Corinna M. Walsh

Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations. Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants. Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits. Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

The impact of a nutrition education programme on the anthropometric nutritional status of low-income children in South Africa

OBJECTIVE The study determined the impact of a community-based nutrition education programme, using trained community nutrition advisors, on the anthropometric nutritional status of mixed-race children aged between 2 and 5 years. DESIGN AND SETTING The programme was implemented over two years in four study areas in the Free State and Northern Cape Provinces. Two control areas were included to differentiate between the effect of the education programme and a food aid programme that were implemented simultaneously. Weight-for-age, height-for-age and weight-for-height were summarised using standard deviations from the NCHS reference median. For each of the indicators, the difference in the percentage of children below minus two standard deviations from the reference NCHS median in the initial and follow-up surveys was determined. SUBJECTS Initially 536 children were measured and, after two years of intervention, 815. RESULTS Weight-for-age improved in all areas, but only significantly in boys and girls in the urban study area, and in boys in one rural study area. No significant improvement in height-for-age occurred in any area. Weight-for-height improved significantly in the urban study area. CONCLUSION The education programme in combination with food aid succeeded in improving the weight status of children, but was unable to facilitate catch-up growth in stunted children after two years of intervention.

Risk-factor profiles for chronic diseases of lifestyle and metabolic syndrome in an urban and rural setting in South Africa

Abstract Background Chronic lifestyle diseases share similar modifiable risk factors, including hypertension, tobacco smoking, diabetes, obesity, hyperlipidaemia and physical inactivity. Metabolic syndrome refers to the cluster of risk factors that increases the risk for developing type 2 diabetes mellitus (DM) and cardiovascular disease. Objectives The study aimed to assess health status and identify distinct risk-factor profiles for both chronic lifestyle diseases and metabolic syndrome in rural and urban communities in central South Africa. Methods The investigation formed part of the Assuring Health for All in the Free State (AHA-FS) study. During interviews by trained researchers, household socio-demographic and health information, diet, risk factors (i.e. history of hypertension and/or diabetes) and habits (e.g. smoking and inadequate physical activity levels) were determined. Adult participants underwent anthropometric evaluation, medical examination and blood sampling. Results The risk-factor profile for chronic lifestyle diseases revealed that self-reported hypertension and physical inactivity were ranked the highest risk factor for the rural and urban groups respectively. The cumulative risk-factor profile showed that 40.1% of the rural and 34.4% of the urban study population had three or more risk factors for chronic lifestyle diseases. Furthermore, 52.2% of rural and 39.7% of urban participants had three or more risk factors for metabolic syndrome. Conclusion This study confirmed that the worldwide increase in the prevalence of chronic lifestyle diseases can be attributed to a more sedentary lifestyle, especially illustrated in the urban study population, and increasing obesity. The rural study population had a higher prevalence of risk factors for metabolic syndrome.

Comparative assessment of absolute cardiovascular disease risk characterization from non-laboratory-based risk assessment in South African populations.

BackgroundAll rigorous primary cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk scores to identify high- and low-risk patients, but laboratory testing can be impractical in low- and middle-income countries. The purpose of this study was to compare the ranking performance of a simple, non-laboratory-based risk score to laboratory-based scores in various South African populations.MethodsWe calculated and compared 10-year CVD (or coronary heart disease (CHD)) risk for 14,772 adults from thirteen cross-sectional South African populations (data collected from 1987 to 2009). Risk characterization performance for the non-laboratory-based score was assessed by comparing rankings of risk with six laboratory-based scores (three versions of Framingham risk, SCORE for high- and low-risk countries, and CUORE) using Spearman rank correlation and percent of population equivalently characterized as ‘high’ or ‘low’ risk. Total 10-year non-laboratory-based risk of CVD death was also calculated for a representative cross-section from the 1998 South African Demographic Health Survey (DHS, n = 9,379) to estimate the national burden of CVD mortality risk.ResultsSpearman correlation coefficients for the non-laboratory-based score with the laboratory-based scores ranged from 0.88 to 0.986. Using conventional thresholds for CVD risk (10% to 20% 10-year CVD risk), 90% to 92% of men and 94% to 97% of women were equivalently characterized as ‘high’ or ‘low’ risk using the non-laboratory-based and Framingham (2008) CVD risk score. These results were robust across the six risk scores evaluated and the thirteen cross-sectional datasets, with few exceptions (lower agreement between the non-laboratory-based and Framingham (1991) CHD risk scores). Approximately 18% of adults in the DHS population were characterized as ‘high CVD risk’ (10-year CVD death risk >20%) using the non-laboratory-based score.ConclusionsWe found a high level of correlation between a simple, non-laboratory-based CVD risk score and commonly-used laboratory-based risk scores. The burden of CVD mortality risk was high for men and women in South Africa. The policy and clinical implications are that fast, low-cost screening tools can lead to similar risk assessment results compared to time- and resource-intensive approaches. Until setting-specific cohort studies can derive and validate country-specific risk scores, non-laboratory-based CVD risk assessment could be an effective and efficient primary CVD screening approach in South Africa.

Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa

Household food security impacts heavily on quality of life. We determined factors associated with food insecurity in 886 households in rural and urban Free State Province, South Africa. Significantly more urban than rural households reported current food shortage (81% and 47%, respectively). Predictors of food security included vegetable production in rural areas and keeping food for future use in urban households. Microwave oven ownership was negatively associated with food insecurity in urban households and using a primus or paraffin stove positively associated with food insecurity in rural households. Interventions to improve food availability and access should be emphasized.

A risk-factor profile for chronic lifestyle diseases in three rural Free State towns

Abstract Background: Chronic diseases of lifestyle account for millions of deaths each year globally. These diseases share similar modifiable risk factors, including hypertension, tobacco smoking, diabetes, obesity, hyperlipidaemia and physical inactivity. In South Africa the burden of noncommunicable disease risk factors is high. To reduce or control as many lifestyle risk factors as possible in a population, the distinct risk-factor profile for that specific community must be identified. Therefore, the aim of this study was to assess the health status in three rural Free State communities and to identify a distinct risk-factor profile for chronic lifestyle diseases in these communities. Methods: This study forms part of the baseline phase of the Assuring Health for All in the Free State project, which is a prospective and longitudinal epidemiological study aimed at determining how living in a rural area can either protect or predispose one to developing chronic lifestyle diseases. The communities of three black and coloured, rural Free State areas, namely Trompsburg, Philippolis and Springfontein, were evaluated. The study population consisted of 499 households, and 658 individuals (including children) participated in the study. Only results of adult participants between 25 and 64 years will be reported in this article. The study group consisted of 29.4% male and 70.6% female participants, with a mean age of 49 years. During interviews with trained researchers, household socio-demographic questionnaires, as well as individual questionnaires evaluating diet, risk factors (history of hypertension and/or diabetes) and habits (tobacco smoking and physical activity levels), were completed. All participants underwent anthropometric evaluation, medical examination and blood sampling to determine fasting blood glucose levels. Results: Multiple risk factors for noncommunicable diseases were identified in this study population, including high blood pressure, tobacco smoking, high body mass index (BMI), diabetes and physical inactivity. The reported risk-factor profile was ranked. Increased waist circumference was ranked highest, high blood pressure second, tobacco smoking third, physical inactivity fourth and diabetes fifth. The cumulative risk-factor profile revealed that 35.6 and 21% of this study population had two and three risk factors, respectively. Conclusions: The study demonstrated a high prevalence of risk factors for noncommunicable diseases, e.g. large waist circumference, high BMI, raised blood pressure, tobacco smoking and raised blood glucose levels. Serious consideration should be given to this escalating burden of lifestyle diseases in the study population. The development and implementation of relevant health promotion and intervention programmes that will improve the general health and reduce the risk for noncommunicable diseases in this population are advised.

Prevalence of diabetes mellitus in the rural southern Free State

Abstract Background: A worldwide increase in the prevalence of diabetes mellitus (DM) has been reported and an even further increase is expected as a result of lifestyle changes. The objectives of this study were to determine the prevalence of DM in the rural southern Free State and to investigate the contribution of risk factors such as age, physical activity, body mass index (BMI), waist-to-hip ratio and waist circumference to the development of impaired fasting glucose (IFG) or DM. Methods: Fasting venous plasma glucose (FVPG) levels were obtained from a total of 552 participants from Springfontein (n = 195), Trompsburg (n = 162) and Philippolis (n = 180). Participants were between 25 and 64 years of age, with 28.1% male (mean age 47.3 years) and 71.9% female (mean age 46 years). Anthropometric status was determined using standardised techniques. Levels of physical activity were determined using a 24-hour recall of physical activity as well as frequency of performing certain activities. Relative risks (RR) as well as 95% confidence intervals (95% CI) were used to distinguish significant risk factors for having IFG or DM. Results: In the study population the prevalence of DM was 7.6% (5.2% in men and 8.6% in women) and that of IFG was 6.3% (4.5% in men and 7.1% in women). The majority of nondiabetic (34%), IFG (55%) and DM (61%) participants were between the ages of 51 and 60 years. Age was found to be a statistically significant risk factor for having IFG or DM in participants older than 40 years of age (RR 2.3; 95% CI [1.22; 4.34]). Crude measurements (not age- and gender-adjusted) of waist circumference (RR 3.23; 95% CI [1.82; 5.74]), BMI (RR 2.32; 95% CI [1.43; 3.78]) and waist-to-hip ratio (RR 2.51; 95% CI [1.55; 4.07]) were statistically significant risk factors for having IFG or DM. Physical inactivity in men ≥ 40 years was also a statistically significant risk factor (RR 3.23; 95% CI [1.15; 9.05]) for having IFG or DM. Conclusions: In this study, 37.5% of diabetics were newly discovered. A high waist circumference, BMI and waist-to-hip-ratio were associated with an increased risk for developing IFG or DM, with a high waist circumference being the most significant general risk factor. Physically inactive men (≤ 40 years) were also at a higher risk of having IFG or DM. Follow-up FVPG and glucose tolerance tests should be performed on participants in the IFG group. A need for intervention regarding the identification and treatment of DM in these rural areas has been identified.

