The association between plasma zinc concentrations and markers of glucose metabolism in adults in Cameroon.

An abnormal Zn status has been suggested to play a role in the pathogenesis of type 2 diabetes. However, epidemiological studies of the relationship between plasma Zn concentrations and diabetes are sparse and inconclusive. We aimed to investigate the association between plasma Zn concentrations and glycaemic markers (fasting glucose, 2-h glucose and homeostatic model assessment of insulin resistance) in rural and urban Cameroon. We studied 596 healthy adults (63·3 % women) aged 25-55 years in a population-based cross-sectional study. The mean plasma Zn concentration was 13·7 ± 2·7 µmol/L overall, with higher levels in men (14·4 ± 2·9 µmol/l) than in women (13·2 ± 2·6 µmol/l), P-value < 0·0001. There was an inverse relationship between tertiles of plasma Zn and 2-h glucose concentrations (P-value for linear trend = 0·002). The difference in 2-h glucose between those in the highest tertile of plasma Zn compared to the lowest was -0·63 (95 % CI - 1·02, -0·23) mmol/l. This remained significant after adjusting for age, sex, smoking status, alcohol intake, education level, area of residence, adiposity and objectively measured physical activity -0·43(-0·82, -0·04). Similar inverse associations were observed between plasma Zn concentrations and fasting glucose and homeostatic model assessment of insulin resistance when adjusted for socio-demographic and health-related behavioural characteristics. The current findings of an inverse association between plasma Zn concentrations and several markers of glucose homeostasis, together with growing evidence from intervention studies, suggest a role for Zn in glucose metabolism. If supported by further evidence, strategies to improve Zn status in populations may provide a cheap public health prevention approach for diabetes.

Shared correlates of maternal and childhood overweight in Cameroon: a cross-sectional analysis of demographic and health survey data.

BACKGROUND: Overweight parents are likelier to bear overweight babies, who are likelier to grow into overweight adults. Understanding the shared risks of being overweight between the mother-child dyad is essential for targeted life course interventions. In this study, we aimed to identify such risk factors in Cameroon. METHODS: We conducted secondary data analysis using Cameroon's 2018 Demographic and Health Surveys. We used weighted multilevel binary logistic regressions to examine individual, household, and community correlates of maternal (15-49 years) and child (under five years) overweight. RESULTS: We retained 4511 complete records for childhood and 4644 for maternal analysis. We found that 37% [95%CI:36-38%] of mothers and 12% [95%CI:11-13%] of children were overweight or obese. Many environmental and sociodemographic factors were positively associated with maternal overweight, namely urban residence, wealthier households, higher education, parity and being a Christian. Childhood overweight was positively associated with a child being older and a mother being overweight, a worker, or a Christian. Therefore, only religion affected both mothers overweight (aOR: 0.71[95%CI:0.56-0.91]) and childhood overweight (aOR 0.67[95%CI: 0.5-0.91]). Most of the potentially shared factors only indirectly affected childhood overweight through maternal overweight. CONCLUSION: Besides religion, which affects both mothers and childhood overweight (with the Muslim faith being protective), much of childhood overweight is not directly explained by many of the observed determinants of maternal overweight. These determinants are likely to influence childhood overweight indirectly through maternal overweight. Extending this analysis to include unobserved correlates such as physical activity, dietary, and genetic characteristics would produce a more comprehensive picture of shared mother-child overweight correlates.

Comparing travel behaviour characteristics and correlates between large and small Kenyan cities (Nairobi versus Kisumu).

