The double burden of malnutrition and cardiometabolic risk widens the gender and socio-economic health gap: a study among adults in Burkina Faso (West Africa)

Updating the association between socioeconomic status and obesity in low-income and lower-middle-income sub-Saharan African countries: A literature review

Globally, the literature tends to emphasize negative associations between socioeconomic status (SES) and bodyweight in countries improving their economic development. However, little is known about the social distribution of obesity in sub-Saharan Africa (SSA) where economic growth has been highly heterogeneous the last decades. This paper reviews an exhaustive set of recent empirical studies examining its association in low-income and lower-middle-income countries in SSA. Although there is evidence of a positive association between SES and obesity in low-income countries, we found mixed associations in lower-middle-income countries, potentially providing evidence of a social reversal of the obesity burden.

Prevalence of the metabolic syndrome in African populations: A systematic review and meta-analysis

BACKGROUND

The metabolic syndrome (MS) is a leading cause of death worldwide. Several studies have found MS to be prevalent in various African regions. However, no specific estimates of MS prevalence in African populations exist. The aim of this study was to estimate the overall prevalence of MS in the African populations.

METHODS

A systematic review was conducted in PubMed, Web of Science, Africa Index Medicus, and African Journal Online Scopus to find studies published up to the 15th of August 2022. Pooled prevalence was calculated based on six diagnostic methods. The pooled prevalence of MS was estimated using a random-effects model. Our risk of bias analysis was based on the Hoy et al. tool. A Heterogeneity (I2) assessment was performed, as well as an Egger test for publication bias. PROSPERO number CRD42021275176 was assigned to this study.

RESULTS

In total, 297 studies corresponding to 345 prevalence data from 29 African countries and involving 156 464 participants were included. The overall prevalence of MS in Africa was 32.4% (95% CI: 30.2-34.7) with significant heterogeneity (I2 = 98.9%; P<0.001). We obtained prevalence rates of 44.8% (95% CI: 24.8-65.7), 39.7% (95% CI: 31.7-48.1), 33.1% (95% CI: 28.5-37.8), 31.6% (95% CI: 27.8-35.6) and 29.3% (95% CI: 25.7-33) using the WHO, revised NCEP-ATP III, JIS, NCEP/ATP III and IDF definition criteria, respectively. The prevalence of MS was significantly higher in adults >18 years with 33.1% (95%CI: 30.8-35.5) compared to children <18 years with 13.3% (95%CI: 7.3-20.6) (P<0.001). MS prevalence was significantly higher in females with 36.9% (95%CI: 33.2-40.7) compared to males with 26.7% (95%CI: 23.1-30.5) (P<0.001). The prevalence of MS was highest among Type 2 diabetes patients with 66.9% (95%CI: 60.3-73.1), followed by patients with coronary artery disease with 55.2% (95%CI: 50.8-59.6) and cardiovascular diseases with 48.3% (95%CI: 33.5-63.3) (P<0.001). With 33.6% (95% CI: 28.3-39.1), the southern African region was the most affected, followed by upper-middle income economies with 35% (95% CI: 29.5-40.6).

CONCLUSION

This study, regardless of the definition used, reveals a high prevalence of MS in Africa, confirming the ongoing epidemiological transition in African countries. Early prevention and treatment strategies are urgently needed to reverse this trend.

Iron status and cardiometabolic risk in children

AIM

We aimed to evaluate associations between serum ferritin and transferrin and variables related to the metabolic syndrome (MetS) in children.

METHODS

Cross-sectional and longitudinal study in prepubertal children(n=832) aged 3-14 years. A subset(n=203) were re-examined after a mean follow-up of 3.7±0.8 years[range 2-6]. Outcomes were MetS and MetS components scores, glycosylated haemoglobin (HbA1c), and their follow-up change.

RESULTS

Children with low ferritin had increased HbA1c Z scores (ANCOVA,P=0.003). Ferritin was inversely associated with glycaemia [fully adjusted β (95% confidence interval): -2.35(-4.36 to -0.34)]. Transferrin was associated with diastolic blood pressure[β: 0.02(0.01-0.04)] and log-HOMA-IR [β:0.001(0.0005-0.002)]. MetS risk score worsened during follow-up in children with the lowest baseline ferritin levels. In contrast, at baseline ferritin was positively associated with all (except glycaemia) the MetS-related variables but adjustments for inflammatory, hepatic function, and body mass markers attenuated those associations(P>0.05).

CONCLUSIONS

Lower iron status was independently associated with glycaemic markers and MetS in children, whereas higher ferritin levels were related to other cardiometabolic risk markers under the influence of inflammation, hepatic injury and body mass. Research is required to study whether this mixed pattern is part of an early risk or would be explained by a normal transition during growth and development.

Prevalence and Determinants of Multiple Forms of Malnutrition among Adults with Different Body Mass Index: A Population-Based Survey in the Philippines

Background

The multiple forms of malnutrition, including overnutrition, undernutrition, and diet-related noncommunicable diseases, are emerging crises in Asian countries. Past studies have focused more on malnutrition among overweight/obese individuals; however, limited research has examined chronic energy-deficient adults. Therefore, this study is aimed at investigating the prevalence and determinants of different forms of malnutrition among adults with different body mass index, using the Philippines as an example. Findings from this study will guide the development and implementation of public health nutrition programs and policies.

Methods

A representative dataset from the 2013 Philippine National Nutrition Survey was used in the study. Adults aged ≥20 years (n = 16,826) were included in the analysis after excluding those with missing values. Six phenotypes of malnutrition were assessed, including three in overweight/obese adults (overweight/obese with metabolic syndrome; those with micronutrient deficiency-anemia, vitamin A deficiency, and iodine insufficiency; and those with both metabolic syndrome and micronutrient deficiency) and three in chronic energy-deficient (CED) adults (CED with either metabolic syndrome or micronutrient deficiency and with both metabolic syndrome and micronutrient deficiency). Sociodemographic and lifestyle factors were examined as the determinants of different forms of malnutrition, and multinomial logistic regression analyses were performed.

Results

The prevalence of the six phenotypes of malnutrition ranged from 0.4% to 10.2%, where overweight/obese with metabolic syndrome was the most predominant type. The multinomial logistic regression models indicated that older age was the major risk factor across all phenotypes. Sex was associated with the outcomes in the overweight/obesity group, whereas employment status was correlated with CED adults. Furthermore, higher educational levels, being married, living in affluent households, and not smoking were protective factors for conditions related to CED but not overweight/obese individuals.

Conclusion

Malnutrition in all its forms is a significant public health concern that must be understood and addressed. Policymakers should implement appropriate intervention programs to control these nutritional problems considering the specific risk factors for the adult population.

Temporal trends in overweight and obesity and chronic disease risks among adolescents and young adults: A ten-year review at a tertiary institution in Nigeria

There is an increasing prevalence of obesity among college/university students in low- and middle-income countries, similar to the trend observed in high-income countries. This study aimed to describe the trend and burden of overweight/obesity and emerging associated chronic disease risks among students at the University of Ibadan (UI), Nigeria. This is a ten-year retrospective review of medical records of students (undergraduate and post-graduate) admitted between 2009 and 2018 at UI. Records of 60,168 participants were analysed. The Body Mass Index (BMI) categories were determined according to WHO standard definitions, and blood pressure was classified according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7). The mean age of the participants was 24.8, SD 8.4 years. The majority were ≤ 40 years (95.1%). There was a slight male preponderance (51.5%) with a male-to-female ratio of 1.1:1; undergraduate students constituted 51.9%. The prevalence of underweight, overweight, and obesity were 10.5%, 18.7% and 7.2%, respectively. We found a significant association between overweight/obesity and older age, being female and undergoing postgraduate study (p = 0.001). Furthermore, females had a higher burden of coexisting abnormal BMI characterised by underweight (11.7%), overweight (20.2%) and obese (10.4%). Hypertension was the most prevalent obesity-associated non-communicable disease in the study population, with a prevalence of 8.1%. Also, a third of the study population (35.1%) had prehypertension. Hypertension was significantly associated with older age, male sex, overweight/obesity and family history of hypertension (p = 0.001). This study identified a higher prevalence of overweight and obesity than underweight among the participants, a double burden of malnutrition and the emergence of non-communicable disease risks with potential lifelong implications on their health and the healthcare system. To address these issues, cost-effective interventions are urgently needed at secondary and tertiary-level educational institutions.

Sustainable dietary weight loss intervention and its effects on cardiometabolic parameters and greenhouse gas emissions: study protocol of a randomised controlled trial with overweight and obese adults in Ouagadougou, Burkina Faso

INTRODUCTION

The global obesity epidemic and its adverse health effects have reached sub-Saharan Africa. In some urban settings, like Burkina Faso's capital Ouagadougou, up to 43% of the adult population are overweight or obese. At the same time, modernised food systems are responsible for 26% of global greenhouse gas emissions, 50% of land use and 70% of freshwater use. International guidelines on the treatment of overweight and obesity recommend dietary intervention programmes that promote reduced calorie intake and increased physical activity. So far, weight loss interventions rarely consider sustainable dietary concepts, including healthfulness, affordability, cultural appropriateness and environmental friendliness. Therefore, we present a study protocol of a novel randomised controlled trial that aims to establish the effects of a sustainable weight loss intervention on cardiometabolic and environmental outcomes in urban Burkina Faso.

