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Magodoro IM, Aluoch A, Claggett B, Nyirenda MJ, Siedner MJ, Wilkinson KA, Wilkinson RJ, Ntusi N. Insulin resistance, and not β-cell impairment, mediates association between Mycobacterium tuberculosis sensitization and type II diabetes mellitus among US adults. medRxiv 2024:2024.03.10.24304039. [PMID: 38559227 PMCID: PMC10980119 DOI: 10.1101/2024.03.10.24304039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Type 2 diabetes mellitus (T2DM) may be a long-term sequela of infection with Mycobacterium tuberculosis (M.tb) by mechanisms that remain to be fully explained. We evaluated association between M.tb sensitization and T2DM among U.S adults and, via formal mediation analysis, the extent to which this association is mediated by insulin resistance and/or β-cell failure. These evaluations accounted for demographic, socio-economic, behavioral and clinical characteristics. T2DM was assessed by fasting plasma glucose, 2-hour oral glucose tolerance testing and HbA1c; homoeostasis model assessment 2 (HOMA2) was used to estimate β-cell dysfunction (HOMA2-B) and insulin resistance (HOMA2-IR); while M.tb sensitization status was ascertained by tuberculin skin testing (TST). Exposure to M.tb was associated with increased risk for T2DM, likely driven by an increase in insulin resistance. Definitive prospective studies examining incident T2DM following tuberculosis are warranted. Research in Context What is already known about this subject?: Accumulating evidence suggests that pre-diabetes and new-onset type 2 diabetes mellitus (T2DM) may be a long-term complication of exposure to Mycobacterium tuberculosis ( M.tb ) via mechanisms that remain to be unraveled What is the key question?: To what extent do insulin resistance and β-cell failure mediate the association between M.tb sensitization with T2DM among US adults? What are the new findings?: M.tb sensitization is characterized by distinct glucose metabolic disturbances manifesting as increased risk of T2DM and isolated impaired fasting glucose (IFG) Insulin resistance, and not β-cell impairment, likely independently mediate the observed diabetogenic effects of M.tb sensitization How might this impact on clinical and/or public health practice in the foreseeable future?: If corroborated by prospective studies, both TB programs and individual clinical care must incorporate monitoring of serum glucose and long-term metabolic outcomesThis will be particularly urgent in sub-Saharan Africa and South-East Asia where scarce health resources coincide with overlapping endemic TB and epidemic T2DM.
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Magodoro IM, Castle AC, Tshuma N, Goedecke JH, Sewpaul R, Manasa J, Manne-Goehler J, Ntusi N, Nyirenda MJ, Siedner MJ. Associations of HIV and prevalent type 2 diabetes mellitus in the context of obesity in South Africa. medRxiv 2024:2024.03.10.24304033. [PMID: 38559082 PMCID: PMC10980116 DOI: 10.1101/2024.03.10.24304033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
It is unclear how rising obesity among people with HIV (PWH) in sub-Saharan Africa (SSA) impacts their risk of type 2 diabetes mellitus (diabetes). Using a South African national cross-sectional sample of adult PWH and their peers without HIV (PWOH), we examined the associations between HIV and prevalent diabetes across the spectrum of body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WtHR). Analyses were sex stratified, and adjusted for age, sociodemographic and behavioral factors. The prevalence of diabetes among males was similar between PWH and PWOH, overall and at all levels of adiposity. In contrast, overall diabetes prevalence was higher among female PWOH than female PWH. However, there were differences according to adiposity such that, compared to female PWOH, relative diabetes prevalence in female PWH was reduced with obesity but accentuated with leanness. These differences in the relationship between adiposity and diabetes by HIV serostatus call for better mechanistic understanding of sex-specific adipose tissue biology in HIV in South Africa, and possibly in other HIV endemic settings in SSA.
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Misra S, Aguilar-Salinas CA, Chikowore T, Konradsen F, Ma RCW, Mbau L, Mohan V, Morton RW, Nyirenda MJ, Tapela N, Franks PW. The case for precision medicine in the prevention, diagnosis, and treatment of cardiometabolic diseases in low-income and middle-income countries. Lancet Diabetes Endocrinol 2023; 11:836-847. [PMID: 37804857 DOI: 10.1016/s2213-8587(23)00164-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 10/09/2023]
Abstract
Cardiometabolic diseases are the leading preventable causes of death in most geographies. The causes, clinical presentations, and pathogenesis of cardiometabolic diseases vary greatly worldwide, as do the resources and strategies needed to prevent and treat them. Therefore, there is no single solution and health care should be optimised, if not to the individual (ie, personalised health care), then at least to population subgroups (ie, precision medicine). This optimisation should involve tailoring health care to individual disease characteristics according to ethnicity, biology, behaviour, environment, and subjective person-level characteristics. The capacity and availability of local resources and infrastructures should also be considered. Evidence needed for equitable precision medicine cannot be generated without adequate data from all target populations, and the idea that research done in high-income countries will transfer adequately to low-income and middle-income countries (LMICs) is problematic, as many migration studies and transethnic comparisons have shown. However, most data for precision medicine research are derived from people of European ancestry living in high-income countries. In this Series paper, we discuss the case for precision medicine for cardiometabolic diseases in LMICs, the barriers and enablers, and key considerations for implementation. We focus on three propositions: first, failure to explore and implement precision medicine for cardiometabolic disease in LMICs will enhance global health disparities. Second, some LMICs might already be placed to implement cardiometabolic precision medicine under appropriate circumstances, owing to progress made in treating infectious diseases. Third, improvements in population health from precision medicine are most probably asymptotic; the greatest gains are more likely to be obtained in countries where health-care systems are less developed. We outline key recommendations for implementation of precision medicine approaches in LMICs.
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Affiliation(s)
- Shivani Misra
- Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Department of Diabetes and Endocrinology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Carlos A Aguilar-Salinas
- Dirección de Nutricion, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - Tinashe Chikowore
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Flemming Konradsen
- Novo Nordisk Foundation, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision Medicine, Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | | | - Viswanathan Mohan
- Madras Diabetes Research Foundation, ICMR Centre for Advanced Research in Diabetes, Chennai, India; Dr Mohan's Diabetes Specialties Centre, IDF Centre of Excellence in Diabetes Care, Chennai, India
| | | | - Moffat J Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda; London School of Hygiene and Tropical Medicine, London, UK
| | - Neo Tapela
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; International Consortium for Health Outcomes Measurement, Oxford, UK
| | - Paul W Franks
- Novo Nordisk Foundation, Copenhagen, Denmark; Lund University Diabetes Centre, Department of Clinical Sciences, Lund University, Malmö, Sweden; Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Harvard T H Chan School of Public Health, Boston, MA, USA.
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Kibirige D, Sekitoleko I, Lumu W, Nyirenda MJ. Type 2 diabetes progression in an adult Ugandan population with new-onset diabetes: an observational prospective study. BMC Prim Care 2023; 24:214. [PMID: 37858088 PMCID: PMC10588137 DOI: 10.1186/s12875-023-02169-4] [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] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND The rate of progression of type 2 diabetes following diagnosis varies across individuals and populations. Studies investigating the progression of type 2 diabetes in adult African populations with newly diagnosed diabetes are limited. We aimed to investigate the prevalence and predictors of short-term (one year) diabetes progression in an adult Ugandan population with new-onset type 2 diabetes (type 2 diabetes diagnosed in < 3 months) initiated on oral hypoglycaemic agents (OHA). METHODS Two hundred and seven adult participants with type 2 diabetes diagnosed within the previous three months were followed up for 12 months. We investigated the association of specific demographic, clinical, and metabolic characteristics, and short-term diabetes progression (defined as glycated haemoglobin or HbA1c ≥ 8% on ≥ 2 OHA and/or treatment intensification). RESULTS One hundred sixteen participants (56%) completed the follow-up period. Sixty-four participants (55.2%, 95% CI 45.7-64.4) showed evidence of diabetes progression during the 12-month period of follow-up. An HbA1c ≥ 8% on ≥ 2 OHA and treatment intensification were noted in 44.8% and 29.3% of the participants, respectively. On multivariate analysis, only the female gender (AOR 3.2, 95% CI 1.1-9.2, p = 0.03) was noted to be independently associated with short-term diabetes progression. CONCLUSION Short-term diabetes progression was relatively common in this study population and was independently associated with the female gender. Early intensified diabetes therapy in adult Ugandan female patients with new-onset type 2 diabetes should be emphasised to avert rapid short-term diabetes progression.
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Affiliation(s)
- Davis Kibirige
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Non-Communicable Diseases Program, Entebbe, Uganda.
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
- Department of Medicine, Uganda Martyrs Hospital Lubaga, Kampala, Uganda.
| | - Isaac Sekitoleko
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Non-Communicable Diseases Program, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Non-Communicable Diseases Program, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, Tumuhairwe F, Ouma S, Namakoola I, Garrib A, van Widenfelt E, Mutungi G, Jaoude GA, Batura N, Musinguzi J, Ssali MN, Etukoit BM, Mugisha K, Shimwela M, Ubuguyu OS, Makubi A, Jeffery C, Watiti S, Skordis J, Cuevas L, Sewankambo NK, Gill G, Katahoire A, Smith PG, Bachmann M, Lazarus JV, Mfinanga S, Nyirenda MJ, Jaffar S. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. Lancet 2023; 402:1241-1250. [PMID: 37805215 DOI: 10.1016/s0140-6736(23)01573-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING European Union Horizon 2020 and Global Alliance for Chronic Diseases.
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Affiliation(s)
- Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kaushik Ramaiya
- Tanzania NCDs Alliance, Dar es Salaam, Tanzania; Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Samafilan Ainan
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Faith Tumuhairwe
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Simple Ouma
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Kenneth Mugisha
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | | | | | | | - Caroline Jeffery
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Stephen Watiti
- The National Forum of People Living with HIV Networks in Uganda, Kampala, Uganda
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Geoff Gill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Institute for Global Health, University College London, London, UK
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Garrib A, Kivuyo S, Bates K, Ramaiya K, Wang D, Majaliwa E, Simbauranga R, Charles G, van Widenfelt E, Luo H, Alam U, Nyirenda MJ, Jaffar S, Mfinanga S. Metformin for the prevention of diabetes among people with HIV and either impaired fasting glucose or impaired glucose tolerance (prediabetes) in Tanzania: a Phase II randomised placebo-controlled trial. Diabetologia 2023; 66:1882-1896. [PMID: 37460828 PMCID: PMC10474205 DOI: 10.1007/s00125-023-05968-7] [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: 02/14/2023] [Accepted: 05/12/2023] [Indexed: 09/02/2023]
Abstract
AIMS/HYPOTHESIS In sub-Saharan Africa (SSA), 5% of adults are living with type 2 diabetes and this is rising sharply, with a greater increase among people with HIV. Evidence on the efficacy of prevention strategies in this cohort is scarce. We conducted a Phase II double-blind placebo-controlled trial that aimed to determine the impact of metformin on blood glucose levels among people with prediabetes (defined as impaired fasting glucose [IFG] and/or impaired glucose tolerance [IGT]) and HIV in SSA. METHODS Adults (≥18 years old) who were stable in HIV care and found to have prediabetes (IFG and/or IGT) and who were attending hospitals in Dar es Salaam, Tanzania, were randomised to receive sustained-release metformin, 2000 mg daily, or matching placebo between 4 November 2019 and 21 July 2020. Randomisation used permuted blocks. Allocation was concealed in the trial database and made visible only to the Chief Pharmacist after consent was taken. All participants, research and clinical staff remained blinded to the allocation. Participants were provided with information on diet and lifestyle and had access to various health information following the start of the coronavirus disease 2019 (COVID-19) pandemic. Participants were followed up for 12 months. The primary outcome measure was capillary blood glucose measured 2 h following a 75 g glucose load. Analyses were by intention-to-treat. RESULTS In total, 364 participants (182 in each arm) were randomised to the metformin or placebo group. At enrolment, in the metformin and placebo arms, mean fasting glucose was 6.37 mmol/l (95% CI 6.23, 6.50) and 6.26 mmol/l (95% CI 6.15, 6.36), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 8.39 mmol/l (95% CI 8.22, 8.56) and 8.24 mmol/l (95% CI 8.07, 8.41), respectively. At the final assessment at 12 months, 145/182 (79.7%) individuals randomised to metformin compared with 158/182 (86.8%) randomised to placebo indicated that they had taken >95% of their medicines in the previous 28 days (p=0.068). At this visit, in the metformin and placebo arms, mean fasting glucose levels were 6.17 mmol/l (95% CI 6.03, 6.30) and 6.30 mmol/l (95% CI 6.18, 6.42), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 7.88 mmol/l (95% CI 7.65, 8.12) and 7.71 mmol/l (95% CI 7.49, 7.94), respectively. Using a linear mixed model controlling for respective baseline values, the mean difference between the metformin and placebo group (metformin-placebo) was -0.08 mmol/l (95% CI -0.37, 0.20) for fasting glucose and 0.20 mmol/l (95% CI -0.17, 0.58) for glucose levels 2 h post a 75 g glucose load. Weight was significantly lower in the metformin arm than in the placebo arm: using the linear mixed model adjusting for baseline values, the mean difference in weight was -1.47 kg (95% CI -2.58, -0.35). In total, 16/182 (8.8%) individuals had a serious adverse event (Grade 3 or Grade 4 in the Division of Acquired Immunodeficiency Syndrome [DAIDS] adverse event grading table) or died in the metformin arm compared with 18/182 (9.9%) in the placebo arm; these events were either unrelated to or unlikely to be related to the study drugs. CONCLUSIONS/INTERPRETATION Blood glucose decreased over time in both the metformin and placebo arms during the trial but did not differ significantly between the arms at 12 months of follow up. Metformin therapy was found to be safe for use in individuals with HIV and prediabetes. A larger trial with longer follow up is needed to establish if metformin can be safely used for the prevention of diabetes in people who have HIV. TRIAL REGISTRATION The trial is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry ( www.isrctn.com/ ), registration number: ISCRTN76157257. FUNDING This research was funded by the National Institute for Health Research using UK aid from the UK Government to support global health research.