Understanding urban travel behaviour is crucial for planning healthy and sustainable cities. Africa is urbanising at one of the fastest rates in the world and urgently needs this knowledge. However, the data and literature on urban travel behaviour, their correlates, and their variation across African cities are limited. We aimed to describe and compare travel behaviour characteristics and correlates of two Kenyan cities (Nairobi and Kisumu). We analysed data from 16,793 participants (10,000 households) in a 2013 Japan International Cooperation Agency (JICA) household travel survey in Nairobi and 5790 participants (2760 households) in a 2016 Institute for Transportation and Development Policy (ITDP) household travel survey in Kisumu. We used the Heckman selection model to explore correlations of travel duration by trip mode. The proportion of individuals reporting no trips was far higher in Kisumu (47% vs 5%). For participants with trips, the mean number [lower - upper quartiles] of daily trips was similar (Kisumu (2.2 [2-2] versus 2.4 [2-2] trips), but total daily travel durations were lower in Kisumu (65 [30-80] versus 116 [60-150] minutes). Walking was the most common trip mode in both cities (61% in Kisumu and 42% in Nairobi), followed by motorcycles (17%), matatus (minibuses) (11%), and cars (5%) in Kisumu; and matatus (28%), cars (12%) and buses (12%) in Nairobi. In both cities, females were less likely to make trips, and when they did, they travelled for shorter durations; people living in households with higher incomes were more likely to travel and did so for longer durations. Gender, income, occupation, and household vehicle ownership were associated differently with trip making, use of transport modes and daily travel times in cities. These findings illustrate marked differences in reported travel behaviour characteristics and correlates within the same country, indicating setting-dependent influences on travel behaviour. More sub-national data collection and harmonisation are needed to build a more nuanced understanding of patterns and drivers of travel behaviour in African cities.

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. PARTNERSHIP: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. CONCLUSION: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.

Chronic kidney disease in sugarcane workers in Cameroon: a cross-sectional study.

BACKGROUND: Agricultural workers especially in sugarcane plantations have a high risk of chronic kidney disease (CKD). Little is known about CKD among sugarcane plantation workers in Cameroon. This study sought to evaluate the prevalence and identify factors associated with CKD in sugarcane plantation workers in Cameroon. METHODS: We conducted an analytic cross-sectional study including 204 adult workers at the sugarcane plantation complex in Mbandjock, Cameroon; over 500 m above sea level. Chronic kidney disease (proteinuria as estimated by urine dipstick analysis and/or estimated glomerular filtration rate < 60 ml/min/1.73 m2 persistent after 3 months) was the outcome of interest. Those with abnormal results were seen again after 3 months to confirm the diagnosis. We evaluated the association between CKD and participant age, sex, contract-type, duration of employment, socio-economic status, workspace, exposure to agrochemicals, heavy metals and heat, selected risk factors and co-morbid conditions. RESULTS: The overall prevalence of CKD was 3.4%. The factory workers were the most affected (7%), compared to the field (2.4%) and office workers (0%). 2.9% of the participants had persistent proteinuria, mild in every case, and 0.5% of them had an estimated glomerular filtration rate < 60 ml/min/1.73 m2. Age ≥ 40 years was an independent predictor of CKD. CONCLUSION: The prevalence of CKD among employees of the Mbandjock sugarcane plantation is low, probably reflecting the preventive measures against heat stress and dehydration in place.

Two decades of tobacco use prevention and control policies in Cameroon: results from the analysis of non-communicable disease prevention policies in Africa.

