South African Medical Research Council
Director, Non-Communicable Diseases Research Unit
Setting-up nurse-led pilot clinics for the management of non-communicable diseases at primary health care level in resource-limited settings of Africa
Abstract Background There is limited data on risk factors associated with childhood overweight and obesity in Ghanaian school children. Therefore, the aim of this study was to assess the prevalence of overweight and obesity and associated risk factors in Ghanaian school children. Methods Data for this study were obtained from a cross-sectional survey of 543 children aged 8 and 11 years, attending private and public primary schools in the Adentan Municipality of Greater Accra Region, Ghana. Anthropometric, dietary, physical activity, sedentary behaviours, sleep duration and socio-demographic data were collected. BMI-for-age Z-scores were used to classify children as overweight/obesity. Multivariable logistic regressions were used to assess the determinants of overweight and obesity. Results The overall prevalence of overweight/obesity was 16.4%. Children living in middle (OR = 1.88; 95% CI = 1.01–3.50) and high socioeconomic status (SES) households (2.58; 1.41–4.70) had increased odds of being overweight or obese compared to those living in low SES household. Attending private school (2.44; 1.39–4.29) and watching television for more than 2 h each day (1.72; 1.05–2.82) were significantly associated with increased likelihood of overweight and obesity. Children who slept for more than 9 h a night (0.53; 0.31–0.88) and walked or cycled to school (0.51; 0.31–0.82) had lower odds of being overweight or obese. Conclusions A number of modifiable risk factors were associated with overweight and obesity in this study. Public health strategies to prevent childhood obesity should target reduction in television watching time, promoting active transport to and from school, and increasing sleep duration.
BACKGROUND: As the relation between socioeconomic status (SES) and obesity may depend on the stage of development of a country, this relation is assessed in adults from urban Cameroon. METHODS: A sample comprising 1530 women and 1301 men aged 25 years and above, from 1897 households in the Biyem-Assi health area in the capital of Cameroon, Yaoundé, were interviewed about their household amenities, occupation, and education. Weight, height, and waist circumference were measured and subjects were classified as obese if their BMI>or=30 kg/m2 or overweight if BMI was between 25.0 and 29.9 kg/m2. Abdominal obesity was defined by a waist circumference>or=80 cm in women and>or=94 cm in men. RESULTS: Of the sample studied 33% of women and 30% of men were overweight (P<0.08), whereas 22% of women and 7% of men were obese (P<0.001). Abdominal obesity was present in 67% of women and 18% of men (P<0.001). After adjusting for age, leisure time physical activity, alcohol consumption, and tobacco smoking, the prevalence of overweight+obesity, obesity, and abdominal obesity increased with quartiles of household amenities in both genders and with occupational level in men. CONCLUSION: SES is positively associated with adiposity in urban Cameroon after adjusting for confounding factors.
Background: Despite the increasing availability of head computerized tomography (CT) in resource-limited settings, it is unclear if brain-imaging-based diagnosis of stroke affects the outcomes in the absence of dedicated structures for acute stroke management. Objectives: In a major referral hospital in the capital city of Cameroon, we compared in-hospital mortality rates in patients with a WHO-based diagnosis of stroke between participants with and without brain imaging on admission. Methods: Stroke patients with and without admission brain imaging were compared for demographic characteristics, risk factors, clinical and laboratory characteristic, and in-hospital mortality. Heterogeneities in mortality rates (CT vs. No CT) across major subgroups were investigated via interaction tests, and logistic regressions used to adjust for extraneous factors such as age, sex, year of study, residency, history of diabetes and hypertension, history of stroke, Glasgow coma scale, and delay between stroke symptoms onset and hospital admission. Results: Of the 1688 participants included in the final analysis, 1048 (62.1%) had brain imaging. The median age of the non-CT vs. CT groups was 65 vs. 62 years (p-value < 0.0001%). The death rate of non-CT vs. CT groups was 27.5% vs. 16.4% (p < 0.0001). This difference was mostly similar across major subgroups, and robust to the adjustments for confounders (in spite of substantial attenuation), with excess deaths in those with CT ranging from 65% to 149%. Conclusion: In this resource-limited environment, the absence of brain imaging on admission was associated with high in-hospital death from stroke, which was only partially explained by delayed hospitalization with severe disease. These results stressed the importance of scaling up acute stroke management in low- and middle-income countries.
Abstract Background Little is known on the magnitude and correlates of insulin resistance in HIV-infected people in Africa. We determined the prevalence of insulin resistance and investigated associated factors in HIV-infected adult Cameroonians. Methods We conducted a cross-sectional study at the Yaoundé Central Hospital, Cameroon; during which we enrolled HIV-infected people aged 30 to 74 years with no previous history of cardiovascular disease. An homeostatic model assessment of insulin resistance (HOMA-IR) like index served to assess insulin sensitivity with insulin resistance defined by values of 2.1 or higher. Results We included 452 patients (20% men). Their mean age was 44.4 ± 9.8 years and 88.5% of them were on antiretroviral therapy (93.3% on first line regimen including Zidovudine, lamivudine and Efavirenz/Nevirapine). Of all participants, 28.5% were overweight, 19.5% had obesity and 2.0% had diabetes. The prevalence of insulin resistance was 47.3% without any difference between patients on ART and those ART-naïve (48.5% vs. 38.5%; p = 0.480). Obesity was the only factor independently associated with insulin resistance (adjusted odds ratio: 2.28; 95% confidence interval: 1.10–4.72). Conclusion Insulin resistance is present in nearly half of HIV-infected patients in Cameroon despite a low prevalence rate of diabetes, and is associated with obesity.
Abstract ; Background and aim: Growing evidence suggests that some of the effects of diet on cardiovascular disease (CVD) occur through mechanisms involving subclinical inflammation. We assessed the relationship between selected dietary constituents and serum high-sensitivity C-reactive protein (hsCRP) concentration in a population-based sample of United States adults. Methods: In this cross-sectional analysis, participants were selected from the US National Health and Nutrition Examination Survey (NHANES) and restricted to those with available data on dietary intake, biochemical and anthropometric measurements from 2001 to 2010. All statistical analyses accounted for the survey design and sample weights by using SPSS Complex Samples v22.0 (IBM Corp, Armonk, NY). Results: Of the 17,689 participants analysed, 8607 (48.3%) were men. The mean age was 45.8 years in the overall sample, 44.9 in men and 46.5 in women ( p = .047). The age-, race-, sex-, energy intake- and body mass index-adjusted mean dietary intakes of total dietary fibre, polyunsaturated fatty-acids, vitamin E, vitamin A, vitamin B6, total folate, vitamin B family, vitamin C, vitamin K, magnesium, iron, copper and potassium monotonically decreased across increasing hsCRP quarters ( p < .001 for all), whereas sugar intake increased ( p < .001). In analysis of covariance adjusted for potential confounders (age-, race-, sex-, energy intake- and body weight-) hsCRP levels increased across increasing quarters of sugar intake ( p < .001). Conclusions: This study provides further evidence of an association between dietary sugar, polyunsaturated fatty-acids, fibre and antioxidant intake and hsCRP levels, a subclinical inflammation marker. hsCRP concentrations are likely modulated by dietary intake.KEY MESSAGES Serum high-sensitivity C-reactive protein (hsCRP) concentration is positively associated with sugar intake, and negatively with the consumption of minerals, vitamins and polyunsaturated fatty-acids (fruit and vegetables). hsCRP concentrations, and accordingly subclinical inflammation, are likely influenced by dietary intake. Serum high-sensitivity C-reactive protein (hsCRP) concentration is positively associated with sugar intake, and negatively with the consumption of minerals, vitamins and polyunsaturated fatty-acids (fruit and vegetables). hsCRP concentrations, and accordingly subclinical inflammation, are likely influenced by dietary intake.
