Browsing by Author "Bahendeka Silver"

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Classifying a distinct form of diabetes in lean individuals with a history of undernutrition: an international consensus statement
(The Lancet Group, 2025-10) Wadivkar Pradnyashree; Jebasingh Felix; Thomas Nihal; Yajnik S Chittaranjan; Vaag Arthur Allan; Kibirige Davis; Bahendeka Silver; Bajaj Mandeep; Boyne S Michael; Bavuma Charlotte; Abodo Jacko; Wild Sarah; Kolthur-Seetharam Ullas; Mukhopadhyay Satinath; Somasundaram P Noel; Schwarz Peter; Christensen L Dirk; Pathan Faruque; Jones G Angus; Mathur Sandeep; Kehlenbrink Sylvia; Hawkins Meredith; on behalf of the Vellore Declaration Signatories
Since 1955, a form of diabetes in lean, young (BMI < 18·5 kg/m2, age < 30 years) individuals with a history suggestive of undernutrition from before birth and throughout childhood has been described in the literature. In 1985, WHO formally classified it as malnutrition-related diabetes, but subsequently removed the classification in 1999 over a disagreement as to whether undernutrition was a sufficient risk factor to cause this type of diabetes. Emerging evidence now strongly supports the distinct classification of this unique diabetes phenotype, which is characterised by substantial impairment of pancreatic insulin secretion, with normal hepatic and peripheral insulin sensitivity, an absence of ketoacidosis, and no islet cell autoantibodies. In this consensus statement, we synthesise this evidence to produce a set of common features of the disease, proposed pathogenetic mechanisms, and suggested management and prevention strategies. During a consensus meeting in Vellore, India, in January, 2025, type 5 diabetes was proposed as the nomenclature for this distinct form of diabetes, subsequently formalised at the International Diabetes Federation (IDF) World Diabetes Congress in April, 2025. We call upon the international diabetes community to recognise this distinct form of the disease, and to support the IDF's Type 5 Diabetes Working Group and its goals to promote more research into its phenotype, pathophysiology, and treatment, which will benefit millions of patients worldwide, particularly in low-income and middle-income countries.
Comment on ‘Lean, Non-Autoimmune Young-Onset Diabetes in Bangladesh
(John Wiley & Sons Ltd, 2026-10-06) Wadivkar Pradnayshree; Bahendeka Silver; Kibirige Davis
We read with great interest the article by Hasan et al., which evaluated the metabolic profile of lean non-autoimmune young-onset diabetes in Bangladesh [1]. We commend the authors for evaluating an important but neglected diabetes phenotype among low- and normal-BMI young individuals, potentially affecting millions of individuals in low-income settings. We appreciate that the authors narrowed down the phenotype by excluding participants with pancreatic pathology, monogenic variants and fasting C-peptide levels below 200 pmol/L. The study's ‘lean’ category in the main text combines participants with BMI < 18.5 kg/m2 and those with BMI 18.5–22.9 kg/m2. Given that the authors concluded that these ‘lean’ subjects have modest insulin resistance and metabolic dysfunction, we looked with interest at the BMI-based sub-analysis (in the supplementary material) and at whether the leanest subjects were insulin-resistant. Of the 53 lean DM participants, only 9 had BMI < 18.5 kg/m2. The authors reported that low- and normal-BMI DM participants showed similar phenotypic and metabolic features. However, we wanted to highlight that the waist-hip ratio, waist circumference and waist-height ratio (p = 0.033) were lower in the low-BMI DM group than in the normal-BMI DM group. Additionally, median triglycerides were much lower (within the normal range and closely matching the median for the lean non-DM group) in the low-BMI DM subgroup than in the normal-BMI subgroup. Median HOMA2-IR, fasting C-peptide and fasting insulin were also lower in the low-BMI DM group than in the normal-BMI group. We recognize that none of these differences were significant except for the waist-height ratio. However, the direction and magnitude of the differences are consistent across nearly every relevant variable. The low-BMI DM subgroup appears consistent with the recently classified Type 5 Diabetes (T5D) phenotype cited