OpenUCT :: Browsing by Author "Levitt, Naomi S"

Browsing by Author "Levitt, Naomi S"

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Open Access
A comparison of indices of glucose metabolism in five black populations: data from modeling the epidemiologic transition study (METS)
(2015-09-15) Atiase, Yacoba; Farni, Kathryn; Plange-Rhule, Jacob; Luke, Amy; Bovet, Pascal; Forrester, Terrence G; Lambert, Vicki; Levitt, Naomi S; Kliethermes, Stephanie; Cao, Guichan; Durazo-Arvizu, Ramon A; Cooper, Richard S; Dugas, Lara R
Background: Globally, Africans and African Americans experience a disproportionate burden of type 2 diabetes, compared to other race and ethnic groups. The aim of the study was to examine the association of plasma glucose with indices of glucose metabolism in young adults of African origin from 5 different countries. Methods: We identified participants from the Modeling the Epidemiologic Transition Study, an international study of weight change and cardiovascular disease (CVD) risk in five populations of African origin: USA (US), Jamaica, Ghana, South Africa, and Seychelles. For the current study, we included 667 participants (34.8 ± 6.3 years), with measures of plasma glucose, insulin, leptin, and adiponectin, as well as moderate and vigorous physical activity (MVPA, minutes/day [min/day]), daily sedentary time (min/day), anthropometrics, and body composition. Results: Among the 282 men, body mass index (BMI) ranged from 22.1 to 29.6 kg/m2 in men and from 25.8 to 34.8 kg/m2 in 385 women. MVPA ranged from 26.2 to 47.1 min/day in men, and from 14.3 to 27.3 min/day in women and correlated with adiposity (BMI, waist size, and % body fat) only among US males after controlling for age. Plasma glucose ranged from 4.6 ± 0.8 mmol/L in the South African men to 5.8 mmol/L US men, while the overall prevalence for diabetes was very low, except in the US men and women (6.7 and 12 %, respectively). Using multivariate linear regression, glucose was associated with BMI, age, sex, smoking hypertension, daily sedentary time but not daily MVPA. Conclusion: Obesity, metabolic risk, and other potential determinants vary significantly between populations at differing stages of the epidemiologic transition, requiring tailored public health policies to address local population characteristics.
Open Access
A food-based dietary strategy lowers blood pressure in a low socio-economic setting: a randomised study in South Africa
(2008) Charlton, Karen E; Steyn, Krisela; Levitt, Naomi S; Peer, Nasheeta; Jonathan, Deborah; Gogela, Theresa; Rossouw, Katja; Gwebushe, Nomonde; Lombard, Carl J
OBJECTIVE: To assess the impact of a food-based intervention on blood pressure (BP) in free-living South African men and women aged 50-75 years, with drug-treated mild-to-moderate hypertension. METHODS: A double-blind controlled trial was undertaken in eighty drug-treated mild-to-moderate hypertensive subjects randomised to an intervention (n 40) or control (n 40) arm. The intervention was 8-week provision of six food items with a modified cation content (salt replacement (SOLO ), bread, margarine, stock cubes, soup mix and a flavour enhancer) and 500 ml of maas (fermented milk)/d. The control diet provided the same quantities of the targeted foods but of standard commercial composition and 500 ml/d of artificially sweetened cooldrink. FINDINGS: The intervention effect estimated as the contrast of the within-diet group changes in BP from baseline to post-intervention was a significant reduction of 6.2 mmHg (95 % CI 0.9, 11.4) for systolic BP. The largest intervention effect in 24 h BP was for wake systolic BP with a reduction of 5.1 mmHg (95 % CI 0.4, 9.9). For wake diastolic BP the reduction was 2.7 mmHg (95 % CI -0.2, 5.6). CONCLUSIONS: Modification of the cation content of a limited number of commonly consumed foods lowers BP by a clinically significant magnitude in treated South African hypertensive patients of low socio-economic status. The magnitude of BP reduction provides motivation for a public health strategy that could be adopted through lobbying of the food industry by consumer and health agencies.
