Prevalence and risk factors of airflow obstruction in a Caribbean population.

SETTING: The prevalence of airflow obstruction (AO) in the Caribbean population is unknown.OBJECTIVE: To measure the prevalence of and risk factors for AO (post-bronchodilator ratio of forced expiratory volume in 1 sec to forced vital capacity of <0.7) in the Trinidad and Tobago general population using the Burden of Obstructive Lung Disease methodology.DESIGN: National cross-sectional, stratified, cluster sampling of adults aged ≥40 years.RESULTS: AO prevalence was 9.5% among 1104 participants, most of whom were unaware of this. Compared to those aged 40-49 years, the adjusted odds ratio of AO by age group was 2.73 (60-69 years) and 3.30 (≥70 years). Risk factors for AO were unemployment (OR 4.31), being retired (OR 2.17), smoking ≥20 pack-years (OR 1.88) and exposure to dusty jobs for more than 1 year (OR 2.06). Related symptoms were history of wheezing, unscheduled visits to the doctor or admission to hospital for breathing problems and in subjects with at least one respiratory symptom (OR 1.90), at least one risk factor (OR 2.81), either symptoms or risk factors (OR 3.71) and both symptoms and risk factors (OR 5.78) (P < 0.05 in all cases).CONCLUSION: AO prevalence in the general population of Trinidad and Tobago aged ≥40 years was 9.5%, almost all of which was undiagnosed. AO was associated with smoking, age >59 years, lack of employment and working in a dusty job.

Occupational dust exposure is independently associated with Chronic Obstructive Pulmonary Disease (COPD) in Trinidad and Tobago population

Objective: COPD is a leading cause of mortality and morbidity worldwide. Although cigarette smoking is a well-known risk factor for COPD, nonsmokers may account for one fourth to half of all cases. The Burden of Obstructive Lung Disease in Trinidad and Tobago (BOLD-TT) study objective was to measure the COPD prevalence and its risk factors in the local population aged 40 years and older. Design and Methodology: In this cross-sectional survey participants were selected using two-stage stratified-cluster sampling to represent the national population in terms of gender, age and ethnic distributions. Quality assured spirometry and questionnaires were administered. Results: Among the 1,104 participants, 36% reported occupational dust exposure for more than one year and about 40% of them were never-smokers. Overall 9.5% (95% CI: 7.78 to 11.23%) of the studied population showed COPD, accounting for an estimated 49,170 persons (95% CI = 40,267; 58,124) in Trinidad and Tobago. The majority (60%) of the diagnosed COPD was attributable to non-smoking causes, and more than half of them reported occupational dust exposure. Multiple logistic regression analysis confirmed COPD's independent association with working in a dusty job (OR 2.05; 95% CI=1.26, 3.35). Conclusions: Risk of COPD in the Trinidad and Tobago general population is significantly associated with occupational dust exposure which is probably contributing about one-third of current COPD burden. International studies showed that only about 15% of overall COPD could be ascribed to occupational risk factors. The higher occupational related COPD risk in the local population should be further studied prospectively.

Quality of sleep in Trinidad among the adult population

Objective: Sleep is a determinant of a positive life which is heavily influenced by the individual's lifestyle. The objectives of the study were to: (i) assess the quality of sleep among the Trinidad population and effects of associated demographics; (ii) assess the determinants of poor sleep quantity and quality; and (iii) evaluate participant's knowledge about sleep and importance of sleep. Design and Methodology: A cross-sectional study among the residents of Trinidad aged 18 and above was conducted from 18th May 2018 to 30th June 2018. Nonprobability convenience sampling was utilized to obtain information at public malls including: Trincity Mall, Gulf City Mall, Long Circular Mall, West mall and Valpark Mall. Results: 1505 participants were interviewed with 56.1% being poor sleepers while 43.9% were good sleepers. Participants over 40 years were found to have the lowest percentage of good sleepers. Diabetes Mellitus and sex were not found to be a significant determinant of sleep quality (p= 0.865; p=0.351 respectively). Employment status was associated with sleep quality (p <0.001). Night shift workers were more likely than other persons to report bad sleep quality was. Persons who lived in noisy areas and were also poor sleepers. Conclusion: The determinants of sleep quality in the adult Trinidad population were found to be older age, night shift workers and persons who lived in noisy areas or streets.