METHODS AND ANALYSIS

We conduct a non-blinded randomised controlled trial, comparing a 6-month sustainable diet weight loss intervention programme (n=125) with a standard weight loss information material and 5 min oral counselling at baseline (n=125). Primary outcome is a reduction in fasting plasma glucose of ≥0.1 mmol/L. Outcome measures are assessed at baseline, after 6 months and after 12 months.

ETHICS AND DISSEMINATION

Ethical approval for the study has been obtained from the Medical Faculty of Heidelberg University (S-376/2019) and from the Ministry of Health and the Ministry of Higher Education, Scientific Research and Innovation in Ouagadougou, Burkina Faso (No 2021-01-001). The results of the study will be disseminated to local stakeholders at a final project meeting and to the wider research community through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

DRKS00025991.

Prevalence of Obesity and Anemia Among Early Adolescents in Junior Secondary Schools: A Cross-Sectional Study in Ouagadougou, Burkina Faso

BACKGROUND

The school presents an ideal environment to positively impact the long-term health and nutrition outcomes of early adolescents, who are at risk of obesity and anemia.

METHODS

In this cross-sectional survey, we described differences in weight and anemia by sociodemographic, diet and physical activity indicators among 1059 students aged 11 to 15 years from 22 junior secondary schools in Ouagadougou, Burkina Faso. Weight was based on body mass index (BMI) z-scores according to the WHO reference and anemia status was defined by standardized hemoglobin (Hb) measure cut-offs. We calculated dietary diversity scores (DDS) from a 24-hour dietary recall and a global diet quality score (GDQS) from a 7-day dietary recall.

RESULTS

The prevalence of obesity (5%) and anemia (50%) was relatively high among the students, which differed significantly between gender, household wealth and school grade, but not age groups. Eighteen percent of the female adolescents were overweight or obese and 22% were moderately anemic compared to 13% and 16% of the male adolescents. Dietary diversity was significantly different between weight categories, but not anemia status. For physical activity, those taking transportation to school were significantly more likely to be overweight or obese. In adjusted multivariable Poisson regression analyses, only the DDS was significantly associated with thinness and both thinness and anemia, while taking transportation to school was significantly associated with overweight among adolescents.

CONCLUSION

We encourage the promotion of school-based interventions and provision of a curriculum on health and healthy eating in order to reduce obesity, anemia, and its comorbidities.

Global Trends in the Availability of Dietary Data in Low and Middle-Income Countries

Individual-level quantitative dietary data can provide suitably disaggregated information to identify the needs of all population sub-groups, which can in turn inform agricultural, nutrition, food safety, and environmental policies and programs. The purpose of this discussion paper is to provide an overview of dietary surveys conducted in low- and middle-income countries (LMICs) from 1980 to 2019, analyzing their key characteristics to understand the trends in dietary data collection across time. The present study analyzes the information gathered by the Food and Agriculture Organization of the United Nations/World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT). FAO/WHO GIFT is a growing repository of individual-level dietary data and contains information about dietary surveys from around the world, collected through published survey results, literature reviews, and direct contact with data owners. The analysis indicates an important increase in the number of dietary surveys conducted in LMICs in the past four decades and a notable increase in the number of national dietary surveys. It is hoped that this trend continues, together with associated efforts to validate and standardize the dietary methods used. The regular implementation of dietary surveys in LMICs is key to support evidence-based policies for improved nutrition.

The Double Burden of Malnutrition at the Individual Level Among Adults: A Nationwide Survey in the Philippines

Introduction: Double burden of malnutrition (DBM) is a fast-evolving public health challenge. The rising prevalence of obesity and diet-related non-communicable diseases alongside persistent nutritional deficiencies are compelling problems in many developing countries. However, there is limited evidence on the coexistence of these conditions in the same individual among community-dwelling adults. This cross-sectional study describes the various forms of DBM and examines the determinants of DBM at the individual level among adults in the Philippines. Materials and Methods: A nationwide dataset from the 2013 Philippine National Nutrition Survey was used. The final study sample consisted of 17,157 adults (8,596 men and 8,561 non-pregnant and non-lactating women). This study focused on three DBM types within adults: (#1) Underweight and at least one cardiometabolic risk factor (Uw + ≥1 CMRF), (#2) Anemia and at least one cardiometabolic risk factor (An + ≥1 CMRF), (#3) Vitamin A deficiency or iodine insufficiency and at least one cardiometabolic risk factor (Other MND + ≥1 CMRF). The total double burden of malnutrition was also evaluated as the sum of the aforementioned three types. Logistic regression models were used to assess associations between socio-demographic and lifestyle factors and DBM. Results: The prevalence of the three types of DBM were: type #1, 8.1%; type #2, 5.6%; type #3, 20.6%, and the total DBM prevalence was 29.4%. Sex, age, educational attainment, employment status, wealth quintile, and alcohol drinking were the risk factors for DBM. In contrast, marital status, smoking, and physical activity were associated with the different DBM types. Conclusion: The study findings contribute to the current state of knowledge on the broad spectrum of individual-level DBM. Understanding the disparities of this phenomenon could guide integrated actions directed to the concomitance of malnutrition in various forms and cardiometabolic disease risks.

Application of the Global Diet Quality Score in Chinese Adults to Evaluate the Double Burden of Nutrient Inadequacy and Metabolic Syndrome

BACKGROUND

The double burdens of under- and overnutrition are changing the health of individuals and the economic and disease burdens in China. Poor diet plays an important role; however, a valid and easily operationalized metric that could capture the full range of characteristics of the diet that are relevant to both under- and overnutrition is lacking in China.

OBJECTIVES

We aimed to examine the application of the Global Diet Quality Score (GDQS) to evaluate nutrient inadequacy and metabolic syndrome in different demographic groups of Chinese adults.

METHODS

A total of 35,146 individuals (men 14,978, women 20,168) aged >18 y from the 2010-2012 China National Nutrition and Health Survey were included. We scored the GDQS using average intakes of 25 food groups from 3 d of 24-h dietary recalls. Double burden was defined as coexisting metabolic syndrome and nutrient inadequacy.

RESULTS

Diet quality assessed by GDQS was significantly higher in urban than in rural residents (20.8 compared with 18.7), and increased with both educational level and household income (P-trends < 0.0001). A higher GDQS score was inversely associated with metabolic syndrome and nutrient inadequacy, or both (P-trends < 0.0001): multivariate adjusted ORs comparing extreme quintiles of GDQS were 0.79 (95% CI: 0.69, 0.91) for metabolic syndrome, 0.17 (95% CI: 0.14, 0.20) for nutrient inadequacy, and 0.59 (95% CI: 0.50, 0.69) for the double burden. These associations were consistent across different household income levels (P-interaction = 0.26), suggestively stronger in younger (<50 y), females, urban residents, and the more highly educated (P-interaction < 0.05) compared with their counterparts.

CONCLUSIONS

A higher GDQS was inversely associated with a double burden of nutrient inadequacy and metabolic syndrome across various subgroups of Chinese adults. The finding supports the use of the GDQS in different demographic groups of Chinese adults to assess diet quality and nutritional status.

Using the first nationwide survey on non-communicable disease risk factors and different definitions to evaluate the prevalence of metabolic syndrome in Burkina Faso

BACKGROUND

The burden of cardiovascular diseases is rising in the developing world including Sub-Saharan Africa. The rapid rise of cardiovascular disease burden is in part due to undetected and uncontrolled cardiovascular risk factors. The clustering of metabolic syndrome (MetS) components is associated with a high risk of cardiovascular diseases. This complex biochemical disorder is still poorly studied in western Africa. In this study, we aimed to determine the prevalence of metabolic syndrome and its determinants among the adult population in Burkina Faso.

METHODS

We performed a secondary analysis of the data from the first national survey on non-communicable diseases risk factors using the World Health Organization (WHO) Stepwise approach. We included 4019 study participants aged 25 to 64 years. The metabolic syndrome prevalence was estimated using six different definitions.

RESULTS

The mean age was 38.6±11.1 years. Women represented 52.4% and three quarters (75%) lived in rural areas. The overall prevalence of metabolic syndrome according to the different definitions was 1.6% (95%CI:1.1-2.2) for the American College of Endocrinology, 1.8% (95%CI: 1.3-2.4) for the WHO, 4.3% (95%CI:3.5-5.2) for the National Cholesterol Education Program Adult Treatment Panel III, 6.2% (95%CI: 5.1-7.6) for the AAH/NHBI, 9.6%(95%CI: 8.1-11.3) for the International Diabetes Federation and 10.9% (95%: 9.2-12.7) for the Joint Interim Statement. The metabolic syndrome components with the highest prevalence were low High density lipoprotein (63.3%), abdominal obesity (22.3%) and hypertension (20.6%). People living in urban areas and those with older age have higher prevalence of metabolic syndrome regardless of the definition used.

