Featured in this issue: Volume 19 Number 1 PEARLOC 4 mg/5 mg, 4 mg/10 mg, 8 mg/ 5 mg, 8 mg/10 mg. Each tablet contains 4, 8 mg perindopril tert -butylamine respectively and 5, 10 mg amlodipine respectively. S3 A50/7.1.3/0230, 0231, 0232, 0233. For full prescribing information, refer to the professional information approved by SAHPRA, February 2021. 1) Bahl VK, et al. Management of hypertension with fixed combination of perindopril and amlodipine in daily clinical practice. Results from the STRONG prospective, observational, multicentre study. American Journal of Cardiovascular Drugs 2009(3):135-142. 2) Bertrand ME. Perindopril/ Amlodipine combination: an optimal synergy for cardiovascular protection. European Heart Journal supplements 2009;11(supplement E):E22-E25. 3) Data on file. *FDC – Fixed-dose combination. PCB925/05/2022. PERINDOPRIL TERT-BUTYLAMINE / AMLODIPINE 4 mg/5 mg 4 mg/10 mg 8 mg/5 mg 8 mg/10 mg NEW INTRODUCING OUR PERINDOPRIL TERT-BUTYLAMINE/ AMLODIPINE *FDC Perindopril/Amlodipine, an optimal synergy for: • Significant BP reductions1 • Improved tolerability1 • Reduction of CV events2 Pearloc is: • Bioequivalent to the Originator (Perindopril Arginine/Amlodipine)3 • Cost-eective vs the Originator3 www.mydynamics.co.za CUSTOMER CARE LINE +27 21 707 7000 July 2022 SAJDVD The South African Journal of Diabetes & Vascular Disease The electronic version of the journal is available at www.diabetesjournal.co.za • Prevalence of the metabolic syndrome in Batswana adults in Gaborone • Pre-morbid cardiometabolic risks in South Africans in informal settlements
NEW INTRODUCING OUR AMLODIPINE / VALSARTAN *FDC RANGE AMLODIPINE / VALSARTAN *FDC : • E ectively lowers BP2 • Gets up to 8/10 patients to goal 2 • Works synergistically to reduce oedema3 DILIGENT WORKERS | | | For further product information contact PHARMA DYNAMICS Email info@pharmadynamics.co.za CUSTOMER CARE LINE +27 21 707 7000 www.pharmadynamics.co.za CALSAR 5/80 mg, 5/160 mg, 10/160 mg. Each tablet contains amlodipine/valsartan 5/80 mg, 5/160 mg, 10/160 mg respectively. S3 A51/7.1.3/1106, 1107, 1108. For full prescribing information, refer to the professional information approved by SAHPRA, March 2021. 1) Data on file. 2) Karpov Y, et. al. Amlodipine/valsartan single-pill combination: a prospective, observational evaluation of the real-life safety and effectiveness in the routine treatment of hypertension. Advanced Therapeutics 2012;29(2):134-147. 3) Fogari R, et. al. Effect of valsartan addition to amlodipine on ankle oedema and subcutaneous tissue pressure in hypertensive patients. Journal of Human Hypertension 2007;21:220-224. 4) Database of Medicine Prices (1 April 2022). Department of Health website. http://www.mpr.gov.za. *FDC - Fixed-dose combination. CRB927/05/2022. 5/80 5/160 10/160 mg mg mg FORMULARY LISTINGS1 DISCOVERY HEALTH Exec/Comp Core/Saver/Priority MPL MMAP MPR MMI UP TO 52 % LESS VS THE ORIGINATOR4 PACKED IN 30 TABLETS OFFERS A UNIQUE 5/80 mg DOSAGE
HYPERINSULINAEMIA ISSN 1811-6515 THE SOUTH AFRICAN JOURNAL OF Diabetes & vascular disease Corresponding Editor DR FA MAHOMED Head of Internal Medicine Madadeni Hospital Newcastle KwaZulu-Natal Consulting Editor PROF J-C MBANYA National Editorial Board DR A AMOD Centre for Diabetes, Endocrinology and Metabolic Diseases, Life Healthcare, Chatsmed Gardens Hospital, Durban SR K BECKERT Diabetes Nurse, Paarl PROF F BONNICI Emeritus Professor, Faculty of Health Sciences, University of Cape Town and President of Diabetes South Africa PROF R DELPORT Department of Family Medicine, University of Pretoria DR L DISTILLER Director of the Centre of Diabetes and Endocrinology, Houghton, Johannesburg PROF WF MOLLENTZE Head of Department of Internal Medicine, University of the Free State, Bloemfontein PROF CD POTGIETER Specialist Nephrologist, University of Pretoria and Jakaranda Hospital, Pretoria PROF K SLIWA Associate Professor of Medicine and Cardiology, Baragwanath Hospital, University of the Witwatersrand, Johannesburg PROF YK SEEDAT Emeritus Professor of Medicine and Honorary Research Associate, University of Natal, Durban International Editorial Board PROF IW CAMPBELL Physician, Victoria Hospital, Kircaldy, Scotland, UK PROF PJ GRANT Professor of Medicine and head of Academic Unit of Molecular Vascular Medicine, Faculty of Medicine and Health, University of Leeds; honorary consultant physician, United Leeds Teaching Hospitals NHS Trust, UK PROF J-C MBANYA Professor of Endocrinology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon and President, International Diabetes Federation PROF N POULTER Professor of Preventive Cardiovascular Medicine, Imperial College, School of Medicine, London, UK DR H PURCELL Senior Research Fellow in Cardiology, Royal Brompton National Heart and Lung Hospital, London, UK VOLUME 19 NUMBER 1 • july 2022 www.diabetesjournal.co.za CONTENTS 3 From the Editor’s Desk FA Mahomed Research Article 4 Prevalence of the metabolic syndrome among Botswana adults in Gaborone and surrounding villages D Tladi, L Mokgatlhe, T Nell, R Michell, S Shaibu, C Mokgothu, T Gabonthone, O Hubona, K Monyeki 10 Pre-morbid cardiometabolic risks among South Africans living in informal settlements K Mokwena, P Modjadj Diabetes News 3 American Diabetes Association updates its Standards of Medical Care for 2022 9 New research holds big promise for a type 1 diabetes cure 17 Verapamil benefits for type 1 diabetes evident two years later 18 AHA names 2021’s top advances in heart disease and stroke research
