The prevalence of type 2 diabetes in South Africa: a systematic review protocol

Cost-effectiveness of Lifestyle Africa: an adaptation of the diabetes prevention programme for delivery by community health workers in urban South Africa

BACKGROUND

Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c).

OBJECTIVE

To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention.

METHODS

Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated.

RESULTS

The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant.

CONCLUSIONS

Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions.

TRIAL REGISTRATION

Trial registration is at ClinicalTrials.gov (NCT03342274).

Waste to Medicine: Evidence from Computational Studies on the Modulatory Role of Corn Silk on the Therapeutic Targets Implicated in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance and/or defective insulin production in the human body. Although the antidiabetic action of corn silk (CS) is well-established, the understanding of the mechanism of action (MoA) behind this potential is lacking. Hence, this study aimed to elucidate the MoA in different samples (raw and three extracts: aqueous, hydro-ethanolic, and ethanolic) as a therapeutic agent for the management of T2DM using metabolomic profiling and computational techniques. Ultra-performance liquid chromatography-mass spectrometry (UP-LCMS), in silico techniques, and density functional theory were used for compound identification and to predict the MoA. A total of 110 out of the 128 identified secondary metabolites passed the Lipinski's rule of five. The Kyoto Encyclopaedia of Genes and Genomes pathway enrichment analysis revealed the cAMP pathway as the hub signaling pathway, in which ADORA1, HCAR2, and GABBR1 were identified as the key target genes implicated in the pathway. Since gallicynoic acid (-48.74 kcal/mol), dodecanedioc acid (-34.53 kcal/mol), and tetradecanedioc acid (-36.80 kcal/mol) interacted well with ADORA1, HCAR2, and GABBR1, respectively, and are thermodynamically stable in their formed compatible complexes, according to the post-molecular dynamics simulation results, they are suggested as potential drug candidates for T2DM therapy via the maintenance of normal glucose homeostasis and pancreatic β-cell function.

Self-Management of Diabetes and Associated Factors among Patients Seeking Chronic Care in Tshwane, South Africa: A Facility-Based Study

The burden of diabetes continues to increase in South Africa and a significant number of diabetes patients present at public primary healthcare facilities with uncontrolled glucose. We conducted a facility-based cross-sectional study to determine the diabetes self-management practices and associated factors among out-patients in Tshwane, South Africa. An adapted validated questionnaire was used to collect data on sociodemography, diabetes knowledge, and summaries of diabetes self-management activities measured in the previous seven days, and over the last eight weeks. Data were analysed using STATA 17. A final sample of 402 diabetes out-patients was obtained (mean age: 43 ± 12 years) and over half of them were living in poor households. The mean total diabetes self-management of score was 41.5 ± 8.2, with a range of 21 to 71. Almost two thirds of patients had average self-management of diabetes, and 55% had average diabetes knowledge. Twenty-two percent of patients had uncontrolled glucose, hypertension (24%) was the common comorbidity, and diabetic neuropathy (22%) was the most common complication. Sex [male: AOR = 0.55, 95% CI: 0.34-0.90], race [Coloured: AOR = 2.84, 95% CI: 1.69-4.77 and White: AOR = 3.84, 95% CI: 1.46-10.1], marital status [divorced: AOR = 3.41, 95% CI: 1.13-10.29], social support [average: AOR = 2.51, 95% CI: 1.05-6.00 and good: AOR = 4.49, 95% CI: 1.61-7.57], body mass index [obesity: AOR = 0.31, 95% CI: 0.10-0.95], diabetes knowledge [average: AOR = 0.58, 95% CI: 0.33-0.10 and good: AOR = 1.86, 95% CI: 0.71-4.91], and uncontrolled glucose [AOR = 2.97, 95% CI: 1.47-5.98] were factors independently predictive of diabetes self-management. This study emphasizes that the self-management of diabetes was mostly on average among patients and was associated with the aforementioned factors. Innovative approaches are perhaps needed to make diabetes education more effective. Face-to-face sessions delivered generally during clinic visits should be better tailored to the individual circumstances of diabetes patients. Considerations should be given to the options of leveraging information technology to ensure the continuity of diabetes education beyond clinic visits. Additional effort is also needed to meet the self-care needs of all patients.

Discovery of Novel Thiazolidinedione-Derivatives with Multi-Modal Antidiabetic Activities In Vitro and In Silico

Diabetes mellitus (DM) and related complications continue to exert a significant burden on health care systems globally. Although conventional pharmacological therapies are beneficial in the management of this metabolic condition, it is still necessary to seek novel potential molecules for its management. On this basis, we have synthesised and evaluated the anti-diabetic properties of four novel thiazolidinedione (TZD)-derivatives. The TZD derivatives were synthesised through the pharmacophore hybridisation strategy based on N-arylpyrrole and TZD. The resultant derivatives at different concentrations were screened against key enzymes of glucose metabolism and glucose utilisation in the liver (HEP-G2) cell line. Additionally, peroxisome proliferator-activated receptor-γ activation was performed through docking studies. Docking of these molecules against PPAR-γ predicted strong binding, similar to that of rosiglitazone. Hence, TZDD2 was able to increase glucose uptake in the liver cells as compared to the control. The enzymatic inhibition assays showed a relative inhibition activity; with all four derivatives exhibiting ≥ 50% inhibition activity in the α-amylase inhibition assay and a concentration dependent activity in the α-glucosidase inhibition assay. All four derivatives exhibited ≥30% inhibition in the aldose reductase inhibition assay, except TZDD1 at 10 µg/mL. Interestingly, TZDD3 showed a decreasing inhibition activity. In the dipeptidyl peptidase-4 inhibition assay, TZDD2 and TZDD4 exhibited ≥20% inhibition activity.

In vitro profiling and functional assessments of the anti-diabetic capacity of phenolic-rich extracts of Bulbine natalensis and Bulbine frutescens

AIMS

Bulbine natalensis (BN) and Bulbine frutescens (BF) are recommended in South African traditional medicine to treat diabetes, but their modes of action are unknown. This study assessed the phenolic acid profiles, mineral composition and in vitro functional effects of BN and BF to better understand their glucose-lowering capabilities.

