Type 2 diabetes, cardiovascular risk factors and offspring overweight and obesity 5 to 6 years after hyperglycaemia first detected in pregnancy in Cape Town, South Africa

Background The number of people with type 2 diabetes mellitus (T2DM) is increasing rapidly in Africa, straining already overstretched health systems. The association between hyperglycaemia first detected in pregnancy (HFDP), which includes both diabetes mellitus in pregnancy (DIP) and gestational diabetes mellitus (GDM), and the later development of T2DM and cardiovascular disease risk in the mothers and possibly overweight in their children is well recognised. This thesis contributes to the largely unexplored body of work on the prevalence of T2DM and CVD risk factors in African women after HFDP and the relationship between HFDP and childhood overweight and obesity. The thesis investigated: 1) the prevalence of T2DM and impaired glucose metabolism in African women of childbearing age; 2) the prevalence of T2DM and cardiovascular disease risk factors in women within 6 years after HFDP, and 3) the influence of maternal blood glucose levels during pregnancy and overweight and obesity in the offspring at the preschool age. Methods A systematic review and meta-analysis of all studies published from January 2000 to 2017 was carried out to estimate the prevalence of T2DM and impaired glucose regulation states. In the PROgression to Diabetes study (PRO2D), women diagnosed with GDM using the 2008 National Institute for Health and Care Excellence (NICE) criteria during 2010 and 2011 at a major referral hospital and their offspring were reviewed up to 6 years later. Relevant maternal and foetal/neonatal data were routinely collected during pregnancy and birth. The women were recalled for an assessment of T2DM (OGTT and HbA1C) and other cardiovascular risk factors (insulin resistance, dysglycaemia, dyslipidaemia and obesity) and their offspring for overweight/obesity. The women were reclassified into DIP and GDM using the WHO 2013 criteria for the diagnosis of HFDP. The pooled prevalence of T2DM was; 7.2% (95% CI 5.6% to 8.9%), impaired fasting glycaemia, 6.0% (95% CI 4.2% to 8.2%) IGT, 0.9% to 37.0% from 39 studies in 27 African countries, and 53 075 participants. The response rate for the PRO2D was 44.2% (final sample n=220). At follow up, almost half of the women, [48% (95% CI 41.2–54.4)], had T2DM, 83% in the DIP subtype and 31% with GDM had T2DM. The type of treatment [insulin (OR 25.8, 95% CI 3.9–171.4, p = 0.001), oral antidiabetic drugs (OR 4.1, 95% CI 1.3–12.9, p = 0.018)], fasting glucose(OR 2.7, 95% CI 1.5–4.8, p = 0.001), OGTT 2-hour glucose (OR 4.3, 95% CI 2.4–7.7, p < 0.001), during pregnancy; current anthropometry [waist circumference (OR 1.1, 95% CI 1.0–1.1, p = 0.007), hip circumference (OR 0.9, 95% CI 0.8–1.0, p = 0.001), BMI (OR 1.1, 95% CI 1.0–1.3, p = 0.001)]) were associated with T2DM. The prevalence of CVD risk factors was: insulin resistance 75% (95%CI 65.9-82.3), dyslipidaemia 74.6% (95%CI 68.3- 79.9), dysglycaemia 62.3% (95%CI 55.6-68.5), and raised blood pressure 41.4% (95%CI 35.0-48.0) and metabolic syndrome 60.9% (95%CI 54.3- 67.2). Of the 443 neonates exposed to HFDP during pregnancy, almost one-third [29.6% (95%CI 25.5 – 34.0)] were large-for-gestational-age (LGA) at birth and just over a fifth [21% (95%CI 15.4 – 27.8)] were either overweight or obese at preschool age. A strong association was found between maternal fasting glucose at HFDP diagnosis and birth weight zscore (OR 1.11, 95%CI 1 -1.22, p=0.046), maternal postprandial 2-hour glucose during the third trimester and weight z-score at birth (OR 1.23, 95%CI: 1.07 - 1.42, p = 0.005) and at preschool age (OR 1.37, 95%CI: 1.03 - 1.81, p = 0.031). Conclusion The high prevalence of T2DM and CVD risk factors in relatively young women and overweight and obesity in their offspring within 6 years of the index pregnancy demonstrates the need for context-specific interventions to prevent HFDP, to optimise screening for HFDP and to reduce cardiometabolic disease risk in the postpartum period

High prevalence of cardiovascular risk factors and insulin resistance 6 years after hyperglycemia first detected in pregnancy in Cape Town, South Africa

