtained, with approval of the
Institutional Review Board.
References
1. Patterson CC, Dahlquist GG, Gyürüs E et al (2009) Incidence
trends for childhood type 1 diabetes in Europe during 1989–2003
and predicted new cases 2005–20: a multicentre prospective
123
Acta Diabetol (2015) 52:365–371
registration study. Lancet 373:2027–2033. doi:10.1016/S0140-
6736(09)60568-7
2. Dabelea D, Mayer-Davis EJ, Saydah S et al (2014) Prevalence of
type 1 and type 2 diabetes among children and adolescents from
2001 to 2009. JAMA 311:1778. doi:10.1001/jama.2014.3201
3. Zhao Z, Sun C, Wang C et al (2014) Rapidly rising incidence of
childhood type 1 diabetes in Chinese population: epidemiology in
Shanghai during 1997–2011. Acta Diabetol. doi:10.1007/s00592-
014-0590-2
4. Jarosz-Chobot P, Deja G, Polanska J (2010) Epidemiology of
type 1 diabetes among Silesian children aged 0–14 years,
1989–2005. Acta Diabetol 47:29–33. doi:10.1007/s00592-009-
0094-7
5. Usher-Smith JA, Thompson M, Ercole A, Walter FM (2012)
Variation between countries in the frequency of diabetic ke-
toacidosis at first presentation of type 1 diabetes in children: a
systematic review. Diabetologia 55:2878–2894. doi:10.1007/
s00125-012-2690-2
6. Scibilia J, Finegold D, Dorman J et al (1986) Why do children
with diabetes die? Acta Endocrinol Suppl (Copenh) 279:326–333
7. Secrest AM, Becker DJ, Kelsey SF et al (2010) Cause-specific
mortality trends in a large population-based cohort with long-
standing childhood-onset type 1 diabetes. Diabetes 59:3216–3222.
doi:10.2337/db10-0862
8. Fernandez Castañer M, Montaña E, Camps I et al (1996) Ke-
toacidosis at diagnosis is predictive of lower residual beta-cell
function and poor metabolic control in type 1 diabetes. Diabetes
Metab 22:349–355
9. Mortensen HB1, Swift PG, Holl RW et al (2010) Multinational
study in children and adolescents with newly diagnosed type 1
diabetes: association of age, ketoacidosis, HLA status, and
autoantibodies on residual beta-cell function and glycemic con-
trol 12 months after diagnosis. Pediatr Diabetes 11:218–226
10. Bowden SA, Duck MM, Hoffman RP (2008) Young children
(\5 yr) and adolescents ([12 yr) with type 1 diabetes mellitus
have low rate of partial remission: diabetic ketoacidosis is an
important risk factor. Pediatr Diabetes 9:197–201. doi:10.1111/j.
1399-5448.2008.00376.x
11. Abdul-Rasoul M, Habib H, Al-Khouly M (2006) ‘‘The honey-
moon phase’’ in children with type 1 diabetes mellitus: frequency,
duration, and influential factors. Pediatr Diabetes 7:101–107.
doi:10.1111/j.1399-543X.2006.00155.x
12. Cameron FJ, Scratch SE, Nadebaum C et al (2014) Neurological
consequences of diabetic ketoacidosis at initial presentation of
type 1 diabetes in a prospective cohort study of children. Diabetes
Care 37:1554–1562. doi:10.2337/dc13-1904
13. Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM (2011)
Factors associated with the presence of diabetic ketoacidosis at
diagnosis of diabetes in children and young adults: a systematic
review. BMJ 343:d4092
14. Dabelea D, Rewers A, Stafford JM et al (2014) Trends in the
prevalence of ketoacidosis at diabetes diagnosis: the SEARCH
for diabetes in youth study. Pediatrics 133:e938–e945. doi:10.
1542/peds.2013-2795
15. Lévy-Marchal C, Patterson CC, Green A (2001) Geographical
variation of presentation at diagnosis of type I diabetes in chil-
dren: the EURODIAB study. Diabetologia 44(Suppl 3):B75–B80
16. De Vries L, Oren L, Lazar L et al (2013) Factors associated with
diabetic ketoacidosis at onset of type 1 diabetes in children and
adolescents. Diabet Med 30:1360–1366. doi:10.1111/dme.12252
17. Lokulo-Sodipe K, Moon RJ, Edge JA, Davies JH (2014) Identi-
fying targets to reduce the incidence of diabetic ketoacidosis at
diagnosis of type 1 diabetes in the UK. Arch Dis Child. doi:10.
1136/archdischild-2013-304818
18. Uçar A, Saka N, Baş F et al (2013) Frequency and severity of
ketoacidosis at onset of autoimmune type 1 diabetes over the past
Acta Diabetol (2015) 52:365–371
decade in children referred to a tertiary paediatric care centre:
potential impact of a national programme highlighted. J Pediatr
Endocrinol Metab 26:1059–1065. doi:10.1515/jpem-2013-0060
19. King BR, Howard NJ, Verge CF et al (2012) A diabetes aware-
ness campaign prevents diabetic ketoacidosis in children at their
initial presentation with type 1 diabetes. Pediatr Diabetes
13:647–651. doi:10.1111/j.1399-5448.2012.00896.x
20. Vanelli M, Chiari G, Ghizzoni L et al (1999) Effectiveness of a
prevention program for diabetic ketoacidosis in children. An
8-year study in schools and private practices. Diabetes Care
22:7–9
21. Klingensmith GJ, Tamborlane WV, Wood J et al (2013) Diabetic
ketoacidosis at diabetes onset: still an all too common threat in
youth. J Pediatr 162:330.e1–334.e1. doi:10.1016/j.jpeds.2012.06.