Open Access
Addison's disease symptoms - a cross sectional study in urban South Africa
(Public Library of Science, 2013) Ross, Ian Louis; Levitt, Naomi S
BACKGROUND: Addison's disease is a potentially life-threatening disorder, and prompt diagnosis, and introduction of steroid replacement has resulted in near normal life-expectancy. There are limited data describing the clinical presentation of Addison's disease in South Africa. It is hypothesised that patients may present in advanced state of ill-health, compared to Western countries. Patients A national database of patients was compiled from primary care, referral centres and private practices. 148 patients were enrolled (97 white, 34 mixed ancestry, 5 Asian and 12 black). METHODS: Demographic and clinical data were elicited using questionnaires. Biochemical data were obtained from folder reviews and laboratory archived results. RESULTS: The majority of the cohort was women (62%). The median and inter-quartile age range (IQR) of patients at enrolment was 46.0 (32.0-61.0) years, with a wide range from 2.8-88.0 years. The median and IQR age at initial diagnosis was 34.0 (20.0-45.0) years (range 0.02-77.0) years, indicating that at the time of enrolment, the patients, on average, were diagnosed with Addison's disease 12 years previously. Hyperpigmentation was observed in 76%, nausea and vomiting occurred in more than 40%, and weight loss was noted in 25%. Loss of consciousness as a presenting feature was recorded in 20 %. with a 95% confidence interval [CI] of (14-28%) and shock occurred in 5% CI (1.5-8.5%). Case-finding was recorded at 3.1 per million. CONCLUSIONS: The usual constellation of hyperpigmentation, nausea, vomiting and weight loss suggests Addison's disease, but a significant proportion present with an advanced state of ill-health and Addisonian crises. A lower prevalence rate, compared to Western countries is suggested.
Open Access
Anti-retroviral therapy increases the prevalence of dyslipidemia in South African HIV-infected patients
(Public Library of Science, 2016) Dave, Joel A; Levitt, Naomi S; Ross, Ian L; Lacerda, Miguel; Maartens, Gary; Blom, Dirk
Purpose Data on the prevalence of dyslipidaemia and associated risk factors in HIV-infected patients from sub-Saharan Africa is sparse. We performed a cross-sectional analysis in a cohort of HIV-infected South African adults. METHODS: We studied HIV-infected patients who were either antiretroviral therapy (ART)-naive or receiving non-nucleoside reverse transcriptase inhibitor (NNRTI)-based or protease inhibitor (PI)-based ART. Evaluation included fasting lipograms, oral glucose tolerance tests and clinical anthropometry. Dyslipidemia was defined using the NCEP ATPIII guidelines. RESULTS: The median age of the participants was 34 years (range 19-68 years) and 78% were women. The prevalence of dyslipidemia in 406 ART-naive and 551 participants on ART was 90.0% and 85%, respectively. Low HDL-cholesterol (HDLC) was the most common abnormality [290/406 (71%) ART-naïve and 237/551 (43%) ART- participants]. Participants on ART had higher triglycerides (TG), total cholesterol (TC), LDL-cholesterol (LDLC) and HDLC than the ART-naïve group. Severe dyslipidaemia, (LDLC> 4.9 mmol/L or TG >5.0 mmol/L) was present in <5% of participants. In multivariate analyses there were complex associations between age, gender, type and duration of ART and body composition and LDLC, HDLC and TG, which differed between ART-naïve and ART-participants. CONCLUSION: Participants on ART had higher TG, TC, LDLC and HDLC than those who were ART-naïve but severe lipid abnormalities requiring evaluation and treatment were uncommon.
Open Access
Antiretroviral therapy, especially Efavirenz, is associated with low bone mineral density in HIV-infected South Africans
(Public Library of Science, 2015) Dave, Joel A; Cohen, Karen; Micklesfield, Lisa K; Maartens, Gary; Levitt, Naomi S
Purpose We determined the prevalence and correlates of low bone mineral density (BMD) in HIV-infected South Africans as there is a paucity of such data from Africa. METHODS: BMD and serum 25-hydroxyvitamin D were measured in HIV-positive participants on antiretroviral therapy (ART) and in those not yet on ART (ART-naïve). RESULTS: We enrolled 444 participants [median age 35(IQR: 30, 40) years; 77% women]. BMD was low (z score <-2SD) in 17% and 5% of participants at the lumbar spine and total hip, respectively. Total hip [0.909 (SD 0.123) vs 0.956 (SD 0.124) g/cm 2 , p = 0.0001] and neck of femur BMD [0.796 (SD 0.130) vs 0.844 (SD 0.120) g/cm 2 , p = 0.0001] were lower in the ART, compared to the ART-naïve group. Vitamin D deficiency was present in 15% of participants and was associated with efavirenz use [adjusted OR 2.04 (95% CI 1.01 to 4.13)]. In a multivariate linear regression, exposure to efavirenz or lopinavir-based ART was associated with lower total hip BMD, whereas higher weight, being male and higher vitamin D concentration were associated with higher total hip BMD (adjusted R 2 = 0.28). Age, weight, sex, and the use of efavirenz-based ART were independently associated with lumbar spine BMD (adjusted R 2 = 0.13). CONCLUSIONS: Vitamin D status, use of efavirenz or lopinavir/ritonavir, weight, age and sex are significantly associated with lower BMD in this young cohort of HIV-infected South Africans.