in this paper, and we believe repeat laboratory and statistical measurements would help clearly distinguish it as a distinct phenotype. Regarding lipid data in the article by Hasan et al., measurements were obtained cross-sectionally from participants with severe, uncontrolled hyperglycemia, without prior correction of glucotoxicity, as mentioned by the authors. The median HbA1c in the lean DM subgroup was 11.6%, which may have contributed to the apparent dyslipidemia in this group. The same caution applies to HOMA2-IR, since insulin resistance estimated during severe hyperglycemia is inflated by glucotoxicity and does not necessarily reflect participants' baseline state [2]. Therefore, the glucose, lipid and HOMA-IR values used by the authors to identify ‘metabolic dysfunction’ in the lean DM group may, in fact, primarily reflect glucotoxicity. Therefore, we propose that repeating these measurements after correcting for glucotoxicity would help assess insulin sensitivity in this group. We wanted to clarify a few points about the T5D phenotype, which is characterized by BMI < 18.5 kg/m2 [3]. Despite ongoing ambiguities regarding optimal diagnostic cut-offs and whether anthropometric measurements are obtained at initial presentation or following metabolic stabilization, we recognize that exposure to persistent undernutrition remains one of the crucial characteristics of T5D. A detailed nutritional history of the study participants would help assess their nutritional status, although it can be challenging in resource-limited areas. This challenge could be addressed using the Global Leadership Initiative on Malnutrition (GLIM) criteria [4], which combine simple, validated phenotypic and etiologic measures to identify malnutrition in adults. Additionally, the study participants were recruited from a young diabetes clinic at a tertiary referral centre in urban Dhaka. T5D is primarily reported in rural and socioeconomically disadvantaged populations [5, 6]. It may also be helpful to obtain data on other factors, such as intentional weight loss, genetic factors, or infections like HIV and TB, that may interact with insulin secretion and action, leading to lower BMI. Thus, the cohort provides valuable characterization of lean, urban young-onset non-autoimmune diabetes. This is such an important diabetes phenotype that expanding catchment areas to include rural and socioeconomically deprived regions would also help identify individuals with this phenotype. Additionally, it would be of particular interest if future studies examining this condition correct glucotoxicity before analysing insulin sensitivity using HOMA-IR. Given Bangladesh's burden of young-onset diabetes, targeted recruitment of underweight participants with diabetes would be a substantial contribution, and this group appears well placed to undertake it.
Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus – International Task Force
(Indian Journal of Endocrinology and Metabolism, 2018) Kalra Sanjay; Bahendeka Silver; Sahay Rakesh; Ghosh Sujoy; Md Fariduddin; Orab Abbas; Ramaiya Kaushik; Shammari Sameer Al; Shrestha Dina; Shaikh Khalid; Abhayaratna Sachitha; Shrestha K Pradeep; Mahalingam Aravinthan; Askheta Mazen; Rahim Aly Ahmed A; Eliana Fatimah; Shrestha Hari K.; Chaudhary Sandeep; Ngugi Nancy; Mbanya Jean Claude; Aye Than Than; Latt Tint Swe; Akanov Zhanay A.; Syed Abbas Raza; Tandon Nikhil; Unnikrishnan A. G.; Madhu S. V.; Jawa Ali; Chowdhury Subhankar; Bajaj Sarita; Das Ashok Kumar
For decades, sulfonylureas(SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose‑lowering drugs.
EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management
(PMC, 2019-02-27) Bahendeka Silver; Ramaiya Kaushik; Babu Swai Andrew; Otieno Fredrick; Bajaj Sarita; Kalra Sanjay; Bavuma Charlotte M; Karigire Claudine
To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, wasconvened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high ([32 C) temperature environments. (2) Insulin should not be transported below 0 C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2–8 C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause ‘‘tattooing’’ of the skin and scarring. (9) In patients presenting in a wasted state, with ‘‘paperlike skin’’, injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times.