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Affiliation(s)
- Anupam Garrib
- UCL Institute for Global Health, University College London, London, UK.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Katie Bates
- UCL Institute for Global Health, University College London, London, UK
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Innsbruck, Austria
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edna Majaliwa
- Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Rehema Simbauranga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Godbless Charles
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Huanyan Luo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University NHS Hospital Foundation Trust, Liverpool, UK
- Department of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Moffat J Nyirenda
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- NCD Theme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- UCL Institute for Global Health, University College London, London, UK
| | - Sayoki Mfinanga
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
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Nakanga WP, Crampin AC, Mkandawire J, Banda L, Andrews RC, Hattersley AT, Nyirenda MJ, Rodgers LR. Waist circumference and glycaemia are strong predictors of progression to diabetes in individuals with prediabetes in sub-Saharan Africa: 4-year prospective cohort study in Malawi. PLOS Glob Public Health 2023; 3:e0001263. [PMID: 37756263 PMCID: PMC10529551 DOI: 10.1371/journal.pgph.0001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Sub-Saharan Africa is projected to have the highest increase in the number of people with diabetes worldwide. However, the drivers of diabetes in this region have not been clearly elucidated. The aim of this study was to evaluate the incidence of diabetes and the predictors of progression in a population-based cohort with impaired fasting glucose (IFG) in Malawi. We used data from an extensive rural and urban non-communicable disease survey. One hundred seventy-five, of 389 individuals with impaired fasting glucose (IFG) at baseline, age 48 ±15 years and body mass index 27.5 ±5.9 kg/m2 were followed up for a median of 4.2 years (714 person-years). Incidence rates were calculated, and predictors of progression to diabetes were analysed using multivariable logistic regression models, with overall performance determined using receiver operator characteristics (ROC) curves. The median follow-up was 4.2 (IQR 3.4-4.7) years. Forty-five out of 175 (26%) progressed to diabetes. Incidence rates of diabetes were 62.9 per 1000 person-years 95% CI, 47.0-84.3. The predictors of progression were higher; age (odds ratio [OR] 1.48, P = 0.046), BMI (OR 1.98, P = 0.001), waist circumference (OR 2.50,P<0.001), waist-hip ratio (OR 1.40, P = 0.03), systolic blood pressure (OR 1.56, P = 0.01), fasting plasma glucose (OR 1.53, P = 0.01), cholesterol (OR 1.44, P = 0.05) and low-density lipoprotein cholesterol (OR 1.80, P = 0.002). A simple model combining fasting plasma glucose and waist circumference was predictive of progression to diabetes (ROC area under the curve = 0.79). The incidence of diabetes in people with IFG is high in Malawi and predictors of progression are like those seen in other populations. Our data also suggests that a simple chart with probabilities of progression to diabetes based on waist circumference and fasting plasma glucose could be used to identify those at risk of progression in clinical settings in sub-Saharan Africa.
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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
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Karonga and Lilongwe, Malawi
| | - Amelia C. Crampin
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Karonga and Lilongwe, Malawi
| | - Joseph Mkandawire
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Karonga and Lilongwe, Malawi
| | - Louis Banda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Karonga and Lilongwe, Malawi
| | - Rob C. Andrews
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
| | - Andrew T. Hattersley
- National Institute for Health Research (NIHR), Exeter Clinical Research Facility, University of Exeter, Exeter, United Kingdom
| | - Moffat J. Nyirenda
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- Medical Research Council/ Uganda Virus and Research Institute and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Lauren R. Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
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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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Sekitoleko I, Tino S, Mubiru M, Nansubuga F, Zaake D, Nakabuye B, Ayiko B, Kalema H, Nakubulwa S, Sekikubo M, Milln J, Nakanga WP, Nakimuli A, Webb EL, Nyirenda MJ. The influence of fasting and post-load glucose levels on maternal and neonatal outcomes in women with hyperglycaemia in pregnancy in Uganda: A prospective observational cohort study. Diabetes Res Clin Pract 2022; 191:110049. [PMID: 36029888 DOI: 10.1016/j.diabres.2022.110049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 06/17/2022] [Accepted: 08/19/2022] [Indexed: 11/03/2022]
Abstract
AIMS The study aims to evaluate the strength of fasting versus post-load glucose levels in predicting adverse outcomes in women with hyperglycaemia in pregnancy (HIP). METHODS Women attending antenatal clinics in urban and peri-urban Uganda had oral glucose tolerance test between 24 and 28 weeks of gestation to screen for HIP, and were followed up to collect data on maternal and neonatal outcomes. Univariable and multivariable Poisson regression models were used to estimate the relative risk adverse outcome associated with fasting hyperglycaemia alone post-load hyperglycaemia alone, or elevation of both fasting and post-load glucose levels. RESULTS We included 3206 participants in the final analysis. HIP was associated with increased risk of Caesarean section, large for gestaional age babies, and neonatal intensive care admission. The risk was highest (2.54-fold compared to normal glycaemic women) when both FBG and post-load glucose levels were elevated. After adjustment for potential confounders, having elevated post-load glucose alone was not associated with increased risk of any of the outcomes, but elevated FBG alone increased the risk of Caesarian section by 1.36-fold. CONCLUSION Fasting hyperglycemia appears to be more strongly associated with adverse pregnancy outcomes than post-load hyperglycaemia, but the risk is even higher in women with elevation of both fasting and post-load glucose levels.
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Affiliation(s)
- Isaac Sekitoleko
- MRC/UVRI and LSHTM Uganda Research Unit, Uganda; London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Salome Tino
- MRC/UVRI and LSHTM Uganda Research Unit, Uganda
| | | | | | | | | | - Ben Ayiko
- Entebbe Grade B Hospital, Entebbe, Uganda
| | | | - Sarah Nakubulwa
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Kawempe Specialized National Referral Hospital, Kampala, Uganda
| | - Musa Sekikubo
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Kawempe Specialized National Referral Hospital, Kampala, Uganda
| | - Jack Milln
- Queen Mary University of London, London, United Kingdom
| | - Wisdom P Nakanga
- National Insititute for Health Research (NIHR), Exeter Clinical Research Faculty, University of Exeter, Exeter, United Kindgom
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Kawempe Specialized National Referral Hospital, Kampala, Uganda
| | - Emily L Webb
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Moffat J Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Uganda; London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kibirige D, Sekitoleko I, Balungi P, Lumu W, Nyirenda MJ. Apparent Insulin Deficiency in an Adult African Population With New-Onset Type 2 Diabetes. Front Clin Diabetes Healthc 2022; 3:944483. [PMID: 36992725 PMCID: PMC10012075 DOI: 10.3389/fcdhc.2022.944483] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022]
Abstract
Identifying patients with new-onset type 2 diabetes who have insulin deficiency can aid in timely insulin replacement therapy. In this study, we measured fasting C-peptide concentration to assess endogenous insulin secretion and determine the prevalence and characteristics of patients with insulin deficiency in adult Ugandan patients with confirmed type 2 diabetes at presentation. Methods Adult patients with new-onset diabetes were recruited from seven tertiary hospitals in Uganda. Participants who were positive for the three islet autoantibodies were excluded. Fasting C-peptide concentrations were measured in 494 adult patients, and insulin deficiency was defined as a fasting C-peptide concentration <0.76 ng/ml. The socio-demographic, clinical, and metabolic characteristics of participants with and without insulin deficiency were compared. Multivariate analysis was performed to identify independent predictors of insulin deficiency. Results The median (IQR) age, glycated haemoglobin (HbA1c), and fasting C-peptide of the participants was 48 (39-58) years,10.4 (7.7-12.5) % or 90 (61-113) mmol/mol, and 1.4 (0.8-2.1) ng/ml, respectively. Insulin deficiency was present in 108 (21.9%) participants. Participants with confirmed insulin deficiency were more likely to be male (53.7% vs 40.4%, p=0.01), and had a lower body mass index or BMI [p<0.001], were less likely to be hypertensive [p=0.03], had reduced levels of triglycerides, uric acid, and leptin concentrations [p<0.001]), but higher HbA1c concentration (p=0.004). On multivariate analysis, BMI (AOR 0.89, 95% CI 0.85-0.94, p<0.001), non-HDLC (AOR 0.77, 95% CI 0.61-0.97, p=0.026), and HbA1c concentrations (AOR 1.08, 95% CI 1.00-1.17, p=0.049) were independent predictors of insulin deficiency. Conclusion Insulin deficiency was prevalent in this population, occurring in about 1 in every 5 patients. Participants with insulin deficiency were more likely to have high HbA1c and fewer markers of adiposity and metabolic syndrome. These features should increase suspicion of insulin deficiency and guide targeted testing and insulin replacement therapy.
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Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Isaac Sekitoleko
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Priscilla Balungi
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Clinical Diagnostics Laboratory Services, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kibirige D, Sekitoleko I, Balungi P, Kyosiimire-Lugemwa J, Lumu W, Jones AG, Hattersley AT, Smeeth L, Nyirenda MJ. Islet autoantibody positivity in an adult population with recently diagnosed diabetes in Uganda. PLoS One 2022; 17:e0268783. [PMID: 35604955 PMCID: PMC9126391 DOI: 10.1371/journal.pone.0268783] [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: 09/09/2021] [Accepted: 05/07/2022] [Indexed: 12/02/2022] Open
Abstract
Aims This study aimed to investigate the frequency of islet autoantibody positivity in adult patients with recently diagnosed diabetes in Uganda and its associated characteristics. Methods Autoantibodies to glutamic acid decarboxylase-65 (GADA), zinc transporter 8 (ZnT8-A), and tyrosine phosphatase (IA-2A) were measured in 534 adult patients with recently diagnosed diabetes. Islet autoantibody positivity was defined based on diagnostic thresholds derived from a local adult population without diabetes. The socio-demographic, clinical, and metabolic characteristics of islet autoantibody-positive and negative participants were then compared. The differences in these characteristics were analysed using the x2 test for categorical data and the Kruskal Wallis test for continuous data. Multivariate analysis was performed to identify predictors of islet autoantibody positivity. Results Thirty four (6.4%) participants were positive for ≥1 islet autoantibody. GADA, IA-2A and ZnT8-A positivity was detected in 17 (3.2%), 10 (1.9%), and 7 (1.3%) participants, respectively. Compared with those negative for islet autoantibodies, participants positive for islet autoantibodies were more likely to live in a rural area (n = 18, 52.9% Vs n = 127, 25.5%, p = 0.005), to be initiated on insulin therapy (n = 19, 55.9% Vs n = 134, 26.8%, p<0.001), to have a lower median waist circumference (90 [80–99] cm Vs 96 [87–104.8], p = 0.04), waist circumference: height ratio (0.55 [0.50–0.63] vs 0.59 [0.53–0.65], p = 0.03), and fasting C-peptide concentration (0.9 [0.6–1.8] Vs 1.4 [0.8–2.1] ng/ml, p = 0.01). On multivariate analysis, living in a rural area (odds ratio or OR 3.62, 95%CI 1.68–7.80, p = 0.001) and being initiated on insulin therapy (OR 3.61, 95% CI 1.67–7.83, p = 0.001) were associated with islet autoantibody positivity. Conclusion The prevalence of islet autoantibody positivity was relatively low, suggesting that pancreatic autoimmunity is a rare cause of new-onset diabetes in this adult Ugandan population. Living in a rural area and being initiated on insulin therapy were independently associated with islet autoantibody positivity in this study population.
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Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Isaac Sekitoleko
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Priscilla Balungi
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Clinical Diagnostics Laboratory Services, Medical Research Council/Uganda Virus Research Institute, and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jacqueline Kyosiimire-Lugemwa
- Clinical Diagnostics Laboratory Services, Medical Research Council/Uganda Virus Research Institute, and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Angus G. Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, United Kingdom
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, United Kingdom
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Liam Smeeth
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kibirige D, Sekitoleko I, Lumu W, Jones AG, Hattersley AT, Smeeth L, Nyirenda MJ. Understanding the pathogenesis of lean non-autoimmune diabetes in an African population with newly diagnosed diabetes. Diabetologia 2022; 65:675-683. [PMID: 35138411 PMCID: PMC8894297 DOI: 10.1007/s00125-021-05644-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 08/26/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS Apparent type 2 diabetes is increasingly reported in lean adult individuals in sub-Saharan Africa. However, studies undertaking robust clinical and metabolic characterisation of lean individuals with new-onset type 2 diabetes are limited in this population. This cross-sectional study aimed to perform a detailed clinical and metabolic characterisation of newly diagnosed adult patients with diabetes in Uganda, in order to compare features between lean and non-lean individuals. METHODS Socio-demographic, clinical, biophysical and metabolic (including oral glucose tolerance test) data were collected on 568 adult patients with newly diagnosed diabetes. Participants were screened for islet autoantibodies to exclude those with autoimmune diabetes. The remaining participants (with type 2 diabetes) were then classified as lean (BMI <25 kg/m2) or non-lean (BMI ≥25 kg/m2), and their socio-demographic, clinical, biophysical and metabolic characteristics were compared. RESULTS Thirty-four participants (6.4%) were excluded from analyses because they were positive for pancreatic autoantibodies, and a further 34 participants because they had incomplete data. For the remaining 500 participants, the median (IQR) age, BMI and HbA1c were 48 years (39-58), 27.5 kg/m2 (23.6-31.4) and 90 mmol/mol (61-113) (10.3% [7.7-12.5]), respectively, with a female predominance (approximately 57%). Of the 500 participants, 160 (32%) and 340 (68%) were lean and non-lean, respectively. Compared with non-lean participants, lean participants were mainly male (60.6% vs 35.3%, p<0.001) and had lower visceral adiposity level (5 [4-7] vs 11 [9-13], p<0.001) and features of the metabolic syndrome (uric acid, 246.5 [205.0-290.6] vs 289 [234-347] μmol/l, p<0.001; leptin, 660.9 [174.5-1993.1] vs 3988.0 [1336.0-6595.0] pg/ml, p<0.001). In addition, they displayed markedly reduced markers of beta cell function (oral insulinogenic index 0.8 [0.3-2.5] vs 1.6 [0.6-4.6] pmol/mmol; 120 min serum C-peptide 0.70 [0.33-1.36] vs 1.02 [0.60-1.66] nmol/l, p<0.001). CONCLUSIONS/INTERPRETATION Approximately one-third of participants with incident adult-onset non-autoimmune diabetes had BMI <25 kg/m2. Diabetes in these lean individuals was more common in men, and predominantly associated with reduced pancreatic secretory function rather than insulin resistance. The underlying pathological mechanisms are unclear, but this is likely to have important management implications.
