DM2 is emerging literally epidemically in SSA . This hospital-based study from urban Ghana shows that DM2 patients are predominantly middle-aged and of low socio-economic status, and characterized by high proportions of central adiposity, a respective family history, hypertension, albuminuria and hyperlipidaemia.
The study population - although not representative for the community as a whole - displays many features of urban life in Africa: life-style is mainly sedentary, socio-economic conditions are severely restricted, overweight is frequent, particularly among women, alcohol and tobacco use are generally low, and recreational sports not very popular [21–25]. In comparison with previous studies on DM2 in urban Africa, our findings on obesity and SES are similar. However, our diabetic patients exhibited lower FPG and blood pressure, worse lipid profiles, more frequently a family history of DM2, and less use of tobacco and alcohol [10, 23, 26–28]. In comparison to African American DM2 patients, blood pressure and lipid profiles were similar in the present study but obesity, family history, and smoking and alcohol intake less frequent [21, 29]. In comparison to African and African American DM2 patients, Caucasian DM2 patients show the worst lipid profiles, the highest rates of tobacco and alcohol consumption, a male predominance in abdominal adiposity, and more physical activity [21, 30, 31].
Rates of hypertension and albuminuria were high among our DM2 patients, confirming previous findings from Kumasi . This suboptimal management of patients may reflect both institutional and individual factors including drug cost and availability, health policy disparities, culturally inappropriate lifestyle recommendations, and diluting effects of traditional medicine . Still, complications occurred at only half the figure reported elsewhere in SSA [28, 34]. Diagnostic restrictions and a majority of medicated patients may be involved. Typically, in African diabetic patients, late-onset microvascular complications predominate over macrovascular events [6, 34]. In fact, reported rates of retinopathy in African DM2 patients (25%) exceed those in African Americans (10%) and Caucasians (9%), whereas cardiovascular diseases are estimated at 8%, 33% and 48%, respectively [34, 35].
Limitations of the study and of associated factor analysis in particular need to be considered. Our DM2 definition by FPG is based on the IDF consensus valid during study conduct and follows general practice. Validated nutritional questionnaires possibly could have improved respective assessments. Importantly, the present study was not matched for e.g., age and sex, and used a convenience sample. Women predominated. Controls were younger than patients and, related to that, roughly a quarter originated from hospital staff. This basically was due to limited project funds and reluctance of community members to participate. Although the multivariate analyses are adjusted for these and other differences, the selection bias has implications for interpreting the results: for instance, the increased odds of DM2 among unemployed individuals are partially an artefact due to the proportion of staff members among controls. This, however, does not invalidate the identification of major risk factors such as, e.g., family history or abdominal adiposity. In analysis, we followed an exploratory approach, i.e., lacking pre-formulated hypotheses, and identified independently associated factors. Thus, associations of e.g. unemployment or crowded living conditions with DM2 are statistically independent which does not mean that they are unrelated in real life. We stratified analysis by the presence of hypertension to illustrate differences in associated factors. For comprehensibility, we abstained from (further) stratification by e.g. age groups but adjusted for age, sex and obesity. Lastly and as a matter of fact, association does not necessarily mean causality, and the direction of an association is subject to interpretation.
Notwithstanding the above mentioned limitations, several and partly inter-related parameters reflecting low SES strongly associated with DM2. The propagation of DM2 among low social classes worldwide may be due to low health care utilization, reduced uptake of prevention messages and SES-dependent differences in risk factors including nutrition and physical inactivity . Associations of DM2 with outskirts residence and illiteracy point to the possibility of inadequate access to health information. Unemployment, expanded working hours, hard work, and overcrowded households were all associated with DM2 and may reflect stressful living conditions. Psycho-social stressors are known to be capable of adversely influencing the metabolic constitution . Stress may lead to overeating and poor exercise. Also, increased sympathetic activity may affect adipose and pancreatic tissue regulation and contribute to insulin resistance . Detailed investigations into the association of psycho-social stress and DM2 in SSA are thus warranted.
The strong association in the present study of DM2 with a respective family history underlines the pronounced predisposition in Africans towards DM2 . However, replication of risk alleles established in Caucasians not rarely has failed in African populations , possibly as a result of their higher genetic diversity . Because of this, validated genetic markers of an increased risk of DM2 in Africans are rare. Large-scale studies accounting for environmental variation and, possibly, epigenetic priming, will thus be needed to disentangle predisposition in, e.g. the Ghanaian population.
Obesity, a prominent DM2 risk factor worldwide  and also in the present study, shows an outstanding prevalence in SSA, particularly in urban women . In many areas of SSA, obesity constitutes an obvious social marker of affluence, and poor knowledge and misconceptions about lifestyle risk factors conflict with appropriate prevention and control of obesity and DM2. Clearly, more research into the traditional cognitive imagery as well as into DM2-related knowledge, attitudes and behaviour is needed to be able to implement socioculturally appropriate health promotion campaigns [1, 43]. Such is of particular importance considering the specifically increased risk for adulthood obesity (and DM2) as a result of frequent undernutrition in African infants .
Serum lipid profiles are constantly associated with DM2 , and so did hyperlipidaemia in the present study, particularly when DM2 was complicated by hypertension. Hyperlipidaemia may result from a combination of low SES and comparatively high urban food prices which, in turn, favours the intake of inexpensive and highly refined foods, i.e. poor in fibre and protein, but rich in simple carbohydrates, fats and sodium [10, 44]. In fact, such corresponds to the diet assessed for most study participants. Contrariwise, popular meals based on peanut and fermented maize may improve lipid profiles and underlie the observed weak association of DM2 with total and HDL-cholesterol [45, 46].