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Sekitoleko I, Nakanga WP, Webb E, Mugamba V, Balungi P, Mpairwe B, Terry O, Makanga R, Nabanoba E, Mugisha JO, Kimbugwe G, Nyirenda MJ, Niwaha AJ. Identification and characterisation of diabetes in Uganda: protocol for the nested, population-based 'Diabetes in low-resource Populations' (DOP) Study. BMJ Open 2023; 13:e071747. [PMID: 37709304 PMCID: PMC10921991 DOI: 10.1136/bmjopen-2023-071747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/16/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Sub-Saharan Africa is experiencing an increasing burden of diabetes, but there are little reliable data, particularly at the community level, on the true prevalence or why this condition affects young and relatively lean individuals. Moreover, the detection of diabetes in Africa remains poor, not only due to a lack of resources but because the performance of available diagnostic tests is unclear. METHODS This research aims to (1) determine the prevalence and risk factors of diabetes in a rural Ugandan population, (2) use clinical and biochemical markers to define different diabetes phenotypes and (3) study the progression of diabetes in this population. We will also assess the utility of the widely used tests (glycated haemoglobin (HbA1c), oral glucose tolerance test (OGTT) and fasting glucose) in diagnosing diabetes. DESIGN This is a population-based study nested within the longstanding general population cohort in southwestern Uganda. We will undertake a population survey to identify individuals with diabetes based on fasting glucose, HbA1c, OGTT results or history of pre-existing diabetes. PARTICIPANTS The study intends to enrol up to 11 700 individuals aged 18 years and above, residing within the study area and not pregnant or within 6 months post-delivery date. All participants will have detailed biophysical and biochemical/metabolic measurements. Individuals identified to have diabetes and a random selection of controls will have repeat tests to test reproducibility before referral and enrolment into a diabetic clinic. Participants will then be followed up for 1 year to assess the course of the disease, including response to therapy and diabetes-related complications. CONCLUSIONS These data will improve our understanding of the burden of diabetes in Uganda, the risk factors that drive it and underlying pathophysiological mechanisms, as well as better ways to detect this condition. This will inform new approaches to improve the prevention and management of diabetes. ETHICS AND DISSEMINATION This study protocol was approved by the Uganda Virus Research Institute Research Ethics Committee (REC) (number: G.C./127/21/09/858), the London School of Hygiene and Tropical Medicine REC (number: 26638) and the Uganda National Council for Science and Technology (protocol number: HS1791ES). Written informed consent will be obtained from all participants before being enrolled on to the study and conducting study-related procedures. Research findings will be disseminated in policy briefs, seminars, local and international conferences and publications in peer-reviewed open-access journals. As part of the dissemination plans, findings will also be disseminated to patient care groups and to clinicians. TRIAL REGISTRATION NUMBER NCT05487079.
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Affiliation(s)
- Isaac Sekitoleko
- Statistics and Data Science, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Wisdom P Nakanga
- Non-communicable diseases, Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Malawi
| | - Emily Webb
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Viola Mugamba
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Priscilla Balungi
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Bernard Mpairwe
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Ongaria Terry
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Ronald Makanga
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Esther Nabanoba
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Joseph O Mugisha
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Geofrey Kimbugwe
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Moffat J Nyirenda
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
- NCD Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Anxious J Niwaha
- Non-communicable diseases Theme, Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
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Kansiime S, Webb EL, Kusemererwa S, Lule SA, Niwaha AJ, Seeley J, Karabarinde A, Hansen CH, Newton R. Blood pressure levels among children in rural Uganda: results from 1913 children in a general population survey. J Hum Hypertens 2022; 36:1021-1026. [PMID: 34537817 DOI: 10.1038/s41371-021-00610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/27/2021] [Accepted: 09/08/2021] [Indexed: 11/08/2022]
Abstract
Despite increasing levels of adult hypertension in sub-Saharan Africa (SSA), there is limited information on elevated blood pressure among children in SSA. We described the distribution of blood pressure among children in rural Uganda and estimated hypertension prevalence. We conducted a cross-sectional study in south-western Uganda, collecting demographic, anthropometric and blood pressure measurements from children aged 6-12 years. Children with elevated blood pressure (systolic and/or diastolic blood pressure greater or equal to the 95th percentile for age, height and sex) were invited for two further assessments 6-18 months later. We described blood pressure distribution at first assessment, assessed associations with demographic and anthropometric characteristics and estimated prevalence of hypertension as defined by having elevated blood pressure on three separate occasions months apart. Blood pressure (BP) was measured in 1913 children (50% male, 3% overweight or obese, 22% stunted) at the first assessment. Mean (SD) systolic and diastolic BP at first assessment was 113.4 mmHg (±10.8) and 69.5 mmHg (±8.3), respectively, and 44.2% had elevated BP. Older age, higher BMI, and being female were associated with higher BP, and stunted height was associated with lower BP. An estimated 7.8% [95% CI:(6.6-9.1)], (males: 6.8%, females: 9.0%), had elevated BP on three separate occasions, and were considered hypertensive. High blood pressure levels among adults in SSA may be set early in life. In this study, obesity (a common lifestyle modifiable risk factor in other settings) was largely irrelevant. More research is needed to understand the main drivers for elevated blood pressure in SSA further.
