Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials.

Background: Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs. Methods: In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227. Findings: We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%]. Interpretation: Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence. Funding: None.

Associations between spirometric impairments and microvascular complications in type 2 diabetes: a cross-sectional study.

OBJECTIVE: Evidence shows that the conventional cardiometabolic risk factors do not fully explain the burden of microvascular complications in type 2 diabetes (T2D). One potential factor is the impact of pulmonary dysfunction on systemic microvascular injury. We assessed the associations between spirometric impairments and systemic microvascular complications in T2D. DESIGN: Cross-sectional study. SETTING: National Diabetes Management and Research Centre in Ghana. PARTICIPANTS: The study included 464 Ghanaians aged ≥35 years with established diagnosis of T2D without primary myocardial disease or previous/current heart failure. Participants were excluded if they had primary lung disease including asthma or chronic obstructive pulmonary disease. PRIMARY AND SECONDARY OUTCOME MEASURES: The associations of spirometric measures (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio) with microvascular complications (nephropathy (albumin-creatinine ratio ≥3 mg/g), neuropathy (vibration perception threshold ≥25 V and/or Diabetic Neuropathy Symptom score >1) and retinopathy (based on retinal photography)) were assessed using multivariable logistic regression models with adjustments for age, sex, diabetes duration, glycated haemoglobin concentration, suboptimal blood pressure control, smoking pack years and body mass index. RESULTS: In age and sex-adjusted models, lower Z-score FEV1 was associated with higher odds of nephropathy (OR 1.55, 95% CI 1.19-2.02, p=0.001) and neuropathy (1.27 (1.01-1.65), 0.038) but not retinopathy (1.22 (0.87-1.70), 0.246). Similar observations were made for the associations of lower Z-score FVC with nephropathy (1.54 (1.19-2.01), 0.001), neuropathy (1.25 (1.01-1.54), 0.037) and retinopathy (1.19 (0.85-1.68), 0.318). In the fully adjusted model, the associations remained significant for only lower Z-score FEV1 with nephropathy (1.43 (1.09-1.87), 0.011) and neuropathy (1.34 (1.04-1.73), 0.024) and for lower Z-score FVC with nephropathy (1.45 (1.11-1.91), 0.007) and neuropathy (1.32 (1.03-1.69), 0.029). Lower Z-score FEV1/FVC ratio was not significantly associated with microvascular complications in age and sex and fully adjusted models. CONCLUSION: Our study shows positive but varying strengths of associations between pulmonary dysfunction and microvascular complications in different circulations. Future studies could explore the mechanisms linking pulmonary dysfunction to microvascular complications in T2D.

Macrovascular and renal microvascular complications in West Africans with intermediate hyperglycemia living in West Africa and Europe: The RODAM study.

Background: Metabolic conditions, including intermediate hyperglycemia (IH), affect migrants to a greater extent than the populations of origin. Evidence suggests that IH increases the risk of vascular complications, but it is unclear whether the differences in IH between the non-migrant and migrant populations translate to differences in vascular complications between the two populations. We compared the prevalence of macrovascular and renal microvascular complications among West Africans with IH living in West Africa and their migrant compatriots in Europe. Methods: Data from the multicenter Research on Obesity and Diabetes among African Migrants(RODAM) study were analyzed. Ghanaians with IH(524 non-migrant and 1439 migrants) were included. Logistic regression analyses were used to determine the associations between migrant status and macrovascular [coronary artery disease(CAD) and peripheral artery disease(PAD)] and renal microvascular[nephropathy] complications with adjustment for age, sex, socioeconomic status, smoking, systolic blood pressure, BMI, total cholesterol, HbA1c, C-reactive protein, and serum uric acid. Findings: The prevalence of microvascular/macrovascular complications was higher in non-migrants than in migrants(nephropathy 15.3vs.9.7%; PAD 3.1%vs.1.3%; and CAD 15.8% vs. 5.0%). The differences persisted in the fully adjusted model: nephropathy [odds ratio, 2.12; 95% CI(1.46-3.08); PAD, 4.44(1.87-10.51); CAD 2.35(1.64-3.37)]. Non-migrant females had higher odds of nephropathy[2.14(1.34-3.43)], PAD[7.47(2.38-23.40)] and CAD [2.10(1.34-3.27)] compared to migrant females. Non-migrant males had higher odds of nephropathy[2.54(1.30-4.97)] and CAD[2.85(1.48-5.50)], but not PAD[1.81(0.32-10.29)],than their migrant peers. Interpretation: Macrovascular and renal microvascular complications were more prevalent in non-migrants than in migrant West Africans with IH. Further studies are needed to identify factors that increase the risk to aid preventive/treatment strategies.

