George Alberti

The metabolic syndrome in children and adolescents

www.thelancet.com Vol 369 June 23, 2007 2059 and community mobilisation was possible for the Mitanin programme, but there were no community-level baselines or controls in the programme design to measure outcomes, and suffi cient sample sizes were neither easy nor aff ordable. At this stage, outcomes can be assessed only by use of indicators in independent surveys of national health and demographics. These surveys show that the rural infant mortality in Chhattisgarh decreased from 85 deaths per 1000 livebirths in 2002 to 65 deaths per 1000 livebirths in 2005, which is much the same as the national rural infant mortality rate (64 deaths per 1000 livebirths). However, estimation of the precise contribution of the Mitanin programme to this decrease is diffi cult. Much of the improvement in child survival in Chhattisgarh undoubtedly relates to better healthseeking behaviour and child-care practices. The initiation of breastfeeding in the fi rst 2 h after birth increased from 24% of livebirths to 71% of livebirths, and the use of oral rehydration salts in the management of diarrhoea in children younger than 3 years increased by 12% in the 2 weeks before the survey. These two interventions substantially aff ect child survival, and were highly mon i tored and eff ective Mitanin interventions. Other re corded improvements include total immunisation and ante natal care, to which Mitanins would have lent support. Community participation and the empowerment of women cause change. The many Mitanins who have since entered elected offi ce in local governance bodies, and the successful Mitanin-led community actions against deforestation, for securing of tribal liveli hoods, for early childhood-care facilities, or against alcoholism and corruption are testimonies to the so-called unintend ed positive outcomes. However, as the programme grows, these actions will pose new problems for the sus tainability of large-scale CHW programmes, and might again lay bare the tensions between the diff erent expec tations and descriptions of the CHW.

Stroke incidence in rural and urban Tanzania: a prospective, community-based study

BACKGROUND There are no methodologically rigorous studies of the incidence of stroke in sub-Saharan Africa. We aimed to provide reliable data on the incidence of stroke in rural and urban Tanzania. METHODS The Tanzania Stroke Incidence Project (TSIP) recorded stroke incidence in two well defined demographic surveillance sites (DSS) over a 3-year period from June, 2003. The Hai DSS (population 159,814) is rural and the Dar-es-Salaam DSS (population 56,517) is urban. Patients with stroke were identified by use of a system of community-based investigators and liaison with local hospital and medical centre staff. Patients who died from stroke before recruitment into the TSIP were identified via verbal autopsy, which was done on all those who died within the study areas. FINDINGS There were 636 strokes during the 3-year period (453 in Hai and 183 in Dar-es-Salaam). Overall crude yearly stroke incidence rates were 94.5 per 100,000 (95% CI 76.0-115.0) in Hai and 107.9 per 100,000 (88.1-129.8) in Dar-es-Salaam. When age-standardised to the WHO world population, yearly stroke incidence rates were 108.6 per 100 000 (95% CI 89.0-130.9) in Hai and 315.9 per 100,000 (281.6-352.3) in Dar-es-Salaam. INTERPRETATION Age-standardised stroke incidence rates in Hai were similar to those seen in developed countries. However, age-standardised incidence rates in Dar-es-Salaam were higher than seen in most studies in developed countries; this could be because of a difference in the prevalence of risk factors and emphasises the importance of health screening at a community level. Health policy makers must continue to monitor the incidence of stroke in sub-Saharan Africa and should base future funding decisions on such data. FUNDING The Wellcome Trust.

Comparison of body mass index with waist circumference, waist-to-hip ratio, and waist-to-stature ratio as a predictor of hypertension incidence in Mauritius.

Objective Comparison of BMI with waist circumference, waist-to-hip ratio (WHR), and waist-to-stature ratio (WSR) as a predictor of hypertension incidence. Methods A total of 1658 men and 1976 women of Mauritian Indian and Mauritian Creole ethnicity, aged 25–74 years, free of hypertension, diabetes, cardiovascular disease, and gout at baseline in 1987 or 1992, were re-examined in 1992 and/or 1998 using the same survey methodology. Hazard ratios (HRs) for hypertension incidence were estimated applying an interval censored survival analysis (R program) using age as timescale based on baseline obesity indicators. Results A total of 787 incident hypertension cases were identified during the follow-up. HRs for hypertension incidence adjusting for baseline systolic blood pressure and cohort corresponding to a 1 SD increase in BMI, waist circumference, WHR, and WSR were 1.20 (1.24), 1.19 (1.21), 1.14 (1.10), and 1.20 (1.26) in Mauritian Indian men (women) and 1.23 (1.32), 1.34 (1.23), 1.41 (1.13), and 1.43 (1.33) in Mauritian Creoles, respectively, indicating that all obesity indicators significantly predicted hypertension incidence except for WHR in Mauritian Creole women. Paired homogeneity tests showed that there was no difference between BMI and the other three indicators for most of the comparisons with two exceptions: WSR was stronger than BMI (P = 0.002) in Mauritian Creole men but BMI was stronger than WHR (P = 0.047) in Mauritian Indian women in predicting the incident cases of hypertension. Conclusion The relation of the development of hypertension with BMI was as strong as that with central obesity indicators in the population studied.