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Affiliation(s)
- Sheila Kansiime
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda.
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK.
| | - Emily L Webb
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Sylvia Kusemererwa
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Swaib A Lule
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- University College London, Institute for Global Health, London, UK
| | - Anxious J Niwaha
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Alex Karabarinde
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Christian Holm Hansen
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert Newton
- Medical Research Council/ Uganda Virus Research Council and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Department of Health Sciences, University of York, York, UK
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Niwaha AJ, Rodgers LR, Carr ALJ, Balungi PA, Mwebaze R, Hattersley AT, Shields BM, Nyirenda MJ, Jones AG. Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study. BMJ Open Diabetes Res Care 2022; 10:10/2/e002714. [PMID: 35450869 PMCID: PMC9024213 DOI: 10.1136/bmjdrc-2021-002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/27/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION People living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated with sulphonylurea (SU) and insulin therapy in people living with type 2 diabetes in a low-resource sub-Saharan African setting. RESEARCH DESIGN AND METHODS This study was conducted in the outpatients' diabetes clinics of two hospitals (one rural and one urban) in Uganda. We used blinded continuous glucose monitoring (CGM) and self-report to compare hypoglycemia rates and duration in 179 type 2 diabetes patients treated with sulphonylureas (n=100) and insulin (n=51) in comparison with those treated with metformin only (n=28). CGM-assessed hypoglycemia was defined as minutes per week below 3mmol/L (54mg/dL) and number of hypoglycemic events below 3.0 mmol/L (54 mg/dL) for at least 15 minutes. RESULTS CGM recorded hypoglycemia was infrequent in SU-treated participants and did not differ from metformin: median minutes/week of glucose <3 mmol/L were 39.2, 17.0 and 127.5 for metformin, sulphonylurea and insulin, respectively (metformin vs sulphonylurea, p=0.6). Hypoglycemia risk was strongly related to glycated haemoglobin (HbA1c) and fasting glucose, with most episodes occurring in those with tight glycemic control. After adjusting for HbA1c, time <3 mmol/L was 2.1 (95% CI 0.9 to 4.7) and 5.5 (95% CI 2.4 to 12.6) times greater with sulphonylurea and insulin, respectively, than metformin alone. CONCLUSIONS In a low-resource sub-Saharan African setting, hypoglycemia is infrequent among people with type 2 diabetes receiving sulphonylurea treatment, and the modest excess occurs predominantly in those with tight glycemic control.
