[Prevalence of conventional cardiovascular risk factors in the Great Tunis population]

New onset heart failure with reduced ejection fraction management: single center, real-life Tunisian experience

BACKGROUND

Heart failure (HF) is a serious and frequent pathology. It represents a major public health problem. We have few data about this pathology in our country. The aim of our study is to determine the epidemiological, clinical, therapeutic, and prognostic characteristics of new-onset HF with reduced left ventricular ejection fraction (HFrEF) and to study the degree of conformity of the management of HF with international recommendations.

RESULTS

Our study population includes 210 patients hospitalized for HFrEF newly diagnosed. The average age of our patients was 64 ± 12 years. A male predominance was noted with a sex ratio of 2.8. The main etiology of HF was ischemic heart disease noted in 97 patients (46.2%). The average LVEF is 33 ± 6%. The triple combination (angiotensin-converting enzyme inhibitors + beta blockers + Mineralocorticoid Receptor Antagonists) was prescribed in 75 patients (35.7%). The quadruple combination (angiotensin-converting enzyme inhibitors + beta blockers + Mineralocorticoid Receptor Antagonists + Sodium-Glucose Co-Transporter 2 inhibitors) was prescribed in 17 patients (8.1%). Myocardial revascularization was indicated in 97 patients (46.6%) and valve surgery was indicated in 49 patients (23.3%). Hospital mortality was 3.8% and at 1 year 18.1%. Among the 192 patients followed during the first year after discharge from hospital, 81 patients had to be re-hospitalized, i.e., a 1-year rehospitalization rate of 42.2%.

CONCLUSIONS

Our study highlighted the epidemiological and clinical features of HF in a Tunisian care center, revealing our patient management deficiency. This pushes us to have a new Tunisian register to enable a better statistical analysis and lead to more relevant conclusions.

Metabolic disorders during endogenous Cushing's syndrome: prevalence, associated factors, and outcome after remission

Objective. The prognosis of Cushing's syndrome (CS) is related to a higher cardiovascular morbidity and mortality. This study aimed to determine the prevalence of metabolic disorders in patients with CS, the associated factors, and the rate of remission of these disorders after the remission from CS. Methods. It is a retrospective study including 75 cases of CS followed up at the university hospital La Rabta of Tunis from 1987 to 2018. Clinical and paraclinical data were collected from medical files. Results. The mean age of the patients was 44.1±18.9 years and the sex ratio was 0.39. At CS diagnosis, the frequencies of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome were 52, 75, 43, 83, and 73%, respectively. The age, gender, body mass index, waist circumference, and baseline serum cortisol level were not associated with the presence of diabetes, hypertension or dyslipidemia. Forty-eight patients were operated on. At one year, 38 patients were in remission from CS. The remission rates of hypertension, diabetes, and dyslipidemia were respectively 58% (p<0.001), 76% (p<0.001), and 17% (NS). Conclusion. Metabolic disorders were frequent during CS and their frequencies decreased after the remission from the syndrome.

Design and Rationale of the National Observational Multicentric Tunisian Registry of Hypertension: Protocol for Evaluating Hypertensive Patient Care in Clinical Practice

BACKGROUND

This study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions.

OBJECTIVE

This study will provide us an overview of hypertension (HTN) management in Tunisia and the degree of adherence of practitioners to international recommendations.

METHODS

This is a national observational cross-sectional multicenter study that will include patients older than 18 years with HTN for a duration of 4 weeks, managed in the public sector from primary and secondary care centers as well as patients managed in the private sector. Every participating patient signed a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated are demographic and anthropometric data, lifestyle habits, blood pressure levels, lipid profiles, treatment, and adherence to treatment. The data are collected via the web interface in the Dacima Clinical Suite.

RESULTS

The study began on April 15, 2019 and ended on May 15, 2019. During this period, we included 25,890 patients with HTN. Data collection involved 321 investigators from 24 Tunisian districts. The investigators were doctors working in the private and public sectors.

