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Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.
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Diabetes Mellitus , Racismo , Humanos , Racismo Sistêmico , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Prevalência , Fatores SociaisRESUMO
Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.
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Diabetes Mellitus , Ecossistema , Humanos , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Meio SocialRESUMO
PURPOSE: To review the rising prevalence of osteopenia and osteoporosis in sub-Saharan Africa and the challenges this poses to governments and healthcare services. Using existing studies, we compare the prevalence of osteopenia and osteoporosis in men and women from sub-Saharan Africa to US and UK cohorts. Context-specific disparities in healthcare are discussed particularly the challenges in diagnosis and treatment of osteoporosis. RECENT FINDINGS: There are few epidemiological data describing the burden of osteoporosis in sub-Saharan Africa. In the studies and cohorts presented here, osteoporosis prevalence varies by sex, country and area of residence, but is generally higher in African populations, than has previously been appreciated. Risk factors contributing to poorer bone health include HIV, malnutrition and "inflammaging." Reprioritization towards care of ageing populations is urgently required. Equitable access to implementable preventative strategies, diagnostic services, treatments and pathways of care for bone health (for example embedded within HIV services) need now to be recognized and addressed by policy makers.
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Doenças Ósseas Metabólicas , Infecções por HIV , Osteoporose , Masculino , Humanos , Feminino , Infecções por HIV/epidemiologia , Prevalência , África Subsaariana/epidemiologia , Osteoporose/epidemiologia , Doenças Ósseas Metabólicas/epidemiologia , Reino Unido/epidemiologiaRESUMO
BACKGROUND: despite rapid population ageing, few studies have investigated frailty in older people in sub-Saharan Africa. We tested a cumulative deficit frailty index in a population of older people from rural South Africa. METHODS: analysis of cross-sectional data from the Health and Ageing in Africa: Longitudinal Studies of an INDEPTH Community (HAALSI) study. We used self-reported diagnoses, symptoms, activities of daily living, objective physiological indices and blood tests to calculate a 32-variable cumulative deficit frailty index. We fitted Cox proportional hazards models to test associations between frailty category and all-cause mortality. We tested the discriminant ability of the frailty index to predict one-year mortality alone and in addition to age and sex. RESULTS: in total 3,989 participants were included in the analysis, mean age 61 years (standard deviation 13); 2,175 (54.5%) were women. The median frailty index was 0.13 (interquartile range 0.09-0.19); Using population-specific cutoffs, 557 (14.0%) had moderate frailty and 263 (6.6%) had severe frailty. All-cause mortality risk was related to frailty severity independent of age and sex (hazard ratio per 0.01 increase in frailty index: 1.06 [95% confidence interval 1.04-1.07]). The frailty index alone showed moderate discrimination for one-year mortality: c-statistic 0.68-0.76; combining the frailty index with age and sex improved performance (c-statistic 0.77-0.81). CONCLUSION: frailty measured by cumulative deficits is common and predicts mortality in a rural population of older South Africans. The number of measures needed may limit utility in resource-poor settings.
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Fragilidade , Atividades Cotidianas , Idoso , Envelhecimento , Estudos Transversais , Feminino , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Humanos , Estudos LongitudinaisRESUMO
BACKGROUND: Chronic kidney disease (CKD) is a substantial cause of morbidity and mortality worldwide with disproportionate effects in sub-Saharan Africa (SSA). The optimal methods to estimate glomerular filtration rate (GFR) and therefore to determine the presence of CKD in SSA are uncertain. We plan to measure iohexol excretion to accurately determine GFR in Malawi, South Africa and Uganda. We will then assess the performance of existing equations to estimate GFR and determine whether a modified equation can better improve estimation of GFR in sub-Saharan Africa. METHODS: The African Research on Kidney Disease (ARK) study is a three-country study embedded within existing cohorts. We seek to enrol 3000 adults > 18 years based on baseline serum creatinine. Study procedures include questionnaires on socio-demographics and established risk factors for kidney disease along with anthropometry, body composition, blood pressure, blood chemistry and urine microscopy and albuminuria. We will measure GFR (mGFR) by plasma clearance of iohexol at 120, 180 and 240 min. We will compare eGFR determined by established equations with mGFR using Bland-Altman plots. We will use regression methods to estimate GFR and compare the newly derived model with existing equations. DISCUSSION: Through the ARK study, we aim to establish the optimal approach to estimate GFR in SSA. The study has the advantage of drawing participants from three countries, which will increase the applicability of the findings across the region. It is also embedded within established cohorts that have longitudinal information and serial measures that can be used to characterize kidney disease over a period of time. This will help to overcome the limitations of previous research, including small numbers, selected population sub-groups, and lack of data on proteinuria. The ARK collaboration provides an opportunity for close working partnerships across different centres, using standardized protocols and measurements, and shared bio-repositories. We plan to build on the collaboration for this study for future work on kidney disease in sub-Saharan Africa, and welcome additional partners from across the continent.