Production Editor SHAUNA GERMISHUIZEN TEL: 021 785 7178 FAX: 086 628 1197 e-mail: shauna@clinicscardive.com Financial & Production Co-ordinator ELSABÉ BURMEISTER TEL: 021 976 8129 CELL: 082 775 6808 FAX: 086 664 4202 e-mail: elsabe@clinicscardive.com Content Manager MICHAEL MEADON (Design Connection) TEL: 021 976 8129 FAX: 086 655 7149 e-mail: michael@clinicscardive.com The South African Journal of Diabetes and Vascular Disease is published twice a year for Clinics Cardive Publishing (Pty) Ltd and printed by Durbanville Commercial Printers/Tandym Print. Online Services: Design Connection. All correspondence to be directed to: THE EDITOR PO BOX 1013 DURBANVILLE 7551 or elsabe@clinicscardive.com TEL: 021 976 8129 FAX: 086 664 4202 INT: +27 (0)21 976-8129 To subscribe to the journal or change address, email elsabe@clinicscardive.com Full text articles available on: www.diabetesjournal.co.za via www.sabinet.co.za The opinions, data and statements that appear in any articles published in this journal are those of the contributors. The publisher, editors and members of the editorial board do not necessarily share the views expressed herein. Although every effort is made to ensure accuracy and avoid mistakes, no liability on the part of the publisher, editors, the editorial board or their agents or employees is accepted for the consequences of any inaccurate or misleading information. 16 VOLUME 19 NUMBER 1 • july 2022
VOLUME 19 NUMBER 1 • July 2022 3 SA JOURNAL OF DIABETES & VASCULAR DISEASE From the Editor’s Desk From the Editor’s Desk Correspondence to: FA Mahomed Head of Internal Medicine, Madadeni Hospital Newcastle, KwaZulu-Natal Tladi and colleagues (page 4) studied metabolic syndrome features in a Batswana population. They found young patients and females were risk groups to watch out for. This is compatible with other data coming from Botswana.1 This may forebode higher future rates of hypertension, diabetes and cardiovascular disease in Botswana. This is useful information for the Botswana government health authorities, to help with prevention strategies and health-resource allocation. Mokwena and Modjaji, from Garankuwa, discuss an interesting set of patients in informal settlements, from a metabolic syndrome viewpoint (page 10). They found striking rates of hypertension and obesity. This group of patients may fall outside the usual public health surveillance net and may be an important group to identify in future surveys, especially when it comes to health planning and budget allocation.2 There are also comments on the American Diabetes Association Standards of Medical Care, new stem cell research in looking for American Diabetes Association updates its Standards of Medical Care for 2022 The American Diabetes Association (ADA) updated its Standards of Medical Care supplement in December, to provide clinicians, researchers, policy makers and other interested individuals with the components of diabetes care, general treatment goals and tools to evaluate the quality of care. Diabetes is a complex, chronic illness requiring continuous medical care with multifactorial risk-reduction strategies beyond glycaemic control. Ongoing self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications. Significant evidence exists that supports a range of interventions to improve diabetes outcomes. The Standards of Care recommendations should be applied in the context of excellent clinical care, with adjustments for individual preferences, co-morbidities and other patient factors. The recommendations include screening, diagnostic and therapeutic actions that are known or believed to favourably affect health outcomes of patients with diabetes. They encompass care for youth (from birth to 11 years and adolescents aged 12–18 years) and older adults (65 years and older). The ADA has been actively involved in the development and dissemination of diabetes care clinical practice recommendations and related documents for more than 30 years and its Standards of Medical Care is viewed as an important resource for those caring for people with diabetes. The annual Standards of Care supplement to Diabetes Care contains official ADA position, is authored by the ADA and provides all of the ADA’s current clinical practice recommendations. The Standards of Medical Care in Diabetes was originally approved in 1988. Source: MedicalBrief 2022 CUSTOMER CARE LINE +27 21 707 7000 www.mydynami cs.co.za CALSAR 5/80 mg, 5/160 mg, 10/160 mg. Each tablet contains amlodipine/valsartan 5/80 mg, 5/160 mg, 10/160 mg respectively. S3 A51/7.1.3/1106, 1107, 1108. For full prescribing information, refer to the professional information approved by SAHPRA, March 2021. CRA928/05/2022. | | | DILIGENT WORKERS BIOEQUIVALENT TO THE ORIGINATOR VALSARTAN/AMLODIPINE CONVENIENTLY PACKED IN 30 TABLETS a cure for type 1 diabetes and some interesting information about verapamil (old drug, new tricks). References 1. Maruapula SD, Jackson JC, Holsten J, Shaibu S, Malete L, Wrotniak B, et al. Socioeconomic status and urbanization are linked to snacks and obesity in adolescents in Botswana. Public Health Nutr 2011; 14(12), 2260–2267. 2. Atun R, Davies J, Gale EAM, Bärnighausen T, Beran D, Kengne AP, et al. Diabetes in sub-Saharan Africa: from clinical care to health policy. Lancet Diabetes Endocrinol Commiss 2017; 5(8): 622–667.