Open Access
Association of lopinavir concentrations with plasma lipid or glucose concentrations in HIV-infected South Africans: a cross sectional study
(BioMed Central Ltd, 2012-10-26) Sinxadi, Phumla Z; McIlleron, Helen M; Dave, Joel A; Smith, Peter J; Levitt, Naomi S; Maartens, Gary
Abstract Background Dyslipidaemia and dysglycaemia have been associated with exposure to ritonavir-boosted protease inhibitors. Lopinavir/ritonavir, the most commonly used protease inhibitor in resource-limited settings, often causes dyslipidaemia. There are contradictory data regarding the association between lopinavir concentrations and changes in lipids. Aim To investigate associations between plasma lopinavir concentrations and lipid and glucose concentrations in HIV-infected South African adults. Methods Participants stable on lopinavir-based antiretroviral therapy were enrolled into a cross-sectional study. After an overnight fast, total cholesterol, triglycerides, and lopinavir concentrations were measured and an oral glucose tolerance test was performed. Regression analyses were used to determine associations between plasma lopinavir concentrations and fasting and 2 hour plasma glucose, fasting cholesterol, and triglycerides concentrations. Results There were 84 participants (72 women) with a median age of 36 years. The median blood pressure, body mass index and waist: hip ratio were 108/72 mmHg, 26 kg/m2 and 0.89 respectively. The median CD4 count was 478 cells/mm3. Median duration on lopinavir was 18.5 months. The median (interquartile range) lopinavir concentration was 8.0 (5.2 to 12.8) μg/mL. Regression analyses showed no significant association between lopinavir pre-dose concentrations and fasting cholesterol (β-coefficient −0.04 (95% CI −0.07 to 0.00)), triglycerides (β-coefficient −0.01 (95% CI −0.04 to 0.02)), fasting glucose (β-coefficient −0.01 (95% CI −0.04 to 0.02)), or 2-hour glucose concentrations (β-coefficient −0.02 (95% CI −0.09 to 0.06)). Lopinavir concentrations above the median were not associated with presence of dyslipidaemia or dysglycaemia. Conclusions There was no association between lopinavir plasma concentrations and plasma lipid and glucose concentrations.
Open Access
Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town
(2005) Haque, Monirul; Navsa, Maryam; Emerson, Sonja Hayden; Dennison, Cheryl R; Levitt, Naomi S
Background. The majority of patients with type 2 diabetes mellitus in Cape Town who attend primary care community health centres (CHCs) have unsatisfactory glycaemic control. Insulin is rarely prescribed despite its being indicated for type 2 diabetic patients with inadequate metabolic control on maximum oral glucose-lowering agent (OGLA) therapy. Objective. The study examined barriers to initiating insulin therapy in poorly controlled type 2 diabetes patients on maximum OGLAs in CHCs in the Cape Town metropole. Methods. Five focus group discussions and 10 in-depth semi-structured individual interviews were conducted with 46 medical officers working at the CHCs. The discussions and interviews were transcribed and common themes were identified and categorised. Results. Doctor, patient, and system barriers to initiating insulin therapy were identified. Doctors’ barriers include lack of knowledge, lack of experience with and use of guidelines related to insulin therapy, language barriers between doctor and patients, and fear of hypoglycaemia. Patient barriers were mistaken beliefs about insulin, noncompliance, lack of understanding of diabetes, use of traditional herbs, fear of injections, and poor socioeconomic conditions. System barriers were inadequate time, lack of continuity of care and financial constraints. Conclusion. Suggestions for overcoming barriers include further education of doctors on insulin initiation and the use of standardised guidelines. In addition, a patient-centred approach with better communication between doctors and patients, which may be achieved by reorganising aspects of the health system, may improve patient knowledge, address mistaken beliefs, improve compliance and help overcome barriers. Further research is needed to investigate these recommendations and assess patients’ and nurses’ perceptions on initiating insulin therapy.