CONCLUSION

Our findings suggest various levels of prevalence of MetS according to the definition used. Identifying the most appropriate criteria for MetS among the adult population is important to early detect and treat this syndrome and its components at the primary health care level to control the rising burden of cardiovascular diseases in the context of ongoing epidemiological transition in the country.

Prevalence of abdominal obesity and its association with cardiovascular risk among the adult population in Burkina Faso: findings from a nationwide cross-sectional study

OBJECTIVE

The objective of this study is to determine the prevalence of abdominal obesity, its predictors and its association with cardiovascular risk among adults in Burkina Faso.

DESIGN

We performed a secondary analysis of data from a national cross-sectional study, using WHO STEPwise approach.

SETTING

The study was conducted in Burkina Faso, in all the 13 regions of the country.

PARTICIPANTS

Our study involved 4308 adults of both sexes, aged between 25 and 64 years.

PRIMARY AND SECONDARY OUTCOMES

Our primary outcome was abdominal obesity, which was defined using a cut-off point of waist circumference (WC) of ≥94 cm for men and ≥80 cm for women. The secondary outcome was very high WC (≥102 cm for men and ≥88 cm for women) (for whom weight management is required).

RESULTS

The mean age of participants was 38.5±11.1 years. The age-standardised prevalence of abdominal obesity was 22.5% (95% CI 21.3% to 23.7%). This prevalence was 35.9% (95% CI 33.9% to 37.9%) among women and 5.2% (95% CI 4.3% to 6.2%) among men. In urban areas, the age-standardised prevalence of abdominal obesity was 42.8% (95% CI 39.9% to 45.7%) and 17.0% (95% CI 15.7% to 18.2%) in rural areas. The age-standardised prevalence of very high WC was 10.2% (95% CI 9.3% to 11.1%). The main predictors of abdominal obesity were being female, increased age, married status, high level of education and living in urban areas. Abdominal obesity was also significantly associated with high blood pressure (adjusted prevalence ratio (aPR): 1.30; 95% CI 1.14 to 1.47) and hypercholesterolaemia (aPR: 1.52; 95% CI 1.18 to 1.94). According to the combination matrix between body mass index and WC, 14.6% of the adult population in Burkina Faso had an increased cardiometabolic risk.

CONCLUSION

Our study showed a high prevalence of abdominal obesity and a high proportion of adults who require weight management strategies to prevent cardiometabolic complications. Strategies to reduce the burden of abdominal obesity and very high WC should be considered by Burkina Faso's policy-makers.

Food addiction symptoms and metabolic changes in children and adolescents with the double burden of malnutrition

The double burden of malnutrition (DBM) has been described in many low-/middle-income countries. We investigated food addiction, thyroid hormones, leptin, the lipid/glucose profile and body composition in DBM children/adolescents. Subjects were allocated into groups according to nutritional status: control (C, n 28), weight excess (WE, n 23) and DBM (WE plus mild stunting, n 22). Both the DBM and WE groups showed higher mean insulin concentrations than the control (DBM = 57·95 (95 % CI 47·88, 70·14) pmol/l, WE = 74·41 (95 % CI 61·72, 89·80) pmol/l, C = 40·03 (95 % CI 34·04, 47·83) pmol/l, P < 0·001). WE and DBM showed more food addiction symptoms than the control (3·11 (95 % CI 2·33, 3·89), 3·41 (95 % CI 2·61, 4·20) and 1·66 (95 % CI 0·95, 2·37)). In DBM individuals, addiction symptoms were correlated with higher body fat and higher insulin and leptin levels. These data provide preliminary evidence consistent with the suggestion that DBM individuals have a persistent desire to eat, but further studies are required to confirm these results in a larger study. These hormonal changes and high body fat contribute to the development of diabetes in long term.

The Double Burden of Malnutrition: A Systematic Review of Operational Definitions

BACKGROUND

Despite increasing research on the double burden of malnutrition (DBM; i.e., coexisting over- and undernutrition), there is no global consensus on DBM definitions.

OBJECTIVES

To identify published operational DBM definitions, measure their frequency of use, and discuss implications for future assessment.

METHODS

Following a structured search of peer-reviewed articles with terms describing "overnutrition" [e.g., overweight/obesity (OW/OB)] and "undernutrition" (e.g., stunting, micronutrient deficiency), we screened 1920 abstracts, reviewed 500 full texts, and extracted 623 operational definitions from 239 eligible articles.

RESULTS

We organized three identified DBM dimensions (level of assessment, target population, and forms of malnutrition) into a framework for building operational DBM definitions. Frequently occurring definitions included coexisting: 1) OW/OB and thinness, wasting, or underweight (n = 289 occurrences); 2) OW/OB and stunting (n = 161); 3) OW/OB and anemia (n = 74); and 4) OW/OB and micronutrient deficiency (n = 73).

CONCLUSIONS

Existing DBM definitions vary widely. Putting structure to possible definitions may facilitate selection of fit-for-purpose indicators to meet public health priorities.

Intraindividual double burden of overweight or obesity and micronutrient deficiencies or anemia among women of reproductive age in 17 population-based surveys

BACKGROUND

Rising prevalence of overweight/obesity (OWOB) alongside persistent micronutrient deficiencies suggests many women face concomitant OWOB and undernutrition.

OBJECTIVES

We aimed to 1) describe the prevalence of the double burden of malnutrition (DBM) among nonpregnant women of reproductive age, defined as intraindividual OWOB and either ≥1 micronutrient deficiency [micronutrient deficiency index (MDI) > 0; DBM-MDI] or anemia (DBM-anemia); 2) test whether the components of the DBM were independent; and 3) identify factors associated with DBM-MDI and DBM-anemia.

METHODS

With data from 17 national surveys spanning low- and middle-income countries (LMICs) and high-income countries from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project (n = 419 to n = 9029), we tested independence of over- and undernutrition using the Rao-Scott chi-square test and examined predictors of the DBM and its components using logistic regression for each survey.

RESULTS

Median DBM-MDI was 21.9% (range: 1.6%-39.2%); median DBM-anemia was 8.6% (range: 1.0%-18.6%). OWOB and micronutrient deficiencies or anemia were independent in most surveys. Where associations existed, OWOB was negatively associated with micronutrient deficiencies and anemia in LMICs. In 1 high-income country, OWOB women were more likely to experience micronutrient deficiencies and anemia. Age was consistently positively associated with OWOB and the DBM, whereas the associations with other sociodemographic characteristics varied. Higher socioeconomic status tended to be positively associated with OWOB and the DBM in LMICs, whereas in higher-income countries the association was reversed.

CONCLUSIONS

The independence of OWOB and micronutrient deficiencies or anemia within individuals suggests that these forms of over- and undernutrition may have unique etiologies. Decision-makers should still consider the prevalence, consequences, and etiology of the individual components of the DBM as programs move towards double-duty interventions aimed at addressing OWOB and undernutrition simultaneously.

Socio-demographic patterning of the individual-level double burden of malnutrition in a rural population in South India: a cross-sectional study

BACKGROUND

The double burden of malnutrition is the co-occurrence of undernutrition (e.g. underweight, stunting, and micronutrient deficiencies) and over-nutrition (e.g. obesity, type 2 diabetes, and cardiovascular disease) at the population, household, or individual level. The objectives of this study were to determine the extent and determinants of individual-level co-morbid anemia and overweight and co-morbid anemia and diabetes in a population in rural Tamil Nadu, South India.

METHODS

We undertook a cross-sectional study of adults (n = 753) in a rural region of Tamil Nadu, South India. A survey assessed socio-demographic factors, physical activity levels, and dietary intake. Clinical measurements included body-mass index, an oral glucose tolerance test, and blood hemoglobin assessments. Multivariable logistic regression analyses were used to determine associations between risk factors and two co-morbid double burden pairings: (1) anemia and overweight, and (2) anemia and diabetes.

RESULTS

Prevalence of co-morbid anemia and overweight was 23.1% among women and 13.1% among men. Prevalence of co-morbid anemia and diabetes was 6.2% among women and 6.3% among men. The following variables were associated with co-morbid anemia and overweight in multivariable models [odds ratio (95% confidence interval)]: female sex [2.3 (1.4, 3.85)], high caste [3.2 (1.34, 7.49)], wealth index [1.1 (1.00, 1.12)], rurality (0.7 [0.56, 0.85]), tobacco consumption [0.6 (0.32, 0.96)], livestock ownership [0.5 (0.29, 0.89)], and energy-adjusted meat intake [1.8 (0.61, 0.94)]. The following variables were associated with co-morbid anemia and diabetes in multivariable models: age [1.1 (1.05, 1.11)], rurality [0.8 (0.57, 0.98)], and family history of diabetes [4.9 (1.86, 12.70).

CONCLUSION

This study determined the prevalence and factors associated with individual-level double burden of malnutrition. Women in rural regions of India may be particularly vulnerable to individual-level double burden of malnutrition and should be a target population for any nutrition interventions to address simultaneous over- and undernutrition.

Deforestation and Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa

Introduction

Although forests and forest-based ecosystems have been shown to influence health and sustainable diets, there is limited evidence on how deforestation affects the current nutrition transition and the double burden of malnutrition. We examined the relationship between deforestation and the individual- and household-level double burden of malnutrition in 15 countries in Sub-Saharan Africa.