METHODS

Phenolic acid and mineral composition of BN and BF methanolic extracts were determined by HPLC and inductively coupled plasma optical emission spectroscopy respectively. Antioxidant capacity was assessed by potassium ferricyanide reducing power and 2,2-diphenyl-2-picrylhydrazyl radical scavenging assays, and inhibition of alpha-amylase, alpha-glucosidase, pancreatic lipase and DPP4 was evaluated by standard enzyme assays. The effects of BN and BF extracts on insulin secretion were investigated using static incubations of isolated mouse islets and molecular docking analysis was used to identify interactions of BN and BF with partners that could mediate stimulatory effects on insulin secretion.

RESULTS

Methanolic extracts of BN and BF contained high concentrations of protocatechuic and gallic acids, and high levels of Zn, Mn and Cr. The extracts inhibited alpha-glucosidase, alpha-amylase, pancreatic lipase and DPP4 activities, and they also inhibited free radical generation. Both extracts significantly potentiated glucose-stimulated insulin secretion without significantly affecting basal insulin secretion or islet cell viability. Protocatechuic acid, the most abundant phenolic acid in the extracts, showed high affinity for PKA, PKC, DPP4 and CaMK II in the docking analysis.

CONCLUSIONS

BN and BF have multiple beneficial effects on glucoregulatory pathways and they, or their derivatives, could be developed to treat type 2 diabetes.

Budget Impact Analysis of Empagliflozin in the Treatment of Patients With Type 2 Diabetes With Established Cardiovascular Disease in South Africa

OBJECTIVES

This study aimed to estimate the budget impact and affordability of empagliflozin added to usual care compared with usual care alone, in a diabetic population with established cardiovascular disease, from a private healthcare payer perspective in South Africa.

METHODS

A budget impact model was adapted and localized. Epidemiological data were obtained from the South African Council for Medical Schemes. Clinical event rates were sourced from the EMPA-REG OUTCOME trial and drug costs from list prices. Clinical event costs were derived from a claims data analysis of the South African private healthcare sector and microcosting. Scenario analyses were performed on select inputs. The modeled outcomes included annual budget impact of empagliflozin, the incremental cost per life per month, cardiovascular deaths averted, and incremental cost per life saved, over 3 years.

RESULTS

A total of 9 503 patients were eligible for empagliflozin (year 1), 12 670 (year 2), and 16 947 (year 3). The incremental cost was $1 272 297, $1 764 705, and $2 455 235, for years 1 to 3, respectively. The incremental cost per beneficiary per month was calculated as $0.012 (year 1), $0.016 (year 2), and $0.023 (year 3). The model estimated a 38.6% reduction in cardiovascular deaths, 305 lives saved, and an incremental cost per life saved of $17 999.

CONCLUSIONS

Adding empagliflozin to usual care has a marginal budget implication and is highly affordable for private healthcare payers, with an acceptable incremental cost based on clinical outcomes.

Dietary Diversity and its Association with Nutritional Status, Cardiometabolic Risk Factors and Food Choices of Adults at Risk for Type 2 Diabetes Mellitus in Cape Town, South Africa

In South Africa, the nutrition transition has led to unhealthy diets lacking variety, contributing to the rise in overweight, obesity and diet-related noncommunicable diseases. Using baseline screening data of the South African Diabetes Prevention Programme (SA-DPP) study, this study aims to determine the relationship of dietary diversity (DD) with nutritional status, cardiometabolic risk factors and food choices of adults at risk of type 2 diabetes in resource-poor communities around Cape Town. Data of 693 adults, 25−65 years old were analysed. This included socio-demographic information, anthropometric measurements, biochemical assessments, food groups consumed the previous day and consumption frequency of certain foods to reflect food choices. The Minimum Dietary Diversity for Women (MDD-W) indicator was calculated; 70.4% of participants had low DD (<5 food groups). Low DD was associated with elevated serum triglycerides [AOR: 1.49, 95% CI (1.03, 2.15) p = 0.036]. The DD score was positively correlated (although weak) with the unhealthy food score (r = 0.191, p = 0.050) and sugary food score (r = 0.139, p < 0.01). Study participants at risk of diabetes consumed a diet low in DD; however, DD was not associated with nutritional status or cardiometabolic risk factors except for serum triglycerides.

Diabetes in the Western Cape, South Africa: A secondary analysis of the diabetes cascade database 2015 - 2020

AIM

The aim was to describe the demographics, comorbidities and outcomes of care for patients with diabetes at primary care facilities in the Western Cape, South Africa, between 2015 and 2020.

METHODS

This was a secondary analysis of the diabetes cascade database.

RESULTS

The database included 116726 patients with mean age of 61.4 years and 63.8 % were female. The mean age at death was 66.0 years. Co-morbidities included hypertension (69.5 %), mental health disorders (16.2 %), HIV (6.4 %) and previous TB (8.2 %). Sixty-three percent had at least one previous hospital admission and 20.2 % of all admissions were attributed to cardiovascular diseases. Coronavirus was the third highest reason for admission over a 10-year period. Up to 70% were not receiving an annual HbA1c test. The mean value for the last HBA1c taken was 9.0%. Three-quarters (75.5 %) of patients had poor glycaemic control (HbA1c >7 %) and a third (33.7 %) were very poorly controlled (HbA1c>10 %). Glycaemic control was significantly different between urban sub-districts and rural areas. Renal disease was prevalent in 25.5 %.

CONCLUSION

Diabetes was poorly controlled with high morbidity and mortality. There was poor compliance with guidelines for HbA1c and eGFR measurement. At least 7% of diabetic patients were being admitted for complications annually.