Background German cockroach or Blattella germanica is commonly found in homes across the inter-tropical region. The contribution of sensitisation to Blattella germanica in people with asthma in sub-Saharan Africa has not received attention. The aim of this study was to assess the prevalence and investigate the predicting factors of sensitisation to Blattella germanica in patients with asthma in Yaounde, Cameroon.Methods This was a cross-sectional study conducted between January 2012 and June 2013. All patients (aged 15 years and above) with asthma, receiving care at the Yaounde Jamot Hospital and the CEDIMER medical practice during the study period and who had received a prick skin testing for perennial aeroallergens were included in the study.Results The final sample comprised 184 patients including 123 (66.8%) women. The median age (25th-75th percentiles) was 38 (24–54) years. Prick skin test for Blattella germanica was positive in 47 (25.5%) patients. Sensitisation to Blattella germanica was associated with a sensitisation to mite in 41 (87.2%) patients, a sensitisation to Alternaria in 18 (38.3%) patients, and a sensitisation to cat or dog dander in 7 (14.9%) patients. Independent predicting factors of a sensitisation to Blattella germanica were the sensitisation to Blomia tropicalis [adjusted odd ratio (95% confidence interval) 4.10 (1.67-10.04), p = 0.002] and sensitisation to Alternaria [3.67 (1.53-7.46), p = 0.003].Conclusions Sensitisation to Blattella germanica is present in about a quarter of adult patients with asthma in Yaounde. Sensitisation to Alternaria and Blomia tropicalis appears to be a powerful predicting factor of sensitisation to Blattella germanica in this setting. Keywords: Asthma, Blattella, Allergy, Aeroallergens, Africa
Summary: Purpose: To assess the prevalence and determinants of non-adherence to antiretroviral therapy (ART) as well as the concordance of two screening criteria in a major center for human immunodeficiency virus (HIV) treatment in Yaounde, Cameroon. Methods: In 2011, we conducted a cross-sectional study involving a random sample of 889 adults (age > 18 years, 67.9% women) infected with HIV who were receiving chronic care at the Yaounde Jamot Hospital. Adherence was assessed via self-administered questionnaires using the Community Programs for Clinical Research on AIDS (CPCRA) index and the Center for Adherence Support Evaluation (CASE) index. Results: The prevalence of non-adherence to ART was 22.5% based on the CPCRA index and 34.9% based on the CASE index, with a low agreement between the two indexes [kappa = 0.37 (95% confidence interval 0.31–0.44)]. Independent determinants of CPCRA-diagnosed non-adherence were as follows: being a remunerated employee [odds ratio (95% confidence interval): 1.61 (1.14–2.28)], Pentecostal Christianity [2.18 (1.25–3.80)], alcohol consumption [1.65 (1.16–2.34)] and non-adherence to cotrimoxazole prophylaxis [5.73 (3.92–8.38)]. The equivalents for CASE-diagnosed non-adherence were [1.59 (1.19–2.12)], [1.83 (1.36–2.47)], [1.70 (1.27–2.28)], respectively, in addition to association with changes to the ART regimen [1.61 (1.17–2.20)]. Conclusions: Non-adherence to ART remains high in this population. The careful evaluation of patients for the presence of determinants of non-adherence identified in this study may aid ART optimization. Keywords: Antiretroviral therapy, Adherence, HIV infection, Cameroon
BACKGROUND AND PURPOSE: Determinants of post-acute stroke outcomes in Africa have been less investigated. We assessed the association of metabolic syndrome (MetS) and insulin resistance with post-stroke mortality in patients with first-ever-in-lifetime stroke in the capital city of Cameroon (sub-Saharan Africa). METHODS: Patients with an acute first-stroke event (n = 57) were recruited between May and October 2006, and followed for 5 years for mortality outcome. MetS definition was based on the Joint Interim Statement 2009, insulin sensitivity/resistance assessed via glucose-to-insulin ratio, quantitative insulin sensitivity check index and homeostatic model assessment. RESULTS: Overall, 24 (42%) patients deceased during follow-up. The prevalence of MetS was higher in patients who died after 28 days, 1 year and 5 years from any cause or cardiovascular-related causes (all p≤0.040). MetS was associated with an increased overall mortality both after 1 year (39% vs. 9%) and 5 years of follow-up (55% vs. 26%, p = 0.022). Similarly, fatal events due to cardiovascular-related conditions were more frequent in the presence of MetS both 1 year (37% vs. 9%) and 5 years after the first-ever-in-lifetime stroke (43% vs. 13%, p = 0.017). Unlike biochemical measures of insulin sensitivity and resistance (non-significant), in age- and sex-adjusted Cox models, MetS was associated with hazard ratio (95% CI) of 2.63 (1.03-6.73) and 3.54 (1.00-12.56) respectively for all-cause and cardiovascular mortality 5 years after stroke onset. CONCLUSION: The Joint Interim Statement 2009 definition of MetS may aid the identification of a subgroup of black African stroke patients who may benefit from intensification of risk factor management.
Both anaemia and cardiovascular disease (CVD) are common in people with diabetes. While individually both characteristics are known to raise mortality risk, their combined influence has yet to be quantified. In this pooling project, we examined the combined impact of baseline haemoglobin levels and existing CVD on all-cause and CVD mortality in people with diabetes. We draw comparison of these effects with those apparent in diabetes-free individuals.A combined analyses of 7 UK population-based cohorts resulted in 26,480 study members. There were 946 participants with physician-diagnosed diabetes, 2227 with anaemia [haemoglobin<13 g/dl (men) or <12 (women)], 2592 with existing CVD (stroke, ischaemic heart disease), and 21,396 with none of the conditions. Across diabetes and anaemia subgroups, and using diabetes-free, non-anaemic participants as the referent group, the adjusted hazard ratios (HR) were 1.46 (95% CI: 1.30-1.63) for anaemia, 1.67 (1.45-1.92) for diabetes, and 2.10 (1.55-2.85) for diabetes and anaemia combined. Across combined diabetes, anaemia and CVD subgroups, and compared with non-anaemic, diabetes-free and CVD-free participants, HR (95% CI) for all-cause mortality were 1.49 (1.32-1.69) anaemia, 1.60 (1.46-1.76) for existing CVD, and 1.66 (1.39-1.97) for diabetes alone. Equivalents were 2.13 (1.48-3.07) for anaemia and diabetes, 2.68 (2.14-3.36) for diabetes and existing CVD, and 3.25 (1.88-5.62) for the three combined. Patterns were similar for CVD mortality.Individually, anaemia and CVD confer similar mortality risks in people with diabetes, and are excessively fatal in combination. Screening for anaemia would identify vulnerable diabetic patients whose outcomes can potentially be improved.
First-line antiretroviral therapy and dyslipidemia in people living with HIV-1 in Cameroon: a cross-sectional study
Background The paucity of data regarding the association between atherogenic index of plasma and risk of cardiovascular disease in HIV-infected populations living in sub-Saharan Africa prompted us to conduct this study which aimed to assess the relationship between atherogenic index of plasma and risk of cardiovascular disease among a Cameroonian HIV-infected population. Methods This was a cross-sectional study conducted among 452 HIV-infected adults in Yaoundé, Cameroon. Risk of cardiovascular disease was calculated using the Framingham risk score; atherogenic index of plasma was derived as log (triglycerides/high-density lipoproteins cholesterol). Results Participants’ mean age (80% females) was 44.4 ± 9.8 years. Atherogenic index of plasma values ranged from –0.63 to 1.36 with a median of 0.11 (25th–75th percentiles: –0.08-0.31). Most participants (88.5%) were on antiretroviral treatment. There was a significant correlation between atherogenic index of plasma and fasting plasma glucose (r = 0.116; p = 0.014), atherogenic index of plasma and total cholesterol (r = –0.164; p < 0.001). Atherogenic index of plasma was significantly associated with the risk of cardiovascular disease either in univariable (β = 5.05, 95% CI: 3.31–6.79; p < 0.001, R 2 = 0.067) or in multivariable linear regression model after adjusting for socio-demographic, clinical and biological confounders (adjusted β = 3.79, 95% CI: 1.65 – 4.88; p < 0.001, R 2 = 0.187). Conclusion Atherogenic index of plasma may be an independent factor impacting the risk of cardiovascular disease among Cameroonian HIV-infected people. More studies are needed to better elucidate the association between atherogenic index of plasma and risk of cardiovascular disease in our setting.
Andre Pascal Kengne1, Anastase Dzudie2, Eugene Sobngwi31The George Institute for International Health, University of Sydney, Australia; 2Heart failure and transplantation Unit, Louis Pradel’s Cardiovascular Hospital, Lyon, France; 3National Obesity Centre, Yaounde Central Hospital, CameroonPurpose: Heart failure is the ultimate complication of cardiac involvements in diabetes. The purpose of this review was to summarize current literature on heart failure among people with diabetes mellitus in sub-Saharan Africa (SSA).Method: Bibliographic search of published data on heart failure and diabetes in sub-Saharan Africa over the past 26 years.Results: Heart failure remains largely unexplored in general population and among people with diabetes in Africa. Heart failure accounts for over 30% of hospital admission in specialized cardiovascular units and 3%–7% in general internal medicine. Over 11% of adults with heart failure have diabetes. Risk factors for heart failure among those with diabetes include classical cardiovascular risk factors, without evidence of diabetes distinctiveness for other predictors common in Africa. Prevention, management, and outcomes of heart failure are less well known; recent data suggest improvement in the management of risk factors in clinical settings.Conclusions: Diabetes mellitus is growing in SSA. Related cardiovascular diseases are emerging as potential health problem. Heart failure as cardiovascular complication remains largely unexplored. Efforts are needed through research to improve our knowledge of heart failure at large in Africa. Multilevel preventive measures, building on evidences from other parts of the world must go along side.Keywords: diabetes mellitus, cardiovascular diseases, heart failure, sub-Saharan Africa
Chronic diseases are becoming increasingly important in sub-Saharan Africa (SSA). The current density and distribution of health workforce suggest that SSA cannot respond to the growing demand for chronic disease care, together with the frequent infectious diseases. Innovative approaches are therefore needed to rapidly expand the health workforce. In this article, we discuss the evidences in support of nurse-led strategies for chronic disease management in SSA, with a focus on hypertension and diabetes mellitus.