Objective To investigate the prevalence and associated cardiovascular risk factors 6 years after hyperglycemia first detected in pregnancy (HFDP) in Cape Town, South Africa. Research design and methods Data were collected during the index pregnancy from all women diagnosed with HFDP at a major referral hospital in Cape Town. Participants were evaluated 6 years later using a cross-sectional study. At follow-up participants had a 75 g oral glucose tolerance test, fasting lipogram, blood pressure and anthropometric measurements, and a fieldworker administered the questionnaire. We used the Adult Treatment Panel III criteria for the diagnosis of metabolic syndrome and individual risk factors. Insulin resistance was assessed using the homeostatic model of insulin resistance. Results At follow-up 220 women were reviewed. Their mean age at follow-up was 37.2 (SD 6.0) years. The prevalence of cardiovascular disease (CVD) risk factors was 60.9% (95% CI 54.3 to 67.2) for metabolic syndrome, 75% (95% CI 65.9 to 82.3) for insulin resistance, 62.3% (95% CI 55.6 to 68.5) for dysglycemia, 41.4% (95% CI 35.0 to 48.0) for raised blood pressure, and 74.6% (95% CI 683 to 79.9) for dyslipidemia. Women with diabetes in pregnancy compared with those with gestational diabetes during the index pregnancy had a higher prevalence of metabolic syndrome (74.3% vs 54.7%, p=0.010) and dysglycemia (88.6% vs 50.0%, p<0.001) at follow-up. Lower school education attainment, having a subsequent pregnancy, waist circumference at follow-up, and fasting blood glucose at HFDP diagnosis were associated with metabolic syndrome. Conclusion We found a high prevalence of CVD risk factors in South African women within 6 years of HFDP, which highlights the need to develop and evaluate interventions optimizing the cardiometabolic health of this vulnerable group. The main limitations of our research are the lack of a comparative group of women without HFDP and that we did not assess for CVD risk factors before HFDP. - Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Funding This research was funded by the Chronic Disease Initiative for Africa. We acknowledge funding from the International Development Research Centre (IDRC) (fund number: 411592) for TC (under the IINDIAGO project).Scopu

The influence of second-hand cigarette smoke exposure during childhood and active cigarette smoking on crohn’s disease phenotype defined by the montreal classification scheme in a Western Cape population, South Africa

CITATION: Chivese, T., et al. 2015. The influence of second-hand cigarette smoke exposure during childhood and active cigarette smoking on crohn’s disease phenotype defined by the montreal classification scheme in a Western Cape population, South Africa. PLoS ONE, 10(9):1-12, doi:10.1371/journal.pone.0139597.The original publication is available at http://journals.plos.org/plosoneBackground: Smoking may worsen the disease outcomes in patients with Crohn’s disease (CD), however the effect of exposure to second-hand cigarette smoke during childhood is unclear. In South Africa, no such literature exists. The aim of this study was to investigate whether disease phenotype, at time of diagnosis of CD, was associated with exposure to second-hand cigarette during childhood and active cigarette smoking habits. Methods: A cross sectional examination of all consecutive CD patients seen during the period September 2011-January 2013 at 2 large inflammatory bowel disease centers in the Western Cape, South Africa was performed. Data were collected via review of patient case notes, interviewer-administered questionnaire and clinical examination by the attending gastroenterologist. Disease phenotype (behavior and location) was evaluated at time of diagnosis, according to the Montreal Classification scheme. In addition, disease behavior was stratified as ‘complicated’ or ‘uncomplicated’, using predefined definitions. Passive cigarette smoke exposure was evaluated during 3 age intervals: 0–5, 6–10, and 11–18 years. Results: One hundred and ninety four CD patients were identified. Cigarette smoking during the 6 months prior to, or at time of diagnosis was significantly associated with ileo-colonic (L3) disease (RRR = 3.63; 95%CI, 1.32–9.98, p = 0.012) and ileal (L1) disease (RRR = 3.54; 95%CI, 1.06–11.83, p = 0.040) compared with colonic disease. In smokers, childhood passive cigarette smoke exposure during the 0–5 years age interval was significantly associated with ileo-colonic CD location (RRR = 21.3; 95%CI, 1.16–391.55, p = 0.040). No significant association between smoking habits and disease behavior at diagnosis, whether defined by the Montreal scheme, or stratified as ‘complicated’ vs ‘uncomplicated’, was observed. Conclusion: Smoking habits were associated with ileo-colonic (L3) and ileal (L1) disease at time of diagnosis in a South African cohort.Publisher's versio

Association between pre-existing conditions and hospitalization, intensive care services and mortality from COVID-19 - a cross sectional analysis of an international global health data repository

