Estimating the changing burden of disease attributable to high fasting plasma glucose in South Africa for 2000, 2006 and 2012.

BACKGROUND: Worldwide, higher-than-optimal fasting plasma glucose (FPG) is among the leading modifiable risk factors associated with all- cause mortality and disability-adjusted life years (DALYs) due to the direct sequelae of diabetes and the increased risk for cardiovascular and chronic kidney disease. OBJECTIVES: To report deaths and DALYs of health outcomes attributable to high FPG by age and sex for South Africa (SA) for 2000, 2006 and 2012. METHODS: Comparative risk assessment methodology was used to estimate the burden attributable to high FPG. A meta-regression analysis was performed using data from national and small-area studies to estimate the population distribution of FPG and diabetes prevalence. Attributable fractions were calculated for selected health outcomes and applied to local burden estimates from the second South African National Burden of Disease Study (SANBD2). Age-standardised rates were calculated using World Health Organization world standard population weights. RESULTS: We estimated a 5% increase in mean FPG from 5.31 (95% confidence interval (CI) 5.18 - 5.43) mmol/L to 5.57 (95% CI 5.41 - 5.72) mmol/L and a 75% increase in diabetes prevalence from 7.3% (95% CI 6.7 - 8.3) to 12.8% (95% CI 11.9 - 14.0) between 2000 and 2012. The age-standardised attributable death rate increased from 153.7 (95% CI 126.9 - 192.7) per 100 000 population in 2000 to 203.5 (95% CI 172.2 - 240.8) per 100 000 population in 2012, i.e. a 32.4% increase. During the same period, age-standardised attributable DALY rates increased by 43.8%, from 3 000 (95% CI 2 564 - 3 602) per 100 000 population in 2000 to 4 312 (95% CI 3 798 - 4 916) per 100 000 population in 2012. In each year, females had similar attributable death rates to males but higher DALY rates. A notable exception was tuberculosis, with an age-standardised attributable death rate in males double that in females in 2000 (14.3 v. 7.0 per 100 000 population) and 2.2 times higher in 2012 (18.4 v. 8.5 per 100 000 population). Similarly, attributable DALY rates were higher in males, 1.7 times higher in 2000 (323 v. 186 per 100 000 population) and 1.6 times higher in 2012 (502 v. 321 per 100 000 population). Between 2000 and 2012, the age-standardised death rate for chronic kidney disease increased by 98.3% (from 11.7 to 23.1 per 100 000 population) and the DALY rate increased by 116.9% (from 266 to 578 per 100 000 population). CONCLUSION: High FPG is emerging as a public health crisis, with an attributable burden doubling between 2000 and 2012. The consequences are costly in terms of quality of life, ability to earn an income, and the economic and emotional burden on individuals and their families. Urgent action is needed to curb the increase and reduce the burden associated with this risk factor. National data on FPG distribution are scant, and efforts are warranted to ensure adequate monitoring of the effectiveness of the interventions.

Perspectives on gestational diabetes mellitus in South Africa.

The field of gestational diabetes mellitus has attracted increasing attention and research in South Africa (SA) over the past decade, creating a better understanding of the disease burden, risk factors, availability of specialised healthcare services, and importantly the far-reaching maternal and childhood consequences beyond the pregnancy. This article brings together all the local published literature in the field and outlines the implications of this condition, together with recommendations regarding particular areas that require attention in order to prevent and alleviate the disease burden in SA.

Cognitive and Motor Development in 3- to 6-Year-Old Children Born to Mothers with Hyperglycaemia First Detected in Pregnancy in an Urban African Population.