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Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Isaac Sekitoleko
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Angus G. Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, 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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15
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Kwanjo Banda C, Gombachika BT, Nyirenda MJ, Muula AS. Self-management and its associated factors among people living with diabetes in Blantyre, Malawi: a cross-sectional study. AAS Open Res 2021. [DOI: 10.12688/aasopenres.12992.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Self-management is key to the control of glycaemia and prevention of complications in people with diabetes. Many people with diabetes in Malawi have poorly controlled glucose and they experience diabetes-related complications. This study aimed to assess diabetes self-management behaviours and to identify factors associated with it among people with diabetes at Queen Elizabeth Central Hospital, Blantyre, Malawi. Methods: This cross-sectional study recruited 510 adults attending a diabetes clinic at a teaching referral hospital in southern Malawi. The social cognitive theory was applied to identify factors associated with following all recommended self-management behaviours. Data on participants’ demographics, clinical history, diabetes knowledge, self-efficacy, outcome expectations, social support, environmental barriers and diabetes self-management were collected. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with following all self-management behaviours. Results: The mean age of participants was 53.6 (SD 13.3) years. The majority (82%) were females. Self-reported medication adherence within the last seven days was 88.6%; 77% reported being physically active for at least 30 minutes on more than three days in the previous seven days; 69% reported checking their feet every day and inspecting inside their shoes; 58% reported following a healthy diet regularly. Only 33% reported following all the self-management behaviours regularly. Multiple logistic regression analysis showed that self-efficacy was the only social cognitive factor associated with following all the self-management practices (p < 0.001). Conclusions: Participants in our study were not consistently achieving all self-management practices with dietary practices being the least adhered to behaviour by many. To improve self-management practices of people with diabetes, current health education programs should not only aim at improving diabetes related knowledge but also self-efficacy. Adopting interventions that promote self-efficacy in diabetes patients such as exposure to role models, peer education, providing positive feedback, and counselling is recommended.
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16
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Birungi J, Kivuyo S, Garrib A, Mugenyi L, Mutungi G, Namakoola I, Mghamba J, Ramaiya K, Wang D, Maongezi S, Musinguzi J, Mugisha K, Etukoit BM, Kakande A, Niessen LW, Okebe J, Shiri T, Meshack S, Lutale J, Gill G, Sewankambo N, Smith PG, Nyirenda MJ, Mfinanga SG, Jaffar S. Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study. BMJ Open 2021; 11:e053412. [PMID: 34728457 PMCID: PMC8565555 DOI: 10.1136/bmjopen-2021-053412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND HIV, diabetes and hypertension have a high disease burden in sub-Saharan Africa. Healthcare is organised in separate clinics, which may be inefficient. In a cohort study, we evaluated integrated management of these conditions from a single chronic care clinic. OBJECTIVES To determined the feasibility and acceptability of integrated management of chronic conditions in terms of retention in care and clinical indicators. DESIGN AND SETTING Prospective cohort study comprising patients attending 10 health facilities offering primary care in Dar es Salaam and Kampala. INTERVENTION Clinics within health facilities were set up to provide integrated care. Patients with either HIV, diabetes or hypertension had the same waiting areas, the same pharmacy, were seen by the same clinical staff, had similar provision of adherence counselling and tracking if they failed to attend appointments. PRIMARY OUTCOME MEASURES Retention in care, plasma viral load. FINDINGS Between 5 August 2018 and 21 May 2019, 2640 patients were screened of whom 2273 (86%) were enrolled into integrated care (832 with HIV infection, 313 with diabetes, 546 with hypertension and 582 with multiple conditions). They were followed up to 30 January 2020. Overall, 1615 (71.1%)/2273 were female and 1689 (74.5%)/2266 had been in care for 6 months or more. The proportions of people retained in care were 686/832 (82.5%, 95% CI: 79.9% to 85.1%) among those with HIV infection, 266/313 (85.0%, 95% CI: 81.1% to 89.0%) among those with diabetes, 430/546 (78.8%, 95% CI: 75.4% to 82.3%) among those with hypertension and 529/582 (90.9%, 95% CI: 88.6 to 93.3) among those with multimorbidity. Among those with HIV infection, the proportion with plasma viral load <100 copies/mL was 423(88.5%)/478. CONCLUSION Integrated management of chronic diseases is a feasible strategy for the control of HIV, diabetes and hypertension in Africa and needs evaluation in a comparative study.
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Affiliation(s)
- Josephine Birungi
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- The AIDS Support Organization, Kampala, Uganda
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Maongezi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | | | | | - Ayoub Kakande
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Louis Wihelmus Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Manda CM, Nakanga WP, Mkandawire J, Muula AS, Nyirenda MJ, Crampin AC, Wagatsuma Y. Handgrip strength as a simple measure for screening prediabetes and type 2 diabetes mellitus risk among adults in Malawi: A cross-sectional study. Trop Med Int Health 2021; 26:1709-1717. [PMID: 34661324 DOI: 10.1111/tmi.13694] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Handgrip strength, a simple measure of muscle strength, has been reported as a predictor of both prediabetes and type 2 diabetes mellitus (T2DM) and has been suggested for screening prediabetes and T2DM risk. This study examined the relationship of handgrip strength with prediabetes and T2DM among rural- and urban-dwelling adults in Malawi. METHODS This was a cross-sectional study nested in a follow-up study of prediabetic and prehypertensive individuals identified during an extensive noncommunicable disease survey in Malawi. A total of 261 participants (women: 64%) were recruited. Univariate and multivariate binary logistic regression analyses were performed to examine the association of prediabetes and T2DM with relative handgrip strength. RESULTS The mean (SD) age of the participants was 49.7 (13.6) years, and 54.0% were between the ages of 40 and 59 years. The mean (SD) absolute handgrip strength and relative handgrip strength were 28.8 (7.3) kg and 1.16 (0.40) kg/BMI, respectively, and the mean relative handgrip strength differed significantly (p < 0.001) by T2DM status. In unadjusted model, the odds ratio (OR) of prediabetes and T2DM per unit increase in relative handgrip strength was 0.12 [95% CI; 0.04-0.33]. The result remained significant after adjusting for age (continuous), sex, place of study, hypertension, dyslipidaemia and level of education (aOR [95% CI]; 0.19 [0.03-0.95]). CONCLUSIONS The findings suggest that handgrip strength could be a relatively inexpensive, noninvasive measure for contributing to risk scores to identify high-risk individuals for screening diabetes in SSA.
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Affiliation(s)
- Chrispin Mahala Manda
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Wisdom P Nakanga
- Malawi Epidemiology and Intervention Research Unit, Lilongwe and Karonga, Malawi
| | - Joseph Mkandawire
- Malawi Epidemiology and Intervention Research Unit, Lilongwe and Karonga, Malawi
| | - Adamson S Muula
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.,The Africa Center of Excellence in Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | | | - Amelia Catherine Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe and Karonga, Malawi.,London School of Hygiene and Tropical Medicine, London, UK
| | - Yukiko Wagatsuma
- Department of Clinical Trial and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Mfinanga SG, Nyirenda MJ, Mutungi G, Mghamba J, Maongezi S, Musinguzi J, Okebe J, Kivuyo S, Birungi J, van Widenfelt E, Van Hout MC, Bachmann M, Garrib A, Bukenya D, Cullen W, Lazarus JV, Niessen LW, Katahoire A, Shayo EH, Namakoola I, Ramaiya K, Wang D, Cuevas LE, Etukoit BM, Lutale J, Meshack S, Mugisha K, Gill G, Sewankambo N, Smith PG, Jaffar S. Integrating HIV, diabetes and hypertension services in Africa: study protocol for a cluster randomised trial in Tanzania and Uganda. BMJ Open 2021; 11:e047979. [PMID: 34645657 PMCID: PMC8515479 DOI: 10.1136/bmjopen-2020-047979] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION HIV programmes in sub-Saharan Africa are well funded but programmes for diabetes and hypertension are weak with only a small proportion of patients in regular care. Healthcare provision is organised from stand-alone clinics. In this cluster randomised trial, we are evaluating a concept of integrated care for people with HIV infection, diabetes or hypertension from a single point of care. METHODS AND ANALYSIS 32 primary care health facilities in Dar es Salaam and Kampala regions were randomised to either integrated or standard vertical care. In the integrated care arm, services are organised from a single clinic where patients with either HIV infection, diabetes or hypertension are managed by the same clinical and counselling teams. They use the same pharmacy and laboratory and have the same style of patient records. Standard care involves separate pathways, that is, separate clinics, waiting and counselling areas, a separate pharmacy and separate medical records. The trial has two primary endpoints: retention in care of people with hypertension or diabetes and plasma viral load suppression. Recruitment is expected to take 6 months and follow-up is for 12 months. With 100 participants enrolled in each facility with diabetes or hypertension, the trial will provide 90% power to detect an absolute difference in retention of 15% between the study arms (at the 5% two-sided significance level). If 100 participants with HIV infection are also enrolled in each facility, we will have 90% power to show non-inferiority in virological suppression to a delta=10% margin (ie, that the upper limit of the one-sided 95% CI of the difference between the two arms will not exceed 10%). To allow for lost to follow-up, the trial will enrol over 220 persons per facility. This is the only trial of its kind evaluating the concept of a single integrated clinic for chronic conditions in Africa. ETHICS AND DISSEMINATION The protocol has been approved by ethics committee of The AIDS Support Organisation, National Institute of Medical Research and the Liverpool School of Tropical Medicine. Dissemination of findings will be done through journal publications and meetings involving study participants, healthcare providers and other stakeholders. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
- Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Janneth Mghamba
- Directors office, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Sarah Maongezi
- Non-Communicable Diseases Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Joshua Musinguzi
- AIDS Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sokoine Kivuyo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Walter Cullen
- School of Medicine, University College Dublin School of Medicine, Dublin, Ireland
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth Henry Shayo
- Policy Analysis and Advocacy, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - L E Cuevas
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
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19
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Shiri T, Birungi J, Garrib AV, Kivuyo SL, Namakoola I, Mghamba J, Musinguzi J, Kimaro G, Mutungi G, Nyirenda MJ, Okebe J, Ramaiya K, Bachmann M, Sewankambo NK, Mfinanga S, Jaffar S, Niessen LW. Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda. BMC Med 2021; 19:230. [PMID: 34503496 PMCID: PMC8431904 DOI: 10.1186/s12916-021-02094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 02/15/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed. METHODS 2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations. RESULTS Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities. CONCLUSION Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.
