Anthropometric profiles of 8-11 year old children from a low-income setting in South Africa.

BACKGROUND: Communities in low-to-middle income countries undergoing rapid urbanisation as well as nutrition transition are particularly at risk for associated health issues such as overweight and obesity. South Africa has a double-burden of both under- and over-nutrition, creating some uncertainty as to where to direct healthcare interventions. Therefore, providing anthropometric data in vulnerable populations, such as in early childhood, is much needed. METHODS: This observational study assessed height, weight, head circumference and age-adjusted BMI in 1785 Grade 4 (9.5 ± 0.7 years old) learners from 12 schools in two different areas in South Africa. RESULTS: Overall, the results of this study found a higher prevalence of overnutrition (>95th percentile for age-adjusted BMI) than undernutrition (<15th percentile for age-adjusted BMI), 27.3% versus 12.4% respectively. Although the boys were significantly older and taller than the girls in this sample, there were no significant sex differences between boys and girls for BMI (19.9 kg/m2 ± 6.0 vs 20 kg/m2 ± 5.8, p = 0.59). Significant differences were found between peri-urban and urban areas for undernutrition (16.1% versus 9.5%, p < 0.001) and overnutrition (9.7% versus 41.2%, p < 0.001). CONCLUSION: South African children living in urban areas are particularly vulnerable to high rates of overweight and obesity. Therefore, interventions that are area and context specific are needed to address the issues of malnutrition in South Africa.

The effect of lifestyle interventions on maternal body composition during pregnancy in developing countries: a systematic review.

Optimal maternal body composition during pregnancy is a public health priority due to its implications on maternal health and infant development. We therefore aimed to conduct a systematic review of randomised, controlled trials, and case-control and cohort studies using lifestyle interventions to improve body composition in developing countries. Of the 1 708 articles that were searched, seven studies, representing three countries (Brazil, Iran and Argentina), were included in the review. Two articles suggested that intervention with physical activity during pregnancy may significantly reduce maternal weight gain, and five studies were scored as being of poor quality. This systematic review highlights the lack of research within developing countries on lifestyle interventions for the management of excessive weight gain during pregnancy. Similar reviews from developed countries demonstrate the efficacy of such interventions, which should be confirmed using well-designed studies with appropriate intervention methods in resource-limited environments.

Is There an Association between Sleeping Patterns and Other Environmental Factors with Obesity and Blood Pressure in an Urban African Population?

Beyond changing dietary patterns, there is a paucity of data to fully explain the high prevalence of obesity and hypertension in urban African populations. The aim of this study was to determine whether other environmental factors (including sleep duration, smoking and physical activity) are related to body anthropometry and blood pressure (BP). Data were collected on 1311 subjects, attending two primary health care clinics in Soweto, South Africa. Questionnaires were used to obtain data on education, employment, exercise, smoking and sleep duration. Anthropometric and BP measurements were taken. Subjects comprised 862 women (mean age 41 ± 16 years and mean BMI 29.9 ± 9.2 kg/m²) and 449 men (38 ± 14 years and 24.8 ± 8.3 kg/m²). In females, ANOVA showed that former smokers had a higher BMI (p<0.001) than current smokers, while exposure to second hand smoking was associated with a lower BMI (p<0.001) in both genders. Regression analyses demonstrated that longer sleep duration was associated with a lower BMI (p<0.05) in older females only, and not in males, whilst in males napping during the day for > 30 minutes was related to a lower BMI (ß = -0.04, p<0.01) and waist circumference (ß = -0.03, p<0.001). Within males, napping for >30 minutes/day was related to lower systolic (ß = -0.02, p<0.05) and lower diastolic BP (ß = -0.02, p = 0.05). Longer night time sleep duration was associated with higher diastolic (ß = 0.005, p<0.01) and systolic BP (ß = 0.003, p<0.05) in females. No health benefits were noted for physical activity. These data suggest that environmental factors rarely collected in African populations are related, in gender-specific ways, to body anthropometry and blood pressure. Further research is required to fully elucidate these associations and how they might be translated into public health programs to combat high levels of obesity and hypertension.

Lower levels of high-density lipoprotein cholesterol in urban Africans presenting with communicable versus non-communicable forms of heart disease: the 'Heart of Soweto' hospital registry study.