Euthymia in Diabetes
(Springer Nature, 2019-04-22) Kalra Sanjay; Das A.K; Baruah M. P.; Unnikrishnan A. G.; Dasgupta Arundhati; Shah Parag; Sahay Rakesh; Shukla Rishi; Das Sambit; Tiwaskar Mangesh; Vijayakumar G.; Chawla Manoj; Eliana Fatimah; Suastika Ketut; Orabi Abbas; Abdul Rahim Aly Ahmed; Uloko Andrew; Lamptey Roberta; Ngugi Nancy; Bahendeka Silver; Abdela Abdurezak Ahmed; Mohammed Fariduddin; Pathan Mohammed Faruque; Rahman Muhammed Hafizur; Afsana Faria; Selim Shajada; Moosa Muaz; Murad Moosa; Shreshtha Pradeep Krishna; Shreshtha Dina; Giri Mimi; Hussain Wiam; Al-Ani Ahmed; Ramaiya Kaushik; Singh Surender; Raza Syed Abbas; Aye Than Than; Garusinghe Chaminda; Muthukuda Dimuthu; Weerakkody Muditha; Kahandawa Shyaminda; Bavuma Charlotte; Ruder Sundeep; Vanny Koy; Khanolkar Manish; Czupryniak Leszek
Aim: To develop an evidence-based expert group opinion on various types of euthymia associated with diabetes mellitus (DM) and its management. Background: Diabetes mellitus is a metabolic syndrome characterized by diverse biomedical and psychosocial features. Emotional health disturbances may lead to psychological and psychiatric dysfunction and may negatively influence glycemic control. Patients with DM may experience diabetes distress (DD) associated with burden of self-care, interpersonal issues, and emotional worries regarding the ability to cope with the illness. Euthymia or a state of positive mental health and psychological well-being should be considered a key outcome of diabetes care. Therefore, to achieve optimal outcomes, the consideration and measurement of psychological and psychiatric aspects along with glycemic levels are very important. A group of multidisciplinary clinical experts came together in an international meeting held in India to develop a workable concept for euthymia in diabetes care. A multidisciplinary approach was suggested to enhance the clinical outcomes and facilitate patient-centered care. During the meeting emphasis was given to the concept of a euthymia model in diabetes care. This model focuses on enhancement of self-care skills in diabetic patients and preventative health awareness among diabetes care providers. Euthymia also encompasses patient–provider communication to aid enhancement of coping skills. Results: After due discussions and extensive deliberations, the expert group provided several recommendations on implementing the concept of euthymia in DM care. Conclusions: Introduction of the concept of euthymia in routine clinical practice is important to improve the quality of life and coping skills in patients with DM. A timely clinical assessment of psychological and psychiatric aspects along with patient-reported outcomes of diabetes contributes to overall health and wellbeing of affected individuals.
Impact of the COVID-19 pandemic on quality of life of adults with diabetes in rural Uganda: a cross-sectional survey
(Oxford Academic, 2025-10-07) Sseguya Wenceslaus; Bahendeka Silver; MacLennan Sara; Guntupalli Meera Aravinda
The coronavirus disease 2019 (COVID-19) pandemic was associated with unprecedented healthcare, economic and social disruptions that impacted persons with diabetes mellitus (PWDM). We aimed to establish how the quality of life (QoL) of persons with diabetes in rural Uganda was impacted by the COVID-19 pandemic, using the pre-pandemic, pandemic and post-pandemic self-reported QoL scores. We surveyed 410 PWDM ≥30 y of age from three rural districts in south-western Uganda. Median QoL scores were computed and variations across the three time periods were analysed using the Friedman analysis of variance and McNemar tests as appropriate. Logistic regression was used to identify factors associated with QoL. A p-value <0.05 indicated statistical significance. The overall median QoL scores were 67.2 (pre-pandemic), 62.4 (pandemic) and 68.8 (post-pandemic) (p<0.001). There was a 75% increase in the proportion of participants with unsatisfactory QoL during the pandemic (p<0.001). Having diabetes complications (p<0.001), chronic comorbidity (p=0.012), no formal education (p<0.003) and travelling for healthcare using non-motorised transport (<0.001) were all independently associated with post-pandemic unsatisfactory QoL. The COVID-19 pandemic caused significant deterioration in QoL among rural PWDM, raising the need for policies to prioritise the consideration of their evolving needs while designing measures for future similar widespread emergencies.
Non-autoimmune, insulin-deficient diabetes in children and young adults in Africa: evidence from the Young-Onset Diabetes in sub-Saharan Africa (YODA) cross-sectional study
(Elsevier Ltd., 2025-07-21) Katte Claude Jean; Squires Steven; Dehayem Y Mesmin; Balungi A Priscilla; Padoa J Carolyn; Sengupta Dhriti; Fatumo Segun; Piloya Thereza; Nyangabyaki-Twesigye Catherine; Bahendeka Silver; Majaliwa Edna; Muze C Kandi; Ramaiya Kaushik; Sap Suzanne; Motala A Ayesha; Pirie J Fraser; Rheeder Paul; Van Dyk C Jacobus; Mbanya Claude Jean; Shields M Beverley; Shah S Amy; Pihoker Catherine; Divers Jasmin; Patel A Kashyap; Oram A Richard; Dabelea Dana; Hattersley T Andrew; McDonald J Timothy; Crowther J Nigel; Nyirenda J Moffat; Sobngwi Eugene; Jones G Angus
