Diabetes in sub-saharan Africa: kenya, mali, mozambique, Nigeria, South Africa and zambia

Discovery of the selective and nanomolar inhibitor of DPP-4 more potent than sitagliptin by structure-guided rational design

Various therapeutic targets and approaches are commonly employed in the management of Type 2 Diabetes. These encompass diverse groups of drugs that target different mechanisms involved in glucose regulation. Inhibition of the DPP-4 enzyme has been proven an excellent target for antidiabetic drug design. Our previous work on discovering multitarget antidiabetic drugs led to the identification of a gallic acid-thiazolidinedione hybrid as a potent DPP4 inhibitor (IC50 = 36 nM). In current research, our efforts resulted in a new dihydropyrimidine-based scaffold with enhanced DPP4 inhibition potential. After virtual evaluation, the designed molecules with excellent interaction patterns and binding energy values were synthesized in the wet laboratory. The inhibition potential of synthesized compounds was assessed against the DPP-4 enzyme. Compound 46 with single digit IC50 value 2 nM exhibited 4-fold and 18-fold higher activity than Sitagliptin and our previously reported hybrid respectively. Moreover, compounds 46, 47 and 50 have shown manyfold selectivity against DPP8 and DPP9. Further pretreatment with compounds 43, 45-47 and 50 (at doses of 10 and 20 mg/kg) in OGTT conducted on rats resulted in a significant decrease in the serum glucose levels compared to the control group. In the long-term STZ-induced diabetic rats, tested compound 50 performed similarly to the reference drug. Molecular dynamics simulations and in-silico molecular docking studies were employed to elucidate the time-dependent interactions of inhibitors within the active sites of DPP4. The compounds examined in this work might serve as a possible lead in the development of effective diabetic mellitus treatments.

Stress-induced overeating behaviors explained from a (transitory) relief-learning perspective

People use various behaviors to cope with stressful events. These behaviors are mostly adaptive, as they allow a successful release of stress without impacting other aspects of life: How nice is it to have a break with a few spoons of that favorite ice cream during a hectic working day? However, when excessive consumption of high-sugar/salt ultra-processed food becomes the gateway to find relief from stress, eating loses this adaptive function and may escalate to binge eating, lead to obesity, and other medical conditions linked to overweight. Several etiological models attempt to explain stress-induced eating and excessive overeating behaviors characterizing these clinical conditions. The popular Emotional Eating Theory proposes that stress-related (over-)eating, a major predictor of obesity and diagnosed binge eating disorders, develops based on negative reinforcement learning since food consumption regulates the negative affective state associated with stressful circumstances. Differently, the prominent Incentive Sensitization Theory explains overeating, binge eating disorders (including bulimia), and obesity in terms of excessive amplification of reward 'wanting', which is thought to emerge from overexposure to obesogenic (food)cues. The several studies oriented by these theories have paved the way to better understand stress-related (over-)eating and its clinical excesses. However, a deep mechanistic understanding of how and why stress-induced (over-)eating can escalate till clinical forms of overeating remain elusive. A well-funded connection of the mechanisms proposed by the Emotional Eating Theory and the Incentive Sensitization Theory might address this etiological open question. To avoid erroneous arguments, it is however essential to first address the internal theoretical and methodological shortcomings of each theory and connected studies. These shortcomings stem from conceptual fallacies and poorly implemented designs, which might partially explain the 'high variability and low replicability' problem of empirical findings. Next, the formulation of a new integrative model could provide fresh insight into the deep learning and biological mechanisms of this escalation. A successful formalization of this model could then create the much-needed impact in clinical and preventive research since excessive overeating is a behavior hard to change once established. In this opinion paper, I propose to apply recent insights we gathered on the role of relief from the field of safety learning to stress (over-)eating. I will present a new relief-based model that, as a starting point, has the potential to connect the Emotional Eating Theory with the Incentive Sensitization Theory, setting the base for more integrative science.

Insights Into Sociodemographic Influences on Type 2 Diabetes Care and Opportunities for Digital Health Promotion in Port Harcourt, Nigeria: Quantitative Study

BACKGROUND

A significant percentage of the Nigerian population has type 2 diabetes (T2D), and a notable portion of these patients also live with comorbidities. Despite its increasing prevalence in Nigeria due to factors such as poor eating and exercise habits, there are insufficient reliable data on its incidence in major cities such as Port Harcourt, as well as on the influence of sociodemographic factors on current self-care and collaborative T2D care approaches using technology. This, coupled with a significant lack of context-specific digital health interventions for T2D care, is our major motivation for the study.

OBJECTIVE

This study aims to (1) explore the sociodemographic profile of people with T2D and understand how it directly influences their care; (2) generate an accurate understanding of collaborative care practices, with a focus on nuances in the contextual provision of T2D care; and (3) identify opportunities for improving the adoption of digital health technologies based on the current understanding of technology use and T2D care.

METHODS

We designed questionnaires aligned with the study's objectives to obtain quantitative data, using both WhatsApp (Meta Platforms, Inc) and in-person interactions. A social media campaign aimed at reaching a hard-to-reach audience facilitated questionnaire delivery via WhatsApp, also allowing us to explore its feasibility as a data collection tool. In parallel, we distributed surveys in person. We collected 110 responses in total: 83 (75.5%) from in-person distributions and 27 (24.5%) from the WhatsApp approach. Data analysis was conducted using descriptive and inferential statistical methods on SPSS Premium (version 29; IBM Corp) and JASP (version 0.16.4; University of Amsterdam) software. This dual approach ensured comprehensive data collection and analysis for our study.

RESULTS

Results were categorized into 3 groups to address our research objectives. We found that men with T2D were significantly older (mean 61 y), had higher household incomes, and generally held higher academic degrees compared to women (P=.03). No statistically significant relationship was found between gender and the frequency of hospital visits (P=.60) or pharmacy visits (P=.48), and cultural differences did not influence disease incidence. Regarding management approaches, 75.5% (83/110) relied on prescribed medications; 60% (66/110) on dietary modifications; and 35.5% (39/110) and 20% (22/110) on traditional medicines and spirituality, respectively. Most participants (82/110, 74.5%) were unfamiliar with diabetes care technologies, and 89.2% (98/110) of those using technology were only familiar with glucometers. Finally, participants preferred seeking health information in person (96/110, 87.3%) over digital means.

CONCLUSIONS

By identifying the influence of sociodemographic factors on diabetes care and health or information seeking behaviors, we were able to identify context-specific opportunities for enhancing the adoption of digital health technologies.

Mapping the evidence on integrated service delivery for non-communicable and infectious disease comorbidity in sub-Saharan Africa: protocol for a scoping review

INTRODUCTION

The concurrent occurrence of infectious diseases (IDs) and non-communicable diseases (NCDs) presents complex healthcare challenges in sub-Saharan Africa (SSA), where healthcare systems often grapple with limited resources. While an integrated care approach has been advocated to address these complex challenges, there is a recognised gap in comprehensive evidence regarding the various models of integrated care, their components and the feasibility of their implementation. This scoping review aims to bridge this gap by examining the breadth and nature of evidence on integrated care models for NCDs and IDs within SSA, thereby updating the current evidence base in the domain.

METHODS AND ANALYSIS

Based on the Joanna Briggs Institute (JBI) framework for scoping reviews, this study will include peer-reviewed and grey literature reporting on integrated care models for NCD-ID comorbidities in SSA. A comprehensive search of published sources in electronic databases (PubMed, Scopus, Embase, the Cochrane Library, Health System Evidence and Research4Life) and grey literature (Google Scholar, EBSCO Open Dissertations and relevant organisational websites) will be conducted to identify sources of information reported in English from 2018 onwards. The review will consider sources of evidence reporting on integrated care model for NCDs such as diabetes; chronic cardiovascular, respiratory and kidney diseases; cancers; epilepsy; and mental illness, and comorbid IDs such as HIV, tuberculosis and malaria. All sources of evidence will be considered irrespective of the study designs or methods used. The review will exclude sources that solely focus on the differentiated or patient-centred care delivery approach, and that focus on other conditions, populations or settings. The reviewers will independently screen the sources for eligibility and extract data using a JBI-adapted data tool on the Parsifal review platform. Data will be analysed using descriptive and thematic analyses and results will be presented in tables, figures, diagrams and a narrative summary.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as it will synthesise published data and does not involve human participants. The final report will be submitted for publication in a peer-reviewed journal. The findings will be used to inform future research.

