Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases.

OBJECTIVE: To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries. METHODS: The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire. RESULTS: Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries. CONCLUSIONS: The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data.

BACKGROUND: WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS: We analysed information about availability and costs of cardiovascular disease medicines (aspirin, ß blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS: Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION: Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Cardiovascular risk and events in 17 low-, middle-, and high-income countries.

BACKGROUND: More than 80% of deaths from cardiovascular disease are estimated to occur in low-income and middle-income countries, but the reasons are unknown. METHODS: We enrolled 156,424 persons from 628 urban and rural communities in 17 countries (3 high-income, 10 middle-income, and 4 low-income countries) and assessed their cardiovascular risk using the INTERHEART Risk Score, a validated score for quantifying risk-factor burden without the use of laboratory testing (with higher scores indicating greater risk-factor burden). Participants were followed for incident cardiovascular disease and death for a mean of 4.1 years. RESULTS: The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 person-years vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3% in high-, middle-, and low-income countries, respectively; P=0.01). Urban communities had a higher risk-factor burden than rural communities but lower rates of cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) and case fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medications and revascularization procedures was significantly more common in high-income countries than in middle- or low-income countries (P<0.001). CONCLUSIONS: Although the risk-factor burden was lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries. The high burden of risk factors in high-income countries may have been mitigated by better control of risk factors and more frequent use of proven pharmacologic therapies and revascularization. (Funded by the Population Health Research Institute and others.).

Body mass index cut-points to identify cardiometabolic risk in black South Africans.

PURPOSE: To determine optimal body mass index (BMI) cut-points for the identification of cardiometabolic risk in black South African adults. METHODS: We performed a cross-sectional study of a weighted sample of healthy black South Africans aged 25-65 years (721 men, 1386 women) from the North West and Free State Provinces. Demographic, lifestyle and anthropometric measures were taken, and blood pressure, fasting serum triglycerides, high-density lipoprotein (HDL) cholesterol and blood glucose were measured. We defined elevated cardiometabolic risk as having three or more risk factors according to international metabolic syndrome criteria. Receiver operating characteristic curves were applied to identify an optimal BMI cut-point for men and women. RESULTS: BMI had good diagnostic performance to identify clustering of three or more risk factors, as well as individual risk factors: low HDL-cholesterol, elevated fasting glucose and triglycerides, with areas under the curve >.6, but not for high blood pressure. Optimal BMI cut-points averaged 22 kg/m2 for men and 28 kg/m2 for women, respectively, with better sensitivity in men (44.0-71.9 %), and in women (60.6-69.8 %), compared to a BMI of 30 kg/m2 (17-19.1, 53-61.4 %, respectively). Men and women with a BMI >22 and >28 kg/m2, respectively, had significantly increased probability of elevated cardiometabolic risk after adjustment for age, alcohol use and smoking. CONCLUSION: In black South African men, a BMI cut-point of 22 kg/m2 identifies those at cardiometabolic risk, whereas a BMI of 30 kg/m2 underestimates risk. In women, a cut-point of 28 kg/m2, approaching the WHO obesity cut-point, identifies those at risk.

HIV stigma experiences and stigmatisation before and after a HIV stigma-reduction community "hub" intervention.

This study sought to explore, describe and determine whether an HIV stigma-reduction community "hub" intervention would change the HIV stigma experiences of people living with HIV (PLWH) and the stigmatisation by the community in an urban area in South Africa. A convergent parallel mixed-method design with a single case pre-test post-test design and an interpretive description approach was utilised. The sample for this study included 62 PLWH recruited through accessibility sampling and 570 community members recruited through random voluntary sampling. A sub-sample of both groups, selected using purposive voluntary sampling, was utilised for the in-depth interviews about stigma experiences of PLWH, and for perceptions and attitudes of the community toward PLWH. Both quantitative and qualitative data showed that stigma is present. Although no statistically significant changes were found, small practically significant changes were demonstrated in the experiences of PLWH and in the perceptions and attitudes of the community. The extent of changes was much more obvious in the responses of the PLWH and the community during their post-intervention qualitative interviews than the changes found with the quantitative measures. This study thus concludes that the HIV stigma-reduction community hub intervention was successful in initiating the onset of changes in a community through the PLWH and people living close to PLWH (PLC) as community mobilisers active in the community hub to mobilise their own communities towards HIV stigma reduction through social change.