Materials and methods

We combined data from geolocated Demographic and Health Surveys and the Global Forest Change dataset. We defined household-level double burden of malnutrition as the co-occurrence of an overweight woman of childbearing age (WCBA) and a stunted pre-school child (PSC) within the same household. We defined individual-level double burden in two ways: 1) as the co-occurrence of overweight and anemia within an individual WCBA, and 2) as the co-occurrence of overweight and stunting within a PSC. We used logistic regression analysis to examine the association between forest cover loss and these three measures after adjusting for potential confounders. We also assessed the mechanisms linking forest cover loss and nutritional status, such as livestock ownership and access to clean water.

Results

In our sample, the prevalence rates of the three measures of the double burden were: overweight and anemic WCBA: 8.4%, overweight WCBA and stunted PSC: 6.9%, overweight and stunted PSC: 2.7%. After adjusting for the confounders as well as country fixed effects and the month of the survey, forest cover loss was marginally associated with a higher odds of an overweight WCBA and stunted PSC (odds ratio (95% CI): 4.80 (0.82, 28.25)). We found no association between forest cover loss and odds of an overweight and stunted PSC (odds ratio (95% CI): 2.47 (0.80, 7.60)) or the odds of an anemic and overweight WCBA (odds ratio (95% CI): 0.71 (0.15, 3.32)).

Discussion

Deforestation does not seem to be an important driver of the double burden of malnutrition in SSA. However, deforestation influences several intermediate factors which, in turn, may influence the double burden. The overall weak association between forest cover loss and double burden measures mask significant heterogeneity across regions within SSA. Future research should unpack the mechanisms behind these regional differences.

Multimorbidity and cardiovascular disease: a perspective on low- and middle-income countries

New and changing patterns of multimorbidity (MM), i.e., multiple concurrent acute or chronic diseases in a person, are emerging in low- and middle-income countries (LMICs). The interplay of underlying population-specific factors and lifestyle habits combined with the colliding epidemics of communicable and non-communicable diseases presents new disease combinations, complexities and risks that are not common in high-income countries (HICs). The complexities and risks include those arising from potentially harmful drug-drug and drug-disease interactions (DDIs), the management of which may be considered as MM in the true sense. A major concern in LMICs is the increasing burden of leading cardiovascular diseases, prevalence of associated risk factors and co-occurrence with other morbidities. New models of MM management and integrated care can respond to the needs of specific multimorbid populations, with some LMICs making substantial progress (e.g., integration of tuberculosis and HIV services in South Africa). But there is a dearth of relevant data on the changing patterns and underlying factors and determinants of MM, the associated complexities and risks of DDIs in MM management, and the barriers to integrated care in LMICs. This requires careful attention.

Economic effects of the double burden of malnutrition

Observations from many countries indicate that multiple forms of malnutrition might coexist in a country, a household, and an individual. In this Series, the double burden of malnutrition (DBM) encompasses undernutrition in the form of stunting, and overweight and obesity. Health effects of the DBM include those associated with both undernutrition, such as impaired childhood development and greater susceptibility to infectious diseases, and overweight, especially in terms of increased risk of added visceral fat and increased risk of non-communicable diseases. These health effects have not been translated into economic costs for individuals and economies in the form of lost wages and productivity, as well as higher medical expenses. We summarise the existing approaches to modelling the economic effects of malnutrition and point out the weaknesses of these approaches for measuring economic losses from the DBM. Where population needs suggest that nutrition interventions take into account the DBM, economic evaluation can guide the choice of so-called double-duty interventions as an alternative to separate programming for stunting and overweight. We address the evidence gap with an economic analysis of the costs and benefits of an illustrative double-duty intervention that addresses both stunting and overweight in children aged 4 years and older by providing school meals with improved quality of diet. We assess the plausibility of our method and discuss how improved data and models can generate better estimates. Double-duty interventions could save money and be more efficient than single-duty interventions.

A model for point of care testing for non-communicable disease diagnosis in resource-limited countries

Non-communicable disease diagnosis frequently relies on biochemical measurements but laboratory infrastructure in low-income settings is often insufficient and distances to clinics may be vast. We present a model for point of care (POC) epidemiology as used in our study of chronic disease in the Haiti Health Study, in rural and urban Haiti. Point of care testing (POCT) of creatinine, cholesterol, and hemoglobin A1c as well as physical measurements of weight, height, and waist circumference allowed for diagnosis of diabetes, chronic kidney disease, dyslipidemias, and obesity. Methods and troubleshooting techniques for the data collection of this study are presented. We discuss our method of community-health worker (CHW) training, community engagement, study design, and field data collection. We also discuss the machines used and our quality control across CHWs and across geographical regions. Pitfalls tended to include equipment malfunction, transportation issues, and cultural differences. May this paper provide information for those attempting to perform similar diagnostic and screening studies using POCT in resource poor settings.

Correlates of the double burden of malnutrition among women: an analysis of cross sectional survey data from sub-Saharan Africa

OBJECTIVE

To investigate the correlates of the double burden of malnutrition (DBM) among women in five sub-Saharan African countries.

DESIGN

Secondary analysis of Demographic and Health Surveys (DHS). The outcome variable was body mass index (BMI), a measure of DBM. The BMI was classified into underweight (BMI <18.50 kg/m²), normal weight (18.50-24.99 kg/m²), overweight (25.0-29.9 kg/m²) and obesity (≥30.0 kg/m²).

SETTINGS

Ghana, Nigeria, Kenya, Mozambique and Democratic Republic of Congo (DRC).

SUBJECTS

Women aged 15-49 years (n=64698).

RESULTS

Compared with normal weight women, number of years of formal education was associated with the likelihood of being overweight and obese in Ghana, Mozambique and Nigeria, while associated with the likelihood of being underweight in Kenya and Nigeria. Older age was associated with the likelihood of being underweight, overweight and obese in all countries. Positive associations were also observed between living in better-off households and overweight and obesity, while a negative association was observed for underweight. Breastfeeding was associated with less likelihood of underweight in DRC and Nigeria, obesity in DRC and Ghana, overweight in Kenya and overweight and obesity in Mozambique and Nigeria relative to normal weight.

CONCLUSIONS

Our analysis reveals that in all the countries, women who are breastfeeding are less likely to be underweight, overweight and obese. Education, age and household wealth index tend to associate with a higher likelihood of DBM among women. Interventions to address DBM should take into account the variations in the effects of these correlates.

Diagnosing the double burden of malnutrition using estimated deviation values in low- and lower-middle-income countries

Objective

To examine the possibility of diagnosing the double burden of malnutrition using estimated deviation values in low- and lower-middle-income countries.

Methods

A modified version of the Japanese Diagnostic Tool was used. Data on 194 countries were analyzed, including data from the United Nations International Children’s Fund, World Health Organization and World Bank. After conducting a Box–Cox transformation, deviation values were calculated. The degree to which the values deviated relative to a deviation cutoff value of 50 was assessed. Focusing on countries with low- and middle-income economic levels, we examined the utility of this tool to show characteristic nutritional problems in each country.

Results

The deviation values had normal, distorted, bimodal, or trimodal distributions. In the lower-middle-income countries, almost all countries had values ranging from 40 to 60 for education and water environments (urban and rural), and the differences were minimal. However, different causes of noncommunicable disease-related deaths were considered, and the primary cause appeared to be related to lifestyle factors, particularly alcohol consumption and tobacco smoking. In comparison, the deviation values related to death among low-income countries also appeared to be related to differences in education and sanitation in urban and rural areas.

Conclusion

The study results can help to determine the status of nutritional inequalities and plan country-specific strategies to reduce the double burden of malnutrition.

Trends of mortality attributable to child and maternal undernutrition, overweight/obesity and dietary risk factors of non-communicable diseases in sub-Saharan Africa, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To assess trends of mortality attributable to child and maternal undernutrition (CMU), overweight/obesity and dietary risks of non-communicable diseases (NCD) in sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD) Study 2015.

DESIGN

For each risk factor, a systematic review of data was used to compute the exposure level and the effect size. A Bayesian hierarchical meta-regression analysis was used to estimate the exposure level of the risk factors by age, sex, geography and year. The burden of all-cause mortality attributable to CMU, fourteen dietary risk factors (eight diets, five nutrients and fibre intake) and overweight/obesity was estimated.

SETTING

Sub-Saharan Africa.ParticipantsAll age groups and both sexes.

RESULTS

In 2015, CMU, overweight/obesity and dietary risks of NCD accounted for 826204 (95 % uncertainty interval (UI) 737346, 923789), 266768 (95 % UI 189051, 353096) and 558578 (95 % UI 453433, 680197) deaths, respectively, representing 10·3 % (95 % UI 9·1, 11·6 %), 3·3 % (95 % UI 2·4, 4·4 %) and 7·0 % (95 % UI 5·8, 8·3 %) of all-cause mortality. While the age-standardized proportion of all-cause mortality accounted for by CMU decreased by 55·2 % between 1990 and 2015 in SSA, it increased by 63·3 and 17·2 % for overweight/obesity and dietary risks of NCD, respectively.