Indo-Caribbean population has lower vital capacities than Afro-Caribbean population in Trinidad and Tobago

Objective: Low forced vital capacity (FVC) is a good predictor of mortality and morbidity including cardiovascular disease, diabetes and chronic kidney disease in the general population. Objective of the current post-hoc analysis was to compare the FVCs among the major ethnic groups of Trinidad and Tobago. Design and Methodology: The Burden of Obstructive Lung Disease in Trinidad and Tobago (BOLD-TT) study was conducted to measure the COPD prevalence and its risk factors in the local population of 40 years and older by using questionnaires and quality assured spirometry. The participants were selected using two-stage stratified, cluster sampling to represent the national population in terms of gender, age and ethnic distributions. To avoid the influence of contentious international spirometry predictive values, FVC was used as a continuous variable after adjusting for age, gender, height and height square. Results: Among the 1,104 participants, 42% were Indo- Caribbeans, and 36% were Afro-Caribbeans. Indo- Caribbeans had a similar prevalence of abnormal waist circumference (57.0% vs. 58.7%; p=0.751), a lower prevalence of obesity (30.0% vs. 41.8%; p=0.008), but a higher prevalence of abnormal waist-hip ratio (74.1% vs. 57.5%; p<0.001) and diabetes (21% vs. 10%; p<0.001) than the Afro- Caribbeans. Multiple regression analysis indicated that FVC was independently associated with ethnicity and revealed lower volumes in Indo- Caribbean participants than Afro-Caribbeans (-180ml; 95%CI:-90ml,-269ml; p<0.001). Conclusions: The Indo-Caribbean population has a lower FVC than the Afro-Caribbean population which was independent of age, gender, and height. Healthrelated consequences of low FVC among local ethnic groups warrant further research using longitudinal studies.

Asymptomatic 'normal' subjects may have a respiratory health burden as assessed by the St Georges Respiratory Questionnaire (SGRQ)

Objectives: The Burden of Obstructive Lung Disease study in Trinidad and Tobago identified subjects with obstruction and no symptoms in approximately 5% of the general population over 40 years old. We reviewed data from a previously published study involving asymptomatic subjects to determine respiratory health burden and relation to lung function. Results: Subject characteristics were: 16 (64%) males, Mean (SD) age 64.8 (6.78) years, forced expiratory volume (FEV1) 2.25 (0.77)L, forced vital capacity (FVC) 2.91 (1.02) L, FEV1/FVC 78.1 (8.31)%. Parameters assessed were FEV1 (1.21 to 3.69 L); FVC (1.32 to 4.88 L); FEV1/FVC (65.2 - 94.7%); SGRQ Total Score (0 to 20.8). Three subjects (12%) had a FEV1/FVC ratio of less than 70%. The correlations (rho, p) of total SGRQ scores were FEV1 (-0.62, 0.001), FEV1% (-0.52, 0.008); FVC (-0.69, < 0.001). Conclusion: Asymptomatic normal elderly subjects had significant respiratory health burden as measured by the SGRQ and this was worse in those with a lower FEV1%. This may apply to elderly persons in the general population.

Sex and social class inequities in physical and mental health: an analysis using data from the Burden of Obstructive Lung Disease Trinidad and Tobago (BOLD-TT) study