Abstract Background To examine the association between serum concentrations of antioxidant and telomere length (TL) in U.S adults. Methods Participants of the National Health and Nutrition Examination Survey (NHANES) with data available on TL measures from 2001 to 2002 were included. Serum lipophilic antioxidants level was measured using high performance liquid chromatography with photodiode array detection. We used analysis of co-variance and multivariable-adjusted linear regression models, accounting for the survey design and sample weights. Results Of the 5992 eligible participants, 47.5% (n = 2844) were men. The mean age was 46.9 years overall, 47.2 years in men and 46.6 in women (p = 0.071). In age, sex, race, education, marital status, adiposity, smoking, C-reactive protein adjusted linear regressions, antioxidant, serum α-carotene, trans-β-carotene, cis- β-carotene, β-cryptoxanthin and combined Lutein/zeaxanthin were positively and significantly associated with TL (all p < 0.001). Conclusions Our findings support a possible positive association between serum concentrations of lipophylic antioxidant and TL. The implications of this association deserve further investigation.
Abstract Objective There is limited data on the quality of primary care management for diabetes mellitus across Africa. The study was aimed at assessing the availability of basic supplies for the rapid diagnosis, treatment and management of diabetes in Malawian rural health facilities. This cross-sectional study was conducted in 55 public and private health centers from 19 districts using a structured questionnaire and checklist to interview the pharmacy personnel or officer in-charge of the health centers. We focused on availability of information, diagnosis and treatment materials for diabetes. Results Of the 55 health facilities surveyed, 21, 23 and 11 were located in the central, southern and northern regions of Malawi, respectively. Overall, 38% (21/55) of the health centres had glucometers, while 24% (13/55) had urine glucose dipsticks. Only 4% (2/55) of the health centres had recommended first-line medicines for treatment of type 1 and type 2 diabetes. No health centre had diabetes patient records and information, education and communication materials. Most rural health centers in Malawi lack basic health commodities for the screening, diagnosis and treatment of diabetes and this impedes on their effective management of growing diabetes burden. Therefore, health care systems need to adequately equip primary care facilities.
Endpoint adjudication committees (EPAC) are widely used in clinical trials. The aim of the present analysis is to assess the effects of the endpoint adjudication process on the main findings of the ADVANCE trial (Trial registration: ClinicalTrials.gov NCT00145925).The ADVANCE trial was a multicentre, 2 × 2 factorial randomised controlled trial of blood pressure lowering and intensive blood glucose control in 11140 patients with type 2 diabetes. Primary outcomes were major macrovascular (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) and microvascular (new or worsening nephropathy and retinopathy) events. Suspected primary outcomes were initially reported by the investigators at the 215 sites with subsequent adjudication by the EPAC. The EPAC also adjudicated upon potential events identified directly by ongoing screening of all reported events. Over a median follow-up of 5 years, the site investigators reported one or more primary outcomes among 2443 participants. After adjudication these events were confirmed for 2077 (85%) with 48 further events added through the EPAC-led database screening process. The estimated relative risk reductions (95% confidence intervals) in the primary outcome for the blood pressure lowering comparison were 8% (-1 to 15%) based on the investigator-reported events and 9% (0 to 17%) based on the EPAC-based events (P for homogeneity = 0.70). The corresponding findings for the glucose comparison were 8% (1 to 15%) and 10% (2% to 18%) (P for homogeneity = 0.60). The effect estimates were also highly comparable when studied separately for macrovascular events and microvascular events for both comparisons (all P for homogeneity>0.6).The endpoint adjudication process had no discernible impact on the main findings in ADVANCE. These data highlight the need for careful consideration of the likely impact of an EPAC on the findings and conclusions of clinical trials prior to their establishment.
BACKGROUND: Cardiovascular disease, the major cause of mortality and morbidity in modern societies, is set to overtake infectious diseases in the developing world as the most common cause of death. The increasing prevalence of major and emerging cardiovascular risk factors accounts for the growing burden of cardiovascular disease in the world. Diabetes in all its forms is one of the main cardiovascular risk factors. Two of 3 diabetic patients will die as a result of cardiovascular complications, and approximately 30% of patients treated in cardiovascular intensive care units have diabetes. METHODS AND RESULTS: This review on the cardiovascular complications of diabetes in sub-Saharan Africa is a bibliographical MEDLINE search of published data over the past 2 decades. Diabetes-related cardiovascular disease complications are considered to be rare in Africa but are on the rise and are regularly associated with classic cardiovascular risk factors. Coronary heart disease may affect 5% to 8% of type 2 diabetic patients and cardiomyopathy, up to 50% of all patients. Close to 15% of patients with stroke have diabetes, and up to 5% of diabetic patients present with cerebrovascular accidents at diagnosis. Peripheral vascular disease prevalence varies across sites from 4% to 28%. CONCLUSIONS: It is obvious that diabetes mellitus and related cardiovascular complications are gaining more importance in sub-Saharan Africa. The relative contribution of putative risk factors is not well defined, and further research is therefore needed.
Abstract Background Death under care is a major challenge for tuberculosis (TB) treatment programs. We derived and validated a simple score to predict mortality during tuberculosis treatment in high endemicity areas. Methods We used data for patients aged ≥15 years, diagnosed and treated for tuberculosis at the Yaounde Jamot Hospital between January 2012 and December 2013. Baseline characteristics associated with mortality were investigated using logistic regressions. A simple prognosis score (CABI) was constructed with regression coefficients for predictors in the final model. Internal validation used bootstrap resampling procedures. Models discrimination was assessed using c-statistics and calibration assessed via calibration plots and the Hosmer and Lemeshwow (H-L) statistics. The optimal score was based on the Youden’s index. Results A total of 2250 patients (men 57.2%) with a mean age of 35.8 years were included; among whom 213 deaths (cumulative incidence 9.5%) were recorded. Clinical form of tuberculosis (C), age (A, years), adjusted body mass index (B, BMI, kg/m2) and status for HIV (Human immunodefiency virus) infection (I) were significant predictors in the final model (p < 0.0001) which was of the form Death risk = 1/(1 + e − (−1.3120 + 0.0474 ∗ age − 0.1866 ∗ BMI + 1.1637 (if smear negative TB) + 0.5418(if extra − pulmonary TB) + 1.3820(if HIV+))). The c-statistic was 0.812 in the derivation sample and 0.808 after correction for optimism. The calibration was good [H-Lχ2 = 6.44 (p = 0.60)]. The optimal absolute risk threshold was 4.8%, corresponding to a sensitivity of 81% and specificity of 67%. Conclusions The preliminary promising findings from this study require confirmation through independent external validation studies. If confirmed, the model derived could facilitate the stratification of TB patients for mortality risk and implementation of additional monitoring and management measures in vulnerable patients.
Abstract Background Half of the estimated annual 28 million non-communicable diseases (NCDs) deaths in low- and middle-income countries (LMICs) are attributed to weak health systems. Current health policy responses to NCDs are fragmented and vertical particularly in the African region. The World Health Organization (WHO) led NCDs Global action plan 2013–2020 has been recommended for reducing the NCD burden but it is unclear whether Africa is on track in its implementation. This paper synthesizes Africa’s progress towards WHO policy recommendations for reducing the NCD burden. Methods Data from the WHO 2011, 2014 and 2015 NCD reports were used for this analysis. We synthesized results by targets descriptions in the three reports and included indicators for which we could trace progress in at least two of the three reports. Results More than half of the African countries did not achieve the set targets for 2015 and slow progress had been made towards the 2016 targets as of December 2013. Some gains were made in implementing national public awareness programmes on diet and/or physical activity, however limited progress was made on guidelines for management of NCD and drug therapy and counselling. While all regions in Africa show waning trends in fully achieving the NCD indicators in general, the Southern African region appears to have made the least progress while the Northern African region appears to be the most progressive. Conclusion Our findings suggest that Africa is off track in achieving the NCDs indicators by the set deadlines. To make sustained public health gains, more effort and commitment is urgently needed from governments, partners and societies to implement these recommendations in a broader strategy. While donors need to suit NCD advocacy with funding, African institutions such as The African Union (AU) and other sub-regional bodies such as West African Health Organization (WAHO) and various country offices could potentially play stronger roles in advocating for more NCD policy efforts in Africa.
Purpose: Heart failure is the ultimate complication of cardiac involvements in diabetes. The purpose of this review was to summarize current literature on heart failure among people with diabetes mellitus in sub-Saharan Africa (SSA). Method: Bibliographic search of published data on heart failure and diabetes in sub-Saharan Africa over the past 26 years. Results: Heart failure remains largely unexplored in general population and among people with diabetes in Africa. Heart failure accounts for over 30 % of hospital admission in specialized cardiovascular units and 3%–7 % in general internal medicine. Over 11 % of adults with heart failure have diabetes. Risk factors for heart failure among those with diabetes include classical cardiovascular risk factors, without evidence of diabetes distinctiveness for other predictors common in Africa. Prevention, management, and outcomes of heart failure are less well known; recent data suggest improvement in the management of risk factors in clinical settings. Conclusions: Diabetes mellitus is growing in SSA. Related cardiovascular diseases are emerging as potential health problem. Heart failure as cardiovascular complication remains largely unexplored. Efforts are needed through research to improve our knowledge of heart failure at large in Africa. Multilevel preventive measures, building on evidences from other parts of the world must go along side.