CONCLUSIONS

The increasing burden of diet- and obesity-related diseases and the reduction of mortality attributable to CMU indicate that SSA is undergoing a rapid nutritional transition. To tackle the impact in SSA, interventions and international development agendas should also target dietary risks associated with NCD and overweight/obesity.

Intra-household double burden of malnutrition in a North African nutrition transition context: magnitude and associated factors of child anaemia with mother excess adiposity

Objective

In the Middle East and North Africa region, the nutrition transition has resulted in drastic increases in excess adiposity, particularly among women, while some types of undernutrition remain prevalent, especially among pre-school children. We assessed the magnitude, nature and associated factors of the within-household co-occurrence of anaemia in children and excess adiposity in mothers.

Design

Cross-sectional survey using stratified two-stage random cluster sampling to survey households with women aged 20–49 years. BMI≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity, while anaemia for children was defined as Hb<110 g/l. The associations between child anaemia and mother excess adiposity, and sociodemographic and lifestyle factors were estimated by multinomial regression.

Setting

Greater Tunis area, Tunisia, in 2009–2010.

Subjects

Children aged 6–59 months living with their 20–49-year-old mothers (437 child–mother pairs).

Results

The most prevalent double burden of malnutrition in child–mother pairs by far was the anaemic child and overweight mother (24·4 %; 95 % CI 20·1, 29·3 %). A significant proportion of pairs were anaemic child and obese mother (14·4 %; 95 % CI 11·0, 18·5 %). The co-occurrence of anaemia in child and excess adiposity in mother was neither synergetic nor antagonistic (P=0·59 and 0·40 for anaemia–overweight and anaemia–obesity, respectively). This double burden was more frequent among child–mother pairs with younger children, with mothers of higher parity and higher energy intakes.

Conclusions

The high prevalence of anaemic child and overweight or obese mother requires special attention e.g. through interventions which simultaneously target both types of malnutrition within the same household.

Community-based diagnosis of non-communicable diseases and their risk factors in rural and urban Haiti: a cross-sectional prevalence study

OBJECTIVE

To estimate the prevalence of hypertension, diabetes and chronic kidney disease and their risk factors in a rural and urban region of Haiti.

SETTING AND PARTICIPANTS

Community health workers enumerated 2648 households (909 rural and 1739 urban) via a multistage cluster random sampling method from July 2015 to May 2016, completed 705 rural and 1419 urban assessments for adults aged 25-65 years.

OUTCOME MEASURES

We performed a WHO STEPS based questionnaire, measured two blood pressure values, weight, height, abdominal circumference and point of care test finger stick blood sample for haemoglobin A1c, creatinine and cholesterol (total, high density lipoprotein (HDL) and triglycerides).

RESULTS

After adjusting for age and sex, the overall prevalence rates of hypertension, diabetes and chronic kidney disease were 15.6% (±2.93%), 19.7% (±1.57%) and 12.3% (±2.72%), respectively. Of the three non-communicable diseases (NCDs), only diabetes showed a significant difference between rural and urban sites (p=0.000), with the rural site (23.1%) having a higher prevalence than the urban site (16.4%). When comparing male and female participants, females were significantly more likely than males to have an NCD (p≤0.011). Females had a higher prevalence of most of the risk factors when compared with males. The urban location had a higher prevalence than the rural location for four risk factors that showed a significant difference between location (p≤0.037).

CONCLUSIONS

Women in Haiti had significantly higher prevalence rates of most NCDs and risk factors than men, and urban populations frequently, but not always, had higher rates of NCDs risk factors than the rural population. Further, it was shown that using point of care blood tests combined with community health workers, it is feasible to screen for NCDs and risk factors in remote areas which otherwise have limited access to healthcare.

Gender differences in sociodemographic and behavioural factors associated with BMI in an adult population in rural Burkina Faso - an AWI-Gen sub-study

BACKGROUND

The global health transition is linked with an increased burden of non-communicable diseases with cardiovascular diseases leading the epidemic. In sub-Saharan Africa (SSA), the prevalence of obesity has increased during the past decades and there is a need to investigate the associated driving factors. In Burkina Faso obesity remains low, especially in rural areas. In this study we recruited middle-aged adults, as part of a larger study on genetic and environmental contributions to cardiometabolic disease among Africans.

OBJECTIVES

To investigate the distribution of BMI and prevalence of obesity in a cross-sectional population-based study and to determine the sociodemographic and behavioural correlates with BMI.

METHODS

Participants (N = 2,076) were recruited from the Nanoro Health and Demographic Surveillance System area and were aged 40-60 years. We applied hierarchical modelling to identify factors associated with BMI and structural equation modelling to identify mediated effects of sociodemographic and behavioural variables on BMI.

RESULTS

Data are presented on 2,076 participants (49.9% female). Men had significantly higher BMI than women with medians of 21.1 (19.2 - 23.4) vs 19.8 (18.1 - 21.6) (p < 0.001), and there were significantly more underweight women compared to men (31.0% vs 17.4%) (p < 0.001). More men were overweight and obese than women (11.9% vs 5.2% and 2.2% vs 1.4%). Socioeconomic status was the major contributor to increased BMI for men, and education was the main contributor in women. Tobacco smoking and chewing, and problematic alcohol consumption were associated with a decrease in BMI in men and women.

CONCLUSION

Overweight and obesity are relatively low among adults in rural Burkina Faso, and men had a higher median BMI than women. Behavioural factors, including tobacco use and alcohol consumption, contributed to a decrease in BMI, whereas socioeconomic status and education (which were both generally low in this community) contributed to an increase in BMI.

Determinants of takeaway and fast food consumption: a narrative review

Out-of-home foods (takeaway, take-out and fast foods) have become increasingly popular in recent decades and are thought to be a key driver in increasing levels of overweight and obesity due to their unfavourable nutritional content. Individual food choices and eating behaviours are influenced by many interrelated factors which affect the results of nutrition-related public health interventions. While the majority of research based on out-of-home foods comes from Australia, the UK and USA, the same issues (poor dietary habits and increased prevalence of non-communicable disease) are of equal concern for urban centres in developing economies undergoing ‘nutrition transition’ at a global scale. The present narrative review documents key facets, which may influence out-of-home food consumption, drawn from biological, societal, environmental, demographic and psychological spheres. Literature searches were performed and references from relevant papers were used to find supplementary studies. Findings suggest that the strongest determinants of out-of-home food availability are density of food outlets and deprivation within the built environment; however, the association between socio-economic status and out-of-home food consumption has been challenged. In addition, the biological and psychological drives combined with a culture where overweight and obesity are becoming the norm makes it ‘fashionable’ to consume out-of-home food. Other factors, including age group, ethnicity and gender demonstrate contrasting effects and a lack of consensus. It is concluded that further consideration of the determinants of out-of-home food consumption within specific populations is crucial to inform the development of targeted interventions to reduce the impact of out-of-home foods on public health.

Adolescent health in rural Ghana: A cross-sectional study on the co-occurrence of infectious diseases, malnutrition and cardio-metabolic risk factors

In sub-Saharan Africa, infectious diseases and malnutrition constitute the main health problems in children, while adolescents and adults are increasingly facing cardio-metabolic conditions. Among adolescents as the largest population group in this region, we investigated the co-occurrence of infectious diseases, malnutrition and cardio-metabolic risk factors (CRFs), and evaluated demographic, socio-economic and medical risk factors for these entities. In a cross-sectional study among 188 adolescents in rural Ghana, malarial infection, common infectious diseases and Body Mass Index were assessed. We measured ferritin, C-reactive protein, retinol, fasting glucose and blood pressure. Socio-demographic data were documented. We analyzed the proportions (95% confidence interval, CI) and the co-occurrence of infectious diseases (malaria, other common diseases), malnutrition (underweight, stunting, iron deficiency, vitamin A deficiency [VAD]), and CRFs (overweight, obesity, impaired fasting glucose, hypertension). In logistic regression, odds ratios (OR) and 95% CIs were calculated for the associations with socio-demographic factors. In this Ghanaian population (age range, 14.4-15.5 years; males, 50%), the proportions were for infectious diseases 45% (95% CI: 38-52%), for malnutrition 50% (43-57%) and for CRFs 16% (11-21%). Infectious diseases and malnutrition frequently co-existed (28%; 21-34%). Specifically, VAD increased the odds of non-malarial infectious diseases 3-fold (95% CI: 1.03, 10.19). Overlap of CRFs with infectious diseases (6%; 2-9%) or with malnutrition (7%; 3-11%) was also present. Male gender and low socio-economic status increased the odds of infectious diseases and malnutrition, respectively. Malarial infection, chronic malnutrition and VAD remain the predominant health problems among these Ghanaian adolescents. Investigating the relationships with evolving CRFs is warranted.

Temporal changes and determinants of childhood nutritional status in Kenya and Zambia

BACKGROUND

The prevalence of undernutrition is decreasing in many parts of the developing world, but challenges remain in many countries. The objective of this study was to determine factors influencing childhood nutrition status in Kenya and Zambia. The objective of this study is to determine factors associated with temporal changes in childhood nutritional status in two countries in sub-Saharan Africa.