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Taxa de Filtração Glomerular , Iohexol/farmacocinética , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Adulto , África Subsaariana , Feminino , Humanos , Malaui , Masculino , Seleção de Pacientes , Garantia da Qualidade dos Cuidados de Saúde , Análise de Regressão , Projetos de Pesquisa , África do Sul , UgandaRESUMO
OBJECTIVE: To examine how multimorbidity might affect progression along the continuum of care among older adults with hypertension, diabetes and human immunodeficiency virus (HIV) infection in rural South Africa. METHODS: We analysed data from 4447 people aged 40 years or older who were enrolled in a longitudinal study in Agincourt sub-district. Household-based interviews were completed between November 2014 and November 2015. For hypertension and diabetes (2813 and 512 people, respectively), we defined concordant conditions as other cardiometabolic conditions, and discordant conditions as mental disorders or HIV infection. For HIV infection (1027 people) we defined any other conditions as discordant. Regression models were fitted to assess the relationship between the type of multimorbidity and progression along the care continuum and the likelihood of patients being in each stage of care for the index condition (four stages from testing to treatment). FINDINGS: People with hypertension or diabetes plus other cardiometabolic conditions were more like to progress through the care continuum for the index condition than those without cardiometabolic conditions (relative risk, RR: 1.14, 95% confidence interval, CI: 1.09-1.20, and RR: 2.18, 95% CI: 1.52-3.26, respectively). Having discordant comorbidity was associated with greater progression in care for those with hypertension but not diabetes. Those with HIV infection plus cardiometabolic conditions had less progress in the stages of care compared with those without such conditions (RR: 0.86, 95% CI: 0.80-0.92). CONCLUSION: Patients with concordant conditions were more likely to progress further along the care continuum, while those with discordant multimorbidity tended not to progress beyond diagnosis.
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Continuidade da Assistência ao Paciente , Diabetes Mellitus , Infecções por HIV , Hipertensão , Multimorbidade , Adulto , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Complicações do Diabetes , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Feminino , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Acessibilidade aos Serviços de Saúde , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Hipertensão/terapia , Entrevistas como Assunto , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Fatores de Risco , População Rural , África do Sul/epidemiologiaRESUMO
BACKGROUND: Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa. METHODS: We use baseline data from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0-26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders. RESULTS: In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50-67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = - 1.11 [95% confidence interval: - 2.01, - 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = - 0.87 [CI: - 1.48, - 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive). CONCLUSIONS: We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.