STUDY REGISTRATION

OSF: https://doi.org/10.17605/OSF.IO/KFVEY.

Burden of cardiovascular disease in Sub-Saharan Africa, 1990-2019: An analysis of the Global Burden of Disease Study

INTRODUCTION

The rise in cardiovascular disease (CVD) in Sub-Saharan Africa (SSA) reflects a major shift from communicable to noncommunicable diseases as primary health challenges. Consequently, this study aims to explore the burden of CVD and associated risk factors in SSA using data from the Global Burden of Disease (GBD) database.

METHODS

This study utilized data from the GBD 1990 to 2019 to examine CVD prevalence in 46 SSA countries. We employed Bayesian regression models, demographic techniques, and mortality-to-incidence ratios to analyze both prevalence and mortality rates. Additionally, disability-adjusted life years (DALYs) were computed, and various risk factors were examined using the GBD's comparative risk assessment framework.

RESULTS

Between 1990 and 2019, CVD raw counts in SSA rose by 131.7 %, with a 2.1 % increase in age-standardized prevalence rates. The most prevalent conditions were ischemic heart disease, stroke, and rheumatic heart disease. During the same period, the age-standardized CVD deaths per 100,000 individuals decreased from 314 (1990) to 269 (2019), reflecting a -14.4 % decline. Age-standardized CVD DALY rates also showed a decrease from 6,755 in 1990 to 5,476 in 2019, with translates to 18.9 % reduction. By 2019, the Central African Republic, Madagascar, and Lesotho were the countries with the highest age-standardized DALY rates for all CVDs.

CONCLUSIONS

The study highlights a contrasting trend in SSA's CVD landscape: a decrease in age-standardized mortality and DALYs contrasts with increasing CVD prevalence, emphasizing the need for targeted public health strategies that balance treatment advancements with intensified prevention and control measures.

Acute coronary syndrome patterns in the Young: risk factor profile and in-hospital outcomes in a tertiary referral hospital in Kenya

INTRODUCTION

Acute coronary syndrome (ACS) accounts for coronary artery disease (CAD) -related morbidity and mortality. There has been growing concern about the rising incidence of ACS among young individuals globally both in developed and developing countries, including Sub-Saharan Africa. This group's phenotypic characteristics; risk factors and clinical outcomes are not well described. contextual and regional studies are necessary to understand the magnitude of ACS among young Individuals and help highlight challenges and opportunities for improved ACS outcomes in the region. The study aimed to describe the demographic and clinical characteristics of young individuals hospitalized with ACS and report on in-hospital outcomes.

METHODOLOGY

This single-center retrospective study was conducted at the Aga Khan University Hospital, Nairobi. Medical records of all young individuals hospitalized with ACS from 30th June 2020 to 1st May 2023 were reviewed. We defined young individuals as 50 years or below. Categorical variables were reported as frequencies and proportions, and compared with Pearson chi- square or Fisher's exact tests. Continuous variables were reported as means or medians and compared with independent t-tests or Mann-Whitney U tests. P- value < 0.05 was considered statistically significant.

RESULTS

Among 506 patients hospitalized with ACS, (n = 138,27.2%) were aged 50 years and below. The study population was male (n = 107, 79.9%) and African(n = 82,61.2%) predominant with a median age of 46.5 years (IQR 41.0-50.0). Hypertension (n = 101,75.4%) was noted in most study participants. More than half of the cohort were smokers (n = 69,51.5%) having a family history of premature ASCVD(n = 70,52.2%) and were on lipid-lowering therapy(n = 68,50.7%) prior to presentation. ST-segment-elevation myocardial infarction (STEMI) was the most common clinical manifestation of ACS (n = 77, 57.5%). Of the significant coronary artery disease (n = 75,56.0%), the majority of the individuals had single vessel disease (n = 60, 80%) with a predilection of left anterior deciding artery(n = 47,62.6%). The Main cause of ACS was atherosclerosis (n = 41,54.6%). The mean left ventricular ejection fraction was 46.0 (± 12.4). The in-hospital mortality was (n = 2, 1.5%).

CONCLUSION

This study highlights that young individuals contribute to a relatively large proportion of patients presenting with ACS at our center. The most common presentation was STEMI. The principal cause was atherosclerosis. The findings of this study highlight the importance of developing systems of care that enable the early detection of CAD. Traditional cardiovascular risk factors were prevalent and modifiable, thus targets of intervention.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya

Background

Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease.

Objectives

The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya.

Methods

This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI.

Results

The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P < .001), majority male (79% of men with AKI vs 63.6% without AKI; P < .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P < .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P < .001) and 1.68 (95% CI = 1.27-2.23; P < .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P < .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge.

Conclusions

This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established.

Thyroid dysfunction and glycaemic control among Type 2 diabetes mellitus patients in Ghana: A comparative cross-sectional study

INTRODUCTION

Thyroid disorders and diabetes mellitus coexist and are prevalent endocrinopathies among adult population. Thyroid dysfunction contributes to metabolic imbalances, increase beta-cell apoptosis and glucose intolerance. There is paucity of data and contradicting findings on how thyroid dysfunction influence glycaemic control. Therefore, we evaluated thyroid dysfunction and glycaemic control among Type 2 diabetes mellitus (T2DM) patients in Ghana.

METHODS

A comparative cross-sectional study was conducted among 192 T2DM patients from Effia Nkwanta Regional Hospital. Three consecutive monthly fasting plasma glucose (FBG) and glycated haemoglobin (HbA1c) were analysed and the results were classified as, moderate hyperglycaemia (MH) (FBG = 6.1-12.0 mmol/L, HbA1c < 7%), severe hyperglycaemia (SH) (FBG ≥ 12.1 mmol/L, HbA1c > 7%) and good glycaemic controls (GC) (FBG = 4.1-6.0 mmol/L, HbA1c < 7%). Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxine (FT4), body mass index (BMI) and other clinical parameters were measured. Data analysis was done using R language version 4.0.2 and p < .05 was considered statistically significant.

RESULTS

There were no significant differences in age (years) between patients in the various glycaemic groups (p = .9053). The overall prevalence of thyroid disorders was 7.8% among T2DM patients. The prevalence of thyroid disorders was higher in patients with SH (11.7%) followed by those with MH (7.5%) and then those with GC (5.4%). Serum levels of TSH and FT3/FT4 ratio were significantly lower in T2DM patients with SH compared to those with MH and the GC (p < .0001). However, FT4 was significantly higher in SH patients compared to the good glycaemic controls (p < .01). The first tertiles of TSH [aOR = 10.51, 95% CI (4.04-17.36), p < .0001] and FT3 [aOR = 2.77, 95% CI (1.11-6.92), p = .0290] were significantly and independently associated with increased odds of hyperglycaemia.

CONCLUSION

The prevalence of thyroid dysfunction is high in T2DM and increases with hyperglycaemia. Reduced TSH and T3 may worsen glycaemic control. Periodic monitoring of thyroid function should be incorporated into management guidelines among T2DM patients in Ghana.

Global Prevalence of Anemia Among Type 2 Diabetic Adult Patients: A Systematic Review and Meta-Analysis

Background

Anemia is a common and often overlooked hematological change observed in patients with diabetes mellitus. However, there is no global survey or health registry that estimates the pooled prevalence of anemia in patients with type 2 diabetes. Therefore, this study aimed to determine the global pooled prevalence of anemia among adult patients with type 2 diabetes.