Differences in incidence, nature of symptoms, and duration of long COVID among hospitalised migrant and non-migrant patients in the Netherlands: a retrospective cohort study.

Background: Comprehensive data on long COVID across ethnic and migrant groups are lacking. We investigated incidence, nature of symptoms, clinical predictors, and duration of long COVID among COVID-19 hospitalised patients in the Netherlands by migration background (Dutch, Turkish, Moroccan, and Surinamese origin, Others). Methods: We used COVID-19 admissions and follow up data (January 2021-July 2022) from Amsterdam University Medical Centers. We calculated long COVID incidence proportions per NICE guidelines by migration background and assessed for clinical predictors via robust Poisson regressions. We then examined associations between migration background and long COVID using robust Poisson regressions and adjusted for derived clinical predictors, and other biologically relevant factors. We also assessed long COVID symptom persistence at one-year post-discharge. Findings: 1886 patients were included. 483 patients had long COVID (26%, 95% CI 24-28%) at 12 weeks post-discharge. Symptoms like dizziness, joint pain, insomnia, and headache varied by migration background. Clinical predictors of long COVID were female sex, hospital admission duration, intensive care unit admission, and receiving oxygen, or corticosteroid therapy. Long COVID risk was higher among patients with migration background than Dutch origin patients after adjustments for derived clinical predictors, age, smoking, vaccination status, comorbidities and remdesivir treatment. Only 14% of long COVID symptoms persisted at one-year post-discharge. Interpretation: There are significant differences in occurrence, nature of symptoms, and duration of long COVID by migration background. Studies assessing the spectrum of functional limitation and access to post-COVID healthcare are needed to help plan for appropriate and accessible healthcare interventions. Funding: The Amsterdam UMC COVID-19 biobank is supported by the Amsterdam UMC Corona Research Fund and the Talud Foundation (Stichting Talud). The current analyses were supported by the Novo Nordisk Foundation [NNF21OC0067528].

How chronic conditions are understood, experienced and managed within African communities in Europe, North America and Australia: A synthesis of qualitative studies.

This review focuses on the lived experiences of chronic conditions among African communities in the Global North, focusing on established immigrant communities as well as recent immigrant, refugee, and asylum-seeking communities. We conducted a systematic and narrative synthesis of qualitative studies published from inception to 2022, following a search from nine databases-MEDLINE, EMBASE, PsycINFO, Web of Science, Social Science Citation Index, Academic Search Complete, CINAHL, SCOPUS and AMED. 39 articles reporting 32 qualitative studies were included in the synthesis. The studies were conducted in 10 countries (Australia, Canada, Denmark, France, Netherlands, Norway, Sweden, Switzerland, United Kingdom, and the United States) and focused on 748 participants from 27 African countries living with eight conditions: type 2 diabetes, hypertension, prostate cancer, sickle cell disease, chronic hepatitis, chronic pain, musculoskeletal orders and mental health conditions. The majority of participants believed chronic conditions to be lifelong, requiring complex interventions. Chronic illness impacted several domains of everyday life-physical, sexual, psycho-emotional, social, and economic. Participants managed their illness using biomedical management, traditional medical treatment and faith-based coping, in isolation or combination. In a number of studies, participants took 'therapeutic journeys'-which involved navigating illness action at home and abroad, with the support of transnational therapy networks. Multi-level barriers to healthcare were reported across the majority of studies: these included individual (changing food habits), social (stigma) and structural (healthcare disparities). We outline methodological and interpretive limitations, such as limited engagement with multi-ethnic and intergenerational differences. However, the studies provide an important insights on a much-ignored area that intersects healthcare for African communities in the Global North and medical pluralism on the continent; they also raise important conceptual, methodological and policy challenges for national health programmes on healthcare disparities.

Multimorbidity of cardiometabolic diseases: a cross-sectional study of patterns, clusters and associated risk factors in sub-Saharan Africa.