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Doenças Cardiovasculares/psicologia , Cognição , Doenças Metabólicas/psicologia , População Rural , Idoso , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Doenças Metabólicas/epidemiologia , Pessoa de Meia-Idade , Fatores de Risco , População Rural/estatística & dados numéricos , África do Sul/epidemiologiaRESUMO
OBJECTIVE: Cholesterol efflux relates to cardiovascular disease but cannot predict cellular cholesterol mass changes. We asked whether influx and net flux assays provide additional insights. APPROACH AND RESULTS: Adapt a bidirectional flux assay to cells where efflux has clinical correlates and examine the association of influx, efflux, and net flux to serum triglycerides (TGs). Apolipoprotein B-depleted (high-density lipoprotein-fraction) serum from individuals with unfavorable lipids (median [interquartile range]; high-density lipoprotein-cholesterol=39 [32-42], low-density lipoprotein-cholesterol=109 [97-137], TGs=258 [184-335] mg/dL; n=13) promoted greater ATP-binding cassette transporter A1-mediated [1,2-(3H)] cholesterol efflux (3.8±0.3%/4 hour versus 1.2±0.4%/4 hour; P<0.0001) from cyclic 3',5'-amp(CTP-amp)-treated J774 macrophages than from individuals with favorable lipids (high-density lipoprotein-cholesterol=72 [58-88], low-density lipoprotein-cholesterol=111 [97-131], TGs=65 [56-69] mg/dL; n=10). Thus, high TGs associated with more ATP-binding cassette transporter A1 acceptors. Efflux of cholesterol mass (µg free cholesterol/mg cell protein per 8 hour) to serum was also higher (7.06±0.33 versus 5.83±0.48; P=0.04). However, whole sera from individuals with unfavorable lipids promoted more influx (5.14±0.65 versus 2.48±0.85; P=0.02) and lower net release of cholesterol mass (1.93±0.46 versus 3.36±0.47; P=0.04). The pattern differed when mass flux was measured using apolipoprotein B-depleted serum rather than serum. Although individuals with favorable lipids tended to have greater influx than those with unfavorable lipids, efflux to apolipoprotein B-depleted serum was markedly higher (6.81±0.04 versus 2.62±0.14; P<0.0001), resulting in an efflux:influx ratio of ≈3-fold. Thus both serum and apolipoprotein B-depleted serum from individuals with favorable lipids promoted greater net cholesterol mass release despite increased ATP-binding cassette transporter A1-mediated efflux in samples of individuals with high TGs/unfavorable lipids. CONCLUSIONS: When considering the efficiency of serum specimens to modulate cell cholesterol content, both influx and efflux need to be measured.
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Aterosclerose/sangue , Colesterol/sangue , Dislipidemias/sangue , Macrófagos/metabolismo , Transportador 1 de Cassete de Ligação de ATP/sangue , Transportador 1 de Cassete de Ligação de ATP/metabolismo , Idoso , Animais , Apolipoproteínas B/sangue , Transporte Biológico , Linhagem Celular , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Feminino , Humanos , Cinética , Masculino , Camundongos , Pessoa de Meia-Idade , Triglicerídeos/sangueRESUMO
BACKGROUND: Diabetes mellitus contributes substantially to the non-communicable disease burden in South Africa. The proposed National Health Insurance system provides an opportunity to consider the development of a cost-effective capitation model of care for patients with type 2 diabetes. The objective of the study was to determine the potential cost-effectiveness of adapting a private sector diabetes management programme (DMP) to the South African public sector. METHODS: Cost-effectiveness analysis was undertaken with a public sector model of the DMP as the intervention and a usual practice model as the comparator. Probabilistic modelling was utilized for incremental cost-effectiveness ratio analysis with life years gained selected as the outcome. Secondary data were used to design the model while cost information was obtained from various sources, taking into account public sector billing. RESULTS: Modelling found an incremental cost-effectiveness ratio (ICER) of ZAR 8 356 (USD 1018) per life year gained (LYG) for the DMP against the usual practice model. This fell substantially below the Willingness-to-Pay threshold with bootstrapping analysis. Furthermore, a national implementation of the intervention could potentially result in an estimated cumulative gain of 96 997 years of life (95% CI 71 073 years - 113 994 years). CONCLUSIONS: Probabilistic modelling found the capitation intervention to be cost-effective, with an ICER of ZAR 8 356 (USD 1018) per LYG. Piloting the service within the public sector is recommended as an initial step, as this would provide data for more accurate economic evaluation, and would also allow for qualitative analysis of the programme.
