International study prompts rethink on rise of diabetes in cities

International research led by University College London (UCL) as part of the ‘Cities Changing Diabetes’ partnership programme challenges current scientific understanding of the rapid rise of diabetes in cities. The findings suggest that in cities around the world, social and cultural factors play a far more important role in the spread of the epidemic than previously thought.

More than two thirds of the world’s 400 million people with diabetes live in urban areas. The year-long study for Cities Changing Diabetes, a unique public-private- academic partnership, sought to better understand what makes people vulnerable to type 2 diabetes in cities in order to inform solutions for one of the most pressing modern-day public health challenges. To explore this complex issue, more than 550 interviews were undertaken with atrisk and diagnosed people in five major cities – Copenhagen, Houston, Mexico City, Shanghai and Tianjin.

“By largely focusing on biomedical risk factors for diabetes, traditional research has not adequately accounted for the impact of social and cultural drivers of disease,” says David Napier, Professor of Medical Anthropology, UCL. “Our pioneering research will enable cities worldwide to help populations adapt to lifestyles that make them less vulnerable to diabetes.”

The study found that diabetes vulnerability in cities is linked to a complex mix of social and cultural factors – responsible for both putting people at greater initial risk and subsequently making them less likely to be diagnosed, receive treatment and maintain good health. The identified social factors included financial, geographical, resource and time constraints while cultural determinants included the perception of body size and health and deep-seated traditions.

“The insights we have gained from the Cities Changing Diabetes research have fundamentally changed the way we think about diabetes in our city,” said Dr Armando Ahued Ortega, Minister of Health of Mexico City. “This new understanding of sociocultural risk factors will guide the development of increasingly efficient and targeted public health policies to support the health and wellbeing of our citizens.”

Key finding from the study:

• In Houston, the traditional notion of disadvantage being equal to vulnerability is no longer the rule and both people with and without financial constraints may be vulnerable to diabetes

• In Mexico City, gender roles may contribute to increased vulnerability as women neglect their own health to avoid being seen as burdensome

• In Copenhagen, diabetes is often not highest in a person’s hierarchy of need, given many other social and health issues such as unemployment, financial difficulties and loneliness

• In Shanghai, the cultural trend for the denial of hardship was seen to prevent people with diabetes from seeking help from friends, family and healthcare professionals

• In Tianjin, people with diabetes reported a wide range of causes of the condition including poor food choices, overworking and poor mental health

Prompted by the findings, Novo Nordisk has pledged to support the fight against urban diabetes via the investment of US$20 million of expert resource and research funds by 2020. Commenting on the promise, Lars Rebien Sorensen, president and chief executive, Novo Nordisk said: “We have a longstanding commitment to provide more than just pharmaceuticals to the fight against diabetes. Research of this nature illustrates precisely why we initiated Cities Changing Diabetes - to fundamentally change the trajectory of the disease through targeted actions informed by new understanding.”

The Cities Changing Diabetes partnership has three distinct but interconnecting phases - mapping, sharing and action. With the initial mapping phase now complete, the Copenhagen Summit meeting will see 250 expert delegates from around the world come together to discuss the learnings and discuss solutions to tackle diabetes in cities.

In the longer-term, the partnership aims to tackle the rise of diabetes in cities around the world via the sharing of insights and knowledge of participants. In 2016, Vancouver and Johannesburg will become the latest cities to join the programme and contribute to the international pool of evidence.

Cities Changing Diabetes

International study prompts rethink on rise of diabetes in cities

WHO releases first global estimates of herpes type 1 infection More than 3.7 billion people under the age of 50 – or 67% of the population – are infected with herpes simplex virus type 1 (HSV-1), according to the World Health Organization’s first global estimates of HSV-1 infection published 28 October 2015 in the journal PLOS ONE.

Herpes simplex virus is categorized into two types: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Both HSV-1 and HSV-2 are highly infectious and incurable. HSV-1 is primarily transmitted by oral-oral contact and in most cases causes orolabial herpes or “cold sores” around the mouth. HSV-2 is almost entirely sexually transmitted through skin-to-skin contact, causing genital herpes.

The new estimates highlight, however, that HSV-1 is also an important cause of genital herpes. Some 140 million people aged 15-49 years are infected with genital HSV-1 infection, primarily in the Americas, Europe and Western Pacific. Fewer people in high-income countries are becoming infected with HSV-1 as children, likely due to better hygiene and living conditions, and instead are at risk of contracting it genitally through oral sex after they become sexually active.