Objectives: To examine sex and social class differences in physical and mental health in the Trinidad and Tobago population aged ≥40 years. Design and Methodology: Data from the BOLD-TT study, which included a stratified cluster sample of 1104 persons, were analysed. The Veteran Rand (VR)-12 instrument assessed physical (general health, physical functioning and role playing and bodily pain) and mental health (vitality, role-emotional, mental health and social functioning); using a physical health component (PCS) and mental health component (MCS) scores. Highest level of education attained, and employment status were used as measures of social class. General Linear Models were used to examine differences in PCS and MCS by sex, education and employment, controlling for age. Results: Mean age of the participants was 54.1 (SD10.8) years; 59.9% were females; 47% had no/primary education; 56% were employed. Mean PCS and MCS (SEM) scores were 47.8 (0.3) and 54.7 (0.3). Females had lower mean PCS and MCS than males (p<.001 in each case). There were significant mean differences in PCS (p<.001) and MCS (p=.04) by employment status. Persons who were not working had lower mean PCS (p<.001) and MCS (p=.002) than those employed. There were differences in PCS by education (p=.019); persons with no/primary education had lower PCS than those with post-secondary and university education. Multiple regression identified employment (p<.001) and education (p=.097) as independent predictors of PCS while sex (p=.002) and employment (p=.021) predicted MCS. Conclusion: The VR-12 provided initial results indicating health inequities i.e. poorer health status among females, the unemployed and uneducated.

A Descriptive Study of Chronic Obstructive Pulmonary Disease in Tertiary Care Clinics of a Caribbean Island / Estudio descriptivo de la enfermedad pulmonar obstructiva crónica en clínicas de atención terciaria de una isla caribeña

ABSTRACT Objective: To determine the relationship between severity of chronic obstructive pulmonary disease (COPD) and quality of life as well as COPD's correlation with depressive symptoms in West Indian subjects. Methods: This is a cross-sectional, observational study of outpatients with COPD in tertiary care. The severity of COPD was determined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, GOLD group, and body mass index, airflow obstruction, dyspnoea and exercise capacity (BODE) index. Quality of life was assessed by the St George Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT), and depression was assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Results: A total of 105 patients (85.7% male, 37.1% Indo-Trinidadian, 42.9% Afro-Trinidadian, 64.8% primary level education) were recruited with a mean age of 66.9 years (standard deviation: 9.60 years). The median body mass index was 25 kg/m2; 26.7% were underweight. Risk factors identified were: ever-smokers (27.6%), marijuana (20%), biomass (81.9%), passive smoke (70.5%), occupational exposures (80%). The CES-D of 25% of the patients was ≥16. Co-morbidities included diabetes (22%), hypertension (29%), gastro-oesophageal reflux disease (10%) and previous myocardial infarction (15%). A total of 59% of the patients reported a monthly household income of less than US$800. Lower level of education was associated with worse SGRQ (total and impact), lower forced expiratory volume in one second, modified Medical Research Council scale (mMRC) of ≥ 2 and higher BODE index. Higher GOLD group correlated with worse SGRQ, CAT and CES-D. Higher CES-D was associated with shorter six-minute walk distance, worse SGRQ, CAT and mMRC scores, higher GOLD group and increased COPD admissions per year. Patients with a CES-D of ≥ 16 walked shorter distances. Higher BODE quartile was associated with worse SGRQ, CAT and CES-D scores. Conclusion: Higher GOLD group and higher BODE quartile were associated with worse quality of life scores and higher depression scores. Patients in higher GOLD groups should be screened for depression. Education on COPD should be targeted at those of lower socioeconomic status.