OBJECTIVE: To determine the patterns of cardiometabolic multimorbidity and associated risk factors in sub-Saharan Africa (SSA). DESIGN: We used data from the WHO STEPwise approach to non-communicable disease risk factor surveillance cross-sectional surveys conducted between 2014 and 2017. PARTICIPANTS: The participants comprised 39, 658 respondents aged 15-69 years randomly selected from nine SSA countries using a multistage stratified sampling design. PRIMARY OUTCOME MEASURE: Using latent class analysis and agglomerative hierarchical clustering algorithms, we analysed the clustering of cardiometabolic diseases (CMDs) including high blood sugar, hypercholesterolaemia, hypertension and cardiovascular diseases (CVDs) such as heart attack, angina and stroke. Clusters of lifestyle risk factors: harmful salt intake, physical inactivity, obesity, tobacco and alcohol use were also computed. Prevalence ratios (PR) from modified Poisson regression were used to assess the association of cardiometabolic multimorbidity with sociodemographic and lifestyle risk factors. RESULTS: Two distinct classes of CMDs were identified: relatively healthy group with minimal CMDs (95.2%) and cardiometabolic multimorbidity class comprising participants with high blood sugar, hypercholesterolaemia, hypertension and CVDs (4.8%). The clusters of lifestyle risk factors included alcohol, tobacco and harmful salt consumption (27.0%), and physical inactivity and obesity (5.8%). The cardiometabolic multimorbidity cluster exhibited unique sociodemographic and lifestyle risk profiles. Being female (PR=1.7, 95% CI (1.5 to 2.0), middle-aged (35-54 years) (3.9 (95% CI 3.2 to 4.8)), compared with age 15-34 years, employed (1.2 (95% CI 1.1 to 1.4)), having tertiary education (2.5 (95% CI 2.0 to 3.3)), vs no formal education and clustering of physical inactivity and obesity (2.4 (95% CI 2.0 to 2.8)) were associated with a higher likelihood of cardiometabolic multimorbidity. CONCLUSION: Our findings show that cardiometabolic multimorbidity and lifestyle risk factors cluster in distinct patterns with a disproportionate burden among women, middle-aged, persons in high socioeconomic positions, and those with sedentary lifestyles and obesity. These results provide insights for health systems response in SSA to focus on these clusters as potential targets for integrated care.

Family participation to enhance care and tackle health worker shortages in resource-limited hospitals: A systematic review.

Background: A growing global shortage of health workers is limiting access to health care, especially in resource-limited countries. Family participation in hospital care could enhance care while tackling health worker shortages. With the same resources, it might deliver additional and more personalised care. This review assessed the effect and safety of family participation interventions in the care of hospitalised adults in resource-limited settings and, ultimately, if it is a viable strategy to tackle health worker shortages. Methods: For this systematic review, Medline, Embase, CINAHL and the Global Health Library were searched from inception till April 7, 2022. Clinical studies were included if they described a family participation intervention for hospitalised adults, were performed in a low- or middle-income country and reported on a patient-related outcome. Data were collected on patient, family, staff and health service-related outcomes. Risk of bias was assessed with the ROB2 and ROBINS-I tool. Results: From 4444 studies, six were included for narrative synthesis, with a total of 1794 participants. Four studies were performed in Asia and two in Africa; all were published between 2017 and 2022. In-hospital family participation interventions aimed at medication administration and adherence, delirium prevention, and palliative cancer care were successful in significantly improving patient outcomes. Involving family in post-stroke rehabilitation interventions showed no significant effect on mortality and long-term disability. Few data were reported on participating family members' outcomes or hospital staffing issues. None of the included studies showed harm from family participation. Conclusions: The limited data suggest that family participation can be effective and safe in specific contexts. However, more research is needed to determine the effect of family participation and justify further implementation. Family participation research for enhancing care while tackling health worker shortages should be a collaborative priority of researchers, health care professionals, funding agencies and policymakers. Registration: PROSPERO registration No. CRD42020205878.

Discrepancies in estimated glomerular filtration rate and albuminuria levels in ethnic minority groups - The multiethnic HELIUS cohort study.