Objective: To investigate the association between pre-existing conditions and hospitalization, need for intensive care services (ICU) and mortality due to COVID-19. Methods: We used data on all cases recorded in the Global Health Data repository up to the 10th of March 2021 to carry out a cross-sectional analysis of associations between cardiovascular diseases (CVD), hypertension, diabetes, obesity, lung diseases and kidney disease and hospitalization, ICU and mortality due to COVID-19. We included data from Brazil, Mexico and Cuba only as they were the only countries where preexisting conditions were reported. We used multivariable logistic regression to compute adjusted and unadjusted odds ratios (OR) of the three outcomes for each pre-existing condition in ten-year age groups from 0-9 years and up to 110-120 years. Results: As of the 10th of March 2021, the Global Health repository held 25 900 000 records of confirmed cases of COVID-19, of which 2 900 000 cases from Brazil, Mexico and Cuba had data on preexisting conditions. The overall adjusted odds of hospitalization for each pre-existing condition were; CVD (OR 1.7, 95%CI 1.7-1.7), hypertension (OR 1.5, 95%CI 1.4-1.5), diabetes (OR 2.2, 95%CI 2.1-2.2), obesity (OR 1.7, 95%CI 1.6-1.7), kidney disease (OR 5.5, 95%CI 5.2-5.7) and lung disease (OR 1.9, 95%CI 1.8-1.9). The overall adjusted odds of ICU for each pre-existing condition were; CVD (OR 2.1, 95%CI 1.8-2.4), hypertension (OR 1.3, 95%CI 1.2-1.4), diabetes (OR 1.7, 95%CI 1.5-1.8), obesity (OR 2.2, 95%%CI 2.1-2.4), kidney disease (OR 1.4, 95%CI 1.2-1.7) and lung disease (OR 1.1, 95%CI 0.9-1.3). The overall adjusted odds of mortality for each pre-existing condition were; CVD (OR 1.7, 95%CI 1.6-1.7), hypertension (OR 1.3, 95%CI 1.3-1.4), diabetes (OR 2.0, 95%CI 1.9-2.0), obesity (OR 1.9, 95%CI 1.8-2.0), kidney disease (OR 2.7, 95%CI 2.6-2.9) and lung disease (OR 1.6, 95%CI 1.5-1.7). The odds of each outcome were considerably larger in children and young adults with these preexisting conditions than for adults, especially for kidney disease, CVD and diabetes. Conclusion: Individuals with CVD, hypertension, diabetes, obesity, lung diseases and kidney diseases have high odds of hospitalization, ICU and mortality from COVID-19. The odds of these outcomes are especially elevated in children and young adults with these preexisting condition

Effectiveness of integrated diabetes care interventions involving diabetes specialists working in primary and community care settings : systematic review and meta-analysis

Introduction: Evidence that integrated diabetes care interventions can substantially improve clinical outcomes is mixed. However, previous systematic reviews have not focussed on clinical effectiveness where the endocrinologist was actively involved in guiding diabetes management. Methods: We searched EMBASE, COCHRANE, MEDLINE, SCOPUS, CINAHL, Google Scholar databases and grey literature published in English language up to 25 January 2021. Reviewed articles included Randomised Controlled Trials (RCTs) and pre-post studies testing the effectiveness on clinical outcomes after ≥6 months intervention in non-pregnant adults (age ≥ 18 years) with type 1 or type 2 diabetes mellitus. Two reviewers independently extracted data and completed a risk of bias assessment. Appropriate meta-analyses for each outcome from RCTs and pre-post studies were performed. Heterogeneity was assessed using the I2 statistic and Cochran’s Q and publication bias assessed using Doi plots. Studies were not pooled to estimate the cost-effectiveness as the cost outcomes were not comparable across trials/studies. Results: We reviewed 4 RCTs and 12 pre-post studies. The integrated care model of diabetes specialists working with primary care health professionals had a positive impact on HbA1c in both RCTs and pre-post studies and on systolic blood pressure, diastolic blood pressure, total cholesterol and weight in pre-post studies. In the RCTs, interventions reduced HbA1c (–0.10% [–0.15 to –0.05]) (–1.1 mmol/mol [–1.6 to –0.5]), versus control. Pre-post studies demonstrated improvements in HbA1c (–0.77% [–1.12 to –0.42]) (–8.4 mmol/mol [–12.2 to –4.6]), systolic blood pressure (–3.30 mmHg [–5.16 to –1.44]), diastolic blood pressure (–3.61 mmHg [–4.82 to –2.39]), total cholesterol (–0.33 mmol/L [–0.52 to –0.14]) and weight (–2.53 kg [–3.86 to –1.19]). In a pre-post study with no control group only 4% patients experienced hypoglycaemia after one year of intervention compared to baseline. Conclusions: Integrated interventions with an active endocrinologist involvement can result in modest improvements in HbA1c, blood pressure and weight management. Although the improvements per clinical outcome are modest, there is possible net improvements at a holistic level

The risk of severe COVID-19 and mortality from COVID-19 in people living with HIV compared to individuals without HIV - a systematic review and meta-analysis of 1 268 676 individuals.