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Capitação , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/economia , Modelos Econômicos , Setor Público , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Setor Privado , África do SulRESUMO
INTRODUCTION: Double malnutrition (co-existing overnutrition and undernutrition) is increasingly prevalent in sub-Saharan Africa due to rapid epidemiological and nutritional transitions. In this region, studies of double malnutrition have largely been conducted at country and household level, with individual-level studies primarily limited to children and women of reproductive age. We investigated the prevalence and determinants of individual-level double malnutrition in middle-aged and older adults who constitute an increasing proportion of the sub-Saharan African population. METHODS: 250 individuals aged 40-70 years (50% women) and resident in the Agincourt Health and socio-Demographic Surveillance System in rural Mpumalanga province, South Africa, were randomly selected. Double malnutrition was defined as overweight/obesity and anaemia only, overweight/obesity and iodine insufficiency, or overweight/obesity and any micronutrient deficiency (anaemia and/or iodine insufficiency). The Chi-squared goodness of fit test was used to compare the expected and observed numbers of individuals with the type of double malnutrition. Logistic regression was used to investigate determinants of each type of double malnutrition. RESULTS: Double malnutrition was present in 22-36% of participants, depending on the definition used. All types of double malnutrition were more common in women than in men (overweight/obesity and anaemia: 34% vs. 10.2%, p < 0.01; overweight/obesity and iodine insufficiency: 32% vs. 12.2%, p < 0.01 and overweight/obesity and any micronutrient deficiency: 50.5% vs. 20.4%, p < 0.01). There were no differences between the overall expected and observed numbers of individuals with combinations of overweight and micronutrient deficiencies [overweight/obesity and anaemia (p = 0.28), overweight/obesity and iodine insufficiency (p = 0.27) or overweight/obesity and any micronutrient deficiency (p = 0.99)]. In models adjusted for socio-demographic factors, HIV and antiretroviral drug status, and food security or dietary diversity, men were 84-85% less likely than women to have overweight/obesity and anaemia, 65% less likely to have overweight/obesity and iodine insufficiency and 74% less likely to have overweight/obesity and any micronutrient deficiency. CONCLUSIONS: Individual-level double malnutrition is prevalent in middle-aged and older adults in a rural sub-Saharan African community. Interventions to improve nutrition in similar settings should target individuals throughout the life course and a focus on women may be warranted.
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BACKGROUND: The burden of peripheral artery disease (PAD) is increasing in low- and middle-income countries. Existing literature from sub-Saharan Africa is limited and lacks population-representative estimates. We estimated the burden and risk factor profile of PAD for a rural South African population. METHODS AND RESULTS: We used data from 1883 participants from a rural, low-income cohort of South African adults aged 40 to 69 years with available ankle-brachial index measurements. We defined clinical PAD as ankle-brachial index ≤0.90 or >1.40, and borderline PAD as ankle-brachial index >0.90 and ≤1.00. We compared the distribution of sociodemographic variables, biomarkers, and comorbidities across PAD classifications. To identify associated factors, we calculated unadjusted and age-sex-adjusted prevalence ratios (PRs) with log-binomial models. Overall, 6.6% (95% CI, 5.6-7.7) of the sample met the diagnostic criteria for clinical PAD, while 44.7% (95% CI, 42.4-47.0) met the diagnostic criteria for borderline PAD. Age (PR: 1.9 [95% CI, 1.2-3.1] for ages 50-59 years compared with 40-49 years; PR: 2.5 [95% CI, 1.5-4.0] for ages 60-69 years compared with 40-49 years); diagnosed hypertension (PR: 1.53 [95% CI, 1.08-2.17]); and C-reactive protein (PR: 1.08 [95% CI, 1.03-1.12]) were associated with increased prevalence of clinical PAD. All other examined factors were not significantly associated with clinical PAD. CONCLUSIONS: We found high PAD prevalence for younger age groups compared with previous research and a lack of statistical evidence for the influence of traditional risk factors for this rural, low-income population. Future research should focus on identifying the underlying risk factors for PAD in this setting. South African policymakers and clinicians should consider expanded screening for early PAD detection in rural areas.