As per guidelines and recommendations, screening for renal diseases should be performed at the time of diagnosis of human immuno-deficiency virus (HIV) infection; however, this remains largely unimplemented in many settings across Sub-Saharan Africa. We evaluated the renal function, urinalysis abnormalities and their correlates in HIV-infected individuals who were naïve to highly active antiretroviral therapy (HAART). This was a cross-sectional study of 2 months′ duration involving 104 HIV-infected outpatients naive to HAART (71 women, 68%) attending the HIV clinic of the Yaoundé General Hospital in Cameroon. Renal and urinalysis parameters were measured and the Student t-test and Fischer exact test were used to compare the groups of participants. The mean age and CD4 count were, respectively, 35 ± 10.7 years and 305 ± 202/mL. Fifty-six (54%) patients presented with stages 3 and 4 of HIV infection. Forty-three (41%) patients had urinalysis abnormalities, including proteinuria (36%), leukocyturia (13%) and hematuria (12%). Proteinuria was associated with increased age, advanced stage of HIV infection, decreased CD4 count, hematuria and renal failure (P <0.04). Hematuria and leukocyturia were associated with decreased CD4 count and advanced stage of HIV infection, respectively (P = 0.04). The mean estimated glomerular filtration (eGFR) rate was100.2 ± 32.7 mL/min; three (3%) patients had renal failure (eGFR <60 mL/min) and 45 (43%) patients had reduced kidney function 60 ≤eGFR ≤90 mL/min. There was a high prevalence of decreased kidney function and proteinuria among Cameroonian HIV-infected patients naïve to HAART. Indicators of the severity of HIV infection, including advanced stage and low CD4 count, were associated with urinalysis abnormalities.
Population-based estimates of asthma and allergic rhinitis in sub-Saharan African adults are lacking. We assessed the prevalence and determinants of asthma and allergic rhinitis in urban adult Cameroonians.A community-based survey was conducted from December 2013 to April 2014 among adults aged 19 years and above (N = 2,304, 57.3% women), selected through multilevel stratified random sampling across all districts of Yaounde (Capital city). Internationally validated questionnaires were used to investigate the presence of allergic diseases. Logistic regressions were employed to investigate the determinants of allergic conditions.Prevalence rates were 2.7% (95% CI: 2.1-3.4) for asthma-ever, 6.9% (5.9-7.9) for lifetime wheezing, 2.9% (92.2-3.6) for current wheezing and 11.4% (10.1-12.7) for self-reported lifetime allergic rhinitis; while 240 (10.4%) participants reported current symptoms of allergic rhinitis, and 125 (5.4%) had allergic rhino-conjunctivitis. The prevalence of current asthma medication use and self-reported asthma attack was 0.8 (0.4-1.2) and 1 (0.6-1.4) respectively. Multivariable adjusted determinants of current wheezing were signs of atopic eczema [2.91 (1.09-7.74)] and signs of allergic rhinitis [3.24 (1.83-5.71)]. Age group 31-40 years [0.27(0.09-0.78), p = 0.016] was an independent protective factor for wheezing. Determinants of current rhinitis symptoms were active smoking [2.20 (1.37-3.54), p<0.001], signs of atopic eczema [2.84 (1.48-5.46)] and current wheezing [3.02 (1.70-5.39)].Prevalence rates for asthma and allergic rhinitis among adults in this population were at the lower tails of those reported in other regions of the world. Beside the classical interrelation between allergic diseases found in this study, active smoking was an independent determinant of allergic rhinitis symptoms. Nationwide surveys are needed to investigate regional variations.
One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.A search strategy with the following terms "task-shifting", "non-physician healthcare workers", "community healthcare worker", "hypertension", "diabetes", "cardiovascular disease", "mental health", "depression", "chronic obstructive pulmonary disease", "respiratory disease", "cancer" was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.
OBJECTIVE — To assess the utility of a point-of-care (POC) capillary blood glucose measurement as compared with routine clinical parameters in predicting undiagnosed diabetes in a low-resource rural India setting. RESEARCH DESIGN AND METHODS — Nine hundred and ninety-four participants aged �30 years and stratified by age and sex were randomly selected from 20 villages in India. A clinical questionnaire, sampling for laboratory venous fasting plasma glucose (FPG), and POC capillary blood glucose assay were performed simultaneously. Diabetes diagnosis was based on the World Health Organization (WHO) definition using FPG. The capacity of the POC glucose to predict the presence of diabetes was assessed and compared with the questionnaire using area under the receiver operating characteristic curves (AUCs). RESULTS — The AUC for POC glucose alone in predicting diabetes was 0.869 (95 % CI 0.810–0.929). This was significantly better (P � 0.001 for AUC comparison) than the models based upon clinical variables alone (AUC for the best clinical model including age, BMI, hypertension, waist circumference: 0.694 [95 % CI 0.621–0.766]). POC glucose appropriately reclassified the risk of up to one-third of participants ranked according to the clinical models. Adding the clinical variables to the POC glucose assay did not significantly improve the discriminatory capability beyond that achieved with the POC glucose measurement alone (all P � 0.37). CONCLUSIONS — POC glucose testing appears to be a simple and reliable tool for identifying undiagnosed diabetes in a high-risk, resource-poor rural population. However, studies evaluating the cost effectiveness of introducing POC glucose testing are needed prior to widespread implementation. The prevalence of type 2 diabetes is rapidly increasing around the world (1). Developing countries are facing the largest increases both in absolute and relative terms (1). It is predicted that this will have devastating consequences on the economies and health systems of these countries. Successful prevention and
Background and Purpose. Leukocyte telomere length (LTL) is a biomarker of biologic age. Whether food security status modulates LTL is still unknown. We investigated the association between food security and LTL in participants of the 1999–2002 US National Health and Nutrition Examination Survey (NHANES). Methods. Analysis of covariance (ANCOVA) was used to evaluate the association between food security categories and LTL controlling for sex, race, and education and accounting for the survey design and sample weights. Results. We included 10,888 participants with 5228 (48.0%) being men. They were aged on average 44.1 years. In all, 2362 (21.7%) had less than high school, 2787 (25.6%) had achieved high school, while 5705 (52.5%) had done more than high school. In sex-, race-, and education-adjusted ANCOVA, average LTL (T/S ratio) for participants with high food security versus those with marginal, low, or very low food security was 1.32 versus 1.20 for the age group 25–35 years and 1.26 versus 1.11 for the 35–45 years, (p<0.001). Conclusion. The association between food insecurity and LTL shortening in young adults suggest that some of the future effects of food insecurity on chronic disease risk in this population could be mediated by telomere shortening.
Abstract Background It has been suggested that trans fatty acids (TFAs) play an important role in cardiovascular diseases. We investigated the association between plasma TFAs and the dietary inflammatory index (DII) ™ in US adults. Methods National Health and Nutrition Examination Survey (NHANES) participants with data on plasma TFAs measured from 1999 to 2010 were included. Energy-adjusted-DII ™ (E-DII ™) expressed per 1000 kcal was calculated from 24-h dietary recalls. All statistical analyses accounted for the survey design and sample weights. Results Of the 5446 eligible participants, 46.8% (n = 2550) were men. The mean age of the population was 47.1 years overall, 47.8 years for men and 46.5 years for women (p = 0.09). After adjustment for C-reactive protein, body-mass-index, smoking, race, age, education, and marital status in linear regressions, trans 9-hexadecenoic acid [β coefficient 0.068 (95% CI: 0.032 to 0.188)], trans 11-octadecenoic acid [β coefficient 0.143 (95% CI: 0.155 to 0.310)], trans 9-octadecenoic acid [β coefficient 0.122 (95% CI: 0.120 to 0.277)], trans 9, and trans 12-octadienoic acid [β coefficient 0.103 (95% CI: 0.090 to 0.247)] were positively associated with the DII (all p < 0.001). Conclusion The association of plasma TFAs with a marker of dietary inflammation suggests an underlying mechanism in the initiation and progression of cardiovascular diseases.
Abstract ; Background and aim: Growing evidence suggests that some of the effects of diet on cardiovascular disease (CVD) occur through mechanisms involving subclinical inflammation. We assessed the relationship between selected dietary constituents and serum high-sensitivity C-reactive protein (hsCRP) concentration in a population-based sample of United States adults. Methods: In this cross-sectional analysis, participants were selected from the US National Health and Nutrition Examination Survey (NHANES) and restricted to those with available data on dietary intake, biochemical and anthropometric measurements from 2001 to 2010. All statistical analyses accounted for the survey design and sample weights by using SPSS Complex Samples v22.0 (IBM Corp, Armonk, NY). Results: Of the 17,689 participants analysed, 8607 (48.3%) were men. The mean age was 45.8 years in the overall sample, 44.9 in men and 46.5 in women ( p = .047). The age-, race-, sex-, energy intake- and body mass index-adjusted mean dietary intakes of total dietary fibre, polyunsaturated fatty-acids, vitamin E, vitamin A, vitamin B6, total folate, vitamin B family, vitamin C, vitamin K, magnesium, iron, copper and potassium monotonically decreased across increasing hsCRP quarters ( p < .001 for all), whereas sugar intake increased ( p < .001). In analysis of covariance adjusted for potential confounders (age-, race-, sex-, energy intake- and body weight-) hsCRP levels increased across increasing quarters of sugar intake ( p < .001). Conclusions: This study provides further evidence of an association between dietary sugar, polyunsaturated fatty-acids, fibre and antioxidant intake and hsCRP levels, a subclinical inflammation marker. hsCRP concentrations are likely modulated by dietary intake.KEY MESSAGES Serum high-sensitivity C-reactive protein (hsCRP) concentration is positively associated with sugar intake, and negatively with the consumption of minerals, vitamins and polyunsaturated fatty-acids (fruit and vegetables). hsCRP concentrations, and accordingly subclinical inflammation, are likely influenced by dietary intake. Serum high-sensitivity C-reactive protein (hsCRP) concentration is positively associated with sugar intake, and negatively with the consumption of minerals, vitamins and polyunsaturated fatty-acids (fruit and vegetables). hsCRP concentrations, and accordingly subclinical inflammation, are likely influenced by dietary intake.