Research Purpose: Findings from existing studies have shown conflicting evidence concerning the risk of severe COVID-19 and death from COVID-19 in people living with HIV (PLHIV) compared to people without HIV. The aim of our review is to compare mortality, hospitalization, and the need for intensive care services due to COVID-19 between PLHIV and individuals without HIV based on data from the existing literature. Methods: A search in major databases of preprints was carried out and eligible studies were screened and selected. From each study, data on numbers of PLHIV and individuals without HIV were extracted. Study quality was assessed using the MethodologicAl STandard for Epidemiological Research (MASTER) scale. Data synthesis used a bias adjusted model where age and geographical subgroups were analysed. Results: From the 2757 records identified, 11 studies were included. The total participants were 1 268 676, of which 13 886 were PLHIV. Overall, the estimated effect of HIV on mortality suggested some worsening (OR 1.3, 95% CI: 0.9 - 2.0, I2 = 78.6%) with very weak evidence against the model hypothesis at this sample size. However, in individuals aged <60 years, the estimated effect on mortality suggested more worsening in PLHIV (OR 2.7, 95% CI: 1.1 -6.5, I2 = 95.7%) with strong evidence against the model hypothesis at this sample size. HIV was also associated with an estimated effect on hospitalization for COVID-19 that suggested worsening (OR 1.6, 95% CI: 1.3-2.1, I2 = 96.0%) with strong evidence against the model hypothesis at this sample size. Conclusion: People living with HIV have higher risk of death and hospitalisation from COVID-19, compared to individuals without HIV with the difference exaggerated in those younger than 60 years old. Our findings suggest that PLHIV are at higher risk than the general population and should be prioritized for vaccine coverage and monitoring if diagnosed with COVID-19

Barriers and facilitators of older adults for professional mental health help-seeking: a systematic review

Background: Older adults are at an increased risk for mental health issues, yet they are less likely to seek professional help. This systematic review aims to identify and summarize literature on the barriers and facilitators that older adults face when seeking professional mental health help. Methods: A comprehensive literature search was conducted using multiple databases including PubMed-Medline, EMBASE, ProQuest central, CINAHL and Scopus to identify relevant studies published between 2010 and 2021 that focused on barriers and/or facilitators to seeking help for depression, anxiety, and psychological distress among older adults aged 65 years or older. Studies' risk of bias was assessed using the Newcastle-Ottawa Scale and results of studies were synthesized guided by the methodological framework of Rodgers and colleagues. Results: A total of eight cross-sectional studies, from Australia, United States, Mexico, Netherlands, and Malaysia met the inclusion criteria for this review. Included studies reported that the majority of their participants had anxiety or depression, yet they exhibited a preference for informal mental health help over professional help. Stigma, negative beliefs about mental health professional services, and cost were the most reported barriers. Main reported facilitators were prior positive experience with mental health services and high socioeconomic status. Conclusion: Older adults are in need of interventions normalizing mental health help seeking and ensuring these services are accessible in terms of costs. This should be the focus of policy makers, healthcare providers, and public health practitioners working with older adults. Protocol registration: PROSPERO 2021 CRD42021238853.Scopu

Questionable utility of the relative risk in clinical research: A call for change to practice