Combination Antiretroviral Therapy (cART) in Diabetes Exacerbates Diabetogenic Effects on Hippocampal Microstructure, Neurogenesis and Cytokine Perturbation in Male Sprague Dawley Rats

The increasing incidence of diabetes and HIV/AIDS–diabetes comorbidity in society has led to the prevalence of combination antiretroviral therapy (cART) in diabetes, with some reported neural effects. Therefore, the effects of cART and type two diabetes (T2D) on the hippocampal levels of cytokines, lipid peroxidation; histomorphology and neurogenesis were investigated. Adult male Sprague–Dawley rats were divided into four groups: DB (diabetic rats); DAV (diabetic rats treated with cART (efavirenz, emtricitabine and tenofovir); AV (normal rats treated with cART) and the NC group (with no treatment). Following ninety days of treatment, the rats were terminated, and the brains excised. Immunoassay (IL-1α, IL-6, TNFα and MDA); immunohistochemical (Ki67 and DCX) and cresyl violet histomorphology analyses were carried out on brain homogenates and sections, respectively. In comparison to the control, the results showed that cART significantly elevated the IL-6, TNFα and MDA levels, while DB and DAV significantly reduced the body weight, glucose tolerance, IL-1α, IL-6, TNFα and MDA levels. The hippocampal neuronal number was reduced in AV (dentate gyrus; DG region), in the DB group (Cornu Ammonis subregion 1; CA1 and DG regions only) and in DAV (all three hippocampal regions). Additionally, the expression of neurogenic markers Ki67 and doublecortin (DCX) were reduced in the diabetic group, with a greater reduction in the cART+T2D group compared to the control. Furthermore, the neuronal number at all hippocampal regions was negatively corelated with the diabetic parameters (FBG; fasting blood glucose, NFBG; non-fasting blood glucose, AUC; area under the glucose tolerance curve) but positively correlated with body weight. Additionally, the increase in the DG neuronal nuclei area of DB and DAV was significantly positively correlated with FBG, NFBG and AUC and inversely correlated with the estimated number of neurons and neurogenesis. These findings indicate that cART in diabetes (DAV) has similar effects as diabetes relative to the induction of oxidative stress and impairment of the cytokine immune response, but exacerbated neurotoxicity is observed in DAV, as shown by a significantly decreased DCX expression compared to DB and reduction in the number of Cornu Ammonis subregion 3 (CA3) hippocampal neurons, unlike in cART or the diabetes-alone groups.

Obesity as a Risk Factor for Hypertension and Diabetes among Truck Drivers in a Logistics Company, South Africa

Despite the occupational nature of truckers predisposing them to cardiovascular diseases and risk factors, data is scarce on their prevalence of obesity and its association with developing hypertension (HBP) and diabetes in South Africa. Extracted from the original cross-sectional study of a sample of 312 employees in a logistics company, a census of 96 male truckers was used to determine the prevalence of obesity and its association with HBP and diabetes. WHO STEPwise approach was used to collect data, including systolic (SBP) and diastolic (DBP) blood pressure and anthropometry measurements. HBP is defined as SBP/DBP ≥ 140/90 mmHg, overweight/obesity as BMI ≥ 25 kg/m2, abdominal obesity by waist circumference as WC ≥ 90cm, waist-to-hip-ratio as WHR ≥ 0.90, and waist-to-height ratio as WHtR ≥ 0.5. Data were analysed using SPSS 22. The mean age of truckers was 46 years, 29% were smokers, and 57% alcohol users, while 26% were physically inactive. The prevalence of overweight (44%) and obesity (30%) were observed, while abdominal obesity was high; WC (59%), WHR (65%), and WHtR (80%). HBP (57%) was prevalent and diabetes was 14%. The odds of developing HBP were high for obese truckers by WC [AOR = 4.68; CI = 1.92–11.34)] and by WHtR [AOR = 5.49 CI = 1.74–17.27), while diabetes was associated with WHR (AOR = 1.19; CI = 1.19–31.21). This study showed an associative link between obesity, HBP, and diabetes among the truckers, which is informative for a relevant prevention programme tailored to their needs.

Role of Circulating Microparticles in Type 2 Diabetes Mellitus: Implications for Pathological Clotting

Type 2 diabetes mellitus (T2DM) is a multifactorial chronic metabolic disease characterized by chronic hyperglycemia due to insulin resistance and a deficiency in insulin secretion. The global diabetes pandemic relates primarily to T2DM, which is the most prevalent form of diabetes, accounting for over 90% of all cases. Chronic low-grade inflammation, triggered by numerous risk factors, and the chronic activation of the immune system are prominent features of T2DM. Here we highlight the role of blood cells (platelets, and red and white blood cells) and vascular endothelial cells as drivers of systemic inflammation in T2DM. In addition, we discuss the role of microparticles (MPs) in systemic inflammation and hypercoagulation. Although once seen as inert by-products of cell activation or destruction, MPs are now considered to be a disseminated storage pool of bioactive effectors of thrombosis, inflammation, and vascular function. They have been identified to circulate at elevated levels in the bloodstream of individuals with increased risk of atherothrombosis or cardiovascular disease, two significant hallmark conditions of T2DM. There is also general evidence that MPs activate blood cells, express proinflammatory and coagulant effects, interact directly with cell receptors, and transfer biological material. MPs are considered major players in the pathogenesis of many systemic inflammatory diseases and may be potentially useful biomarkers of disease activity and may not only be of prognostic value but may act as novel therapeutic targets.

Interactive workshops as a learning and teaching method for primary healthcare nurses

BACKGROUND

Traditionally, learning by and teaching for primary healthcare (PHC) nurses use didactic, teacher-centred approaches. Hence, the feasibility of interactive workshops in non-threatening PHC environments to refresh nurses' knowledge on patient care needs exploring.

AIM

To describe interactive workshops as a learning and teaching method for PHC nurses.

SETTING

Primary healthcare clinics.

METHODS

Systematic literature search followed by an exploratory experimental pre or post-test control group design. Random clinic sampling (n = 26) led to clinic inclusion at the control (n = 5) and experimental (n = 5) sites. Nurses (n = 42) were conveniently selected for the control (n = 21) and experimental (n = 21) groups. Experimental participants (n = 21) attended interactive workshops (n = 5) where various strategies were applied, whilst addressing key diabetes messages. Both groups completed a questionnaire aligned to diabetes messages pre- and post-workshop. Additionally, a Likert scale questionnaire was posed to the experimental group post-workshop. Data was analysed statistically and presented as descriptive statistics, frequencies and percentages.

RESULTS

Articles reviewed (n = 20) identified types of interactive activities, role players, learning content covered, feasibility and duration of the interactive workshops. Pre or post-testing results of the workshops participants indicate improved knowledge related to peripheral sensation (0.03) and (< 0.01). Results from the questionnaire revealed participants' satisfaction with the interactive workshops.