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Doença Arterial Periférica , Adulto , Humanos , Estudos Transversais , África do Sul/epidemiologia , Prevalência , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Fatores de Risco , Índice Tornozelo-BraçoRESUMO
The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.
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Análise de Custo-Efetividade , Diabetes Mellitus , Masculino , Humanos , Feminino , África do Sul , Análise Custo-Benefício , Gastos em Saúde , Renda , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/terapiaRESUMO
AIMS: We seek to understand the coexisting effects of population aging and a rising burden of diabetes on healthy longevity in South Africa. METHODS: We used longitudinal data from the 2015 and 2018 waves of the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) study to explore life expectancy (LE) and disability-free life expectancy (DFLE) of adults aged 45 and older with and without diabetes in rural South Africa. We estimated LE and DFLE by diabetes status using Markov-based microsimulation. RESULTS: We find a clear gradient in remaining LE and DFLE based on diabetes status. At age 45, a man without diabetes could expect to live 7.4 [95% CI 3.4 - 11.7] more years than a man with diabetes, and a woman without diabetes could expect to live 3.9 [95% CI: 0.8 - 6.9] more years than a woman with diabetes. Individuals with diabetes lived proportionately more years subject to disability than individuals without diabetes. CONCLUSIONS: We find large and important decrements in disability-free aging for people with diabetes in South Africa. This finding should motivate efforts to strengthen prevention and treatment efforts for diabetes and its complications for older adults in this setting.
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Diabetes Mellitus , Pessoas com Deficiência , Masculino , Feminino , Humanos , Idoso , Pessoa de Meia-Idade , Longevidade , África do Sul/epidemiologia , Estudos Longitudinais , Expectativa de Vida Saudável , Estudos Prospectivos , Diabetes Mellitus/epidemiologia , Expectativa de VidaRESUMO
BACKGROUND: South Africa has introduced regulations to reduce sodium in processed foods. Assessing salt consumption with 24-h urine collection is logistically challenging and expensive. We assess the accuracy of using spot urine samples to estimate 24-h urine sodium (24hrUNa) excretion at the population level in a cohort of older adults in rural South Africa. METHODS: 24hrUNa excretion was measured and compared to that estimated from matched spot urine samples in 399 individuals, aged 40-75 years, from rural Mpumalanga, South Africa. We used the Tanaka, Kawasaki, International Study of Sodium, Potassium, and Blood Pressure (INTERSALT), and Population Mean Volume (PMV) method to predict 24hrUNa at the individual and population level. RESULTS: The population median 24hrUNa excretion from our samples collected in 2017 was 2.6âg (interquartile range: 1.53-4.21) equal to an average daily salt intake of 6.6âg, whereas 65.4% of participants had a salt excretion above the WHO recommended 5âg/day. Estimated population median 24hrUNa derived from the INTERSALT, both with and without potassium, showed a nonsignificant difference of 0.25âg (Pâ=â0.59) and 0.21âg (Pâ=â0.67), respectively. In contrast, the Tanaka, Kawasaki, and PMV formulas were markedly higher than the measured 24hrUNa, with a median difference of 0.51âg (Pâ=â0.004), 0.99âg (Pâ=â0.00), and 1.05âg (Pâ=â0.00) respectively. All formulas however performed poorly when predicting an individual's 24hrUNa. CONCLUSION: In this population, the INTERSALT formulas are a well suited and cost-effective alternative to 24-h urine collection for the evaluation of population median 24hrUNa excretion. This could play an important role for governments and public health agencies in evaluating local salt regulations and identifying at-risk populations.