Lung function, inflammation and cardiovascular mortality in Africans.

BACKGROUND: The link between impaired lung function and cardiovascular outcome is well established in European and American populations. It is possible that this association may be driven by a systemic spillover of inflammation occurring within the lungs. As several studies have found an increased level of inflammatory markers in African populations, we aimed to establish the contribution of lung function in predicting all-cause and cardiovascular mortality in Africans, whilst taking inflammatory markers into account. DESIGN: We followed 1442 black South Africans from the North West Province participating in the South African leg of the Prospective Urban and Rural Epidemiology (PURE) study, over a five-year period. Spirometry, cardiovascular and metabolic measures were performed, and cardiovascular mortality as well as all-cause mortality used as endpoints. RESULTS: In univariate Cox regression models, both forced expiratory volume in 1-s (FEV1 ) and forced vital capacity (FVC) predicted all-cause (P = 0·022; P < 0·001) and cardiovascular mortality (P = 0·004; P < 0·001). In multivariate adjusted standardized Cox regression analyses, only FVC predicted cardiovascular mortality independent of several covariates (hazard ratio, 0·57 [0·35-0·94]), including C-reactive protein (CRP). When CRP was replaced by interleukin-6 in the model, the significance of FVC was lost (hazard ratio, 0·85 [0·55-1·30]). CONCLUSION: FVC, but not FEV1 , is a strong predictor of both all-cause and CV mortality in black South Africans, which may be mediated by inflammation.

Wealth and cardiovascular health: a cross-sectional study of wealth-related inequalities in the awareness, treatment and control of hypertension in high-, middle- and low-income countries.

BACKGROUND: Effective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household's ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urban and Rural Epidemiology study. METHODS: A cross-section of 163,397 adults aged 35 to 70 years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in the levels of hypertension awareness, treatment, and control in each of the 21 country samples. RESULTS: Overall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control was observed to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed for hypertension control in countries at all levels of economic development. In some countries, hypertension awareness was greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden). CONCLUSION: Inequality in hypertension management outcomes decreased as countries became richer, but the considerable variation in patterns of wealth-related inequality - even among countries at similar levels of economic development - underscores the importance of health systems in improving hypertension management for all. These findings show that some, but not all, countries, including those with limited resources, have been able to achieve more equitable management of hypertension; and strategies must be tailored to national contexts to achieve optimal impact at population level.

Effect of African leafy vegetables on the micronutrient status of mildly deficient farm-school children in South Africa: a randomized controlled study.

OBJECTIVE: A randomized controlled trial was conducted to assess the effect of African leafy vegetable (ALV) consumption on Fe, Zn and vitamin A status in children. DESIGN: Children were randomly allocated to receive either a 300 g cooked ALV dish and school meal starch (n 86) or the normal school meal (n 81) five times per week for three months. ALV in the dish consisted mainly of Amaranthus cruentus (at least 80 %) and the remainder of Cleome gynandra, Cucurbita maxima or Vigna unguiculata. Nutrient content and consumer acceptance of the ALV dish were also determined. SETTING: North West Province, South Africa. SUBJECTS: Grade R to grade 4 children (6-12 years old) of two farm schools. RESULTS: The ALV dish contributed 11·6-15·8 mg Fe and 1·4-3·7 mg Zn. At baseline, prevalence of deficiencies in the intervention group was 16·0 %, 16·3 %, 7·0 % and 75·6 %, respectively, for anaemia (Hb<11·5 g/dl), Fe (serum ferritin<15 µg/l), vitamin A (serum retinol<20 µg/dl) and Zn (serum Zn<65 µg/dl); and in the control group 10·5 %, 18·5 %, 2·5 % and 75·3 %, respectively. No significant estimated intervention effect was found. CONCLUSIONS: This randomized controlled trial showed that ALV were unable to improve serum retinol, serum ferritin or Hb if there are only mild deficiencies present. Furthermore, despite the low Zn status in the study population, ALV consumption did not improve serum Zn concentrations either.