Methods

This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The study protocol was registered on PROSPERO with the reference number (CRD42022327135), and the link provided (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022327135) display the published methodology. Previously published articles were searched in PubMed/Medline, Cochrane Library, WHO Global Index Medicus, African Journals Online, ScienceDirect, Google Scholar, and Google from October 26 to November 09, 2022. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal tool. Random-effects model was used to estimate the pooled prevalence of anemia. The degree of heterogeneity among the included studies was assessed using I2 statistics. Publication bias was detected using funnel plot symmetry analysis supplemented by Egger's and Begg's tests.

Results

Twenty-four studies with a total number of 19,118 participants were included in this systematic review and meta-analysis. The overall pooled prevalence of anemia among type 2 diabetic adult patients was 27.0% (95% CI: 24.0, 31.0, I2 = 96.45%; P< 0.001). Geographical and time-based subgroup analysis showed that higher prevalence of anemia was observed in Africa region 28.0% (95% CI: 17.0, 39.0) and from 2015 to 2022, 28.0% (95% CI: 24.0, 33.0), respectively.

Conclusion

Anemia is a moderate public health problem among adult patients with type 2 diabetes. Nearly one in four patients with type 2 diabetes develops anemia. Therefore, considering the negative impact of anemia, it is important to include anemia screening in the routine assessment of diabetes-related complications.

Patients' Satisfaction, Diabetic Control and Associated Factors at a Tertiary Health Facility in Rivers State, Nigeria

Background

Non-communicable diseases (NCDs) are the leading cause of death globally and diabetes mellitus (DM) is the fourth main contributor. The incidence of its complications could be reduced with high-quality care and good glycaemic control. Treatment satisfaction is an important aspect of quality of care, especially in treating chronic diseases like DM. This study sought to determine the satisfaction of diabetics with their care and to identify the relationship between patients' satisfaction and diabetic control alongside other associated factors.

Methodology

The study was a descriptive cross-sectional, hospital-based study. Respondents were admitted into the study based on inclusion criteria and selected using a systematic random sampling technique. Blood samples for fasting plasma glucose and total cholesterol were collected. Diabetic Treatment Satisfaction Questionnaire and the Patient Satisfaction Questionnaire were used to assess treatment satisfaction. The SPSS version 21.0 was used for data analysis and linear regression was used to determine the factors influencing satisfaction. The level of significance was set at 0.05.

Results

The mean total Diabetes Treatment Satisfaction score was 33.8 ± 8.2 and the mean total Short-Form Patient Satisfaction score was found to be 16.8 ± 3.6. There was a statistically significant difference between the mean satisfaction scores with treatment of diabetes mellitus and age groups (p < 0.001). There was also a statistically significant association between DM treatment satisfaction with the use of oral antidiabetic agents (p = 0.043) and the presence of complications (P < 0.001).

Conclusion

There was a significant correlation between patient satisfaction scores and other factors like accessibility and convenience, time spent with doctors, and so on. In conclusion, the study identified the use of oral anti-diabetic agents, and the presence of complications, among others as factors affecting patient satisfaction. This study, therefore, suggests improving the practice of patient-centered medicine by increasing patient satisfaction through addressing these factors.

Type 2 diabetes prevalence, awareness, and risk factors in rural Mali: a cross-sectional study

Diabetes is currently a crisis in sub-Saharan West Africa (SSWA) with dramatic implications for public health and national budgets prioritizing infectious diseases. There is limited recent literature about the prevalence, awareness, and risk factors for type 2 diabetes (T2D) in rural parts of SSWA. This study characterized T2D prevalence and risk factors for the rural Malian community of Nièna, which is situated in Mali's second-largest province of Sikasso. Between December 2020 and July 2021, a cross-sectional study of 412 participants was conducted in the Nièna community using clinical questionnaires and rapid diagnostic tests. Among 412 participants, there were 143 (34.7%) and 269 (65.3%) males and females, respectively. The overall prevalence of T2D in Nièna was 7.5% (31/412), and prevalence rates were 8.6% (23/269) and 5.6% (8/143) for females and males, respectively. Age, family history of diabetes, hypertension, waist circumference, and fetal macrosomia were significantly associated with T2D (p = 0.007, p < 0.001, p = 0.003, p = 0.013, and p < 0.001, respectively). Notably, 61.3% (19/31) of T2D subjects were unaware of their diabetic status before the study. Field surveys have considerable utility in driving T2D awareness in rural African settings.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda

BACKGROUND

The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda.

METHODS

Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes.

RESULTS

In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001.

CONCLUSION

Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book.

TRIAL REGISTRATION

The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17^th May 2019. The registration number is PACTR201905538846394.

Non-adherence to medication and associated factors among type 2 diabetes patients at Clinique Medicale Fraternite, Rwanda: a cross-sectional study

BACKGROUND

Type 2 Diabetes Miletus (T2DM) is a public health burdens that alarmingly increases and leads to morbidity and mortality over the last decades globally. Its management is multifaceted and adherence to diabetic medications plays great roles in life of T2DM patients. But epidemiology on adherence and its associated factors remain unknown in Rwanda. Therefore, this study determined the extent of non-adherence and its predictors among T2DM patients seeking healthcare services at the Clinique Medicale la Fraternite.

METHODS

A cross-sectional study among 200 adults' patients with T2DM receiving care in the Medicale la Fraternite clinic was investigated. Bivariate and multivariate logistic regression models were performed based on odds ratio employed to examine associated predictors of non-adherence. The cut-off value for all statistical significances tests were considered at p < 0.05 with 95% for the confidence intervals.

RESULTS

Overall, more than a half of T2DM patients (53.5%) had poor medication adherence. Being females [OR = 2.1, 95%CI(1.13-3.71), p = 0.002], consuming anti-diabetic drugs for 4-10 years [OR = 2.18, 95%CI(1.09-4.34), p = 0.027], experiencing poor communication with healthcare providers [OR = 2.4; 95%CI (1.36-4.25), p = 0.003] and being perceived as burden of the family [OR = 5.8; 95%CI(1.3-25.7), p < 0.021] had higher odds of non-adherence to anti-diabetic medications. Those with poor HbA1C [OR = 4.26; 95%CI(1.7-10.67), p = 0.002] had 4.26 times higher odds to be non-adherent compared to those with good HbA1C. Respondents with primary [OR = 3.56; 95%CI (1.12-11.28), p = 0.031] and secondary education [OR = 2.96; 95%CI (1.11-7.87), p = 0.03] were more likely to be non-adherent than those with informal education respectively. Those with normal BMI [OR = 5.17; 95%CI(1.63-16.37), p = 0.005] and those with overweight or obese [OR = 3.6; 95%CI (1.04-9.1), p < 0.02] had higher odds of being non-adherent than those with underweight.

CONCLUSION

Sex, glycaemia, communication with healthcare providers, education and gycosylated hemoglobin were the major predictors of non-adherence. Interventions for tackling this problem through bringing together efforts to stem this epidemic and controlling predictors of non-adherence are urgently recommended.

Development of a Complex Intervention for Effective Management of Type 2 Diabetes in a Developing Country

There has been little focus on designing tailored diabetes management strategies in developing countries. The aim of this study is to develop a theory-driven, tailored and context-specific complex intervention for the effective management of type 2 diabetes at a tertiary care setting of a developing country. We conducted interviews and focus groups with patients, health professionals, and policymakers and undertook thematic analysis to identify gaps in diabetes management. The results of our previously completed systematic review informed data collection. We used the United Kingdom Medical Research Council framework to guide the development of the intervention. Results comprised 48 interviews, two focus groups with 11 participants and three co-design panels with 24 participants. We identified a lack of structured type 2 diabetes education, counselling, and collaborative care of type 2 diabetes. Through triangulation of the evidence obtained from data collection, we developed an intervention called VICKY (patient-centred collaborative care and structured diabetes education and counselling) for effective management of type 2 diabetes. VICKY comprised five components: (1) patient-centred collaborative care; (2) referral system for patients across transitions of care between different health professionals of the diabetes care team; (3) tools for the provision of collaborative care and documentation of care; (4) diabetes education and counselling by trained diabetes educators; and (5) contextualised diabetes education curriculum, educational materials, and documentation tools for diabetes education and counselling. Implementation of the intervention may help to promote evidence-based, patient-centred, and contextualised diabetes care for improved patient outcomes in a developing country.