CONCLUSION

Interactive workshops as a learning and teaching method could lead to change in knowledge, and participant satisfaction. However, using a combination of interactive workshops and other teaching modalities may enhance learning and teaching further.

CONTRIBUTION

Interactive workshops are a feasible instructional method during refresher courses for healthcare providers.

Exploring Factors Associated with Diabetic Retinopathy Treatment Compliance Behaviour in Cape Town, South Africa

Complete patient adherence to treatment for diabetic retinopathy (DR) is critical to limit vision loss. There is a dearth of evidence regarding the reasons why South African patients referred for suspected vision-threatening DR stay compliant to or default their treatment. The current study sought to explore factors associated with treatment compliance among patients living with diabetes who have been referred for suspected vision-threatening DR in the Northern/Tygerberg sub-Structure (NTSS) public health care system of Cape Town, South Africa. A qualitative research approach was used where semi-structured in-depth interviews were conducted with 13 adult patients living with DR, and 2 key informants who are primary eye care providers. Thematic data analysis was conducted using taguette.org. Fear of going blind was the most notable patient-related factor associated with compliance. Notable patient-related barriers reported were forgetfulness and a poor state of health. Notable institution-related barriers included suboptimal information received from health care service providers, poor referral management by the organisation delivering retinal screening services, as well as the inaccessibility of the main NTSS hospital via telephone calls. All these factors were confirmed by the key informants of the current study. Finally, all patients and key informants agreed that SARS-CoV-2 negatively affected patients’ adherence to their DR treatment. Hence, scaling up of health care, referral, and appointment setting services could increase the uptake of treatment and retinal screenings among patients attending the Cape Town, NTSS public health care system.

Lifestyle medicine: A positive approach to stemming the tide of non-communicable diseases in South Africa

Non-communicable diseases account for most deaths globally and they are the main reason for patient consultations. Conventional medicine focuses on pharmaceutical and surgical interventions to manage these diseases. Most management protocols recognise the foundational role of lifestyle changes, but practical lifestyle medicine interventions need to become part of the medical curriculum and part of each consultation to make an impact. This article presents the rationale for the launch of the South African Lifestyle Medicine Association as an important facilitator of that process.

Multimorbidity in South Africa: a systematic review of prevalence studies

OBJECTIVES

To review prevalence studies of multimorbidity in South Africa to identify prevalence estimates, common disease clusters and factors associated with multimorbidity.

DESIGN

Systematic review.

SETTING

South Africa (general community and healthcare facilities).

DATA SOURCES

Articles were retrieved from electronic databases (PubMed, Web of Science, Scopus, CINAHL, Science Direct and JSTOR).

ELIGIBILITY CRITERIA

Studies addressing the prevalence of multimorbidity in South Africa were eligible for inclusion. A systematic search was done in various databases up to December 2020. A risk of bias assessment was conducted for each article using a modified checklist.

STUDY SELECTION

Two researchers independently screened titles and abstracts; assessed the risk of bias of each study and extracted data. Included studies were described using a narrative synthesis.

RESULTS

In total, 1407 titles were retrieved; of which 10 articles were included in the narrative synthesis. Six studies had a low risk of bias and three had a moderate risk of bias. One study was not assessed for risk of bias, because there was no criteria that apply to routine health information systems. Three of the included studies were population-based surveys, four were community-based cohorts and three cross-sectional studies of health facility data. The prevalence of multimorbidity was low to moderate (3%-23%) in studies that included younger people or had a wide range of selected age groups; and moderate to high (30%-87%) in studies of older adults. The common disease clusters were hypertension and diabetes, hypertension and HIV, and TB and HIV.

CONCLUSION

All studies indicated that multimorbidity is a norm in South Africa, especially among older adults. Hypertension is the main driver of multimorbidity. Research on multimorbidity in South Africa needs to be strengthened with high-quality study designs.

PROSPERO REGISTRATION NUMBER

CRD42020196895.

The Effect of Periodontal Disease on Metabolic Control in Patients With Diabetes Mellitus in South Africa: Protocol for a Systematic Review

BACKGROUND

The increase in the prevalence of type 2 diabetes mellitus (T2DM) and its associated complications is burdensome to the South African health system. Understanding the role of comorbid diseases, such as periodontal disease (PD), and their effect on metabolic control in patients with DM in South Africa will raise awareness about the importance of periodontal interventions among patients with DM in South Africa.

OBJECTIVE

The review will aim to determine the effect of PD on the metabolic control of T2DM in a South African population.

METHODS

A systematic review of the relationship between PD and metabolic control in patients with T2DM in a South African population will be conducted. Cohort, cross-sectional, and case-controlled studies will be considered in which the outcome of interest is diabetic control. A search will be done in the following sources: EBSCOhost (academic search complete; dentistry and oral sciences), PubMed, ScienceDirect, and the South African National ETD Portal for articles published in English. There will be no limit placed on the date of the publication. The reference list of articles will be reviewed for further inclusion of critical articles. Two independent reviewers (AJ and FK-D) will do study selection, data extraction, and quality analysis. All disputes will be resolved by discussion, and the entire team will verify final decisions.

RESULTS

The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). A preliminary search was conducted using the keywords ((perio*) AND (diabet*)) AND ("South Africa"). The review process should be completed by December 2021.

CONCLUSIONS

The review will determine the effect of PD on metabolic control in patients with T2DM in South Africa. The outcome would inform health policy to highlight the need to include periodontal care into treatment protocols in patients with T2DM. In this process, the feasibility for future research in this area of interest will also be defined.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020221064; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=221064.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/27471.

Real-world data from Europe and Africa suggest that accuracy of systems for self-monitoring of blood glucose is frequently impaired by low hematocrit

AIMS

Certain systems for self-monitoring of blood glucose (SMBG) demonstrate inaccuracy at low and high hematocrit (HCT). Manufacturers define HCT ranges for accurate performance. Our objective was to assess the frequency of HCT values that can lead to clinically relevant errors.

METHODS

In this cross-sectional study, we collected real-world data representing over 360,000 outpatients from the Netherlands (NL), the Czech Republic (CZ), and South Africa (ZA). These were subsequently stratified by sex and age and compared to commonly specified HCT range limits, reference intervals, and data from 1780 healthy Czech subjects.

