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1.  A review of co-morbidity between infectious and chronic disease in Sub Saharan Africa: TB and Diabetes Mellitus, HIV and Metabolic Syndrome, and the impact of globalization 
Background
Africa is facing a rapidly growing chronic non-communicable disease burden whilst at the same time experiencing continual high rates of infectious disease. It is well known that some infections increase the risk of certain chronic diseases and the converse. With an increasing dual burden of disease in Sub Saharan Africa the associations between diseases and our understanding of them will become of increased public health importance.
Aims
In this review we explore the relationships reported between tuberculosis and diabetes mellitus, human immunodeficiency virus, its treatment and metabolic risk. We aimed to address the important issues surrounding these associations within a Sub Saharan African setting and to describe the impact of globalization upon them.
Findings
Diabetes has been associated with a 3-fold incident risk of tuberculosis and it is hypothesised that tuberculosis may also increase the risk of developing diabetes. During co-morbid presentation of tuberculosis and diabetes both tuberculosis and diabetes outcomes are reported to worsen. Antiretroviral therapy for HIV has been associated with an increased risk of developing metabolic syndrome and HIV has been linked with an increased risk of developing both diabetes and cardiovascular disease. Globalization is clearly related to an increased risk of diabetes and cardiovascular disease. It may be exerting other negative and positive impacts upon infectious and chronic non-communicable disease associations but at present reporting upon these is sparse.
Conclusion
The impact of these co-morbidities in Sub Saharan Africa is likely to be large. An increasing prevalence of diabetes may hinder efforts at tuberculosis control, increasing the number of susceptible individuals in populations where tuberculosis is endemic, and making successful treatment harder. Roll out of anti-retroviral treatment coverage within Sub Saharan Africa is an essential response to the HIV epidemic however it is likely to lead to a growing number of individuals suffering adverse metabolic consequences. One of the impacts of globalization is to create environments that increase both diabetes and cardiovascular risk but further work is needed to elucidate other potential impacts. Research is also needed to develop effective approaches to reducing the frequency and health impact of the co-morbidities described here.
doi:10.1186/1744-8603-5-9
PMCID: PMC2753337  PMID: 19751503
2.  Diabetes Mellitus: Indigenous naming, indigenous diagnosis and self-management in an African setting: the example from Cameroon 
Background
The objective was to examine how the indigenous naming, indigenous self-diagnosis and management of diabetes evolved with awareness in order to develop a socially oriented theoretical model for its care.
Methods
The data was collected through a one-year extended participant observation in Bafut, a rural health district of Cameroon. The sample consisted of 72 participants in a rural health district of Cameroon (men and women) with type 2 diabetes. We used participant observation to collect data through focus group discussions, in depth interviews and fieldwork conversations. The method of analysis entailed a thick description, thematic analysis entailing constant comparison within and across FGD and across individual participants and content analysis.
Results
The core concepts identified were the evolution of names for diabetes and the indigenous diagnostic and self-management procedures. Participants fell into one of two naming typologies: (a) Naming excluding any signs and symptoms of diabetes; (b) naming including signs and symptoms of diabetes. Participants fell into two typologies of diagnostic procedures: (a) those that use indigenous diagnostic procedures for monitoring and controlling diabetes outcomes and b) those that had initially used it only for diagnosis and continued to use them for self management. These typologies varied according to how participants' awareness evolved and the impact on self-diagnosis and management.
Conclusion
The evolution of names for diabetes was an important factor that influenced the subsequent self-diagnosis and management of diabetes in both traditional and modern biomedical settings.
doi:10.1186/1472-6823-9-5
PMCID: PMC2661081  PMID: 19224650
3.  "Obesity" and "Clinical Obesity" Men's understandings of obesity and its relation to the risk of diabetes: A qualitative study 
BMC Public Health  2008;8:311.
Background
The 2007 Wanless report highlights the ever increasing problem of obesity and the consequent health problems. Obesity is a significant cause of diabetes. An increasing evidence base suggests that in terms of reducing diabetes and CVD risk, it is better to be "fit and fat" than unfit and of normal weight. There has been very little previous research into the understandings that men in the general population hold about the issues of weight, exercise and health; we therefore undertook this study in order to inform the process of health promotion and diabetes prevention in this group.
Methods
A qualitative study in North East England General Practice using a purposive sample of men aged 25 and 45 years (selection process designed to include 'normal', 'overweight' and 'obese' men). One to one audio-recorded semi structured interviews focused on: overweight and obesity, diet, physical activity and diabetes. Transcripts were initially analysed using framework analysis. Emerging themes interlinked.
Results
The men in this study (n = 17) understand the word obesity differently from the clinical definition; "obesity" was used as a description of those with fat in a central distribution, and understandings of the term commonly take into account fitness as well as weight. Men in their late 30s and early 40s described becoming more aware of health issues. Knowledge of what constitutes a 'healthy lifestyle' was generally good, but men described difficulty acting upon this knowledge for various reasons e.g. increasing responsibilities at home and at work. Knowledge of diabetes and the link between obesity and diabetes was poor.
Conclusion
Men in this study had a complex understanding of the interlinked importance of weight and fitness in relation to health. Obesity is understood as a description of people with centrally distributed fat, in association with low fitness levels. There is a need to increase understanding of the causes and consequences of diabetes. Discussion of increased health awareness by men round the age of 40 may indicate a window of opportunity to intervene at this time.
doi:10.1186/1471-2458-8-311
PMCID: PMC2557012  PMID: 18789165
4.  Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study 
BMJ : British Medical Journal  2001;322(7299):1389-1393.
Objectives
To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation in an unselected population with diabetes.
Design
Longitudinal study, using a population based district diabetes register.
Setting
South Tees, United Kingdom.
Participants
All people known to have diabetes living in Middlesbrough and Redcar and Cleveland local authorities on 1 January 1994.
Main outcome measure
Death, from any cause, between 1 January 1994 and 31 December 1999.
Results
Over the six years of the study 1205 (24.9%) of 4842 participants died. All cause standardised mortality ratios for type 1 diabetes were 641 (95% confidence interval 406 to 962) in women and 294 (200 to 418) in men, and those for type 2 diabetes were 160 (147 to 174) in women and 141 (130 to 152) in men. Cause specific standardised mortality ratios were increased for ischaemic heart disease, cerebrovascular disease, and renal disease; no reductions in mortality from other causes were seen. The risk of premature death increased significantly with increasing material deprivation (P<0.001).
Conclusions
Diabetes is associated with excess mortality, even in an area with high background death rates from cardiovascular disease. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by material deprivation. Aggressive approaches to the management of cardiovascular risk factors could reduce the excess mortality in people with diabetes.
What is already known on this topicMortality, mainly from cardiovascular disease, is increased in people with diabetes, but this excess varies considerably by country and ethnic groupPrevious British studies have reported no excess mortality in old age, a reduction in deaths from non-cardiovascular causes, and that mortality may be adversely affected by deprivationWhat this study addsMortality is increased, across all ages, in an unselected population with diabetes compared with the local population without diabetes, which itself has high mortalityMost of the excess is from cardiovascular causes, but there are no reductions in other causes of deathMortality among people with diabetes is increased even in the most affluent group, and this excess increases with worsening material deprivation
PMCID: PMC32252  PMID: 11397742
5.  Do obese but metabolically normal women differ in intra-abdominal fat and physical activity levels from those with the expected metabolic abnormalities? A cross-sectional study 
BMC Public Health  2010;10:723.
Background
Obesity remains a major public health problem, associated with a cluster of metabolic abnormalities. However, individuals exist who are very obese but have normal metabolic parameters. The aim of this study was to determine to what extent differences in metabolic health in very obese women are explained by differences in body fat distribution, insulin resistance and level of physical activity.
Methods
This was a cross-sectional pilot study of 39 obese women (age: 28-64 yrs, BMI: 31-67 kg/m2) recruited from community settings. Women were defined as 'metabolically normal' on the basis of blood glucose, lipids and blood pressure. Magnetic Resonance Imaging was used to determine body fat distribution. Detailed lifestyle and metabolic profiles of participants were obtained.
Results
Women with a healthy metabolic profile had lower intra-abdominal fat volume (geometric mean 4.78 l [95% CIs 3.99-5.73] vs 6.96 l [5.82-8.32]) and less insulin resistance (HOMA 3.41 [2.62-4.44] vs 6.67 [5.02-8.86]) than those with an abnormality. The groups did not differ in abdominal subcutaneous fat volume (19.6 l [16.9-22.7] vs 20.6 [17.6-23.9]). A higher proportion of those with a healthy compared to a less healthy metabolic profile met current physical activity guidelines (70% [95% CIs 55.8-84.2] vs 25% [11.6-38.4]). Intra-abdominal fat, insulin resistance and physical activity make independent contributions to metabolic status in very obese women, but explain only around a third of the variance.
Conclusion
A sub-group of women exists who are metabolically normal despite being very obese. Differences in fat distribution, insulin resistance, and physical activity level are associated with metabolic differences in these women, but account only partially for these differences. Future work should focus on strategies to identify those obese individuals most at risk of the negative metabolic consequences of obesity and on identifying other factors that contribute to metabolic status in obese individuals.
doi:10.1186/1471-2458-10-723
PMCID: PMC3001436  PMID: 21106050

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