Prevalence of microvascular and macrovascular complications of diabetes in newly diagnosed type 2 diabetes in low-and-middle-income countries: A systematic review and meta-analysis

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings.

Prevalence and Socioeconomic Factors of Diabetes and High Blood Pressure Among Women in Kenya: A Cross-Sectional Study

Background

The emerging burden of high blood pressure (HBP) and diabetes in sub-Saharan Africa will create new challenges to health systems in African countries. There is a scarcity of studies that have reported associations of diabetes and HBP with socioeconomic factors on women within the population. We assessed the prevalence and socioeconomic factors of diabetes and high blood pressure among women in Kenya.

Methods

We analysed cross-sectional data from the 2014 Kenya Demographic and Health Survey. Subjects were women aged 15–49 years. Self-reported status of HBP and diabetes was used to measure the prevalences. The association between educational and wealth index with HBP and diabetes was assessed by multivariable binary logistic regression.

Results

The prevalences of self-reported HBP and diabetes were 9.4% and 1.3%, respectively. Women with secondary [aOR = 1.53; 95% CI = 1.15–2.02] and primary [aOR = 1.48; 95% CI = 1.15–1.92] levels of education were more likely to report having HBP, compared to those with no formal education. However, there was no significant association between educational level and self-reported diabetes. In terms of wealth quintile, we found that women with higher wealth quintile were more likely to report having HBP and diabetes compared to those with poorest wealth quintile. Specifically, the highest odds of self-reported HBP was found among women with richest wealth quintile compared to those with poorest wealth quintile [aOR = 2.22; 95% CI = 1.71–2.88]. Also, women with poorer wealth quintile were more likely to have self-reported diabetes compared to those with poorest wealth quintile [aOR = 1.89; 95% CI = 1.08–2.38].

Conclusion

The prevalence of HBP and diabetes was low among women in Kenya. Household wealth status was associated with HBP and diabetes. No causation can be inferred from the data; hence, longitudinal studies focusing on health-related behaviour associated with NCDs are recommended. Proper dissemination of health information regarding the risk factors for HBP and diabetes may prove to be beneficial for NCD prevention programmes.

The Role of Finding Out in Type 2 Diabetes Management among West-African Immigrants Living in the UK

Type 2 diabetes (T2DM) prevalence is three times higher among West African Immigrants compared to the general population in the UK. The challenges of managing T2DM among this group have resulted in complications. Reports have highlighted the impact of migration on the health of the immigrant population, and this has contributed to the need to understand the influence of living in West Africa, and getting diagnosed with T2DM, in the management of their condition in the UK. Using a qualitative constructivist grounded theory approach, thirty-four West African immigrants living in the UK were recruited for this study. All participants were interviewed using Semi-structured interviews. After coding transcripts, concepts emerged including noticing symptoms, delayed diagnosis, affordability of health services, beliefs about health, feelings at diagnosis, and emotions experienced at diagnosis all contribute to finding out about diagnosis T2DM. These factors were linked to living in West Africa, among participants, and played significant roles in managing T2DM in the UK. These concepts were discussed under finding out as the overarching concept. Findings from this study highlight important aspects of T2DM diagnosis and how lived experiences, of living in West Africa and the UK, contribute to managing T2DM among West African immigrants. The findings of this study can be valuable for healthcare services supporting West African immigrants living in the UK.

Challenge of diabetes mellitus and researchers’ contributions to its control

The aim of this review study was to assess the past significant events on diabetes mellitus, transformations that took place over the years in the medical records of treatment, countries involved, and the researchers who brought about the revolutions. This study used the content analysis to report the existence of diabetes mellitus and the treatments provided by researchers to control it. The focus was mainly on three main types of diabetes (type 1, type 2, and type 3 diabetes). Ethical consideration has also helped to boost diabetic studies globally. The research has a history path from pharmaceuticals of organic-based drugs to metal-based drugs with their nanoparticles in addition to the impacts of nanomedicine, biosensors, and telemedicine. Ongoing and future studies in alternative medicine such as vanadium nanoparticles (metal nanoparticles) are promising.

Anaemia and its associated factors among diabetes mellitus patients in Ethiopia: A systematic review and meta-analysis

Introduction

Anaemia is common but often overlooked in diabetes mellitus (DM) patients. There is also no official nationwide survey registry that estimated the prevalence of anaemia in DM patients in Ethiopia. Therefore, the main aim of this study is to determine the countrywide pooled prevalence and associated factors of anaemia in DM patients.

Methods

This systematic review and meta‐analysis were conducted as per the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. STATA 11 software was used for all statistical analysis. Random effects model was used to estimate the pooled prevalence of anaemia and associated factors at a 95% confidence interval (CI) with its respective odds ratio (OR). Subgroup analysis and egger test were used to determine heterogeneity and publication bias, respectively.

Results

Nine articles were included in this systematic review and meta‐analysis with a total of 2889 DM patients. The pooled prevalence of anaemia among DM patients in Ethiopia was 22.11% (95% CI: 15.83–28.39) I² = 94.8%. The prevalence of anaemia in type I and type II DM patients was (16.78% [95% CI: 11.53–22.04]) and (31.12% [95% CI; 9.66–52.58]), respectively. The prevalence of anaemia was higher among male (36.72% [95% CI: 22.58–50.87] I² = 97.6%) than female (27.51% [95% CI: 16.12–38.90] I² = 96.3%). Moreover, the odds of anaemia were higher among patients with age ˃ 60 (OR = 2.98; 95% CI: 1.83, 4.87), low estimated glomerular filtration rate (eGFR) (OR = 8.59; 95% CI: 4.76, 15.57), and duration of illness ≥5 years (OR = 2.66; 95%: 1.38, 5.13).

Conclusions

The result of this review implies that anaemia is a moderate public health problem among DM patients in Ethiopia. Older age, poor glycemic control, low eGFR and longer duration of illness were found to be the contributing factors for the development of anaemia in DM patients. Therefore, by considering the negative impact of anaemia, it is important to include anaemia screening into routine assessment of DM‐related complications targeting patients with older age, poor glycemic control, low eGFR, and longer duration of illness to reduce the magnitude of the problem.

Seeding COVID-19 across Sub-Saharan Africa: An Analysis of Reported Importation Events across 49 Countries

The first case of COVID-19 in sub-Saharan Africa (SSA) was reported by Nigeria on February 27, 2020. Whereas case counts in the entire region remain considerably less than those being reported by individual countries in Europe, Asia, and the Americas, variation in preparedness and response capacity as well as in data availability has raised concerns about undetected transmission events in the SSA region. To capture epidemiological details related to early transmission events into and within countries, a line list was developed from publicly available data on institutional websites, situation reports, press releases, and social media accounts. The availability of indicators-gender, age, travel history, date of arrival in country, reporting date of confirmation, and how detected-for each imported case was assessed. We evaluated the relationship between the time to first reported importation and the Global Health Security Index (GHSI) overall score; 13,201 confirmed cases of COVID-19 were reported by 48 countries in SSA during the 54 days following the first known introduction to the region. Of the 2,516 cases for which travel history information was publicly available, 1,129 (44.9%) were considered importation events. Imported cases tended to be male (65.0%), with a median age of 41.0 years (range: 6 weeks-88 years; IQR: 31-54 years). A country's time to report its first importation was not related to the GHSI overall score, after controlling for air traffic. Countries in SSA generally reported with less publicly available detail over time and tended to have greater information on imported than local cases.