OBJECTIVES: Hyperglycaemia first detected in pregnancy (HFDP), on the rise in urban sub-Saharan Africa (SSA), may negatively impact foetal neurodevelopment, with potential long-term cognitive consequences for the child. Data on this association from SSA is lacking, and we aimed to investigate the association in 3- to 6-year-old children in Soweto, South Africa. METHODS: In this comparative study, we compared cognitive skills measured with the Herbst Early Childhood Development Criteria test in 95 children born to mothers with HFDP and 99 participants unexposed to maternal HFDP. Fine and gross motor skills were secondary outcomes. Ordinal regression analysis with known confounders was performed for children born at-term. RESULTS: Of children exposed to HFDP born at-term, 24.3% scored 'high' and 25.7% scored 'low' in the cognitive subsection of the test, as opposed to 37.7% and 12.9% in the HFDP-unexposed group, respectively. In ordinal regression, exposed participants had a significantly lower odds of scoring in a higher cognitive category when adjusting for maternal confounders and socio-economic status (OR 0.33, 95% CI 0.15-0.74, p = 0.007). No difference was found in gross motor development between the two groups; differences in fine motor development were attenuated after adjustment for maternal pregnancy factors and household socioeconomic status (OR 0.62, 95% CI 0.28-1.37, p = 0.239). CONCLUSIONS FOR PRACTICE: Exposure to HFDP was negatively associated with cognitive development at preschool age. Optimising maternal (preconception) health and early childhood cognitive stimulation could help more children reach their developmental potential.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial.

BACKGROUND: Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes. METHODS: StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals. RESULTS: The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (- 0.08% (- 0.31 to 0.16) (IFCC - 0.82 mmol/mol (- 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was - 0.71% (- 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful. CONCLUSIONS: Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes. TRIAL REGISTRATION: Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa.

BACKGROUND: The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes. METHODS: We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes. RESULTS: Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants' ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one's blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services. CONCLUSION: This process evaluation provided context and insight into the factors influencing participants' engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808 , registered 03/08/2015.).

Maternal and neonatal outcomes following the introduction of oral hypoglycaemic agents for gestational diabetes mellitus were comparable to insulin monotherapy in two historical cohorts.

BACKGROUND: Gestational diabetes mellitus (GDM), a disorder of glucose intolerance first encountered during pregnancy, has far-reaching implications for both mother and child. Insulin therapy remains the 'gold standard' of care, with oral hypoglycaemic agents (OHAs) increasingly being viewed as potential alternatives. OBJECTIVES: To compare maternal and neonatal outcomes in two cohorts of women with GDM exposed to either insulin monotherapy or OHAs. METHODS: A retrospective medical record review at Chris Hani Baragwanath Academic Hospital in South Africa was conducted for women with GDM diagnosed using the 100 g oral glucose tolerance test and/or random capillary blood glucose >11.1 mmol/L in 2010 - 2014. The findings were compared with a previous audit at the same clinic for the period 1992 - 2002. Variables of interest included maternal demographics, maternal comorbidities, glycaemic indices, treatments used during pregnancy, and obstetric and neonatal outcomes. RESULTS: A total of 192 women with GDM were identified for 2010 - 2014, and there were 348 women in the previous audit (1992 - 2002). Baseline characteristics and outcomes of women in the two cohorts were similar apart from earlier presentation (mean (standard deviation) gestational age (GA) 27 (7.5) weeks v. 28.3 (6.4) weeks; p=0.04), lower GA at delivery (36.3 (3.6) weeks v. 37 (1.6) weeks); p=0.008) and lower macrosomia rates (12.5% v. 4.9%; p=0.011) in the later cohort. When comparing the individual OHAs against insulin in the later cohort, both agents were comparable to insulin in terms of maternal and neonatal outcomes. CONCLUSIONS: This study contributes to the paucity of data on the safety of OHAs in GDM pregnancy in terms of maternal and neonatal outcomes. OHAs were shown to be an effective alternative to insulin for women with GDM in whom lifestyle measures fail, particularly in a resource-poor setting.

Elevated resting heart rate is associated with several cardiovascular disease risk factors in urban-dwelling black South Africans.