METHODS

Data from national demographic and health surveys from the World Bank for Kenya (1998-2009) and Zambia (1996-2014) were used to select the youngest child of each household with complete data for all variables studied. Multiple linear regression analyses were used for data from 2902 and 11,335 children from Kenya and Zambia, respectively, in each year to determine the relationship between social and economic factors and measures of nutritional status, including wasting, stunting, and overweight.

RESULTS

There was a decreased prevalence of stunting (35% in Kenya and 40% in Zambia), while the prevalence of wasting was unchanged (6-8% in both countries). From 1998 to 2009, there was a protective effect against stunting for wealthier families and households with electricity, for both countries. Finally, better educated mothers were less likely to have stunted children and girls were less likely to be stunted than boys.

CONCLUSIONS

Based on the data analyzed, there was a higher risk of stunting in both Kenya and Zambia, for those with lower literacy, less education, no electricity, living in rural areas, no formal toilet, no car ownership, and those with an overall lower wealth index. Improving the education of mothers was also a significant determinant in improving the nutritional status of children in Kenya and Zambia. More broad-based efforts to reduce the prevalence of undernutrition need to focus on reducing the prevalence of undernutrition without promoting excess weight gain. Future economic advances need to consider integrated approaches to improving economic standings of households without increasing the risk for overnutrition.

Can Urbanization, Social and Spatial Disparities Help to Understand the Rise of Cardiometabolic Risk Factors in Bobo-Dioulasso? A Study in a Secondary City of Burkina Faso, West Africa

Background: Unplanned urbanization plays a key role in chronic disease growth. This population-based cross-sectional study assessed the occurrence of cardiometabolic risk factors in Bobo-Dioulasso and their association with urbanization conditions. Methods: Through spatial sampling, four Bobo-Dioulasso sub-spaces were selected for a population survey to measure the adult health status. Yéguéré, Dogona, Tounouma and Secteur 25 had very different urbanization conditions (position within the city; time of creation and healthcare structure access). The sample size was estimated at 1000 households (250 for each sub-space) in which one adult (35 to 59-year-old) was randomly selected. Finally, 860 adults were surveyed. Anthropometric, socioeconomic and clinical data were collected. Arterial blood pressure was measured and blood samples were collected to assess glycemia. Results: Weight, body mass index and waist circumference (mean values) and serum glycemia (83.4 mg/dL ± 4.62 mmol/L) were significantly higher in Tounouma, Dogona, and Secteur 25 than in Yéguéré; the poorest and most rural-like sub-space (p = 0.001). Overall, 43.2%, 40.5%, 5.3% and 60.9% of participants had overweight, hypertension, hyperglycemia and one or more cardiometabolic risk markers, respectively. Conclusions: Bobo-Dioulasso is unprepared to face this public health issue and urgent responses are needed to reduce the health risks associated with unplanned urbanization.

Household food insecurity in Mexico is associated with the co-occurrence of overweight and anemia among women of reproductive age, but not female adolescents

We aimed to determine the association between household food insecurity (HFI) and the co-occurrence of overweight and anemia among women of reproductive age in the Mexican population. We analyzed data on 4,039 nonpregnant female adolescents (15-19 years) and 10,760 nonpregnant adult women of reproductive age (20-49 years) from the 2012 National Health and Nutrition Survey of Mexico. The survey uses a two-stage sampling design, stratified by rural and urban regions. The Latin American and Caribbean Food Security Scale was used to assess HFI. We assessed overweight and obesity in women based on World Health Organization classifications for body mass index, and BMI-for-age Z-scores for female adolescents, and defined anemia as an altitude-adjusted hemoglobin (Hb) concentration < 120 g/L based on measurement of capillary Hb concentrations. In multiple logistic regression models adjusting for potential confounding covariates, HFI was not associated with the co-occurrence of anemia and overweight among female adolescents. The adjusted odds of women of reproductive age from mildly and moderately food-insecure households, respectively, experiencing concurrent anemia and overweight were 48% (OR: 1.48; 95% CI: 1.15, 1.91) and 49% (OR: 1.49; 95% CI: 1.08, 2.06) higher than among women from food-secure households. Severe HFI was not associated with concurrent overweight and anemia among female adolescents or women. HFI may be a shared mechanism for dual forms of malnutrition within the same individual, simultaneously contributing to overconsumption and dietary inadequacy.

Cardiovascular Disease Risk Factors in Ghana during the Rural-to-Urban Transition: A Cross-Sectional Study

Populations in sub-Saharan Africa are shifting from rural to increasingly urban. Although the burden of cardiovascular disease is expected to increase with this changing landscape, few large studies have assessed a wide range of risk factors in urban and rural populations, particularly in West Africa. We conducted a cross-sectional, population-based survey of 3317 participants from Ghana (≥18 years old), of whom 2265 (57% female) were from a mid-sized city (Sunyani, population ~250,000) and 1052 (55% female) were from surrounding villages (populations <5000). We measured canonical cardiovascular disease risk factors (BMI, blood pressure, fasting glucose, lipids) and fibrinolytic markers (PAI-1 and t-PA), and assessed how their distributions and related clinical outcomes (including obesity, hypertension and diabetes) varied with urban residence and sex. Urban residence was strongly associated with obesity (OR: 7.8, 95% CI: 5.3–11.3), diabetes (OR 3.6, 95% CI: 2.3–5.7), and hypertension (OR 3.2, 95% CI: 2.6–4.0). Among the quantitative measures, most affected were total cholesterol (+0.81 standard deviations, 95% CI 0.73–0.88), LDL cholesterol (+0.89, 95% CI: 0.79–0.99), and t-PA (+0.56, 95% CI: 0.48–0.63). Triglycerides and HDL cholesterol profiles were similarly poor in both urban and rural environments, but significantly worse among rural participants after BMI-adjustment. For most of the risk factors, the strength of the association with urban residence did not vary with sex. Obesity was a major exception, with urban women at particularly high risk (26% age-standardized prevalence) compared to urban men (7%). Overall, urban residents had substantially worse cardiovascular risk profiles, with some risk factors at levels typically seen in the developed world.

[Abdominal obesity and other cardiometabolic risk biomarkers: influence of socioeconomic status and lifestyle on two African-origin population groups, Cotonou (Benin) and Port-au-Prince (Haiti)]

INTRODUCTION

Increased cardio metabolic risk (CMR) in low- and middle-income countries is largely due to rapid nutrition transition. We conducted a study of two African-origin populations groups living, however, in widely different settings. It aimed to assess the relationship between lifestyle and CMR biomarkers as well as between abdominal obesity (AO) and other biomarkers.

METHODS

The study included 200 Benineses from Cotonou and 252 Haitians from Port-with-Prince (PAP) aged between 25 to 60 years and apparently in good health. AO was specifically defined as waist circumference ≥ 88cm (men) and ≥ 95 cm (women). Other most common biomarkers were: high total cholesterol/HDL cholesterol ratio, high blood pressure and insulin resistance by HOMA (Homeostasis Model Assessement). Socioeconomic status, diet, alcohol and tobacco were documented by questionnaire. Two dietary patterns emerged from cluster analysis, one traditional and the other "transitional" with increasing frequency of western foods.

RESULTS

Socioeconomic status, consumption of alcohol and nicotinism were associated with CMR, but not the food diagram. AO was associated with other CMR markers, with no marked effect of socioeconomic status and lifestyle variables.

CONCLUSION

Specific TT threshold values are confirmed as socioeconomic status and lifestyle have an impact on CMR, but not the relationship between AO and other CMR biomarkers.

Urbanicity Gradients Are Associated with the Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa

BACKGROUND

The nutrition transition is advancing throughout sub-Saharan Africa (SSA). However, the nutritional risk across urbanicity gradients associated with this transition is not clear.

OBJECTIVES

We aimed to determine 1) the extent to which overweight and anemia in women of childbearing age (WCBA) and stunting in preschool-age children (PSC) are spatially correlated within countries of SSA; and 2) the association of urbanicity with the individual-level nutritional double burden (i.e., concurrent overweight and anemia within an individual WCBA), the household-level double burden (i.e., overweight WCBA and stunted PSC in the same household), and the 3 components of these double burdens (i.e., overweight, anemia, and stunting).

METHODS

We used Demographic and Health Surveys (DHS) data for 30 countries in SSA from 2006-2012. We calculated overweight [body mass index (BMI; in kg/m(2)) ≥25] and anemia (hemoglobin concentration <120 g/L) in WCBA, and stunting in PSC aged 12-59 mo (height-for-age z score <-2). We used population density, measured using a high-resolution population distribution dataset, to define gradients of urbanicity. We used geolocated DHS data to calculate cluster-level mean population densities and the Moran's I statistic to assess spatial autocorrelation.