RESEARCH ARTICLE SA JOURNAL OF DIABETES & VASCULAR DISEASE 4 VOLUME 19 NUMBER 1 • July 2022 Prevalence of the metabolic syndrome among Batswana adults in Gaborone and surrounding villages DAWN TLADI, LUCKY MOKGATLHE, THEO NELL, RONEL MICHELL, SHEILA SHAIBU, COMFORT MOKGOTHU, TEBOGO GABONTHONE, OMPHILE HUBONA, KOTSEDI MONYEKI Correspondence to: Dawn Tladi Comfort Mokgothu, Tebogo Gabonthone, Omphile Hubona Department of Physical Education, Health and Recreation, University of Botswana, Gaborone, Botswana e-mail: tladidm@ub.ac.bw Lucky Mokgatlhe Department of Statistics, University of Botswana, Gaborone, Botswana Theo Nell Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa Ronel Michell Gaborone Biokinetics, Gaborone, Botswana Sheila Shaibu School of Nursing and Midwifery, Aga Khan University, Nairobi, Kenya S Afr J Diabetes Vasc Dis 2022; 19: 4–9 Abstract Background: Non-communicable diseases (NCDs), including hypertension, diabetes and obesity, are on the increase in Botswana and yet the prevalence of the metabolic syndrome (MetS) among the apparently healthy Batswana is unknown. Objective: The study aimed to describe the prevalence of the MetS among apparently healthy Batswana adults. Methods: A cross-sectional, descriptive study was used to collect demographic and anthropometric (weight, height, waist and hip circumferences) data, and blood pressure (BP), blood glucose, triglyceride, high-density lipoprotein cholesterol (HDL-C) and total cholesterol measurements from 800 participants. Results: The prevalence of the MetS was 32.7%, with women mostly afflicted (44.5%). Low HDL-C levels (50%) in women and hypertension (HTN) (50.3%) in men were the most prevalent individual components. Older participants showed a high prevalence (55–65 years; 57.2%), followed by a fairly high prevalence among the younger age group (25–34 years; men 39.0% vs women 26.6%). Conclusion: There was an overall high prevalence of the MetS among the Batswana adults in the study, with women in general and the younger population at high risk for NCDs. Further research is necessary to establish additional risk factors, guidelines, strategic plans and appropriate public health interventions. Keywords: metabolic syndrome, abdominal obesity, blood pressure, blood glucose, blood cholesterol Introduction Non-communicable diseases (NCDs) constitute a major public health challenge affecting socio-economic development. Approximately 85% of premature deaths resulting from cardiovascular diseases (CVDs), cancers, chronic respiratory diseases and diabetes occur in low- and middle-income countries.1 CVDs rank highest (~18 million annually) for most NCD deaths, followed by lifestyle-associated cancers (9 million), respiratory diseases (~4 million) and diabetes (1.6 million).1 The metabolic syndrome (MetS) constitutes a group of metabolic-related disorders including abdominal obesity, elevated fasting blood glucose (BG) level, glucose intolerance, dyslipidaemia and hypertension (HTN).2-5 Globally, there has been an increased prevalence of the MetS in sub-Saharan Africa (SSA)6 due to urbanisation and the nutritional transition that is linked to lifestyle changes.6,7 The individual risk factors for NCDs that present together as a cluster in individuals increase the risk for the MetS. Populations from developing countries as well as minority and disadvantaged groups are more at risk of developing-lifestyle associated NCDs.8 Evidence shows that NCDs are now a leading cause of death globally, accounting for more deaths than HIV, tuberculosis and malaria combined.9-11 A local study1 reported an increased prevalence in NCDs among the Batswana aged 15 to 69 years old.1 Almost one-third of the population presented as either overweight or obese, and women were more at risk (42.2%) compared to men (19.8%). Furthermore, the prevalence of individual risk factors was almost 30% for HTN, approximately 6% for elevated BG and 11% for elevated total cholesterol (TC) levels. When the overall NCD risk factors were combined, almost 73.1% presented with one or two risk factors and 25.7% between three and five risk factors.1 To date and to our knowledge, no study has documented the prevalence of these disease risk factors congregating as the MetS in the apparently healthy Batswana population. Existing evidence has only documented the prevalence of the MetS in small selected populations. Surprisingly, Garrido et al.12 reported a high prevalence of the MetS and obesity among healthcare workers at the Kanye Adventist Hospital in Botswana. Similarly, Omech et al.13 recently reported a high prevalence of the MetS in two Botswana general medical out-patient clinics of Princess Marina Hospital and Letsholathebe II Memorial Hospital. Providing scientific evidence will guide the development and implementation of educational and physical activity intervention programmes aiming to lower the MetS epidemic. The current study aimed to describe the prevalence and most prevalent risk factors of the MetS among Batswana adults aged 25 to 69 years in Gaborone and surrounding villages.
SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE VOLUME 19 NUMBER 1 • July 2022 5 Methods A cross-sectional study using a complex multi-stage cluster sampling method was used to recruit 1 000 participants in the city of Gaborone and surrounding villages. The target population included Batswana men and women aged between 25 and 65 years residing in Gaborone, Tlokweng and Mogoditshane. Data were collected at shopping malls where people of heterogeneous characteristics converge. A total of 37 shopping malls were classified as either a super mall or satellite mall across Gaborone and the two villages. A total of seven malls were randomly selected for the study. The International Diabetes Federation (IDF) Africa region14 reports an estimated diabetes prevalence of approximately 4% among Batswana adults. Since the required sample size will increase with higher population prevalence, a prevalence of 8% among the 25- to 65-year cohort was assumed. d2 Z2 (1-α/2)P(1–P) = where d is the margin of error, P the prevalence level and Z the normal score corresponding to the (1–α) % confidence level. With a 5% type I error and assumed 8% diabetes prevalence in Botswana, the sample was calculated at = 452. With cognisance of the cluster sampling method being employed, the correlated responses were accounted for. A design effect of two was applied, which doubled the sample size to 904. Furthermore, some critical questions on anthropometric measures may not have been available for some respondents due to refusal and/or nonresponse. Assuming a refusal rate of 10%, the final sample size used was 1 000. A sampling frame of all shopping malls in Gaborone and surrounding villages of Tlokweng and Mogoditshane was compiled and a sample was randomly selected from the list. In the selected malls, shoppers were recruited as they passed by the testing area. The recruitment was alternated between a stratifying variable, gender, to ensure a balance between male and female participants. Once eligibility had been established and consent to participate had been obtained, the participants were enrolled in the study. Ethical approval was obtained from the institutional review boards of both the University of Botswana and Stellenbosch University (ref #: IRB0005239), as well as from the Ministry of Health, Botswana (ref # HRU 00806). Data were collected from volunteers who agreed to participate in the study after an introduction and briefing on the study intent. Following written, informed consent, a total of 800 volunteers were recruited, interviewed and assessed. Data collection included demographic, anthropometric, biochemical and behavioural factors. All procedures specified by the Health Professions Council of Botswana as good clinical practices were strictly adhered to. Demographic