RESULTS

HCT values were comparably distributed in NL and CZ. Outpatients had a higher dispersion of values than healthy subjects. Low HCT values in Europe were common in age groups with a high prevalence of diabetes. All ZA age groups showed a higher prevalence of low HCT than in Europe.

CONCLUSIONS

Real-world data indicate that SMBG systems specified to perform only within the frequently used 30-55% HCT range would leave 3% of outpatients in Europe and 18% in South Africa at risk of false SMBG results, with individual age strata being substantially higher. This could affect their diabetes management. Adequate SMBG systems should thus be chosen.

Prevalence of Type 2 Diabetes in South Africa: A Systematic Review and Meta-Analysis

Synthesis of existing prevalence data using rigorous systematic review methods is considered an effective strategy to generate representative and robust prevalence figures to inform health planning and policy. The purpose of this systematic review was to identify, collate, and synthesise all studies reporting the prevalence of total and newly diagnosed type 2 diabetes (T2DM), impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) in South Africa. Four databases, PubMed, Scopus, Web of Science, and African Index Medicus were searched for articles published between January 1997 and June 2020. A total of 1886 articles were identified, of which 11 were included in the meta-analysis. The pooled prevalence in individuals 25 years and older was 15.25% (11.07–19.95%) for T2DM, 9.59% (5.82–14.17%) for IGT, 3.55% (0.38–9.61%) for IFG, and 8.29% (4.97–12.34%) for newly diagnosed T2DM. Although our pooled estimate may be imprecise due to significant heterogeneity across studies with regard to population group, age, gender, setting, diagnostic test, and study design, we provide evidence that the burden of glucose intolerance in South Africa is high. These factors contribute to the paucity of representative T2DM prevalence data. There is a need for well-designed epidemiological studies that use best-practice and standardised methods to assess prevalence.

Trends in diabetes research outputs in South Africa over 30 years from 2010 to 2019: A bibliometric analysis

Diabetes mellitus (DM) is one of the leading causes of mortality in South Africa, which is impelled by people's consumption of unhealthy diets and lifestyles, negligence about an individual's health status, and increased urbanization. DM can be linked to several human diseases and thus, making it an important public health issue in the South African health sector. Therefore, it is necessary to assess the level of research that has been conducted in the country on diabetes, in a quest for solutions against the deadly disease. Hence, the present study aimed to map diabetes-related research in South Africa from 2010 to 2019. Data on the subject was retrieved from the Web of Science Core Collection (WoSCC) and bibliometrix package in Rstudio statistical software was used to analyze the data while VOSviewer was explored for data visualization networks. Our analysis revealed that the annual growth rate of publication trends was 23.2%. The authors per document were 23.3 with a collaboration index of 23.4. From the 416 articles analyzed, Islam MS (n = 34) was the most prolific author and the top active institution was University of KwaZulu-Natal (n = 165) and the top journal was Diabetes Research and Clinical Practice (n = 20). Findings from this study reveal that the quantity of research on diabetes has significantly increased over the decade, and the outcomes of this scientific progress can guide future research and substantially provide the basic needs for improving management procedures for diabetes in the country.

Demographic stratification of Type 2 diabetes and comorbidities in district healthcare in KwaZulu-Natal

Background

Diabetes has been reported as the second leading cause of death and the top leading cause of death amongst women in South Africa; it is important to evaluate any epidemiological or demographic transition related to diabetes. This study evaluated the demographically stratified prevalence of type 2 diabetes mellitus (T2DM) and existing comorbidities amongst an outpatient population in a district healthcare facility in Kwazulu-Natal (KZN).

Methods

This retrospective cross-sectional study was conducted at a district hospital, and a retrospective record review of all outpatients who reported to the hospital to be treated for T2DM between the period, August 2018–January 2019, was used. Data, such as age, sex, ethnicity and any coexisting morbidity, were collected from outpatient hospital registers and electronically captured using a record review tool.

Results

There were significantly more female patients (3072) compared to male patients (1050) (p < 0.001) with a mean age of 59.21 years. Hypertension (77.9%) and cardiovascular problems (11.16%) were most frequent. Approximately 84% of women presented with T2DM and either one or two morbidities simultaneously. Female patients were at significantly higher risk of presenting with hypertension (odds ratio [OR] = 1.44, 95% confidence interval [CI]: 1.20;1.71), whilst their risk for cardiovascular problems was significantly lower compared to male patients (OR = 0.67, 95% CI: 0.54;0.83).

Conclusion

The prevalence of T2DM and comorbidities differed by demographic factors, such as sex, ethnicity and age. There is a need for flexible and adaptive approaches for the prevention and management of T2DM cases in order to allocate medical resources efficiently and according to the true burden of disease because of T2DM complications.

Thymoquinone, the Most Prominent Constituent of Nigella Sativa, Attenuates Liver Damage in Streptozotocin-Induced Diabetic Rats via Regulation of Oxidative Stress, Inflammation and Cyclooxygenase-2 Protein Expression

Diabetes mellitus (DM) is a multifaceted metabolic disorder that results in dysfunction and failure of various organs. The present study aimed to evaluate the role of Thymoquinone (TQ), on antidiabetic, oxidative stress, and anti-inflammatory activities in streptozotocin (STZ)-induced (55 mg/kg b.w) diabetic rats. TQ was orally given for 8 consecutive weeks at dose of 150 mg/kg b.w. The blood glucose, insulin, total cholesterol, triglycerides, liver function enzymes, high density lipoprotein (HDL)-cholesterol, and low-density lipoprotein (LDL)-cholesterol levels were measured accordingly in control, diabetes control (DC), and TQ-treatment groups. These experiments confirmed that TQ conserves the insulin level (0.4 ng/mL vs. 0.23 ng/mL), fasting blood glucose (146 ± 7 mg/dL vs. 225 ± 5 mg/dL), and HbA1c (7.5% vs. 10.6%) quite considerably as compared to DC animals. Our results also confirmed that TQ treatment conserves the body weight and lipid profile significantly in STZ-treated animals as compared to the DC group. Moreover, the antioxidant enzymes (GSH, SOD, GST, and CAT) levels decreased, liver function enzymes (ALT, AST, and ALP), lipid peroxidation and inflammatory markers (TNF-α, CRP, IL-1β, IL-6) increased by STZ treatment, that is significantly restored after TQ treatment. As compared to untreated animals, TQ restored the hepatocytes architectural changes and collagen fibers and cox-2 protein expression in liver tissues as evaluated by hematoxylin and eosin, Masson’s trichrome, and immunohistochemistry staining. Taken together, all these findings indicated that TQ ameliorates glucose level and lipid metabolism. It restores liver function, antioxidant enzymes, anti-inflammatory markers, and maintains hepatocytes architecture in STZ-induced diabetes mellitus rats. Here, in this study, we have demonstrated for the first time the role of TQ in the reduction of the expression of cyclooxygenase-2 and fibrosis formation in diabetic rats. Based on the findings, the study suggests that TQ is a novel natural drug with a wide range of clinical applications including the management of diabetes mellitus.