Background: Classification of chronic kidney disease (CKD) and evaluation of prognosis is based on two components: estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (ACR). In multiethnic populations, ethnic-specific discrepancies in both parameters may exist. It is unknown whether variations in CKD risk factors may explain these discrepancies. Methods: We cross-sectionally analyzed baseline eGFR (CKD-EPI formula) and ACR of 21,421 participants (aged 18-70 years) of the HELIUS cohort who were randomly sampled between 2011 and 2015, stratified by ethnicity, through the municipality register of Amsterdam. Six ethnic groups were distinguished, including participants of Dutch (4539), South-Asian Surinamese (3027), African Surinamese (4114), Ghanaian (2297), Turkish (3576) and Moroccan (3868) descent. Multiple regression analyses to determine ethnic differences were performed, with additional adjustments for age, sex, traditional cardiovascular and renal risk factors, and adjustment for level of education. Findings: Mean (SE) eGFR was higher in all ethnic minority groups as compared to Dutch participants (eGFR 94.7 ± 0.3 mL/min/1.73 m2) with age- and sex-adjusted differences ranging from 1.5 ± 0.30 in South-Asian Surinamese to 10.1 ± 0.28 mL/min/1.73 m2 in Moroccan participants. ACR was higher in ethnic minority groups as compared to Dutch participants (ACR 0.64 ± 0.20 mg/mmol), with age- and sex-adjusted differences ranging from 0.46 ± 0.20 in African Surinamese participants to 1.70 ± 0.21 mg/mmol in South-Asian Surinamese participants. Differences in both parameters diminished after multiple adjustments, but remained highly significant. Interpretation: Both eGFR and ACR are higher among ethnic minority groups as compared to individuals of Dutch origin-independent of age, sex, prevalence of traditional cardiovascular and renal risk factors, and parameters of socioeconomic status. Future studies should address the potential uncertainty in predicting CKD and CKD-related complications when using both parameters in ethnically diverse populations. Also, identification of driving factors leading to these discrepancies might contribute to improved population screening for CKD. Funding: The HELIUS study is conducted by the Amsterdam University Medical Center and the Public Health Service of Amsterdam. Both organizations provided core support for HELIUS. The HELIUS study is also funded by the Dutch Heart Foundation (2010T084), the Netherlands Organization for Health Research and Development (ZonMw: 200500003), the European Union (FP7: 278901), and the European Fund for the Integration of non-EU immigrants (EIF: 2013EIF013).

Associations of Serum Uric Acid Levels With Macrovascular and Renal Microvascular Dysfunction Among Individuals From Sub-Saharan Africa.

Importance: Serum uric acid (SUA) level is associated with vascular dysfunction in Eurasian populations, but little is known about this association in individuals from sub-Saharan Africa, who have a high prevalence of both relatively high SUA levels and vascular dysfunction. Objectives: To assess the associations of SUA levels with macrovascular and kidney microvascular dysfunction in individuals of sub-Saharan African ancestry and evaluate potential factors that could mediate these associations. Design, Setting, and Participants: Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes Among African Migrants study, conducted from 2012 to 2015, were performed from January to March 2021. The population included Ghanaian individuals living in Ghana and Europe. Exposure: Abnormal SUA levels. Main Outcomes and Measures: Logistic regression was used to examine the associations of SUA level quartiles with microvascular (albuminuria) and macrovascular (peripheral artery disease and coronary artery disease) dysfunction, with adjustments for age, sex, estimated glomerular filtration rate, site of residence, socioeconomic status, alcohol, smoking, diabetes, hypertension, waist-hip ratio, and total cholesterol level. Mediation analysis was performed to assess whether the association was via elevated blood pressure, hemoglobin A1c, and high-sensitivity C-reactive protein levels or via weight-hip ratio. The research questions were formulated after data collection. Results: A total of 4919 Ghanaian individuals (3047 [61.9%] women) aged 25-75 years (mean [SD], 46.26 [11.08] years) were included. There was a significant positive association between SUA quartiles and albuminuria, but not coronary artery disease or peripheral artery disease, after adjustment for covariates. After full adjustment, individuals in the fourth SUA quartile had higher odds of albuminuria (adjusted odds ratio [aOR], 1.54; 95% CI, 1.07-2.21), but not peripheral artery disease (aOR, 1.35; 95% CI, 0.87-2.08) or coronary artery disease (aOR, 1.09; 95% CI, 0.77-1.55), compared with individuals in the first quartile. After full adjustment, systolic and diastolic blood pressure significantly mediated the association between SUA concentrations and albuminuria, accounting for 19.4% of the total association for systolic and 17.2% for diastolic blood pressure; hemoglobin A1c, high-sensitivity C-reactive protein, and waist-hip ratio did not mediate this association. Conclusions and Relevance: In this cross-sectional study among a sub-Saharan African population, elevated SUA levels were significantly associated with kidney microvascular dysfunction and mediated partly through elevated blood pressure. These findings suggest that individuals from sub-Saharan Africa with elevated SUA levels may benefit from periodic screening for kidney microvascular dysfunction to aid early detection or treatment.

Inflammation and its associations with aortic stiffness, coronary artery disease and peripheral artery disease in different ethnic groups: The HELIUS Study.