BACKGROUND: Tobacco use is the leading cause of preventable death in the world today. In 2010, the World Health Organization (WHO) proposed efficient and inexpensive "best buy" interventions for prevention of tobacco use including: tax increases, smoke-free indoor workplaces and public places, bans on tobacco advertising, promotion and sponsorship, and health information and warnings. This paper analyzes the extent to which tobacco use prevention policies in Cameroon align with the WHO tobacco "best buy" interventions. It further explores the context, content, formulation and implementation level of these policies. METHODS: This was a case study combining a structured review of 19 government policy documents related to tobacco use and prevention, in-depth interviews with 38 key stakeholders and field observations. The Walt and Gilson's policy analysis triangle was used to describe and interpret the context, content, processes and actors during the formulation and implementation of tobacco prevention and control policies. Direct observations ascertained the level of implementation of some selected policies. RESULTS: Twelve out of 19 policies for tobacco use and prevention address the WHO "best buy" interventions. Cameroon policy formulation was driven locally by the social context of non-communicable diseases, and globally by the adoption of the WHO Framework Convention on Tobacco Control. These policies incorporated at a certain level all four domains of tobacco use "best buy" interventions. Formulating policy on smoke-free areas was single-sector oriented, while determining tobacco taxes and health warnings was more complex utilizing multisectoral approaches. The main actors involved were ministerial departments of Health, Education, Finances, Communication and Social Affairs. The level of implementation varied widely from one policy to another and from one region to another. Political will, personal motivation and the existence of formal exchange platforms facilitated policy formulation and implementation, while poor resource allocation and lack of synergy constituted barriers. CONCLUSIONS: Despite actions made by the Government, there is no real political will to control tobacco use in Cameroon. Significant shortcomings still exist in developing and/or implementing comprehensive tobacco use and prevention policies. These findings highlight major gaps as well as opportunities that can be harnessed to improve tobacco control in Cameroon.

Influence of the WHO framework convention on tobacco control on tobacco legislation and policies in sub-Saharan Africa.

BACKGROUND: The World Health Organization's Framework Convention on Tobacco Control, enforced in 2005, was a watershed international treaty that stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on health. This paper describes the timelines, context, key actors, and strategies in the development and implementation of the treaty and describes how six sub-Saharan countries responded to its call for action on tobacco control. METHODS: A multi-country policy review using case study design was conducted in Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo. All documents related to the WHO Framework Convention on Tobacco Control and individual country implementation of tobacco policies were reviewed, and key informant interviews related to the countries' development and implementation of tobacco policies were conducted. RESULTS: Multiple stakeholders, including academics and activists, led a concerted effort for more than 10 years to push the WHO treaty forward despite counter-marketing from the tobacco industry. Once the treaty was enacted, Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo responded in unique ways to implement tobacco policies, with differences associated with the country's socio-economic context, priorities of country leaders, industry presence, and choice of strategies. All the study countries except Malawi have acceded to and ratified the WHO tobacco treaty and implemented tobacco control policy. CONCLUSIONS: The WHO Framework Convention on Tobacco Control provided an unprecedented opportunity for global action against the public health effects of tobacco including non-communicable diseases. Reviewing how six sub-Saharan countries responded to the treaty to mobilize resources and implement tobacco control policies has provided insight for how to utilise international regulations and commitments to accelerate policy impact on the prevention of non-communicable diseases.

Insulin resistance and associated factors among HIV-infected patients in sub-Saharan Africa: a cross sectional study from Cameroon.

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.

NEWS for Africa: adaptation and reliability of a built environment questionnaire for physical activity in seven African countries.

BACKGROUND: Built environment and policy interventions are effective strategies for controlling the growing worldwide deaths from physical inactivity-related non-communicable diseases. To improve built environment research and develop African specific evidence, it is important to first tailor built environment measures to African contexts and assess their psychometric properties across African countries. This study reports on the adaptation and test-retest reliability of the Neighborhood Environment Walkability Scale in seven sub-Saharan African countries (NEWS-Africa). METHODS: The original NEWS comprising 8 subscales measuring reported physical and social attributes of neighborhood environments was systematically adapted for Africa through extensive input from physical activity and public health researchers, built environment professionals, and residents in seven African countries: Cameroon, Ghana, Kenya, Mozambique, Nigeria, South Africa and Uganda. Cognitive testing of NEWS-Africa was conducted among diverse residents (N = 109, 50 youth [12 - 17 years] and 59 adults [22 - 67 years], 69 % from low socioeconomic status [SES] neighborhoods). NEWS-Africa was translated into local languages and evaluated for 2-week test-retest reliability in adult participants (N = 301; female = 50.2 %; age = 32.3 ± 12.9 years) purposively recruited from neighborhoods varying in walkability (high and low walkable) and SES (high and low income) and from villages in six of seven participating countries. RESULTS: The original 67 NEWS items was expanded to 89 scores (76 individual NEWS items and 13 computed scales). Several modifications were made to individual items, and some new items were added to capture important attributes in the African environment. A new scale on personal safety was created, and the aesthetics scale was enlarged to reflect African specific characteristics. Over 95 % of all NEWS-Africa scores (items plus computed scales) demonstrated evidence of "excellent" (ICCs > .75 %) or "good" (ICCs = 0.60 to 0.74) reliability. Seven (53.8 %) of the 13 computed NEWS scales demonstrated "excellent" agreement and the other six had "good" agreement. No items or scales demonstrated "poor" reliability (ICCs < .40). CONCLUSIONS: The systematic adaptation and initial psychometric evaluation of NEWS-Africa indicates the instrument is feasible and reliable for use with adults of diverse demographic characteristics in Africa. The measure is likely to be useful for research, surveillance of built environment conditions for planning purposes, and to evaluate physical activity and policy interventions in Africa.