Studies of type 1 diabetes in sub-Saharan Africa have suggested that the clinical phenotype might differ from phenotypes reported elsewhere. We aimed to establish whether type 1 diabetes diagnosed in children and young adults in three countries across sub-Saharan Africa is of autoimmune origin. In this observational, cross-sectional study, we identified participants without obesity from outpatient clinics in government and private hospitals in Cameroon, Uganda, and South Africa who were of self-reported Black African ethnicity with young-onset (age <30 years), insulin-treated, clinically diagnosed type 1 diabetes. We measured islet autoantibodies to GADA, IA-2A, and ZnT8A, and calculated a genetic risk score (GRS) for type 1 diabetes, which we compared with control populations without diabetes derived from the Uganda Genome Resource databank and other studies. Endogenous insulin secretion was assessed using plasma C-peptide. We compared findings with those for participants with self-reported Black (n=429) and White (n=2602) ancestry with type 1 diabetes from the SEARCH for Diabetes in Youth (SEARCH) study in the USA. Of 1072 participants identified between Aug 28, 2019, and March 31, 2022 (Cameroon and Uganda), and Oct 3, 2007, to Sept 14, 2015 (South Africa), 894 were included in our analysis (454 [50·8%] were male and 440 [49·2%] were female): 248 participants were from Cameroon, 370 from Uganda, and 276 from South Africa. Participants from sub-Saharan Africa were diagnosed with diabetes at a median age of 15 years (IQR 11–19), with a median diabetes duration of 5 years (2–10), and a BMI of 21·7 kg/m² (19·5–24·1). Only 312 (34·9%) of 894 participants were positive for islet autoantibodies; these participants had classic features of type 1 diabetes, including 225 (82·7%) of 272 with plasma C-peptide <200 pmol/L, and high type 1 diabetes GRS. Those without islet autoantibodies (582 [65·1%] of 894) had significantly lower median type 1 diabetes GRS than those with autoantibodies (9·66 [IQR 7·77–11·33] vs 11·76 [10·49–12·91]; p<0·0001), suggesting a subgroup with a non-autoimmune diabetes subtype, with clinical features and C-peptide concentrations not consistent with type 2 diabetes. Among participants diagnosed younger than 20 years, autoantibody-negative diabetes was also observed in 65 (15·1%) of 429 participants with Black ancestry in SEARCH (although less frequently than in sub-Saharan Africa [59 (55·1%) of 107]), and these participants also had a low type 1 diabetes GRS (median 10·41 [IQR 8·65–12·22] in autoantibody-negative subgroup). No such pattern was observed in White participants in SEARCH: 241 (9·3%) of 2602 were autoantibody negative and median GRS for type 1 diabetes was similar in autoantibody-negative and autoantibody-positive participants (median 13·42 [IQR 11·80–14·61] vs 13·49 [12·29–14·58]). In sub-Saharan Africa, clinically diagnosed type 1 diabetes is heterogeneous, comprising classic autoimmune type 1 diabetes and a novel, non-autoimmune, insulin-deficient diabetes subtype. There is evidence of this subtype in Black but not White individuals in the USA. Therefore, alternative causes must be considered in this group of individuals, and understanding the drivers of this subtype might offer new insights into prevention and treatment.
Obesity and type 2 diabetes in sub-Saharan Africans – Is the burden in today’s Africa similar to African migrants in Europe? The RODAM study
(BMC, 2016-10-21) Agyemang Charles; Meeks Karlijn; Beune Erik; Dabo Ellis Owusu; Mockenhaupt Frank P; Addo Juliet; Aikins Ama de Graf; Bahendeka Silver; Danquah Ina; Schulze Matthias B; Spranger Joachim; Burr Tom; Baffour Peter Agyei; Amoah Stephen K; Galbete Cecilia; Henneman Peter; Grobusch Kerstin Klipstein; Nicolaou Mary; Adeyemo Adebowale; Straalen Jan van; Smeeth Liam; Stronks Karien
Background: Rising rates of obesity and type 2 diabetes (T2D) are impending major threats to the health of African populations, but the extent to which they differ between rural and urban settings in Africa and upon migration to Europe is unknown. We assessed the burden of obesity and T2D among Ghanaians living in rural and urban Ghana and Ghanaian migrants living in different European countries. Methods: A multi-centre cross-sectional study was conducted among Ghanaian adults (n = 5659) aged 25–70 years residing in rural and urban Ghana and three European cities (Amsterdam, London and Berlin). Comparisons between groups were made using prevalence ratios (PRs) with adjustments for age and education. Results: In rural Ghana, the prevalence of obesity was 1.3 % in men and 8.3 % in women. The prevalence was considerably higher in urban Ghana (men, 6.9 %; PR: 5.26, 95 % CI, 2.04–13.57; women, 33.9 %; PR: 4.11, 3.13–5.40) and even more so in Europe, especially in London (men, 21.4 %; PR: 15.04, 5.98–37.84; women, 54.2 %; PR: 6.63, 5.04–8.72). The prevalence of T2D was low at 3.6 % and 5.5 % in rural Ghanaian men and women, and increased in urban Ghanaians (men, 10.3 %; PR: 3.06; 1.73–5.40; women, 9.2 %; PR: 1.81, 1.25–2.64) and highest in Berlin (men, 15.3 %; PR: 4.47; 2.50–7.98; women, 10.2 %; PR: 2.21, 1.30–3.75). Impaired fasting glycaemia prevalence was comparatively higher only in Amsterdam, and in London, men compared with rural Ghana. Conclusion: Our study shows high risks of obesity and T2D among sub-Saharan African populations living in Europe. In Ghana, similarly high prevalence rates were seen in an urban environment, whereas in rural areas, the prevalence of obesity among women is already remarkable. Similar processes underlying the high burden of obesity and T2D following migration may also be at play in sub-Saharan Africa as a consequence of urbanisation.