data included questions related to gender, age, level of education, marital and work status, number of people above 18 years in the household and average annual earnings. Medical history included questions related to history of elevated blood pressure (BP), diabetes, TC and CVDs. Resting BP, height and weight, and waist and hip circumferences were measured and recorded. Biochemical measures gathered data related to BG and blood lipids [TC, triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C)]. BP measurements were taken using an automated BP monitor (OMRON Intelli Sense M3W) after a five-minute rest following the interview. Waist and hip circumferences were measured using a SECA measuring tape (201 cm) according to the International Society for the Advancement of Kinanthropometry (ISAK) standard guidelines.15 Height was measured with a portable SECA stadiometer using the free-standing method with the head placed in the Frankfort plane, and weight was measured with the SECA Alpha digital scale (model 770). Capillary BG, TG and TC were assessed with the finger-prick test with the Care Sense N BG monitoring system, while blood lipids were measured using the Cardio Check PA system. Although several definitions are formulated for the MetS,16-18 the IDF is considered more relevant for the African context.19 We therefore classified participants as having the MetS using the IDF criterion where central obesity (defined as waist circumference ≥ 94 cm for men and ≥ 80 cm for the women was indicated, with ethnicspecific values for other groups), and any two of the following four; raised levels of TG ≥ 3.9 mmol/l, low HDL-C levels (men < 1.0 mmol/l; women < 1.3 mmol/l) or on dyslipidaemia medication, elevated BG ≥ 5.6 mmol/l or on diabetes medication, or elevated BP ≥ 130/85 mmHg or on HTN medication. Statistical analysis Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS version 22). Most of the variables analysed for this output were quantitative, hence we report their means ± standard deviations. All variables tested were contrasted by gender using Student’s t-tests. Contrasts for proportions among subpopulations were performed using homogeneity chi-squared tests. A significant difference was accepted if p-values were less than 0.05 for both tests. Results A total of 800 respondents participated in the study drawn from seven shopping malls, yielding an 80% response rate. From the 800 participants, 664 were selected from malls in Gaborone and the remaining 136 from Tlokweng and Mogoditshane. The results are based on the 756 participants (363 men and 393 women) who had complete data for all variables. Therewereno significant differences for age,waist circumference, diastolic BP, BG and TG between genders (Table 1). There was a significant gender effect observed for body mass index (BMI) (p < 0.001), hip circumference (p < 0.001), waist–hip ratio (p < 0.001), systolic BP (p < 0.001) and HDL-C (p < 0.001). Women presented with a higher BMI (34.4 vs 13.0%) and waist circumference (45.5 vs 11.0%), and low HDL-C levels (50.0 vs 48.7%), while the men had higher systolic BP (50.3 vs 39.4%). Overall prevalence of the MetS was estimated at 32.7%. The prevalence was higher among women at 44.5% versus men at 20.0% (Table 1). Overall, low HDL-C levels identified the highest candidates for the MetS at a prevalence of 49.4%, followed by waist circumference (47.9%), TG (47.4%) and elevated BP (44.7%) (Table 1). The oldest age group (55–65-year-olds) had the highest prevalence of the MetS, with men having 52.9% and women 61.5% (Table 2). The MetS prevalence increased with age among men, from 26.6% in the 25–34 age group, 41.3% in the 35–44 age group, 46.7% in the 45–54 age group and 52.9% in the 55–65 age group. A similar trend was observed in the women, with the prevalence increasing from 39.0% in the 25–34 age group,
RESEARCH ARTICLE SA JOURNAL OF DIABETES & VASCULAR DISEASE 6 VOLUME 19 NUMBER 1 • July 2022 50.5% in the 35–44 age group, 53.7% in the 45–54 age group and 61.5% in the 55–65 age group. Overall, women had a higher prevalence than men at all age groups, from the youngest to the oldest (Table 2). To assess the prevalence of individual components of the MetS, comparative levels of component risk among those classified with and without the MetS were also estimated. Additional analysis explored the risk factors among those who did not present with the MetS. Among men with the MetS, elevated TG level was the most prevalent risk factor at 80.3%, followed by elevated BP at 77.6%. The women with the MetS showed a 74.0% prevalence of low HDL-C levels, followed by elevated TG levels at 66.9% (Table 3). Discussion The main objective of the study was to determine the prevalence of the MetS among Batswana adults in Gaborone and surrounding villages of Tlokweng and Mogoditshane. The findings revealed a high prevalence of 32.7% among those sampled. Garrido et al.12 assessed the prevalence of the MetS among a group of Batswana healthcare workers at Kanye Seventh Day Adventist Hospital and reported a prevalence of 34%. Omech et al.13 also recently reported a prevalence of 27.1% among an outpatient population from two general medical out-patient clinics in Botswana. However, Garrido et al.12 and Omech et al.13 both applied the National Cholesterol Education Program Expert Panel Table 1. Participants characteristics by gender Characteristics n All Men Women p-value Number (%) 800 384 (48) 416 (52) Age (years) 743 36.1 ± 8.9 36.3 ± 9.2 35.9 ± 8.6 0.583 BMI (kg/m2) 797 26.2 ± 5.7 24.2 ± 4.5 27.9 ± 6.1 < 0.001 Waist (cm) 794 85.1 ± 13.9 84.1 ± 13.3 86.0 ± 14.4 0.05 Hip (cm) 795 104.2 ± 12.8 99.6 ± 10.5 108.5 ± 13.3 < 0.001 WHR 794 0.82 ± 0.1 0.85 ± 0.11 0.79 ± 0.11 < 0.001 Systolic blood pressure (mmHg) 795 127.5 ± 16.9 130.4 ± 16.7 124.7 ± 16.6 < 0.001 Diastolic blood pressure (mmHg) 795 78.8 ± 10.8 79.2 ± 11.0 78.5 ± 10.7 0.378 BMI (kg/m2) (%) 25 ≤ BMI < 30 232 29.1 15.1 31.0 < 0.001 BMI ≥ 30 192 24.1 13.0 34.4 < 0.001 Waist (men/women) (%) ≥ 94/80 cm 380 47.9 24.5 69.6 < 0.001 ≥ 102/88 cm* 230 29.0 11.0 45.7 < 0.001 WHR > 1.0/0.85 106 13.4 3.7 22.6 < 0.001 Elevated BP (≥ 130 | ≥ 85) (%) 355 44.7 50.3 39.4 0.002 Blood glucose (mmol/l) 779 5.3 ± 1.3 5.3 ± 1.2 5.4 ± 1.5 0.201 ≥ 5.6 mmol/l (%) 251 32.2 29.9 34.2 0.207 Blood cholesterol (mmol/l) Total triglycerides 785 1.9 ± 2.4 1.8 ± 1.0 2.0 ± 1.1 0.057 ≥ 1.7 mmol/l (%) 372 47.4 46.3 48.4 HDL-C 778 1.2 ± 0.4 1.1 ± 0.4 1.3 ± 0.4 < 0.001 < 1.03/1.29 mmol/l (%) 384 49.4 48.7 50.0 Metabolic syndrome (%) 787 32.7 20.0 44.5 < 0.001 BMI: body mass index; WHR: waist–hip raito; BP: blood pressure; HDL-C: high-density lipoprotein cholesterol. Table 2. Age- and gender-specific percentage prevalence of the MetS MetS Variables Men (n = 327) Women (n = 374) Age groups (years) n (%) n (%) 25–34 173 (26.6) 200 (39.0) 35–44 92 (41.3) 107 (50.5) 45–54 45 (46.7) 54 (53.7) 55–65 17 (52.9) 13 (61.5) Missing 34 (26.5) 17 (47.1) Total crude 361 (34.1) 391 (46.5) Age adjusted - (17.2) - (21.5) Table 3. Component-wise prevalence among participants with and without the MetS Component Total Without MetS With MetS p-value Number 756 449 307 Central obesity (%) 375 22.5 100.0 < 0.001 High triglycerides (%) 368 35.8 70.9 < 0.001 Low HDL-C (%) 383 36.8 75.2 < 0.001 Elevated BP (%) 348 33.6 66.4 < 0.001 High blood glucose 249 23.9 49.2 < 0.001 Male Number 363 240 123 Central obesity (%) 93 5.6 100.0 < 0.001 High triglycerides (%) 174 37.7 80.3 < 0.001 Low HDL-C (%) 182 41.5 76.3 < 0.001 Elevated BP (%) 189 42.8 77.6 < 0.001 High blood glucose (%) 110 25.5 47.9 < 0.001 Female Number 393 209 184 Central obesity (%) 282 45.1 100.0 < 0.001 High triglycerides (%) 194 33.3 66.9 < 0.001 Low HDL-C (%) 201 25.3 74.7 < 0.001 Elevated BP (%) 159 21.3 61.7 < 0.001 High blood glucose (%) 139 21.9 49.7 < 0.001 BP: blood pressure; HDL-C: high-density lipoprotein cholesterol.
SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE VOLUME 19 NUMBER 1 • July 2022 7 on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) criterion17 to determine the presence of the MetS. The prevalence they reported (Garrido et al. at 34.0% and Omech et al. at 27.1%) were almost similar to that of the current study (30.4%).13 These results confirm a prevalence of the MetS of approximately 31% among Batswana adults, indicating an emerging population-wide health problem. Similar to our findings, Erasmus et al.19 and Peer et al.20 also reported a higher prevalence (60.6%) in urban South African mixed-ancestry populations, and a high age-adjusted prevalence of 31.7% among blacks in the same population. The prevalence in SSA varies between 0 and 50% or even higher,21 placing Botswana among the most afflicted countries in the region, at 32.7%. The prevalence of the MetS was found to be higher among women, at 44.5%, compared to men at 20%, corresponding to most studies that investigated the prevalence of the MetS in SSA,6,19,20,22-24 as well as African-Americans.25 Peer et al.19 attributed this gender difference in SSA and African-Americans to cultural values and positive social attitudes towards obesity. Traditionally, being overweight among these cultures is generally associated with good health and attractiveness in women,20 as is the custom also among the Batswana.12,26 Furthermore, due to the HIV/AIDS epidemic in Botswana, adiposity is associated with being HIV/AIDS negative and most women would naturally prefer to be overweight. The high prevalence of the MetS and obesity among women is of great concern and urgently needs culturally sensitive interventions. The oldest age group (55–65 years) was found to be more at risk for the MetS (~70% of women and 41.2% among men). Several studies reported an increased MetS prevalence with ageing in SSA.27-31 The MetS seemed to escalate in women between 55 and 65 years, which might be related to the physiological changes occurring with pre-menopause and menopause.32,33 The high prevalence of the MetS among women in the current study is of great concern. It is therefore necessary to initiate screening for CVDs earlier or at the onset of menopause and screening should also be available to younger at-risk women in order to prevent the early onset of NCDs. The two MetS risk factors accompanying central obesity that were found to be the most prevalent among all women were low HDL-C and high TG levels (Table 1). Among the women with the MetS, the most prevalent risk factors were still found to be low HDL-C and high TG levels (Fig. 1). Visceral fat contributes to dyslipidaemia, which was observed among the women in this study.4 The most prevalent risk factor accompanying central obesity in the men was elevated BP, followed by low HDL-C levels (Table1). Among men with the MetS, the risk factors accompanying central obesity were elevated TG, followed by elevated BP (Fig. 1). The present results reveal high TG levels as an emerging high MetS risk factor predominant in both men and women with the MetS. Here, our results are similar to Erasmus et al.19 who reported a prevalence of the MetS of 75%, low HDL-C levels in women, and 51.4% of men residing in the predominantly black townships of Cape Town, South Africa had elevated BP. Characterising the most prevalent risk factors in the MetS can help guide interventional programmes geared towards lowering the risk of acquiring the MetS, as the risk factors can be isolated and individually treated. Overall, the three most common risk factors for the MetS were found to be central obesity, elevated BP and dyslipidaemia (low HDL-C and high TG levels), suggesting a high risk for CVDs in the population investigated. The results are not surprising since increased obesity has been reported to increase circulating free fatty acid concentrations, thus increasing plasma TG levels.4 To successfully prevent or treat the MetS, lifestyle modification and pharmacological interventions should be employed. Pharmacologically, medications for the treatment of all the MetS Fig 1. Proportion with risk components among metabolic syndrome participants. CUSTOMER CARE LINE +27 21 707 7000 www.mydynami cs.co.za PEARINDA PLUS 8. Each tablet contains 8 mg perindopril tert - butylamine and 2,5 mg indapamide. S3 A49/7.1.3/0013. For full prescribing information, refer to the professional information approved by SAHPRA, 20 April 2021. PAA924/05/2022. THE ENDURANCE ACE- i PERINDOPRIL TERT-BUTYLAMINE/ INDAPAMIDE 8/2,5 mg ATHLETE: AJ Calitz – CHAMPION TRAIL RUNNER BIOEQUIVALENT TO THE ORIGINATOR PERINDOPRIL ARGININE/INDAPAMIDE 10/2,5 mg Percentage (%) 90 80 70 60 50 40 30 20 10 0 High triglycerides High fasting glucose Elevated BP Low HDL-C Male Female 80.3 66.9 47.9 49.7 77.6 61.7 76.3 74.7
RESEARCH ARTICLE SA JOURNAL OF DIABETES & VASCULAR DISEASE 8 VOLUME 19 NUMBER 1 • July 2022 risk factors exist and they can be individually treated. Due to the clustering of these risk factors, the individual has to take several types of medication to treat each factor. The increased medication burden could lead to increased cost, increased side effects and contribute to poor adherence. This leaves lifestyle modification as the most viable intervention to be pursued, through community-based educational programmes aiming towards behavioural change, and ultimately increasing physical activity. Regular physical activity has been found to successfully mitigate all MetS risk factors.34,35 A life-course prevention approach for both men and women should be encouraged as it has been shown to mitigate NCDs later in life.36 Although considered a useful screening tool, a single biochemical measurement could be viewed as a limitation of this study. It was not possible to obtain fasting blood samples for all participants and hence we did not control for this. The results were based on random blood sampling in an apparently healthy population, of which their MetS status has never been investigated in Botswana. Conclusion This study uncovered a high prevalence of the MetS among Batswana women in an age-dependent fashion and an alarmingly high prevalence in the younger group of Batswana adults. The most prevalent components were