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Affiliation(s)
- Tinevimbo Shiri
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Anupam V Garrib
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Sokoine L Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Joshua Musinguzi
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Godfather Kimaro
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Moffat J Nyirenda
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Kaushik Ramaiya
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - M Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sayoki Mfinanga
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- National Institutes for Medical Research, Dar es Salaam, Tanzania
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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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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Adler A, Bennett P, Colagiuri Chair S, Gregg E, Narayan KMV, Inês Schmidt M, Sobngwi E, Tajima N, Tandon N, Unwin N, Wild S, Yudkin J, Levitt N, Mohan V, Montgomery S, Nyirenda MJ, Tuomilehto J, Den Boon S, Hocking S. REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS. Diabetes Res Clin Pract 2021:108972. [PMID: 34343595 DOI: 10.1016/j.diabres.2021.108972] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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Affiliation(s)
| | - Peter Bennett
- Phoenix Epidemiology & Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, USA
| | | | - Edward Gregg
- Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Eugene Sobngwi
- Faculté de Medecine et des Sciences Biomedicales et Centre de Biotechnologie, Université de Yaounde 1, Cameroon
| | - Naoko Tajima
- Jikei University School of Medicine, Tokyo, Japan
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Nigel Unwin
- Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados, and MRC Epidemiology Unit, University of Cambridge, UK
| | | | | | - Naomi Levitt
- Diabetic Medicine and Endocrinology, Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa
| | | | | | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute/London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
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Milln J, Nakabuye B, Natamba BK, Sekitoleko I, Mubiru M, Namara AA, Tumwesigire S, Tino S, Mirembe M, Kakande A, Agaba B, Nansubuga F, Zaake D, Ayiko B, Kalema H, Nakubulwa S, Sekikubo M, Nakimuli A, Webb EL, Nyirenda MJ. Antenatal management and maternal/fetal outcomes associated with hyperglycaemia in pregnancy (HIP) in Uganda; a prospective cohort study. BMC Pregnancy Childbirth 2021; 21:386. [PMID: 34011299 PMCID: PMC8132348 DOI: 10.1186/s12884-021-03795-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hyperglycaemia in pregnancy (HIP) is associated with complications for both mother and baby. The prevalence of the condition is likely to increase across Africa as the continent undergoes a rapid demographic transition. However, little is known about the management and pregnancy outcomes associated with HIP in the region, particularly less severe forms of hyperglycaemia. It is therefore important to generate local data so that resources may be distributed effectively. The aim of this study was to describe the antenatal management and maternal/fetal outcomes associated with HIP in Ugandan women. METHODS A prospective cohort study of 2917 pregnant women in five major hospitals in urban/semi-urban central Uganda. Women were screened with oral glucose tolerance test (OGTT) at 24-28 weeks of gestation. Cases of gestational diabetes (GDM) and diabetes in pregnancy (DIP) were identified (WHO 2013 diagnostic criteria) and received standard care. Data was collected on maternal demographics, anthropometrics, antenatal management, umbilical cord c-peptide levels, and pregnancy outcomes. RESULTS Two hundred and seventy-six women were diagnosed with HIP (237 classified as GDM and 39 DIP). Women had between one and four fasting capillary blood glucose checks during third trimester. All received lifestyle advice, one quarter (69/276) received metformin therapy, and one woman received insulin. HIP was associated with large birthweight (unadjusted relative risk 1.30, 95% CI 1.00-1.68), Caesarean delivery (RR 1.34, 95% CI 1.14-1.57) and neonatal hypoglycaemia (RR 4.37, 95% CI 1.36-14.1), but not perinatal mortality or preterm birth. Pregnancy outcomes were generally worse for women with DIP compared with GDM. CONCLUSION HIP is associated with significant adverse pregnancy outcomes in this population, particularly overt diabetes in pregnancy. However pregnancy outcomes in women with milder forms of hyperglycaemia are similar to those with normoglycaemic pregnancies. Intervention strategies are required to improve current monitoring and management practice, and more research needed to understand if this is a cost-effective way of preventing poor perinatal outcomes.
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Affiliation(s)
- Jack Milln
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda. .,Department of Endocrinology and Diabetes, Queen Mary University of London, Mile End Road, London, UK.
| | - Betty Nakabuye
- Rubaga Uganda Martyrs Hospital, Kampala, Uganda.,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barnabas Kahiira Natamba
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Isaac Sekitoleko
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Michael Mubiru
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Arthur Araali Namara
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Samuel Tumwesigire
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Salome Tino
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Mandy Mirembe
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Ayoub Kakande
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - Brian Agaba
- Rubaga Uganda Martyrs Hospital, Kampala, Uganda
| | | | | | - Ben Ayiko
- Entebbe Regional Referral Hospital, Entebbe, Uganda
| | | | - Sarah Nakubulwa
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Kawempe National Referral Hospital, Kampala, Uganda
| | - Musa Sekikubo
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Kawempe National Referral Hospital, Kampala, Uganda
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Kawempe National Referral Hospital, Kampala, Uganda
| | - Emily L Webb
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Moffat J Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Milln J, Nakabuye B, Natamba B, Sekitoleko I, Mubiru M, Namara A, Tumwesigire S, Salome T, Mirembe M, Kakanda A, Agaba B, Nansubuga F, Zaake D, Ayiko B, Kalema H, Nakubulwa S, Sekikubo M, Nakimuli A, Webb EL, Nyirenda MJ. Adverse pregnancy outcomes associated with moderate elevations in blood pressure or blood glucose in Ugandan women; a prospective cohort study. AJOG Glob Rep 2021; 1:100007. [PMID: 34095888 PMCID: PMC8164086 DOI: 10.1016/j.xagr.2021.100007] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The association between overt hypertension and diabetes and adverse pregnancy outcomes is well documented. Recent evidence suggests that even moderate elevations in blood pressure or blood glucose may confer a significant risk in a dose-dependent manner. However, these studies have primarily been undertaken in white populations in high-income settings. Hypertension and diabetes are emerging as major public health issues in sub-Saharan Africa as the region undergoes rapid urbanization. It is therefore important to understand how such noncommunicable conditions contribute to pregnancy outcomes in these populations. OBJECTIVE This study aimed to determine the association between stage 1 hypertension or fasting blood glucose in the gestational diabetes mellitus-range and adverse pregnancy outcomes in Uganda, and to describe the effects of other contributing factors such as maternal obesity. STUDY DESIGN This was a prospective cohort study of 2857 women at 5 major hospitals in urban and semiurban central Uganda. Women were enrolled at 24 to 28 weeks' gestation. Data about the maternal demographics, anthropometrics, fasting venous blood glucose, blood pressure, and pregnancy outcomes were collected. Moderate elevations in blood pressure and blood glucose were defined using the latest American College of Cardiology and American Heart Association definition of stage 1 hypertension and the World Health Organization's criteria for fasting blood glucose in the gestational diabetes mellitus-range. The primary outcomes of interest were perinatal death and large birthweight for gestational age, and the secondary outcomes were preterm birth, cesarean delivery, and neonatal admission. A multivariable logistic regression analysis was used. RESULTS Stage 1 hypertension increased the odds of perinatal death by more than 2-fold (adjusted odds ratio, 2.68; 95% confidence interval, 1.36-5.29), with a positive but insignificant association with preterm birth. Hyperglycemia in the gestational diabetes mellitus-range was associated with cesarean delivery only (adjusted odds ratio, 1.65; 95% confidence interval, 1.20-2.27). Maternal obesity increased the risk of having large birthweight babies (adjusted odds ratio, 2.30; 95% confidence interval, 1.74-3.02), a cesarean delivery (adjusted odds ratio, 2.75; 95% confidence interval, 2.17-3.48), and neonatal admission (adjusted odds ratio, 1.63; 95% confidence interval, 1.16-2.30). CONCLUSION Moderate elevations in blood pressure and maternal obesity are stronger predictors of adverse maternal and neonatal outcomes than moderate elevations in blood glucose levels and should be the focus of intervention in these resource-poor settings. Further research is needed to determine the cost-effectiveness of identifying and managing moderate elevations in blood pressure and maternal obesity.
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Affiliation(s)
- Jack Milln
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
- Department of Endocrinology and Diabetes, Queen Mary University of London, London, United Kingdom (Dr Milln)
| | - Betty Nakabuye
- Department of Obstetrics and Gynaecology Uganda Martyrs Hospital, Lubaga, Kampala, Uganda (Drs Nakabuye and Agaba)
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda (Dr Nakabuye)
| | - Barnabas Natamba
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Isaac Sekitoleko
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Michael Mubiru
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Arthur Namara
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Samuel Tumwesigire
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Tino Salome
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Mandy Mirembe
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Ayoub Kakanda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Brian Agaba
- Department of Obstetrics and Gynaecology Uganda Martyrs Hospital, Lubaga, Kampala, Uganda (Drs Nakabuye and Agaba)
| | - Faridah Nansubuga
- Department of Obstetrics and Gynaecology, St. Francis Hospital, Nsambya, Kampala, Uganda (Drs Nansubuga and Zaake)
| | - Daniel Zaake
- Department of Obstetrics and Gynaecology, St. Francis Hospital, Nsambya, Kampala, Uganda (Drs Nansubuga and Zaake)
| | - Ben Ayiko
- Department of Obstetrics and Gynaecology, Entebbe Regional Referral Hospital, Entebbe, Uganda (Dr Ayiko)
| | - Herbert Kalema
- Department of Obstetrics and Gynaecology, Masaka Regional Referral Hospital, Masaka, Uganda (Dr Kalema)
| | - Sarah Nakubulwa
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Musa Sekikubo
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Emily L. Webb
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom (Drs Webb and Nyirenda)
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom (Drs Webb and Nyirenda)
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Gonzales GB, Lelijveld N, Bourdon C, Chimwezi E, Nyirenda MJ, Wells JC, Kerac M, Bandsma RHJ. Childhood Malnutrition and Association of Lean Mass with Metabolome and Hormone Profile in Later Life. Nutrients 2020; 12:E3593. [PMID: 33238545 PMCID: PMC7700560 DOI: 10.3390/nu12113593] [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] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 11/17/2022] Open
Abstract
This study aimed to determine the associations of targeted metabolomics and hormone profiles data with lean mass index (LMI), which were estimated using bioelectrical impedance, in survivors of child severe malnutrition (SM) (n = 69) and controls (n = 77) in Malawi 7 years after being treated. Linear associations between individual metabolite or hormone and LMI were determined, including their interaction with nutrition status 7 years prior. Path analysis was performed to determine structural associations. Lastly, predictive models for LMI were developed using the metabolome and hormone profile by elastic net regularized regression (EN). Metabolites including several lipids, amino acids, and hormones were individually associated (p < 0.05 after false discovery rate correction) with LMI. However, plasma FGF21 (Control: β = -0.02, p = 0.59; Case: β = -0.14, p < 0.001) and tryptophan (Control: β = 0.15, p = 0.26; Case: β = 0.70, p < 0.001) were associated with LMI among cases but not among controls (both interaction p-values < 0.01). Moreover, path analysis revealed that tryptophan mediates the association between child SM and LMI. EN revealed that most predictors of LMI differed between groups, further indicating altered metabolic mechanisms driving lean mass accretion among SM survivors later in life.
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Affiliation(s)
- Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University, 6708 WE Wageningen, The Netherlands
- Laboratory of Gastroenterology, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (C.B.); (R.H.J.B.)
- The Childhood Acute Illness & Nutrition Network, Nairobi 43640-00100, Kenya
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S, Canada
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi;
| | | | - Jonathan C. Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Robert H. J. Bandsma
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (C.B.); (R.H.J.B.)
- The Childhood Acute Illness & Nutrition Network, Nairobi 43640-00100, Kenya
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S, Canada
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Milln JM, Walugembe E, Ssentayi S, Nkabura H, Jones AG, Nyirenda MJ. Comparison of oral glucose tolerance test and ambulatory glycaemic profiles in pregnant women in Uganda with gestational diabetes using the FreeStyle Libre flash glucose monitoring system. BMC Pregnancy Childbirth 2020; 20:635. [PMID: 33076849 PMCID: PMC7574406 DOI: 10.1186/s12884-020-03325-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 10/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of hyperglycaemia in sub-Saharan Africa (SSA) is challenging. Blood glucose levels obtained during oral glucose tolerance test (OGTT) may not reflect home glycaemic profiles. We compare OGTT results with home glycaemic profiles obtained using the FreeStyle Libre continuous glucose monitoring device (FSL-CGM). METHODS Twenty-eight women (20 with gestational diabetes [GDM], 8 controls) were recruited following OGTT between 24 and 28 weeks of gestation. All women wore the FSL-CGM device for 48-96 h at home in early third trimester, and recorded a meal diary. OGTT was repeated on the final day of FSL-CGM recording. OGTT results were compared with ambulatory glycaemic variables, and repeat OGTT was undertaken whilst wearing FSL-CGM to determine accuracy of the device. RESULTS FSL-CGM results were available for 27/28 women with mean data capture 92.8%. There were significant differences in the ambulatory fasting, post-prandial peaks, and mean glucose between controls in whom both primary and secondary OGTT was normal (n = 6) and those with two abnormal OGTTs or "true" GDM (n = 7). There was no difference in ambulatory mean glucose between these controls and the 13 women who had an abnormal primary OGTT and normal repeat OGTT. These participants had significantly lower body mass index (BMI) than the true GDM group (29.0 Vs 36.3 kg/m2, p-value 0.014). Paired OGTT/FSL-CGM readings revealed a Mean Absolute difference (MAD) -0.58 mmol/L and Mean Absolute Relative Difference (MARD) -11.9%. Bland-Altman plot suggests FSL-CGM underestimated blood glucose by approximately 0.78 mmol/L. CONCLUSION Diagnosis of GDM on a single OGTT identifies a proportion of women who do not have a significantly higher home glucose levels than controls. This raises questions about factors which may affect the reproducibility of OGTT in this population, including food insecurity and atypical phenotypes of diabetes. More investigation is needed to understand the suitability of the OGTT as a diagnostic test in sub-Saharan Africa.
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Affiliation(s)
- J M Milln
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda.