Nutritional status of undergraduate healthcare students at the University of the Free State

Abstract Objectives: This study aimed to evaluate the lifestyle habits of South African students preparing for careers in health care that could influence the efficacy of their counselling practices on risk factors for noncommunicable diseases (NCDs) as future healthcare professionals. Design: Cross-sectional descriptive study. Setting and subjects: One hundred and sixty-one students (median age 21.5 years, 75.8% women) enrolled in the Faculty of Health Sciences at the University of the Free State. Outcome measures: Anthropometry was measured and structured questionnaires administered to assess dietary and lifestyle habits. Results: Many students were at risk of NCDs, with 19.8% being overweight or obese (body mass index > 25 kg/m2), 11.8% had a waist circumferences above gender-specific cut-off points, 98.1% consumed < 3 servings of vegetables/day, 58.4% consumed < 2 servings of fruit/day, 83% consumed < 2 servings of dairy products/day, 60% did not eat a beta-carotenerich fruit or vegetable daily, 31% did not eat a vitamin C-rich fruit or vegetable daily, 62% never consumed legumes, 43% reported a high intake of fats and sweets, 11% smoked a median of 3.5 cigarettes/day and 63% consumed a median of three drinks of alcohol/day on a median of four days (95% weekend days) per month. Fifty-nine per cent were active and 39% were very active owing to busy class schedules, but only 32% participated in formal exercise and sports. Conclusion: The poor dietary and lifestyle habits of most participants highlight the need to not just educate, but better empower these students to deal with the growing public health problem of obesity and related NCDs in the country.

Nutritional status of disabled schoolchildren in Bloemfontein (2002-2003)

Objectives: To assess the nutritional status of disabled schoolchildren using anthropometric measures and dietary intake, and to compare estimated energy expenditure with energy intake and body weight.

Micronutrient intake of HIV-infected women in Mangaung, Free State

Background. Poor nutritional status in HIV/AIDS patients can affect immune function profoundly, leading to faster disease progression and earlier death. Objective. To determine the micronutrient intake of HIV-infected women in Mangaung. Design and setting. A cross-sectional study was undertaken in Mangaung, Bloemfontein, Free State. Subjects and methods. A representative group of 500 pre-menopausal women (25 - 44 years) was randomly selected to participate in the study. Micronutrient intake was determined using a Quantitative Food Frequency Questionnaire (QFFQ). Median micronutrient intakes were compared with the Recommended Dietary Allowance (RDA) or Adequate Intake (AI) values. The prevalence of women with intakes ≤ 67% of the RDA or AI was calculated. Median micronutrient intakes were compared between HIV-infected and uninfected women using non-parametric 95% confidence intervals (CIs) and the Mann-Whitney test. Results. Sixty-one per cent of women in the younger age group (25 - 34 years) and 38% of older women (35 - 44 years) were HIV-infected. Between 46.6% and 70.7% of all women consumed ≤ 67% of the RDA or AI for calcium, total iron, selenium, folate and vitamin C. At least 25% of HIV-infected women did not meet either the RDA or the AI for vitamins A, D and E. Younger HIV-infected women had significantly higher intakes of calcium (p = 0.046), phosphorus (p = 0.04), potassium (p = 0.04), vitamin B12 (p = 0.01), vitamin D (p = 0.03) and vitamin E (p = 0.04) than their HIV-uninfected counterparts. Older HIV-infected women had significantly lower intakes of haem iron (p = 0.03), non-haem iron (p = 0.04) and selenium (p = 0.04) than their HIV-uninfected counterparts. Conclusions. Insufficient micronutrient intakes are common in both HIV-infected and uninfected women. A well-balanced diet and micronutrient supplementation seem warranted to ensure optimal health and survival, particularly in HIV-infected women. South African Journal of Clinical Nutrition Vol. 20 (1) 2007: pp. 28-36