RESUMEN Objetivo: Determinar la relación entre la severidad de la enfermedad pulmonar obstructiva crónica (EPOC) y la calidad de vida, así como la correlación de la EPOC con síntomas depresivos en sujetos antillanos. Métodos: Se realizó un estudio observacional transversal de pacientes ambulatorios con EPOC en cuidados terciarios. La severidad de la EPOC fue determinada por la etapa de la Iniciativa Global para la Enfermedad Pulmonar Obstructiva Crónica (GOLD, en inglés), el grupo GOLD, así como el índice de masa corporal, la obstrucción del flujo de aire, la disnea y la capacidad de ejercicio (índice BODE). La calidad de vida fue evaluada mediante el Cuestionario Respiratorio de Saint George (CRSG) y la prueba de evaluación de la EPOC (CAT, en inglés), en tanto que la depresión fue evaluada por la Escala de Depresión del Centro de Estudios Epidemiológicos (CES-D). Resultados: Un total de 105 pacientes (85.7% varones, 37.1% indotrinitenses, 42.9% afrotrinitenses, 64.8% nivel de educación primaria) fueron reclutados con una edad promedio de 66.9 años (desviación estándar: 9.60 años). El índice de masa corporal promedio fue de 25 kg/m2; 26.7% por debajo del peso normal. Los factores de riesgo identificados fueron: fumar ocasionalmente (27.6%), marihuana (20%), biomasa (81.9%), humo pasivo (70.5%), exposición ocupacional (80%). El CES-D del 25% de los pacientes fue ≥ 16. Las comorbilidades incluyeron diabetes (22%), hipertensión (29%), enfermedad por reflujo gastroesofágico (10%), y previo infarto del miocardio (15%). Un total de 59% de los pacientes reportaron un ingreso mensual familiar de menos de $800 USD. El nivel más bajo de educación se asoció con un peor (CRSG) (total e impacto), menor volumen espiratorio forzado en un segundo, Escala del Consejo de Investigaciones Médicas modificada (mMRC) de ≥ 2, y más alto índice de BODE. Un grupo más alto de GOLD se correlacionó con peores resultados de CRSG, CAT y CES-D. El CES-D más alto se asoció con una caminata de una distancia más corta en seis minutos, peores puntuaciones de CRSG, CAT y mMRC, un grupo más alto de GOLD, y mayores ingresos de EPOC por año. Los pacientes con CES-D de ≥ 16 caminaron distancias más cortas. El cuartil más alto de BODE estuvo asociado con las puntuaciones peores de CRSG, CAT y CES-D. Conclusión: El grupo GOLD más alto y el cuartil más alto de BODE se asociaron con peores puntuaciones de calidad de vida y puntuaciones de depresión más altas. Los pacientes en los grupos de GOLD más altos deben ser tamizados para detectar si padecen depresión. La educación sobre la EPOC debe estar dirigida a aquellos que tienen una situación socioeconómica inferior.

Prevalence of COPD in Trinidad and Tobago - A National Study

Purpose: Chronic Obstructive Pulmonary Disease (COPD) is preventable and treatable, yet it is the third leading cause of death and fifth leading cause of disability globally. Local studies in restricted settings have reported about 20% COPD prevalence, but the national prevalence and risk factors are unknown. We aimed to measure the prevalence of COPD and its risk factors in Trinidad and Tobago as part of the multicentre Burden of Obstructive Lung Disease (BOLD) Study. Research Design and Methodology Used: A cross-sectional study was conducted during 2014-2015 using the BOLD standardised protocol. A stratified cluster sample of non-institutionalised males and females aged ≥ 40 years (N = 1104) and a sample of 18-39 year olds (N = 807) were selected. Questionnaires on respiratory symptoms, health status, and exposure to COPD risk factors were administered and spirometry conducted before and after bronchodilator. Spirometry quality control measures utilised were (1) direct spirometer feedback and (2) BOLD international centre review. Spirometry readings below international standards required technician retraining. Post- bronchodilator forced expiratory volume in the first second of expiration (FEV1) was expressed as a percentile of the forced vital capacity (FVC). COPD was defined by FEV1/FVC < 70% and a smoker as having smoked >200 cigarettes in a lifetime. Logistic regression was used to examine associations a (expressed as Odds Ratios (OR) and multivariate logistic regression to determine independent risk factors. Findings: There was a 95% response rate The mean age (SD) of these participants was 54 (11) years and Body Mass Index (BMI) 29 (7) kg/m2; with N (%) males, 443 (40) males; Afro-Trinidadians 400 (37), Indos 454(42), Mixed 234 (21), ever-smokers 302 (27), current smokers 157 (14), Adverse events 13(<1%)]. The prevalence of COPD was 9.5%, Of those with COPD, only 4% reported a previous doctor diagnosed COPD. COPD was more likely among those aged 60-69 years or over 70 (OR=4.15 and 5.88 respectively, p<0.001), among males (OR=1.64, p=0.023), ever smokers (OR=1.72, p=.016), retirees and the unemployed (OR=4.41 and 3.59 respectively, p<.001), with BMI<21 (OR=2.64, p=.001), asthma (OR=5.20, p<.001) or wheezing (OR=3.48, p<.001). Multivariate analysis showed significant risk factors for COPD were: older age groups, low BMI, working over a year in dusty jobs, cigarette or cannabis smoking. There was no non-responder bias in age, gender, ethnicity, smoking or BMI but unacceptable spirometry was more likely in the elderly and smokers. Among the 807 participants aged 18-39 years old, 23% smoked with the prevalence of smoking in males being 32% vs. 11.7% in females (p < 0.001). Conclusions: COPD is prevalent yet under-diagnosed in the general population. Health care education and use of spirometry for prevention of COPD should target males, the elderly, smokers, those working in dusty jobs and those with a history of asthma or wheeze. We suggest spirometry measurements be available at all district health facilities.