Risk factors of impaired fasting glucose and type 2 diabetes in Yaoundé, Cameroon: a cross sectional study.

BACKGROUND: The prevalence of diabetes is increasing worldwide, particularly in low and middle income countries, where treatment and control are often unavailable and inaccessible. Information on risk factors at local and regional levels is of utmost importance for tailored prevention programmes to curb the rise in diabetes. The current study was undertaken to investigate the prevalence of Impaired Fasting Glucose (IFG)/Type 2 Diabetes (T2D) and its risk factors in the adult population in Biyem-Assi-Yaoundé, Cameroon. METHODS: Information on cardiovascular risk factors using the WHO STEPwise approach was obtained for 1623 men and women aged 25 years and older of the CAMBoD Project in Biyem-Assi, Yaoundé, Cameroon. T2D was defined as fasting capillary glucose (FCG) ≥ 7.0 mmol/l and/or being on diabetes medication, IFG/T2D as FCG ≥ 6.1 mmol/l and/or being on diabetes medication. Descriptive statistics and multivariate logistic regression analyses were used to describe prevalence of IFG/T2D, prevalence of risk factors for IFG/T2D and to investigate the association of risk factors with prevalence of IFG/T2D. RESULTS: Prevalence of T2D and of IFG/T2D was 3.3% and 5.7%. Prevalence of hypertension, obesity and abdominal obesity (elevated waist circumference) was 26.6%, 28.4% and 34.9%, respectively. Age and abdominal obesity were significantly associated with IFG/T2D in multivariate logistic regression. CONCLUSION: For successful primary prevention of T2D in the general population in Cameroon tailored efforts to address obesity, particularly abdominal obesity, and associated life-style factors are warranted.

Obesity and type 2 diabetes in Sub-Sahara Africa.

There is a mounting body of evidence regarding the challenge posed by diabetes and obesity on the health systems of many Sub-Sahara African countries. This trend has been linked to the changing demographic profile together with rapid urbanization and changing lifestyles in both rural and urban settings in Africa. Africa is expected to witness the greatest increase in the number of people with diabetes from 19.8 million in 2013 to 41.4 million in 2035 if current trends persist. Excess weight alone currently accounts for at least 2.8 million deaths globally each year through increased risk for type 2 diabetes and cardiovascular complications. This review highlights recent literature on the problem of obesity and type 2 diabetes in Sub-Sahara Africa. It exposes the need for concrete interventions based on the now available wealth of evidence.

Active travel and paratransit use in African cities: Mixed-method systematic review and meta-ethnography.