identified as central obesity and low HDL-C levels in women and HTN among men. The presence of dyslipidaemia needs close attention as it appeared to be quite prevalent among apparently healthy adults; especially since it is not routinely checked during hospital visits, as is BP. If risk factors leading to the MetS are not identified and sustainable preventative measures put into place, this could lead to far-reaching public health consequences. Therefore, there is a need to establish guidelines that provide strategic planning and appropriate public health measures to prevent and control the MetS. Development of a comprehensive national policy addressing the risk factors of the MetS through an integrated multi-sectorial approach is recommended. There should be increased promotion of healthy lifestyles and all health programmes should include a preventative element. The programmes should drive all the focus towards risk reduction, fighting obesity, developing healthpromotion legislation, promoting regular physical exercise and ultimately providing periodic basic screening tests. The authors acknowledge the participants and research assistants for their contribution towards the success of the study. The shopping mall owners are also acknowledged for allowing recruiting and data collection on their premises. This work was supported by a grant from the office of Research and Development of the University of Botswana, reference no UBR/ RES 3/2 and the Stellenbosch University’s African Collaboration grant DRTAN (ACG). Opinions, findings and conclusions or recommendations expressed in this study are those of the authors; the above funding sources do not accept any liability in regard thereto. References 1. Botswana steps survey report on non-communicable disease risk factors. December 30 2015. https://www.who.int/ncds surveillance/steps/STEPS_ BOTSWANA_2014_Report_Final.pdf?ua=1 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases 2. Cornier MA, Dabelea D, Hernandez T L, et al. The metabolic syndrome. Endocr Rev 2008; 29: 777–822. 3. Young F, Critchley JA, Johnstone LK, Unwin NC. A review of co-morbidity between infectious and chronic disease in sub-Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome and the impact of globalization. Glob Health 2009; 5: 1–9. 4. O’Neill S, O’Driscoll L. Metabolic syndrome: a closer look at the growing epidemic and its associated pathologies. Obes Rev 2015; 16: 1–12. 5. Frequently asked questions on non-communicable diseases. Ministry of Health – Republic of Botswana. www.moh.bw. 6. Mbanya JC, Motala AA, Sobngwi E, et al. Diabetes in sub-Saharan Africa. Lancet 2010; 375: 2254–2266. 7. Ntandou G, Delisle H, Agueh V, Fayomi B. Abdominal obesity explains the positive rural-urban gradient in the prevalence of the metabolic syndrome in Benin, West Africa. Nutr Res 2009; 29: 180–189. 8. King H, Rewers M. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults: WHO ad hoc diabetes reporting group. Diabetes Care 1993; 16: 157–177. 9. Botswana National Multisectoral Strategy for the Prevention and Control of NonCommunicable Diseases 2017-2022. https://www.iccp- portal.org/system/files/ plans /20171129%20Botswana%20multisec%20NCDs%20strategy%20-%20 final.pdf. 10. Haubrich RH, Riddler SA, Di Rienzo AG, et al. Metabolic outcomes in a randomized trial of nucleoside, nonnucleoside and protease inhibitor-sparing regimens for initial HIV treatment. AIDS 2009; 23: 1109–1118. 11. Villarroya F, Domingo P, Giralt M. Drug-induced lipotoxicity: lipodystrophy associated with HIV-1 infection and antiretroviral treatment. Biochim Biophys Acta 2010; 1801: 392–399. 12. Garrido RA, Semeraro MB, Temesgen SM, Simi MR. Metabolic syndrome and obesity among workers at Kanye Seventh Day Adventists Hospital, Botswana. S Afr Med J 2009; 99; 331–334. 13. OmechB, Tshikuka, J, Mwita JC, Tsima B, et al. Prevalence and determinants of metabolic syndrome: a cross-sectional survey of general medical outpatient clinics using National Cholesterol Expanded Program-Adult Treatment Panel III criteria in Botswana. Diabetes Metab Syndr Obes 2016; 9: 273–279. 14. IDF Africa region https://www.idf.org/our-network/regions-members/africa/ diabetes-in-africa.html 15. Syewart A, Marfell-Jones M, Olds T, de Ridder H. International Standards for Anthropometric Assessment ISAK Manual, 2011. ISBN 0 620 36207 3. 16. WHO. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report. Diabet Med 1998; 15: 539–553. 17. Expert panel on detection, evaluation and treatment of high blood cholesterol in adults: executive summary of the third report of the National Cholesterol Education Program. J Am Med Assoc 2001; 285: 2486–2497. 18. The IDF consensus worldwide definition of the metabolic syndrome. Available from: http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf. 19. Erasmus RT, Soita DJ, Hassan MS, et al. High prevalence of diabetes mellitus and metabolic syndrome in a South African colored population: Baseline data of a study in Bellville, Cape Town. S Afr Med J 2012; 102: 841–844. 20. Peer N, Lombard C, Steyn K, Levitt N. High prevalence of metabolic syndrome in the black population of Cape Town: the Cardiovascular Risk in Black South Africans (CABRISA) study. Eur J Prev Cardiol 2015; 22(8): 1036–1042. 21. Okafor C. The metabolic syndrome in Africa. Indian J Endocr Metab 2012; 16: 56–66. 22. Kelliny C, William J, Riesen W, et al. Metabolic syndrome according to different definitions in a rapidly developing country of the African region. Cardiovasc Diabetol 2008; 7: 27. 23. Tran A, Gelaye B, Girma B, et al. Prevalence of metabolic syndrome among working adults in Ethiopia. Int J Hypertens 2011; 2011: 193719. 24. Kaduka LU, Kombe Y, Kenya E, et al. Prevalence of metabolic syndrome among an urban population in Kenya. Diabetes Care 2012; 35: 887–893. 25. Grundy SM. Metabolic syndrome pandemic Arterioscler Thromb Vasc Biol 2008; 28: 629–36. 26. Shaibu S, Holsten JE, Stettler N, et al. Adolescent obesity prevention in Botswana: Beliefs and recommendations of school personnel. J Sch Nurs 2012; 28: 220– 229. 27. Fezeu L, Balkau BK, Sobngwi E, Mbanya JC. Metabolic syndrome in sub-Saharan African setting: Central obesity may be the key determinant. Atherosclerosis 2007; 193: 70–76.
SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE VOLUME 19 NUMBER 1 • July 2022 9 28. Ogbera, A. Prevalence and gender distribution of the metabolic syndrome. Diabetol Metab Syndr 2010; 2: 1–5. 29. Third National Health and Nutrition Examination Survey. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. J Am Med Assoc 2002; 287: 356–359. 30. Azizi F, Salehi P, Etemadi A, Zahedi-Asl S. Prevalence of metabolic syndrome in an urban population: Tehran Lipid and Glucose Study. Diabetes Res Clin Pract 2003; 61: 29–37. 31. Hwang L, Bai C, Chen C. Prevalence of obesity and metabolic syndrome in Taiwan. J Formos Med Assoc 2006; 105: 626–635. 32. Lobo RA. Metabolic syndrome after menopause and the role of hormones. Maturitas 2008; 60: 10–18. 33. Jouyandeh Z, Nayebzadeh F, Qorbani M, Asadi M. Metabolic syndrome and menopause. J Diabetes Metab Disord 2013; 12: 1. 34. Lindström J, Louheranta A, Mannelin M. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003; 26: 3230–3236. 35. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344: 1343–1350. 36. Karmali KN, Lloyd-Jones DM. Adding a life-course perspective to cardiovascularrisk communication. Nat Rev Cardiol 2013; 10: 111–115. New research holds big promise for a type 1 diabetes cure An implant containing insulin-producing stem cells An experimental implant containing stem cells designed to mature into insulin-secreting cells passed its first human trails. The studies reported the implant (designed to replace the missing insulin cells) to be mildly effective, offering promising signs of a ‘functional cure’ for diabetics with type 1 diabetes. The implanted stem may mature and become islet tissue that includes the beta-cells that produce insulin when needed so that normal blood sugar levels may be maintained. An open-label, first-in-human phase 1/2 study is being conducted to evaluate the safety and efficacy of pancreatic endoderm cells (PECs) implanted in non-immunoprotective macro-encapsulation devices for the treatment of type 1 diabetes. We report an analysis on one year of data from the first cohort of 15 patients from a single trial site that received subcutaneous implantation of cell products combined with an immunosuppressive regimen. Implants were well tolerated with no teratoma formation or severe graft-related adverse events. After implantation, patients had increased fasting C-peptide levels and increased glucose-responsive C-peptide levels and developed mixed meal-stimulated C-peptide secretion. There were immunosuppression-related transient increases in circulating regulatory T cells, PD1high T cells, and IL17A+CD4+ T cells. Explanted grafts contained cells with a mature β-cell phenotype that were immunoreactive for insulin, islet amyloid polypeptide and MAFA. These data and associated findings are the first reported evidence of meal-regulated insulin secretion by differentiated stem cells in patients. ‘Because of this initial success, we are now implanting larger numbers of cells in additional patients and we hope that this will result in a significant reduction or even elimination of the need for patients to take insulin injections in the near future,’ says David Thompson, a researcher working on the trial from the Vancouver General Hospital Diabetes Centre. Published in Cell Stem Cell 2021; 28(12): 2047–2061. A new pill that could help treat and even prevent type 1 diabetes Yale researchers have developed a pill that controls insulin levels while simultaneously reversing the inflammatory effects of the disease. The pill addresses three issues: • it helps control immediate blood glucose levels • restores pancreatic function • re-establishes normal immunity in the pancreatic environment. Developer Tarek Fahmy, associate professor of Biomedical Engineering and of Immunobiology: ‘What excites me about this is that it’s a two-pronged approach. It’s facilitating normal metabolism as well as correcting immune defects in the long term.’ The nanoparticle or nanocarrier, made from polymerised bile acid, protects the insulin while carrying it to the pancreas. Published in Yale Biomedical Engineering J 2021; 5(11): 1403.
RESEARCH ARTICLE SA JOURNAL OF DIABETES & VASCULAR DISEASE 10 VOLUME 19 NUMBER 1 • July 2022 Pre-morbid cardiometabolic risks among South Africans living in informal settlements Kebogile Mokwena, Perpetua ModjadjI Correspondence to: Perpetua Modjadji Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa e-mail: Perpetua.modjadji@smu.ac.za Kebogile Mokwena Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa S Afr J Diabetes Vasc Dis 2022; 19: 10–16 Abstract Aim: Numerous studies have been conducted on cardiometabolic risk factors in South Africa. However, not much has been done in informal settlement populations faced with their own set of health risks. This study screened for pre-morbid cardiometabolic risks and associated factors among adults living in informal settlements in South Africa. Methods: A cross-sectional study used the WHO STEPwise questionnaire to collect data on demography, anthropometry, blood pressure, and glucose and cholesterol levels (n = 329). Cardiometabolic risks were based on the criteria considered by the International Diabetes Federation and the National Cholesterol Education Program Adult Treatment Panel III. Data were analysed using STATA 14. Results: The median age was 35 (25–42) years. Cardiometabolic risk factors in the study subjects were hypertension (66%), overweight/obesity (45%), abdominal obesity (46%), and elevated cholesterol (15%) and glucose levels (7%). The metabolic syndrome was found in 17% of the subjects, with a high prevalence observed among participants aged 35–59 years (28%) and ≥ 60 years (40%). The metabolic syndrome was significantly associated with gender [males, adjusted odds ratio (AOR) = 0.4, 95% CI: 0.20–0.90] and age, 35–59 years (AOR = 5.07, 95% CI: 2.24– 11.23) and ≥ 60 years (AOR = 6.57, 95% CI; 1.57–27.54). Conclusion: Prevalent cardiometabolic risk factors in informal settlements indicate the need for routine screening for all the components of the metabolic syndrome at the primary healthcare level. Keywords: cardiometabolic risks, metabolic syndrome, informal settlements, South Africa Introduction South Africa has experienced steady urbanisation over the last two decades.1 One of the most prominent major consequences of urbanisation in developing countries is the persistence of and rise in informal settlements, including slums.2,3 The United Nations defines informal settlements as unplanned residential areas where housing, shelter and services have been constructed on land that the occupants occupy illegally.4 The steady increase in the number of informal settlements in South Africa comes with poverty and resultant ill health.5 The health literature concentrates more on communicable diseases, yet low-income urban residents also suffer from noncommunicable diseases (NCDs), which are increasingly creating a double burden in these households.6 The largest burden of NCDs is now occurring in resource-limited countries undergoing demographic and epidemiological transitions.7 These transitions are attributed to changes in lifestyle, such as sedentariness,8 smoking9 and consumption of a high-fat diet.10 NCDs and associated cardiometabolic risk factors pose health challenges in populations.11 Cardiometabolic risk factors increase the likelihood of vascular events or of developing diabetes, and encompass hypertension, dyslipidaemia, abdominal obesity and ethnicity.12,13 South Africa is experiencing alarming rates of hypertension (54–77%),14-16 overweight/obesity (56–68%)17 and abdominal obesity (56.4–65.2%).18,19 In addition, the prevalence of dyslipidaemia in community-level assessments has been reported to be between 14 and 69%.20-22 Furthermore, the prevalence of diabetes is rapidly increasing and has been reported to be between 