Unravelling the involvement of gut microbiota in type 2 diabetes mellitus

Type 2 diabetes mellitus is the most prevalent metabolic disorder characterized by hyperglycemia, hyperlipidemia as well as insulin resistance and is affecting the lives of a huge population across the globe. Genetic mutations, obesity and lack of physical activity constitute the possible factors that can lead to onset and progression of this disorder. However, there is another major factor that can be the root cause of type 2 diabetes mellitus and that is an imbalance in the microorganisms that inhabit the gut. The gut microbiome is a vital component that needs to be given significant attention because any "dysbiosis" in the colonic microorganisms can transform the host from a state of health to a state of disease. This transformation is quite obvious since the gut barrier integrity, host metabolism such as sensitivity to insulin and maintaining blood glucose level are carried out by the tiny organisms inhabiting our intestine. In fact, the normal functioning of the human body is accredited to the microbes, particularly the bacteria, because they generate their metabolites that communicate with host cells and maintain normal physiology. Giving importance to gut health is, therefore, necessary to prevent metabolic diseases that can be maintained by the intake of prebiotics, probiotics, synbiotics along with healthy diet. The tiny microorganisms in the gut that keep our body free of disorders such as type 2 diabetes mellitus need to be in a state of 'eubiosis', else the consequences of disturbance in gut microbes can progress to serious complications in the host.

Diabetic polyneuropathy with/out neuropathic pain in Mali: A cross-sectional study in two reference diabetes treatment centers in Bamako (Mali), Western Africa

INTRODUCTION

Diabetic polyneuropathy (DPN) with or without neuropathic pain is a frequent complication of diabetes. This work aimed to determine the prevalence of diabetic polyneuropathy, to describe its epidemiological aspects, and to analyze the therapeutic itinerary of patients with DPN.

METHODS

This was a cross-sectional, descriptive study performed synchronously over six months at two major follow-up sites for patients with diabetes in Mali. DPN was diagnosed based on the Michigan Neuropathy Screening Instrument (MNSI). The neuropathic nature of the pain and the quality of life of patients were evaluated by the DN4 and the ED-5D scale, respectively. We used three (3) different questionnaires to collect data from patients (one at inclusion and another during the follow-up consultation) and from the caregivers of patients with DPN.

RESULTS

We included 252 patients with diabetes, and DPN was found to have a healthcare facility-based prevalence of 69.8% (176/252). The sex ratio was approximately three females for every male patient. The patients were mostly 31 to 60 years of age, 83% had type 2 diabetes, and 86.9% had neuropathic pain Approximately half of the patients (48.3%) had autonomic neuropathy and they reported moderate to intense pain, which was mainly described as a burning sensation. The patients exhibited impaired exteroceptive and proprioceptive sensations in 51.7% of cases. The patients smoked tobacco in 3.4% of cases, while 36.6% of the patients were obese and had dyslipidemia. The caregivers clearly indicated that appropriate medications were not readily accessible or available for their patients with DPN.

CONCLUSION

The healthcare facility-based prevalence of DPN with or without neuropathic pain was high in our cohort. These inexpensive and easy-to-use tools (MNSI, DN4) can be used to adequately diagnose DPN in the African context. In Mali, screening and early treatment of patients at risk of DPN should allow for a reduction of the burden of the disease, while caregivers need to be adequately trained to manage DPN.

A quality improvement project to improve diabetes self-management and patient satisfaction in a low-resourced central Kenyan hospital

Background

There is limited evidence about effective strategies for promoting culturally congruent diabetes education in low-resourced primary-care settings.

Objectives

This project, conducted in Central Kenya, examined the effect of an intervention on provider practices and patients' knowledge of diabetes self-care management.

Methods

The intervention consisted of short (30-minute) sessions that offered providers evidenced-based, culturally congruent diabetes education and teaching materials to use with patients. A checklist was used to assess providers' diabetes care practices at baseline and post intervention. Data from semi-structured patient interviews assessed patients' diabetes knowledge at baseline and post intervention. Providers and patients also completed post-intervention satisfaction surveys.

Results

Six providers and 74 patients participated in the project. Statistical analysis was completed using SPSS. Significant increases were noted in patients' post-intervention overall diabetes knowledge score (p=.05) and the foot care knowledge subscale (p=.02). No significant differences were noted between patients' baseline and post-intervention scores in the general diabetes (p=.86) or nutrition knowledge (p=.32) subscales.

Conclusion

These findings suggest supporting providers with culturally congruent tools and resources about diabetes care guidelines can improve knowledge of self-care practices in patients with diabetes.

INTREPID II: protocol for a multistudy programme of research on untreated psychosis in India, Nigeria and Trinidad

INTRODUCTION

There are few robust and directly comparable studies of the epidemiology of psychotic disorders in the Global South. INTREPID II is designed to investigate variations in untreated psychotic disorders in the Global South in (1) incidence and presentation (2) 2-year course and outcome, (3) help-seeking and impact, and (4) physical health.

METHODS

INTREPID II is a programme of research incorporating incidence, case-control and cohort studies of psychoses in contiguous urban and rural areas in India, Nigeria and Trinidad. In each country, the target samples are 240 untreated cases with a psychotic disorder, 240 age-matched, sex-matched and neighbourhood-matched controls, and 240 relatives or caregivers. Participants will be followed, in the first instance, for 2 years. In each setting, we have developed and are employing comprehensive case-finding methods to ensure cohorts are representative of the target populations. Using methods developed during pilot work, extensive data are being collected at baseline and 2-year follow-up across several domains: clinical, social, help-seeking and impact, and biological.

ETHICS AND DISSEMINATION

Informed consent is sought, and participants are free to withdraw from the study at any time. Participants are referred to mental health services if not already in contact with these and emergency treatment arranged where necessary. All data collected are confidential, except when a participant presents a serious risk to either themselves or others. This programme has been approved by ethical review boards at all participating centres. Findings will be disseminated through international conferences, publications in international journals, and through local events for key stakeholders.

Development of a graphic blood glucose monitoring chart for glycaemic control in diabetes mellitus: a modified Delphi method study

BACKGROUND

In Kenya 30% of patients admitted with ketoacidosis due to hyperglycaemia die within 48 hours of hospitalisation. Effective monitoring of blood glucose levels is critical for glycaemic control and prevention of mortality. Kenya public hospitals lack a graphic blood glucose monitoring tool.

AIMS

To develop a graphic blood glucose monitoring tool.

METHODS

Modified Delphi technique was used for consensus-building among nurses on the features of an appropriate blood glucose monitoring tool. A total of 150 nurses selected by purposive sampling participated in the study. Data were collected for 24 months through sequential interactive rounds and workshops using a questionnaire. At every round, consensus was reached if ≥75% of the nurses agreed or disagreed on a feature.

RESULTS

A graphic blood glucose monitoring chart was developed with the following features: time on the x-axis, blood glucose values on the y-axis, colour codes corresponding to blood glucose levels, existing conditions during blood glucose measurement.

SIGNIFICANCE

The chart may improve glycaemic control while stimulating further research on its effectiveness.

CONCLUSION

Modified Delphi method is useful for successive collation of judgments of nurse experts in the development of a graphic blood glucose monitoring chart.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Factors Associated with Poor Glycemic and Lipid Levels in Ambulatory Diabetes Mellitus Type 2 Patients in Asmara, Eritrea: A Cross-Sectional Study

OBJECTIVE

There is a dearth of relevant research on the rapidly evolving epidemic of diabetes mellitus (particularly Type 2 diabetes mellitus) in sub-Saharan Africa. To address some of these issues in the Eritrean context, we conducted a cross-sectional study on glycemic and lipid profiles and associated risk factors.

METHODS

A total of 309 patients with diabetes mellitus on regular follow-up at the Diabetic and Hypertensive Department at Halibet Regional Referral Hospital, Asmara, were enrolled for the study. Data on specific clinical chemistry and anthropomorphic parameters was collected. Chi-squared (χ ²) test or Fischer's exact test was used to evaluate the relationship between specific variables. Multivariate logistic regression (backward: conditional) was undertaken to identify the factors associated with increased odds of suboptimal values in glucose and specific lipid panel subfractions.