Open Access
Changes in blood pressure, glucose levels, insulin secretion and anthropometry after long term exposure to antiretroviral therapy in South African women
(2015-08-05) Abrahams, Zulfa; Dave, Joel A; Maartens, Gary; Levitt, Naomi S
Abstract Background A number of metabolic abnormalities, such as dysglycaemia, insulin resistance, lipodystrophy and dyslipidaemia, are associated with the use of antiretroviral drugs. We aimed to assess the effects of long-term antiretroviral exposure on blood pressure, glycaemia, insulin secretion and anthropometric measures in black South African women. Methods A convenience sample of HIV-infected women on first-line ART for a median of 16 months at baseline, had the following evaluations twice, at baseline and after approximately 5 years: anthropometry, including skin fold thicknesses, blood pressure, oral glucose test, and insulin. Insulin sensitivity and secretion (HOMA-IR, IGI and DIo) were estimated. Results At baseline more than half the 103 women were using stavudine and efavirenz. The median interval between baseline and follow-up evaluation was 66 months. Weight, waist circumference, and waist-hip ratio increased over time, while limb skinfold thickness decreased over time. Systolic and diastolic blood pressure increased significantly and the proportion of participants with hypertension increased from 3.9 to 15.5% (p < 0.001). There were increases from baseline in plasma glucose concentrations at 30 and 120 min; insulin concentrations at 0 and 30 min; and IGI and DIo. The proportion of participants with diabetes increased from 1 to 7.5% (p = 0.070). Conclusion In black South African women with long-term exposure to ART, increases in hypertension and possibly diabetes were observed. Participants experienced an increase in central fat and a decrease in peripheral fat distribution. Early identification and management of these metabolic changes are important, especially in a region with the highest HIV-infected population in the world.
Open Access
Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition
(BioMed Central, 2014-06-09) Oni, Tolu; McGrath, Nuala; BeLue, Rhonda; Roderick, Paul; Colagiuri, Stephen; May, Carl R; Levitt, Naomi S
Background: The burden of non-communicable diseases is rising, particularly in low and middle-income countries undergoing rapid epidemiological transition. In sub-Saharan Africa, this is occurring against a background of infectious chronic disease epidemics, particularly HIV and tuberculosis. Consequently, multi-morbidity, the co-existence of more than one chronic condition in one person, is increasing; in particular multimorbidity due to comorbid non-communicable and infectious chronic diseases (CNCICD). Such complex multimorbidity is a major challenge to existing models of healthcare delivery and there is a need to ensure integrated care across disease pathways and across primary and secondary care. Discussion: The Innovative Care for Chronic Conditions (ICCC) Framework developed by the World Health Organization provides a health systems roadmap to meet the increasing needs of chronic disease care. This framework incorporates community, patient, healthcare and policy environment perspectives, and forms the cornerstone of South Africa’s primary health care re-engineering and strategic plan for chronic disease management integration. However, it does not significantly incorporate complexity associated with multimorbidity and CNCICD. Using South Africa as a case study for a country in transition, we identify gaps in the ICCC framework at the micro-, meso-, and macro-levels. We apply the lens of CNCICD and propose modification of the ICCC and the South African Integrated Chronic Disease Management plan. Our framework incorporates the increased complexity of treating CNCICD patients, and highlights the importance of biomedicine (biological interaction). We highlight the patient perspective using a patient experience model that proposes that treatment adherence, healthcare utilization, and health outcomes are influenced by the relationship between the workload that is delegated to patients by healthcare providers, and patients’ capacity to meet the demands of this workload. We link these issues to provider perspectives that interact with healthcare delivery and utilization. Summary: Our proposed modification to the ICCC Framework makes clear that healthcare systems must work to make sense of the complex collision between biological phenomena, clinical interpretation, beliefs and behaviours that follow from these. We emphasize the integration of these issues with the socio-economic environment to address issues of complexity, access and equity in the integrated management of chronic diseases previously considered in isolation.
Open Access
Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol
(2021-02-26) Okop, Kufre J; Murphy, Kathy; Lambert, Estelle V; Kedir, Kiya; Getachew, Hailemichael; Howe, Rawleigh; Niyibizi, Jean B; Ntawuyirushintege, Selemani; Bavuma, Charlotte; Rulisa, Stephen; Kasenda, Stephen; Chipeta, Effie; Bunn, Christopher; Crampin, Amelia C; Chapotera, Gertrude; King, Abby C; Banchoff, Ann; Winter, Sandra J; Levitt, Naomi S
Background In sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk. Methods This protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy. Discussion Contextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.