Active travel, as a key form of physical activity, can help offset noncommunicable diseases as rapidly urbanising countries undergo epidemiological transition. In Africa a human mobility transition is underway as cities sprawl and motorization rises and preserving active travel modes (walking, cycling and public transport) is important for public health. Across the continent, public transport is dominated by paratransit, privately owned informal modes serving the general public. We reviewed the literature on active travel and paratransit in African cities, published from January 2008 to January 2019. We included 19 quantitative, 14 mixed-method and 8 qualitative studies (n = 41), narratively synthesizing the quantitative data and meta-ethnographically analysing the qualitative data. Integrated findings showed that walking was high, cycling was low and paratransit was a critical mobility option for poor peripheral residents facing long livelihood-generation journeys. As an indigenous solution to dysfunctional mobility systems shaped by colonial and apartheid legacies it was an effective connector, penetrating areas unserved by formal public transport and helping break cycles of poverty. From a public health perspective, it preserved active travel by reducing mode-shifting to private vehicles. Yet many city authorities viewed it as rogue, out of keeping with the 'ideal modern city', adopting official anti-paratransit stances without necessarily considering the contribution of active travel to public health. The studies varied in quality and showed uneven geographic representation, with data from Central and Northern Africa especially sparse; notably, there was a high prevalence of non-local authors and out-of-country funding. Nevertheless, drawing together a rich cross-disciplinary set of studies spanning over a decade, the review expands the literature at the intersection of transport and health with its novel focus on paratransit as a key active travel mode in African cities. Further innovative research could improve paratransit's legibility for policymakers and practitioners, fostering its inclusion in integrated transport plans.

A Systematic Review Protocol of Opportunities for Noncommunicable Disease Prevention via Public Space Initiatives in African Cities.

Public spaces have the potential to produce equitable improvements in population health. This mixed-methods systematic review aims to understand the components of, determinants, risks, and outcomes associated with public space initiatives in African cities. This study will include quantitative and qualitative study designs that describe public space initiatives in African cities with implications for promoting health and wellbeing, particularly through the prevention of noncommunicable diseases. Only studies published after 1990 and that contain primary or secondary data will be included in the review. Literature search strategies will be developed with a medical librarian. We will search PubMed, using both text words and medical subject headings. We will adapt this search to Scopus, Global Health, and Web of Science. This systematic review will adopt a mixed methods analytical approach. Mixing will occur in extracting both qualitative and quantitative findings; in synthesizing findings; and in the analysis where we will integrate the qualitative and quantitative strands. The learnings from this study will contribute to advancing knowledge on noncommunicable disease prevention through public space initiatives in African cities.

Association between circulating 25-hydroxyvitamin D and cardiometabolic risk factors in adults in rural and urban settings.

BACKGROUND: An inverse association between vitamin D status and cardiometabolic risk has been reported but this relationship may have been affected by residual confounding from adiposity and physical activity due to imprecise measures of these variables. We aimed to investigate the relationship between serum 25-hydroxyvitamin D (25(OH)D) and cardiometabolic risk factors, with adjustment for objectively-measured physical activity and adiposity. METHODS: This was a population-based cross-sectional study in 586 adults in Cameroon (63.5% women). We assessed markers of glucose homoeostasis (fasting blood glucose (BG), 2 h post glucose load BG, HOMA-IR)) and computed a metabolic syndrome score by summing the sex-specific z-scores of five risk components measuring central adiposity, blood pressure, glucose, HDL cholesterol and triglycerides. RESULTS: Mean±SD age was 38.3 ± 8.6 years, and serum 25(OH)D was 51.7 ± 12.5 nmol/L. Mean 25(OH)D was higher in rural (53.4 ± 12.8 nmol/L) than urban residents (50.2 ± 12.1 nmol/L), p = 0.002. The prevalence of vitamin D insufficiency (<50 nmol/L) was 45.7%. There was an inverse association between 25(OH)D and the metabolic syndrome score in unadjusted analyses (ß = -0.30, 95% CI -0.55 to -0.05), which became non-significant after adjusting for age, sex, smoking status, alcohol intake and education level. Serum 25(OH)D was inversely associated with fasting BG (-0.21, -0.34 to -0.08)), which remained significant after adjustment for age, sex, education, smoking, alcohol intake, the season of data collection, BMI and physical activity (-0.17, -0.29 to -0.06). There was an inverse association of 25(OH)D with 2-h BG (-0.20, -0.34 to -0.05) and HOMA-IR (-0.12, -0.19 to -0.04) in unadjusted analysis, but these associations became non-significant after adjustment for potential confounders. CONCLUSION: Vitamin D insufficiency was common in this population. This study showed an inverse association between vitamin D status and fasting glucose that was independent of potential confounders, including objectively measured physical activity and adiposity, suggesting a possible mechanism through insulin secretion.