“Access to education and information on both types of herpes and sexually transmitted infections is critical to protect young people’s health before they become sexually active,” says Dr Marleen Temmerman, Director of WHO’s Department of Reproductive Health and Research.

In January, WHO estimated that 417 million people aged 15-49 years have HSV-2 infection, which causes genital herpes. Taken together, the estimates reveal that over half a billion people between the ages of 15-49 years have genital infection caused by either HSV-1 or HSV-2. “The new estimates highlight the crucial need for countries to improve data collection for both HSV types and sexually transmitted infections in general,” says Dr Temmerman.

Given the lack of a permanent and curative treatment for both HSV-1 and HSV-2, WHO and partners are working to accelerate development of HSV vaccines and topical microbicides, which will have a crucial role in preventing these infections in the future. Several candidate vaccines and microbicides are currently being studied. Regional infection estimates:

Estimates for HSV-1 prevalence by region among people aged 0-49 in 2012

• Americas: 178 million women (49%), 142 million men (39%)

• Africa: 350 million women (87%), 355 million men (87%)

• Eastern Mediterranean: 188 million women (75%), 202 million men (75%)

• Europe: 207 million women (69%), 187 million men (61%)

• South-East Asia: 432 million women (59%), 458 million men (58%)

• Western Pacific: 488 million women (74%), 521 million men (73%)

Estimates of new HSV-1 infections among people aged 0-49 in 2012

• Americas: 6 million women, 5 million men

• Africa: 17 million women, 18 million men

• Eastern Mediterranean: 6 million women, 7 million men

• Europe: 5 million women, 5 million men

• South-East Asia: 13 million women, 14 million men

• Western Pacific: 11 million women, 12 million men

Symptoms: Herpes is a lifelong infection, which often has mild or no symptoms but can be detected by the presence of antibodies for HSV-1 or HSV-2 in the blood. It is difficult to determine the proportion of HSV-infected people worldwide who have symptomatic disease, as symptoms may be mild or simply not recognized as herpes. In the United States of America, about 15% of people with HSV-2 infection report a prior diagnosis of genital herpes.

When genital herpes symptoms do occur, they take the form of one or more painful genital or anal blisters or ulcers. Herpes symptoms can be treated with antivirals, but after an initial episode, symptoms can recur. Recurrences of genital herpes due to HSV-1 are generally much less frequent than for HSV-2.

Transmission of HSV most often occurs without symptoms. The virus can have a significant negative impact upon an infected person’s mental wellness and personal relationships.

People with orolabial herpes symptoms may face social stigma, and can experience psychological distress as a result. In people with weak immune systems, such as those with advanced HIV infection, HSV-1 can have more severe symptoms and more frequent recurrences. Rarely, HSV-1 infection can also lead to more serious complications such as encephalitis or ocular disease.

WHO is currently working on the development of a global health sector strategy for sexually transmitted infections (STIs), including for HSV-1 and HSV-2, to be finalized for consideration at the 69th World Health Assembly in 2016.

HIV scientists launch 23-million euro project to develop vaccine

A new 23-million euro initiative to accelerate the search for an effective HIV vaccine was launched in November. Financed by the European Commission, the European AIDS Vaccine Initiative (EAVI2020) brings together leading HIV researchers from public organisations and biotech companies from across Europe, Australia, Canada and the USA in a focused effort to develop protective and therapeutic HIV vaccines.

According to the World Health Organisation, around 35 million people were living with HIV at the end of 2013. Over two million people are newly infected every year, and it is estimated that around 22 billion US dollars is spent yearly on HIV treatment and care. An effective vaccine remains the best hope of ending the epidemic.

Although researchers have been working on developing a vaccine for 30 years, recent advances are helping to speed up their quest. Scientists have isolated antibodies that are able to block HIV infection in preclinical models, and there have been new developments in using synthetic biology to design better vaccines.

The EAVI2020 consortium, which is led by Imperial College London, unites scientists from 22 institutions, pooling their knowledge and expertise to develop novel candidate vaccines that can be taken through to human trials within five years. EAVI2020 is funded with an EU grant under the health program of Horizon 2020 for research and innovation.

Professor Robin Shattock, Coordinator of EAVI2020, from the Department of Medicine at Imperial College London, said: “Creating an effective vaccine against HIV represents one of the greatest biological challenges of a generation. This project creates a unique opportunity for us to build on the enormous scientific progress gleaned over the last few years, providing an unprecedented insight into the nature of protective antibodies and antiviral cellular response that will be needed for an effective vaccine. We now understand much more about how humans make protective immune responses and how to structure vaccine candidates. We have a level of understanding at a molecular level that was not previously available.