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Sódio na Dieta , Urinálise , Humanos , Idoso , Urinálise/métodos , África do Sul , Sódio/urina , Cloreto de Sódio na Dieta/urina , Coleta de Urina/métodos , Potássio/urinaRESUMO
OBJECTIVE: To compare the risk factors for cardiometabolic disease between pre- and postmenopausal women from four sub-Saharan African countries. STUDY DESIGN: This cross-sectional study included 3609 women (1740 premenopausal and 1869 postmenopausal) from sites in Ghana (Navrongo), Burkina Faso (Nanoro), Kenya (Nairobi), and South Africa (Soweto and Dikgale). Demographic, anthropometric and cardiometabolic variables were compared between pre- and postmenopausal women, within and across sites using multivariable regression analyses. The sites represent populations at different stages of the health transition, with those in Ghana and Burkina Faso being rural, whilst those in Kenya and South Africa are more urbanised. MAIN OUTCOME MEASURES: Anthropometric and cardiometabolic variables. RESULTS: The prevalence rates of risk factors for cardiometabolic disease were higher in South (Soweto and Dikgale) and East (Nairobi) Africa than in West Africa (Nanoro and Navrongo), irrespective of menopausal status. Regression models in combined West African populations demonstrated that postmenopausal women had a larger waist circumference (ß = 1.28 (95 % CI: 0.58; 1.98) cm), log subcutaneous fat (ß =0.15 (0.10; 0.19)), diastolic (ß = 3.04 (1.47; 4.62) mm Hg) and log systolic (ß = 0.04 (0.02; 0.06)) blood pressure, log carotid intima media thickness (ß = 0.03 (0.01; 0.06)), low-density lipoprotein cholesterol (ß = 0.14 (0.04; 0.23) mmol/L) and log triglyceride (ß= 0.10 (0.04; 0.16)) levels than premenopausal women. No such differences were observed in the South and East African women. CONCLUSIONS: Menopause-related differences in risk factors for cardiometabolic disease were prominent in West but not East or South African study sites. These novel findings should inform cardiometabolic disease prevention strategies in midlife women specific to rural and urban and peri-urban locations in sub-Saharan Africa.
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Doenças Cardiovasculares , Pós-Menopausa , Humanos , Feminino , Estudos Transversais , Espessura Intima-Media Carotídea , África do Sul/epidemiologia , Quênia , Fatores de Risco , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologiaRESUMO
BACKGROUND: Over half of the South African adults aged 45 years and older have hypertension but its effective management along the treatment cascade (awareness, treatment, and control) remains poorly understood. METHODS: We compared the prevalence of all stages of the hypertension treatment cascade in the rural HAALSI cohort of older adults at baseline and after four years of follow-up using household surveys and blood pressure data. Hypertension was a mean systolic blood pressure >140 mm Hg or diastolic pressure >90 mm Hg, or current use of anti-hypertension medication. Control was a mean blood pressure <140/90 mm Hg. The effects of sex and age on the treatment cascade at follow-up were assessed. Multivariate Poisson regression models were used to estimate prevalence ratios along the treatment cascade at follow-up. RESULTS: Prevalence along the treatment cascade increased from baseline (B) to follow-up (F): awareness (64.4% vs. 83.6%), treatment (49.7% vs. 73.9%), and control (22.8% vs. 41.3%). At both time points, women had higher levels of awareness (B: 70.5% vs. 56.3%; F: 88.1% vs. 76.7%), treatment (B: 55.9% vs. 41.55; F: 79.9% vs. 64.7%), and control (B: 26.5% vs. 17.9%; F: 44.8% vs. 35.7%). Prevalence along the cascade increased linearly with age for everyone. Predictors of awareness included being female, elderly, or visiting a primary health clinic three times in the previous 3 months, and the latter two also predicted hypertension control. CONCLUSIONS: There were significant improvements in awareness, treatment, and control of hypertension from baseline to follow-up and women fared better at all stages, at both time points.
