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Emerging evidence suggests that type 2 diabetes in African individuals who are lean may represent a distinct phenotype driven by impaired insulin secretion rather than insulin resistance, raising concerns about treatment mismatch and divergent disease outcomes. We examined complication profiles in Africans with type 2 diabetes who are lean vs overweight\/obese.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We analysed harmonised, individual-level cross-sectional data from two large, well-characterised African cohorts (Africa America Diabetes Mellitus study,\n                      <jats:italic>n<\/jats:italic>\n                      =2790; Research on Obesity and Diabetes among African Migrants study,\n                      <jats:italic>n<\/jats:italic>\n                      =541; total\n                      <jats:italic>n<\/jats:italic>\n                      =3331) of adults with type 2 diabetes from Ghana, Nigeria and Kenya. Participants were classified as lean (BMI &lt;25 kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      ) or overweight\/obese (BMI \u226525 kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      ). Robust Poisson regression, adjusted for age, sex, education and treatment, assessed associations with retinopathy, chronic kidney disease, stroke, hypertension and 10-year cardiovascular disease risk. Cohort-specific estimates were pooled using random effects, followed by mediation analysis examining contributions of lifestyle and metabolic markers to observed differences.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Type 2 diabetes in Africans who are lean was characterised by lower beta cell function and low insulin levels. Compared with individuals who are overweight\/obese, adults who are lean showed a higher prevalence of retinopathy (pooled prevalence ratio [pPR] 1.36 [95% CI 1.13, 1.63]) and stroke (pPR 1.41 [95% CI 1.01, 1.99]), but lower hypertension (pPR 0.77 [95% CI 0.71, 0.85]) and 10-year cardiovascular disease risk (pPR 0.85 [95% CI 0.74, 0.97]). Chronic kidney disease prevalence did not differ between groups. Body fat percentage accounted for most differences (up to 92%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions\/interpretation<\/jats:title>\n                    <jats:p>Complication patterns in Africans with type 2 diabetes who are lean vs overweight\/obese follow divergent paths. In Africa, where nearly 24 million people have type 2 diabetes, two-fifths of whom are lean, our findings add to growing evidence that lean type 2 diabetes may be a distinct phenotype, underscoring the urgent need for investigation into better-targeted management for this large, potentially mistreated, population.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00125-026-06830-2","type":"journal-article","created":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T04:01:30Z","timestamp":1787457690000},"page":"3232-3247","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Divergent complication patterns of type 2 diabetes in African individuals who are lean versus overweight or obese: a multi-cohort analysis"],"prefix":"10.1007","volume":"69","author":[{"given":"Sabrina","family":"Esmail","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0175-0340","authenticated-orcid":false,"given":"Charles","family":"Hayfron-Benjamin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0750-4311","authenticated-orcid":false,"given":"Samuel N.","family":"Darko","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4232-4292","authenticated-orcid":false,"given":"Ellis","family":"Owusu-Dabo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6229-0256","authenticated-orcid":false,"given":"Erik","family":"Beune","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8080-7872","authenticated-orcid":false,"given":"Silver","family":"Bahendeka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayo P.","family":"Doumatey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guanjie","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3882-7295","authenticated-orcid":false,"given":"Charles","family":"Agyemang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3105-3231","authenticated-orcid":false,"given":"Adebowale A.","family":"Adeyemo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5759-053X","authenticated-orcid":false,"given":"Charles N.","family":"Rotimi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3032-405X","authenticated-orcid":false,"given":"Karlijn A. 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We also thank the dedicated fieldworkers, research staff and local study teams in Ghana, Nigeria, Kenya and Europe, whose commitment made recruitment, data collection and follow-up possible. The findings and conclusions presented in this paper are those of the authors and do not necessarily reflect the views of the National Institutes of Health (NIH) or the U.S. Department of Health and Human Services.","order":1,"name":"Ethics","label":"Acknowledgements","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"The data supporting the findings of this study are available upon request from the corresponding authors (FPC and KACM) and will remain accessible for a minimum of 10 years following publication. Due to privacy and ethical considerations, the data cannot be made publicly available. Requests for access should be directed to the corresponding authors and will be reviewed by the scientific committees of the RODAM and AADM studies. Data may be shared with qualified researchers for non-commercial research purposes, including replication, meta-analysis and secondary analyses consistent with the original study aims. Access will be granted subject to approval by the relevant institutional ethics committees, execution of a data sharing agreement and compliance with the ethical guidelines of the RODAM and AADM studies and their participating institutions. There is no restriction on the nationality or affiliation of requesting researchers provided these conditions are met.","order":2,"name":"Ethics","label":"Data availability","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"The current analyses are supported by the Amsterdam Public Health (Global Health) seed grant (2024105\/MdB\/DvDL). This research was additionally supported in part by the Intramural Research Program of the NIH. The RODAM study was funded by the European Commission under Framework Programme 7 (grant no. 278901). The AADM study received support for participant recruitment from the NIH grant no. 3T37TW00041-03S2 from the Office of Research on Minority Health. KACM is additionally supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Pathway to Independence Award (K99\/R00) DK131018. The funders of the study had no role in study design, data collection, data analysis, data interpretation or the writing of the report.","order":3,"name":"Ethics","label":"Funding","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.","order":4,"name":"Ethics","label":"Authors\u2019 relationships and activities","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"FPC, KACM, CA and SE conceived and designed the study. APD, GC, AAA and CNR contributed to the acquisition of data in the AADM study, and CH-B, SND, EO-D, EB and SB contributed to the acquisition of data in the RODAM study. SE and KACM conducted the statistical analyses, and FPC cross-checked the analyses. SE, FPC and KACM drafted the manuscript. CH-B, SND, EO-D, EB, SB, APD, GC, AAA, CNR and CA critically revised the manuscript for important intellectual content. All authors reviewed and approved the final version for publication. FPC and KACM are guarantors of this work and accept full responsibility for the integrity of the work as a whole. The contributions of the NIH authors are considered works of the United States Government.","order":5,"name":"Ethics","label":"Contribution statement","group":{"name":"EthicsHeading","label":"Ethics"}}]}}