Is obesity a significant impacting factor of asthma control?

OBJECTIVE: To measure the control of bronchial asthma, quality of life, trigger factors and co-morbidities in patients of different weight classes. SUBJECTS AND METHODS: This cross-sectional study involved 365 adult asthmatics from outpatient clinics at four major health facilities in Trinidad. Data were obtained from patient interviews, asthma control test (ACT) and the Mini Asthma Quality of Life Questionnaire (Mini AQLQ). Weight and height measurements were taken to determine body mass index (BMI), waist circumference and waist/hip ratio. Data obtained were analysed to determine associations between obesity and asthma control, associated co-morbidities, risk factors and impaired quality of life. RESULTS: A significant number of participants was females(81%), aged 60+ years (37%), Indo-Trinidadians (62%),obese (41%) and uncontrolled asthmatics (72%). Chisquared analysis revealed significant association between obesity and asthma control status (5.810; df = 1; p =0.016). Receiver operating characteristic analysis revealed BMI (AUC = 0.648) as the strongest predictor of asthma control among all obesity parameters. Logistic regression showed that higher BMI (OR = 1.05; p = 0.008) or general obesity (OR = 2.37; p = 0.003) were significantly associated with the increased odds of having uncontrolled asthma. Major trigger factors and co-morbidities were similar among obese and non-obese asthmatics. Sub analysis of obese asthmatics showed that the following were significantly associated with poor asthma control: sleep apnoea (OR = 0.45, p = 0.006), allergic rhinitis (OR= 0.562, p = 0.031) and stress (OR = 0.480, p = 0.027). CONCLUSION: Obesity negatively affects asthma control and the quality of life of asthmatics. Further studies are needed to confirm these findings and to evaluate the role of weight reduction in asthma control.

Spirometry quality control: man versus machine

OBJECTIVE: To compare the efficacy of local quality control (QC) of BOLD (Burden of Obstructive Lung Disease) Trinidad and Tobago study with spirometer machine quality grades as well as with BOLD Pulmonary Function Reading Centre QC standards at Imperial College, London. METHODOLOGY: Quality of the randomly chosen two hundred spirometries was independently assessed by the local team based on the 2005 ATS/ERS spirometry standards. Central QC quality assessment results were blinded to the local team. However, the machine quality grades were readily available to both the central and local teams during interpretation. Local and machine QC performances were correlated with the central QC which was taken as the gold standard for this study. RESULTS: According to central QC, 17.5% of the spirometries were declared as unacceptable. The noted common errors were prolonged peak expiratory flow time(14.5%), submaximal blasts (11.5%), variable efforts (11%) and poor reproducibility (10%). Cronbach’s alpha assessment revealed an overall reliability of 0.82 and a correlation of 0.73 between central and local QC. The correlation between central and machine QC was poor(0.548). Local QC exhibited 89.1% sensitivity and 94.3% specificity relative to the central QC. Though the machine QC displayed a better sensitivity (97.6%), its specificity was significantly lower 45.7%). CONCLUSION: Local QC was effective when compared with the central QC and executed better performance than the machine’s QC. This expertise can now be utilized for the future spirometry based local research studies. Due to limitations in identifying various errors, machine QC should not solely be used as the determinant of acceptability.