ObjectiveIn clinical trials, the relative risk or risk ratio (RR) is a mainstay of reporting of the effect magnitude for an intervention. The RR is the ratio of the probability of an outcome in an intervention group to its probability in a control group. Thus the RR provides a measure of change in the likelihood of an event linked to a given intervention. This measure has been widely used because it is today considered a measure with ‘portability’ across varying outcome prevalence, especially when the outcome is rare. It turns out however that there is a much more important problem with this ratio, and this paper aims to demonstrate this problem. MethodsWe used mathematical derivation to determine if the RR is a measure of effect magnitude alone (i.e. a larger absolute value always indicating a stronger effect) or not. We also used the same derivation to determine its relationship to prevalence of an outcome. We confirm the derivation results with a follow-up analysis of 140,620 trials scraped from the Cochrane. ResultsWe demonstrate that the RR varies for reasons other than magnitude of the effect because it is a ratio of two posterior probabilities, both of which are dependent on baseline prevalence of an outcome. Additionally we demonstrate that the RR shifts towards its null value with increasing outcome prevalence. The shift towards the null happens regardless of the strength of the association between intervention and outcome. The odds ratio (OR), the other commonly used ratio, measures solely the effect magnitude and has no relationship to prevalence of an outcome in a study nor does it overestimate the RR as is commonly thought. ConclusionsThe results demonstrate the need to a) end the primary use of the RR in clinical trials and meta-analyses as its direct interpretation is not meaningful; b) replace the RR by the OR; and c) only use the post-intervention risk recalculated from the OR for any expected level of baseline risk in absolute terms for purposes of interpretation such as the number needed to treat. These results will have far reaching implications such as reducing misleading results from clinical trials and meta-analyses and ushering in a new era in the reporting of such trials or meta-analyses in practice

A program evaluation reporting student perceptions of early clinical exposure to primary care at a new medical college in Qatar

Background: Though common practice in Europe, few studies have described the efficacy of early clinical exposure (ECE) in the Middle East. The barriers to clinical learning experienced by these novice medical students have not been reported. This evaluation reports on introducing ECE in primary care, supported by Experiential Review (ER) debriefing sessions. The evaluation explores students' experiences of their acquisition of clinical and non-technical skills, sociocultural issues commonly encountered but underreported and barriers to clinical learning experienced. Methods: We conducted a cross-sectional study of three student cohorts in 2017-19: All second and third-year students at the new College of Medicine were invited to participate. The primary outcome was students' perceptions of the aims of the Primary Health Centre Placement (PHCP) programme and how it facilitated learning. Secondary outcome measures were students' perceptions of their learning in ER sessions and perceived barriers to learning during PHCPs. Student perceptions of the PHCPs were measured using a Likert scale-based questionnaire. Results: One hundred and fifty-one students participated: 107 in year 2 and 44 in year 3; 72.3% were female. Overall, most students (> 70%) strongly agreed or agreed with the purposes of the PCHPs. Most students (71%) strongly agreed or agreed that the PCHPs allowed them to learn about patient care; 58% to observe doctors as role models and 55% to discuss managing common clinical problems with family physicians. Most students (year 2 = 62.5% and year 3 = 67%) strongly agreed/agreed that they were now confident taking histories and examining patients. Student barriers to clinical learning included: Unclear learning outcomes (48.3%); faculty too busy to teach (41.7%); lacking understanding of clinical medicine (29.1%); shyness (26.5%); and finding talking to patients difficult and embarrassing (25.8%). Over 70% reported that ER enabled them to discuss ethical and professional issues. Conclusions: Overall, our Middle Eastern students regard ECE as beneficial to their clinical learning. PHCPs and ER sessions together provide useful educational experiences for novice learners. We recommend further exploration of the barriers to learning to explore whether these novice students' perceptions are manifesting underlying cultural sensitivities or acculturation to their new environment.Scopu

The Association Between Short Sleep Duration and Metabolic Syndrome: A Case-Control Study

Purpose: Short sleep duration and quality are increasingly common in the Middle East and North Africa (MENA) region and has been linked to metabolic syndrome, which increases the risk of cardiovascular disease and diabetes. This study aimed to examine the link between short sleep duration and metabolic syndrome. Patients and Methods: We conducted a case-control study using data from Qatar Biobank, with 1000 participants categorized into two groups: less than 7 hours of sleep (n=500) and 7 or more hours of sleep (n=500). Metabolic syndrome was defined using WHO criteria, and logistic regression analysis adjusted for age and gender. Results: There was a higher proportion of individuals with MetS in the short sleep duration group compared to the normal sleep duration group (22.8% vs 15.8%, respectively). The multivariable regression showed that short sleep duration was associated with metabolic syndrome (OR 1.91, 95% CI: 1.14–3.20, P=0.014) and having 1–2 components of metabolic syndrome (OR 1.91, 95% CI: 1.14–3.20, P=0.014), particularly in males (OR: 2.30, 95% CI: 1.07–4.94, P=0.032). Being overweight (OR 2.17, 95% CI: 1.30–3.63, P=0.003) was also associated with a shorter sleep duration. BMI was identified as the main contributor to the association between short sleep duration and metabolic syndrome, while diabetes played a minor role. Conclusion: Short sleep duration was associated with metabolic syndrome in Qatar, particularly in males.The open access publication of this article was made possible due to a generous fund from Qatar National Library