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Hipertensão , Idoso , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , África do Sul/epidemiologia , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Pressão Sanguínea , Anti-Hipertensivos/uso terapêutico , PrevalênciaRESUMO
BACKGROUND: Sub-Saharan Africa is undergoing an epidemiologic transition from infectious diseases to cardiovascular diseases. From 2014 to 2019, sociodemographic surveillance was performed in a large cohort in rural South Africa. METHODS: Disease prevalence and incidence were calculated using inverse probability weights. Poisson regression was used to identify disease predictors. The percentage of individuals with controlled (<140/90 mm Hg) versus uncontrolled hypertension was compared between 2014 and 2019. RESULTS: Compared with 2014 (n=5059), study participants in 2019 (n=4176) had similar rates of obesity (mean body mass index, 27.5±10.0 versus 27.0±6.5) but higher smoking (9.1% versus 11.5%) and diabetes (11.1% versus 13.9%). There was no significant increase in hypertension prevalence (58.4% versus 59.8%; age adjusted, 64.3% versus 63.3%), and there was a significant reduction in mean systolic blood pressure (138.0 versus 128.5 mm Hg; P<0.001). Among hypertensive individuals who reported medication use in 2014 and 2019 (n=796), the proportion with controlled hypertension on medication increased from 44.5% to 62.3%. Hypertension incidence was 6.2 per 100 person-years, and age was the only independent predictor. Among normotensive individuals in 2014 (n=2257), 15.2% developed hypertension by 2019, with the majority already controlled on medications by 2019. CONCLUSIONS: The hypertension prevalence and incidence are plateauing in this aging cohort. There was a statistically and clinically significant decline in mean blood pressure and a substantial increase in individuals with controlled hypertension on medication. The prevalence of cardiometabolic risk factors did not decrease over time, suggesting that the blood pressure decrease is likely due to increased medication access and adherence, promoted by local health systems.
Assuntos
Doenças Cardiovasculares , Hipertensão , Humanos , Idoso , Pressão Sanguínea , África do Sul/epidemiologia , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Fatores de Risco , Doenças Cardiovasculares/epidemiologia , PrevalênciaRESUMO
OBJECTIVES: We investigated progression through the care cascade and associated factors for people with diabetes in sub-Saharan Africa to identify attrition stages that may be most appropriate for targeted intervention. DESIGN: Cross-sectional study. SETTING: Community-based study in four sub-Saharan African countries. PARTICIPANTS: 10 700 individuals, aged 40-60 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the diabetes cascade of care defined as the age-adjusted diabetes prevalence (self-report of diabetes, fasting plasma glucose (FPG) ≥7 mmol/L or random plasma glucose ≥11.1 mmol/L) and proportions of those who reported awareness of having diabetes, ever having received treatment for diabetes and those who achieved glycaemic control (FPG <7.2 mmol/L). Secondary outcome measures were factors associated with having diabetes and being aware of the diagnosis. RESULTS: Diabetes prevalence was 5.5% (95% CI 4.4% to 6.5%). Approximately half of those with diabetes were aware (54%; 95% CI 50% to 58%); 73% (95% CI 67% to 79%) of aware individuals reported ever having received treatment. However, only 38% (95% CI 30% to 46%) of those ever having received treatment were adequately controlled. Increasing age (OR 1.1; 95% CI 1.0 to 1.1), urban residence (OR 2.3; 95% CI 1.6 to 3.5), hypertension (OR 1.9; 95% CI 1.5 to 2.4), family history of diabetes (OR 3.9; 95% CI 3.0 to 5.1) and measures of central adiposity were associated with higher odds of having diabetes. Increasing age (OR 1.1; 95% CI 1.0 to 1.1), semi-rural residence (OR 2.5; 95% CI 1.1 to 5.7), secondary education (OR 2.4; 95% CI 1.2 to 4.9), hypertension (OR 1.6; 95% CI 1.0 to 2.4) and known HIV positivity (OR 2.3; 95% CI 1.2 to 4.4) were associated with greater likelihood of awareness of having diabetes. CONCLUSIONS: There is attrition at each stage of the diabetes care cascade in sub-Saharan Africa. Public health strategies should target improving diagnosis in high-risk individuals and intensifying therapy in individuals treated for diabetes.