- Department of Endocrinology and Diabetes, Queen Mary University of London, Mile End Road, London, UK.
| | - E Walugembe
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - S Ssentayi
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - H Nkabura
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - A G Jones
- National Institute for Health and Research (NIHR), Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - M J Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Hamilton SA, Nakanga WP, Prynn JE, Crampin AC, Fecht D, Vineis P, Caplin B, Pearce N, Nyirenda MJ. Prevalence and risk factors for chronic kidney disease of unknown cause in Malawi: a cross-sectional analysis in a rural and urban population. BMC Nephrol 2020; 21:387. [PMID: 32894093 PMCID: PMC7487679 DOI: 10.1186/s12882-020-02034-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/20/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND An epidemic of chronic kidney disease of unknown cause (CKDu) is occurring in rural communities in tropical regions of low-and middle-income countries in South America and India. Little information is available from Southern African countries which have similar climatic and occupational characteristics to CKDu-endemic countries. We investigated whether CKDu is prevalent in Malawi and identified its potential risk factors in this setting. METHODS We conducted a cross-sectional study from January-August 2018 collecting bio samples and anthropometric data in two Malawian populations. The sample comprised adults > 18 years (n = 821) without diabetes, hypertension, and proteinuria. Estimates of glomerular filtration rate (eGFR) were calculated using the CKD-EPI equation. Linear and logistic regression models were applied with potential risk factors, to estimate risk of reduced eGFR. RESULTS The mean eGFR was 117.1 ± 16.0 ml/min per 1.73m2 and the mean participant age was 33.5 ± 12.7 years. The prevalence of eGFR< 60 was 0.2% (95% confidence interval (95% CI) 0.1, 0.9); the prevalence of eGFR< 90 was 5% (95% CI =3.2, 6.3). We observed a higher prevalence in the rural population (5% (3.6, 7.8)), versus urban (3% (1.4, 6.7)). Age and BMI were associated with reduced eGFR< 90 [Odds ratio (OR) (95%CI) =3.59 (2.58, 5.21) per ten-year increment]; [OR (95%CI) =2.01 (1.27, 3.43) per 5 kg/m2 increment] respectively. No increased risk of eGFR < 90 was observed for rural participants [OR (95%CI) =1.75 (0.50, 6.30)]. CONCLUSIONS Reduced kidney function consistent with the definition of CKDu is not common in the areas of Malawi sampled, compared to that observed in other tropical or sub-tropical countries in Central America and South Asia. Reduced eGFR< 90 was related to age, BMI, and was more common in rural areas. These findings are important as they contradict some current hypothesis that CKDu is endemic across tropical and sub-tropical countries. This study has enabled standardized comparisons of impaired kidney function between and within tropical/subtropical regions of the world and will help form the basis for further etiological research, surveillance strategies, and the implementation and evaluation of interventions.
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Affiliation(s)
- Sophie A Hamilton
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
- MRC Centre for Environment and Health, Imperial College London, London, UK.
- Imperial College London, School of Public Health, London, UK.
| | - Wisdom P Nakanga
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Josephine E Prynn
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Institute of Cardiovascular Science, University College London, London, UK
| | - Amelia C Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Departments of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniela Fecht
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
- MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Paolo Vineis
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
- MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Ben Caplin
- Centre for Nephrology, Division of Medicine, University College London, London, UK
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
- Centre for Global NCDs, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Departments of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Soares ALG, Banda L, Amberbir A, Jaffar S, Musicha C, Price AJ, Crampin AC, Nyirenda MJ, Lawlor DA. A comparison of the associations between adiposity and lipids in Malawi and the United Kingdom. BMC Med 2020; 18:181. [PMID: 32669098 PMCID: PMC7364601 DOI: 10.1186/s12916-020-01648-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/07/2019] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The prevalence of excess adiposity, as measured by elevated body mass index (BMI) and waist-hip ratio (WHR), is increasing in sub-Saharan African (SSA) populations. This could add a considerable burden of cardiovascular and metabolic diseases for which these populations are currently ill-prepared. Evidence from white, European origin populations shows that higher adiposity leads to an adverse lipid profile; whether these associations are similar in all SSA populations requires further exploration. This study compared the association of BMI and WHR with lipid profile in urban Malawi with a contemporary cohort with contrasting socioeconomic, demographic, and ethnic characteristics in the United Kingdom (UK). METHODS We used data from 1248 adolescents (mean 18.7 years) and 2277 Malawian adults (mean 49.8 years), all urban-dwelling, and from 3201 adolescents (mean 17.8 years) and 6323 adults (mean 49.7 years) resident in the UK. Adiposity measures and fasting lipids were assessed in both settings, and the associations of BMI and WHR with total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were assessed by sex and age groups in both studies. RESULTS Malawian female adults were more adipose and had more adverse lipid profiles than their UK counterparts. In contrast, Malawian adolescent and adult males were leaner and had more favourable lipid profiles than in the UK. Higher BMI and WHR were associated with increased TC, LDL-C and TG and reduced HDL-C in both settings. The magnitude of the associations of BMI and WHR with lipids was mostly similar or slightly weaker in the Malawian compared with the UK cohort in both adolescents and adults. One exception was the stronger association between increasing adiposity and elevated TC and LDL-C in Malawian compared to UK men. CONCLUSIONS Malawian adult women have greater adiposity and more adverse lipid profiles compared with their UK counterparts. Similar associations of adiposity with adverse lipid profiles were observed for Malawian and UK adults in most age and sex groups studied. Sustained efforts are urgently needed to address the excess adiposity and adverse lipid profiles in Malawi to mitigate a future epidemic of cardio-metabolic disease among the poorest populations.
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Affiliation(s)
- Ana Luiza G Soares
- MRC Integrated Epidemiology Unit, University of Bristol, Bristol, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.
| | - Louis Banda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Malawi, Malawi
| | - Alemayehu Amberbir
- Partners in Hope, Lilongwe, Malawi
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Crispin Musicha
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Malawi, Malawi
| | - Alison J Price
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Malawi, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Amelia C Crampin
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Malawi, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Moffat J Nyirenda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Malawi, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Deborah A Lawlor
- MRC Integrated Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
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Chilunga FP, Musicha C, Tafatatha T, Geis S, Nyirenda MJ, Crampin AC, Price AJ. Investigating associations between rural-to-urban migration and cardiometabolic disease in Malawi: a population-level study. Int J Epidemiol 2020; 48:1850-1862. [PMID: 31603469 PMCID: PMC6929524 DOI: 10.1093/ije/dyz198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background The extent to which rural-to-urban migration affects risk for cardiometabolic diseases (CMD) in Africa is not well understood. We investigated prevalence and risk for obesity, diabetes, hypertension and precursor conditions by migration status. Methods In a cross-sectional survey in Malawi (February 2013–March 2017), 13 903 rural, 9929 rural-to-urban migrant and 6741 urban residents (≥18 years old) participated. We interviewed participants, measured blood pressure and collected anthropometric data and fasting blood samples to estimate population prevalences and odds ratios, using negative binomial regression, for CMD, by migration status. In a sub-cohort of 131 rural–urban siblings-sets, migration-associated CMD risk was explored using conditional Poisson regression. Results In rural, rural-to-urban migrant and urban residents, prevalence estimates were; 8.9, 20.9 and 15.2% in men and 25.4, 43.9 and 39.3% in women for overweight/obesity; 1.4, 2.9 and 1.9% in men and 1.5, 2.8 and 1.7% in women for diabetes; and 13.4, 18.8 and 12.2% in men and 13.7, 15.8 and 10.2% in women for hypertension. Rural-to-urban migrants had the greatest risk for hypertension (adjusted relative risk for men 1.18; 95% confidence interval 1.04–1.34 and women 1.17: 95% confidence interval 1.05–1.29) and were the most screened, diagnosed and treated for CMD, compared with urban residents. Within sibling sets, rural-to-urban migrant siblings had a higher risk for overweight and pre-hypertension, with no evidence for differences by duration of stay. Conclusions Rural-to-urban migration is associated with increased CMD risk in Malawi. In a poor country experiencing rapid urbanization, interventions for the prevention and management of CMD, which reach migrant populations, are needed.
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Affiliation(s)
- Felix P Chilunga
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
| | - Crispin Musicha
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
| | - Terence Tafatatha
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
| | - Steffen Geis
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Institute for Medical Microbiology and Illnesses, Philipps University of Marburg, Marburg, Germany.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,MRC/UVRI & LSHTM Uganda Research Unit, Kampala, Uganda
| | - Amelia C Crampin
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison J Price
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Amberbir A, Lin SH, Berman J, Muula A, Jacoby D, Wroe E, Maliwichi-Nyirenda C, Mwapasa V, Crampin A, Makwero M, Singogo E, Phiri S, Gordon S, Tobe SW, Masiye J, Newsome B, Hosseinipour M, Nyirenda MJ, van Oosterhout JJ. Systematic Review of Hypertension and Diabetes Burden, Risk Factors, and Interventions for Prevention and Control in Malawi: The NCD BRITE Consortium. Glob Heart 2020; 14:109-118. [PMID: 31324364 DOI: 10.1016/j.gheart.2019.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/16/2022] Open
Abstract
Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi.
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Affiliation(s)
- Alemayehu Amberbir
- Dignitas International, Zomba, Malawi; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Sabrina H Lin
- Dignitas International, Zomba, Malawi; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Adamson Muula
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Darren Jacoby
- Center for Innovative Global Health Technologies, Northwestern University, Chicago, Illinois, USA
| | | | | | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Amelia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Martha Makwero
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sam Phiri
- University of North Carolina-Malawi Project, Lilongwe, Malawi
| | | | - Sheldon W Tobe
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Jones Masiye
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | | | - Mina Hosseinipour
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi
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Kwanjo Banda C, Gombachika BT, Nyirenda MJ, Muula AS. Self-management and its associated factors among people living with diabetes in Blantyre, Malawi: a cross-sectional study. AAS Open Res 2019. [DOI: 10.12688/aasopenres.12992.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Self-management is key to the control of glycaemia and prevention of complications in people living with diabetes. Many people living with diabetes in Malawi have poorly controlled glucose and they experience diabetes-related complications. This study aimed to assess diabetes self-management behaviours and to identify factors associated with it among people living with diabetes at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. Methods: This cross-sectional study recruited 510 adults attending a diabetes clinic at a teaching referral hospital in southern Malawi. The social cognitive theory was applied to identify factors associated with following all recommended self-management behaviours. Data on participants’ demographics, clinical history, diabetes knowledge, self-efficacy, outcome expectations, social support, environmental barriers and diabetes self-management were collected. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with following all self-management behaviours. Results: The mean age of participants was 53.6 (SD 13.3) years. Self-reported medication adherence within the last seven days was 88.6% (n=494); 77% reported being physically active for at least 30 minutes on more than three days in the previous seven days; 69% reported checking their feet every day and inspecting inside their shoes; 58% reported following a healthy diet regularly. Overall, only 33% reported following all the self-management behaviours regularly. Multiple logistic regression analysis showed that self-efficacy was the only social cognitive factor associated with following all the self-management practices (p < 0.001). Conclusions: Participants in our study were not consistently achieving all self-management practices with dietary practices being the least adhered to behaviour by many. To improve self-management practices of people living with diabetes, current health education programs should not only aim at improving diabetes related knowledge but also self-efficacy. Adopting interventions that promote self-efficacy in diabetes patients such as exposure to role models, peer education, providing positive feedback, and counselling is recommended.
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Soares ALG, Banda L, Amberbir A, Jaffar S, Musicha C, Price A, Nyirenda MJ, Lawlor DA, Crampin A. Sex and area differences in the association between adiposity and lipid profile in Malawi. BMJ Glob Health 2019; 4:e001542. [PMID: 31565403 PMCID: PMC6747887 DOI: 10.1136/bmjgh-2019-001542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/24/2019] [Accepted: 06/29/2019] [Indexed: 12/14/2022] Open
Abstract
Background Evidence from high-income countries shows that higher adiposity results in an adverse lipid profile, but it is unclear whether this association is similar in Sub-Saharan African (SSA) populations. This study aimed to assess the association between total and central adiposity measures and lipid profile in Malawi, exploring differences by sex and area of residence (rural/urban). Methods In this cross-sectional study, data from 12 096 rural and 12 847 urban Malawian residents were used. The associations of body mass index (BMI) and waist to hip ratio (WHR) with fasting lipids (total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C) and triglycerides (TG)) were assessed by area and sex. Results After adjusting for potential confounders, higher BMI and WHR were linearly associated with increased TC, LDL-C and TG and reduced HDL-C. BMI was more strongly related to fasting lipids than was WHR. The associations of adiposity with adverse lipid profile were stronger in rural compared with urban residents. For instance, one SD increase in BMI was associated with 0.23 mmol/L (95% CI 0.19 to 0.26) increase in TC in rural women and 0.13 mmol/L (95% CI 0.11 to 0.15) in urban women. Sex differences in the associations between adiposity and lipids were less evident. Conclusions The consistent associations observed of higher adiposity with adverse lipid profiles in men and women living in rural and urban areas of Malawi highlight the emerging adverse cardio-metabolic epidemic in this poor population. Our findings underline the potential utility of BMI in estimating cardiovascular risk and highlight the need for greater investment to understand the long-term health outcomes of obesity and adverse lipid profiles and the extent to which lifestyle changes and treatments effectively prevent and modify adverse cardio-metabolic outcomes.
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Affiliation(s)
- Ana Luiza G Soares
- Population Health Sciences, University of Bristol, Bristol, UK.,MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK, Bristol, UK
| | - Louis Banda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
| | - Alemayehu Amberbir
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Crispin Musicha
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
| | - Alison Price
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Debbie A Lawlor
- Population Health Sciences, University of Bristol, Bristol, UK.,MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK, Bristol, UK
| | - Amelia Crampin
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.,Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
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Bourdon C, Lelijveld N, Thompson D, Dalvi PS, Gonzales GB, Wang D, Alipour M, Wine E, Chimwezi E, Wells JC, Kerac M, Bandsma R, Nyirenda MJ. Metabolomics in plasma of Malawian children 7 years after surviving severe acute malnutrition: "ChroSAM" a cohort study. EBioMedicine 2019; 45:464-472. [PMID: 31255658 PMCID: PMC6642285 DOI: 10.1016/j.ebiom.2019.06.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 04/25/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND More children are now surviving severe acute malnutrition (SAM), but evidence suggests that early-life malnutrition is associated with increased risk of long-term cardio-metabolic disorders. To better understand potential mechanisms, we studied the metabolite profiles of children seven years after treatment for SAM. METHODS We followed-up children (n = 352) treated for SAM in 2006-2007, at Queen Elizabeth Central Hospital, in Malawi. Using nuclear magnetic resonance spectroscopy, tandem mass spectrometry and enzyme-linked immunosorbent assay, we measured circulating metabolites in fasting blood in a subset of SAM survivors (n = 69, 9·6 ± 1·6 years), siblings (n = 44, 10·5 ± 2·7 years), and age and sex-matched community controls (n = 37, 9·4 ± 1·8 years). Data were analysed using univariate and sparse partial least square (sPLS) methods. Differences associated with SAM survival, oedema status, and anthropometry were tested, adjusting for age, sex, HIV, and wealth index. FINDINGS Based on 194 measured metabolites, the profiles of SAM survivors were similar to those of siblings and community controls. IGF1, creatinine, and FGF21, had loading values >0·3 and ranked stably in the top 10 distinguishing metabolites, but did not differ between SAM survivors and controls with univariate analysis. Current stunting was associated with IGF1 (β = 15·2, SE = 3·5, partial R2 = 12%, p < 0·0001) and this relationship could be influenced by early childhood SAM (β = 17·4, SE = 7·7, partial R2 = 2·8%, p = 0·025). No metabolites were associated with oedema status, duration of hospital stay, anthropometry measured during hospitalization, nor with changes in anthropometry since hospitalization. INTERPRETATION In this group of survivors, SAM was not associated with longer-term global metabolic changes 7 years after treatment. However, SAM may influence the relationship between current stunting and IGF1. Further risk markers for NCDs in SAM survivors may only be revealed by direct metabolic challenge or later in life.