RESULTS

High proportions of patients (76.7%) had suboptimal levels of HbA1c with a mean ± SD of 8.6% ± 1.36, respectively. In multivariate regression analysis, the likelihood of HbA1c ≥ 7% was higher in patients with abnormal WHR (AOR = 3.01, 95% CI, 3.01 (1.15-7.92 = 0.024)) and in patients without hypertension (AOR = 1.97, 95% CI (1.06-3.56), p = 0.021). A unit reduction in eGFR was also associated with HbA1c ≥ 7% (AOR = 0.99, 95% CI (0.98-1 = 0.031)). In a separate analysis, the data shows that 80.9% of the patients had dyslipidemia. In particular, 62.1% of the patients had TC ≥ 200 mg/dL (risk factors: sex, hypertension, and HbA1c concentration), 81.6% had LDL-C ≥ 100 mg/dL (risk factors: sex and hypertension), 56.3% had TG ≥ 150 (risk factors: sex, HbA1c, and waist circumference), 62.8% had abnormal HDL-C (risk factors: waist circumference), 78.3% had non-HDL < 130 mg/dL (risk factors: duration of disease, reduced estimated glomerular filtration rate, and HbA1c), and 45.3% had abnormal TG/HDL (risk factors: sex, age of patient, FPG, and waist circumference).

CONCLUSIONS

The quality of care, as measured by glycemic and specific lipid targets, in this setting is suboptimal. Therefore, there is an urgent need for simultaneous improvements in both indicators. This will require evidence-based optimization of pharmacological and lifestyle interventions. Therefore, additional studies, preferably longitudinal studies with long follow-up, are required on multiple aspects of DM.

Challenges And Factors Associated With Poor Glycemic Control Among Type 2 Diabetes Mellitus Patients At Nekemte Referral Hospital, Western Ethiopia

Background

Diabetes is increasing at an alarming rate throughout the world, and ~80% of diabetics live in developing countries. Similar to the rest of sub-Saharan African countries, Ethiopia is experiencing a significant burden of diabetes, with increased prevalence, complications, and mortality, as well as life threatening disabilities. Reasons for poor glycemic control among type 2 diabetes patients are complex and multivariable. Hence, this study aimed to identify challenges and factors associated with poor glycemic control among type 2 diabetes patients.

Method

A hospital-based cross-sectional study was conducted among type 2 diabetic patients attending the diabetic clinic of Nekemte Referral Hospital (NRH) from February 1 to April 30, 2018. Fasting blood glucose levels of the last three clinic visits were obtained and the mean fasting blood glucose measurement was used to determine the level of glycemic control. Analysis included both descriptive and inferential statistics with SPSS version 20.0. Predictor variable P<0.05 was considered statistically significant.

Results

Out of the total 228 included type 2 diabetes mellitus (DM) patients, 51.8% were males. The mean age of patients was 43±12.4 years and 154 (67.5%) were found to not be following their general dietary program correctly. Nearly one third, 73 (32%), of patients never attended diabetic education and 52 (22.8%) of the patients had greater than 10 years’ duration on treatment. The majority, 148 (64.9%), of patients had poor blood glucose control. Age 40–60 years (AOR=2.01, 95% CI=0.04–0.06, P=0.044), being illiterate (AOR=3.12, 95% CI=1.52–8.50, P=0.001), having informal education only (AOR=2.28, 95% CI=2.14–32.60, P=0.024), longer duration of diabetes treatment (>10 years) (AOR=3.94, 95% CI=1.51–27.83, P=0.012), inadequate physical exercise (AOR=3.19, 95% CI=1.05–19.84, P=0.019), and smoking (AOR=4.51, 95% CI=0.00–0.50, P=0.022) were independent predictors of poor glycemic control on multivariable logistic regression analysis.

Conclusion

Nearly two-thirds of patients had poorly controlled diabetes. Age, exercise, level of education, duration of the treatment, and smoking were significantly associated with poor glycemic control. Health facilities should provide continuous education, and barriers of glycemic control should be explored with further research.

Mitigating The Burden Of Diabetes In Sub-Saharan Africa Through An Integrated Diagonal Health Systems Approach

Diabetes is a chronic non-communicable disease (NCD) presenting growing health and economic burdens in sub-Saharan Africa (SSA). Diabetes is unique due to its cross-cutting nature, impacting multiple organ systems and increasing the risk for other communicable and non-communicable diseases. Unfortunately, the quality of care for diabetes in SSA is poor, largely due to a weak disease management framework and fragmented health systems in most sub-Saharan African countries. We argue that by synergizing disease-specific vertical programs with system-specific horizontal programs through an integrated disease-system diagonal approach, we can improve access, quality, and safety of diabetes care programs while also supporting other chronic diseases. We recommend utilizing the six World Health Organization (WHO) health system building blocks - 1) leadership and governance, 2) financing, 3) health workforce, 4) health information systems, 5) supply chains, and 6) service delivery - as a framework to design a diagonal approach with a focus on health system strengthening and integration to implement and scale quality diabetes care. We discuss the successes and challenges of this approach, outline opportunities for future care programming and research, and highlight how this approach can lead to the improvement in the quality of care for diabetes and other chronic diseases across SSA.

Prevalence and risk factors for diabetes mellitus among adults in Ghana: a systematic review and meta-analysis

BACKGROUND

The prevalence and risk factors for diabetes in Ghana vary from location to location, yet no study has been conducted to quantitatively synthesize the available studies.

METHODS

The authors conducted a comprehensive literature search in Medline (PubMed), Embase, Cinahl, Web of Science, Scopus, African journals and grey literature. Two reviewers screened the articles for relevance, identified and selected studies based on inclusion and exclusion criteria. Methodological quality was independently assessed, using two validated assessment-of-bias tools. We explored study heterogeneity and performed a publication bias check.

RESULTS

This search yielded a total of 624 articles, of which 17 studies were finally selected for the qualitative review and 12 studies included in the meta-analysis. The overall prevalence of diabetes mellitus among adult Ghanaians was high at 6.46% (95% CI: 4.66-8.26%) based on the inverse-variance random-effects model. Significant risk factors associated with diabetes were a family history of diabetes (OR: 3.46, 95% CI: 2.50-4.78), physical inactivity (OR: 3.06, 95% CI: 1.66-5.64) and age ≥40 years (OR: 2.36, 95% CI: 1.77-3.16).

CONCLUSION

Studies with high methodological quality provided sufficient evidence about diabetes prevalence among adults and the associated significant risk factors in Ghana.

The general public's knowledge of diabetes mellitus: A cross-sectional study in Cameroon

OBJECTIVE

To assess the general public's level of knowledge on diabetes mellitus (DM) and identify related sources of information in Cameroon.

STUDY DESIGN

This was a cross-sectional study conducted in 2015 in two health facilities in Yaoundé and Edéa.

METHODS

We included consenting adults, except health professionals. The level of knowledge on DM was evaluated on 24 points corresponding to 24 questions addressing either DM definition, signs and symptoms, risk factors or complications.

RESULTS

Overall, 1524 persons (40.2% males) were included. Almost 99% of respondents had already heard of DM, but only 16.3% had ever received education on DM. The median score for the global knowledge was 79% (IQR 67-88). A person in the close entourage (71.3%) or a health professional (58.8%) constituted the major sources of information; school (13.3%) and media (television (23.6%), newspaper/magazine (10.0%), radio (9.6%) and internet (6.8%) were less common. Younger ages (<45years), lower levels of education, semi-urban residency, were independently associated with a lower level of knowledge on DM.

CONCLUSIONS

The general public's level of knowledge on DM may be satisfactory, though needing to be improved. Schools and media should be capitalized to educate people on DM, targeting especially young adults and the less educated.

Time to onset of type 2 diabetes mellitus in Ghana

BACKGROUND

Type 2 diabetes affects an increasing number of Ghanaians. The timing of the onset of diabetes is linked to several other co-morbid conditions, yet no study has examined the timing of the onset of type 2 diabetes in Ghana.

METHODS

To fill this gap in the literature, this study applied logit models to data extracted from the medical records at the Diabetes Clinic of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Gender-specific models were also estimated.