Assuntos
Diabetes Mellitus , Hipertensão , Pessoa de Meia-Idade , Adulto , Humanos , Estudos Transversais , Glicemia , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Hipertensão/epidemiologia , África Subsaariana/epidemiologia , PrevalênciaRESUMO
OBJECTIVES: To determine the prevalence of multimorbidity, to identify which chronic conditions cluster together and to identify factors associated with a greater risk for multimorbidity in sub-Saharan Africa (SSA). DESIGN: Cross-sectional, multicentre, population-based study. SETTING: Six urban and rural communities in four sub-Saharan African countries. PARTICIPANTS: Men (n=4808) and women (n=5892) between the ages of 40 and 60 years from the AWI-Gen study. MEASURES: Sociodemographic and anthropometric data, and multimorbidity as defined by the presence of two or more of the following conditions: HIV infection, cardiovascular disease, chronic kidney disease, asthma, diabetes, dyslipidaemia, hypertension. RESULTS: Multimorbidity prevalence was higher in women compared with men (47.2% vs 35%), and higher in South African men and women compared with their East and West African counterparts. The most common disease combination at all sites was dyslipidaemia and hypertension, with this combination being more prevalent in South African women than any single disease (25% vs 21.6%). Age and body mass index were associated with a higher risk of multimorbidity in men and women; however, lifestyle correlates such as smoking and physical activity were different between the sexes. CONCLUSIONS: The high prevalence of multimorbidity in middle-aged adults in SSA is of concern, with women currently at higher risk. This prevalence is expected to increase in men, as well as in the East and West African region with the ongoing epidemiological transition. Identifying common disease clusters and correlates of multimorbidity is critical to providing effective interventions.
Assuntos
Dislipidemias , Infecções por HIV , Hipertensão , Adulto , Pessoa de Meia-Idade , Masculino , Humanos , Feminino , Multimorbidade , Fatores de Risco , Estudos Transversais , Prevalência , Fatores Sexuais , Hipertensão/epidemiologia , África Subsaariana/epidemiologia , Dislipidemias/epidemiologiaRESUMO
Background: In Africa, true prevalence of chronic kidney disease (CKD) is unknown, and associated clinical and genetic risk factors remain understudied. This population-based cohort study aimed to investigate CKD prevalence and associated risk factors in rural South Africa. Methods: A total 2021 adults aged 20-79 years were recruited between 2017-2018 from the Agincourt Health and Socio-Demographic Surveillance System in Bushbuckridge, Mpumalanga, South Africa. The following were collected: sociodemographic, anthropometric, and clinical data; venous blood samples for creatinine, hepatitis B serology; DNA extraction; spot urine samples for dipstick testing and urine albumin: creatinine ratio (UACR) measurement. Point-of-care screening determined prevalent HIV infection, diabetes, and hypercholesterolemia. DNA was used to test for apolipoprotein L1 ( APOL1) kidney risk variants. Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to diagnose CKD as low eGFR (<60mL/min/1.73m 2) and /or albuminuria (UACR ≥ 3.0mg/mmol) confirmed with follow up screening after at least three months. eGFR was calculated using the CKD-EPI (creatinine) equation 2009 with no ethnicity adjustment. Multivariable logistic regression was used to model CKD risk. Results: The WHO age-adjusted population prevalence of CKD was 6.7% (95% CI 5.4 - 7.9), mostly from persistent albuminuria. In the fully adjusted model, APOL1 high-risk genotypes (OR 2.1; 95% CI 1.3 - 3.4); HIV infection (OR 1.8; 1.1 - 2.8); hypertension (OR 2.8; 95% CI 1.8 - 4.3), and diabetes (OR 4.1; 95% CI 2.0 - 8.4) were risk factors. There was no association with age, sex, level of education, obesity, hypercholesterolemia, or hepatitis B infection. Sensitivity analyses showed that CKD risk factor associations were driven by persistent albuminuria, and not low eGFR. One third of those with CKD did not have any of these risk factors. Conclusions: In rural South Africa, CKD is prevalent, dominated by persistent albuminuria, and associated with APOL1 high-risk genotypes, hypertension, diabetes, and HIV infection.