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Affiliation(s)
- Celine Bourdon
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Canada
| | - Natasha Lelijveld
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Institute for Global Health, University College London, London, UK.
| | - Debbie Thompson
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Prasad S Dalvi
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Morosky College of Health Professions and Sciences, Gannon University, Erie, PA, USA
| | - Gerard Bryan Gonzales
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Gastroenterology, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium; VIB Inflammation Research Centre, Ghent, Belgium
| | - Dominic Wang
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Misagh Alipour
- Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | - Eytan Wine
- Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University College London, London, UK
| | - Marko Kerac
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert Bandsma
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi; Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University Medical Center Groningen, Groningen, the Netherlands; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Moffat J Nyirenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; MRC / UVRI Uganda Research Unit, Entebbe, Uganda
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Affiliation(s)
- Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
| | - Peter Byass
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Kibirige D, Lumu W, Jones AG, Smeeth L, Hattersley AT, Nyirenda MJ. Understanding the manifestation of diabetes in sub Saharan Africa to inform therapeutic approaches and preventive strategies: a narrative review. Clin Diabetes Endocrinol 2019; 5:2. [PMID: 30783538 PMCID: PMC6376682 DOI: 10.1186/s40842-019-0077-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 02/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Globally, the burden of diabetes mellitus has increased to epidemic proportions. Estimates from the International Diabetes Federation predict that the greatest future increase in the prevalence of diabetes mellitus will occur in Africa. METHODS This article reviews literature on the manifestation of diabetes in adult patients in sub-Saharan Africa highlighting the distinct phenotypes, plausible explanations for this unique manifestation and the clinical significance of comprehensively defining and understanding the African diabetes phenotype. RESULTS There are few studies on the manifestation or phenotype of diabetes in Africa. The limited data available suggests that, compared to the Western world, the majority of patients with diabetes in Africa are young and relatively lean in body size. In addition, hyperglycaemia in most cases is characterised by a significantly blunted acute first phase of insulin secretion in response to an oral or intravenous glucose load and pancreatic beta cell secretory dysfunction, rather than peripheral insulin resistance predominates. Genetic and environmental factors like chronic infections/inflammation, early life malnutrition and epigenetic modifications are thought to contribute to these distinct differences in manifestation. CONCLUSIONS While published data is limited, there appears to be distinct phenotypes of diabetes in sub-Saharan Africa. Large and more detailed studies are needed especially among newly diagnosed patients to fully characterize diabetes in this region. This will further improve the understanding of manifestation of diabetes and guide the formulation of optimal therapeutic approaches and preventive strategies of the condition on the continent.
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Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 51-59, Nakiwogo Road, P.O. BOX 49 Entebbe, Uganda
- Department of Medicine, Uganda Martyrs hospital Lubaga, Kampala, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Angus G. Jones
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Liam Smeeth
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew T. Hattersley
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 51-59, Nakiwogo Road, P.O. BOX 49 Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Rathod SD, Crampin AC, Musicha C, Kayuni N, Banda L, Saul J, McLean E, Branson K, Jaffar S, Nyirenda MJ. Glycated haemoglobin A 1c (HbA 1c) for detection of diabetes mellitus and impaired fasting glucose in Malawi: a diagnostic accuracy study. BMJ Open 2018; 8:e020972. [PMID: 29730628 PMCID: PMC5942411 DOI: 10.1136/bmjopen-2017-020972] [Citation(s) in RCA: 6] [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] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the accuracy of glycated haemoglobin A1c (HbA1c) in detecting type 2 diabetes and impaired fasting glucose among adults living in Malawi. DESIGN A diagnostic validation study of HbA1c. Fasting plasma glucose (FPG) ≥7.0 mmol/L was the reference standard for type 2 diabetes, and FPG between 6.1 and 6.9 mmol/L as impaired fasting glucose. PARTICIPANTS 3645 adults (of whom 63% were women) recruited from two demographic surveillance study sites in urban and rural Malawi. This analysis excluded those who had a previous diagnosis of diabetes or had history of taking diabetes medication. RESULTS HbA1c demonstrated excellent validity to detect FPG-defined diabetes, with an area under the receiver operating characteristic (AUROC) curve of 0.92 (95% CI 0.90 to 0.94). At HbA1c ≥6.5% (140 mg/dL), sensitivity was 78.7% and specificity was 94.0%. Subgroup AUROCs ranged from 0.86 for participants with anaemia to 0.94 for participants in urban Malawi. There were clinical and metabolic differences between participants with true diabetes versus false positives when HbA1c was ≥6.5% (140 mg/dL). CONCLUSIONS The findings from this study provide justification to use HbA1c to detect type 2 diabetes. As HbA1c testing is substantially less burdensome to patients than either FPG testing or oral glucose tolerance testing, it represents a useful option for expanding access to diabetes care in sub-Saharan Africa.
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Affiliation(s)
- Sujit D Rathod
- Department of Population Health at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
| | - Amelia C Crampin
- Department of Infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
| | - Crispin Musicha
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Malawi
| | - Ndoliwe Kayuni
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Malawi
| | - Louis Banda
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Malawi
| | - Jacqueline Saul
- Department of Infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
| | - Estelle McLean
- Department of Infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Malawi
| | - Keith Branson
- Department of Infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
| | - Shabbar Jaffar
- Department of International Public Health at Liverpool School of Tropical Medicine, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moffat J Nyirenda
- Department of Infectious Disease Epidemiology at London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
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Mudie K, Lawlor DA, Pearce N, Crampin A, Tomlinson L, Tafatatha T, Musicha C, Nitsch D, Smeeth L, Nyirenda MJ. How does the association of general and central adiposity with glycaemia and blood pressure differ by gender and area of residence in a Malawian population: a cross-sectional study. Int J Epidemiol 2018; 47:887-898. [PMID: 29648664 PMCID: PMC6005143 DOI: 10.1093/ije/dyy047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/07/2018] [Accepted: 03/15/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In high-income settings, body mass index (BMI) and measures of central adiposity, such as waist-to-hip ratio (WHR) are associated with cardiometabolic risk, but evidence from low-income settings, particularly sub-Saharan Africa (SSA), is limited. We assessed whether there are differences between central and general adiposity in their associations with fasting glucose, diabetes, systolic and diastolic blood pressures and hypertension, and whether these associations differ with gender or rural/urban setting in Malawi. METHODS We used data from a population-based study of 27 880 Malawian adults aged ≥18 years, from both rural and urban areas. We used age-standardized z-scores of the means of BMI and WHR to directly compare their associations with glycaemic and blood pressure outcomes. RESULTS Mean fasting glucose and blood pressure values and odds of hypertension increased linearly across fifths of BMI and WHR, with stronger associations with BMI. For both BMI and WHR, the associations with outcomes were stronger in urban versus rural residents. The association with diabetes was stronger in women than men, whereas for blood-pressure related outcomes a stronger association was seen in men. CONCLUSIONS BMI is more strongly associated with cardiometabolic risk in SSA, and might be a more useful measure than WHR, in this population. The greater positive association of adiposity with cardiometabolic outcomes in urban residents (where rates of overweight/obesity are already high) highlights the particular importance of addressing obesity within urban SSA populations.
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Affiliation(s)
- Kathleen Mudie
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Debbie A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Neil Pearce
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Amelia Crampin
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Laurie Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Crispin Musicha
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
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37
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Nyirenda MJ, Ramsay M, Byass P. Patterns of adult body mass in sub-Saharan Africa. Glob Health Action 2018; 11:1556497. [PMID: 30845897 PMCID: PMC6407596 DOI: 10.1080/16549716.2018.1556497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Affiliation(s)
- Moffat J. Nyirenda
- London School of Hygiene and Tropical Medicine, London, UK
- STIAS Wallenberg Research Centre, Stellenbosch University, Stellenbosch, South Africa
| | - Michèle Ramsay
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Byass
- STIAS Wallenberg Research Centre, Stellenbosch University, Stellenbosch, South Africa
- Epidemiology and Global Health, Umeå University, Umeå, Sweden
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38
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Nyirenda MJ. Non-communicable diseases in sub-Saharan Africa: understanding the drivers of the epidemic to inform intervention strategies. Int Health 2017; 8:157-8. [PMID: 27178673 DOI: 10.1093/inthealth/ihw021] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 04/12/2016] [Indexed: 11/13/2022] Open
Abstract
Sub-Saharan Africa is experiencing a rapidly increasing epidemic of non-communicable diseases (NCDs), while it continues to face longstanding challenges from infectious diseases. This double burden of disease could have a devastating impact on a continent that already has significant resource constraints, emphasizing the urgent need for appropriate interventions in the region. However, it is crucial to have a careful understanding of the local drivers of NCDs. This should not only include study of the traditional lifestyle risk factors, but also an examination of emerging risk factors (such as the influence of insults early in life or interactions with infection), which may be of particular importance in Africa.