BACKGROUND: evidence shows important ethnic differences in vascular dysfunction rates; however, the mechanisms driving these differences remain unclear. One potential factor is the ethnic differences in the role of inflammation in vascular injury. We tested the hypothesis that low-grade inflammation is unequally associated with vascular dysfunction in different ethnic groups. METHODS: we included 5698 participants (similar-sized Dutch, African Surinamese, South-Asian Surinamese, Ghanaians, Turkish, and Moroccans) of the HELIUS study (the Netherlands) conducted between 2011 and 2015. Logistic regression was used to examine the associations of Z-score inflammatory biomarker concentration (high sensitivity C-reactive protein [hs-CRP], fibrinogen, and d-dimer) with vascular dysfunction (aortic stiffness, coronary artery disease [CAD], and peripheral artery disease [PAD]), with adjustments for age, sex, smoking (pack-years), BMI, hypertension, HbA1c, total cholesterol, and statin use. FINDINGS: in the fully adjusted models, higher Z-score hs-CRP was positively associated with CAD in Dutch [OR 1·63, (95% CI 1·21-2·18)] and PAD in South Asians [1·25(1·03-1·53)], respectively. Higher Z-score fibrinogen was positively associated with CAD in African Surinamese [1·28(1·03-1·59)] while higher Z-score d-dimer was positively associated with PAD in Moroccans [1·39(1·01-1·93)]. Higher Z-score hs-CRP [0·71(0·54-0·94)] and fibrinogen [0·75(0·58-0·97)] concentrations were negatively associated with PAD in African Surinamese. INTERPRETATION: our study shows that inflammatory biomarkers are unequally associated with vascular dysfunction in different ethnic groups. These observations provide opportunities for future studies aimed at assessing the predictive roles of inflammation on vascular disease in different ethnic groups.

Associations between macrovascular and renal microvascular dysfunction in type 2 diabetes and non-diabetes: the HELIUS study.

BACKGROUND: Although the associations between measures of macrovascular and microvascular dysfunctions are well characterized in diabetes, there is limited data on these associations in individuals without diabetes. We compared the associations between macrovascular dysfunction and renal microvascular dysfunction in individuals with type 2 diabetes (T2D) and without diabetes. METHODS: Cross-sectional analyses of baseline data from the multiethnic Healthy Life in an Urban Setting (HELIUS) study (Amsterdam, the Netherlands), including 986 participants with T2D and 7680 participants without diabetes were done. Logistic regression analyses were used to examine the associations between macrovascular dysfunction [aortic stiffness, coronary artery disease (CAD), peripheral artery disease (PAD), and stroke] and renal microvascular dysfunction [albuminuria] with adjustments for age, sex, ethnicity, waist-to-hip ratio, systolic blood pressure, LDL-cholesterol, and smoking (and HbA1c and diabetes duration for the T2D group). RESULTS: In the fully adjusted models, aortic stiffness was associated with albuminuria in individuals with T2D [OR 2.55; 95% CI,1.30-4.98], but not without diabetes [0.96; 0.63-1.45]; stroke was associated with albuminuria in T2D [2.40;1.10-5.25], but not in non-diabetes [1.39;0.83-2.33]. In age-sex adjusted models, CAD was associated with albuminuria in T2D [1.65;1.09-2.50] and in non-diabetes [1.56;1.13-2.15]; the associations were no longer significant in the fully adjusted model. There were no associations between PAD and albuminuria in T2D and non-diabetes. CONCLUSIONS: Our study shows important differences in the associations between measures of macrovascular and renal microvascular dysfunction in T2D and non-diabetes. These findings provide opportunities for future research aimed at prevention and treatment strategies for individuals with vascular dysfunction.

Determinants of suboptimal blood pressure control in a multi-ethnic population: The Healthy Life in an Urban Setting (HELIUS) study.