Assessing global risk factors for non-fatal injuries from road traffic accidents and falls in adults aged 35-70†years in 17 countries: a cross-sectional analysis of the Prospective Urban Rural Epidemiological (PURE) study.

OBJECTIVES: To assess risk factors associated with non-fatal injuries (NFIs) from road traffic accidents (RTAs) or falls. METHODS: Our study included 151 609 participants from the Prospective Urban Rural Epidemiological study. Participants reported whether they experienced injuries within the past 12 months that limited normal activities. Additional questions elicited data on risk factors. We employed multivariable logistic regression to analyse data. RESULTS: Overall, 5979 participants (3.9% of 151 609) reported at least one NFI. Total number of NFIs was 6300: 1428 were caused by RTAs (22.7%), 1948 by falls (30.9%) and 2924 by other causes (46.4%). Married/common law status was associated with fewer falls, but not with RTA. Age 65-70 years was associated with fewer RTAs, but more falls; age 55-64 years was associated with more falls. Male versus female was associated with more RTAs and fewer falls. In lower-middle-income countries, rural residence was associated with more RTAs and falls; in low-income countries, rural residence was associated with fewer RTAs. Previous alcohol use was associated with more RTAs and falls; current alcohol use was associated with more falls. Education was not associated with either NFI type. CONCLUSIONS: This study of persons aged 35-70 years found that some risk factors for NFI differ according to whether the injury is related to RTA or falls. Policymakers may use these differences to guide the design of prevention policies for RTA-related or fall-related NFI.

Inflammation as Possible Mediator for the Relationship Between Lung and Arterial Function.

INTRODUCTION: Reduced lung function is associated with a risk for the development of cardiovascular disease. This association may be due to chronic inflammation which is often present in those with reduced lung function. PURPOSE: We investigated the possible role of systemic inflammation as the mediator between lung function and arterial stiffness in 1534 black South Africans. METHODS: Spirometric data including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were obtained. C-reactive protein (CRP), interleukin-6 (IL-6), blood pressure (BP) and carotid-radial pulse wave velocity (PWV) were determined. RESULTS: In multivariable-adjusted models, an independent inverse association was found between IL-6 and FEV1 (ß = -0.20, p < 0.001) and FVC (ß = -0.18, p < 0.001). Similar results were found for CRP. PWV was inversely associated with FEV1 (ß = -0.06, p = 0.037). No association was found between inflammatory markers, BP or PWV. CONCLUSION: Reduced lung function was associated with increased inflammation and arterial stiffness. The lack of association between arterial stiffness and inflammatory markers suggests that inflammation may not be the mediating link between lung and vascular function in this population.

Psychosocial well-being of people living with HIV and the community before and after a HIV stigma-reduction community "hub" network intervention.

The purpose of the research was to determine whether an HIV stigma-reduction community "hub" network intervention in a South African urban area would bring about a difference in the psychosocial well-being of people living with HIV (PLWH), as well as their community (living in the same municipal ward). A single case pre-test post-test design was implemented. The sample for this study included 62 PLWH who were selected through accessibility sampling and 570 community members who were selected through random voluntary sampling. Participants completed the Patient Health Questionnaire (PHQ-9) and the Mental Health Continuum-Short Form (MHC-SF) before and after the intervention. A dependent t-test as well as Cohen's d-values were used to calculate the differences between the pre- and post-test results for depression and well-being. Levels of languishing, moderate mental health and flourishing before and after the intervention were determined. Although the focus of the HIV stigma-reduction community "hub" intervention that was followed in this study was on the involvement of PLWH and people living close to them (PLC) to share their knowledge as community mobilisers and to mobilise and empower their own community to reduce HIV stigma, it can be concluded that a secondary gain was the effect it had on both depression and mental health of the PLWH as well as the community. Of interest is how these effects differed for PLWH and the community. It is thus recommended that future interventions should give special attention to aspects of depression and well-being.

Evidence that fibrinogen γ' regulates plasma clot structure and lysis and relationship to cardiovascular risk factors in black Africans.

