Jean Claude Mbanya

Diabetes in sub-Saharan Africa

In Sub-Saharan Africa, prevalence and burden of type 2 diabetes are rising quickly. Rapid uncontrolled urbanisation and major changes in lifestyle could be driving this epidemic. The increase presents a substantial public health and socioeconomic burden in the face of scarce resources. Some types of diabetes arise at younger ages in African than in European populations. Ketosis-prone atypical diabetes is mostly recorded in people of African origin, but its epidemiology is not understood fully because data for pathogenesis and subtypes of diabetes in sub-Saharan African communities are scarce. The rate of undiagnosed diabetes is high in most countries of sub-Saharan Africa, and individuals who are unaware they have the disorder are at very high risk of chronic complications. Therefore, the rate of diabetes-related morbidity and mortality in this region could grow substantially. A multisectoral approach to diabetes control and care is vital for expansion of socioculturally appropriate diabetes programmes in sub-Saharan African countries.

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.

Peer Support For Self-Management Of Diabetes Improved Outcomes In International Settings

Self-management of diabetes is essential to reducing the risks of associated disabilities. But effective self-management is often short-lived. Peers can provide the kind of ongoing support that is needed for sustained self-management of diabetes. In this context, peers are nonprofessionals who have diabetes or close familiarity with its management. Key functions of effective peer support include assistance in daily management, social and emotional support, linkage to clinical care, and ongoing availability of support. Using these four functions as a template of peer support, project teams in Cameroon, South Africa, Thailand, and Uganda developed and then evaluated peer support interventions for adults with diabetes. Our initial assessment found improvements in symptom management, diet, blood pressure, body mass index, and blood sugar levels for many of those taking part in the programs. For policy makers, the broader message is that by emphasizing the four key peer support functions, diabetes management programs can be successfully introduced across varied cultural settings and within diverse health systems.

Hypertension in four African-origin populations : current 'Rule of Halves', quality of blood pressure control and attributable risk of cardiovascular disease

Objective To assess the public health burden from high blood pressure and the current status of its detection and management in four African-origin populations at emerging or high cardiovascular risk. Design Cross-site comparison using standardized measurement and techniques. Setting Rural and urban Cameroon; Jamaica; Manchester, Britain. Subjects Representative population samples in each setting. African-Caribbeans (80% of Jamaican origin) and a local European sample in Manchester. Main outcome measures Cross-site age-adjusted prevalence; population attributable risk. Results Among 1587 men and 2087 women, age-adjusted rates of blood pressure ⩾ 160 or 95 mmHg or its treatment rose from 5% in rural to 17% in urban Cameroon, despite young mean ages, to 21% in Jamaica and 29% in Caribbeans in Britain. Treatment rates reached 34% in urban Cameroon, and 69% in Jamaican- and British- Caribbean-origin women. Sub-optimal blood pressure control (> 140 and 90 mmHg) on treatment reached 88% in European women. Population attributable risks (or fractions) indicated that up to 22% of premature all-cause, and 45% of stroke mortality could be reduced by appropriate detection and treatment. Additional benefit on just strokes occurring on treatment could be up to 47% (e.g. in both urban Cameroon men and European women) from tighter blood pressure control on therapy. Cheap, effective therapy is available. Conclusion With mortality risk now higher from non-communicable than communicable diseases in sub-Saharan Africa and elsewhere, systematic measurement, detection and genuine control of hypertension once treated can go hand-in-hand with other adult health programmes in primary care. Cost implications are not great. The data from this collaborative study suggest that such efforts should be well rewarded.

Accuracy and validity of a combined heart rate and motion sensor for the measurement of free-living physical activity energy expenditure in adults in Cameroon

BACKGROUND The increasing burden of non-communicable diseases in sub-Saharan Africa (SSA) warrants rigorous studies of contributing lifestyle factors. Combined heart rate (HR) and movement monitoring make it possible to objectively measure physical activity in free-living individuals. We examined the validity of a combined HR and motion sensor in estimating physical activity energy expenditure (PAEE) in free-living adults in rural and urban Cameroon compared with doubly-labelled water (DLW) as criterion. METHODS PAEE was measured in 33 free-living rural and urban dwellers by DLW over 7 consecutive days. Simultaneously, the combined sensor recorded HR and uni-axial acceleration. Individual HR vs PAEE calibration was done by a step test. Branched equation modelling was used to estimate PAEE from HR and acceleration. Validity and accuracy of prediction were expressed as mean bias and root mean square error (RMSE). Agreement was analysed using Bland and Altman limits of agreement (LOA). RESULTS There was no significant mean bias between PAEE estimated from the combined sensor or measured by DLW [mean bias (standard error): -5.4 (5.1) kJ/kg/day; P = 0.3; RMSE = 29.3 kJ/kg/day]. The bias doubled for group compared with individual calibration of HR [-9.1 (5.0) kJ/kg/day, P = 0.08]. PAEE prediction was more accurate in urban compared with rural volunteers. The 95% LOAs between predicted and measured PAEE were ∼50-60 kJ/kg/day above or below perfect agreement. CONCLUSIONS Combined HR and movement sensing is a valid method for estimating free-living PAEE on group level in adults in SSA.