Evaluating the risk of obstructive sleep apnea in type 2 diabetic patients, and its associations

OBJECTIVE: To assess the prevalence of high risk of Obstructive Sleep Apnoea (OSA) in Type 2 diabetics. To identify risk associations of OSA with obesity, sleep quality, daytime sleepiness and Acanthosis Nigricans. DESIGN AND METHODS: A cross sectional study was done in the diabetic wards of health facilities governed by three Regional Health Authorities in Trinidad. OSA risk was assessed by the Snoring, Tiredness, Observed Apnea, high blood Pressure (STOP) – Body mass index, Age, Neck circumference and Gender (BANG) questionnaire. Sleep quality and daytime sleepiness were also assessed by the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale respectively. Bioimpedance analysis was also done using a stadiometer and standard bioimpedance scale. RESULTS: A total of 281 diabetic patients and 147 non-diabetic patients were interviewed throughout Trinidad. Females made up the majority of the sample, 67% of the diabetics and 66% of the non diabetics. The prevalence of OSA was found to be 73.2% in type 2 diabetics. Non diabetics had an OSA prevalence of 39.5%. Results from a binary regression showed that having diabetes increased the probability of “High Risk of OSA” by 93.1%. CONCLUSION: The prevalence of high risk of OSA in Trinidad was high in type 2 diabetic patients, and has strong correlations with obesity and Acanthosis Nigricans.

High prevalence of diabetes mellitus in a cohort of Trinidadian patients with chronic obstructive pulmonary disease

OBJECTIVE: To define the prevalence of diabetes mellitus (DM) in a cohort of Trinidadian chronic obstructive pulmonary disease (COPD) patients, and investigate its relationship to lung function, quality of life, and depression. DESIGN AND METHODS: Anthropometric and spirometric data were obtained from 108 COPD (91 males) patients from Trinidad chest clinics, who also had HbA1c test results. Questionnaires on quality of life St. George’s Respiratory questionnaire ({SGRQ} and COPD Assessment Test {CAT}) and depression (Center for Epidemiologic Studies Depression Scale {CES-D & CESD-R}) were administered, and an interview conducted. RESULTS: Mean (SD) age: 67.4 (11.0) years. Median (IQR) HbA1c: 6.1 (5.7, 6.7) %. HbA1c values were obtained for 105 patients of whom 40% had diabetes, and 40% pre-diabetes. Diabetics had a greater (p=0.001) median (IQR) BMI [27.3 (24.1, 30.4)] than non-diabetics [24.2 (21.2, 27.2)]. Patients with at least one chest infection/exacerbation in the past year had increasing CAT & SGRQ Total (p<0.001), and CES-D & CESD-R (p≤0.013) scores. CAT and SGRQ total scores were negatively related to lung function and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages (p<0.001). All lung function parameters, except Forced expiratory volume/Forced vital capacity (FEV1/FVC), decreased with increasing CES-D and CESD-R scores (p<0.05). CAT & SGRQ correlated well with CES-D & CESD-R scores (p<0.001). Intravenous corticosteroid use was positively associated with HbA1c (p=0.043). Dosage of inhaled corticosteroids was associated with lower FEV1 (p=0.034) and higher SGRQ & CAT (p≤0.048). FVC % predicted was negatively related to HbA1c (p=0.033). CONCLUSION: The prevalence of DM in the COPD patients was 40%; however no significant correlations of DM to outcome measures were observed. Patients with worse quality of life due poor lung function were more depressed.

Association between health literacy, inhaler technique and disease control in obstructive airway disease

OBJECTIVE: The association of health literacy with compliance, inhaler technique and disease control with respect to both asthma and chronic obstructive pulmonary disease (COPD) patients is poorly addressed. We examined the association between health literacy, inhaler technique and disease control in patients suffering from obstructive lung disease in Trinidad. DESIGN AND METHODS: The method was a cross-sectional study which employed 781 patients from Chest Clinics in Trinidad (Arima Health Facility, Eric Williams Medical Sciences Complex, Port of Spain and San Fernando General Hospitals). Out-patients were interviewed on a pilot tested questionnaire for information on compliance and disease control. Morisky 8- item Medication Adherence Questionnaire, Asthma Control Test (ACT), and COPD Assessment Test (CAT) were used to assess compliance, asthma and COPD control respectively. Health literacy was assessed using Rapid Estimate of Adult Literacy in Medicine – short form (REALM- SF), and inhaler technique was observed on dummies.