Sixth NIH Rwandan Fellow Studies Low-Cost Diabetes Remission and Diagnosis

After finishing medical school in the Rwandan capital of Kigali, M. Grace Duhuze Karera, M.D., M.Sc., moved to the country’s rural western province for postgraduate service at Bushenge Provincial Hospital. From the top floor of the hospital’s hilltop building, a view of a beautiful lake and miles of rolling hills unfolds.

There, Dr. Duhuze Karera saw many patients suffering from the devastating results of diabetes. Many were not diagnosed with the disease until they had serious complications, including kidney failure, blindness, and foot ulcers. The nearest treatment for those complications was in Kigali, almost 150 miles away. Many of the patients Dr. Duhuze Karera saw were subsistence farmers; they couldn’t spare the time or expense for a 7-hour, multiple-bus journey to the capital.

Many people with untreated foot ulcers ended up having to have part of the leg amputated, which can create particular difficulty in rural areas. “Many people stay home, because you have to walk to get to places,” Dr. Duhuze Karera says. That experience in rural Rwanda is part of what inspired Dr. Duhuze Karera to spend the last year at NIH doing research related to relieving the devastation of diabetes in lower-resourced areas in a clinical research fellowship with the NIH-Rwandan Health Program.

Every year since 2016, NIMHD has hosted a research fellow from Rwanda to conduct research on diabetes. The fellows work under the guidance of Anne E. Sumner, M.D., a senior investigator at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) who has a joint appointment at NIMHD. The program has the full support of NIMHD Director Eliseo J. Pérez-Stable, M.D., and NIMHD Scientific Director Anna María Nápoles, Ph.D., M.P.H. The program is a collaboration between NIMHD, NIDDK, and Rwanda’s University of Global Health Equity (UGHE)—particularly the university’s vice chancellor, Agnes Binagwaho, M.D., M(Ped), Ph.D. Dr. Duhuze Karera is the program’s sixth fellow. A seventh fellow has already been selected for the program and starts in July 2022.

A Cheaper Way to Screen for Diabetes

Diabetes is predicted to increase dramatically in Sub-Saharan Africa, rising by 134% between 2021 and 2045. But many people in the region do not have access to health care or the economic resources needed to manage a chronic disease.

A common test for diabetes measures how the body reacts to sugar. For this test, a person first fasts for 8 hours, then has a blood draw to measure their fasting blood glucose level. Then they have an oral glucose tolerance test (OGTT): They drink a standard beverage called glucola that contains a high concentration of glucose and have another blood draw 2 hours later to check their blood glucose level again. People who have a lot of glucose in their blood may have diabetes.

Glucola is expensive and is not always available in Africa. One of Dr. Duhuze Karera’s projects while at NIH was to find a low-cost alternative to glucola.

She tried tests based on a juice brand (Ceres Juice) that is produced in South Africa and widely available in Africa, but it did not affect blood glucose levels in the same way as the standard glucose drink.

However, a mixture of water and pastry sugar, also known as confectioner’s sugar or powdered sugar, performed very similarly to the standard drink but was much cheaper. The brand-name drink is $8 a bottle, which would be prohibitively expensive for diabetes screening in an under-resourced area. But 75 grams of powdered sugar—the amount in one drink—costs less than a dollar. Dr. Duhuze Karera suggested that the sugar could be pre-packaged in individual doses to ensure standardization and ease of administration.

A Mediterranean Diet for Rwanda

During her fellowship, Dr. Duhuze Karera also investigated low-cost ways to treat diabetes. She carried out a literature search on ways to treat diabetes without medication, through lifestyle interventions such as diet or physical activity. She focused on studies that included participants who were newly diagnosed with diabetes and had not received treatment yet, like the patients she often saw in Bushenge. This led her to research showing that diet and exercise brought about diabetes remission for many people and that a Mediterranean diet specifically could help remission last longer.

A Mediterranean diet is not practical in rural Rwanda; olive oil is not widely available, for example. But Dr. Duhuze Karera plans to work with Rwandan nutritionists to identify locally available foods that have similar benefits to those in the Mediterranean diet. She will do this in another rural area of Rwanda: Butaro, the home of UGHE.

The team will also work with community members to determine what diet is palatable and acceptable. “We will test the diet with people at UGHE who are overweight and want to lose weight so we can get feedback on the diet,” Dr. Duhuze Karera said. Then the team will test the diet in the community, to see whether it works as well as in other studies to bring about diabetes remission.

Bringing Research Home to Rwanda

When she saw patients in Rwanda, Dr. Duhuze Karera was often frustrated that the information she was using to treat them was based on research done in Europe or North America, on very different populations.

“All of the articles we would use were not done in Rwanda,” she said. “The guidelines were based on studies that were done elsewhere.” The typical diabetes patient described in international guidelines was very different from the patients she saw in her rural hospital, who were often adults in their 30s who were not overweight and lived active lives doing intense manual labor.

Dr. Duhuze Karera chose to pursue a master’s degree at University of Leeds, in the United Kingdom, so she could learn to do research in Rwanda, and the NIH fellowship helped her advance this goal. After her fellowship ends in July 2022, she will return to Rwanda to do research and teach at UGHE. There she will collaborate with past NIH-Rwandan Health Program fellows, some of whom continue to work in research-related roles at UGHE and some of whom are in clinical practice elsewhere in Rwanda.

“Non-communicable diseases such as diabetes are a threat to low- and middle-income countries,” said Dr. Binagwaho, who is working with all of the NIH fellows who have returned to Rwanda. As these clinician-researchers return to the country, they share their knowledge with others, helping students gain research skills and building the capacity for research by Africans and with participation by African volunteers. “This program will help achieve better health for Rwandans in both urban and rural areas,” Dr. Binagwaho said.

Page updated July 28, 2022