CONCLUSIONS

Observational studies are extremely useful in improving the management of HTN in developing countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04013503; https://clinicaltrials.gov/ct2/show/NCT04013503.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21878.

Burden of non-communicable diseases in Tunisia, 1990-2017: results from the global burden of disease study

INTRODUCTION

non-communicable diseases (NCDs) are the leading cause of mortality and disability worldwide especially in developing countries such as Tunisia. We aimed to describe the national burden of non-communicable diseases in 2017 and to analyze disability-adjusted life year trends from 1990 to 2017 in Tunisia by cause and gender.

METHODS

we used Joinpoint regression analysis to assess trends of the age standardized disability-adjusted life year rate from 1990 to 2017 and to determine average annual percentage change.

RESULTS

non-communicable diseases accounted for 87.7% of total disability-adjusted life year in Tunisia in 2017. The five leading causes of this rate in Tunisia in 2017 were cardiovascular diseases, musculoskeletal disorders, neoplasms, mental disorders and neurological disorders. The trend of disability-adjusted life year rate of non-communicable diseases decreased significantly from 23403.2 per 100.000 (95% CI: 20830.2-26285.8) in 1990 to 18454.6 (95% CI: 15611.3-21555.4) in 2017, with a change of -0.9%; p=0.00. The decrease of the age standardized disability-adjusted life year rate concerned mainly cardiovascular diseases and neoplasms secondly. This decrease was more important in female (change=-1.1, p=0.00) in comparison to males (change=-0.7, p=0.00). On the other hand, the increase of the standardized disability-adjusted life year rate was related to musculoskeletal disorders, diabetes, kidney disorders and substance use disorders with a significant annual percentage change of 0.1%, 0.2% and 1.3% (p=0.00) respectively. Conclusion: the implementation of the national strategy is the key solution to mitigate the impact of non-communicable diseases in Tunisia.

Implementation of the WHO Framework Convention on Tobacco Control in Tunisia: Progress and challenges

INTRODUCTION

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was the first health treaty that requires state parties to adopt and implement the MPOWER package. The aim of this study is to review the current status of tobacco control policies in Tunisia according to the WHO FCTC recommendations.

METHODS

This paper is a critical narrative literature review in which information was obtained from peer-reviewed articles, official government documents, reports, decrees and grey literature in French, Arabic and English.

RESULTS

Modest progress in FCTC implementation in Tunisia was noted. The smoking ban in public places is not regularly or largely enforced. The advertising and promotion for tobacco and its products is prohibited by law, but, the ban does not cover the display and visibility of tobacco products at points-of-sale, through the internet, and the depiction of tobacco or tobacco use in entertainment media products. Health warnings on tobacco products consist only of text and do not exceed 30% of the main display areas but are expected to increase to 70% with graphics and text when the new law is passed.

CONCLUSIONS

Effective intervention efforts are urgently required. These actions should include accelerating the adoption of a new law, enforcing the present law and the new one once adopted, developing an advocacy and argument about the positive impact on state budget balance, increasing taxes, combating smuggling and illicit manufacturing and counterfeiting, increased education, increased smoking cessation support and implementing periodic surveillance.

Gender disparities in midlife hypertension: a review of the evidence on the Arab region

Objective

While gender differences in hypertension and increased prevalence rates among women at midlife have been documented in multiple settings, the evidence on the Arab world has not been systematically examined. This review summarizes the evidence related to gender disparities in midlife hypertension in this region.

Methods

We searched MEDLINE and Social Sciences Citation Index (SSCI) databases for studies, published between January 2000 and August 2015, on hypertension in the 22 countries of the Arab region. We abstracted information on the prevalence of hypertension among women and men, in general populations during midlife.

Results

Nineteen studies provided data on the prevalence of hypertension by gender and age in the Arab world. Higher rates of hypertension were found among Arab women at midlife in most countries. In studies that included subjects younger than 35 years old, a decrease in sex ratios (M/F) at midlife was observed in all countries except Palestine. Higher female prevalence rates are observed in the 4^th decade of life in most countries of the region, almost two decades earlier than in other parts of the world.