BACKGROUND: This article describes the setting-up process for nurse-led pilot clinics for the management of four chronic diseases: asthma, type 2 diabetes mellitus, epilepsy and hypertension at the primary health care level in urban and rural Cameroon. METHODS: The Biyem-Assi urban and the Bafut rural health districts in Cameroon served as settings for this study. International and local guidelines were identified and adapted to the country's; circumstances. Training and follow-up tools were developed and nurses trained by experienced physicians in the management of the four conditions. Basic diagnostic and follow-up materials were provided and relevant essential drugs made available. RESULTS: Forty six nurses attended six training courses. By the second year of activity, three and four clinics were operational in the urban and the rural areas respectively. By then, 925 patients had been registered in the clinics. This represented a 68.5% increase from the first year. While the rural clinics relied mainly on essential drugs for their prescriptions, a prescription pattern combining generic and proprietary drugs was observed in the urban clinics. CONCLUSION: In the quest for cost-effective health care for NCD in sub-Saharan Africa, rethinking health workforce and service delivery has relevance. Nurse-led clinics, algorithm driven service delivery stands as alternatives to overcome the shortage of trained physicians and other issues relating to access to care.
Hydroquinone-containing creams cause false increases in capillary glycemia. However, the magnitude of this false increase, and the means to reverse it have not been investigated.To evaluate the technical and clinical impact of hydroquinone-containing creams on capillary glycemia and investigate the efficacy of hand washing and other common practices, in reversing cream effects.We included 91 participants in a quasi-experimental study in Buea, Cameroon. After determining the hydroquinone content of a cream, Caro Light, we used two glucometers with different enzymatic systems (Accu-Chek Active and OneTouch Ultra 2) to measure fasting glycemia after: initial hand washing (reference), application of 1 ml of hydroquinone-containing cream, finger swabbing with wet gauze, sanitizer application and a series of three hand washings following cream application. Reference glycemia was compared to those obtained after various interventions. Statistical significance was assessed by paired sample t-test, clinical significance by total error allowable (TEa), and clinical impact by Parke's error grid analysis.The mean differences in capillary glycemia (Intervention-reference) measured by Accu-Chek Active in mg/dl were 28, 27, 38, 16, 4, and -2 after cream application, finger swabbing, sanitizer application, one, two, and three hand washings respectively. Corresponding values for OneTouch Ultra2 were 41, 44, 64, 22, 5 and -5. These differences, except after two and three hand washings were both statistically (p < 0.0001) and clinically significant (TEa). After cream application, Accu-Check had 9.9% of values in Parke's Zones C-E, while OneTouch had 18.7%.Hydroquinone-containing creams cause significant false increase in capillary glycemia irrespective of the enzymatic system of the glucometer used, and can lead to potentially wrong clinical decisions. A minimum of two hand washings is required prior to capillary glucose measurement.
OBJECTIVE: Though single nucleotide polymorphisms (SNPs) in the non-muscle myosin gene (MYH9) have been reported to explain most of the excess risk of nondiabetic chronic kidney disease (CKD), in African-Americans, some studies have also shown associations with diabetic end-stage renal disease. We investigated the association of MYH9 SNPs with renal traits in a mixed-ancestry South African population prone to diabetes. RESEARCH DESIGN AND METHODS: Three SNPs known to be associated with CKD (rs4821480, rs5756152 and rs12107) were genotyped using Taqman assay in 716 adults (198 with diabetes) from the Bellville-South community, Cape Town. Glomerular filtration rate was estimated (eGFR) and urinary albumin/creatinine ratio (ACR) assessed. Multivariable regressions were used to relate the SNPs with renal traits. RESULTS: Mean age was 53.6 years, with the expected differences observed in characteristics by diabetic status. Significant associations were found between rs575152 and serum creatinine, and eGFR in the total population, and in diabetic participants (all p≤0.003), but not in non-diabetics (all p≥0.16), with significant interactions by diabetes status (interaction-p≤0.009). The association with ACR was borderline in diabetic participants (p = 0.05) and non-significant in non-diabetics (p = 0.85), with significant interaction (interaction p = 0.02). rs12107 was associated with fasting-, 2-hour glucose and HbA1c in diabetic participants only (interaction-p≤0.003), but not with renal traits. CONCLUSION: MYH9 SNPs were associated with renal traits only in diabetic participants in this population. Our findings and other studies suggest that MYH9 may have a broader genetic risk effect on kidney diseases.
The distribution of body size phenotypes in people with human immunodeficiency virus (HIV) infection has yet to be characterized. We assessed the distribution of body size phenotypes overall, and according to antiretroviral therapy (ART), diagnosed duration of the infection and CD4 count in a sample of HIV infected people recruited across primary care facilities in the Western Cape Province, South Africa. Adults aged ≥ 18 years were consecutively recruited using random sampling procedures, and their cardio-metabolic profile were assessed during March 2014 and February 2015. They were classified across body mass index (BMI) categories as normal-weight (BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), and obese (BMI ≥ 30 kg/m2), and further classified according to their metabolic status as “metabolically healthy” vs. “metabolically abnormal” if they had less than two vs. two or more of the following abnormalities: high blood glucose, raised blood pressure, raised triglycerides, and low HDL-cholesterol. Their cross-classification gave the following six phenotypes: normal-weight metabolically healthy (NWMH), normal-weight metabolically abnormal (NWMA), overweight metabolically healthy (OvMH), overweight metabolically abnormal (OvMA), obese metabolically healthy (OMH), and obese metabolically abnormal (OMA). Among the 748 participants included (median age 38 years (25th–75th percentiles: 32–44)), 79% were women. The median diagnosed duration of HIV was five years; the median CD4 count was 392 cells/mm3 and most participants were on ART. The overall distribution of body size phenotypes was the following: 31.7% (NWMH), 11.7% (NWMA), 13.4% (OvMH), 9.5% (OvMA), 18.6% (OMH), and 15.1% (OMA). The distribution of metabolic phenotypes across BMI levels did not differ significantly in men vs. women (p = 0.062), in participants below vs. those at or above median diagnosed duration of HIV infection (p = 0.897), in participants below vs. those at or above median CD4 count (p = 0.447), and by ART regimens (p = 0.205). In this relatively young sample of HIV-infected individuals, metabolically abnormal phenotypes are frequent across BMI categories. This highlights the importance of general measures targeting an overall improvement in cardiometabolic risk profile across the spectrum of BMI distribution in all adults with HIV.
BACKGROUND: This study aimed to assess the association between lifetime exposure to urban environment (EU) and obesity, diabetes, and hypertension in an adult population of Sub-Saharan Africa. METHODS: We studied 999 women and 727 men aged > or =25 years. They represent all the adults aged > or =25 years living in households randomly selected from a rural and an urban community of Cameroon with a 98% and 96% participation rate respectively. Height, weight, blood pressure, and fasting blood glucose were measured in all subjects. Current levels of physical activity (in metabolic equivalents [MET]) were evaluated through the Sub-Saharan African Activity Questionnaire. Chronological data on lifetime migration were collected retrospectively and expressed as the total (EUt) or percentage (EU%) of lifetime exposure to urban environment. RESULTS: Lifetime EUt was associated with body mass index (BMI) (r = 0.42; P < 0.0001), fasting glycaemia (r = 0.23; P < 0.0001), and blood pressure (r = 0.17; P < 0.0001) but not with age. The subjects who recently settled in a city (< or =2 years) had higher BMI (+2.9 kg/m(2); P < 0.001), fasting glycaemia (+0.8 mmol/l; P < 0.001), systolic (+23 mmHg; P < 0.001) and diastolic (+9 mmHg; P = 0.001) blood pressure than rural dwellers with a history of 2 years EU. EU during the first 5 years of life was not, on its own, associated with glycaemia or BMI. However, both lifetime EUt and current residence were independently associated with obesity and diabetes. The association between lifetime EUt and hypertension was not independent of current residence and current level of physical activity. CONCLUSIONS: This study suggests that for the study of obesity and diabetes, in addition to current residence, both lifetime exposure to an urban environment and recent migration history should be investigated.
Abstract Background Obesity is a major risk factor for non-communicable diseases (NCDs) and is growing rapidly globally including in sub-Saharan Africa (SSA). We aimed to assess the trend in adiposity markers in Cameroonian university students, and investigated their associations with hypertension. Methods From 2009 to 2012, we annually measured weight, height, blood pressure, waist (WC) and hip circumferences, and calculated the body mass index (BMI) and other indices of adiposity in consecutive students aged 18 years or above, during their registration. Time-trends in prevalence of overweight and obesity were estimated, and their associations with prevalent hypertension investigated. Results Among the 2726 participants, the overall prevalence of obesity, overweight and obesity combined, and hypertension was 3.5%, 21.0% and 6.3% respectively. From 2009 to 2012, the prevalence of overweight and obesity increased in men only, from 13.1% to 20.9% (p-trend = 0.002), whereas prevalent abdominal obesity increased in women only, from 6.5% to 11.7% (p-trend = 0.027). The BMI and the WC were independent predictors of hypertension; each kg/m2 higher BMI was associated with 11% higher odds of hypertension, and each centimeter higher WC was associated with 9% higher odds of hypertension. Conclusion Our results show that overweight and obesity are rapidly increasing in this population of young sub-Saharan African adults, and are contributing to an increasing burden of hypertension.