OBJECTIVES: To investigate if urban Africans displayed lower levels of atheroprotective high-density lipoprotein cholesterol (HDLC) when presenting with communicable versus non-communicable forms of heart disease (HD) as both acute infection and chronic inflammation reduce HDLC levels. DESIGN: Hospital registry of 5328 de novo cases of HD over a 3-year period. SETTING: Cardiology Unit, Baragwanath Hospital in Soweto, South Africa. PARTICIPANTS: A total of 1199 patients of African descent (59% women; 57.0±13.4 years) had fasting blood lipid levels (total cholesterol (TC), triglyceride, HDLC and low-density lipoprotein cholesterol (LDLC)) documented on admission. Serum inflammatory marker C reactive protein (CRP) was measured in a subset of 367 patients (31% of cases). MAIN OUTCOME MEASURES: Lipid profiles were compared according to prespecified classification of non-communicable (eg, hypertensive HD) versus communicable (eg, rheumatic HD) HD. Low HDLC was defined as <1.0 mmol/L for men and <1.2 mmol/L for women, according to applicable South African Clinical Guidelines. RESULTS: Overall 694 (58%) of those presenting with HD had low HDLC levels; 344 of 678 (51%) and 350 of 521 (67%) for non-communicable and communicable, respectively (p<0.001). Comparatively, overall prevalence of high TC was 32% and high LDLC was 37%. On an adjusted basis, those with non-communicable HD were more likely to record a low HDLC relative to non-communicable presentations (odds ratio (OR) 1.91, 95% CI 1.42 to 2.57; p<0.001). There was a strong relationship between low HDLC and higher levels of CRP, but only in women. CONCLUSIONS: Despite largely favourable lipid profiles, there are clear differences according to aetiology of underlying HD in urban Africans, with younger patients with communicable HD having particularly low levels of HDLC. Appropriate prospective evidence is needed to determine if persistent low levels of HDLC expose patients to increased, long-term risk of atherosclerotic forms of HD. The women-only inverse association between HDLC and CRP warrants further investigation.

The impact of dietary habits and nutritional deficiencies in urban African patients living with heart failure in Soweto, South Africa--a review.

In South Africa, rapid urbanisation and epidemiological transition have left the black urban population vulnerable to diseases of lifestyle such as diabetes, high blood pressure, obesity and heart disease, as well as chronic heart failure. This is in part due to the fact that changes in dietary patterns during urbanisation play an important role in the increase of risk factors of these diseases. The South African population is made up of many different ethnic and cultural groups, each with its own way of eating and food choices. The black African population is one such an ethnic group, with its own distinct eating patterns and food choices. The diets of people living in rural areas tend to still be higher in carbohydrates, lower in fat, lower in sugar and higher in fibre, corresponding to the more traditional way of eating. With urbanisation their diet has changed to a more westernised diet with the resultant decrease in carbohydrates and fibre and an increased fat, processed food and salt consumption. Factors that might contribute to this change in dietary patterns include lack of awareness and knowledge around nutritional recommendations for persons suffering from chronic heart failure, urbanisation, socio-economic circumstances, food insecurity and level of education. Nutritional recommendations and intervention programs for the prevention and management of CHF focusing on food that is culturally sensitive and affordable should be implemented.

Feeding the emergence of advanced heart disease in Soweto: a nutritional survey of black African patients with heart failure.

AIM: To describe dietary habits and potential nutritional deficiencies in black African patients diagnosed with heart failure (HF). METHODS AND RESULTS: Dietary intake in 50 consecutively consenting HF patients (mean age: 47 ± 18 years, 54% female) attending a major hospital in Soweto, South Africa were surveyed using validated quantitative food frequency questionnaires. Food intakes, translated into nutrient data were compared with recommended values. In women, food choices likely to negatively impact on heart health included added sugar [consumed by 75%: median daily intake (interquartile range) 16 g (10-20)], sweet drinks [54%: 310 ml (85-400)] and salted snacks [61%: 15 g (2-17)]. Corresponding figures for men were added sugar [74%: 15 g (10-15)], sweet drinks [65%: 439 ml (71-670)] and salted snacks [74%: 15 g (4-22)]. The womens' intake of calcium, vitamin C and vitamin E was only 66, 37 and 40% of the age-specific requirement, respectively. For men, equivalent figures were 66, 87 and 67%. Mean sodium intake was 2 372 g/day for men and 1 972 g/day for women, 470 and 294% respectively, of recommended consumption levels. CONCLUSIONS: The nutritional status of black African patients with HF could be improved by recommending healthier food choices and by reducing the intake of sweet drinks and excess salt.

Elevated risk factors but low burden of heart disease in urban African primary care patients: a fundamental role for primary prevention.