RESULTS

Cluster-level BMI values and hemoglobin concentrations for WCBA were spatially correlated. The odds of overweight in WCBA were higher in periurban and urban areas than in rural areas (periurban, OR: 1.08; 95% CI: 1.01, 1.16; urban, OR: 1.26; 95% CI: 1.18, 1.36), as were the odds of stunting in PSC in periurban areas (OR: 1.13; 95% CI: 1.06, 1.22). The odds of both double burden conditions were higher in periurban and urban areas than in rural areas (individual-level-periurban, OR: 1.18; 95% CI: 1.05, 1.33; urban, OR: 1.43; 95% CI: 1.27, 1.61; household-level-periurban, OR: 1.24; 95% CI: 1.06, 1.44; urban, OR: 1.24; 95% CI: 1.06, 1.46).

CONCLUSION

Urban and periurban areas in SSA may be particularly vulnerable to the nutritional double burden compared with rural areas. Clearly differentiating urban environments is important for assessing changing patterns of nutritional risk associated with the nutrition transition in SSA.

Gender inequalities in excess adiposity and anaemia combine in a large double burden of malnutrition gap detrimental to women in an urban area in North Africa

OBJECTIVE

The nutrition transition has exacerbated the gender gap in health in the Middle East and North Africa region as the increase in excess adiposity has been much higher among women than men. This is not exclusive of the persistence of anaemia, generally also more prevalent among women. We assessed the magnitude and sociodemographic factors associated with gender inequality vis-à-vis the double burden of excess adiposity and anaemia.

DESIGN

Cross-sectional study, stratified two-stage cluster sample. BMI (=weight/height2) ≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity. Anaemia was defined as Hb <120 g/l for women, <130 g/l for men. Gender inequalities vis-à-vis the within-subject coexistence of excess adiposity and anaemia were assessed by women v. men relative prevalence ratios (RPR). Their variation with sociodemographic characteristics used models including gender × covariate interactions.

SETTING

Greater Tunis area in 2009-2010.

SUBJECTS

Adults aged 20-49 years (women, n 1689; men, n 930).

RESULTS

Gender inequalities in excess adiposity were high (e.g. overweight: women 64·9 % v. men 48·4 %; RPR=2·1; 95 % CI 1·6, 2·7) and much higher for anaemia (women 38·0 % v. men 7·2 %; RPR=8·2; 95 % CI 5·5, 12·4). They were striking for overweight and anaemia (women 24·1 % v. men 3·4 %; RPR=16·2; 95 % CI 10·3, 25·4). Gender inequalities in overweight adjusted for covariates increased with age but decreased with professional activity and household wealth score; gender inequality in anaemia or overweight and anaemia was more uniformly distributed.

CONCLUSIONS

Women were much more at risk than men, from both over- and undernutrition perspectives. Both the underlying gender-related and sex-linked biological determinants of this remarkable double burden of malnutrition inequality must be addressed to promote gender equity in health.

Biological Status and Dietary Intakes of Iron, Zinc and Vitamin A among Women and Preschool Children in Rural Burkina Faso

Background

Food-based approaches such as biofortification are meant to sustainably address micronutrient deficiencies in poor settings. Knowing more about micronutrient intakes and deficiencies is a prerequisite to designing and evaluating interventions.

Objective

The objectives of the study were to assess biological status and dietary intakes of iron, zinc and vitamin A among women and children aged 36–59 months in rural Burkina Faso and to study relationships between intake and status to better inform future food-based interventions.

Design

A cross-sectional survey was carried out in two rural provinces of Burkina Faso on a random cluster sample of 480 mother-child pairs. Dietary data was obtained by 24-hour recalls repeated on a random sub-selection of 37.5% of subjects to allow calculation of nutrient’s probability of adequacy (PA). Biomarkers were measured on a sub-sample of 180 mother-child pairs. Blood samples were analyzed for hemoglobin, serum ferritin, soluble transferrin receptors (sTfR), C-reactive protein, alpha-1-glycoprotein, serum zinc concentration (SZnC) and retinol. For each micronutrient the relationship between biomarker and dietary intake was investigated by multiple linear regression models accounting for inflammatory biomarkers.

Results

Mean PA for iron, zinc and vitamin A was 0.49, 0.87 and 0.21 among women and 0.61, 0.95 and 0.33 among children, respectively. Prevalence of anemia, corrected low serum ferritin and high sTfR was 37.6%, 4.0% and 77.5% among women and 72.1%, 1.5% and 87.6% among children, respectively. Prevalence of low SZnC and corrected low serum retinol was 39.4% and 12.0% among women and 63.7% and 24.8% among children, respectively. There was a tendency for a positive relationship between vitamin A intakes and serum retinol among women (β = 0.0003, P = 0.06). Otherwise, no link was found between micronutrients biomarkers and intakes.

Conclusion

Our study depicted different images of micronutrient deficiencies when based on dietary intakes or biomarkers results, thus highlighting the need for more suitable biomarkers and more precise measures of absorbable micronutrient intakes at the individual level. It thus points to challenges in the design and evaluation of future biofortification or other food-based interventions in rural areas of Burkina Faso.

The co-occurrence of anemia and cardiometabolic disease risk demonstrates sex-specific sociodemographic patterning in an urbanizing rural region of southern India

BACKGROUND/OBJECTIVES

To determine the extent and sociodemographic determinants of anemia, overweight, metabolic syndrome (MetS) and the co-occurrence of anemia with cardiometabolic disease risk factors among a cohort of Indian adults.

SUBJECT/METHODS

Cross-sectional survey of adult men (n=3322) and nonpregnant women (n=2895) aged 18 years and older from the third wave of the Andhra Pradesh Children and Parents Study that assessed anemia, overweight based on body mass index, and prevalence of MetS based on abdominal obesity, hypertension and blood lipid and fasting glucose measures. We examined associations of education, wealth and urbanicity with these outcomes and their co-occurrence.

RESULTS

The prevalence of anemia and overweight was 40% and 29% among women, respectively, and 10% and 25% among men (P<0.001), respectively, whereas the prevalence of MetS was the same across sexes (15%; P=0.55). The prevalence of concurrent anemia and overweight (9%), and anemia and MetS (4.5%) was highest among women. Household wealth was positively associated with overweight and MetS across sexes (P<0.05). Independent of household wealth, higher education was positively correlated with MetS among men (odds ratio (95% confidence interval): MetS: 1.4 (0.99, 2.0)) and negatively correlated with MetS among women (MetS: 0.54 (0.29, 0.99)). Similar sex-specific associations were observed for the co-occurrence of anemia with overweight and MetS.

CONCLUSIONS

Women in this region of India may be particularly vulnerable to co-occurring anemia and cardiometabolic risk, and associated adverse health outcomes as the nutrition transition advances in India.

Conflicting effects of BMI and waist circumference on iron status

The association between obesity and iron status has a long history and is still receiving attention. However comparative analysis of the association between general obesity (BMI) and visceral obesity (waist circumference) with iron status has not been extensively researched. The aim of the present study is thus to determine if body mass index and waist circumference have the same correlation with iron status. One thousand one hundred and thirty people (225 men and 905 women) aged 30 years and above participated in this study. Anthropometric parameters, haemoglobin, iron and total iron binding capacity concentrations were measured using standard methods. Percentage transferrin saturation was calculated and ferritin concentrations were measured using an enzyme linked immunosorbent assay. Obese or overweight women had significantly lower iron and transferrin saturation concentration when compared to non-obese women. In contrast, women with high waist circumference had comparable plasma iron and transferrin saturation to women with normal waist circumference. Partial correlation analysis and linear regression analysis showed that BMI is negatively and significantly associated with plasma iron, transferrin saturation, Hb and ferritin concentration, whilst waist circumference is positively but insignificantly associated with plasma iron, transferrin saturation, Hb and ferritin concentration. Binary regression analysis showed that obese or overweight people are more likely to have iron deficiency, whilst those with raised waist circumference are more likely to have iron overload. Multivariate analysis showed that body mass index is negatively and significantly associated with low iron status, while waist circumference is positively and insignificantly associated with iron status. This is supported by a comparison of plasma iron, transferrin saturation and ferritin concentrations in participants with high body mass index and normal waist circumference and participants with normal body mass index and high waist circumference to those participants having normal body mass index and normal waist circumference. The present study suggests that in women body mass index is associated with low plasma iron, transferrin saturation and ferritin concentrations, while waist circumference is associated with high plasma iron, transferrin saturation and ferritin concentrations.

The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal?

BACKGROUND

Chronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as 'multimorbidity'. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs.

METHODS

Data was obtained from the WHO's Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries.

RESULTS

The prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases.

CONCLUSIONS

Findings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes.

The prevalence, awareness, and control of hypertension among workers in West Africa: a systematic review

BACKGROUND

: Interventions in workplace settings are considered to be cost-effective in preventing cardiovascular diseases. A systematic review was conducted to assess the prevalence of hypertension and the level of awareness and control among workers in West Africa.

DESIGN

A systematic search for studies on formal and informal sector workers aged ≥15 years in West Africa published between 1980 and September 2014 was undertaken using the Ovid Medline, Embase, PubMed, and Google Scholar databases. Clinical and obstetric studies and studies that did not report prevalence were excluded. Data on study settings, characteristics of workers, blood pressure (BP) levels, prevalence of hypertension, and associated demographic factors were extracted.