058
22. Engel-Yeger B (2012) Leisure activities preference of Israeli
Jewish children from secular versus orthodox families. Scand J
Occup Ther 19:341–349. doi:10.3109/11038128.2011.600330
23. The Central Bureau of Statistics (CBS) (2013) Israel in figures.
http://www.cbs.gov.il/reader/publications/israel_fig_e.htm
24. Wolfsdorf J, Glaser N, Sperling MA (2006) Diabetic ketoacidosis
in infants, children, and adolescents: a consensus statement
from the American Diabetes Association. Diabetes Care
29:1150–1159. doi:10.2337/diacare.2951150
25. The Diabetes Control and Complications Trial (DCCT) (1986)
Design and methodologic considerations for the feasibility phase.
The DCCT Research Group. Diabetes 35:530–45
26. Dunger DB, Sperling MA, Acerini CL et al (2004) ESPE/LWPES
consensus statement on diabetic ketoacidosis in children and
adolescents. Arch Dis Child 89:188–194
27. Blumenfeld O, Dichtiar R, Shohat T (2013) Trends in the inci-
dence of type 1 diabetes among Jews and Arabs in Israel. Pediatr
Diabetes. doi:10.1111/pedi.12101
28. Bui H, To T, Stein R et al (2010) Is diabetic ketoacidosis at
disease onset a result of missed diagnosis? J Pediatr 156:472–477.
doi:10.1016/j.jpeds.2009.10.001
29. Alvi NS, Davies P, Kirk JM, Shaw NJ (2001) Diabetic ketoaci-
dosis in Asian children. Arch Dis Child 85:60–61
30. Sundaram PCB, Day E, Kirk JMW (2009) Delayed diagnosis in
type 1 diabetes mellitus. Arch Dis Child 94:151–152. doi:10.
1136/adc.2007.133405
31. Hilmi A, Pasternak Y, Friger M et al (2013) Ethnic differences in
glycemic control and diabetic ketoacidosis rate among children
371
with diabetes mellitus type 1 in the Negev area. Isr Med Assoc J
15:267–270
32. Colagiuri S (The Boden Institute of Obesity N, and Exercise,
University of Sydney A) (2011) The global IDF/ISPAD guideline
for diabetes in children and adolescence
33. Greenberg D, Witztum E (2013) Challenges and conflicts in the
delivery of mental health services to ultra-orthodox Jews. Asian J
Psychiatr 6:71–73. doi:10.1016/j.ajp.2012.10.008
34. Lightman E (Faculty of Social Work, University of Toronto, 246
Bloor Street W., Toronto, Ontario M5S1A1, Canada) Shor R
(Paul Baerwald School of Social Work, Hebrew University of
Jerusalem, Mt. Scopus, 91905 I) (2002) Askanim: informal
helpers and cultural brokers as a bridge to secular helpers for the
ultra-orthodox Jewish communities of Israel and Canada. Fam
Soc 83:315–324
35. Rier DA, Schwartzbaum A, Heller C (2008) Methodological
issues in studying an insular, traditional population: a women’s
health survey among Israeli haredi (ultra-orthodox) Jews. Women
Health 48:363–381. doi:10.1080/03630240802575054
36. Baron-Epel O, Friedman N, Lernau O (2008) Validity of self-
reported mammography in a multicultural population in Israel.
Prev Med (Baltim) 46:489–491. doi:10.1016/j.ypmed.2008.03.
003
37. Katz ML, Ferketich AK, Paskett ED, Bloomfield CD (2013)
Health literacy among the Amish: measuring a complex concept
among a unique population. J Community Health 38:753–758.
doi:10.1007/s10900-013-9675-z
38. Rewers A, Klingensmith G, Davis C et al (2008) Presence of
diabetic ketoacidosis at diagnosis of diabetes mellitus in youth:
the search for diabetes in youth study. Pediatrics 121:e1258–
e1266. doi:10.1542/peds.2007-1105
39. Komulainen J, Lounamaa R, Knip M et al (1996) Ketoacidosis at
the diagnosis of type 1 (insulin dependent) diabetes mellitus is
related to poor residual beta cell function. Childhood diabetes in
Finland study group. Arch Dis Child 75:410–415
40. Sadauskaite-Kuehne V, Samuelsson U, Jasinskiene E et al (2002)
Severity at onset of childhood type 1 diabetes in countries with
high and low incidence of the condition. Diabetes Res Clin Pract
55:247–254
41. Stein-Zamir C, Abramson N, Zentner G et al (2008) Invasive
meningococcal disease in children in Jerusalem. Epidemiol Infect
136:782–789. doi:10.1017/S0950268807009259
123