This study determined the associations of resting heart rate (RHR) with cardiovascular disease risk factors (CVDRF) in 25-74-year-old black South Africans. This cross-sectional study determined CVDRF by administered questionnaires, clinical measurements and biochemical analyses, including oral glucose tolerance tests. Multivariable linear regression models determined the associations of rising RHR with CVDRF. The basic model comprised age, gender, urbanisation, problematic alcohol use, daily cigarette smoking, physical activity and waist circumference. Glucose, blood pressure and cholesterol variables were entered separately and individually in the above model. Among the 1054 participants (382 men and 672 women, mean age 42.8 years), mean RHR was 70.6 beats per minute (bpm) and significantly higher in women (73.6 bpm) compared with men (65.3 bpm). RHR peaked in 45-54-year-old men (69.3 bpm) and 25-34-year-old women (75.3 bpm). Prevalence of RHR < 60 bpm and ≥90 bpm was 24.3% and 6.2%. In the regression model, female gender, problematic alcohol use, decreasing physical activity and increasing waist circumference were significantly associated with rising RHR. All glycaemic variables (diabetes, fasting glucose and 2-hour glucose) and diastolic blood pressure were significantly associated with RHR. The use of RHR in daily primary healthcare settings to identify increased risk for CVDRF should perhaps be encouraged.

A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach.

AIMS: To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes. METHODS: We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals. RESULTS: The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment. CONCLUSIONS: We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

Multiple Sclerosis Performance Test: validation of self-administered neuroperformance modules.

BACKGROUND AND PURPOSE: The purpose was to determine the test-retest reliability, practice effects, convergent validity and sensitivity to multiple sclerosis (MS) disability of neuroperformance subtests from the patient self-administered Multiple Sclerosis Performance Test (MSPT) designed to assess low contrast vision (Contrast Sensitivity Test, CST), upper extremity motor function (Manual Dexterity Test, MDT) and lower extremity motor function (Walking Speed Test, WST) and to introduce the concept of regression-based norms to aid clinical interpretation of performance scores using the MSPT cognition test (Processing Speed Test, PST) as an example. METHODS: Substudy 1 assessed test-retest reliability, practice effects and convergent validity of the CST, MDT and WST in 30 MS patients and 30 healthy controls. Substudy 2 examined sensitivity to MS disability in over 600 MS patients as part of their routine clinic assessment. Substudy 3 compared performance on the PST in research volunteers and clinical samples. RESULTS: The CST, MDT and WST were shown to be reliable, valid and sensitive to MS outcomes. Performance was comparable to technician-administered testing. PST performance was poorer in the clinical sample compared with the research volunteer sample. CONCLUSIONS: The self-administered MSPT neuroperformance modules produce reliable, objective metrics that can be used in clinical practice and support outcomes research. Published studies which require patient voluntary consent may underestimate the rate of cognitive dysfunction observed in a clinical setting.

Cardiovascular risk prevalence in South Africans with drug-resistant tuberculosis: a cross-sectional study.

In South Africa, the risk factors for cardiovascular disease (CVD) are increasing, thereby impacting patients with drug-resistant tuberculosis (DR-TB). To determine the prevalence of traditional CVD risk factors (diabetes mellitus [DM], smoking, hypertension, increased body mass index [BMI]) and a total risk score for CVD among patients with DR-TB. This cross-sectional study was nested within an ongoing cluster-randomized trial in 10 DR-TB hospitals in South Africa. The data for the present study were collected between November 2014 and July 2016. Of 900 participants aged 18 years, 75.1% were co-infected with the human immunodeficiency virus (HIV), and 52.3% had one or more CVD risk factors. The prevalence of CVD risk factors was hypertension (16.7%), increased BMI (16.6%), DM (5.2%), and smoking (31.4%). Among patients with DM or hypertension, 58.8-95.5% had additional comorbid CVD risk factors. Of 398 participants eligible for the CVD risk score (age 35 years), 23.4% had a moderate or high CVD risk score. Patients with multiple diseases, including DR-TB and HIV, with traditional CVD risk factors, may have higher risks for negative outcomes during treatment for DR-TB. TB providers should identify people at risk to initiate primary and secondary prevention to improve outcomes. .

Sugar-sweetened beverage intake and relative weight gain among South African adults living in resource-poor communities: longitudinal data from the STOP-SA study.