Abstract Background Little is known about the impact of the school environmental context on the emerging trend of childhood obesity in Africa. We examined the association of the schools’ contextual factors with body mass index (BMI), abdominal obesity and overweight (including obesity) in urban Ghana. Method Using cross-sectional data from 543 school children aged 8–11 years attending 14 primary schools, we applied multilevel logistic regressions and linear regression models to investigate the association of child- and school level attributes with overweight, abdominal obesity, and BMI. Results We observed significant variance of the random effects of schools in BMI (2.65, p < 0.05), abdominal obesity (0.85, p < 0.05), and overweight (1.41, p < 0.05), with school contextual levels accounting for 19.7, 20.6, and 30.0% of the total variability observed in BMI, abdominal obesity and overweight respectively. Attending high socioeconomic (SES) level school, private school and school with increased after-school recreational facilities were associated with higher BMI. Children were more likely to be overweight if they attended a high SES level school, had access to healthful foods at school, and after-school recreational facilities. With regards to abdominal obesity, attending a school with increased physical activity facilities decreased the odds of abdominal obesity; however the odds increased if they attended a school with access to after-school recreational facilities. Conclusion A number of school-level factors were associated with BMI, overweight and abdominal obesity of children in the present study. Our results provide support for improved school environment to reduce overweight.
patients receiving protease inhibitors after initial treatment with first-line-based non-nucleoside reverse transcriptase inhibitors: a cross-sectional study
BACKGROUND: Co-inheritance of α-thalassemia was reported to be associated with a delayed age of disease onset among Cameroonian Sickle Cell Anemia (SCA) patients. The present study aimed to explore the correlation between α-thalassemia, hematological indices, and clinical events in these patients. METHODS AND FINDINGS: We studied 161 Cameroonian SCA patients and 103 controls (59.1% HbAA) with median ages of 17.5 and 23 years. RFLP-PCR was used to confirm SCA genotype and to describe haplotypes in the HBB-like genes cluster. Multiplex Gap-PCR was performed to investigate the 3.7 kb α-globin gene deletions. SNaPshot PCR, capillary electrophoresis and cycle sequencing were used for the genotyping of 10 SNPs in BCL11A, HMIP1/2, OR51B5/6 and HBG loci, known to influence HbF levels. Generalised linear regression models adjusted for age, sex and SNPs genotypes was used to investigate effects of α-thalassemia on clinical and hematological indices. The median rate of vaso-occlusive painful crisis and hospitalisations was two and one per year, respectively. Stroke was reported in eight cases (7.4%). Benin haplotype was the most prevalent (66.3%; n = 208 chromosomes). Among patients, 37.3% (n = 60) had at least one 3.7 kb deletion, compared to 10.9% (n = 6) among HbAA controls (p<0.001). Among patients, the median RBC count increased with the number of 3.7 kb deletions [2.6, 3.0 and 3.4 million/dl, with no, one and two deletions (p = 0.01)]. The median MCV decreased with the number of 3.7 kb deletion [86, 80, and 68fl, with no, one and two deletions (p<0.0001)], as well as median WBC counts [13.2, 10.5 and 9.8×109/L (p<0.0001. The co-inheritance of α-thalassemia was associated with lower consultations rate (p = 0.038). CONCLUSION: The co-inheritance of α-thalassemia and SCA is associated with improved hematological indices, and lower consultations rate in this group of patients. This could possibly improve their survival and explain the higher proportion of α-thalassemia among patients than controls.
To assess the availability and affordability of medicines and routine tests for cardiovascular disease (CVD) and diabetes in the West region of Cameroon, a low-income setting.A survey was conducted on the availability and cost of twelve routine tests and twenty medicines for CVD and diabetes in eight health districts (four urban and four rural) covering over 60% of the population of the region (1.8 million). We analyzed the percentage of tests and medicines available, the median price against the international reference price (median price ratio) for the medicines, and affordability in terms of the number of days' wages it would cost the lowest-paid unskilled government worker for initial investigation tests and procurement for one month of treatment.The availability of tests varied between 10% for the ECG to 100% for the fasting blood sugar. The average cost for the initial investigation using the minimum tests cost 29.76 days' wages. The availability of medicines varied from 36.4% to 59.1% in urban and from 9.1% to 50% in rural settings. Only metformin and benzathine-benzylpenicilline had a median price ratio of ≤ 1.5, with statins being largely unaffordable (at least 30.51 days' wages). One month of combination treatment for coronary heart disease costs at least 40.87 days' wages.The investigation and management of patients with medium-to-high cardiovascular risk remains largely unavailable and unaffordable in this setting. An effective non-communicable disease program should lay emphasis on primary prevention, and improve affordable access to essential medicines in public outlets.
Chronic diseases are becoming increasingly important in sub-Saharan Africa (SSA). The current density and distribution of health workforce suggest that SSA cannot respond to the growing demand for chronic disease care, together with the frequent infectious diseases. Innovative approaches are therefore needed to rapidly expand the health workforce. In this article, we discuss the evidences in support of nurse-led strategies for chronic disease management in SSA, with a focus on hypertension and diabetes mellitus.
Background The growing burden of type 2 diabetes in Sub-Saharan Africa (SSA) and related cardiovascular complications call for vigorous actions into prevention. Comprehensive cardiovascular risk evaluation is important for the success of such actions. Methods We have reviewed 3 currently existing sets of recommendations for cardiovascular prevention in diabetes in SSA. Distribution of major risk factors and patterns of reported cardiovascular outcomes are used to suggest orientations for cardiovascular prevention in diabetes in this region. Papers and reports published over the period 1990 to 2007 were used. Results Existing guidelines share some similarities, but also have areas of inconsistencies. They are generally adaptations of existing guidelines, focused more on individual risk factors, and are not usually backed-up by local evidence. They all have a projection on blood pressure lowering. This focus is supported by the high prevalence of hypertension among people with diabetes in SSA. Blood pressure and tobacco smoking are the modifiable risk factors accessible to evaluation and interventions on a wide scale in SSA. Appropriate blood pressure control will have a major impact on stroke (the commonest cardiovascular disease) through a reduction of the cerebrovascular risk, and to a lesser extent on coronary heart disease and total deaths in diabetes in this region. Conclusions In the absence of global risk evaluation tools, the use of blood pressure lowering as a primary focus of cardiovascular prevention strategies is relevant for SSA. However, there is a need to set-up diabetes and stroke registers to monitor outcomes and generate tools for accurate risk prediction and management in diabetes in this region.
Background Smoking is one of the major preventable causes of disease and premature death globally. Emerging findings have highlighted the intersection of cigarette smoking and HIV/AIDS as a significant public health concern. For adults with HIV, smoking increases both HIV-related and non-related outcomes. There is scarcity of information on the incidence and effects of cigarette smoking as well as its management in the HIV-infected population in South Africa. This study therefore aimed to determine the occurrence of smoking in HIV positive patients attending public healthcare facilities in the Western Cape Province of South Africa. Methods An overall of 751 patients living with HIV randomly selected and screened from 17 different HIV/AIDS public facilities in the Western Cape at both primary and secondary level were included for this study between 2014 and 2015. This article focuses on the self-reported tobacco-using behavior of adults aged >18 years. The survey instrument included questions on the respondents´ history of smoking tobacco, current use of other tobacco products, frequency and duration of use, and attempts to stop smoking tobacco or using other tobacco products. Results Of the 751 HIV positive patients receiving medical care at public healthcare facilities, an overall of 20.7% (95% CI, 17.3% to 24.1%) were current smokers, 14.5% (CI, 11.6% to 17.4%) were former smokers, while 65.3% (CI, 54.6% to 68.9%) had never smoked. Out of these the current smokers, 18.9% (95% CI, 12.3% to 25.5%) were men while 20.8% (95% CI, 16.9% to 24.7%) were women. Among the patients living with HIV, factors independently associated with greater smoking prevalence were gender, age, unemployment, household smoking, and excessive alcohol use. Conclusions We found a high prevalence of hypertension among patients receiving routine care for HIV infection across public HIV clinics in this setting.