Fibrinogen γ' is known to influence fibrin clot structure in purified experimental models, but little is known regarding its influence on clot structure in plasma. Furthermore, the environmental and biological factors that affect its concentration are poorly described. We analyzed fibrinogen γ', total fibrinogen concentration, and fibrin clot structure in 2010 apparently healthy black South Africans and related them to traditional cardiovascular disease (CVD) risk factors. Fibrinogen γ' generally increased with increasing fibrinogen concentration, but a decreased γ'/total fibrinogen ratio was found at the highest total fibrinogen concentrations. Clot maximum absorbance increased with total fibrinogen and fibrinogen γ', but decreased with γ'/total fibrinogen ratio. Clot lysis time showed a stronger relationship with fibrinogen γ' than with total fibrinogen, whereby increased fibrinogen γ' delayed clot lysis. CVD risk factors (excluding fibrinogen) explained 20% and 3%, respectively, of the variance in fibrinogen γ' and the γ'/total fibrinogen ratio, with C-reactive protein making the biggest contribution. More than 50% of the variance in fibrinogen γ' and γ'/total fibrinogen ratio is explained by factors other than total fibrinogen or other traditional CVD risk factors. Our data show that fibrinogen γ' modulates plasma clot structure and fibrinolysis and is also influenced by factors other than fibrinogen.

The environmental profile of a community's health: a cross-sectional study on tobacco marketing in 16 countries.

OBJECTIVE: To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing. METHODS: Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders. FINDINGS: Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15-1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17-5.67 and IRR: 2.52; CI: 1.23-5.17, respectively). Of the 11,842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24-76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities. CONCLUSION: Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.

A decade of nutrition research in Africa: assessment of the evidence base and academic collaboration.

OBJECTIVE: Malnutrition in Africa has not improved compared with other regions in the world. Investment in the build-up of a strong African research workforce is essential to provide contextual solutions to the nutritional problems of Africa. To orientate this process, we reviewed nutrition research carried out in Africa and published during the last decade. DESIGN: We assessed nutrition research from Africa published between 2000 and 2010 from MEDLINE and EMBASE and analysed the study design and type of intervention for studies indexed with major MeSH terms for vitamin A deficiency, protein-energy malnutrition, obesity, breast-feeding, nutritional status and food security. Affiliations of first authors were visualised as a network and power of affiliations was assessed using centrality metrics. SETTING: Africa. SUBJECTS: Africans, all age groups. RESULTS: Most research on the topics was conducted in Southern (36%) and Western Africa (34%). The intervention studies (9%; n 95) mainly tested technological and curative approaches to the nutritional problems. Only for papers on protein-energy malnutrition and obesity did lead authorship from Africa exceed that from non-African affiliations. The 10% most powerfully connected affiliations were situated mainly outside Africa for publications on vitamin A deficiency, breast-feeding, nutritional status and food security. CONCLUSIONS: The development of the evidence base for nutrition research in Africa is focused on treatment and the potential for cross-African networks to publish nutrition research from Africa remains grossly underutilised. Efforts to build capacity for effective nutrition action in Africa will require forging a true academic partnership between African and non-African research institutions.

Association of alcohol consumption with specific biomarkers: a cross-sectional study in South Africa.

Alcohol consumption plays an important role in the health transition associated with urbanization in developing countries. Thus, reliable tools for assessing alcohol intake levels are necessary. We compared two biological markers of alcohol consumption and self-reported alcohol intakes in participants from urban and rural South African communities. This cross-sectional epidemiological survey was part of the North West Province, South African leg of the 12-year International Prospective Urban and Rural Epidemiology (PURE) study which investigates the health transition in urban and rural subjects. A total of 2,010 apparently healthy African volunteers (35 years and older) were recruited from a sample of 6,000 randomly-selected households. Alcohol consumption was assessed through self-reports (24-hour recalls and quantitative food frequency questionnaire) and by two biological markers: percentage carbohydrate-deficient transferrin (%CDT) and gamma-glutamyl transferase (GGT). Of the 716 men and 1,192 women volunteers, 64% and 33% respectively reported regular alcohol consumption. Reported mean habitual intakes of drinker men and women were 29.9 (± 30.0) and 23.3 (± 29.1) g of pure alcohol per day. Reported habitual intake of the whole group correlated positively and significantly with both %CDT (R=0.32; p ≤ 0.01) and GGT (R=0.43; p ≤ 0.01). The correlation between the two biomarkers was low (0.211; p ≤ 0.01). GGT and %CDT values should be interpreted with care in Africans as self-reported non-drinker men and women had elevated levels of GGT (19% and 26%) and %CDT (48% and 38%). A need exists for a more specific biological marker for alcohol consumption in black Africans.