OBJECTIVES: This study examines the prospective association between sugar-sweetened beverages (SSB) consumption and change in body weight over a 4-5-year period in a socio-economically disadvantaged South African population. METHODS: This is a longitudinal study involving 800 adults (212 men, 588 women); 247 from the original METS (Modelling the Epidemiological Transition Study) cohort (N = 504) and 553 of the original 949 members of the PURE (Prospective Urban and Rural Epidemiology) Study. Both cohorts were drawn from low-income, socio-economically disadvantaged communities. Mean follow-up duration and age were 4.5 (SD 0.45) and 50.0 (SD 11.8) years, respectively. Harmonised measurements included body mass index, self-reported moderate-to-vigorous physical activity, and intake of meat, snacks and 'take-aways', fruits and vegetables and SSB (in servings/week). Multivariate logistic regression models were developed to determine the extent to which SSB consumption predicted relative weight gain, after controlling for potential confounders and known predictors. RESULTS: Nearly a third (29%) of participants had a relative weight change ≥5.0%; higher in the non-obese compared to the obese group (32% vs. 25%; p = 0.026). The average SSB consumption was 9.9 servings/week and was higher in the food insecure compared to the food secure group (11.5 vs. 9.0 servings/week; p = 0.006); but there were no differences between women and men (10.3 vs. 9.1 servings/week; p = 0.054). Mean SSB consumption was higher in the group who gained ≥5% weight compared to those who did not (11.0 vs. 8.7; p = 0.004). After adjustment, SSB consumption of 10 or more servings/week was associated with a 50% greater odds of gaining at least 5% body weight (AOR: 1.50, 95% CI (1.05-2.18)). CONCLUSION: These results show that higher intake of SSB predicts weight gain in a sample of South Africans drawn from low-income settings. Comprehensive, population-wide interventions are needed to reduce SSB consumption in these settings.

Physical activity behaviours of persons living with HIV of low socioeconomic status: domain, intensity and sociodemographic correlates.

Physical activity (PA) is healthy for People Living with HIV and AIDS (PLWHA). This study examined the PA profile of 978 PLWHA based on PA domains and PA intensity. The study also sought to determine whether employment status and level of education can predict PA among PLWHA of low SES. PA and sociodemographic data of 978 PLWHA of mean age 35 (8.77) years were collected using the global physical activity questionnaire and a sociodemographic questionnaire. Results showed that, participants engaged more in work-related PA [160.11 (346.95) min/wk], followed by transport related PA [115.21(SD = 142.04) min/wk], and lastly in leisure related PA [40.84 (SD = 110.37) min/wk]. Participants also engaged more in moderate PA [265.86 (SD = 335.45) min/wk], than in vigorous PA [50.29 (SD = 205.30) min/wk]. Employment was a significant predictor of overall PA controlling for age, CD4 count and education level. The model explained 2.5% of the variance (R2 = 0.025) on overall PA and tested significant at a 0.01 alpha level (p < 0.01). PA interventions for this population should be domain- and intensity-specific. Researchers promoting healthy lifestyle behaviour change can benefit from determining the factors that facilitate domain-specific PA.

Pregnancy outcome in patients with pregestational and gestational diabetes attending Groote Schuur Hospital, Cape Town, South Africa.

BACKGROUND: The burden of diabetes mellitus (DM) has increased dramatically worldwide. The association between poorly controlled DM and poor pregnancy outcomes has been well described. OBJECTIVES: To describe the pregnancy outcomes of patients with pregestational and gestational DM attending Groote Schuur Hospital, Cape Town, South Africa. METHODS: A retrospective audit was undertaken of all women with pregestational and gestational DM (GDM) who attended Groote Schuur Hospital obstetric care from 1 September 2010 to 31 August 2011. Information routinely collected at booking and during the rest of pregnancy was entered onto a data abstraction form. Patients diagnosed with GDM were further subdivided into two groups, GDM and impaired glucose tolerance (IGT), depending on the oral glucose tolerance test results. RESULTS: A total of 725 diabetic pregnancies were managed: 35 women had type 1 DM (T1DM), 194 had type 2 DM (T2DM), 192 had GDM and 304 had IGT. The median glycated haemoglobin (HbA1c) value at booking was highest for T1DM, followed by T2DM and lastly GDM. Overall, 10.7% of women had pre-existing hypertension and 9.8% developed pre-eclampsia (PET). The preterm delivery rate (before 38 weeks) was 68.8% for women with T1DM, 38.7% for those with T2DM, 34.9% for those with GDM and 22.4% for those with IGT. The caesarean section rate exceeded 50% in all groups. The overall perinatal mortality rate was 2.5% (25/1 000 births) for the study population, with T1DM and T2DM contributing most deaths (6.4% and 4.2%). The overall rate of congenital malformations was 2.4% (n=18 cases), but the rate was 5.7% for patients with T1DM and 4.6% for those with T2DM. CONCLUSION: The audit demonstrated outcomes similar to those in the developed world, with major congenital malformations, unexplained stillbirths and PET accounting for the majority of perinatal deaths. Stricter control with the aim of achieving lower or normal HbA1c levels before conception may be the only intervention that could bring about change.