Open Access
The contribution of diabetes mellitus to lower extremity amputations in four public sector hospitals in Cape Town for 2009 and 2010
(2012) Dunbar, Graeme Leslie; Levitt, Naomi S; Hellenberg, Derek
Diabetes is the most common non-communicable disease worldwide and contributes to substantial morbidity and mortality. The prevalence of diabetes is increasing and reaching epidemic proportions, with the largest increase being seen in developing countries, including South Africa. Among the many complications of diabetes, lower extremity amputations are common, with a leg being lost to diabetes somewhere in the world every thirty seconds. The vast majority of these amputations is preventable and is a reflection of inadequate care of diabetic patients. Studies done in South Africa have shown that the care of diabetes in the public sector is suboptimal. A study in the private sector in South Africa showed that by ensuring optimal care of diabetic patients, long term glycaemic control and a decrease in complications and hospital admissions can be achieved. Lower extremity amputations can be the result of complications due to poor glycaemic control. There are, however, few studies that have been done in South Africa assessing the contribution that diabetes makes to the performance of lower extremity amputations. This study will attempt to begin to fill in this gap in South African data and the results will be compared to a previous unpublished South African study in the Cape Town Metropole from 1999.
Open Access
Cost-effectiveness analysis of alternative statin prescribing strategies for the secondary prevention of cardiovascular disease at a South African public sector tertiary hospital
(2016) De Waal, Reneé; Cleary, Susan; Steyn, Krisela; Levitt, Naomi S
Strokes and ischaemic heart disease are among the top ten causes of death in South Africa. Given that burden of disease, it is important to establish whether interventions aimed at preventing cardiovascular disease are not only effective, but cost effective too. Cost-effectiveness analyses compare interventions in terms of both their costs and consequences and are a useful tool for policymakers. Statins reduce the risk of cardiovascular events such as myocardial infarctions and strokes, by lowering low density lipoprotein cholesterol (LDL-C) concentrations. Several studies, mostly conducted in Europe or North America, have demonstrated that statins are cost effective, particularly when used to reduce the risk of further cardiovascular events in patients who already have cardiovascular disease (secondary prevention). Despite their widespread use, there are no published cost-effectiveness analyses of statins for the secondary prevention of cardiovascular disease in South Africa. There are also only limited local efficacy data from clinical trials and no costing data of cardiovascular events from a public healthcare sector perspective. There is some debate regarding the optimal statin dose. Some guidelines recommend increasing statin doses until target LDL-C concentrations are achieved, while others recommend prescribing statins at a fixed high dose without monitoring LDL-C. Monitoring LDL-C is relatively expensive compared to the cost of statins, but there is limited evidence that it might improve adherence. I compared the costs (from a provider perspective) and outcomes (life years), of increasing statin doses based on regular measurement of LDL-C concentrations, to achieve a target LDL-C concentration of <1.8 mmol/L; prescribing atorvastatin 80 mg without LDL-C monitoring; and the status quo, simvastatin 20 mg without LDL-C monitoring. I constructed a Markov model with annual cycles; a five-year timeline; starting age of 60 years; and the following health states: ≤1 year after first cardiovascular event, ≤1 year after subsequent cardiovascular event, >1 year after any cardiovascular event, and dead. I estimated transition probabilities using published literature. I estimated the costs of hospitalisation for myocardial infarctions, strokes, unstable angina pectoris and coronary revascularisation procedures using health services utilisation and expenditure data from a sample of patients at a public sector hospital. I discounted costs and outcomes at 3% per year; and explored alternative scenarios and timelines in sensitivity analyses. Atorvastatin 80 mg without LDL-C monitoring, was both the cheapest and most effective option over a five-year period. It remained the most effective option over a lifetime period, but with an incremental cost-effectiveness ratio (ICER) of $146.94 per life year gained relative to the status quo. Treat to target was as effective as atorvastatin 80 mg if I assumed adherence rates of 80% and 60% respectively, but with an ICER of $54 930.96. Treat to target would dominate atorvastin 80 mg only if the frequency of LDL-C monitoring was reduced from 3-monthly to 6-monthly until targets were reached, and the cost of LDL-C monitoring decreased by $9.25 (84%). Fixed-dose statin treatment without cholesterol monitoring is the most cost-effective option for providing statins for the secondary prevention of cardiovascular disease. The costs of regular LDL-C monitoring currently make a treat to target strategy unaffordable in our setting. These results might be used to help guide policy regarding secondary prevention of cardiovascular disease in South Africa.
Open Access
Delivery of health care for cardiovascular and metabolic diseases among people living with HIV/AIDS in African countries: a systematic review protocol
(BioMed Central, 2016) Watkins, David A; Tulloch, Nathaniel L; Anderson, Molly E; Barnhart, Scott; Steyn, Krisela; Levitt, Naomi S
Background: People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV. Methods/design: We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the “cascade of care”—i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective). Discussion: CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings.