Abstract Background Growing evidence suggests an inverse association between whole grain (WG) consumption and insulin resistance (IR) or inflammation. However, it is still unclear whether adiposity plays a role in this relationship. We investigated whether the associations between WG intake with IR, glucose homeostasis and inflammation are mediated by adiposity in US adults. Methods The 2005–2010 National Health and Nutrition Examination Surveys participants were included. WG intake was assessed and markers of IR and glucose homeostasis, inflammation, general and central adiposity. Analysis of co-variance and mediation analysis were applied, while accounting for survey design. Results Overall 16,621 participants were included in this analysis (mean age = 47.1 years, 48.3% men). After adjustment for age, gender, and race, mean C-reactive protein (CRP), apolipoprotein B (apo-B), fasting blood glucose (FBG), insulin, homeostatic model assessment of IR (HOMA-IR) and β cell function (HOMA-β), hemoglobin A1c (HbA1c), and 2 h glucose after an oral glucose tolerance test decreased with increasing quarters of WG (all p < 0.001). Body mass index (BMI) had significant mediation effects on the associations between WG intake and CRP, apo-B, fasting glucose, insulin, HOMA-IR, HOMA-B, HbA1c, triglyceride to high density lipoprotein-cholesterol (TG:HDL-C) ratio and triglyceride-glucose (TyG) index (all p < 0.05) after adjustment for age, gender, race/ethnicity, educational status, smoking and level of physical activity. Both waist circumference (WC) and anthropometrically predicted visceral adipose tissue (apVAT) mediated the association between WG intakes with CRP, FBG, HbA1c, TG:HDL-C ratio and TyG index, i.e. WC and apVAT had indirect effect (all p < 0.05). Conclusion Our findings provide insights into the favourable impact of WG consumption on IR and inflammation, which may be affected by both central and visceral adiposity, i.e. the link between WG with IR and inflammation is more mediated in overweight/obese compared with lean individuals.
Qualitative and quantitative approaches were used in a rural hospital of Cameroon to assess how much nursing personnel know about and practise in regard to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and to determine health service factors that influence knowledge, attitudes and practices (KAP). Participants included 107 nursing and laboratory staff and 62 patients with AIDS. Self-administered questionnaires were used for nurses, and close-ended questionnaires were administered to patients with AIDS (as a verification tool for staff responses). Focus group discussions (FGD) held with nurse supervisors evaluated health service factors that influence KAP. Overall, 70.1% of the nurses who responded scored highly in the knowledge section compared to 50.5% in the attitude and practice section. There were several outstanding misconceptions and malpractices about HIV/AIDS. Knowledge, but not attitude, was significantly influenced by the grade of the staff (P< 0.001 and P = 0.17, respectively). Approximately 15% of 62 patients with AIDS indicated that they were attended to with signs of disgust and/or hatred. The major health service factors thought to influence KAP, confirmed by many in all the FGD, included: the lack of adequate information; the lack of commitment to alter attitudes and practices; the lack of in-service promotions; and the ongoing fear of becoming infected with the virus through caring for patients with AIDS. Low income also seemed to have an influence on KAP. Therefore, it is imperative that ongoing education programmes are provided for nurses to enable them to meet the needs of the increasing HIV prevalence in our community. Information, education and communication, and compliance with international working norms, remain essential tools in the control of HIV/AIDS spread in our hospital settings.
OBJECTIVES: To evaluate and compare physical activity patterns of urban and rural dwellers in Cameroon, and study their relationship with obesity, diabetes and hypertension. METHODS: We studied 2465 subjects aged >or=15 y, recruited on the basis of a random sampling of households, of whom 1183 were urban dwellers from Yaoundé, the capital city of Cameroon and 1282 rural subjects from Bafut, a village of western Cameroon. They all had an interviewer-administered questionnaire for the assessment of their physical activity and anthropometric measurements, blood pressure and fasting blood glucose determination. The procedure was satisfactorily completed in 2325 (94.3%) subjects. Prevalences were age-adjusted and subjects compared according to their region, sex and age group. RESULTS: Obesity was diagnosed in 17.1 and 3.0% urban and rural women, respectively (P<0.001), and in 5.4 vs 1.2% urban and rural men, respectively (P<0.001). The prevalence of hypertension was significantly higher in urban vs rural dwellers (11.4 vs 6.6% and 17.6 vs 9.1% in women and men, respectively; P<0.001). Diabetes was more prevalent in urban compared to rural women (P<0.05), but not men. Urban subjects were characterized by lower physical activity (P<0.001), light occupation, high prevalence of multiple occupations, and reduced walking and cycling time compared to rural subjects. Univariate analysis showed significant associations between both physical inactivity and obesity and high blood pressure. The relationship of physical inactivity with hypertension and obesity were independent in both urban and rural men, but not in women. Body mass index, blood pressure and glycaemia were higher in the first compared with the fourth quartiles of energy expenditure. CONCLUSION: Obesity, diabetes and hypertension prevalence is higher in urban compared to rural dwellers in the populations studied. Physical activity is significantly lower and differs in pattern in urban subjects compared to rural. Physical inactivity is associated with these diseases, although not always significant in women.
Abstract Background Reactivation of adult hemoglobin (HbF) is currently a dominant therapeutic approach to sickle cell disease (SCD). In this study, we have investigated among SCD patients from Cameroon, the association of HbF level and variants in the HU-inducible small guanosine triphosphate-binding protein, secretion-associated and RAS-related (SAR1a) protein, previously shown to be associated with HbF after HU treatment in African American SCD patients. Results Only patients >5 years old were included; hemoglobin electrophoresis and a full blood count were conducted upon arrival at the hospital. RFLP-PCR was used to describe the HBB gene haplotypes and Gap PCR to investigate the 3.7 kb α-globin gene deletion. The iPLEX Gold Sequenom Mass Genotyping Array and cycle sequencing were used for the genotyping of four selected SNPs in SAR1a (rs2310991; rs4282891; rs76901216 and rs76901220). Genetic analysis was performed using an additive genetic model, under a generalized linear regression framework. 484 patients were studied. No associations were observed between any of the promoter variants and baseline HbF, clinical events or other hematological indices. Conclusion The results of this study could be explained by possible population-specificity of some tagging genomic variants associated with HbF production and illustrated the complexity of replicating HbF-promoting variants association results across African populations.
Background: Both anaemia and cardiovascular disease (CVD) are common in people with diabetes. While individually both characteristics are known to raise mortality risk, their combined influence has yet to be quantified. In this pooling project, we examined the combined impact of baseline haemoglobin levels and existing CVD on all-cause and CVD mortality in people with diabetes. We draw comparison of these effects with those apparent in diabetes-free individuals. Methods/Principal Findings: A combined analyses of 7 UK population-based cohorts resulted in 26,480 study members. There were 946 participants with physician-diagnosed diabetes, 2227 with anaemia [haemoglobin,13 g/dl (men) or,12 (women)], 2592 with existing CVD (stroke, ischaemic heart disease), and 21,396 with none of the conditions. Across diabetes and anaemia subgroups, and using diabetes-free, non-anaemic participants as the referent group, the adjusted hazard ratios (HR) were 1.46 (95 % CI: 1.30–1.63) for anaemia, 1.67 (1.45–1.92) for diabetes, and 2.10 (1.55–2.85) for diabetes and anaemia combined. Across combined diabetes, anaemia and CVD subgroups, and compared with non-anaemic, diabetes-free and CVD-free participants, HR (95 % CI) for all-cause mortality were 1.49 (1.32–1.69) anaemia, 1.60 (1.46–1.76) for existing CVD, and 1.66 (1.39–1.97) for diabetes alone. Equivalents were 2.13 (1.48–3.07) for anaemia and diabetes, 2.68 (2.14–3.36) for diabetes and existing CVD, and 3.25 (1.88–5.62) for the three combined. Patterns were similar for CVD mortality.
BACKGROUND: The proposed waist-to-height ratio (WHtR) cut-off of 0.5 is less optimal for cardiometabolic risk screening in children in many settings. The purpose of this study was to determine the optimal WHtR for children from South Africa, and investigate variations by gender, ethnicity and residence in the achieved value. METHODS: Metabolic syndrome (MetS) components were measured in 1272 randomly selected learners, aged 10-16 years, comprising of 446 black Africans, 696 mixed-ancestry and 130 Caucasians. The Youden's index and the closest-top-left (CTL) point approaches were used to derive WHtR cut-offs for diagnosing any two MetS components, excluding the waist circumference. RESULTS: The two approaches yielded similar cut-off in girls, 0.465 (sensitivity 50.0, specificity 69.5), but two different values in boys, 0.455 (42.9, 88.4) and 0.425 (60.3, 67.7) based on the Youden's index and the CTL point, respectively. Furthermore, WHtR cut-off values derived differed substantially amongst the regions and ethnic groups investigated, whereby the highest cut-off was observed in semi-rural and white children, respectively, Youden's index0.505 (31.6, 87.1) and CTL point 0.475 (44.4, 75.9). CONCLUSION: The WHtR cut-off of 0.5 is less accurate for screening cardiovascular risk in South African children. The optimal value in this setting is likely gender and ethnicity-specific and sensitive to urbanization.
Objectives. We determined metabolic syndrome (MetS) prevalence and assessed the agreement between different diagnostic criteria in HIV-infected South Africans. Method. A random sample included 748 HIV-infected adult patients (79% women) across 17 HIV healthcare facilities in the Western Cape Province. MetS was defined using the Joint Interim Statement (JIS 2009), International Diabetes Federation (IDF 2005), and Adult Treatment Panel III (ATPIII 2005) criteria. Results. Median values were 38 years (age), 5 years (diagnosed HIV duration), and 392 cells/mm3 (CD4 count), and 93% of the participants were on antiretroviral therapy (ART). MetS prevalence was 28.2% (95%CI: 25–31.4), 26.5% (23.3–29.6), and 24.1% (21–27.1) by the JIS, IDF, and ATPIII 2005 criteria, respectively. Prevalence was always higher in women than in men (all p<0.001), in participants with longer duration of diagnosed HIV (all p≤0.003), and in ART users not receiving 1st-line regimens (all p≤0.039). The agreement among the three criteria was very good overall and in most subgroups (all kappa≥0.81). Conclusions. The three most popular diagnostic criteria yielded similarly high MetS prevalence in this relatively young population receiving care for HIV infection. Very good levels of agreement between criteria are unaffected by some HIV-specific features highlighting the likely comparable diagnostic utility of those criteria in routine HIV care settings.