A Mixed-Methods Participatory Intervention Design Process to Develop Intervention Options in Immediate Food and Built Environments to Support Healthy Eating and Active Living among Children and Adolescents in Cameroon and South Africa.

Rates of obesity and related non-communicable diseases are on the rise in sub-Saharan Africa, associated with sub-optimal diet and physical inactivity. Implementing evidence-based interventions targeting determinants of unhealthy eating and physical inactivity in children and adolescents' immediate environments is critical to the fight against obesity and related non-communicable diseases. Setting priorities requires a wide range of stakeholders, methods, and context-specific data. This paper reports on a novel participatory study design to identify and address contextual drivers of unhealthy eating and physical inactivity of children and adolescents in school and in their home neighborhood food and built environments. We developed a three-phase mixed-method study in Cameroon (Yaoundé) and South Africa (Johannesburg and Cape Town) from 2020-2021. Phase one focused on identifying contextual drivers of unhealthy eating and physical inactivity in children and adolescents in each setting using secondary analysis of qualitative data. Phase two matched identified drivers to evidence-based interventions. In phase three, we worked with stakeholders using the Delphi technique to prioritize interventions based on perceived importance and feasibility. This study design provides a rigorous method to identify and prioritize interventions that are tailored to local contexts, incorporating expertise of diverse local stakeholders.

Socioeconomic and gendered inequities in travel behaviour in Africa: Mixed-method systematic review and meta-ethnography.

Travel has individual, societal and planetary health implications. We explored socioeconomic and gendered differences in travel behaviour in Africa, to develop an understanding of travel-related inequity. We conducted a mixed-methods systematic review (PROSPERO CRD42019124802). In 2019, we searched MEDLINE, TRID, SCOPUS, Web of Science, LILACS, SciELO, Global Health, Africa Index Medicus, CINAHL and MediCarib for studies examining travel behaviour by socioeconomic status and gender in Africa. We appraised study quality using Critical Appraisal Skills Programme checklists. We synthesised qualitative data using meta-ethnography, followed by a narrative synthesis of quantitative data, and integrated qualitative and quantitative strands using pattern matching principles. We retrieved 103 studies (20 qualitative, 24 mixed-methods, 59 quantitative). From the meta-ethnography, we observed that travel is: intertwined with social mobility; necessary to access resources; associated with cost and safety barriers; typified by long distances and slow modes; and dictated by gendered social expectations. We also observed that: motorised transport is needed in cities; walking is an unsafe, 'captive' mode; and urban and transport planning are uncoordinated. From these observations, we derived hypothesised patterns that were tested using the quantitative data, and found support for these overall. In lower socioeconomic individuals, travel inequity entailed reliance on walking and paratransit (informal public transport), being unable to afford travel, travelling less overall, and travelling long distances in hazardous conditions. In women and girls, travel inequity entailed reliance on walking and lack of access to private vehicles, risk of personal violence, societally-imposed travel constraints, and household duties shaping travel. Limitations included lack of analytical rigour in qualitative studies and a preponderance of cross-sectional quantitative studies (offering a static view of an evolving process). Overall, we found that travel inequity in Africa perpetuates socioeconomic and gendered disadvantage. Proposed solutions focus on improving the safety, efficiency and affordability of public transport and walking.

Diabetes in sub-Saharan Africa.