Conclusions

This review highlights the need for more systematic examinations of hypertension in the Arab region, its risk factors, and the reasons for the particular patterns of gender differences that are observed. Such research would have considerable implications for prevention, treatment, and improved well-being.

Effectiveness of a Community-Based Intervention Program to Reduce Hypertension Prevalence Among Adults: Results of a Quasiexperimental Study With Control Group in the Region of Sousse, Tunisia

BACKGROUND

High blood pressure is preventable and is directly related to lifestyle habits such as an unbalanced diet, low levels of physical activity, and tobacco use.

OBJECTIVES

This quasiexperimental study aimed to assess the effectiveness of a 3-year community intervention targeting healthy lifestyle promotion in reducing hypertension prevalence among adults.

METHODS

A quasiexperimental design was used to evaluate the effectiveness of a 3-year intervention for healthy lifestyle that was implemented between 2010 and 2013 in a community of adults in the region of Sousse in Tunisia. The population study was randomly selected in both intervention and control groups at pre-assessment and post-assessment. After considering a type 1 error α of 5%, a type 2 error β of 20%, and a change in the prevalence of various risk factors of 6% between pre-intervention and post-intervention, the sample size was fixed to 2,000 adults in intervention and control areas.

RESULTS

The intervention group was composed of 940 and 1,001 adults, and the control group was composed of 940 and 976, respectively, at pre-assessment and post-assessment. The prevalence of hypertension decreased in the intervention group globally from 37.3% to 33.7% but not significantly (p = 0.1). In the control group, this proportion increased from 31.1% to 33.4% without significant difference (p = 0.28). In the intervention group, after stratification for age, a significant decrease (p = 0.007) in the prevalence of hypertension was observed for participants younger than 40 years old: it decreased from 22.8% to 16.2%. In the control group, it increased from 14% to 15.4% (p = 0.52). In intervention group, a significant decrease of the hypertension from 31.4% to 26% (p = 0.03) was observed among nonobese participants after stratification for weight status. No significant change was observed in the control group.

CONCLUSIONS

This study showed the feasibility and effectiveness of a community-based intervention to reduce the prevalence of hypertension in the context of a developing country.

A Community-Based Assessment of Hypertension and Some Other Cardiovascular Disease Risk Factors in Ngaoundéré, Cameroon

Background and Objective. Cardiovascular diseases are primary causes of death worldwide with well documented risk factors whose varying impacts added to the complexity in CVD management dictate the need for region-specific studies. We aimed at investigating the interactions between CVD risk factors and hypertension in Ngaoundéré. Methods. A cross-sectional survey was carried out from March to August 2014. Sociodemographic, fasting blood glucose, blood pressure, and anthropometric data were recorded. Statistical analyses were carried out using SAS software version 9.1. Results. 700 adults resident in Ngaoundéré for at least two years consented and were included in the survey. Abdominal obesity, physical inactivity, and hypertension were the dominant risk factors recording 51.1%, 35.4%, and 20.4%, respectively. The prevalence of hyperglycaemia, tobacco consumption, obesity, and alcohol consumption was 5.6%, 8.3%, 9.6%, and 18.1%, respectively. Advanced age, hyperglycaemia, a divorced marital status, and alcohol consumption were independent determinants of high blood pressure. Conclusion. Physical inactivity, abdominal obesity, and hypertension were the most prevalent CVD risk factors, and the role of advanced age and hyperglycaemia in the occurrence of high blood pressure was reiterated. Health programs need to focus on effective screening, prevention, and control of CVDs in the Adamawa Region and Cameroon at large.

Assessment of cardiovascular risk in Tunisia: applying the Framingham risk score to national survey data

OBJECTIVE

This paper aims to assess the socioeconomic determinants of a high 10 year cardiovascular risk in Tunisia.

SETTING

We used a national population based cross sectional survey conducted in 2005 in Tunisia comprising 7780 subjects. We applied the non-laboratory version of the Framingham equation to estimate the 10 year cardiovascular risk.