Among ethnic minority groups in Europe, blood pressure (BP) control is often suboptimal. We aimed to identify determinants of suboptimal BP control in a multi-ethnic population. We analyzed cross-sectional data of the Healthy Life in an Urban Setting (HELIUS) study, including 3571 participants aged 18-70 with prescribed antihypertensive medication, of various ethnic backgrounds (500 Dutch, 1052 African Surinamese, 656 South-Asian Surinamese, 637 Ghanaian, 433 Turkish, and 293 Moroccan) living in Amsterdam, the Netherlands. 53.3% of the population had suboptimal BP control, defined as BP ≥140/90 mmHg despite prescribed antihypertensives. Using multivariate logistic regression analysis, female sex (OR 0.50, 95%CI 0.43-0.59), being married (0.83, 0.72-0.96), smoking (0.78, 0.65-0.94), alcohol intake (0.80, 0.66-0.96), obesity (1.67, 1.35-2.06), cardiovascular disease (CVD) history (0.56, 0.46-0.68), non-adherence to antihypertensives (1.26, 1.00-1.58), and family history of hypertension (1.19, 1.02-1.38) were identified to be independently associated with suboptimal BP control in the total population. In the ethnic-stratified analysis, factors associated with better BP control were female sex (all ethnic groups), smoking (Turks), and CVD history (Dutch, South-Asian Surinamese, and African Surinamese), whereas factors associated with suboptimal BP control were older age (Turks), obesity (Dutch, African Surinamese, Ghanaian, and Turks), and non-adherence to antihypertensives (Dutch). In conclusion, our analysis identifies several key determinants that are independently associated with suboptimal BP control in a multi-ethnic population, with some important variations between ethnic groups. Targeting these determinants may help to improve BP control.

Epigenetic age acceleration in the emerging burden of cardiometabolic diseases among migrant and non-migrant African populations: the population based cross-sectional RODAM study.

BACKGROUND: African populations are experiencing health transitions due to rapid urbanization and international migration. However, the role of biological aging in this emerging burden of cardiometabolic diseases (CMD) among migrant and non-migrant Africans is unknown. We aimed to examine differences in epigenetic age acceleration (EAA) as measured by four clocks (Horvath, Hannum, PhenoAge and GrimAge) and their associations with cardiometabolic factors among migrant Ghanaians in Europe and non-migrant Ghanaians. METHODS: Genome-wide DNA methylation (DNAm) data of 712 Ghanaians from cross-sectional RODAM study were used to quantify EAA. We assessed correlation of DNAmAge measures with chronological age, and then performed linear regressions to determine associations of body mass index (BMI), fasting blood glucose (FBG), blood pressure, alcohol consumption, smoking, physical activity, and one-carbon metabolism nutrients with EAA among migrant and non-migrants. We replicated our findings among 172 rural-urban sibling pairs from India migration study and among 120 native South Africans from PURE-SA-NW study. FINDINGS: We found that Ghanaian migrants have lower EAA than non-migrants. Within migrants, higher FBG was positively associated with EAA measures. Within non-migrants, higher BMI, and Vitamin B9 (folate) intake were negatively associated with EAA measures. Our findings on FBG, BMI and folate were replicated in the independent cohorts. INTERPRETATION: Our study shows that migration is negatively associated with EAA among Ghanaians. Moreover, cardiometabolic factors are differentially associated with EAA within migrant and non-migrant subgroups. Our results call for context-based interventions for CMD among transitioning populations that account for effects of biological aging. FUNDING: European Commission.

The Upcoming Epidemic of Heart Failure in South Asia.

Currently, South Asia accounts for a quarter of the world population, yet it already claims ≈60% of the global burden of heart disease. Besides the epidemics of type 2 diabetes mellitus and coronary heart disease already faced by South Asian countries, recent studies suggest that South Asians may also be at an increased risk of heart failure (HF), and that it presents at earlier ages than in most other racial/ethnic groups. Although a frequently underrecognized threat, an eventual HF epidemic in the densely populated South Asian nations could have dramatic health, social and economic consequences, and urgent interventions are needed to flatten the curve of HF in South Asia. In this review, we discuss recent studies portraying these trends, and describe the mechanisms that may explain an increased risk of premature HF in South Asians compared with other groups, with a special focus on highly relevant features in South Asian populations including premature coronary heart disease, early type 2 diabetes mellitus, ubiquitous abdominal obesity, exposure to the world's highest levels of air pollution, highly prevalent pretransition forms of HF such as rheumatic heart disease, and underdevelopment of healthcare systems. Other rising lifestyle-related risk factors such as use of tobacco products, hypertension, and general obesity are also discussed. We evaluate the prognosis of HF in South Asian countries and the implications of an anticipated HF epidemic. Finally, we discuss proposed interventions aimed at curbing these adverse trends, management approaches that can improve the prognosis of prevalent HF in South Asian countries, and research gaps in this important field.

Prevalence of Cardiovascular Disease Risk Factors in the Gambia: A Systematic Review.