Linking market authorizations of medicines with disease burden in South Africa

BACKGROUND

Sub-Saharan Africa is going through an epidemiological transition, including an impressive increase in non-communicable diseases. The introduction of medicines has not kept pace with the needs in developing countries. The objectives of this study were to (i) examine the correlation between the number of medicine approvals and disease burden and (ii) compare approval timelines of medicines with disease burden in South Africa in the period 2012-2017.

METHODS

The dataset was compiled from publicly available data on medicines registered in South Africa between 2012 and 2017. A correlation analysis was conducted to determine the level of alignment between the number and nature of medicines registered, as determined by the WHO ATC Classification and the Lancet Global Burden of Disease data. Median registration timelines were determined to assess whether medicines for diseases of higher burden were registered faster.

RESULTS

A total of 3059 registered medicines were included in the study, including 2779 generic medicines, 267 new chemical entities and 13 vaccines. There was a high level of alignment between the number of medicines registered to treat diseases with higher disease burden levels more effectively, except for lower respiratory tract infections and HIV/AIDS which showed less medicines registered as compared to expectations based on disease burden, respectively. HIV/AIDS showed a lower level of correlation with a much higher disease burden compared to number of medicines registered, but simultaneously also a much shorter median registration timeline (32 months) compared to the other disease areas.

CONCLUSIONS

There was generally a high level of alignment between disease burden and number of medicines authorised, except for HIV/AIDS and lower respiratory tract infections. Regulatory authorities should continue to consider burden of disease data to ensure that public health needs are met.

Alotaibi A, Al-zharani M, Ziyyat A, Mekhfi H, Legssyer A, Aziz M, Bnouham M. Opuntia dillenii (Ker Gawl.) Haw., Seeds Oil Antidiabetic Potential Using In Vivo, In Vitro, In Situ, and Ex Vivo Approaches to Reveal Its Underlying Mechanism of Action

Opuntia dillenii Ker Gawl. is one of the medicinal plants used for the prevention and treatment of diabetes mellitus (DM) in Morocco. This study aims to investigate the antihyperglycemic effect of Opuntia dillenii seed oil (ODSO), its mechanism of action, and any hypoglycemic risk and toxic effects. The antihyperglycemic effect was assessed using the OGTT test in normal and streptozotocin (STZ)-diabetic rats. The mechanisms of action were explored by studying the effect of ODSO on the intestinal absorption of d-glucose using the intestinal in situ single-pass perfusion technique. An Ussing chamber was used to explore the effects of ODSO on intestinal sodium-glucose cotransporter 1 (SGLT1). Additionally, ODSO’s effect on carbohydrate degrading enzymes, pancreatic α-amylase, and intestinal α-glucosidase was evaluated in vitro and in vivo using STZ-diabetic rats. The acute toxicity test on mice was performed, along with a single-dose hypoglycemic effect test. The results showed that ODSO significantly attenuated the postprandial hyperglycemia in normal and STZ-diabetic rats. Indeed, ODSO significantly decreased the intestinal d-glucose absorption in situ. The ex vivo test (Ussing chamber) showed that the ODSO significantly blocks the SGLT1 (IC₅₀ = 60.24 µg/mL). Moreover, ODSO indu\ced a significant inhibition of intestinal α-glucosidase (IC₅₀ = 278 ± 0.01 µg/mL) and pancreatic α-amylase (IC₅₀ = 0.81 ± 0.09 mg/mL) in vitro. A significant decrease of postprandial hyperglycemia was observed in sucrose/starch-loaded normal and STZ-diabetic ODSO-treated rats. On the other hand, ODSO had no risk of hypoglycemia on the basal glucose levels in normal rats. Therefore, no toxic effect was observed in ODSO-treated mice up to 7 mL/kg. The results of this study suggest that ODSO could be suitable as an antidiabetic functional food.

Prevalence of multimorbidity in South Africa: a systematic review protocol

INTRODUCTION

Multimorbidity has increased globally over the past two decades, due to ageing populations and increased burden of non-communicable diseases (NCDs). In a country like South Africa, with a growing burden of NCDs and a high prevalence of HIV, information on multimorbidity can improve planning for healthcare delivery and utilisation, and reduce costs in the context of constrained health resources. This review aims to synthesise prevalence studies on multimorbidity, and identify dominant clusters and trends of multimorbidity in South Africa.

METHODS AND ANALYSIS

We will search electronic bibliographic databases (PubMed, Scopus, JSTOR, POPLINE, PsycINFO, ScienceDirect, Web of Science and CINAHL), and the reference lists of included articles. Two researchers will independently screen title and abstracts, and then full text to identify studies published before and in 2020 that report on prevalence of multimorbidity in South Africa. Risk of bias assessments will be done for each study. Information on the prevalence of multimorbidity and disease clusters will be extracted from each study. Where possible, prevalence of specific clusters of multimorbidity will be pooled using a random effects meta-analysis to account for variability between studies. The I2 statistic will be used to establish the extent of heterogeneity due to variation in prevalence estimates rather than due to chance. The systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

Only published journal articles will be included in the systematic review. This review received ethics approval as part of a larger project by the University of the Western Cape Biomedical Science Research Ethics Committee (BM20/5/8). The findings from this research will be used to estimate the prevalence of multimorbidity in South Africa and will contribute to the design of future research projects. The findings will be disseminated in a peer-reviewed journal article.

PROSPERO REGISTRATION NUMBER

CRD42020196895.