In Sub-Saharan Africa, prevalence and burden of type 2 diabetes are rising quickly. Rapid uncontrolled urbanisation and major changes in lifestyle could be driving this epidemic. The increase presents a substantial public health and socioeconomic burden in the face of scarce resources. Some types of diabetes arise at younger ages in African than in European populations. Ketosis-prone atypical diabetes is mostly recorded in people of African origin, but its epidemiology is not understood fully because data for pathogenesis and subtypes of diabetes in sub-Saharan African communities are scarce. The rate of undiagnosed diabetes is high in most countries of sub-Saharan Africa, and individuals who are unaware they have the disorder are at very high risk of chronic complications. Therefore, the rate of diabetes-related morbidity and mortality in this region could grow substantially. A multisectoral approach to diabetes control and care is vital for expansion of socioculturally appropriate diabetes programmes in sub-Saharan African countries.

Associations of Serum Folate and Holotranscobalamin with Cardiometabolic Risk Factors in Rural and Urban Cameroon.

A low intake of fruit and vegetables and a high intake of meat are associated with higher cardiometabolic disease risk; however much prior research has relied on subjective methods for dietary assessment and focused on Western populations. We aimed to investigate the association of blood folate as an objective marker of fruit and vegetable intake and holotranscobalamin (holoTC) as a marker of animal-sourced food intake with cardiometabolic risk factors. We conducted a population-based cross-sectional study on 578 adults (mean ± SD age = 38.2 ± 8.6 years; 64% women). The primary outcome was a continuous metabolic syndrome score. The median serum folate was 12.9 (IQR: 8.6-20.5) nmol/L and the mean holoTC was 75 (SD: 34.3) pmol/L. Rural residents demonstrated higher serum folate concentrations (15.9 (9.8-25.9) nmol/L) than urban residents (11.3 (7.9-15.8) nmol/L), but lower holoTC concentrations (rural: 69.8 (32.9) pmol/L; urban: 79.8 (34.9)) pmol/L, p < 0.001 for both comparisons. There was an inverse association between serum folate and metabolic syndrome score by -0.20 in the z-score (95% CI, -0.38 to -0.02) per 10.8 (1 SD) of folate) in a model adjusted for socio-demographic factors, smoking status, alcohol intake, BMI, and physical activity. HoloTC was positively associated with the metabolic syndrome score in unadjusted analysis (0.33 (95% CI, 0.10 to 0.56)) but became non-significant (0.17 (-0.05 to 0.39)) after adjusting for socio-demographic and behavioural characteristics. In conclusion, serum folate and holoTC were associated with the metabolic syndrome score in opposite directions. The positive association between serum holoTC and the metabolic syndrome score was partly dependent on sociodemographic characteristics. These findings suggest that, based on these biomarkers reflecting dietary intakes, public health approaches promoting a higher intake of fruit and vegetables may lower cardiometabolic risk factors in this population.

Analysis of Cameroon's Sectoral Policies on Physical Activity for Noncommunicable Disease Prevention.

Physical inactivity is increasing in low- and middle-income countries (LMICs), where noncommunicable diseases (NCDs), urbanisation and sedentary living are rapidly growing in tandem. Increasing active living requires the participation of multiple sectors, yet it is unclear whether physical activity (PA)-relevant sectors in LMICs are prioritising PA. We investigated to what extent sectors that influence PA explicitly integrate it in their policies in an LMIC such as Cameroon. We systematically identified policy documents relevant to PA and NCD prevention in Cameroon; and using the Walt and Gilson policy triangle we described, analysed, and interpreted the policy contexts, contents, processes, and actors. We found 17 PA and NCD policy documents spanning from 1974 to 2019 across seven ministries. Thirteen (13/17) policies targeted infrastructure improvement, and four (4/17) targeted communication for behaviour change, all aiming to enhance leisure domain PA. Only the health sector explicitly acknowledged the role of PA in NCD prevention. Notably, no policy from the transport sector mentioned PA. Our findings highlight the need for intersectoral action to integrate PA into policies in all relevant sectors. These actions will need to encompass the breadth of PA domains, including transport, while emphasising the multiple health benefits of PA for the population.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol.

BACKGROUND: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. OBJECTIVE: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. METHODS: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. RESULTS: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. CONCLUSIONS: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26739.