RESULTS

The results show that obesity was a significant predictor of the timing of the first onset of diabetes among both males and females. Women with high school education compared with no formal education, and female employees compared with the unemployed were more likely to experience an early onset of type 2 diabetes.

CONCLUSION

Policymakers must educate Ghanaians about behaviors that will reduce their risk of obesity and diabetes.

Identification of risk factors of diabetes mellitus in bank employees of selected banks in Ndola town

BACKGROUND

Diabetes mellitus, a lifelong disease is achieving pandemic proportions. The prevalence of diabetes is on the rise and is expected to be worlds 7th leading cause of death by 2030. Studies have associated a number of risk factors like obesity, lack of physical activity, sedentarism, diet, and stress to diabetes mellitus. The job of bank employees is both sedentary in nature and involves high levels of stress. These people spend almost all their working hours seated as they carry out their work. With this background, the primary objective study of this project is to identify risk factors of diabetes mellitus among bank employees of selected banks in Ndola town. This study also aims to find the prevalence of diabetes among bank employees in the selected nine banks.

METHODS

A cross-section study was conducted on 121 bank employees from nine (9) selected banks of Ndola town center. Information about their biosocial characteristics, their weight, height, blood pressure, fasting plasma glucose was measured and recorded and a questionnaire on physical activity of participants was administered. Data was analyzed by SPSS 20.0 for Windows. Univariate, bivariate and multivariate analysis were conducted to ascertain any correlation between the dependent variables and independent variables.

RESULTS

Prevalence of diabetes mellitus was found to be 15%. The risk of developing Diabetes mellitus was high in obese participants (OR 5.1 [cl95%] p = 0.000). And in physical inactive participants it was also high (OR 7.6 [cl95%] p = 0.046).

CONCLUSION

and recommendations: Diabetes mellitus shows significant correlation with physical inactivity, body mass index, blood pressure, age and sex. Findings in this study support the need for programs to promote employee health, to help prevent and monitor the enormity and temporal trends of these factor as well as asses the actions that are directed toward this population group.

Experiences and challenges of adults living with type 2 diabetes mellitus presenting at the University Teaching Hospital in Lusaka, Zambia

OBJECTIVE

The study explored the experiences and challenges of adults living with type 2 diabetes mellitus (T2DM) presenting at the University Teaching Hospital (UTH) in Lusaka.

RESEARCH DESIGN

A qualitative descriptive study was conducted. The research relied on purposive sampling to select 28 participants for in-depth interviews. Participants were interviewed during clinical visits at UTH.

RESULTS

Views from participants showed that some adults living with T2DM experienced physical and mental illnesses. Participants' views reflected that their livelihood with T2DM was influenced by family support, poor or non-adherence to treatment guidelines and access to information, education and communication materials. The most important challenges reported were psychosocial and financial.

CONCLUSION

The study concluded that some adults living with T2DM experience a lot of physical sicknesses and their challenges, especially of the psychosocial nature may require professional attention. However, particular attention should be paid to the patient's self-care and psychosocial therapy. Self-care protocols should be tailored to complement the different types of patients with diabetes and improve their quality of life. Cite Now.

Retrospective assessment of the quality of diabetes care in a rural diabetes clinic in Western Kenya

BACKGROUND

Sub-Saharan Africa continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care. We assessed the quality of diabetes care in a rural diabetes clinic in western Kenya.

METHODS

To provide a comprehensive assessment, a set of clinical outcomes, process, and structure metrics were evaluated to assess the quality of diabetes care provided in the outpatient clinic at Webuye District Hospital. The primary clinical outcome measures were the change in HbA1c and point of care blood glucose. In assessing process metrics, the primary measure was the percentage of patients who were lost to follow up. The structure metrics were assessed by evaluating different facets of the operation of the clinic and their accordance with the International Diabetes Federation (IDF) guidelines.

RESULTS

A total of 524 patients were enrolled into the diabetes clinic during the predefined period of evaluation. The overall clinic population demonstrated a statistically significant reduction in HbA1c and point of care blood glucose at all time points of evaluation after baseline. Patients had a mean baseline HbA1C of 10.2% which decreased to 8.4% amongst the patients who remained in care after 18 months. In terms of process measures, 38 patients (7.3%) were characterized as being lost to follow up as they missed clinic visits for more than 6 months. Through the assessment of structural metrics, the clinic met at least the minimal standards of care for 14 out of the 19 domains recommended by the IDF.

CONCLUSION

This analysis illustrates the gains made in various elements of diabetes care quality which can be used by other programs to guide diabetes care scale up across the region.

Hypertension and diabetes management: a policy perspective from Ghana

PURPOSE

The purpose of this paper is to assess policy and management of hypertension and diabetes in Ghana.

DESIGN/METHODOLOGY/APPROACH

The authors conducted 26 key informant interviews with policy makers, payers, providers and participants from advocacy groups associated with the management of hypertension and diabetes both at national and district levels in Ghana; conducted focus group discussions with a total of 18 hypertensive and diabetic patients; and analyzed documentation detailing activities that have been undertaken in response to the management of hypertension and diabetes in Ghana. The authors then conducted a content analysis after combining the three sources of information.

FINDINGS

Using a stepwise policy process, the Ghanaian health sector has developed overarching policies and strategies on management of diabetes, hypertension, other non-communicable diseases, tobacco, alcohol and nutrition-related issues. Availability of funds and over-concentration on communicable diseases are the main barriers to the implementation of policies. Besides, response of the health sector to address the problems of hypertension and diabetes is focused more on clinical management than prevention; while the structures and processes to manage diabetes and hypertension is available at all levels of service delivery, more needs to be done on preventive aspects.

ORIGINALITY/VALUE

This is the first study in Ghana to combine individual interviews, focus groups and document analysis to review policy development, implementation and response activities on the management of hypertension and diabetes. The authors believe that the evidence from this research will inform future policy initiatives on hypertension and diabetes management in Ghana.

Prevalence and factors associated with pre-diabetes and diabetes mellitus in Kenya: results from a national survey

BACKGROUND

Diabetes Mellitus is one of the four major non-communicable diseases causing about 4 million deaths in 2017. By 2040, low income countries are projected to experience 92% increase in mortality due to diabetes. Undiagnosed diabetes poses a public health concern with costly public health implications especially in Africa. It is therefore crucial to examine the burden and risk factors for diabetes at national level to inform policy and national programs.

METHODS

Data from the 2015 Kenya national STEPs survey of adults aged 18-69 years were used. Pre-diabetes was defined as impaired fasting blood glucose level (6.1 mmol/l to < 7 mmol/l) while diabetes was defined as impaired fasting blood glucose level ≥ 7 mmol/l. Descriptive statistics were used to determine the prevalence of pre-diabetes and diabetes and logistic regression was used to identify associated factors.

RESULTS

Complete data for 4069 respondents (51% females), with 46% aged 18-29 and 61% in rural areas were analyzed. The age-standardized prevalence for pre-diabetes and diabetes were 3.1% (95% CI: 2.2, 4.0) and 2.4% (1.8, 3.0) respectively. Only 43.7% were aware of their glycemic condition, one in five of those who had diabetes had received treatment, and only 7% of those diagnosed with diabetes had their blood glucose under control. Primary education ((both incomplete (0.21, 95%CI 0.10-0.47) and complete (0.40, 95%CI 0.23-0.71)) were associated with lower odds of pre-diabetes. Older age (60-69 years, AOR; 5.6, 95%CI 2.1-15.1) and raised blood pressure (2.8, 95% CI 1.5-5.0) were associated diabetes while overweight/obesity among women was associated with diabetes.

CONCLUSION

The overall diabetes prevalence in Kenya is consistent with what has been reported in other sub-Saharan African countries. Of concern is the higher prevalence of pre-diabetes and undiagnosed diabetes that can progress to complications in the absence of interventions and the low diabetes awareness and control. This is the first nationally representative study to identify important groups at risk of pre-diabetes and diabetes that can be targeted for screening, health promotion and treatment.