A systematic analysis on prevalence and sub-regional distribution of undiagnosed diabetes mellitus among adults in African countries

BACKGROUND

Despite the high prevalence of diabetes in Africa, the extent of undiagnosed diabetes in the region is still poorly understood. This systematic review and meta-analysis was designed to determine the pooled prevalence of undiagnosed diabetes mellitus among adults in Africa.

METHODS

We conducted a systematic desk review and electronic web-based search of PubMed, Google Scholar, EMBASE, and the World Health Organization's Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases), identifying peer-reviewed research studies on the prevalence of undiagnosed diabetes among adult individuals using pre-defined quality and inclusion criteria. We ran our search from June 1, 2018 to Jun 14, 2020. We extracted relevant data and presented descriptive summaries of the studies in tabular form. The I² test was used to assess heterogeneity across studies. A random effects model was used to estimate the pooled prevalence of undiagnosed diabetes mellitus at a 95% confidence interval (CI). Funnel plot asymmetry and Egger's tests were used to check for publication bias. The final effect size was determined by applying a trim and fill analysis in a random-effects model.

RESULTS

Our search identified 1442 studies amongst which 23 articles were eligible for inclusion in the final meta-analysis. The average pooled prevalence of undiagnosed diabetes mellitus among adults was 3.85 (95% CI: 3.10-4.60). The pooled prevalence of undiagnosed diabetes mellitus based on geographic location was 4.43 (95% CI: 3.12-5.74) in Eastern Africa; 4.72 (95% CI: 2.64-6.80) in Western Africa; 4.27 (95% CI: 1.77-6.76) in Northern Africa and 1.46 (95%CI: 0.57-2.34) in southern Africa respectively.

CONCLUSION

Our findings indicate a high prevalence of undiagnosed diabetes in Africa and suggest that it may be more prevalent in Western Africa than the rest of the regions. Given the high levels of undiagnosed diabetes in the Africa region, more attention should be paid to incorporating diabetes screening and treatment services into existing diabetes related programs to reduce the prevalence of undiagnosed cases.

In Vitro Antidiabetic and Antioxidant Effects of Different Extracts of Catharanthus roseus and Its Indole Alkaloid, Vindoline

The Catharanthus roseus plant has been used traditionally to treat diabetes mellitus. Scientific evidence supporting the antidiabetic effects of this plant's active ingredient-vindoline has not been fully evaluated. In this study, extracts of C. roseus and vindoline were tested for antioxidant activities, alpha amylase and alpha glucosidase inhibitory activities and insulin secretory effects in pancreatic RIN-5F cell line cultured in the absence of glucose, at low and high glucose concentrations. The methanolic extract of the plant showed the highest antioxidant activities in addition to the high total polyphenolic content (p < 0.05). The HPLC results exhibited increased concentration of vindoline in the dichloromethane and the ethylacetate extracts. Vindoline showed noticeable antioxidant activity when compared to ascorbic acid at p < 0.05 and significantly improved the in vitro insulin secretion. The intracellular reactive oxygen species formation in glucotoxicity-induced cells was significantly reduced following treatment with vindoline, methanolic and the dichloromethane extracts when compared to the high glucose untreated control (p < 0.05). Plant extracts and vindoline showed weaker inhibitory effects on the activities of carbohydrate metabolizing enzymes when compared to acarbose, which inhibited the activities of the enzymes by 80%. The plant extracts also exhibited weak alpha amylase and alpha glucosidase inhibitory effects.

Self-management of persons living with diabetes mellitus type 2: Experiences of diabetes nurse educators

Background

The global pandemic of diabetes mellitus type 2 (DM2) is the direct cause of significant health and economic problems for both governments and individuals owing to the high level of morbidity and mortality. South Africa has the second highest incidence of DM2 in sub-Saharan Africa.

Aim

This article describes the experiences of diabetes nurse educators in relation to self-management of DM2 of persons living with DM2.

Setting

This article involves nurse educators working in diabetes clinics in public and private hospitals in Nelson Mandela Bay Municipality, South Africa.

Methods

A semi-structured interview guide was used to collect data from a focus group interview comprising three participants and two individual interviews. The interviews were recorded with the permission of participants, transcribed and then coded using Tesch’s model of data analysis. Themes were agreed upon with the consensus of the researcher, two supervisors and an independent coder.

Results

Three themes were identified: (1) diabetes nurse educators have clear perceptions about the importance of self-management of DM2 of persons living with DM2, (2) there are factors that affect persons living with DM2 with respect to self-management and (3) there are ways in which professional nurses can assist persons living with DM2 in the self-management of their condition.

Conclusion

This article identified factors that diabetes nurse educators experienced in either assisting or hindering patients in self-management of their DM2. The diabetes nurse educators voiced their views on how professional nurses can provide support to the patients living with DM2.

Ethnicity, age and disease-associated variation in body fluid-specific CpG sites in a diverse South African cohort

Tissue-specific differential DNA methylation has been an attractive target for the development of markers for discrimination of body fluids found at crime scenes. Though mostly stable, DNA methylation patterns have been shown to vary between different ethnic groups, in different age groups as well as between healthy and diseased individuals. To the best of our knowledge, none of the markers for body fluid identification have been applied to different ethnic groups to ascertain if variability exists. In the present study, saliva and blood were collected to determine the effects of ethnicity (Blacks, Whites, Coloureds and Indians), age (20-30 years, 40-50years and above 60 years) and diabetes on methylation profiles of potential saliva- and blood-specific DMSs. Both DMSs were previously shown to exhibit hypermethylation in their target body fluids at single CpG sites, however in the present study, additional CpG sites flanking the reported sites were also screened. Bisulfite sequencing revealed that Coloureds showed highest methylation levels for both body fluids, and blacks displayed significant differences between other ethnic groups in the blood-specific CpG sites. A decline in methylation for both potential DMRs was observed with increasing age. Heavily methylated CpG sites in different ethnic groups and previously reported DMSs displayed hypomethylation with increasing age and disease status. Diabetic status did not show any significant difference in methylation when compared to healthy counterparts. Thus, the use of methylation markers for forensics needs thorough investigation of influence of external factors and ideally, several CpG sites should be co-analysed instead of a single DMS.