Cardiovascular disease (CVD) is increasingly becoming a major chronic disease burden in sub-Saharan Africa. The aim of this review was to provide an up-to-date overview on prevalence of CVD risk factors in the Gambia. The findings from seven included studies revealed that most CVD risk factors are very prevalent in the Gambia, with some specific groups in the population such as urban dwellers being more at risk. Obesity prevalence ranged from 2.3% to 11.7%, with rate being particularly high in urban women aged ≥35 years. Diabetes prevalence was 0.3%. Hypertension prevalence ranged from 18.3% to 29%. Prevalence of hypercholesterolemia ranged from 2.2% to 29.1%. Prevalence of smoking ranged from 16% to 42.2% in men. Prevalence of insufficient fruit and vegetable consumption, inadequate physical activity, and alcohol consumption was 77.8%, 14.6%, and 2.3%, respectively. These findings suggest urgent need for preventive measures and further research to prevent CVD in the Gambia.

Indirect implications of COVID-19 prevention strategies on non-communicable diseases : An Opinion Paper of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk Assessment in Subjects Living in or Emigrating from Low Resource Settings.

BACKGROUND: After its outbreak in China, the novel COronaVIrus Disease 19 is spreading across the globe. It is an emergency the world has never seen before. MAIN TEXT: The attention of health systems is mainly focused on COronaVIrus Disease 19 patients and on the risk that intensive care units might be overwhelmed by the serious pulmonary complications. Different countries are also attempting to establish infection prevention and control strategies which proved effective in China where the outbreak was initially reported. We reflect on important lessons to be learnt from different countries. The effects that infection prevention and control strategies, such as social distancing or isolation, can have on the care of millions of patients with non-communicable diseases, who may be indirectly affected, have not been taken into consideration so much. CONCLUSIONS: When dealing with COronaVIrus Disease 19, policy makers and healthcare personnel should consider the indirect effects on the treatment of non-communicable diseases.

Association between C reactive protein and microvascular and macrovascular dysfunction in sub-Saharan Africans with and without diabetes: the RODAM study.

INTRODUCTION: Although inflammation assessed by elevated C reactive protein (CRP) concentration is known to be associated with risk of cardiovascular disease, its association with microvascular and macrovascular dysfunction in diabetes and non-diabetes remains unclear. We examined the association between CRP and diabetes and associated microvascular and macrovascular dysfunction in sub-Saharan Africans with and without diabetes. RESEARCH DESIGN AND METHODS: Cross-sectional analyses of baseline data from the multicenter RODAM study (Research on Obesity and Diabetes among African Migrants) including 5248 Ghanaians (583 with diabetes, 4665 without diabetes) aged 25-70 years were done. Logistic regression analyses were used to examine the associations between CRP Z-scores and diabetes and microvascular (nephropathy) and macrovascular (peripheral artery disease (PAD)) dysfunction, with adjustments for age, sex, site of residence, smoking, body mass index, systolic blood pressure, and low-density lipoprotein cholesterol. RESULTS: In the fully adjusted models, higher CRP concentration was significantly associated with diabetes (adjusted OR 1.13; 95% CI 1.05 to 1.21, p=0.002). In participants with diabetes, higher CRP concentration was associated with PAD (1.19; 1.03 to 1.41, p=0.046) but not nephropathy (1.13; 0.97 to 1.31, p=0.120). Among participants without diabetes, higher CRP concentration was associated with higher odds of PAD (1.10; 1.01 to 1.21, p=0.029) and nephropathy (1.12; 1.04 to 1.22, p=0.004). CONCLUSIONS: In this study, higher CRP concentration was associated with higher odds of diabetes in sub-Saharan Africans. Also, higher CRP concentration was associated with higher odds of nephropathy and PAD in non-diabetes and higher odds of PAD in diabetes. CRP may be an important marker for assessment of risk of diabetes and risk for PAD and nephropathy in sub-Saharan Africans with and without diabetes.

Inverse Association between Iron Deficiency and Glycated Hemoglobin Levels in Ghanaian Adults-the RODAM Study.