Open Access
Development and validation of a short questionnaire to assess sodium intake
(2008) Charlton, Karen E; Steyn, Krisela; Levitt, Naomi S; Jonathan, Deborah; Zulu, Jabulisiwe V; Nel, Johanna H
OBJECTIVES: To develop and validate a short food-frequency questionnaire to assess habitual dietary salt intake in South Africans and to allow classification of individuals according to intakes above or below the maximum recommended intake of 6 g salt day-1. DESIGN: Cross-sectional validation study in 324 conveniently sampled men and women. METHODS: Repeated 24-hour urinary Na values and 24-hour dietary recalls were obtained on three occasions. Food items consumed by >5% of the sample and which contributed > or =50 mg Na serving-1 were included in the questionnaire in 42 categories. A scoring system was devised, based on Na content of one index food per category and frequency of consumption. RESULTS: Positive correlations were found between Na content of 35 of the 42 food categories in the questionnaire and total Na intake, calculated from 24-hour recall data. Total Na content of the questionnaire was associated with Na estimations from 24-hour recall data (r = 0.750; P < 0.0001; n = 328) and urinary Na (r = 0.152; P = 0.0105; n = 284). Urinary Na was higher for subjects in tertile 3 than tertile 1 of questionnaire Na content (P < 0.05). Questionnaire Na content of <2400 and > or =2400 mg day-1 equated to a reference cut-off score of 48 and corresponded to mean (standard deviation) urinary Na values of 145 (68) and 176 (99) mmol day-1, respectively (P < 0.05). Sensitivity and specificity against urinary Na > or =100 and <100 mmol day-1 was 12.4% and 93.9%, respectively. CONCLUSION: A 42-item food-frequency questionnaire has been shown to have content-, construct- and criterion-related validity, as well as internal consistency, with regard to categorising individuals according to their habitual salt intake; however, the devised scoring system needs to show improved sensitivity.
Open Access
Development and validation of instruments measuring body image and body weight dissatisfaction in South African mothers and their daughters
(2005) Mciza, Zandile; Goedecke, Julia H; Steyn, Nelia P; Charlton, Karen; Puoane, Thandi; Meltzer, Shelly; Levitt, Naomi S; Lambert, Estelle V
OBJECTIVE: We sought to validate questionnaires concerning body image perception, body size dissatisfaction and weight-related beliefs in multi-ethnic South African mothers and their daughters. SETTINGS AND SUBJECTS: Girls attending primary school (ages 9-12 years, n = 333) and their mothers (n = 204) were interviewed regarding their demographics and body image. Weight, height and skinfold thicknesses were measured. Body image questions and body mass index (BMI) were compared with silhouettes adapted from the Pathways Study for girls and Stunkard's body image figures for mothers. A Feel-Ideal Difference (FID) index score was created by subtracting the score of the silhouette selected by the participants as 'Ideal' from the one selected as most closely representing their current appearance or 'Feel'. We hypothesised that a higher FID index score would be associated with greater body size dissatisfaction. RESULTS: BMI percentiles in girls (r = 0.46, P < 0.05) and BMI in mothers (r = 0.68, P < 0.05) were positively correlated with the selected silhouettes based on size. Participants who reported feelings of being 'fat' and those who perceived that their family and friends were more dissatisfied with their body size had significantly higher FID index scores. Scores were lower in black than white girls (all P<0.05). No differences were found in FID index scores between ethnic groups of mothers. Internal reliability of the 'thin' and 'fat' belief constructs for girls was demonstrated by standardised Cronbach's alpha values > or = 0.7. CONCLUSION: Silhouettes, FID index, 'fat' and 'thin' belief constructs (in girls) are age-appropriate, culturally sensitive and can be used in further intervention studies to understand body image.