Abstract Aim To investigate the association of major dietary patterns with glucose and insulin homeostasis parameters in a large American sample. The association between dietary patterns (DP) derived via principal components analysis (PCA), with glucose/insulin homeostasis parameters was assessed. The likelihood of insulin resistance (IR) across the DPs quarters was also explored. Method The United States National Health and Nutrition Examination Survey (NHANES) participants during 2005–2012 were included if they underwent measurement of dietary intake as well as glucose and insulin homeostasis parameters. Analysis of covariance (ANCOVA) and adjusted logistic and linear regression models were employed to account for the complex survey design and sample weights. Results A total of 24,182 participants were included; 48.9% (n = 11,815) were men. Applying PCA revealed three DP (56.8% of variance): the first was comprised mainly of saturated fat (SFA), total fat, mono-unsaturated fatty acids (MUFA) and carbohydrate (CHO); the second is highly enriched with vitamins, trace elements and dietary fiber; and the third was composed of polyunsaturated fatty acids (PUFA), cholesterol and protein. Among the total population, after adjustment for age, sex, race, C-reactive protein, smoking, and physical activity, glucose homeostasis factors, visceral adiposity index and lipid accumulation product improved across the quarters of the first and third DP; and a reverse pattern with the second DP. The same trend was observed for the non-diabetic subjects. Moreover, subjects with higher adherence to the first and third DP had higher likelihood for developing IR, whereas there was a lower likelihood for the second DP. Conclusion This study shows that the DP heavily loaded with CHO, SFA, PUFA, protein, total fat and MUFA as well as high-cholesterol-load foods is associated with impaired glucose tolerance; in contrast, the healthy pattern which is high in vitamins, minerals and fiber may have favourable effects on insulin sensitivity and glucose tolerance.
Summary: Background: The burden of dyslipidaemia in Africa remains inadequately characterised. We aimed to estimate the prevalence of dyslipidaemia in African adults from hospital-based and community-based studies. Methods: In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, African Journals Online, and African Index Medicus for studies published between Jan 1, 1980, and July 31, 2017, without language restriction. We assessed methodological quality of all cross-sectional studies reporting on the prevalence of elevated concentrations of total cholesterol, LDL cholesterol, or triglycerides, or low concentrations of HDL cholesterol in adults residing in African countries. We excluded reports on Africans living outside Africa, studies of individuals selected on the basis of existing dyslipidaemia or those including children and adolescents, and case series with a small sample size. The most frequently used cutoffs in the included studies were chosen for the subgroup analysis. We used random-effect model meta-analysis to derive the pooled prevalence of elevated total cholesterol, low HDL cholesterol, elevated LDL cholesterol, and elevated triglyceride concentrations. This study is registered with PROSPERO, number CRD42014015376. Findings: 181 studies (309 207 participants) were included in the meta-analysis. The pooled prevalence of dyslipidaemia in the general population from population-based studies was 23·6% (95% CI 18·4–29·2) for elevated concentrations of total cholesterol with a cutoff of at least 5·2 mmol/L, 41·1% (33·0–49·4) for low concentrations of HDL cholesterol with a cutoff of less than 1·0 mmol/L, 25·7% (16·2–36·6) for elevated concentrations of LDL cholesterol with a cutoff of at least 3·3 mmol/L, and 16·5% (11·8–21·6) for elevated concentrations of triglycerides with a cutoff of at least 1·7 mmol/L. Interpretation: The prevalence of dyslipidaemia is high in the general adult population in Africa. Ongoing efforts to reduce cardiovascular diseases in Africa should integrate effective detection and treatment of dyslipidaemia. Funding: None.
EDCTP-GSK fellowship: Cardiometabolic Diseases Risk Evaluation and Reduction in African People Living with HIV Infection
TMA2017GSF-1962
EDCTP2
Senior Fellowship (SF)
Department | Institution | Country |
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Non-Communicable Diseases Research Unit | South African Medical Research Council | South Africa |
The Cardiometabolic Diseases Risk Evaluation and Reduction in African People Living with HIV Infection (CaDERAL) aims to enhance the understanding of common CMDs, and improve their co-detection and co-management in African people living with HIV infection, through a program of research and capacity development based on a network of institutions led by the South African Medical Research Council (SAMRC), and comprising the Nigerian Institute of Medical Research (NIMR), the Clinical Research Education, Networking and Consultancy (CRENC, Cameroon). Specifically we will: 1) Characterise the cardiometabolic profile of adults HIV-infected individuals at their baseline enrolment in Cameroon, using data from the Cameroon arm of the ongoing International Epidemiologic Databases to Evaluate AIDS (IeDEA). 2) Assess the incidence and remission of dyslipidemia and impaired kidney function in people with HIV on ART in Nigeria, using data from the NIMR HIV cohort. 3) Conduct a clinical trial to test the effectiveness of sending weekly SMS-text message in improving health outcomes and supporting medication adherence in South African adults with co-morbid HIV and hypertension. This will be augmented with process evaluation and cost-effectiveness analysis. 4) The three research projects in 1-3 will support the training of a PhD student in each of the three countries, and reinforce the research capacities of junior and senior researchers where appropriate.
The core component of the project is a 12-month, individually randomized controlled two-arm trial, open-labelled single blinded, to assess the effect of text messaging vs. usual care on adherence to hypertension medications and outcomes of care among adult South Africans with co-morbid HIV and hypertension. This will be augmented with process evaluation and economic analysis. The trial is based on an adaptation of the StAR trial conducted in the general population in Cape Town. A software algorithm will assigned participants independent of the research team to the intervention and control arms in a 1:1 ratio using a non-deterministic minimization algorithm to ensure balance between groups with respect to key characteristics including gender, age, baseline blood pressure and known duration of hypertension. The treatment group will receive messages to motivate collecting and taking medicine and to provide education about and motivation for secondary adherence, in particular, on healthy lifestyle choices. These messages will be sent three times a week for 52 weeks. Outcome measures will include: Primary – mean difference in SBP and DBP; Secondary – 1) uptake and adherence to BP medications; with adherence measured using the 5 item Medication Adherence Report Scale (MARS) adiminstered at baseline and at the end of the trial;, 2) uptake and adherence to HIV specific medications, 3) mean change in lipid variables, 4) mean change in CD4 count and viral load, 4) mean change in adiposity variables, 5) change in kidney function; Tertiary - 1) Descriptive analysis of the process involved in the intervention, 2) Economic analysis, 3) Quality of life. Using the standard deviation from the baseline work (18 mmHg for SBP)12 and 90% power for a 5mmHg drop in SBP in the intervention as compared to the control arm, 546 participants will be needed per study arm. Allowing for a 20% dropout rate, the total number of participants will be 1300 (650 per arm/site).
Care of people with HIV across sub-Saharan Africa (SSA) is provided through dedicated parallel health streams, primarily designed to address HIV and related infectious co-morbidities. Consequently, the opportunity of addressing co-morbid non-communicable disease (NCD) is not fully realized in this population in regular contacts with the health system. Integration of HIV and NCD care has been suggested to improve the co-detection and co-management of co-morbid HIV and NCDs. Key to the success of this integration is a better understanding of the burden and drivers of NCDs in people with HIV, and appropriate strategies for promoting their care without compromising HIV specific care. We will conduct a 5-year program of research and capacity development, in view of establishing a sustainable network to generate the evidence to inform successful integration of HIV and NCD care in SSA. The proposal builds on an existing platform comprising the South African Medical Research Council (SAMRC, lead institution), the Nigerian Institute of Medical Research (NIMR) and the Clinical Research, Education and Consultancy Network (CRENC) in Cameroon. Our program of research will be developed around three complementary projects. In Nigeria, using data from the NIMR HIV cohort of nearly 24,000 HIV people on ART with over 15 years of follow-up, we will investigate the incidence, remission and determinants (including HIV predictive characteristics) of dyslipidemia and impaired kidney function. In Cameroon, we will use the country arm of the ongoing International Epidemiologic Databases to Evaluate AIDS (IeDEA), to characterize the baseline distribution and determinants of cardiometabolic risk factors in nearly 20,000 adults in care for HIV infections. Across the two country we will assess and strengthen the scope of data collection for improved research on co-morbid NCDs and HIV. In South Africa, we will execute a clinical trial to determine the effect of mobile phone text messaging support, to improve the uptake and adherence and outcome of hypertension care in patients with comorbid HIV and hypertension. The three projects will support the training of three PhD students (one/per country), mentoring of the NIMR biostatistician in handling longitudinal data and a junior SAMR researcher in coordinating clinical trials; and results in many peer-reviewed publications and several communications at conferences.