BACKGROUND: Glycated hemoglobin (HbA1c) is often used to diagnose type 2 diabetes (T2D), but studies show that iron deficiency (ID) is associated with elevated HbA1c in the absence of hyperglycemia. It is unknown whether ID prevalence varies between sub-Saharan African populations living in different locations and whether ID influences HbA1c levels in these populations. OBJECTIVES: We assessed the prevalence of ID among Ghanaian migrants in Europe and nonmigrant Ghanaians, and the influence of ID on HbA1c categories among Ghanaians without T2D. METHODS: We used the database from the cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study. This contained data on 3377 Ghanaian men and women aged 25-70 y living in urban and rural Ghana and Ghanaian migrants living in Amsterdam, London, and Berlin. ID was defined as ferritin < 15 ng/mL or, if C-reactive protein was ≥5 mg/mL, as ferritin < 30 ng/mL according to the WHO. We used binary logistic regression to assess differences in ID between sites and its association with clinically defined HbA1c categories (<5.5%, ≥5.5% to <6.5%, ≥6.5%). Men and women were analyzed separately. RESULTS: The prevalence of ID was higher in migrant [28.4%; adjusted OR (aOR): 3.08; 95% CI: 2.04, 4.65)] and urban (23.2%; aOR: 2.37; 95% CI: 1.56, 3.59) women than in rural women (11.9%). Among women, ID was associated with higher odds of HbA1c ≥ 5.5% to <6.5% in the absence of hyperglycemia (aOR: 1.43; 95% CI: 1.08, 1.87). This association was not found in men. CONCLUSIONS: Further research is needed to identify factors underlying the high prevalence of ID among urban and migrant Ghanaian women, and the association of ID with HbA1c ≥ 5.5% to <6.5% in women. In addition, our study reinforces the need to consider iron concentrations if interpreting HbA1c among African populations.

Physical Inactivity among Ghanaians in Ghana and Ghanaian Migrants in Europe.

PURPOSE: There is a paucity of data on physical activity (PA) among migrants from sub-Saharan Africa, yet physical inactivity is a key risk factor for noncommunicable diseases. We examined the levels of physical inactivity and its determinants among Ghanaians in different geographical locations. METHODS: We used the Research on Obesity and Diabetes among African Migrants data of Ghanaian adults (n = 4760) age 25-70 yr in rural and urban Ghana and three European cities (Amsterdam, London, and Berlin). Using total physical activity metabolic equivalent of task, physical inactivity was defined as total physical activity metabolic equivalent of task minutes per week less than 600. Logistic regression was used to examine the differences in the levels and the determinants of physical inactivity across sites. RESULTS: Physical inactivity was higher among Ghanaian migrants (14.6% in Amsterdam, 24.1% in Berlin, and 36.6% in London) and urban Ghanaians (29.0%) compared with rural Ghanaians (11.2%). After adjustment for covariates (age, sex, education, health status, smoking status, body mass index, and social network) using rural Ghanaians as the comparator group, the odds ratios for physical inactivity in men ranged from 3.67 (95% confidence interval, 2.19-6.16) in urban Ghanaians to 10.37 (5.96-18.02) in London Ghanaians, and from 3.27 (2.46-4.35) in urban Ghanaians to 4.41 (3.12-6.22) in London Ghanaians in women. Migrants in London and Berlin had higher odds of physical inactivity compared with Amsterdam. Increased age, university education, and overweight/obesity were positively associated with physical inactivity, whereas social support was inversely associated with physical inactivity with variability across sites. CONCLUSIONS: Findings indicate high prevalence of physical inactivity among Ghanaians in all sites, particularly among Ghanaians in Europe. Hence, there is the need to take local context into account to improve PA.

Hypertension prevalence, awareness, treatment, and control in Surinamese living in Suriname and The Netherlands: the HELISUR and HELIUS studies.

We studied hypertension prevalence, awareness, treatment, and control among persons living in a middle-income country compared with those of similar ethnicity living in a high-income country. Data from the cross-sectional HELISUR and HELIUS studies were used among 1000 Surinamese and 6971 Surinamese migrants living in The Netherlands (18-70 years), respectively. Groups were formed based on country and self-defined ethnicity, and stratified by sex. Age-adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated for hypertension prevalence, awareness, treatment, and control. Subsequently, we focused on hypertension prevalence and adjusted for risk factors for hypertension: BMI and waist circumference (model 2), educational level, physical activity, and smoking (model 3). After adjustment for age, no significant differences in hypertension prevalence, awareness, treatment, and control between countries were seen in men. However, women in Suriname were more often hypertensive with lower levels of awareness and control than those in The Netherlands (African: OR 1.54 [95% CI 1.19, 2.00]; South-Asian: 1.90 [1.35, 2.67]; awareness: 0.62 [0.43, 0.88] in African women; control: 0.48 [0.28, 0.84] in South-Asian women). Higher hypertension prevalence was explained by differences in BMI and waist circumference in African women (adjusted OR 1.26 [0.96, 1.65]) and by education, physical activity, and smoking in South-Asian women (adjusted OR 1.29 [0.87, 1.89]). Particularly, women in Suriname bear a relatively high hypertension burden with lower levels of awareness and control. As the higher hypertension prevalence was mainly explained by lifestyle-related risk factors, health promotion interventions may reduce the hypertension burden in Suriname.