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Affiliation(s)
- Moffat J Nyirenda
- London School of Hygiene & Tropical Medicine, Department of Non-Communicable Disease Epidemiology, Keppel Street, London, WC1E 7HT, UK
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39
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Atun R, Davies JI, Gale EAM, Bärnighausen T, Beran D, Kengne AP, Levitt NS, Mangugu FW, Nyirenda MJ, Ogle GD, Ramaiya K, Sewankambo NK, Sobngwi E, Tesfaye S, Yudkin JS, Basu S, Bommer C, Heesemann E, Manne-Goehler J, Postolovska I, Sagalova V, Vollmer S, Abbas ZG, Ammon B, Angamo MT, Annamreddi A, Awasthi A, Besançon S, Bhadriraju S, Binagwaho A, Burgess PI, Burton MJ, Chai J, Chilunga FP, Chipendo P, Conn A, Joel DR, Eagan AW, Gishoma C, Ho J, Jong S, Kakarmath SS, Khan Y, Kharel R, Kyle MA, Lee SC, Lichtman A, Malm CP, Mbaye MN, Muhimpundu MA, Mwagomba BM, Mwangi KJ, Nair M, Niyonsenga SP, Njuguna B, Okafor OLO, Okunade O, Park PH, Pastakia SD, Pekny C, Reja A, Rotimi CN, Rwunganira S, Sando D, Sarriera G, Sharma A, Sidibe A, Siraj ES, Syed AS, Van Acker K, Werfalli M. Diabetes in sub-Saharan Africa: from clinical care to health policy. Lancet Diabetes Endocrinol 2017; 5:622-667. [PMID: 28688818 DOI: 10.1016/s2213-8587(17)30181-x] [Citation(s) in RCA: 275] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Rifat Atun
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Justine I Davies
- Centre for Global Health, King's College London, Weston Education Centre, London, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa
| | | | - Till Bärnighausen
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; Institute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany; Africa Health Research Institute, KwaZulu, South Africa
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Naomi S Levitt
- Division of Diabetic Medicine & Endocrinology, University of Cape Town, Cape Town, South Africa; Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Moffat J Nyirenda
- Department of NCD Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; NCD Theme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Graham D Ogle
- International Diabetes Federation Life for a Child Program, Glebe, NSW, Australia; Diabetes NSW & ACT, Glebe, NSW, Australia
| | | | - Nelson K Sewankambo
- Department of Medicine, and Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | - Eugene Sobngwi
- University of Newcastle at Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Solomon Tesfaye
- Sheffield Teaching Hospitals and University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - John S Yudkin
- Institute of Cardiovascular Science, Division of Medicine, University College London, London, UK
| | - Sanjay Basu
- Center for Population Health Sciences and Center for Primary Care and Outcomes Research, Department of Medicine and Department of Health Research and Policy, Stanford University, Palo Alto, CA, USA
| | - Christian Bommer
- University of Goettingen, Centre for Modern Indian Studies & Department of Economics, Goettingen, Germany
| | - Esther Heesemann
- University of Goettingen, Centre for Modern Indian Studies & Department of Economics, Goettingen, Germany
| | - Jennifer Manne-Goehler
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Iryna Postolovska
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Vera Sagalova
- University of Goettingen, Centre for Modern Indian Studies & Department of Economics, Goettingen, Germany
| | - Sebastian Vollmer
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; University of Goettingen, Centre for Modern Indian Studies & Department of Economics, Goettingen, Germany
| | - Zulfiqarali G Abbas
- Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania
| | - Benjamin Ammon
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Akhila Annamreddi
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Ananya Awasthi
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | | | - Agnes Binagwaho
- Harvard Medical School, Harvard University, Boston, MA, USA; Geisel School of Medicine at Dartmouth, Hanover, NH, USA; University of Global Health Equity, Kigali, Rwanda
| | | | - Matthew J Burton
- International Centre for Eye Health, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeanne Chai
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Felix P Chilunga
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | | | - Anna Conn
- The Fletcher School of Law and Diplomacy, Tufts University, Medford, MA, USA
| | - Dipesalema R Joel
- Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana and Princess Marina Hospital, Gaborone, Botswana
| | - Arielle W Eagan
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | | | - Julius Ho
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Simcha Jong
- Leiden University, Science Based Business, Leiden, Netherlands
| | - Sujay S Kakarmath
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Ramu Kharel
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael A Kyle
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Seitetz C Lee
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Amos Lichtman
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Maïmouna N Mbaye
- Clinique Médicale II, Centre de diabétologie Marc Sankale, Hôpital Abass Ndao, Dakar, Senegal
| | - Marie A Muhimpundu
- The Institute of HIV/AIDS, Disease Prevention & Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | | | - Mohit Nair
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Simon P Niyonsenga
- The Institute of HIV/AIDS, Disease Prevention & Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Obiageli L O Okafor
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Oluwakemi Okunade
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Paul H Park
- Partners In Health, Rwinkwavu, South Kayonza, Rwanda
| | - Sonak D Pastakia
- Purdue University College of Pharmacy (Purdue Kenya Partnership), Indiana Institute for Global Health, Uasin Gishu, Kenya
| | | | - Ahmed Reja
- Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Charles N Rotimi
- Center for Research on Genomics and Global Health, National Institutes of Health, Bethesda, MD, USA
| | - Samuel Rwunganira
- The Institute of HIV/AIDS, Disease Prevention & Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - David Sando
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Anshuman Sharma
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | | | - Azhra S Syed
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Kristien Van Acker
- Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Mahmoud Werfalli
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Meghji J, Nadeau G, Davis KJ, Wang D, Nyirenda MJ, Gordon SB, Mortimer K. Noncommunicable Lung Disease in Sub-Saharan Africa. A Community-based Cross-Sectional Study of Adults in Urban Malawi. Am J Respir Crit Care Med 2017; 194:67-76. [PMID: 26788760 DOI: 10.1164/rccm.201509-1807oc] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
RATIONALE Noncommunicable diseases are major causes of morbidity and mortality in sub-Saharan Africa (sSA). Valid burden of disease estimates are lacking for noncommunicable lung disease in sSA. OBJECTIVES We performed a community-based survey to determine the prevalence of chronic lung disease among adults 18 years or older in Malawi, using American Thoracic Society standard spirometry, internationally validated respiratory symptom and exposure questionnaires, and an assessment of HIV status. METHODS An age- and sex-stratified random sample of 2,000 adults was taken from the population of the Chilomoni district of Blantyre, Malawi. Fieldworkers collected questionnaire data, conducted HIV testing, and performed pre- and post-bronchodilator spirometry on eligible participants. Survey-weighted population prevalence estimates of respiratory symptoms and spirometric abnormalities were computed, and bivariate and multivariable regression were used to identify associated variables. MEASUREMENTS AND MAIN RESULTS Questionnaire data, HIV status, and standard spirometry were obtained from 1,059, 933, and 749 participants, respectively. Current respiratory symptoms, exposure to biomass, and ever-smoking were reported by 11.8, 85.2, and 10.4% of participants, respectively. HIV prevalence was 24.2%. Moderate to severe airway obstruction was seen in 3.6%. The prevalence of spirometric restriction was 38.6% using National Health and Nutrition Examination Survey III reference ranges and 9.0% using local reference ranges. Age was positively associated with obstruction, whereas low body mass index was associated with restriction. CONCLUSIONS More than 40% of the Malawian adults in our urban population sample had abnormal lung function (mostly restrictive) in the context of widespread exposure to biomass smoke and a high prevalence of HIV. These findings potentially have major public health implications for Malawi and the broader sSA region.
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Affiliation(s)
- Jamilah Meghji
- 1 Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, United Kingdom.,2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Gilbert Nadeau
- 3 Medical Affairs, GSK Canada, Mississauga, Ontario, Canada
| | | | - Duolao Wang
- 2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Moffat J Nyirenda
- 5 London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Stephen B Gordon
- 2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,6 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Kevin Mortimer
- 2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,6 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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41
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Lelijveld N, Kerac M, Seal A, Chimwezi E, Wells JC, Heyderman RS, Nyirenda MJ, Stocks J, Kirkby J. Long-term effects of severe acute malnutrition on lung function in Malawian children: a cohort study. Eur Respir J 2017; 49:49/4/1601301. [PMID: 28381429 PMCID: PMC5540677 DOI: 10.1183/13993003.01301-2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/03/2016] [Indexed: 12/31/2022]
Abstract
Early nutritional insults may increase risk of adult lung disease. We aimed to quantify the impact of severe acute malnutrition (SAM) on spirometric outcomes 7 years post-treatment and explore predictors of impaired lung function. Spirometry and pulse oximetry were assessed in 237 Malawian children (median age: 9.3 years) who had been treated for SAM and compared with sibling and age/sex-matched community controls. Spirometry results were expressed as z-scores based on Global Lung Function Initiative reference data for the African–American population. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were low in all groups (mean FEV1 z-score: −0.47 for cases, −0.48 for siblings, −0.34 for community controls; mean FVC z-score: −0.32, −0.38, and −0.15 respectively). There were no differences in spirometric or oximetry outcomes between SAM survivors and controls. Leg length was shorter in SAM survivors but inter-group sitting heights were similar. HIV positive status or female sex was associated with poorer FEV1, by 0.55 and 0.31 z-scores, respectively. SAM in early childhood was not associated with subsequent reduced lung function compared to local controls. Preservation of sitting height and compromised leg length suggest “thrifty” or “lung-sparing” growth. Female sex and HIV positive status were identified as potentially high-risk groups. Despite stunting, survivors of acute malnutrition do not have worse lung function than controlshttp://ow.ly/2nvH308LroU
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Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK .,Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Marko Kerac
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability and Inclusive Development Centre, Dept of Epidemiology and Child Health, University College London, London, UK
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
| | - Robert S Heyderman
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Division of Infection and Immunity, University College London, London, UK
| | - Moffat J Nyirenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Stocks
- Respiratory, Critical Care and Anaesthesia section in III, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
| | - Jane Kirkby
- Respiratory, Critical Care and Anaesthesia section in III, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
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42
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Divala OH, Amberbir A, Ismail Z, Beyene T, Garone D, Pfaff C, Singano V, Akello H, Joshua M, Nyirenda MJ, Matengeni A, Berman J, Mallewa J, Chinomba GS, Kayange N, Allain TJ, Chan AK, Sodhi SK, van Oosterhout JJ. The burden of hypertension, diabetes mellitus, and cardiovascular risk factors among adult Malawians in HIV care: consequences for integrated services. BMC Public Health 2016; 16:1243. [PMID: 27955664 PMCID: PMC5153818 DOI: 10.1186/s12889-016-3916-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 12/08/2016] [Indexed: 11/15/2022] Open
Abstract
Background Hypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics. Methods Cross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk. Results Nine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients’ characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1–26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0–5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens. Conclusion Among patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.
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Affiliation(s)
| | | | | | | | | | - Colin Pfaff
- Dignitas International, PO Box 1071, Zomba, Malawi
| | | | | | - Martias Joshua
- Ministry of Health, Zomba Central Hospital, Zomba, Malawi
| | | | | | - Josh Berman
- Dignitas International, PO Box 1071, Zomba, Malawi
| | - Jane Mallewa
- Department of Medicine, College of Medicine, Blantyre, Malawi
| | | | - Noel Kayange
- Department of Medicine, College of Medicine, Blantyre, Malawi
| | | | | | - Sumeet K Sodhi
- Dignitas International, PO Box 1071, Zomba, Malawi.,Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Joep J van Oosterhout
- Dignitas International, PO Box 1071, Zomba, Malawi. .,Department of Medicine, College of Medicine, Blantyre, Malawi.
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43
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Lelijveld N, Seal A, Wells JC, Kirkby J, Opondo C, Chimwezi E, Bunn J, Bandsma R, Heyderman RS, Nyirenda MJ, Kerac M. Chronic disease outcomes after severe acute malnutrition in Malawian children (ChroSAM): a cohort study. Lancet Glob Health 2016; 4:e654-62. [PMID: 27470174 PMCID: PMC4985564 DOI: 10.1016/s2214-109x(16)30133-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [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: 02/25/2016] [Revised: 05/17/2016] [Accepted: 06/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tackling severe acute malnutrition (SAM) is a global health priority. Heightened risk of non-communicable diseases (NCD) in children exposed to SAM at around 2 years of age is plausible in view of previously described consequences of other early nutritional insults. By applying developmental origins of health and disease (DOHaD) theory to this group, we aimed to explore the long-term effects of SAM. METHODS We followed up 352 Malawian children (median age 9·3 years) who were still alive following SAM inpatient treatment between July 12, 2006, and March 7, 2007, (median age 24 months) and compared them with 217 sibling controls and 184 age-and-sex matched community controls. Our outcomes of interest were anthropometry, body composition, lung function, physical capacity (hand grip, step test, and physical activity), and blood markers of NCD risk. For comparisons of all outcomes, we used multivariable linear regression, adjusted for age, sex, HIV status, and socioeconomic status. We also adjusted for puberty in the body composition regression model. FINDINGS Compared with controls, children who had survived SAM had lower height-for-age Z scores (adjusted difference vs community controls 0·4, 95% CI 0·6 to 0·2, p=0·001; adjusted difference vs sibling controls 0·2, 0·0 to 0·4, p=0·04), although they showed evidence of catch-up growth. These children also had shorter leg length (adjusted difference vs community controls 2·0 cm, 1·0 to 3·0, p<0·0001; adjusted difference vs sibling controls 1·4 cm, 0·5 to 2·3, p=0·002), smaller mid-upper arm circumference (adjusted difference vs community controls 5·6 mm, 1·9 to 9·4, p=0·001; adjusted difference vs sibling controls 5·7 mm, 2·3 to 9·1, p=0·02), calf circumference (adjusted difference vs community controls 0·49 cm, 0·1 to 0·9, p=0·01; adjusted difference vs sibling controls 0·62 cm, 0·2 to 1·0, p=0·001), and hip circumference (adjusted difference vs community controls 1·56 cm, 0·5 to 2·7, p=0·01; adjusted difference vs sibling controls 1·83 cm, 0·8 to 2·8, p<0·0001), and less lean mass (adjusted difference vs community controls -24·5, -43 to -5·5, p=0·01; adjusted difference vs sibling controls -11·5, -29 to -6, p=0·19) than did either sibling or community controls. Survivors of SAM had functional deficits consisting of weaker hand grip (adjusted difference vs community controls -1·7 kg, 95% CI -2·4 to -0·9, p<0·0001; adjusted difference vs sibling controls 1·01 kg, 0·3 to 1·7, p=0·005,)) and fewer minutes completed of an exercise test (sibling odds ratio [OR] 1·59, 95% CI 1·0 to 2·5, p=0·04; community OR 1·59, 95% CI 1·0 to 2·5, p=0·05). We did not detect significant differences between cases and controls in terms of lung function, lipid profile, glucose tolerance, glycated haemoglobin A1c, salivary cortisol, sitting height, and head circumference. INTERPRETATION Our results suggest that SAM has long-term adverse effects. Survivors show patterns of so-called thrifty growth, which is associated with future cardiovascular and metabolic disease. The evidence of catch-up growth and largely preserved cardiometabolic and pulmonary functions suggest the potential for near-full rehabilitation. Future follow-up should try to establish the effects of puberty and later dietary or social transitions on these parameters, as well as explore how best to optimise recovery and quality of life for survivors. FUNDING The Wellcome Trust.