“But it is impossible for one group or institution to create an HIV vaccine on its own. This new project should enable us to move much more quickly. It brings together a multidisciplinary team of molecular biologists, immunologists, virologists, biotechnologists and clinicians, providing the breadth of expertise needed to take the latest discoveries in the lab and rapidly advance them through preclinical testing and manufacture, into early human trials.”

At Imperial, researchers will be looking at how healthy human volunteers’ immune systems respond to potential vaccines, studying the antibodies that the volunteers produce. The researchers will explore the pathways in the body that make these antibodies, in order to fine-tune candidate vaccines.

Dr Ruxandra Draghia-Akli, Director of the Health Directorate at the Directorate General for Research and Innovation of the European Commission said: “In its dual role of policy maker and research funder, the European Commission has played an essential part for over thirty years in supporting HIV vaccine research. Despite major global investments in the field and the promising progress, several scientific obstacles have to be overcome to develop novel promising HIV vaccine candidates. It is with this in mind that the European Commission is providing an almost 23 million Euro grant to the EAVI2020 consortium from which we have high hopes for success. This will allow European scientists to work together and in collaboration with researchers from outside Europe to successfully develop predictive tools and better vaccine candidates to be tested at an early stage of the process.”

Maternal mortality falls by 44% since 1990

Maternal mortality has fallen by 44% since 1990, United Nations agencies and the World Bank Group reported in November.

Maternal deaths around the world dropped from about 532,000 in 1990 to an estimated 303,000 this year, according to the report, the last in a series that has looked at progress under the Millennium Development Goals (MDGs). This equates to an estimated global maternal mortality ratio (MMR) of 216 maternal deaths per 100,000 live births, down from 385 in 1990. Maternal mortality is defined as the death of a woman during pregnancy, childbirth or within 6 weeks after birth.

“The MDGs triggered unprecedented efforts to reduce maternal mortality,” said Dr Flavia Bustreo, WHO Assistant Director-General, Family, Women’s and Children’s Health. “Over the past 25 years, a woman’s risk of dying from pregnancy-related causes has nearly halved. That’s real progress, although it is not enough. We know that we can virtually end these deaths by 2030 and this is what we are committing to work towards.”

Achieving that goal will require much more effort, according to Dr Babatunde Osotimehin, the Executive Director of UNFPA, the United Nations’ Population Fund. “Many countries with high maternal death rates will make little progress, or will even fall behind, over the next 15 years if we don’t improve the current number of available midwives and other health workers with midwifery skills,” he said. “If we don’t make a big push now, in 2030 we’ll be faced, once again, with a missed target for reducing maternal deaths.”

The analyses contained in Trends in Maternal Mortality: 1990 to 2015 – Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division are also published in the The Lancet.

Ensuring access to high-quality health services during pregnancy and child birth is helping to save lives. Essential health interventions include: practising good hygiene to reduce the risk of infection; injecting oxytocin immediately after childbirth to reduce the risk of severe bleeding; identifying and addressing potentially fatal conditions like pregnancy-induced hypertension; and ensuring access to sexual and reproductive health services and family planning for women.

Despite global improvements, only 9 countries achieved the MDG 5 target of reducing the maternal mortality ratio by at least 75% between 1990 and 2015. Those countries are Bhutan, Cabo Verde, Cambodia, Iran, Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda and Timor-Leste. Despite this important progress, the MMR in some of these countries remains higher than the global average.

“As we have seen with all of the healthrelated MDGs, health system strengthening needs to be supplemented with attention to other issues to reduce maternal deaths,” said UNICEF Deputy Executive Director Geeta Rao Gupta. “The education of women and girls, in particular the most marginalized, is key to their survival and that of their children. Education provides them with the knowledge to challenge traditional practices that endanger them and their children.”

By the end of 2105, about 99% of the world’s maternal deaths will have occurred in developing regions, with Sub-Saharan Africa alone accounting for 2 in 3 (66%) deaths. But that represents a major improvement: Sub-Saharan Africa saw nearly 45% decrease in MMR, from 987 to 546 per 100,000 live births between 1990 and 2015. The greatest improvement of any region was recorded in Eastern Asia, where the maternal mortality ratio fell from approximately 95 to 27 per 100,000 live births (a reduction of 72%).

In developed regions, maternal mortality fell 48% between 1990 and 2015, from 23 to 12 per 100,000 live births.