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Affiliation(s)
- Anxious J Niwaha
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Alice L J Carr
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Priscilla A Balungi
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Raymond Mwebaze
- Department of Medicine, St. Francis Hospital Nsambya, Kampala, Uganda
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Moffat J Nyirenda
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- NCD Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Nakanga WP, Balungi P, Niwaha AJ, Shields BM, Hughes P, Andrews RC, Mc Donald TJ, Nyirenda MJ, Hattersley AT. Alternative pre-analytic sample handling techniques for glucose measurement in the absence of fluoride tubes in low resource settings. PLoS One 2022; 17:e0264432. [PMID: 35226681 PMCID: PMC8884485 DOI: 10.1371/journal.pone.0264432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Sodium fluoride (NaF) tubes are the recommended tubes for glucose measurements, but these are expensive, have limited number of uses, and are not always available in low resource settings. Alternative sample handling techniques are thus needed. We compared glucose stability in samples collected in various tubes exposed to different pre-analytical conditions in Uganda. METHODS Random (non-fasted) blood samples were drawn from nine healthy participants into NaF, Ethylenediaminetetraacetic acid (EDTA), and plain serum tubes. The samples were kept un-centrifuged or centrifuged with plasma or serum pipetted into aliquots, placed in cool box with ice or at room temperature and were stored in a permanent freezer after 0, 2, 6, 12 and 24 hours post blood draw before glucose analysis. RESULTS Rapid decline in glucose concentrations was observed when compared to baseline in serum (declined to 64%) and EDTA-plasma (declined to 77%) after 6 hours when samples were un-centrifuged at room temperature whilst NaF-plasma was stable after 24 hours in the same condition. Un-centrifuged EDTA-plasma kept on ice was stable for up to 6 hours but serum was not stable (degraded to 92%) in the same conditions. Early centrifugation prevented glucose decline even at room temperature regardless of the primary tube used with serum, EDTA-plasma and NaF-plasma after 24 hours. CONCLUSION In low resource settings we recommend use of EDTA tubes placed in cool box with ice and analysed within 6 hours as an alternative to NaF tubes. Alternatively, immediate separation of blood with manual hand centrifuges will allow any tube to be used even in remote settings with no electricity.
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Affiliation(s)
- Wisdom P. Nakanga
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Priscilla Balungi
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Anxious J. Niwaha
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Beverly M. Shields
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
| | - Peter Hughes
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Rob C. Andrews
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
| | - Tim J. Mc Donald
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Moffat J. Nyirenda
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Andrew T. Hattersley
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
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Niwaha AJ, Rodgers LR, Greiner R, Balungi PA, Mwebaze R, McDonald TJ, Hattersley AT, Shields BM, Nyirenda MJ, Jones AG. HbA1c performs well in monitoring glucose control even in populations with high prevalence of medical conditions that may alter its reliability: the OPTIMAL observational multicenter study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002350. [PMID: 34535465 PMCID: PMC8451306 DOI: 10.1136/bmjdrc-2021-002350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/22/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The utility of HbA1c (glycosylated hemoglobin) to estimate glycemic control in populations of African and other low-resource countries has been questioned because of high prevalence of other medical conditions that may affect its reliability. Using continuous glucose monitoring (CGM), we aimed to determine the comparative performance of HbA1c, fasting plasma glucose (FPG) (within 5 hours of a meal) and random non-fasting glucose (RPG) in assessing glycemic burden. RESEARCH DESIGN AND METHODS We assessed the performance of HbA1c, FPG and RPG in comparison to CGM mean glucose in 192 Ugandan participants with type 2 diabetes. Analysis was undertaken in all participants, and in subgroups with and without medical conditions reported to affect HbA1c reliability. We then assessed the performance of FPG and RPG, and optimal thresholds, in comparison to HbA1c in participants without medical conditions thought to alter HbA1c reliability. RESULTS 32.8% (63/192) of participants had medical conditions that may affect HbA1c reliability: anemia 9.4% (18/192), sickle cell trait and/or hemoglobin C (HbC) 22.4% (43/192), or renal impairment 6.3% (12/192). Despite high prevalence of medical conditions thought to affect HbA1c reliability, HbA1c had the strongest correlation with CGM measured glucose in day-to-day living (0.88, 95% CI 0.84 to 0.91), followed by FPG (0.82, 95% CI 0.76 to 0.86) and RPG (0.76, 95% CI 0.69 to 0.81). Among participants without conditions thought to affect HbA1c reliability, FPG and RPG had a similar diagnostic performance in identifying poor glycemic control defined by a range of HbA1c thresholds. FPG of ≥7.1 mmol/L and RPG of ≥10.5 mmol/L correctly identified 78.2% and 78.8%, respectively, of patients with an HbA1c of ≥7.0%. CONCLUSIONS HbA1c is the optimal test for monitoring glucose control even in low-income and middle-income countries where medical conditions that may alter its reliability are prevalent; FPG and RPG are valuable alternatives where HbA1c is not available.
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Affiliation(s)
- Anxious J Niwaha
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Rosamund Greiner
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Priscilla A Balungi
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Raymond Mwebaze
- Department of Medicine, St. Francis Hospital Nsambya, Kampala, Uganda
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Moffat J Nyirenda
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- NCD Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
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