High prevalence of "non-dipping" blood pressure and vascular stiffness in HIV-infected South Africans on antiretrovirals.

BACKGROUND: HIV-infected individuals are at increased risk of tissue inflammation and accelerated vascular aging ('inflamm-aging'). Abnormal diurnal blood pressure (BP) rhythms such as non-dipping may contribute to an increased risk of cardiovascular and cerebrovascular events in HIV infected individuals. However, little data exists on ambulatory blood pressure (ABP) and measures of vascular stiffness in the black African HIV infected population. METHODS: This is a cross-sectional analysis of otherwise well, HIV infected outpatients on ART for >5 years. Study assessments included: 24hr ABP monitoring, pulse wave velocity (PWV) and central aortic systolic pressure (CASP) using a AtCor Medical Sphygmocor device, fasting lipogram, oral glucose tolerance test, high-sensitivity C-reactive protein (hsCRP) and anthropometric data. Patients completed a questionnaire of autonomic symptoms. CD4+ counts and viral loads were obtained from the National Laboratory results system. RESULTS: Sixty seven black participants were included in the analysis of whom 91% (n = 61) were female with a mean age of 42.2 ± 8.6 years. The median duration on ART was 7.5 years (IQR = 6-10), 84% were virally supressed and the median CD4 count was 529.5cells/mm3 (IQR = 372.0-686.5). The majority (67%) were classified as overweight and 76% had an increased waist circumference, yet only 88% of participants were normotensive. A hsCRP level in the high cardiovascular risk category was found in 68% of participants. The prevalence of non-dipping BP was 65%. Interestingly, there was no association on multivariable analysis between dipping status and traditional risk factors for non-dipping BP, such as: obesity, autonomic dysfunction and older age. CONCLUSION: This relatively young cross-sectional sample of predominantly normotensive, but overweight black women on effective ART >5 years showed: a high prevalence of non-dipping BP, inflammation and vascular stiffness. Causality cannot be inferred but cardiovascular risk reduction should be emphasized in these patients.

Training community health workers to screen for cardiovascular disease risk in the community: experiences from Cape Town, South Africa

This article describes a training process to equip community health workers (CHWs) with knowledge and skills to identify individuals at high risk for cardiovascular disease (CVD) in a township in Cape Town.Methods: CHWs were employed by a non-governmental organisation (NGO) primarily focusing on non-communicable diseases (NCDs). They were trained in the theory of CVD, including physiological changes and related risk factors and in obtaining anthropometric and blood pressure measurements. Pre- and post-training tests assessed learning needs and the effectiveness of imparting knowledge about CVD, respectively.Results: Training increased knowledge about CVD risk factors. CHWs were able to screen and identify those at risk for CVD and refer them to health professionals for validation of scores. The initial one-week training was too short, given the amount of information covered. Some CHWs had difficulty with English as the primary instruction medium and as the only language in which tests were offered.Conclusion: Although CHWs could be trained to screen for CVD risk, increased training time was required to impart the knowledge. The language used during training and testing presented challenges for those trainees whose dominant, spoken language was not English

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa.