A new Global Strategy for Women’s, Children’s and Adolescents’ Health, launched by the UN Secretary General in September 2015, aims to help achieve the ambitious target of reducing maternal deaths to fewer than 70 per 100,000 live births globally, as included in the Sustainable Development Goals (SDGs). Reaching that goal will require more than tripling the pace of progress – from the 2.3% annual improvement in MMR that was recorded between 1990 and 2015 to 7.5% per year beginning next year. The Global Strategy highlights the need to reinforce country leadership by mobilizing domestic and international resources for women’s, children’s and adolescents’ health.

It will be important to strengthen health systems so they can provide good quality care in all settings, promote collaboration across sectors, and support individuals and communities to make informed decisions about their health and demand the quality care they need. The strategy emphasizes that special attention is imperative during humanitarian crises and in fragile settings, since maternal deaths tend to rise in these contexts.

“The SDG goal of ending maternal deaths by 2030 is ambitious and achievable provided we redouble our efforts,” said Dr Tim Evans, Senior Director of Health, Nutrition and Population at the World Bank Group. “The recently launched Global Financing Facility in Support of Every Woman Every Child, which focuses on smarter, scaled and sustainable financing, will help countries deliver essential health services to women and children.”

The 2015 maternal mortality estimates present the tremendous progress achieved towards the Millennium Development Goal 5 on maternal mortality reduction. They show a strong trend of reduction over the years. At the same time, we have seen more and better data coming from various countries, enhancing the accuracy of the absolute numbers reported.

Efforts to strengthen data and accountability especially over the past years have helped fuel this improvement. However, much more needs to be done to develop complete and accurate civil and vital registration systems that include births, deaths and causes of death.

Maternal death audits and reviews also need to be implemented to understand why, where and when women die and what can be done to prevent similar deaths.

The global diet is getting sweeter

A Personal View, published 1 December 2015 in The Lancet Diabetes & Endocrinology journal, highlights that the global diet is getting sweeter, particularly when it comes to beverages. This Personal View paper is written by Professor Barry M Popkin, School of Public Health, Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA, and Dr Corinna Hawkes, City University London, UK. Previous research has shown that consuming foods and beverages with added caloric sweeteners is linked to an increased risk of weight gain, heart disease, diabetes and stroke. Currently, 68% of packaged foods and beverages in the USA contain caloric sweeteners, 74% include both caloric and low-calorie sweeteners, and just 5% are made with low-calorie sweeteners only. The added sugar comes from hundreds of different versions of sugar, all of which have the same equal health effect, says Professor Popkin.

He expects that in the absence of intervention, the rest of the world will move towards a similar pervasiveness of added sugars in the entire packaged food and beverage supply, with added sugars of all kinds increasing rapidly in the diets of people living in developing countries, while many high-income countries, despite being among the highest sugar consumers, are beginning to see a slight decline in sugar consumption.

After analysing nutritional datasets from around the world, the authors found that trends in sales of sugar-sweetened beverages around the world are increasing in terms of calories sold per person per day and volume sold per person per day. They say: “Consumption is rising fastest in low- and middle-income countries in Latin America, the Caribbean, Africa, the Middle East, Asia and Oceania. The four regions with the current highest consumption are Latin America, North America, Australasia and Western Europe, though intakes are beginning to decline in the latter three.”

Because of the major health risks, particularly weight gain and increased risk of diabetes, hypertension and many cardiovascular problems associated with added caloric sweetener consumption, the World Health Organization is promoting major initiatives to reduce intake. Many governments have already implemented policies with this goal, including taxation, reduction of availability in schools, restrictions on marketing of sugary foods to children, public awareness campaigns and front-of-pack labeling.

Evidence of the effectiveness of these actions shows they are moving in the right direction, but the authors suggest governments should view them as a learning process and improve their design over time. For example, one current challenge for policy makers is the absence of a consensus on the healthiness of fruit juices and beverages containing low-calorie sweeteners.

Future research may better inform decisions about whether these are good substitutes for sugar-sweetened beverages, as the literature suggests fruit juice consumption may have adverse health effects; and while there are well-conducted studies suggesting low-calorie diet sweeteners have positive effects, no global consensus exists strongly in favour of either of these potential substitutes.

While the latest data show that many countries consume high levels of sugarsweetened beverages, and other countries with lower intakes are seeing steep increases, the authors did find that consumption seems to be decreasing in countries with taxes on such products (e.g., Mexico, Finland, Hungary and France).

The authors conclude: “We have…shown from trends data that consumption seems to be decreasing in countries with taxes on sugar-sweetened beverages (eg, Mexico, Finland, Hungary, and France). WHO, major scientific bodies, and most countries recognise the importance of reducing consumption of sugar-sweetened beverages to improve public health. The evaluation of not only sugar taxes, but also new marketing controls and front-of-pack labelling, is important and represents one of the next frontiers – namely, can these policies effectively reduce consumption of sugar-sweetened beverages and intake of total added sugars?”