Open Access
The development of simple anthropometric measures to diagnose antiretroviral therapy-associated lipodystrophy in resource limited settings
(BioMed Central, 2014-08-04) Abrahams, Zulfa; Dave, Joel A; Maartens, Gary; Lesosky, Maia; Levitt, Naomi S
Abstract Background Lipohypertrophy does not appear to be an adverse ART reaction while lipoatrophy is clearly associated with the use of stavudine (d4T) and zidovudine (AZT). In low and middle income countries d4T has only recently been phased out and AZT is still widely being used. Several case definitions have been developed to diagnose lipodystrophy, but none of them are generalizable to sub-Saharan Africa where black women have less visceral adipose tissue and more subcutaneous adipose tissue than white women. We aimed to develop a simple, objective measure to define lipoatrophy and lipohypertrophy by comparing patient report to anthropometric and dual-energy X-ray absorptiometry (DXA) -derived variables. Methods DXA and anthropometric measures were obtained in a cross sectional sample of black HIV-infected South African men (n = 116) and women (n = 434) on ART. Self-reported information on fat gain or fat loss was collected using a standard questionnaire. Receiver operating characteristic (ROC) curves were used to describe the performance of anthropometric and DXA-derived variables using patient reported lipoatrophy and lipohypertrophy as the reference standard. Results Lipoatrophy and lipohypertrophy were more common in women (25% and 33% respectively) than in men (10% and 13% respectively). There were insufficient numbers of men with DXA scans for meaningful analysis. The best predictors of lipoatrophy in women were the anthropometric variables tricep (AUC = 0.725) and thigh skinfold (AUC =0.720) thicknesses; and the DXA-derived variables percentage lower limb fat (AUC = 0.705) and percentage lower limb fat/height (AUC = 0.713). The best predictors of lipohypertrophy in women were the anthropometric variable waist/hip ratio (AUC = 0.645) and the DXA-derived variable percentage trunk fat/percentage limb fat (AUC = 0.647). Conclusions We were able to develop simple, anthropometric measures for defining lipoatrophy and lipohypertrophy, using a sample of black HIV-infected South African women with DXA scans. This is of particular relevance in resource limited settings, where health professionals need simple and inexpensive methods of diagnosing patients with lipoatrophy and lipohypertrophy.
Open Access
Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services
(2002) Nthangeni, Gladys; Steyn, Nelia P; Alberts, Marianne; Steyn, Krisela; Levitt, Naomi S; Laubscher, Ria; Bourne, Lesley; Dick, Judy; Temple, Norman
OBJECTIVE: To determine the dietary intake, practices, knowledge and barriers to dietary compliance of black South African type 2 diabetic patients attending primary health-care services in urban and rural areas. DESIGN: A cross-sectional survey. Dietary intake was assessed by three 24-hour recalls, and knowledge and practices by means of a structured questionnaire (n = 133 men, 155 women). In-depth interviews were then conducted with 25 of the patients to explore their underlying beliefs and feelings with respect to their disease. Trained interviewers measured weight, height and blood pressure. A fasting venous blood sample was collected from each participant in order to evaluate glycaemic control. SETTING: An urban area (Sheshego) and rural areas near Pietersburg in the Northern Province of South Africa. SUBJECTS: The sample comprised 59 men and 75 women from urban areas and 74 men and 80 women from rural areas. All were over 40 years of age, diagnosed with type 2 diabetes for at least one year, and attended primary health-care services in the study area over a 3-month period in 1998. RESULTS: Reported dietary results indicate that mean energy intakes were low (< 70% of Recommended Dietary Allowance), 8086-8450 kJ day(-1) and 6967-7382 kJ day(-1) in men and women, respectively. Urban subjects had higher (P < 0.05) intakes of animal protein and lower ratios of polyunsaturated fat to saturated fat than rural subjects. The energy distribution of macronutrients was in line with the recommendations for a prudent diet, with fat intake less than 30%, saturated fat less than 10% and carbohydrate intake greater than 55% of total energy intake. In most respects, nutrient intakes resembled a traditional African diet, although fibre intake was low in terms of the recommended 3-6 g/1000 kJ. More than 90% of patients ate three meals a day, yet only 32-47% had a morning snack and 19-27% had a late evening snack. The majority of patients indicated that they followed a special diet, which had been given to them by a doctor or a nurse. Only 3.4-6.1% were treated by diet alone. Poor glycaemic control was found in both urban and rural participants, with more than half of subjects having fasting plasma glucose above 8 mmol l(-1) and more than 35% having plasma glycosylated haemoglobin level above 8.6%. High triglyceride levels were found in 24 to 25% of men and in 17 to 18% of women. Obesity (body mass index > or = 30 kg m(-2)) was prevalent in 15 to 16% of men compared with 35 to 47% of women; elevated blood pressure (> or = 160/95 mmHg) was least prevalent in rural women (25.9%) and most prevalent in urban men (42.4%). CONCLUSIONS: The majority of black, type 2 diabetic patients studied showed poor glycaemic control. Additionally, many had dyslipidaemia, were obese and/or had an elevated blood pressure. Quantitative and qualitative findings indicated that these patients frequently received incorrect and inappropriate dietary advice from health educators.
