Knowledge, attitude, and perceptions towards the 2019 Coronavirus Pandemic : A bi-national survey in Africa

Publisher Copyright: Copyright: © 2020 Hager et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.The current Coronavirus (COVID-19) pandemic has impacted and changed lives on a global scale since its emergence and spread from China in late 2019. It has caused millions of infections, and thousands of deaths worldwide. However, the control of this pandemic still remains unachievable in many African countries including Egypt and Nigeria, despite the application of some strict preventive and control measures. Therefore, this study assessed the knowledge, attitude, and perceptions of Egyptians and Nigerians towards the COVID-19 pandemic. This study was designed as a cross-sectional community-based questionnaire survey in both countries. Participants’ demography, knowledge, attitude, and perceptions towards the COVID-19 outbreak were obtained using a convenience sampling technique. Data collected were subjected to descriptive statistics and logistic regression analysis. A total of 1437 respondents were included in this preliminary report. The mean knowledge score was 14.7±2.3. The majority of the respondents (61.6%) had a satisfactory knowledge of the disease. Age (18–39 years), education (College/bachelors), and background of respondents were factors influencing knowledge levels. The attitude of most respondents (68.9%) towards instituted preventive measures was satisfactory with an average attitude score of 6.9 ± 1.2. The majority of the respondents (96%) practiced self-isolation and social-distancing but only 36% follow all health recommendations. The perception of most respondents (62.1%) on the global efforts at controlling the virus and preventing further spread was satisfactory with an average score of 10.9 ± 2.7. Only 22% of the respondents were satisfied with their country’s handling of the pandemic. An apprehensive understanding of the current status in Africa through studies like KAP is crucial to avoid Africa being the next epicenter of the pandemic. For the populace to follow standard infection prevention and control measures adequately, governments need to gain the trust of citizens by strengthening the health systems and improving surveillance activities in detecting cases, to offer the optimum health services to their communities.Peer reviewe

COVID-19 pandemic impacted food security and caused psychosocial stress in selected states of Nigeria

SUPPLEMENTARY MATERIALS : TABLE S1: Economic and livelihood data and food-related issues for respondents psychosocial and food security-related impacts of COVID-19, Nigeria; TABLE S2: Psychological stress and self-rated quality of life of respondents per socioeconomic earning category due to impact of COVID-19.DATA AVAILABLITY STATEMENT : The data used in this study are available upon reasonable request from the corresponding author.The COVID-19 disease has infected many countries, causing generalized impacts on different income categories. We carried out a survey among households (n = 412) representing different income groups in Nigeria. We used validated food insecurity experience and socio-psychologic tools. Data obtained were analyzed using descriptive and inferential statistics. The earning capacities of the respondents ranged from 145 USD/month for low-income earners to 1945 USD/month for high-income earners. A total of 173 households (42%) ran out of food during the COVID-19 pandemic. All categories of households experienced increasing dependency on the general public and a perception of increasing insecurity, with the high-income earners experiencing the greatest shift. In addition, increasing levels of anger and irritation were experienced among all categories. Of the socio-demographic variables, only gender, educational level of the household head, work hours per day, and family income based on society class were associated (p < 0.05) with food security and hunger due to the COVID-19 pandemic. Although psychological stress was observed to be greater in the low-income earning group, household heads with medium and high family income were more likely to have satisfactory experiences regarding food security and hunger. It is recommended that socio-economic groups should be mapped and support systems should target each group to provide the needed support in terms of health, social, economic, and mental wellness.http://www.mdpi.com/journal/ijerphVeterinary Tropical DiseasesSDG-02:Zero HungerSDG-03:Good heatlh and well-bein

Knowledge, attitudes, and risk perception of broiler grow-out farmers on antimicrobial use and resistance in Oyo state, Nigeria

Assessing knowledge, attitudes, and risk perception of Nigerian broiler grow-out farmers (n = 152) to antimicrobial resistance (AMR) with a five sectional purposive-structured-questionnaire: demographics; knowledge; attitudes; risk-perception; and response to regulation of antimicrobial practices. Data were analyzed using descriptive statistics, chi-square test, and binary logistic regression. Respondents’ knowledge score, in total, was lower than average, with all (100%) respondents having the understanding that antibiotics kill/reduce bacteria, most participants (>73%) believing that feeding antibiotics to broiler chickens is a necessity for weight gain, and many (>69%) thinking that no negative side-effects exist with the use of antibiotics. Poor attitude towards antimicrobial usage was prevalent (>63%) with unsatisfactory performance in most instruments: >60% of farmers reported using antimicrobials every week and still use antimicrobials when birds appear sick, and most (>84%) arbitrarily increase the drug dosages when used. However, a satisfactory performance score was reported (68%) in risk perception of AMR with >63% perceiving that inappropriate use of antibiotics is the main factor causing the emergence of resistant bacteria; >65.8% expressed that AMR in broiler chickens is not essential for public health, that AMR cannot develop from broiler bacteria diseases, that increasing the frequency of antimicrobial use cannot increase AMR in future, and that usage cannot lead to antibiotic residue in broiler-meat products leading to AMR development in human. None of the respondents were aware of any regulation for monitoring antimicrobial use. Significant factors associated with knowledge, attitudes, and risk perception of antimicrobial use and resistance among broiler grow-out farmers include marital status, farm category, education, educational specialization, sales target, growth duration/cycle, broiler stocking batch, and feed source. Identified gaps exist in AMR awareness among Nigerian broiler farmers and should be targeted through stakeholders’ participation in combatting AMR threatshttp://www.mdpi.com/journal/antibioticsVeterinary Tropical Disease