PARTICIPANTS

8007 participants, aged 35-74 years, were included in the sample but effective exclusion of individuals with cardiovascular diseases and cancer resulted in 7780 subjects (3326 men and 4454 women) included in the analysis.

RESULTS

Mean age was 48.7 years. Women accounted for 50.5% of participants. According to the Framingham equation, 18.1% (17.25-18.9%) of the study population had a high risk (≥20% within 10 years). The gender difference was striking and statistically significant: 27.2% (25.7-28.7%) of men had a high risk, threefold higher than women (9.7%; 8.8-10.5%). A higher 10 year global cardiovascular risk was associated with social disadvantage in men and women; thus illiterate and divorced individuals, and adults without a professional activity had a significantly higher risk of developing a cardiovascular event in 10 years. Illiterate men were at higher risk than those with secondary and higher education (OR=7.01; 5.49 to 9.14). The risk in illiterate women was more elevated (OR=13.57; 7.58 to 24.31). Those living in an urban area had a higher risk (OR=1.45 (1.19 to 1.76) in men and OR=1.71 (1.35 to 2.18) in women).

CONCLUSIONS

The 10 year global cardiovascular risk in the Tunisian population is already substantially high, affecting almost a third of men and 1 in 10 women, and concentrated in those more socially disadvantaged.

TGF-beta-induced early gene-1 overexpression promotes oxidative stress protection and actin cytoskeleton rearrangement in human skin fibroblasts

BACKGROUND

Transforming growth factor beta inducible early gene-1 (TIEG-1), a member of the Krüppel-like factor, was identified as a primary response gene for TGF-β. The role of TIEG-1 in skin repair has been mainly addressed in vivo on TIEG-1 null mice model and the mechanism remains unexplored.

METHODS

We investigated the modulation of TIEG-1 expression in normal human skin fibroblasts by either down-expressing or overexpressing the gene. We evaluated reactive oxygen species production and the cell viability of treated cells. The effect of TIEG-1 overexpression was monitored by wound healing assay and immunofluorescence staining of actin fibers organization and alpha-smooth muscle actin (α-SMA). Western blots were carried out to identify the level of expression or phosphorylation of key proteins such as cofilin, Rho GTPases, and p38 mitogen-activated protein kinase (p38 MAPK).

RESULTS

TIEG-1 down-regulation had a deleterious effect on the cell viability. It was significantly reduced (65±5%) and exposure to ultraviolet further increased this effect (47±3%). By contrast, cells overexpressing TIEG-1 had a reduced reactive oxygen species production (75%) compared to control and mock-transfected cells. This overexpression also resulted in formation of actin stress fibers and increased α-SMA expression and an enhanced wound healing feature. RhoB GTPase was upregulated and phosphorylation of cofilin and p38 MAPK was observed.

CONCLUSION

TIEG-1 overexpression in normal human skin fibroblasts results in improved resistance to oxidative stress, myofibroblast-like conversion that involved RhoB signaling pathway with cofilin and p38 MAPK proteins activation.

GENERAL SIGNIFICANCE

This study enlightens the role of TIEG-1 role in skin biology.

[Prevalence of dyslipidemia in the rural population of Gueoul (Senegal)]

INTRODUCTION

The cardiovascular risk factors are clearly increasing in developing countries. Among these factors, dyslipidemia is often found, this due to the change in behavioral and dietary habits (OMS, 2006). Dyslipidemia is a "primary or secondary pathological changes in serum lipids". It is a chronic and metabolic abnormality, characterized by persistently elevated TG, LDL-c, and a decrease in HDL (Attias et al., 2013-2014). The objective of this study is to determine the prevalence of dyslipidemia, and give the lipid profile of the population in Gueoul.

PATIENTS AND METHODS

We performed a comprehensive observational study, cross-sectional descriptive on Senegalese aged 35 or over, living in Gueoul for at least 6 months. Lipid profile (total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol) was systematically after 12hours of fasting.