Prevalence and correlates of diagnosed and undiagnosed diabetes mellitus among adults in rural Uganda during the COVID-19 pandemic: an evaluation of a community-based screening programme
(Oxford Academic, 2025-05-02) Sseguya Wenceslaus; Bahendeka Silver; Mody Nimesh; MacLennan Sara; Guntupalli M Aravinda
One in two people with diabetes in sub-Saharan Africa remains undiagnosed, which has contributed to the region's high rates of diabetes-related morbidity and mortality. While the COVID-19 pandemic likely exacerbated diabetes prevalence, limited data from the region, including Uganda, hampers our understanding of this impact. To address this gap, we analysed the diabetes prevalence and correlates among adults from three rural districts of Uganda using data from a community-based screening programme conducted by community health workers (CHWs) during the pandemic. We used anonymised data of 2587 records to analyse the prevalence and correlates of diagnosed and undiagnosed diabetes. Prevalence was presented as proportions with 95% CIs. Correlates of diabetes and undiagnosed diabetes prevalence were analysed using logistic regression and presented as ORs. The overall prevalence of diabetes was 11.3% (95% CI 10.2 to 12.5%), with a 7.2% (95% CI 6.2 to 8.1%) prevalence for diagnosed diabetes. A high proportion (36.4%) of diabetes cases were undiagnosed. Older age, high body mass index and pre-existing hypertension were associated with high diabetes prevalence. There was a high proportion of undiagnosed diabetes among rural adults during the pandemic. Engaging CHWs in routine diabetes screening and awareness programmes can reduce the burden of undiagnosed diabetes.
Prevalence of hyperglycaemia frst detected during pregnancy and subsequent obstetric outcomes at St. Francis Hospital Nsambya
(BMC, 2017-05-02) Nakabuye Betty; Bahendeka Silver; Byaruhanga Romano
Background: Women with hyperglycaemia detected during pregnancy are at greater risk for adverse pregnancy outcomes. Data on hyperglycaemia in pregnancy in sub-Saharan Africa is scanty and varied depending on the populations studied and the methodologies used to defne hyperglycaemia in pregnancy. With the recent 2013 World Health Organisation (WHO) diagnostic criteria and classifcation, there is yet no sufcient data on the prevalence of hyperglycaemia in sub-Saharan Africa. The objective was to determine the prevalence of Hyperglycaemia frst detected during pregnancy and subsequent obstetric outcomes among patients attending antenatal care (ANC) at St. Francis Hospital Nsambya. Methods: A prospective cohort study. All women with no history of diabetes mellitus attending at or after 24 weeks gestation were eligible to participate in the study. Participants underwent a standard 75 g oral glucose tolerance test (OGTT) after an informed written consent. The primary outcome was diagnosis of hyperglycaemia. Enrolled participants were followed up to delivery to assess obstetric outcomes (secondary outcomes were birth weight, neonatal admission, maternal genital trauma, delivery mode, neonatal and maternal status at discharge). Results: 251 women were screened between December 2013 and February 2014. The prevalence of hyperglycaemia frst detected in pregnancy was 31.9%. We found 23.8 % of women with hyperglycaemia had no known risk factor. Macrosomia was the only obstetric outcome that was signifcantly associated with hyperglycaemia. Conclusion: The prevalence of hyperglycaemia frst detected in pregnancy was high in the studied population. Clinicians, therefore, should become more vigilant to screen for the condition. Selective screening may miss 23.8% of pregnant women with hyperglycaemia. However the cost/beneft implications of screening strategy and the recent 2013 WHO diagnostic criteria need to be studied in our setting.