Prevalence of Non-Communicable Diseases and Associated Factors in South Africa: Evidence from National Income Dynamics Survey, 2008-2017.

Introduction The unprecedented global increase in non-communicable diseases (NCDs) death incidences resulted in a joint initiative by the United Nations (UN) and the World Health Organization (WHO) to reduce NCD-related mortality by 25% by the year 2025. In this study, we ascertained the prevalence of NCDs in South Africa and its associated factors. Method We used 5-panel waves secondary datasets conducted by national income dynamic survey (NIDS) from 2008 to 2017 among 64,735 South Africans. We calculated the prevalence of all selected NCDs separately and together for each year at the descriptive level. This was followed by the distribution of selected NCDs across the socio-demographic and behavioural characteristics of the respondents. Finally, we used binary logistic regression to assess NCDs' likelihood by the respondents’ socio-demographic and behavioural characteristics. The results were presented as crude odds ratios (cOR) and adjusted odds ratios (aOR) with their corresponding 95% confidence intervals, signifying precision. Statistical significance was set at p-value < 0.05. Results We found that, the prevalence of NCDs in South Africa was highest in the year 2012 (23.8%) and lowest in the year 2015 (15.2%). Over the 10-year period, the NCDs with highest and lowest prevalence were high blood pressure and cancer, respectively. Females [cOR = 1.88, 95% CI=1.79-1.96], smokers [cOR=2.01, 95% CI=1.85-2.19] and those very satisfied with life [cOR=1.10, 95% CI=1.04-1.17] were more likely to have atleast one NCDs. This persisted after adjusting for significant covariates: [aOR = 1.84, 95% CI=1.74-1.94], [aOR=1.49, 95% CI=1.35-1.65] and [aOR = 1.01, 95% CI=0.95-1.09] respectively. Conclusion South Africa’s department of health and other health agencies need to strengthen existing policies and develop new interventional frameworks that will deliberately consider various significant factors contributing to the high prevalence of NCDs identified in this study. This will reduce the NCDs prevalence and reduce the morbidity and mortality levels attributable to NCDs in the country

Time-series analysis of ruminant foetal wastage at a slaughterhouse in North Central Nigeria between 2001 and 2012

In developing countries, foetal wastage from slaughtered ruminants and the associated economic losses appear to be substantial. However, only a limited number of studies have comprehensively evaluated these trends. In the current study, secondary (retrospective) and primary data were collected and evaluated to estimate the prevalence of foetal wastage from cattle, sheep and goats slaughtered at an abattoir in Minna, Nigeria, over a 12-year period (January 2001 – December 2012). Time-series modelling revealed substantial differences in the rate of foetal wastage amongst the slaughtered species, with more lambs having been wasted than calves or kids. Seasonal effects seem to influence rates of foetal wastage and certain months in the year appear to be associated with higher odds of foetal wastage. Improved management systems are suggested to reduce the risk of foetal losses.http://www.ojvr.org/index.php/ojvrhb201

Prevalence of Post COVID-19 Condition among Healthcare Workers: Self-Reported Online Survey in Four African Countries, December 2021–January 2022