South African and international reference values for lung function and its relationship with blood pressure in Africans.

BACKGROUND: In South Africa respiratory diseases are highly prevalent, with cardiovascular disease being a manifestation. However, international reference values for lung function are commonly used, which may not be appropriate to correctly identify reduced lung function. An inverse relationship exists between lung function and blood pressure (BP) but is not investigated extensively in black South Africans. METHODS: We included 2010 Africans from the PURE (Prospective Urban Rural Epidemiology) study (aged > 35 years) in the North West Province. Spirometry was performed and predicted values for forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were calculated from South African, European and United States prediction equations. RESULTS: With the exception of the European predicted values, all other predicted mean FEV1 and FVC were above 80%. South African reference values displayed the highest percentages of the predicted values for FEV1 and FVC (87.9 and 99.7%, respectively.) BP increased from quintiles five to one for both FEV1 and FVC, (p for trend <0.001). After adjustment the differences remained (p<0.05). CONCLUSIONS: South African reference values yielded higher percentages of predicted FEV1 and FVC values than European and US equations suggesting that South African prediction equations may be more useful when investigating lung function in black South Africans. Elevated BP is related to reduced lung function, highlighting the importance in managing both respiratory- and cardiovascular disease.

Associations of suPAR with lifestyle and cardiometabolic risk factors.

BACKGROUND: Soluble urokinase plasminogen activator receptor (suPAR), a novel indicator of low-grade inflammation, is associated with cardiovascular disease and mortality in the general population, while an unhealthy lifestyle influences inflammatory status. We aimed to explore the relationship of suPAR with lifestyle and cardiometabolic risk factors in a black South African population. DESIGN: This cross-sectional study includes 1068 men and women (56·4 ± 10·1 years) from the North West province who took part in the South African leg of the Prospective Urban and Rural Epidemiology (PURE) study in 2010. Captured data included a detailed lifestyle profile (tobacco use, alcohol consumption, physical activity, psychological and dietary intake status), biochemical analyses (suPAR, C-reactive protein (CRP), glucose and lipids), as well as cardiovascular and anthropometric measurements. RESULTS: In exploratory analyses, we observed positive relationships between suPAR and lifestyle factors, such as tobacco use (P-trend < 0·001), both alcohol consumption (P-trend = 0·001) and γ-glutamyl transferase (GGT) (P-trend < 0·001) and unemployment (P-trend = 0·002). suPAR and CRP correlated significantly (r = 0·23; P < 0·001). These relationships were confirmed in multiple regression analyses as suPAR independently associated with tobacco use (ß = 0·13; P < 0·001), GGT (ß = 0·24; P < 0·001) and unemployment (ß = 0·07; P = 0·039). suPAR did not associate with the cardiometabolic factors glucose, lipids, blood pressure or measures of adiposity. CONCLUSION: suPAR was independently associated with unhealthy lifestyle behaviours, but not with cardiometabolic risk factors suggesting that suPAR, as known predictor of cardiovascular disease and mortality, is augmented by modifiable cardiovascular risk factors. These findings emphasise the need for a healthy lifestyle to decrease the burden of cardiovascular disease in Africans.

The association between ownership of common household devices and obesity and diabetes in high, middle and low income countries.