BACKGROUND: Few data describe the case burden of heart disease and cardiovascular risk factors relative to other conditions in urban Africans seeking primary health care. METHODS: A clinical registry captured data on 1311 consecutive primary care patients (99% African) from two primary care clinics in Soweto, South Africa. Those with suspected sub-clinical heart disease had more advanced cardiologic assessment. RESULTS: Overall, 862 women (66%, 41 ± 16 years) and 449 men (38 ± 14 years) were studied. Whilst more men were smokers (47% vs. 14%; OR 5.23, 95% CI 4.01-6.82), more women were obese (42% vs. 14%; OR 4.54, 95% CI 3.33-5.88); blood glucose levels doubling with age in obese women. Although 33% were hypertensive, only 4.9% had type 2 diabetes (n=45), heart disease (n=10) and/or cerebrovascular disease (n=12). Overall, 16% (n=205) had an abnormal 12-lead ECG with more men than women showing a major abnormality (24% vs. 11%; OR 2.63, 95% CI 1.89-3.46). Of 99 cases (7.6%) subject to advanced cardiologic assessment, 29 (2.2%) had newly diagnosed heart disease: including hypertensive heart failure (13 women vs. 2 men, OR 4.51 95% CI 1.00-21.2), coronary artery disease (n=3), valve disease (n=3), dilated cardiomyopathy (n=3) and 2 cases of acute myocarditis. CONCLUSIONS: These data demonstrate a relatively low burden of heart disease in urban African patients seeking primary health care. Alternatively, high antecedent risk, particularly among obese women, highlights a key role for enhanced primary prevention.

A not-so-rare form of heart failure in urban black Africans: pathways to right heart failure in the Heart of Soweto Study cohort.

AIMS: Preliminary data suggest that right heart failure (RHF) may be more common in urban Africans than first suspected. We examined the characteristics and pathways to RHF in the Heart of Soweto cohort. METHODS AND RESULTS: A clinical registry captured data from 5328 de novo presentations of heart disease to the Cardiology Unit, Chris Hani Baragwanath Hospital in Soweto, South Africa during 2006-08. Of 2505 cases of HF (47% of total cohort), 697 (28%) were diagnosed with RHF (50% primary diagnosis). Despite more females than males (379 vs. 318 cases), proportionately more men presented with RHF [15 vs. 12% of cases; odds ratios (OR) 1.27, 95% confidence intervals (CI) 1.08-1.49] and Africans predominated overall (n= 642, 92%). Apart from concurrent left-sided heart disease (213 cases, 31%) there were many pathways to RHF including chronic lung disease (179 cases, 26% including COPD and tuberculosis) and 141 cases (20%) of pulmonary arterial hypertension (PAH). On an adjusted basis, women were almost two-fold more likely to present with PAH (OR 1.72, 95% CI 1.17-2.55; P= 0.006) while those with low levels of education (OR 0.69, 95% CI 0.47-1.01; P= 0.054) and originating from Soweto (OR 0.64, 95% CI 0.42-0.96; P= 0.029) were less likely to present with PAH compared with the rest of the cohort. CONCLUSION: These data suggest cases of RHF and related PAH are relatively common among urban Africans presenting with de novo heart disease.

Standing at the crossroads between new and historically prevalent heart disease: effects of migration and socio-economic factors in the Heart of Soweto cohort study.

AIMS: Migration, urbanization, and change in socio-economic factors have potentially profound effects on heart disease in low-to-middle income countries. METHODS AND RESULTS: Chris Hani Baragwanath Hospital in Soweto, South Africa, provides health care to >1 million Africans. We systematically captured data from all de novo presentations of suspected heart disease (focusing on 'new' vs. historically prevalent forms) during 2006-2008. There were 3168 female (52 ± 18 years) vs. 2160 male (53 ± 17 years) cases. Overall, 999 (19%) presented with uncomplicated hypertension (n = 988) or type II diabetes, 1862 cases (35%) 'new' heart disease (1146 and 581 cases of hypertensive heart failure and coronary artery disease), and 2092 cases (39%) of historically prevalent heart disease (including 724 with primary valve disease and 502 idiopathic dilated cardiomyopathies). Level of education and non-communicable risk factors were important correlates of advanced disease. The rate of historically prevalent cases was higher in those aged 20-49 years (19-60 cases/100,000 population/annum) whilst being higher for "new" heart disease in those aged >50 years (155-343 cases/population/annum). Historically prevalent heart disease cases were younger [adjusted odds ratio (OR) 0.98, 95% 0.97-0.99 per year], more likely to be African (OR 4.59, 95% 2.76-7.60) while being less likely to originate from Soweto (OR 0.87, 95% 0.75-1.00) and be female (OR 0.67, 95% 0.49-0.92). CONCLUSION: Dynamic socio-economic and lifestyle factors characteristic of epidemiological transition appear to have positioned the urban, mainly African community of Soweto at the crossroads between historically prevalent and 'new' forms of heart disease.