Evaluation of Health Status of Type 2 Diabetes Outpatients Receiving Care in a Tertiary Hospital in Nigeria

OBJECTIVES

The aim of this study was to determine the health status of type 2 diabetes patients in a Nigerian tertiary hospital, and examine the sociodemographic and clinical variables that predicted the health status of type 2 diabetes patients in terms of utility valuations and EuroQol Visual Analogue Scale (EQ-VAS) score.

METHODS

This was a cross-sectional study of 147 diabetes patients attending the University of Nigeria Teaching Hospital, Enugu State, Nigeria. The EQ-5D-5L instrument, version 2.1, was used to evaluate patients' self-reported health status, and patients who gave informed consent completed the questionnaire while waiting to see a doctor. Descriptive and multiple linear regression analyses were performed using SPSS version 20.

RESULTS

Overall, 147 patients participated in this study, with a mean age (± standard deviation) of 56.7 years (± 10.33). Over half of the respondents were females (55.1%) and more than half were older than 60 years of age. The mean EQ-VAS and utility valuations of respondents were 72.59 ± 10.51 and 0.72 ± 0.13, respectively. The age of respondents independently and significantly predicted EQ-VAS by -2.659 per year, while the age of respondents, level of education, duration of diabetes, and presence of other illnesses independently and significantly predicted utility valuations by -0.020 per year, +0.029 per level of education, -0.008 per year, and -0.044 per illness, respectively. Less than 39% of patients experienced no problems for each of the dimensions, except self-care (68%).

CONCLUSION

The results of this study revealed a relatively low health status among type 2 diabetic patients in Nigeria. Old age, duration of diabetes and the presence of other illnesses were major contributors to the negative impact on health status, while a higher level of education contributed positively to health status. Adequate family support, as well as regular and effective patient counseling and education, may be worthwhile.

Integration of care for hypertension and diabetes: a scoping review assessing the evidence from systematic reviews and evaluating reporting

BACKGROUND

With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension.

METHODS

We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting.

RESULTS

We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes.

CONCLUSIONS

Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.

The efficacy and safety of Ginkgo biloba extract as an adjuvant in type 2 diabetes mellitus patients ineffectively managed with metformin: a double-blind, randomized, placebo-controlled trial

Background and aim

Type 2 diabetes mellitus (T2DM) is one of the major diseases confronting the health care systems. In diabetes mellitus (DM), combined use of oral hypoglycemic medications has been shown to be more effective than metformin (Met) alone in glycemic control. This study determined the effects of Ginkgo biloba (GKB) extract as an adjuvant to Met in patients with uncontrolled T2DM.

Subjects and methods

Sixty T2DM patients were recruited in a randomized, placebo-controlled, double-blinded, and multicenter trial. The patients, currently using Met, were randomly grouped into those treated with either GKB extract (120 mg/day) or placebo (starch, 120 mg/day) for 90 days. Blood glycated hemoglobin (HbA1c), fasting serum glucose, serum insulin, body mass index (BMI), waist circumference (WC), insulin resistance, and visceral adiposity index (VAI) were determined before (baseline) and after 90 days of GKB extract treatment.

Results

GKB extract significantly decreased blood HbA1c (7.7%±1.2% vs baseline 8.6%±1.6%, P<0.001), fasting serum glucose (154.7±36.1 mg/dL vs baseline 194.4±66.1 mg/dL, P<0.001) and insulin (13.4±7.8 μU/mL vs baseline 18.5±8.9 μU/mL, P=0.006) levels, BMI (31.6±5.1 kg/m² vs baseline 34.0±6.0 kg/m², P<0.001), waist WC (102.6±10.5 cm vs baseline 106.0±10.9 cm, P<0.001), and VAI (158.9±67.2 vs baseline 192.0±86.2, P=0.007). GKB extract did not negatively impact the liver, kidney, or hematopoietic functions.

Conclusion

GKB extract as an adjuvant was effective in improving Met treatment outcomes in T2DM patients. Thus, it is suggested that GKB extract is an effective dietary supplement for the control of DM in humans.

Tropisetron modulates peripheral and central serotonin/insulin levels via insulin and nuclear factor kappa B/receptor for advanced glycation end products signalling to regulate type-2 diabetes in rats

Despite its known central effect, 5% of serotonin is found centrally, while around 95% is found peripherally. Serotonin is stored and co-released with insulin upon pancreatic islets stimulation by glucose. This fact raises the curiosity regarding its possible role in diabetes. Hence, in this study, we assessed the possible modulatory effects of tropisetron, a 5-HT3 receptor antagonist, on type 2 diabetes mellitus models in rats. The rats were allocated into two groups: normal and diabetic. The latter group was treated with metformin (500 mg kg-1, p.o.), tropisetron (1 and 2 mg kg-1, i.p.), and a combination of metformin and tropisetron (1 mg kg-1). The different treatment regimens corrected glucose and lipid homeostasis manifested by the decrease in serum levels of glucose, fructosamine, homeostasis model of insulin resistance, triglycerides, total cholesterol, free fatty acid, as well as receptor for advanced glycation end products. Additionally, the treatments elevated levels of insulin, serotonin, and homeostasis model of β-cell function. On the molecular level, treatments corrected the altered insulin signaling cascade (phosphorylated insulin receptor substrate 1, phosphorylated protein kinase B, and glucose transporter 4), and inhibited β-catenin and phosphorylated nuclear factor kappa B p65 in the assessed soleus skeletal muscle. A similar pattern was duplicated in the hippocampus. This study provided evidence for the role of tropisetron on type 2 diabetes mellitus via modulating the insulin signaling cascade (insulin, phosphorylated insulin receptor substrate 1, phosphorylated protein kinase B, and glucose transporter 4), improving lipid/glucose profile, decreasing inflammatory markers (receptor for advanced glycation end products, and phosphorylated nuclear factor kappa B p65), as well as increasing 5-HT and reducing β-catenin.

Correlation of diabetes mellitus and body weight of adults above the age of 30 years in a medical facility in Ghana

BACKGROUND

Diabetes mellitus (DM) is a metabolic disorder characterized by insufficient insulin production or ineffective pancreatic secretions. In Ghana, the prevalence of DM was estimated to be 6.3% amongst men and women older than 30 years living in the Greater Accra region. The disease can be determined by various means including the use of the multistix that assesses the presence of glucose in urine.

MATERIALS AND METHODS

In this study, 100 subjects were sampled made up of 65% males and 35% females whose urine samples were verified using multistix.

RESULTS

Most (63%) of the subjects diagnosed with the disease fell within the age ranges of 60-69 years and 70-79 years, thus establishing the fact that the incidence of the disease increases with increasing age and increasing body mass index (BMI) over above 25kg/m². Some (44%) had a family history of diabetes. Other factors such as the socioeconomic status (SES) categories, physical activity levels and eating habits of the respondents played different roles in the occurrence of the disease.

CONCLUSION

The sex of the individual, however, did not have a major impact on the occurrence of the disease. This study confirmed that overweight body (BMI≥25kg/m²) especially of older ages above 50 years of have very strong link with the prevalence of diabetes mellitus.

Diabetes in the Cape Coast metropolis of Ghana: an assessment of risk factors, nutritional practices and lifestyle changes

Background

Despite the significant increase in the incidence of diabetes in Ghana, research in this area has been lagging. The purpose of the study was to assess the risk factors associated with diabetes in the Cape Coast metropolis of Ghana, and to describe nutritional practices and efforts toward lifestyle change.

Methods

A convenient sample of 482 adults from the Cape Coast metropolis was surveyed using a self-reported questionnaire. The survey collected information on the demographic, socioeconomic characteristics, health status and routine nutritional practices of respondents. The aims of the study were addressed using multivariable regression analyses.

Results

A total of 8% of respondents reported that they had been diagnosed with diabetes. Older age and body weight were found to be independently associated with diabetes. Individuals living with diabetes were no more likely than those without diabetes to have taken active steps at reducing their weight.

Conclusion

The percentage of self-reported diabetes in this population was consistent with what has been reported in previous studies in Ghana. The findings from this study highlight the need for more patient education on physical activity and weight management.