BACKGROUND: Low socioeconomic status is associated with the risk of hypertension. There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). OBJECTIVES: To investigate associations between patients' socio-economic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. METHODS: We enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for antihypertension medications were recorded at baseline and follow-up. Logistic regression models assessed associations between patients' socioeconomic status, characteristics of primary healthcare facilities, and control and treatment of blood pressure. RESULTS: Blood pressure was uncontrolled in 60% (1 917/3 220) of patients at baseline, which was less likely in patients with a higher level of education (p=0.001) and in English compared with Afrikaans respondents (p=0.033). Treatment was intensified in 48% (892/1 872) of patients with uncontrolled blood pressure at baseline, which was more likely in patients with higher blood pressure at baseline (p<0.001), concurrent diabetes (p=0.013), more education (p=0.020), and those who attended clinics offering off-site drug supply (p=0.009), with a doctor every day (p=0.004), or with more nurses (p<0.001). CONCLUSION: Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics.

Salivary Cortisol and Cortisone do not Appear to be Useful Biomarkers for Monitoring Hydrocortisone Replacement in Addison's Disease.

Salivary cortisol has been used to monitor hydrocortisone replacement in patients with Addison's disease (AD). Since salivary cortisol is metabolised to salivary cortisone, it may be an adjunctive analyte to assess adequacy of hydrocortisone replacement in patients with AD. We aimed to characterise the exposure of salivary cortisol and cortisone in patients and healthy controls. We measured salivary cortisol and cortisone by liquid chromatography-tandem mass spectrometry and constructed a day curve (08:00 until 24:00 h) with 16 time points in 25 AD patients taking their usual hydrocortisone dose and in 26 healthy controls. The median (interquartile range) area under the curve (AUC) for cortisol was not different for patients, compared with controls [55.63 (32.91-151.07) nmol*min*l-1 vs. 37.49 (27.41-52.00) nmol*min*l-1; p=0.098, respectively], whereas the peak cortisol Cmax was higher in patients [32.61 (5.75-146.19) nmol/l vs. 8.96 (6.96-12.23) nmol/l; p=0.013], compared with controls. The AUC for cortisone [23.65 (6.10-54.76) nmol*min*l-1 vs. 227.73 (200.10-280.52) nmol*min*l-1; p≤ 0.001, respectively], and peak cortisone Cmax was lower in patients than in controls [11.11 (2.91-35.85) nmol/l vs. 33.12 (25.97-39.95) nmol/l; p=0.002]. The AUC for salivary cortisol and salivary cortisone were not correlated with any measures of hydrocortisone dose. The time-course and AUC of salivary cortisol were similar between Addison's patients and healthy controls. Patients had substantially lower salivary cortisone AUC, compared to healthy controls. Salivary cortisol AUC and pharmacokinetics were not related to hydrocortisone dose and thus are not likely useful markers for the adequacy of hydrocortisone replacement.

Differential associations of cardiovascular disease risk factors with relative wealth in urban-dwelling South Africans.

BACKGROUND: To examine the associations of cardiovascular disease risk factors (CVDRF) with wealth, defined by the asset index, in 25- to 74-year-old black Africans in Cape Town. METHODS: Assets, including consumer durable goods, and CVDRF were determined in a randomly selected cross-sectional sample. A principal component analysis of the pooled data, based on assets that defined wealth, was used to develop an asset index. Ordinal logistic regression analyses assessed the independent associations of CVDRF with wealth tertiles. RESULTS: Among the 1099 participants, the least poor compared with the poorest tertile had significantly higher prevalence of diabetes (16.3 versus 9.6%), hypercholesterolaemia (33.9 versus 21.4%), obesity (45.4 versus 26.3%) and fat intake ≥30% of diet (44.2 versus 29.3%). Daily smoking was highest in the poorest (35.8%) versus the least poor (26.4%). Psychosocial stress (low sense of coherence or locus of control) was significantly higher in poorer participants. In the regression analyses, wealth was associated with male gender [odds ratio (OR): 1.89, 95% confidence interval (CI): 1.37-2.60], urbanization (OR: 1.02, 95% CI: 1.01-1.02), high fat intake, obesity and hypercholesterolaemia. Daily smoking, problematic alcohol use (OR: 0.70, 95% CI: 0.52-0.94) and psychosocial stress were inversely related to wealth. CONCLUSIONS: Differential distribution of CVDRF by wealth mandates incorporating equity components when developing tailored interventions.