Evaluation of the suitability of 19 pharmacogenomics biomarkers for individualized metformin therapy for type 2 diabetes patients

Objectives Type 2 Diabetes mellitus is a progressive metabolic disease characterized by relative insulin insufficiency and insulin resistance resulting in hyperglycemia. Despite the widespread use of metformin, there is considerable variation in treatment response; with approximately one-third of patients failing to achieve adequate glycemic control. Studies have reported the involvement of single nucleotide polymorphisms and their interactions in genetic pathways i.e., pharmacodynamics and pharmacokinetics. This study aims to investigate the association between 19 pharmacogenetics biomarkers and response to metformin treatment. Methods MassARRAY panels were designed and optimized by Inqaba Biotechnical Industries, to genotype 19 biomarkers for 140 type 2 diabetic outpatients. Results The CT genotype of the rs12752688 polymorphism was significantly associated with increased response to metformin therapy after correction (OR=0.33, 95% CI [0.16-0.68], p-value=0.006). An association was also found between the GA genotype of SLC47A2 rs12943590 and a decreased response to metformin therapy after correction (OR=2.29, 95% CI [1.01-5.21], p-value=0.01). Conclusions This is the first study investigating the association between genetic variants and responsiveness to medication for diabetic patients from the indigenous Nguni population in South Africa. It is suggested that rs12752688 and rs12943590 be included in pharmacogenomics profiling systems to individualize metformin therapy for diabetic patients from African populations.

Evaluation of the suitability of 19 pharmacogenomics biomarkers for individualized metformin therapy for type 2 diabetes patients

Objectives Type 2 Diabetes mellitus is a progressive metabolic disease characterized by relative insulin insufficiency and insulin resistance resulting in hyperglycemia. Despite the widespread use of metformin, there is considerable variation in treatment response; with approximately one-third of patients failing to achieve adequate glycemic control. Studies have reported the involvement of single nucleotide polymorphisms and their interactions in genetic pathways i.e., pharmacodynamics and pharmacokinetics. This study aims to investigate the association between 19 pharmacogenetics biomarkers and response to metformin treatment. Methods MassARRAY panels were designed and optimized by Inqaba Biotechnical Industries, to genotype 19 biomarkers for 140 type 2 diabetic outpatients. Results The CT genotype of the rs12752688 polymorphism was significantly associated with increased response to metformin therapy after correction (OR=0.33, 95% CI [0.16-0.68], p-value=0.006). An association was also found between the GA genotype of SLC47A2 rs12943590 and a decreased response to metformin therapy after correction (OR=2.29, 95% CI [1.01-5.21], p-value=0.01). Conclusions This is the first study investigating the association between genetic variants and responsiveness to medication for diabetic patients from the indigenous Nguni population in South Africa. It is suggested that rs12752688 and rs12943590 be included in pharmacogenomics profiling systems to individualize metformin therapy for diabetic patients from African populations.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background

There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.

Objective

Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.

Our Approach

Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.

Ongoing Activities

A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities.

Conclusion

There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

In Vitro Antidiabetic Activity Affecting Glucose Uptake in HepG2 Cells Following Their Exposure to Extracts of Lauridia tetragona (L.f.) R.H. Archer

The incidence of diabetes is on the rise and one of the medically active plants used for the treatment of diabetes in South Africa is Lauridia tetragona. The aim of this study is to investigate the antidiabetic property of the polyphenolics (PP) compounds isolated from the methanolic extract of Lauridia tetragona. The α-amylase, α-glucosidase, dipeptidyl peptidase IV (DPPIV), lipase inhibitory activities, and glucose uptake in HepG2 were investigated. The methanolic extract fractions of L. tetragona yielded six fractions (PP1–PP6) all of which showed weak inhibition against DPPIV and lipase compared to the standards. However, PP4 and PP6 showed the best inhibition against α-amylase (IC50 of 359.3 ± 2.11 and 416.82 ± 2.58 μg/mL, respectively) and α-glucosidase (IC50 of 95.93 ± 2.34 and 104.49 ± 2.21 μg/mL, respectively) and only PP4 (173.6%) resulted in enhanced glucose uptake in HepG2 cells compared to berberine (129.89%) and metformin (187.16%) used as positive controls. The previous investigation on PP4 and PP6 showed the presence of polyphenolics such as ferulic acid, coumaric acid, and caffeic acid. The results of this study suggest that L. tetragona could be suitable as an antidiabetic agent and justifies the folkloric use of the plant to treat diabetes.

Migration status and prevalence of diabetes and hypertension in Gauteng province, South Africa: effect modification by demographic and socioeconomic characteristics-a cross-sectional population-based study

INTRODUCTION

Evidence from low-income and middle-income countries suggests that migration status has an impact on health. However, little is known about the effect that migration status has on morbidity in sub-Saharan Africa. The aim of this study is to investigate the association between migration status and hypertension and diabetes and to assess whether the association was modified by demographic and socioeconomic characteristics.

METHODS

A Quality ofLife survey conducted in 2015 collected data on migration status and morbidity from a sample of 28 007 adults in 508 administrative wards in Gauteng province (GP). Migration status was divided into three groups: non-migrant if born in Gauteng province, internal migrant if born in other South African provinces, and external migrant if born outside of South Africa. Diabetes and hypertension were defined based on self-reported clinical diagnosis. We applied a recently developed original, stepwise-multilevel logistic regression of discriminatory accuracy to investigate the association between migration status and hypertension and diabetes. Potential effect modification by age, sex, race, socioeconomic status (SES) and ward-level deprivation on the association between migration status and morbidities was tested.

RESULTS

Migrants have lower prevalence of diabetes and hypertension. In multilevel models, migrants had lower odds of reporting hypertension than internal migrants (OR=0.86; 95% CI 0.78 to 0.95) and external migrant (OR=0.60; 95% CI 0.49 to 0.75). Being a migrant was also associated with lower diabetes prevalence than being an internal migrant (OR=0.84; 95% CI 0.75 to 0.94) and external migrant (OR=0.53; 95% CI 0.41 to 0.68). Age, race and SES were significant effect modifiers of the association between migration status and morbidities. There was also substantial residual between-ward variance in hypertension and diabetes with median OR of 1.61 and 1.24, respectively.

CONCLUSIONS

Migration status is associated with prevalence of two non-communicable conditions. The association was modified by age, race and SES. Ward-level effects also explain differences in association.