5.5 and 9% among adults in the country.23,24 Cardiometabolic risks are particularly prevalent in people diagnosed with the metabolic syndrome (MetS), a complex disorder of interconnected risk factors, including hypertension, dyslipidaemia, obesity and high blood glucose levels.25-28 The prevalence of the MetS in South Africa varies from five to 62%,18,2933 and is attributable to factors such as age, gender, lifestyle, socioeconomic variables and ethnicity.34 People with the MetS have a three-fold risk of heart attack or stroke, a two-fold risk of cardiovascular diseases (CVDs) or of dying from such events, and a five-fold risk of developing type 2 diabetes mellitus, compared to people without the MetS.35 However, the MetS has been investigated in the context of high-income and urban settings in South Africa,36,37 while only a few studies are reported in low-income rural settings.30,32 The literature documents that the mushrooming of informal settlements in South Africa drives cardiometabolic diseases, such as CVDs and related risks.38,39 However, there is very little research directly addressing cardiometabolic risk in informal settlements known to be occupied by vulnerable populations.5,40 In light of this, the aim of the study was to screen for cardiometabolic risk factors among South African adults living in informal settlements and determine their association with selected demographic and lifestyle variables. Getting screening tests is one of the most important disease-prevention strategies used in public health in general, and health promotion in particular.41 Methods A cross-sectional study was conducted to screen for cardiometabolic risk factors and determine their association with selected
SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE VOLUME 19 NUMBER 1 • July 2022 11 demographic and lifestyle variables among South African adults living in informal settlements. Gauteng is the smallest of the nine provinces in South Africa, but comprises the largest portion of the South African population, at about 13 million. The province serves as the economic hub of the country and is responsible for over 34.8% of the country’s total gross domestic product.42 Gauteng Province remains a desirable place to live and work compared to other regions in South Africa, therefore, the province is likely to experience in-migration.43 Migrants often settle in informal settlements on the periphery of cities,44 with the province being one of three out of the nine provinces in South Africa with the highest number of households living in informal settlements.45 The literature has documented the difficulties of obtaining reliable figures for informal settlement backlog in South Africa,46 which is estimated to be at least two million.47 Rao software was used to calculate a sample size, taking into consideration the population size, estimated at two million, a 5% margin of error and 95% confidence level. A minimum sample size of 329 adults, aged 18 years, was obtained and convenience sampling was used to select the participants. Ndlovu48 indicated a loss of interest of informal settlers to take part in the community activities due to poor service delivery, hence, sampling was challenged by the willingness of residents to participate in the study. The study was conducted among presumably healthy adults, not diagnosed with any CVD and not on any medication.49 Data were collected between October 2016 and April 2017 during the pilot study of a faith-based organisation during a health expo for the identified informal settlement community. The health expo consisted of a number of health services, health education and health-promotion activities, which were offered at no cost to the community members. The health expo team of volunteers included medical practitioners, nurses, dentists and public health practitioners. Treatment for minor illnesses, screening for medical and dental conditions and referring of members to mobile clinics or hospitals was done, according to individual needs. As part of the health expo programme, the metabolic screening team conducted specific screening activities. An adapted WHO STEPwise questionnaire was used for this study.50 Three readings of each of systolic (SBP) and diastolic (DBP) blood pressure were measured at intervals of at least one minute, while participants were seated, as per the Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure.51 Body weight was measured to the nearest 0.1 kg using a calibrated smart D-quip electronic scale, while height was measured to the nearest 0.5 cm with a wall-mounted stadiometer. Body mass index (BMI) was calculated as weight divided by height squared (kg/m2). Waist and hip circumferences were measured to the nearest 0.1 cm using a non-stretchable plastic tape. Abdominal obesity was computed as waist circumference (WC), waist-to-hip ratio (WHR)45,52 and waist-to-height ratio (WHtR).53 Capillary blood was taken using disposable lancets to determine cholesterol and glucose levels with an Accutrend® GCT (Roche Diagnostics, Basel, Switzerland). Two consecutive measurements were taken, and the mean value was used for the study. Risk factors determined in this study were central/abdominal obesity determined by a WC of ≥ 94 cm in males and ≥ 80 cm in females, or a BMI > 30 kg/m2 (in the case of a BMI > 30 kg/m2, central obesity can be assumed and WC does not need to be measured). In addition to overweight/obesity, hypertension (≥ 130/85 mmHg) and glucose level were determined. We used ≤ 7.8 mmol/l instead of 5.6 mmol/l for fasting glucose, since we could not confirm that participants had fasted overnight. These risk factors were adapted from the criteria of the International Diabetes Federation (IDF) and the National Cholesterol Education Program Adult Treatment Panel III for the metabolic syndrome (ATPIII),54 which was used to determine the presence of the MetS by a combination of any three. The study was conducted according to the guidelines laid down in the Declaration of Helsinki,55 and all procedures involving human subjects were approved by the Sefako Makgatho Health Sciences University Research and Ethics Committee [SMUREC/H/74/2016:IR]. Written informed consent was obtained from all participants. Statistical analysis Statistical analyses were performed using STATA (Intercooled Stata® version 14). Skewness and kurtosis tests for normality were performed to check the distribution of data. All variables had chi-squared p-values less than 0.05, which indicated skewed data. The medians for continuous data were compared using the Mann–Whitney test by gender. Results are presented as median [interquartile range (IQR)]. A chi-squared test was used to compare the cardiometabolic risk factors and the MetS, stratified by gender and age to generate the proportions, and the results are presented as categorical variables [frequency (n) and percentage (%)]. Fisher’s exact test was applied to variables with expected values less than five in a cell. Multivariate logistic regression analysis was used to determine the association of the MetS (outcome measure) with selected REDUCE THE RIPPLE EFFECT OF UNCONTROLLED HYPERTENSION VALSARTAN 80 mg 160 mg 320 mg NEW VALSARTAN 320 mg CUSTOMER CARE LINE +27 21 707 7000 www.mydynami cs.co.za REGOVAL 80, 160, 320 mg. Each tablet contains 80, 160, 320 mg valsartan respectively. S3 A43/7.1.3/0548, 0549, A47/7.1.3/0693. For full prescribing information, refer to the professional information approved by SAHPRA, October 2021. REGOVAL Co 80/12,5, 160/12,5, 160/25 mg. Each tablet contains 80, 160, 160 mg valsartan respectively and 12,5, 12,5, 25 mg hydrochlorothiazide respectively. S3 A44/7.1.3/0018, 0019, 0020. For full prescribing information, refer to the professional information approved by SAHPRA, September 2019. RGLB930/05/2022.
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