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Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University College London, London, UK
| | - Jane Kirkby
- Respiratory, Critical Care & Anaesthesia section in IIIP, Institute of Child Health, University College London, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - James Bunn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Robert Bandsma
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert S Heyderman
- Division of Infection & Immunity, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Moffat J Nyirenda
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Marko Kerac
- Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Child Health, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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44
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Reniers G, Wamukoya M, Urassa M, Nyaguara A, Nakiyingi-Miiro J, Lutalo T, Hosegood V, Gregson S, Gómez-Olivé X, Geubbels E, Crampin AC, Wringe A, Waswa L, Tollman S, Todd J, Slaymaker E, Serwadda D, Price A, Oti S, Nyirenda MJ, Nabukalu D, Nyamukapa C, Nalugoda F, Mugurungi O, Mtenga B, Mills L, Michael D, McLean E, McGrath N, Martin E, Marston M, Maquins S, Levira F, Kyobutungi C, Kwaro D, Kasamba I, Kanjala C, Kahn K, Kabudula C, Herbst K, Gareta D, Eaton JW, Clark SJ, Church K, Chihana M, Calvert C, Beguy D, Asiki G, Amri S, Abdul R, Zaba B. Data Resource Profile: Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network). Int J Epidemiol 2016; 45:83-93. [PMID: 26968480 DOI: 10.1093/ije/dyv343] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Georges Reniers
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa,
| | | | - Mark Urassa
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Amek Nyaguara
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Vicky Hosegood
- Africa Centre for Population Health, Mtubatuba, South Africa, Department of Social Statistics and Demography, Southampton University, Southampton, UK
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Xavier Gómez-Olivé
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Amelia C Crampin
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Laban Waswa
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Stephen Tollman
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Centre for Global Health Research, Umea° University, Umea°, Sweden
| | - Jim Todd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Emma Slaymaker
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Serwadda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda, School of Public Health, Makerere University, Kampala, Uganda
| | - Alison Price
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Samuel Oti
- African Population and Health Research Center, Nairobi, Kenya
| | - Moffat J Nyirenda
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Dorean Nabukalu
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Fred Nalugoda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Rakai, Uganda
| | - Owen Mugurungi
- Manicaland Centre for Public Health Research, Harare, Zimbabwe, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Baltazar Mtenga
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Lisa Mills
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya, Division of HIV/AIDS Prevention, CDC, Atlanta GA, USA and
| | - Denna Michael
- Tazama Project, Tanzania National Institute for Medical Research, Mwanza, Tanzania
| | - Estelle McLean
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Nuala McGrath
- Africa Centre for Population Health, Mtubatuba, South Africa, Department of Social Statistics and Demography, Southampton University, Southampton, UK
| | - Emmanuel Martin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Milly Marston
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sewe Maquins
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | | | | | - Daniel Kwaro
- Kenya Medical Research Institute and the Centers for Disease Control, Kisumu, Kenya
| | - Ivan Kasamba
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Chifundo Kanjala
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kathleen Kahn
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Centre for Global Health Research, Umea° University, Umea°, Sweden
| | - Chodziwadziwa Kabudula
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kobus Herbst
- Africa Centre for Population Health, Mtubatuba, South Africa
| | - Dickman Gareta
- Africa Centre for Population Health, Mtubatuba, South Africa
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College, London, UK
| | - Samuel J Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Department of Sociology, University of Washington, Seattle WA, USA
| | - Kathryn Church
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Menard Chihana
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, UK
| | - Clara Calvert
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Donatien Beguy
- African Population and Health Research Center, Nairobi, Kenya
| | - Gershim Asiki
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Shamte Amri
- Ifakara Health Institute, Dar-Es-Salaam, Tanzania
| | | | - Basia Zaba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Banda HT, Mortimer K, Bello GAF, Mbera GB, Namakhoma I, Thomson R, Nyirenda MJ, Faragher B, Madan J, Malmborg R, Stenberg B, Mpunga J, Mwagomba B, Gama E, Piddock K, Squire SB. Informal Health Provider and Practical Approach to Lung Health interventions to improve the detection of chronic airways disease and tuberculosis at primary care level in Malawi: study protocol for a randomised controlled trial. Trials 2015; 16:576. [PMID: 26679768 PMCID: PMC4683704 DOI: 10.1186/s13063-015-1068-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In developing countries like Malawi, further investigation is rare after patients with chronic cough test negative for tuberculosis. Chronic airways disease has presentations that overlap with tuberculosis. However, chronic airways disease is often unrecognised due to a lack of diagnostic services. Within developing countries, referral systems at primary health care level are weak and patients turn to unskilled informal health providers to seek health care. Delayed diagnosis and treatment of these diseases facilitates increased severity and tuberculosis transmission. The World Health Organisation developed the Practical Approach to Lung Health strategy which has been shown to improve the management of both tuberculosis and chronic airways disease. The guidelines address the need for integrated guidelines for tuberculosis and chronic airways disease. Engaging with informal health providers has been shown to be effective in improving health services uptake. However, it is not known whether engaging community informal health providers would have a positive impact in the implementation of the Practical Approach to Lung Health strategy. We will use a cluster randomised controlled trial to determine the effect of using the two interventions to improve case detection and treatment of patients with tuberculosis and chronic airways disease. METHODS A three-arm cluster randomised trial design will be used. A primary health centre catchment population will form a cluster, which will be randomly allocated to one of the arms. The first arm personnel will receive the Practical Approach to Lung Health strategy intervention. In addition to this strategy, the second arm personnel will receive training of informal health providers. The third arm is the control. The effect of interventions will be evaluated by community surveys. Data regarding the diagnosis and management of chronic cough will be gathered from primary health centres. DISCUSSION This trial seeks to determine the effect of Informal Health Provider and Practical Approach to Lung Health interventions on the detection and management of chronic airways disease and tuberculosis at primary care level in Malawi. TRIAL REGISTRATION The unique identification number for the registry is PACTR201411000910192--21 November 2014.
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Affiliation(s)
| | | | | | - Grace B Mbera
- Research for Equity and Community Health Trust, ᅟ, Malawi.
| | | | | | | | | | | | | | | | - James Mpunga
- Ministry of Health, 30377, Capital City, Lilongwe 3, Malawi.
| | | | - Elvis Gama
- Liverpool School of Tropical Medicine, Liverpool, UK.
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46
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Assayed AA, Muula AS, Nyirenda MJ. The quality of care of diabetic patients in rural Malawi: A case of Mangochi district. Malawi Med J 2014; 26:109-114. [PMID: 26167259 PMCID: PMC4325344] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Diabetes mellitus is a global public health problem. In Malawi, the prevalence of diabetes is 5.6% but the quality of care has not been well studied. OBJECTIVE The aim of this study was to assess the quality of care offered to diabetic patients in Mangochi district. METHODS This was a cross sectional descriptive study. Quantitative data were collected using a questionnaire from a sample of 75 diabetic patients (children and adults) who attended the Diabetes Clinic at Mangochi District Hospital between 20012 and 2013. Qualitative data were also collected using semi-structured interviews with eight Key Informants from among the District Health Management Team. Frequencies and cross-tabulation were obtained from the quantitative data. Patients' master cards were checked to validate results. Clinical knowledge about diabetes, care practices and resources were the themes analysed from the qualitative data. RESULTS Among the 75 participants interviewed, 46 were females and 29 males. The overall mean age was 48.3 years (45.6 for females and 53.3 for males). More than half of patients had little or no information about diabetes (40.0 % (n=30) and 22.7 (n=17) respectively. The majority of patients were taking their medicines regularly 98.7% (n=74). Only 17.3% (n=13) reported having their feet inspected regularly. Fifty-six percent of patients were satisfied about services provision. Some nurses and clinicians were trained on diabetes care but most of them left. Guidelines on diabetes management were not accessible. There were shortages in medicines (e.g. soluble insulin) and reagents. Information Education and Communication messages were offered through discussions, experiences sharing and posters. CONCLUSION Quality of diabetes care provided to diabetic patients attended to Mangochi hospital was sub-optimal due to lack of knowledge among patients and clinicians and resources. More efforts are needed towards retention of trained staff, provision of pharmaceutical and laboratory resources and health education.
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Affiliation(s)
- A A Assayed
- Albaraka Charity Trust, Mama Kadija Clinic, Mangochi, Malawi
| | - A S Muula
- Department of Community Health, College of Medicine, University of Malawi, Blantyre Malawi
| | - M J Nyirenda
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi ; Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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47
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Tang JI, Seckl JR, Nyirenda MJ. Prenatal glucocorticoid overexposure causes permanent increases in renal erythropoietin expression and red blood cell mass in the rat offspring. Endocrinology 2011; 152:2716-21. [PMID: 21540288 DOI: 10.1210/en.2010-1443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Glucocorticoids promote maturation of fetal systems, including erythropoiesis, in preparation for extrauterine life. However, recent studies have shown that prenatal glucocorticoid excess can cause long-term deleterious cardiometabolic and other consequences to the offspring. Here, we examined the effect of prenatal treatment with the synthetic glucocorticoid dexamethasone (DEX) during the last week of gestation on red blood cell (RBC) mass in the rat offspring. DEX-treated offspring at 9 months of age had significantly higher RBC count (9.4 ± 0.1 vs. 8.8 ± 0.2 × 10(12) liter; P = 0.02), hematocrit (50.0 ± 0.5 vs. 46.7 ± 0.7%; P=0.004), hemoglobin (17.3 ± 0.2 vs. 16.2 ± 0.2 g/dl; P = 0.02) and number of reticulocytes (258.2 ± 8.8 vs. 235.7 ± 5.6 × 10(9) liter; P = 0.04), compared with offspring of vehicle-treated control pregnancies. White blood cells and platelets were unaltered. Renal mRNA expression and plasma concentrations of erythropoietin, the main regulator of erythropoiesis, were increased by nearly 100% in both newborn and adult DEX-treated rats (P < 0.01). This increase was accompanied by marked elevation in renal expression of hepatocyte nuclear factor 4α mRNA, whereas other erythropoietin-regulating transcription factors, such as hypoxia-inducible factor 1, hypoxia-inducible factor 2, and GATA2 were unchanged. These data indicate that RBC mass can be programmed by prenatal glucocorticoid excess, and if extrapolatable to humans, provide a novel mechanism for fetal origins of polycythemia and its associated complications.
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Affiliation(s)
- Justin I Tang
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4 TJ, Scotland, United Kingdom
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48
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Macfarlane DP, Zou X, Andrew R, Morton NM, Livingstone DEW, Aucott RL, Nyirenda MJ, Iredale JP, Walker BR. Metabolic pathways promoting intrahepatic fatty acid accumulation in methionine and choline deficiency: implications for the pathogenesis of steatohepatitis. Am J Physiol Endocrinol Metab 2011; 300:E402-9. [PMID: 21119028 PMCID: PMC3043621 DOI: 10.1152/ajpendo.00331.2010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The pathological mechanisms that distinguish simple steatosis from steatohepatitis (or NASH, with consequent risk of cirrhosis and hepatocellular cancer) remain incompletely defined. Whereas both a methionine- and choline-deficient diet (MCDD) and a choline-deficient diet (CDD) lead to hepatic triglyceride accumulation, MCDD alone is associated with hepatic insulin resistance and inflammation (steatohepatitis). We used metabolic tracer techniques, including stable isotope ([¹³C₄]palmitate) dilution and mass isotopomer distribution analysis (MIDA) of [¹³C₂]acetate, to define differences in intrahepatic fatty acid metabolism that could explain the contrasting effect of MCDD and CDD on NASH in C57Bl6 mice. Compared with control-supplemented (CS) diet, liver triglyceride pool sizes were similarly elevated in CDD and MCDD groups (24.37 ± 2.4, 45.94 ± 3.9, and 43.30 ± 3.5 μmol/liver for CS, CDD, and MCDD, respectively), but intrahepatic neutrophil infiltration and plasma alanine aminotransferase (31 ± 3, 48 ± 4, 231 ± 79 U/l, P < 0.05) were elevated only in MCDD mice. However, despite loss of peripheral fat in MCDD mice, neither the rate of appearance of palmitate (27.2 ± 3.5, 26.3 ± 2.3, and 28.3 ± 3.5 μmol·kg⁻¹·min⁻¹) nor the contribution of circulating fatty acids to the liver triglyceride pool differed between groups. Unlike CDD, MCDD had a defect in hepatic triglyceride export that was confirmed using intravenous tyloxapol (142 ± 21, 122 ± 15, and 80 ± 7 mg·kg⁻¹·h⁻¹, P < 0.05). Moreover, hepatic de novo lipogenesis was significantly elevated in the MCDD group only (1.4 ± 0.3, 2.3 ± 0.4, and 3.4 ± 0.4 μmol/day, P < 0.01). These findings suggest that important alterations in hepatic fatty acid metabolism may promote the development of steatohepatitis. Similar mechanisms may predispose to hepatocyte damage in human NASH.
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Affiliation(s)
- David P Macfarlane
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
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49
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Lockman KA, Nyirenda MJ. Interrelationships between hepatic fat and insulin resistance in non-alcoholic fatty liver disease. Curr Diabetes Rev 2010; 6:341-7. [PMID: 20701585 DOI: 10.2174/157339910793360879] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 06/10/2010] [Indexed: 12/16/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is strongly associated with insulin resistance, and its prevalence is rising in parallel with worldwide increases in obesity and type 2 diabetes. However, the nature of this relationship remains debatable. In particular, it is unclear whether insulin resistance causes NAFLD or hepatic steatosis per se reduces insulin sensitivity. This review will examine data from recent studies on the link between insulin resistance and NAFLD, focusing on studies that have attempted to dissociate fatty liver and hepatic insulin resistance.
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50
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Abstract
Hepatocyte nuclear factor 4-alpha (HNF4-alpha) regulates expression of a number of genes in several metabolic organs. The HNF4-alpha gene has two promoters and encodes at least nine isoforms through differential splicing. In mouse liver, transcription initiates at promoter 2 (P2) during fetal life, but switches to P1 at birth. Developmental and tissue-specific expression of HNF4-alpha in other organs is largely unknown. Here, we examined expression of P1- and P2-derived transcripts in a number of mouse and rat tissues. Both P1 and P2 were active in mouse fetal liver, but P2-derived isoforms were detected 50% more abundantly than P1 transcripts. Conversely, the adult mouse liver expressed significantly higher levels of P1- than P2-derived mRNA. In contrast, in the rat, P1 was used more predominantly in both fetal and adult liver. Exposure of fetal rats to the synthetic glucocorticoid dexamethasone caused suppression of P2 while enhancing hepatic expression of transcripts from P1. This was associated with increased expression of erythropoietin and phosphoenolpyruvate carboxykinase, which are key HNF4-alpha targets in the liver. Unlike liver, the kidney and stomach used promoters more selectively, so that only P1-derived isoforms were detected in fetal and adult kidneys in mice or rats, whereas the stomach in both species expressed P2-derived transcripts exclusively. No significant HNF4-alpha mRNA was detected in the spleen. These data reveal striking developmental and tissue-specific variation in expression of HNF4-alpha, and indicate that this can be influenced by environmental factors (such as exposure to glucocorticoid excess), with potential pathophysiological consequences.
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Affiliation(s)
- Samena Dean
- Endocrinology Unit, Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Justin I. Tang
- Endocrinology Unit, Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Jonathan R. Seckl
- Endocrinology Unit, Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Moffat J. Nyirenda
- Endocrinology Unit, Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
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