RESULTS

A total of 45 studies from six countries were identified involving 30,727 formal and informal sector workers. In 40 studies with a common definition of hypertension, the prevalence ranged from 12.0% among automobile garage workers to 68.9% among traditional chiefs. In 15 of these studies, the prevalence exceeded 30%. Typically sedentary workers such as traders, bank workers, civil servants, and chiefs were at high risk. Among health care workers, the prevalence ranged from 17.5 to 37.5%. The prevalence increased with age and was higher among males and workers with higher socio-economic status. Complications of hypertension, co-morbidities, and clustering of risk factors were common. The crude prevalence of hypertension increased progressively from 12.9% in studies published in the 1980s to 34.4% in those published in 2010-2014. The proportion of hypertensives who were previously aware of their diagnosis, were on treatment or had their BP controlled was 19.6-84.0%, 0-79.2%, and 0-12.7%, respectively. Hypertensive subjects, including health workers, rarely checked their BP except when they were ill.

CONCLUSIONS

There is a high prevalence of hypertension among West Africa's workforce, of which a significant proportion is undiagnosed, severe or complicated. The clustering of risk factors, co-morbidities, and general low awareness warrant an integrated and multisectoral approach. Models for workplace health programmes aiming to improve cardiovascular health should be extended to informal sector workers.

An overview of the nutrition transition in West Africa: implications for non-communicable diseases

The nutrition landscape in West Africa has been dominated by the programmes to address undernutrition. However, with increasing urbanisation, technological developments and associated change in dietary patterns and physical activity, childhood and adult overweight, and obesity are becoming more prevalent. There is an evidence of increasing intake of dietary energy, fat, sugars and protein. There is low consumption of fruit and vegetables universally in West Africa. Overall, the foods consumed are predominantly traditional with the component major food groups within recommended levels. Most of the West African countries are at the early stages of nutrition transition but countries such as Cape Verde, Ghana and Senegal are at the latter stages. In the major cities of the region, children consume energy-dense foods such as candies, ice cream and sweetened beverages up to seven times as frequently as fruit and vegetables. Adult obesity rates have increased by 115 % in 15 years since 2004. In Ghana, the prevalence of overweight/obesity in women has increased from 12·8 % in 1993 to 29·9 % in 2008. In Accra, overweight/obesity in women has increased from 62·2 % in 2003 to 64·9 % in 2009. The age-standardised proportion of adults who engage in adequate levels of physical activity ranges from 46·8 % in Mali to 94·7 % in Benin. The lingering stunting in children and the rising overweight in adults have resulted to a dual burden of malnutrition affecting 16·2 % of mother-child pairs in Cotonou. The prevalence of hypertension has been increased and ranges from 17·6 % in Burkina Faso to 38·7 % in Cape Verde. The prevalence is higher in the cities: 40·2 % in Ougadougou, 46·0 % in St Louis and 54·6 % in Accra. The prevalence of diabetes ranges from 2·5 to 7·9 % but could be as high as 17·9 % in Dakar, Senegal. The consequences of nutrition transition are not only being felt by the persons in the high socioeconomic class, but also in cities such as Accra and Ouagadougou, where at least 19 % of adults from the poorest households are overweight and 19-28 % have hypertension. Concerted national action involving governments, partners, private sector and civil society is needed to re-orient health systems and build capacity to address the dual burden of malnutrition, to regulate the food and beverage industry and to encourage healthy eating throughout the life course.

Non-Communicable Disease Mortality and Risk Factors in Formal and Informal Neighborhoods, Ouagadougou, Burkina Faso: Evidence from a Health and Demographic Surveillance System

The expected growth in NCDs in cities is one of the most important health challenges of the coming decades in Sub-Saharan countries. This paper aims to fill the gap in our understanding of socio-economic differentials in NCD mortality and risk in low and middle income neighborhoods in urban Africa. We use data collected in the Ouagadougou Health and Demographic Surveillance System. 409 deaths were recorded between 2009–2011 among 20,836 individuals aged 35 years and older; verbal autopsies and the InterVA program were used to determine the probable cause of death. A random survey asked in 2011 1,039 adults aged 35 and over about tobacco use, heavy alcohol consumption, lack of physical activity and measured their weight, height, and blood pressure. These data reveal a high level of premature mortality due to NCDs in all neighborhoods: NCD mortality increases substantially by age 50. NCD mortality is greater in formal neighborhoods, while adult communicable disease mortality remains high, especially in informal neighborhoods. There is a high prevalence of risk factors for NCDs in the studied neighborhoods, with over one-fourth of the adults being overweight and over one-fourth having hypertension. Better-off residents are more prone to physical inactivity and excessive weight, while vulnerable populations such as widows/divorced individuals and migrants suffer more from higher blood pressure. Females have a significantly lower risk of being smokers or heavy drinkers, while they are more likely to be physically inactive or overweight, especially when married. Muslim individuals are less likely to be smokers or heavy drinkers, but have a higher blood pressure. Everything else being constant, individuals living in formal neighborhoods are more often overweight. The data presented make clear the pressing need to develop effective programs to reduce NCD risk across all types of neighborhoods in African cities, and suggest several entry points for community-based prevention programs.

Dietary patterns and physical inactivity, two contributing factors to the double burden of malnutrition among adults in Burkina Faso, West Africa

A population-based cross-sectional study was carried out in the northern neighbourhoods of Ouagadougou (Burkina Faso), to examine the relationship of nutritional deficiencies and cardiometabolic risk factors (CMRF) with lifestyle in adults. We randomly selected 330 households stratified by income tertile. In each income stratum, 110 individuals aged 25-60 years and having lived in Ouagadougou for at least 6 months were randomly selected. We performed anthropometric, dietary intake and physical activity measurements, and blood sample collection. Cluster analysis of dietary intake identified two dietary patterns: 'urban' (29 % of subjects) and 'traditional' (71 %). The 'urban' cluster exhibited a higher intake of fat and sugar, whereas a higher intake of plant protein, complex carbohydrate and fibre was observed in the 'traditional' pattern. Female sex, low income and lack of education were associated with the 'traditional' cluster, as well as Fe and vitamin A deficiency. CMRF prevalence (abdominal obesity, hypertension, hyperglycaemia, dyslipidaemia) was similar in both clusters. Subjects in the 'traditional' cluster spent more time in physical activity and had less sedentary time than those in the 'urban' cluster. 'Traditional' dietary pattern, low income, female sex and sedentary time were significant contributing factors to the double burden of malnutrition. The rapid nutrition transition is reflected in this co-occurrence of CMRF and nutritional deficiencies. This stresses the need for prevention strategies addressing both ends of the nutrition spectrum.

Differences in hypertension between informal and formal areas of Ouagadougou, a sub-Saharan African city

Background

Countries of sub-Saharan Africa are increasingly confronted with hypertension and urbanization is considered to favor its emergence. This study aims to assess the difference in the prevalence of hypertension between formal and informal urban areas of Ouagadougou and to determine the risk factors associated with hypertension in these urban populations of sub-Saharan Africa.

Methods

A cross-sectional survey was conducted in 2010 on 2041 adults aged 18 years and older in formal and informal areas of Ouagadougou. Data was collected through personal interviews conducted at home. Blood pressure and anthropometric measurements were taken by trained interviewers. Logistic regressions were fitted to identify factors associated with hypertension.

Results

The overall prevalence of hypertension was 18.6% (95% confidence interval [CI], 16.9-20.3) and its detection was 27.4% (95% CI, 22.9-31.9). Prevalence of hypertension in formal settings was 21.4% (95% CI, 19.0-23.8), significantly higher than prevalence in informal settings: 15.3% (95% CI, 13.0-17.6). However, this difference disappeared after adjusting for age. In addition to age, being an unmarried woman (odds ratio [OR] = 1.7; 95% CI, 1.1-2.4), recent rural-to-urban migration (OR = 1.8; 95% CI, 1.2-2.8), obesity (OR = 1.8; 95% CI, 1.1-3.1) and physical inactivity (OR = 1.9; 95% CI, 1.2-3.0), were independent risk factors for hypertension.

Conclusions

Hypertension is common among the adult population of Ouagadougou but its detection is low. While there are no differences between formal and informal areas of the city, rural-to-urban migration emerges as an independent risk factor. Known risk factors as obesity and physical inactivity are confirmed while the vulnerability of unmarried women and rural-to-urban migrants maybe specific to this west African population.

Obesity and the nutrition transition in Sub-Saharan Africa

This review illustrates the outcomes of the nutrition transition in Sub-Saharan Africa (SSA) and its association with overweight and obesity; the relationship with the double burden of malnutrition is also explored. We describe the increase in overweight in nearly all Sub-Saharan African countries and present data on associated increased gross domestic product, and availability of energy, protein, fat, and sugar at country national levels. Predictors of overweight are described by means of various studies undertaken in SSA, and dietary intakes of numerous countries are presented. Overall, we show that socioeconomic status, gender, age, parity, physical inactivity, and increased energy, fat, and sugar intake are powerful predictors of overweight and/or obesity. The urgency for health interventions in countries in the early stages of the nutrition transition is emphasized, particularly in view of the fact that fat intake is still less than 30% of energy intake in nearly all Sub-Saharan African countries.