BACKGROUND: Household devices (e.g., television, car, computer) are common in high income countries, and their use has been linked to obesity and type 2 diabetes mellitus. We hypothesized that device ownership is associated with obesity and diabetes and that these effects are explained through reduced physical activity, increased sitting time and increased energy intake. METHODS: We performed a cross-sectional analysis using data from the Prospective Urban Rural Epidemiology study involving 153,996 adults from high, upper-middle, lower-middle and low income countries. We used multilevel regression models to account for clustering at the community and country levels. RESULTS: Ownership of a household device increased from low to high income countries (4% to 83% for all 3 devices) and was associated with decreased physical activity and increased sitting, dietary energy intake, body mass index and waist circumference. There was an increased odds of obesity and diabetes with the ownership of any 1 household device compared to no device ownership (obesity: odds ratio [OR] 1.43, 95% confidence interval [CI] 1.32-1.55; diabetes: OR 1.38, 95% CI 1.28-1.50). Ownership of a second device increased the odds further but ownership of a third device did not. Subsequent adjustment for lifestyle factors modestly attenuated these associations. Of the 3 devices, ownership of a television had the strongest association with obesity (OR 1.39, 95% CI 1.29-1.49) and diabetes (OR 1.33, 95% CI 1.23-1.44). When stratified by country income level, the odds of obesity and diabetes when owning all 3 devices was greatest in low income countries (obesity: OR 3.15, 95% CI 2.33-4.25; diabetes: OR 1.97, 95% CI 1.53-2.53) and decreased through country income levels such that we did not detect an association in high income countries. INTERPRETATION: The ownership of household devices increased the likelihood of obesity and diabetes, and this was mediated in part by effects on physical activity, sitting time and dietary energy intake. With increasing ownership of household devices in developing countries, societal interventions are needed to mitigate their effects on poor health.

The use of predefined diet quality scores in the context of CVD risk during urbanization in the South African Prospective Urban and Rural Epidemiological (PURE) study.

OBJECTIVE: Urbanization is generally associated with increased CVD risk and accompanying dietary changes. Little is known regarding the association between increased CVD risk and dietary changes using approaches such as diet quality. The relevance of predefined diet quality scores (DQS) in non-Western developing countries has not yet been established. DESIGN: The association between dietary intakes and CVD risk factors was investigated using two DQS, adapted to the black South African diet. Dietary intake data were collected using a quantitative FFQ. CVD risk was determined by analysing known CVD risk factors. SETTING: Urban and rural areas in North West Province, South Africa. SUBJECTS: Apparently healthy volunteers from the South African Prospective Urban and Rural Epidemiological (PURE) study population (n 1710). RESULTS: CVD risk factors were significantly increased in the urban participants, especially women. Urban men and women had significantly higher intakes of both macro- and micronutrients with macronutrient intakes well within the recommended CVD guidelines. While micronutrient intakes were generally higher in the urban groups than in the rural groups, intakes of selected micronutrients were low in both groups. Both DQS indicated improved diet quality in the urban groups and good agreement was shown between the scores, although they seemed to measure different aspects of diet quality. CONCLUSIONS: The apparent paradox between improved diet quality and increased CVD risk in the urban groups can be explained when interpreting the cut-offs used in the scores against the absolute intakes of individual nutrients. Predefined DQS as well as current guidelines for CVD prevention should be interpreted with caution in non-Western developing countries.

Cardiometabolic changes in treated versus never treated HIV-infected black South Africans: the PURE study.

BACKGROUND: The use of antiretroviral treatment is known to be accompanied by several negative health outcomes and may negatively affect a country such as South Africa, which is the most burdened by the human immunodeficiency virus (HIV) in the world. We aimed to determine whether receiving antiretroviral treatment changes the cardiometabolic profile of HIV-infected South Africans. METHODS: In this sub-study, embedded in the Prospective Urban and Rural Epidemiology (PURE) study, we compared the cardiometabolic profile in a cohort of 66 treated and 71 never treated HIV-infected participants from the North-West province, South Africa. By using standard techniques, these participants' cardiometabolic, biochemical and lifestyle variables were assessed in 2005 and 2010, respectively. RESULTS: The treated group showed a higher percentage change in pulse pressure (13.3%; p = 0.004), systolic blood pressure (4.5%; p = 0.029) and CD4 cell count (9.2%; p = 0.009) levels over five years. During follow-up (2010), lipid variables were worse in the treated group. Further, antiretroviral treatment was associated with the percentage change in pulse pressure (R(2) = 0.24; ß = 0.19; p = 0.020). CONCLUSIONS: We concluded that Africans receiving antiretroviral treatment had a greater increase in pulse pressure and systolic blood pressure, as well as an unfavourable lipid profile when compared to never treated participants. Whether, in the long term, antiretroviral treatment will lead to increased arterial stiffness and/or accelerated atherosclerosis among this HIV-infected African population remains to be seen.