Urbanization, Physical Activity, and Metabolic Health in Sub-Saharan Africa

OBJECTIVE We examined the independent associations between objectively measured free-living physical activity energy expenditure (PAEE) and the metabolic syndrome in adults in rural and urban Cameroon. RESEARCH DESIGN AND METHODS PAEE was measured in 552 rural and urban dwellers using combined heart rate and movement sensing over 7 continuous days. The metabolic syndrome was defined using the National Cholesterol Education Program-Adult Treatment Panel III criteria. RESULTS Urban dwellers had a significantly lower PAEE than rural dwellers (44.2 ± 21.0 vs. 59.6 ± 23.7 kJ/kg/day, P < 0.001) and a higher prevalence of the metabolic syndrome (17.7 vs. 3.5%, P < 0.001). In multivariate regression models adjusted for possible confounders, each kJ/kg/day of PAEE was associated with a 2.1% lower risk of prevalent metabolic syndrome (odds ratio 0.98, P = 0.03). This implies a 6.5 kJ/kg/day difference in PAEE, equivalent to 30 min/day of brisk walking, corresponds to a 13.7% lower risk of prevalent metabolic syndrome. The population attributable fraction of prevalent metabolic syndrome due to being in the lowest quartile of PAEE was 26.3% (25.3% in women and 35.7% in men). CONCLUSIONS Urban compared with rural residence is associated with lower PAEE and higher prevalence of metabolic syndrome. PAEE is strongly independently associated with prevalent metabolic syndrome in adult Cameroonians. Modest population-wide changes in PAEE may have significant benefits in terms of reducing the emerging burden of metabolic diseases in sub-Saharan Africa.

Management of hyperglycaemia in type 2 diabetes: the end of recurrent failure?

The epidemic of type 2 diabetes imposes an enormous and growing burden on health care worldwide. The number of people with type 2 diabetes around the world is estimated to rise from 151 million in 2000 to 300 million by 2025.1 The recognition that strict glycaemic control can reduce microvascular complications has made the effective treatment of hyperglycaemia a priority.2 3 4 5 6 Recently, the diabetes control and complications trial reported that intensive therapy aimed at normoglycaemia has beneficial effects on cardiovascular disease in type 1 diabetes.7 In type 2 diabetes, epidemiological data from the UK prospective diabetes study suggest that lowering glycaemia will reduce the risk of cardiovascular disease.8 The treatment of hyperglycaemia in type 2 diabetes is complex; combinations of glucose lowering drugs are often needed to achieve and maintain blood glucose at target values. The development of new classes of drugs to lower blood glucose has increased the treatment options for type 2 diabetes and has contributed to the uncertainty surrounding these new therapeutic approaches. Here we present a management guideline that may help healthcare providers treat patients with type 2 diabetes. #### Sources and selection criteria This review is largely based on the recently published American Diabetes Association/European Association for the Study of Diabetes treatment guideline for type 2 diabetes.9 We also searched the Cochrane Library for evidence based guidelines using the keywords “type 2 diabetes”, “blood glucose lowering agents”, “glucose monitoring”, “lifestyle”, and “exercise and diet” Studies have shown that the development of microvascular disease is reduced when glycaemic control is improved and have helped establish treatment targets for glycaemia in type 2 diabetes.4 6 Ideally glycated haemoglobin (HbA1C) should be as close to normal as possible without imposing a high risk of severe hypoglycaemia. The upper limit of normal of the …

Diabetes in the Africa region: An update

The Africa Region (AFR), where diabetes was once rare, has witnessed a surge in the condition. Estimates for type 1 diabetes suggest that about 39,000 people suffer from the disease in 2013 with 6.4 new cases occurring per year per 100,000 people in children <14 years old. Type 2 diabetes prevalence among 20-79-year-olds is 4.9% with the majority of people with diabetes <60 years old; the highest proportion (43.2%) is in those aged 40-59 years. Figures are projected to increase with the numbers rising from 19.8 million in 2013 to 41.5 million in 2035, representing a 110% absolute increase. There is an apparent increase in diabetes prevalence with economic development in AFR with rates of 4.4% in low-income, 5.0% in lower-middle income and 7.0% in upper-middle income countries. In addition to development and increases in life-expectancy, the likely progression of people at high risk for the development of type 2 diabetes will drive the expected rise of the disease. This includes those with impaired glucose tolerance, the prevalence of which is 7.3% among 20-79-year-olds in 2013. Mortality attributable to diabetes in 2013 in AFR is expected to be over half a million with three-quarter of these deaths occurring in those <60 years old. The prevalence of undiagnosed diabetes remains unacceptably high at 50.7% and is much higher in low income (75.1%) compared to lower- and upper-middle income AFR countries (46.0%). This highlights the inadequate response of local health systems which need to provide accessible, affordable and optimal care for diabetes.

Metabolic and immunogenetic prediction of long-term insulin remission in African patients with atypical diabetes.

Aims We aimed to characterize a cohort of ‘atypical’ diabetic patients of sub‐Saharan African origin and to analyse possible determinants of long‐term remission.

Diabetes care in Africa

1628 www.thelancet.com Vol 368 November 11, 2006 No-one should have to die of untreated diabetes. Although this disease is only one among a host of health problems that afflict the poorest countries, it is one for which effective and potentially inexpensive remedies are available. Sustainable, locally-appropriate, and cost-effective strategies are what we need, and affordable insulin is a necessary part of any solution. Philanthropic initiatives, such as that of Novo Nordisk, are immensely welcome, but equity pricing needs to extend to the private pharmacies where most patients still have to buy their insulin. On a wider perspective, the marketing policy of the pharmaceutical industry has escalated the costs of diabetes for diminishing benefit, thereby exacerbating existing inequalities. Africa’s problem is indeed our problem too. Edwin A M Gale Diabetes and Metabolism, Department of Clinical Science, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK Edwin.Gale@bristol.ac.uk