RESULTS

Dyslipidemia was found in 61.3 % of cases with 50 % pure hypercholesterolemia (n=705). Only 20 subjects (2.3 %) knew they had dyslipidemia. The detection rate was 59.8 % (n=844). The type most represented was hypoHDLemia (45.6 %) followed by hyperLDLemia (28.8 %). Triglycerides were increased in only 2.8 % of cases.

CONCLUSION

The prevalence of dyslipidemia is very high in our regions. It is often associated with female gender, hypertension, diabetes, and obesity. Its main causes are physical inactivity, change in lifestyle and eating habits. It is often misunderstood and its management is limited in most cases to low-calorie diet.

Forecasting Tunisian type 2 diabetes prevalence to 2027: validation of a simple model

BACKGROUND

Most projections of type 2 diabetes (T2D) prevalence are simply based on demographic change (i.e. ageing). We developed a model to predict future trends in T2D prevalence in Tunisia, explicitly taking into account trends in major risk factors (obesity and smoking). This could improve assessment of policy options for prevention and health service planning.

METHODS

The IMPACT T2D model uses a Markov approach to integrate population, obesity and smoking trends to estimate future T2D prevalence. We developed a model for the Tunisian population from 1997 to 2027, and validated the model outputs by comparing with a subsequent T2D prevalence survey conducted in 2005.

RESULTS

The model estimated that the prevalence of T2D among Tunisians aged over 25 years was 12.0% in 1997 (95% confidence intervals 9.6%-14.4%), increasing to 15.1% (12.5%-17.4%) in 2005. Between 1997 and 2005, observed prevalence in men increased from 13.5% to 16.1% and in women from 12.9% to 14.1%. The model forecast for a dramatic rise in prevalence by 2027 (26.6% overall, 28.6% in men and 24.7% in women). However, if obesity prevalence declined by 20% in the 10 years from 2013, and if smoking decreased by 20% over 10 years from 2009, a 3.3% reduction in T2D prevalence could be achieved in 2027 (2.5% in men and 4.1% in women).

CONCLUSIONS

This innovative model provides a reasonably close estimate of T2D prevalence for Tunisia over the 1997-2027 period. Diabetes burden is now a significant public health challenge. Our model predicts that this burden will increase significantly in the next two decades. Tackling obesity, smoking and other T2D risk factors thus needs urgent action. Tunisian decision makers have therefore defined two strategies: obesity reduction and tobacco control. Responses will be evaluated in future population surveys.

Health system challenges of NCDs in Tunisia

OBJECTIVES

The objective of this study was to present a qualitative 'situation analysis' of the healthcare system in Tunisia, as it applies to management of cardiovascular disease (CVD) and diabetes. A primary concern was the institutional capacity to manage non-communicable diseases (NCDs).

METHODS

Research took place during 2010 (analysis of official documents, semi-structured interviews with key informants, and case studies in four clinics). Walt and Gilson's framework (1994) for policy analysis was used: content, actors, context, and process.

RESULTS

Problems of integration and coordination have compounded funding pressures. Despite its importance in Tunisian healthcare, primary health is ill-equipped to manage NCDs. With limited funds, and no referral or health information system, staff morale in the public sector was low. Private healthcare has been the main development filling the void.

CONCLUSION

This study highlights major gaps in the implementation of a comprehensive approach to NCDs, which is an urgent task across the region. In strategic planning, research on the health system is vital; but the capacity within Ministries of Health to use research has first to be built, with a commitment to grounding policy change in evidence.

Living with diabetes and hypertension in Tunisia: popular perspectives on biomedical treatment

OBJECTIVES

The growing prevalence of non-communicable diseases across the Middle East and North Africa poses major challenges for underfunded health services. This article presents data on the perspectives of ordinary Tunisians who are coping with two of these diseases--diabetes and hypertension--and who are obtaining treatment through Tunisian public health clinics. Little has been written to date on patient experiences of biomedical treatment in Maghreb countries.

METHODS

Based on qualitative methods and semi-structured interviews with 24 patients attending two clinics, one urban and one rural.

RESULTS

We examine popular aetiological beliefs, ideas about biomedical treatment and its implications, and comparative views on the benefits and drawbacks of treatment in both public and private clinics.

CONCLUSIONS

We highlight two main themes. One was nostalgia for a recent past when 'pure' and 'natural' food, 'proper' meals and less stressful lives meant less chronic illness, with demanding and costly treatment. The other concerned communication in the clinic, and the recurrent dismay patients felt at what they saw as the cursory attention and guidance they received from clinic staff in public facilities.

Prevalence of diabetes in Northern African countries: the case of Tunisia

BACKGROUND

Although diabetes is recognized as an emerging disease in African and Middle East, few population-based surveys have been conducted in this region. We performed a national survey to estimate the prevalence of type 2 diabetes (T2D) and to evaluate the relationship between this diagnosis, demographic and socioeconomic variables.

METHODS

The study was conducted on a random sample of 6580 households (940 in each region). 7700 subjects adults 35-70 years old were included in the analyses. T2D was assessed on the basis of a questionnaire and fasting blood glucose level according to the WHO criteria. Access to health care and diabetes management were also assessed.

RESULTS

Overall, the prevalence of T2D was 15.1%. There were sharp urban vs. rural contrasts, the prevalence of diabetes being twice higher in urban area. However, the ratio urban/rural varied from 3 in the less developed region to 1.6 in the most developed ones. A sharp increase of prevalence of T2D with economic level of the household was observed. For both genders those with a family history of T2D were much more at risk of T2D than those without. Awareness increase with age, economic level and were higher amongst those with family history of T2D. Drugs were supplied by primary health care centers for 57.7% with a difference according to gender, 48.9% for men vs. 66.0% women (p < 0.001) and area, 53.3% on urban area vs. 75.2% on rural one (p < 0.001).

CONCLUSIONS

Through its capacity to provide the data on the burden of diabetes in the context of the epidemiological transition that North Africa is facing, this survey will not only be valuable source for health care planners in Tunisia, but will also serve as an important research for the study of diabetes in the region where data is scarce. In this context, NCDs emerge as an intersectoral challenge and their social determinants requiring social, food and environmental health policy.

Clustering of risk factors with smoking habits among adults, Sousse, Tunisia

Introduction

In Tunisia, few studies have assessed the association between tobacco use and other lifestyle risk factors for chronic disease (eg, unhealthy diet, physical inactivity). We studied 1,880 adults to determine the association between tobacco use and other lifestyle risk factors in Tunisia.

Methods

This study was part of an assessment of the prevalence of chronic disease risk factors in a community-based trial conducted in 2009 to implement a chronic disease prevention program. The study population was randomly selected from 3 districts of the region of Sousse. The questionnaires were administered by personal interview and included the assessment of tobacco use and other chronic disease risk factors such as unhealthful diet habits and physical inactivity.

Results

Of the 1,880 study participants, 64% were women. The mean age of the participants was 37.9 (standard deviation, 13.5 y). The prevalence of tobacco use in our population was 50.4% for men and 3.1% for women. Among men, the proportion of alcohol consumption was significantly higher among smokers (25.3% vs 5.7% [P <.001]). Smokers consumed fewer fruits and vegetables and more high-fat, high-salt, and high-sugar foods than did nonsmokers. There was no significant difference between male smokers and nonsmokers regarding physical activity (P = .36).

Conclusion

Physical activity and dietary characteristics may be important areas for physicians to assess during smoking-cessation interventions.

Diabetes in the Middle East and North Africa

AIMS

Even though the Middle East and North Africa (MENA) region had the highest comparative prevalence of diabetes in 2012, little is known about the nuances of diabetes risk and capacity to address the burdens. To provide a comprehensive overview, we reviewed the literature on diabetes in the MENA region.

METHODS

We conducted a systematic search in PubMed between January 1990 and January 2012 for studies on diabetes in the MENA region without language restriction.

RESULTS

There was a paucity of country-specific epidemiology data in the region. Diabetes prevalence varied widely across studies, from 2.5% in 1982 to 31.6% in 2011. Older age and higher body mass index were the most strongly associated risk factors for diabetes. Among people with diabetes, over half did not meet recommended care targets. In addition, macrovascular and microvascular complications were observed in 9-12% and 15-54% of diabetes population, respectively.

CONCLUSIONS

This review suggests a need for more representative surveillance data in this noteworthy focal point of the global diabetes epidemic. Such actions will not only help to understand the actual burden of diabetes but also motivate actions on design and implementation of diabetes prevention and control programs.

Analyzing recent coronary heart disease mortality trends in Tunisia between 1997 and 2009

BACKGROUND

In Tunisia, Cardiovascular Diseases are the leading causes of death (30%), 70% of those are coronary heart disease (CHD) deaths and population studies have demonstrated that major risk factor levels are increasing.

OBJECTIVE

To explain recent CHD trends in Tunisia between 1997 and 2009.

METHODS

DATA SOURCES

Published and unpublished data were identified by extensive searches, complemented with specifically designed surveys.

ANALYSIS

Data were integrated and analyzed using the previously validated IMPACT CHD policy model. Data items included: (i)number of CHD patients in specific groups (including acute coronary syndromes, congestive heart failure and chronic angina)(ii) uptake of specific medical and surgical treatments, and(iii) population trends in major cardiovascular risk factors (smoking, total cholesterol, systolic blood pressure (SBP), body mass index (BMI), diabetes and physical inactivity).

RESULTS

CHD mortality rates increased by 11.8% for men and 23.8% for women, resulting in 680 additional CHD deaths in 2009 compared with the 1997 baseline, after adjusting for population change. Almost all (98%) of this rise was explained by risk factor increases, though men and women differed. A large rise in total cholesterol level in men (0.73 mmol/L) generated 440 additional deaths. In women, a fall (-0.43 mmol/L), apparently avoided about 95 deaths. For SBP a rise in men (4 mmHg) generated 270 additional deaths. In women, a 2 mmHg fall avoided 65 deaths. BMI and diabetes increased substantially resulting respectively in 105 and 75 additional deaths. Increased treatment uptake prevented about 450 deaths in 2009. The most important contributions came from secondary prevention following Acute Myocardial Infarction (AMI) (95 fewer deaths), initial AMI treatments (90), antihypertensive medications (80) and unstable angina (75).

CONCLUSIONS

Recent trends in CHD mortality mainly reflected increases in major modifiable risk factors, notably SBP and cholesterol, BMI and diabetes. Current prevention strategies are mainly focused on treatments but should become more comprehensive.

Prevalence and complications of diabetes mellitus in Northern Africa, a systematic review

Background

Diabetes is increasingly becoming a major chronic disease burden all over the world. This requires a shift in healthcare priorities and up-to-date data on the epidemiology and impact of diabetes in all regions of the world to help plan and prioritize health programs. We systematically reviewed the literature on diabetes prevalence and its complications in the UN sub region of Northern Africa including Morocco, Algeria, Tunisia, Libya, Egypt, Sudan, South Sudan and Western Sahara.

Methods

A systematic literature review of papers published on diabetes prevalence and complications in North Africa from January 1990 to July 2012. Literature searches were conducted using electronic databases.

Results

Diabetes prevalence ranged from 2.6% in rural Sudan to 20.0% in urban Egypt. Diabetes prevalence was significantly higher in urban areas than in rural areas. Undiagnosed diabetes is common in Northern Africa with a prevalence ranging from 18% to 75%. The prevalence of chronic diabetes complications ranged from 8.1% to 41.5% for retinopathy, 21% to 22% for albuminuria, 6.7% to 46.3% for nephropathy and 21.9% to 60% for neuropathy.

Conclusions

Diabetes is an important and common health problem in Northern Africa. Variations in prevalence of diabetes between individual countries are observed. Chronic complications of diabetes are common. Urgent measures are needed to prevent diabetes and its related complications in Northern Africa.