The impact of Post COVID-19 Condition (PCC) is ongoing despite the declaration that the 2019 COVID-19 pandemic has ended. In this study, we explore the prevalence of PCC among healthcare workers (HCWs) in four African Countries and its influence on their professional performance. This study was conducted as an online cross-sectional survey of healthcare workers from four African countries (Cameroon, Egypt, Nigeria, and Somalia) between the 20th of December 2021 to 12th of January 2022. We determined the prevalence of PCC based on the WHO case definition and assessed variables associated with a higher prevalence of PCC in these countries using univariable and multivariable logistic regression analyses. A total of 706 HCWs from four African countries were included in this survey. Most of the HCWs were aged between 18–34 years (75.8%, n = 535). Our findings showed that 19.5% (n = 138) of the HCWs had tested positive for SARS-CoV-2. However, 8.4% (n = 59) were symptomatic for COVID-19 but tested negative or were never tested. Two-thirds of the HCWs (66.4%, n = 469) have received a COVID-19 vaccine and 80.6% (n = 378) of those vaccinated had been fully vaccinated. The self-reported awareness rate of PCC among the HCWs was 16.1% (n = 114/706) whereas the awareness rate of PCC among COVID-19-positive HCWs was 55.3% (n = 109/197). The prevalence of PCC among HCWs was 58.8% (n = 116). These changes include the self-reported symptoms of PCC which included headache (58.4%, n = 115), fatigue (58.8%, n = 116), and muscle pain (39.6%, n = 78). Similarly, 30% (n = 59) and 20.8% (n = 41) of the HCWs reported the loss of smell and loss of taste long after their COVID-19 infection, respectively. Some HCWs (42%, n = 83) believed that their work performance has been affected by their ongoing symptoms of PCC. There was no significant difference in the prevalence of PCC among the vaccinated and unvaccinated HCWs (p > 0.05). Of the socio-demographic variables, age (older HCWs between 45–54 years; OR:1.7; 95% CI: 1.06, 10.59; p = 0.001) and location (Egypt; OR:14.57; 95% CI: 2.62, 26.76; p = 0.001) were more likely to have experienced PCC than other age groups and countries respectively. The study revealed a low prevalence of PCC among the surveyed HCWs. In addition, it observed the need for adequate medical and psychological support to HCWs with PCC and improved mass advocacy campaigns on PCC

Will Africans take COVID-19 vaccination?

The economic and humanistic impact of COVID-19 pandemic is enormous globally. No definitive treatment exists, hence accelerated development and approval of COVID-19 vaccines, offers a unique opportunity for COVID-19 prevention and control. Vaccine hesitancy may limit the success of vaccine distribution in Africa, therefore we assessed the potentials for coronavirus vaccine hesitancy and its determinants among Africans. An online cross-sectional African-wide survey was administered in Arabic, English, and French languages. Questions on demographics, self-reported health status, vaccine literacy, knowledge and perception on vaccines, past experience, behavior, infection risk, willingness to receive and affordability of the SARS-COV-2 vaccine were asked. Data were subjected to descriptive and inferential statistics. A total of 5,416 individuals completed the survey. Approximately, 94% were residents of 34 African countries while the other Africans live in the Diaspora. Only 63% of all participants surveyed were willing to receive the COVID-19 vaccination as soon as possible and 79% were worried about its side effects. Thirty-nine percent expressed concerns of vaccine-associated infection. The odds of vaccine hesitancy was 0.28 (95% CI: 0.22, 0.30) among those who believed their risk of infection was very high, compared to those who believed otherwise. The odds of vaccine hesitancy was one-fifth (OR = 0.21, 95% CI: 0.16, 0.28) among those who believed their risk of falling sick was very high, compared to those who believed their risk of falling very sick was very low. The OR of vaccine hesitancy was 2.72 (95% CI: 2.24, 3.31) among those who have previously refused a vaccine for themselves or their child compared to counterparts with no self-reported history of vaccine hesitancy. Participants want the vaccines to be mandatory (40%), provided free of charge (78%) and distributed in homes and offices (44%). COVID-19 vaccine hesitancy is substantial among Africans based on perceived risk of coronavirus infection and past experiences

Public Health Surveillance for Adverse Events Following COVID-19 Vaccination in Africa

Local, national, and international health agencies have advocated multi-pronged public health strategies to limit infections and prevent deaths. The availability of safe and effective vaccines is critical in the control of a pandemic. Several adverse events have been reported globally following reception of different vaccines, with limited or no data from Africa. This cross-sectional epidemiological study investigated adverse events following COVID-19 vaccination in Africans from April–June, 2021 using a structured online questionnaire. Out of 1200 participants recruited, a total of 80.8% (n = 969) respondents from 35 countries, including 22 African countries and 13 countries where Africans live in the diaspora, reported adverse events. Over half of the vaccinees were male (53.0%) and frontline healthcare workers (55.7%), respectively. A total of 15.6% (n = 151) reported previous exposure to SARS-CoV-2, while about one-fourth, 24.8% (n = 240), reported different underlying health conditions prior to vaccination. Fatal cases were 5.1% (n = 49), while other significant heterogenous events were reported in three categories: very common, common, and uncommon, with the latter including enlarged lymph nodes 2.4% (n = 23), menstrual disorder 0.5% (n = 5), and increased libido 0.2% (n = 2). The study provided useful data for concerned authorities and institutions to prepare plans that will address issues related to COVID-19 vaccines

Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the Global Burden of Disease Study 2021

Background: Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050. Methods: Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. Findings: In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8–63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0–45·0] in 2050) and south Asia (31·7% [29·2–34·1] to 15·5% [13·7–17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4–40·3) to 41·1% (33·9–48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6–25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5–43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5–17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7–11·3) in the high-income super-region to 23·9% (20·7–27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5–6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2–26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [–0·6 to 3·6]). Interpretation: Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions