Title: NIHR Global Health Research Group on improving outcomes in sub-Saharan African diabetes through better diagnosis and treatment at the University of Exeter
Funder: Department of Health and Social Care

Abstract: University of Exeter Strategy and Support This work will take Exeter’s world leading expertise in diabetes research and apply this to address the challenge of diagnosing and treating diabetes in low income countries. This will be achieved through a true partnership and collaboration with leading sub-Saharan African (SSA) institutions to enable skills transfer, capacity building and world class education that will have an enduring legacy. Our research directly addresses the strategic objectives of the University of Exeter, to deliver research capable of solving global challenges, which will have international impact. The University of Exeter will support this as part of its international strategy. To facilitate the development of this group and its long term impact, the University of Exeter will provide no-cost training for SSA staff and students through our researcher development programme, fund overheads and underwrite a PhD position, and provide a dedicated research development manager to assist further funding. Using leading expertise in diabetes characterisation, diagnostics and treatment to improve patient care in SSA Professor Hattersley leads the premier international group on characterising diabetes which has been recognised with every top award in the field of diabetes, received over £60m funding and, most importantly, has improved the lives of patients with diabetes worldwide. The group works in very close collaboration with the NIHR Exeter Clinical Research Facility (CRF) (Director Hattersley) and leads current national multicentre studies at over 50 sites. There is also close collaboration with Exeter Clinical Laboratory International (McDonald) which has an international reputation for excellence in moving research results into clinical practice. The group has combined cutting edge science with creating the clinical evidence and tools so that their research has had global impact on clinical practice. An example is their research on single gene diabetes; Exeter not only discovered many of the responsible genes but also identified gene-specific treatments supported by clinical trials, developed the diagnostic tests, pathways and guidelines needed for clinicians to identify patients, and established national and international education programmes to assist implementation. The end result has been >50,000 patients worldwide being able to switch from insulin to specific tablet therapy with markedly improved glucose levels and quality of life. Our strategy is to combine our expertise in Exeter with the expertise of researchers, clinicians and patients in Uganda and Cameroon to build lasting relationships, research capacity, and other resources (such as patient cohorts) that will address key problems of diabetes in the developing world and create lasting benefit for SSA patients, healthcare systems and institutions. We will use the best science to answer simple clinical questions needed to effectively and cost effectively detect and manage diabetes in the resource-poor setting of SSA. Building a network with the skills and capacity to perform the highest quality patient focussed research in sub-Saharan Africa Our collaboration will build on existing relationships and strengthen research capacity in SSA, with the majority of the proposed funding spent in Africa and on training of African researchers. Key initial academic partners include Professor Nyirenda, lead for Chronic diseases at the MRC/UVRI Uganda research unit and Prof. Eugene Sobngwi, University of Yaoundé, both of whom have extensive expertise in sub-Saharan African diabetes and conducting research in this environment. They will play a key role in the development of ongoing research studies alongside leading sub-Saharan African and international collaborators. To ensure the most effective use of resources and time our strategy is to initially focus our activities in Uganda, leveraging the expertise, infrastructure and local collaborative network at the MRC Uganda Unit. We will learn from and build on experience in Uganda to expand to Cameroon. To enrich the team scientifically and prepare the environment in Cameroon, this partner will be involved from the beginning and contribute to the activities in Uganda. Building on existing partnerships and investment The Exeter team was initially approached in 2014 by Professor Nyirenda, who was struck by the unusual young-onset slim phenotype of many sub-Saharan Africans diagnosed as having type 2 diabetes in his clinic and cohorts. Jones and Hattersley subsequently collaborated with Nyirenda on developing proposals to address these questions, including a visit to the MRC Uganda Unit and diabetes clinics in Uganda, during which the research questions addressed in this proposal were developed. Most recently, Professor Nyirenda visited the Exeter team and was able to appreciate the environment in the NIHR Clinical Research Facility and participate in further development of the research ideas. Our partnership will build on existing MRC investment in Uganda to facilitate the Unit’s adaption from HIV focused research to chronic diseases. We have clear synergies with the NIHR funded Liverpool School of Tropical Medicine group researching integration of HIV and chronic disease care, with Professor Nyirenda a key partner for both groups. NIHR has invested substantially in the Exeter group though career development (Jones and McDonald are both current and previous award holders), a leading NIHR Clinical Research Facility and the large NIHR funded studies (StartRight (Jones), UNITED (Hattersley)) that will provide comparison UK cohorts for the proposed research. Training strategy Central to our capacity building strategy will be an extensive programme of studentships, reciprocal visits and training between the Exeter, Uganda, and Cameroon teams which will: 1. Develop strong relationships between the institutions needed for effective collaboration 2. Allow Exeter researchers to develop an understanding of the local clinical and research environment and detailed knowledge of the clinical and research issues specific to SSA and opportunities to address them 3. Train African researchers in specific areas of Exeter expertise 4. Further develop the diagnostic facilities in partner institutions through a focus on reciprocal laboratory visits and diagnostics capacity building Research strategy Our research strategy is to: 1. Use the best science/tools to address pragmatic questions and generate reliable data that impact clinical care and policy in SSA. 2. Build contactable recallable cohorts of well characterised participants with diabetes that will be needed for robust future research in this field and will be a key part in developing future sustainable research capacity. 3. Use these initial research studies to inform future study questions/designs and as a key platform for training, networking and capacity building. 4. Begin to develop a critical mass of future leaders in diabetes care and research leaders in SSA. 5. Capitalise on this award (including early publication), and existing reputation and expertise, to secure further funding to propel our research and partnership to continue to directly address some of the key questions for diabetes in SSA, including those raised by a recent Lancet commission. We will create a steering committee to guide us in our strategic ambitions, ensuring that our research continues to focus on relevant questions that will improve diabetes outcomes in SSA. In addition to our SSA partners the Committee will include independent leading international experts. We have approached and received commitment from Prof Edwin Gale Chair (UK) Prof Ranjan Yajnik (India), and Prof Naomi Levitt (South Africa). A key remit of the steering committee will be to approve our training and development strategy and also to assist prioritisation of research topics and themes to reflect the ongoing needs and requirements of SSA DACS.

Lay abstract: Diabetes is a major cause of death and long-term ill health throughout sub-Saharan Africa (SSA). It is rapidly increasing and already affects over 25 million people (7% of the adult population). A recent international commission highlighted that the care of people with diabetes in SSA was greatly limited by a striking lack of knowledge as well as limited resources: we do not know the best way to either detect or treat diabetes in this population. Fundamental differences in both the diabetes and the environment in which medical care is provided mean importing care plans from the West is not appropriate. Research to develop and assess practical solutions for detection and management of diabetes in Africa are urgently needed. The University of Exeter Diabetes Research team are ideally placed to help in the efforts to improve diabetes care in SSA. The internationally renowned 60 person team leads the world in identifying and diagnosing different forms of diabetes, in pioneering new diagnostic tests and cost-effective treatment, and in training the next generation of researchers. Their work has had global impact and improved the lives of thousands of patients, including replacing insulin treatment with inexpensive tablets for over 50,000 patients with genetic types of diabetes around the world, and the development of simple tests for diabetes type used in nearly every UK hospital and worldwide. The overall aim of this research group is to transfer Exeter’s internationally leading expertise in diagnosis and management of diabetes to researchers in Africa to create capacity to support collaborative multi-disciplinary research to improve diabetes care in SSA. Within the NIHR Global Health group they will focus their research skills on the very specific requirements of SSA diabetes identified by their African partners. They will conduct important studies and transfer, in a sustainable fashion, key research, clinical and laboratory skills. The group’s objectives are to: 1. Create the foundation of a long-term partnership between Exeter and researchers, healthcare professionals and patient groups in Uganda and Cameroon to identify, design and perform critical research to improve the care of people with diabetes in SSA. 2. Strengthen research capacity in SSA through an extensive programme of training in Exeter for African researchers at all levels, and reciprocal placements of UK researchers in African institutions. 3. Conduct initial studies to determine the best methods for detection and monitoring of different diabetes subtypes found in SSA, aiming to find practical solutions that make the best use of limited resources. 4. Establish long term studies (cohorts) of patients with diabetes in SSA that will form the basis of future research into the best treatment of diabetes in this population. The initial projects will have immediate benefit for patients with diabetes in SSA as they will: 1. Determine the most cost effective way to diagnose and monitor diabetes in SSA 2. Establish what social interventions and medical care is needed for the survival of young patients with Type 1 diabetes The long term benefit to patients with diabetes will come from the increased capacity that will result from the development of the researchers, laboratories, studies and networks in SSA. This will create an enduring legacy of capacity to perform high quality research that will continue to improve patient outcomes by informing guidelines and policy across the region.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: METABOLIC AND ENDOCRINE