Stroke risk factors in an incident population in urban and rural Tanzania: a prospective, community-based, case-control study

Summary Background The burden of stroke on health systems in low-income and middle-income countries is increasing. However, high-quality data for modifiable stroke risk factors in sub-Saharan Africa are scarce, with no community-based, case-control studies previously published. We aimed to identify risk factors for stroke in an incident population from rural and urban Tanzania. Methods Stroke cases from urban Dar-es-Salaam and the rural Hai district were recruited in a wider study of stroke incidence between June 15, 2003, and June 15, 2006. We included cases with first-ever and recurrent stroke. Community-acquired controls recruited from the background census populations of the two study regions were matched with cases for age and sex and were interviewed and assessed. Data relating to medical and social history were recorded and blood samples taken. Findings We included 200 stroke cases (69 from Dar-es-Salaam and 131 from Hai) and 398 controls (138 from Dar-es-Salaam and 260 from Hai). Risk factors were similar at both sites, with previous cardiac event (odds ratio [OR] 7·39, 95% CI 2·42–22·53; p<0·0001), HIV infection (5·61, 2·41–13·09; p<0·0001), a high ratio of total cholesterol to HDL cholesterol (4·54, 2·49–8·28; p<0·0001), smoking (2·72, 1·49–4·96; p=0·001), and hypertension (2·14, 1·09–4·17; p=0·026) identified as significant independent risk factors for stroke. In Hai, additional risk factors of diabetes (4·04, 1·29–12·64) and low HDL cholesterol (9·84, 4·06–23·84) were also significant. Interpretation We have identified many of the risk factors for stroke already reported for other world regions. HIV status was an independent risk factor for stroke within an antiretroviral-naive population. Clinicians should be aware of the increased risk of stroke in people with HIV, even in the absence of antiretroviral treatment. Funding The Wellcome Trust.

ABC of Obesity: Obesity—can we turn the tide?

The problem of rising prevalence in obesity may get much worse—rates could climb still further, bankrupting the health system and leading soon to reductions in life expectancy. So, can we offer effective management? And can we reverse the rising trend in the prevalence of obesity, and if so, when? Recent headlines highlighting the current and projected obesity levels in the United Kingdom—in 2010 a third of adults will be obese—reiterate the cry that “its time to do something about it.” As already shown in this series, the consequences of obesity affect all ages and nearly all organ systems. Obesity diminishes quality of life, and many problems begin well before reaching a body mass index of 30. Well over half the entire population of the UK have a BMI of >25, and they will experience greater morbidity and total mortality. Medical complications of obesity Trends in obesity in adults in England, 1980-2002 (graph adapted from Health Survey for England 2004 ). Projected levels suggest that by 2010 nearly a third of adult men and 28% of women in England will be obese ( Forecasting obesity to 2010 , www.dh.gov.uk/). The figures will be higher for older people Vicious cycle of weight gain. Food provides short term pleasure and is addictive Although the old attitude of “pull yourself together, eat less, and exercise more” is receding, it is still evident among less perceptive health professionals and is commonly voiced by the media. Most overweight or obese individuals would prefer to be normal weight, and many are doing as much as they can to keep their weight lower than it would otherwise be. It is increasingly apparent that most individuals are unable to make enough “proactive” changes to prevent excess weight gain but are simply “reactive” to their environment. Thus education alone will fail to …

Post-stroke case fatality within an incident population in rural Tanzania

Background and purpose To establish post-stroke case fatality rates within a community based incident stroke population in rural Tanzania. Methods Incident stroke cases were identified by the Tanzanian Stroke Incidence Project and followed-up over the next 3–6 years. In order to provide a more complete picture, verbal autopsy (VA) was also used to identify all stroke deaths occurring within the same community and time period, and a date of stroke was identified by interview with a relative or friend. Results Over 3 years, the Tanzanian Stroke Incidence Project identified 130 cases of incident stroke, of which 31 (23.8%, 95% CI 16.5 to 31.2) died within 28 days and 78 (60.0%, 95% CI 51.6 to 68.4) within 3 years of incident stroke. Over the same time period, an additional 223 deaths from stroke were identified by VA; 64 (28.7%, 95% CI 20.9 to 36.5) had died within 28 days of stroke and 188 (84.3%, 95% CI 78.1 to 90.6) within 3 years. Conclusions This is the first published study of post-stroke mortality in sub-Saharan Africa from an incident stroke population. The 28 day case fatality rate is at the lower end of rates reported for other low and middle income countries, even when including those identified by VA, although CIs were wide. Three year case fatality rates are notably higher than seen in most developed world studies. Improving post-stroke care may help to reduce stroke case fatality in sub-Saharan Africa.

Risk prediction models for the development of diabetes in Mauritian Indians

Aims  To develop risk prediction models of future diabetes in Mauritian Indians.

Serum uric acid and incident diabetes in Mauritian Indian and Creole populations.

OBJECTIVE To investigate the predictive value of serum uric acid (UA) for the development of diabetes in Asian Indians and Creoles living in Mauritius. METHODS A total of 1941 men (1409 Indians, 532 Creoles) and 2318 non-pregnant women (1645 Indians, 673 Creoles), aged 25-74 years and free of diabetes, cardiovascular disease and gout at baseline examinations in 1987 or 1992, were re-examined in 1992 and/or 1998. Diabetes was determined according to WHO/IDF 2006 criteria. The relationship between baseline UA and the development of diabetes during the follow-up was estimated using interval censored survival analysis. RESULTS In this cohort 337 (17.4%) men and 379 (16.4%) women developed diabetes during the follow-up. Individuals who developed diabetes during the follow-up had a lower serum UA levels at follow-up compared with their baseline UA levels, but this is not observed for post-menopausal women. Multivariate adjusted hazard ratios (HRs) (95% CIs) for the development of diabetes corresponding to one S.D. increase in UA concentration at baseline were 1.14 (1.01, 1.30) in Indian men and 1.37 (1.11, 1.68) in Creole men. They were 1.07 (0.95, 1.22) and 1.01 (0.84, 1.22), respectively, in Indians and Creole women. CONCLUSION Elevated serum UA is an independent risk marker for future diabetes in Mauritian men, whereas the prediction is weak in women.

Serum uric acid and components of the metabolic syndrome in non-diabetic populations in Mauritian Indians and Creoles and in Chinese in Qingdao, China.

OBJECTIVE To assess the association of serum uric acid (UA) with components of metabolic syndrome (MetS) in different ethnic groups. METHODS Nondiabetic men (3285) and nondiabetic women (4078) aged 25 to 74 years without a history of cardiovascular disease and gout from Mauritius and Qingdao China, comprising Mauritian Indians, Mauritian Creoles, and an urban Chinese population, were studied. The top quintile of waist circumference, body mass index (BMI), blood pressure, serum total cholesterol and triglycerides, plasma glucose levels, and the bottom quintile of HDL cholesterol was defined as the metabolic disorder. Hyperuricemia was defined if UA values were in the top quintile. RESULTS In a multivariate model (adjusted for age, cohort, smoking, and alcohol consumption), waist circumference, BMI, and serum triglycerides appeared to be independently associated with hyperuricemia in both sexes and in all ethnic groups except in Chinese women. Multivariate adjusted odds ratios (95% confidence intervals [CIs]) for having three or more metabolic disorders vs fewer than three, corresponding to a one SD increase in serum UA concentration, were 1.75 (1.51 to 2.02), 2.19 (1.71 to 2.82) and 2.30 (1.68 to 3.16) in Indian, Creole, and Chinese men, respectively, and 1.74 (1.52 to 2.00), 1.75 (1.40 to 2.19) and 1.72 (1.37 to 2.16) in Indian, Creole, and Chinese women, respectively. CONCLUSIONS In nondiabetics of Asian and African ancestry, elevated serum UA was closely associated with components of MetS, but whether UA provides additional information to the definition of the MetS in predicting future cardiovascular disease and diabetes needs to be studied.

Metabolic Control With the Bio-inspired Artificial Pancreas in Adults With Type 1 Diabetes: A 24-Hour Randomized Controlled Crossover Study.

Background: The Bio-inspired Artificial Pancreas (BiAP) is a closed-loop insulin delivery system based on a mathematical model of beta-cell physiology and implemented in a microchip within a low-powered handheld device. We aimed to evaluate the safety and efficacy of the BiAP over 24 hours, followed by a substudy assessing the safety of the algorithm without and with partial meal announcement. Changes in lactate and 3-hydroxybutyrate concentrations were investigated for the first time during closed-loop. Methods: This is a prospective randomized controlled open-label crossover study. Participants were randomly assigned to attend either a 24-hour closed-loop visit connected to the BiAP system or a 24-hour open-loop visit (standard insulin pump therapy). The primary outcome was percentage time spent in target range (3.9-10 mmol/l) measured by sensor glucose. Secondary outcomes included percentage time in hypoglycemia (<3.9 mmol/l) and hyperglycemia (>10 mmol/l). Participants were invited to attend for an additional visit to assess the BiAP without and with partial meal announcements. Results: A total of 12 adults with type 1 diabetes completed the study (58% female, mean [SD] age 45 [10] years, BMI 25 [4] kg/m2, duration of diabetes 22 [12] years and HbA1c 7.4 [0.7]% [58 (8) mmol/mol]). The median (IQR) percentage time in target did not differ between closed-loop and open-loop (71% vs 66.9%, P = .9). Closed-loop reduced time spent in hypoglycemia from 17.9% to 3.0% (P < .01), but increased time was spent in hyperglycemia (10% vs 28.9%, P = .01). The percentage time in target was higher when all meals were announced during closed-loop compared to no or partial meal announcement (65.7% [53.6-80.5] vs 45.5% [38.2-68.3], P = .12). Conclusions: The BiAP is safe and achieved equivalent time in target as measured by sensor glucose, with improvement in hypoglycemia, when compared to standard pump therapy.