Gender obesity inequities are huge but differ greatly according to environment and socio-economics in a North African setting: a national cross-sectional study in Tunisia

Introduction

Southern Mediterranean countries have experienced a marked increase in the prevalence of obesity whose consequences for gender related health inequities have been little studied. We assessed gender obesity inequalities and their environmental and socio-economic modifiers among Tunisian adults.

Methods

Cross-sectional survey in 2005; national, 3 level random cluster sample of 35–70 years Tunisians (women: n = 2964, men: n = 2379). Overall adiposity was assessed by BMI = weight(kg)/height(m)² and obesity was BMI≥30, WHtR = waist circumference to height ratio defined abdominal obesity as WHtR≥0.6. Gender obesity inequality measure was women versus men Prevalence Proportion Odds-Ratio (OR); models featuring gender x covariate interaction assessed variation of gender obesity inequalities with area (urban versus rural), age, marital status or socio-economic position (profession, education, household income proxy).

Results

BMI was much higher among women (28.4(0.2)) versus men (25.3(0.1)), P<0.0001) as was obesity (37.0% versus 13.3%, OR = 3.8[3.1–7.4], P<0.0001) and abdominal obesity (42.6% versus 15.6%, 4.0[3.3–4.8], P<0.0001). Gender obesity inequalities (women versus men adjusted OR) were higher in urban (OR = 3.3[1.3–8.7]) than rural (OR = 2.0[0.7–5.5]) areas. These gender obesity inequalities were lower for subjects with secondary education or more (OR = 3.3[1.3–8.6]), than among those with no schooling (OR = 6.9[2.0–23.3]). They were also lower for those with upper/intermediate profession (OR = 1.4[0.5–4.3]) or even employees/workers OR = 2.3[1.0–5.4] than those not professionaly active at all (OR = 3.3[1.3–8.6]). Similar results were observed for addominal obesity.

Conclusion

The huge overall gender obesity inequities (women much more corpulent than men) were higher in urban settings, but lower among subjects of higher education and professional activity. Reasons for gender inequalities in obesity and their variation with socio-economic position should be sought so that appropriate policies to reduce these inequalities can be implemented in Tunisia and similar settings.

Metabolic syndrome in Tunisian psoriatic patients: prevalence and determinants

BACKGROUND

A significant association between psoriasis and the metabolic syndrome (MetS) has been frequently reported.

OBJECTIVE

The aim of this study was to specify the main factors that determine the MetS in psoriatic Tunisian patients.

METHODS

A case-control study has included 164 psoriatic patients and 216 controls.

RESULTS

The prevalence of MetS was higher in cases than in controls but without statistical differences [35.5% vs. 30.8%, odds ratio (OR): 1.39 CI: 0.88-2.18; P=0.095]. According to gender, the prevalence of MetS was significantly increased only in psoriatic women (47.4% vs. 30%, OR: 1.89, CI: 1.11-3.21; P=0.01). A multiple logistic regression, considering the effect of age, and gender, showed that the prevalence of MetS was significantly higher in cases than in controls (OR: 1.73, CI: 1.06-2.82; P=0.03). MetS components analysed seperately showed a significantly higher prevalence of decreased high-density lipoprotein cholesterol (HDLc) (60.9% vs. 35.9%, OR: 2.77, CI: 1.8-4.27, P<0.001) and for increased hypertension (50% vs. 40%, OR: 1.48, CI: 0.97-2.257, P=0.04) in psoriatic patients. According to gender, HDLc was significantly decreased in both genders (male: OR: 2.075, CI: 1.24-3.47, P=0.004; female: OR: 3.58, CI: 2.07-6.19, P<0.0001), while hypertension was increased only in psoriatic men (OR: 2.09, CI: 1.24-3.51, P=0.004) and abdominal obesity only in psoriatic women (OR: 2.31, CI: 1.30-4.11, P=0.002).

CONCLUSION

Decreased HDLc is the main biological abnormality that characterized MetS in Tunisian psoriatic patients. Moreover, contrary to men, psoriatic women have shown a significantly higher prevalence of MetS, which is, in addition to decreased HDLc, mainly attributed to abdominal obesity.