Open Access
Efficacy of a text messaging (SMS) based intervention for adults with hypertension: protocol for the StAR (SMS Text-message Adherence suppoRt trial) randomised controlled trial
(2014-01-11) Bobrow, Kirsty; Brennan, Thomas; Springer, David; Levitt, Naomi S; Rayner, Brian; Namane, Mosedi; Yu, Ly-Mee; Tarassenko, Lionel; Farmer, Andrew
Abstract Background Interventions to support people with hypertension in attending clinics and taking their medication have potential to improve outcomes, but delivery on a wide scale and at low cost is challenging. Some trials evaluating clinical interventions using short message service (SMS) text-messaging systems have shown important outcomes, although evidence is limited. We have developed a novel SMS system integrated with clinical care for use by people with hypertension in a low-resource setting. We aim to test the efficacy of the system in improving blood pressure control and treatment adherence compared to usual care. Methods/design The SMS Text-message Adherence suppoRt trial (StAR) is a pragmatic individually randomised three-arm parallel group trial in adults treated for hypertension at a single primary care centre in Cape Town, South Africa. The intervention is a structured programme of clinic appointment, medication pick-up reminders, medication adherence support and hypertension-related education delivered remotely using an automated system with either informational or interactive SMS text-messages. Usual care is supplemented by infrequent non-hypertension related SMS text-messages. Participants are 1:1:1 individually randomised, to usual care or to one of the two active interventions using minimisation to dynamically adjust for gender, age, baseline systolic blood pressure, years with hypertension, and previous clinic attendance. The primary outcome is the change in mean systolic blood pressure at 12-month follow-up from baseline measured with research staff blinded to trial allocation. Secondary outcomes include the proportion of patients with 80% or more of days medication available, proportion of participants achieving a systolic blood pressure less than 140 mmHg and a diastolic blood pressure less than 90 mmHg, hospital admissions, health status, retention in clinical care, satisfaction with treatment and care, and patient related quality of life. Anonymised demographic data are collected on non-participants. Discussion The StAR trial uses a novel, low cost system based on widely available mobile phone technology to deliver the SMS-based intervention, manage communication with patients, and measure clinically relevant outcomes. The results will inform implementation and wider use of mobile phone based interventions for health care delivery in a low-resource setting. Trial registration NCT02019823
Open Access
Evidence insufficient to confirm the value of population screening for diabetes and hypertension in low- and-middle-income settings
(2015) Durao, Solange; Ajumobi, Oluwayemisi; Kredo, Tamara; Naude, Celeste; Levitt, Naomi S; Steyn, Krisela; Bradshaw, Debbie; Young, Taryn
To assess the evidence from systematic reviews on the effect on morbidity and mortality of blanket screening for hypertension or diabetes mellitus compared with targeted, opportunistic or no screening, we searched for relevant systematic reviews and conducted duplicate study selection, data extraction and quality appraisal. Results were summarised narratively. We included two completed reviews of moderate quality and one ongoing Cochrane review. In one completed review, general health checks had no effect on total morbidity or mortality or on healthcare services compared with no health checks. In the other, intensive hypertension screening methods were ineffective in increasing screening uptake or detecting new cases compared with less intensive methods. Both reviews included studies in high-income settings. There is insufficient evidence from currently available systematic reviews to confirm a beneficial effect of blanket screening for hypertension and/or diabetes compared with other types of screening methods in low- and middle-income settings. Scarce resources are being mobilised to implement mass screening intervention for diabetes and hypertension without adequate evidence of its effects. A systematic review is needed to assess clinical effectiveness, cost-effectiveness and overall impact on the health system of screening strategies, especially in low- and middle-income settings such as exist in South Africa. Robust evaluation of these outcomes would then be necessary to inform secondary prevention strategies.
Open Access
Excessive weight gain following therapy for hyperthyroidism - a major problem
(Health and Medical Publishing Group, 2003) Ross, Ian Louis; Levitt, Naomi S
One of the most characteristic presenting features of hyperthyroidism is weight loss, despite an increased appetite. This phenomenon is easily understandable, as hyperthyroidism is accompanied by a rise in metabolic rate, energy expenditure and thermogenesis which is clearly not matched by an increased appetite and caloric intake in the vast majority of patients. Consequently a decrease in adipose tissue and muscle results. (Curiously a small proportion of hyperthyroid patients, fewer than 10%, present with weight gain owing to an increased appetite that exceeds the rise in metabolic rate.