US NIH to develop robots for healthcare As part of the National Robotics Initiative (NRI), the US National Institutes of Health announced that it will fund the development of three innovative co-robots – robots that work cooperatively with people. Two of the robots will improve health and quality of life for individuals with disabilities, and the third will serve as a social companion for children that inspires curiosity and teaches the importance of hard work and determination. Funding for the NIH projects will total approximately US$2.2 million over the next five years, subject to the availability of funds.

“When the general public thinks about the research that NIH supports, they don’t usually imagine robots. But robots have a tremendous potential to contribute to the health and well-being of our society, whether they are helping an elderly person engage in physical activity or promoting the curiosity of a child,” said Grace Peng, Ph.D., program director of Rehabilitation Engineering at the National Institute of Biomedical Imaging and Bioengineering, part of NIH. “These three highly innovative projects demonstrate the power of encouraging leaders in the field of robotics to focus their attention on solving issues that pertain to health.”

• Smart-walker to increase mobility for elderly Xiangrong Shen, Ph.D. University of Alabama, Tuscaloosa As individuals age, their ability to walk without assistance diminishes, leading to a decrease in physical activity and quality of life. To stay in their homes, elderly with mobility issues often require costly home modifications such as replacing steps with ramps or installing wheelchair lifts. The goal of this project is to develop a fourlegged robot that enhances mobility, so that the elderly can remain physically active and enjoy a healthier life with reduced reliance on the assistance of caregivers or expensive home renovations.

The robot has two modes: smart powerassist walker and smart mule. In the smart power-assist walker mode, the user is situated within the robot and chooses the amount of powered assistance that is needed. In the smart mule mode, the robot walks alongside the user while carrying a load, for example groceries. The robot uses a 3-D computer vision-based sensing system to detect the user’s motion and the environment.

With its smart legs, the robot is able to easily overcome environmental obstacles in ways that powered wheelchairs cannot. This project is funded jointly by the National Institute of Biomedical Imaging and Bioengineering, the National Institute of Nursing Research, and the Eunice Kennedy Shriver National Institute of Child Health & Human Development grant NR016151.

• Hand-worn device to help visually impaired grasp objects

Cang Ye, Ph.D. University of Arkansas at Little Rock

This project proposes to create a handworn assistive device that uses computer vision to identify target objects in a user’s environment, determine misalignment between the user’s hand and the object, and then convey -- via natural human-device interfaces -- the hand motion needed to grasp the object. The device will contribute to the independent lives of the visually impaired in two major ways: It will enhance the individual’s ability to travel independently by helping the user identify moveable obstacles and manipulate them so that they can pass, and it will assist in object grasping for non-navigational purposes such as identifying and correctly manoeuvring a specific door handle.

• A social-robot companion for kids Cynthia Breazeal, Ph.D. Massachusetts Institute of Technology, Cambridge

Curiosity, resilience to challenging environments, and a growth mindset – the belief that one’s basic abilities can be improved through dedication and hard work – are important factors that influence a child’s mental health, academic achievement, and general well-being. The goal of this project is to create an autonomous, long-term social robotic companion for children that will promote and assess curiosity and a growth mindset through various interactions. After developing the robot, the researchers plan to evaluate its influence by conducting a sixmonth longitudinal study in which children learn and play while interacting with the robot companion.

Johns Hopkins Children’s Center successfully treats child for XDR TB Johns Hopkins Children’s Center specialists report they have successfully treated and put in remission a 2-year-old, now age 5, with a highly virulent form of tuberculosis known as XDR TB, or extensively drug-resistant TB. The case, researchers say, provides the first detailed account of a young child in the United States diagnosed and treated for XDR TB.

The bug’s resistance to most known TB drugs render it particularly challenging to treat in anyone but even more so in children, the Johns Hopkins team says, with only a handful of cases of children younger than 5 described in the medical literature worldwide. Despite the successful outcome, the Johns Hopkins experts say the child’s case underscores the shape-shifting nature of a bacterium increasingly resistant to drugs, and the serious challenges of monitoring and treating paediatric TB.

“We are thrilled that our patient is doing so well,” says Johns Hopkins Children’s Center paediatrician and TB expert Sanjay Jain, M.D. “But at the same time, this is a wake-up call to the realities of TB.” An account of the case is published online 16 November in The Lancet Infectious Diseases.

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