To fast or not to fast: Lipid measurement and cardiovascular disease risk estimation in rural sub-Saharan Africa

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Abstract

Background

Cardiovascular disease (CVD) morbidity and mortality are increasing in sub-Saharan Africa (sSA), highlighting the need for tools to enable CVD risk stratification in the region. Although non-HDL-cholesterol (nHDL-C) has been promoted as a method to measure lipids without a requirement for fasting in the USA, its diagnostic validity has not been assessed in sSA. We sought to estimate: 1) the association between LDL-cholesterol (LDL-C) and nHDL-C, 2) the impact of fasting on their measurement, and 3) their correlation with carotid atherosclerosis, within a rural Ugandan population with high HIV prevalence.

Methods

We collected traditional CVD risk factors, blood for serum lipid levels, self-reported fasting status, and performed carotid ultrasonography in 301 participants in rural Uganda. We fit regression models, stratified by fasting status, to estimate associations between carotid intima media thickness (cIMT), LDL-C, and nHDL-C.

Results

Median age was 50 years (interquartile range = 46-54), 49% were female, 51% were HIV-positive, and at the time of blood collection, 70% had fasted overnight. Mean LDL-C, nHDL-C, and triglycerides in the non-fasting and fasting groups were 85 vs 88 mg/dL ( P = 0.39), 114 vs 114 mg/dL ( P = 0.98), and 130 vs 114 mg/dL ( P = 0.05) mg/dL, respectively. In unadjusted models, mean cIMT (mm) was associated with both increased LDL-C (β = 0.0078 per 10mg/dL, P < 0.01) and nHDL-C (β = 0.0075, P < 0.01), and these relationships were similar irrespective of fasting status. After adjustment for traditional CVD risk factors, we observed similar associations, albeit with muted effect sizes within the fasting group.

Conclusions

We found a high correlation between LDL-C and nHDL-C, and both were correlated with cIMT, irrespective of fasting or HIV serostatus in rural Uganda. Our findings support use of either fasting or non-fasting serum lipids for CVD risk estimation in rural sSA.

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Most cited references 40

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Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987-1993.

L E Chambless, G Heiss, A Folsom … (1997)

Few studies have determined whether greater carotid artery intima-media thickness (IMT) in asymptomatic individuals is associated prospectively with increased risk of coronary heart disease (CHD). In the Atherosclerosis Risk in Communities Study, carotid IMT, an index of generalized atherosclerosis, was defined as the mean of IMT measurements at six sites of the carotid arteries using B-mode ultrasound. The authors assessed its relation to CHD incidence over 4-7 years of follow-up (1987-1993) in four US communities (Forsyth County, North Carolina; Jackson, Mississippi; Minneapolis, Minnesota; and Washington County, Maryland) from samples of 7,289 women and 5,552 men aged 45-64 years who were free of clinical CHD at baseline. There were 96 incident events for women and 194 for men. In sex-specific Cox proportional hazards models adjusted only for age, race, and center, the hazard rate ratio comparing extreme mean IMT (> or = 1 mm) to not extreme (< 1 mm) was 5.07 for women (95% confidence interval 3.08-8.36) and 1.85 for men (95% confidence interval 1.28-2.69). The relation was graded (monotonic), and models with cubic splines indicated significant nonlinearity. The strength of the association was reduced by including major CHD risk factors, but remained elevated at higher IMT. Up to 1 mm mean IMT, women had lower adjusted annual event rates than did men, but above 1 mm their event rate was closer to that of men. Thus, mean carotid IMT is a noninvasive predictor of future CHD incidence.

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The role of carotid arterial intima-media thickness in predicting clinical coronary events.

Howard Hodis (1998)

Carotid arterial intima-media thickness is used as a noninvasive surrogate end point to measure progression of atherosclerosis, but its relation to coronary events has not been fully explored. To determine whether carotid arterial intima-media thickness predicts coronary events. Long-term follow-up (average, 8.8 years) of a previously assembled cohort of persons who completed the 2-year Cholesterol Lowering Atherosclerosis Study, a randomized arterial imaging trial designed to study the effects of lipid lowering on progression of atherosclerosis. University-based ultrasonography laboratory. 146 men 40 to 59 years of age who had previously had coronary artery bypass graft surgery. Preintrusive atherosclerosis in the common carotid artery was evaluated every 6 months with B-mode ultrasonography, and intrusive atherosclerosis in the coronary arteries was evaluated at baseline and at 2 years with quantitative coronary angiography. After the trial, the incidences of coronary events (nonfatal acute myocardial infarction, coronary death, and coronary artery revascularization) were documented. For each 0.03-mm increase per year in carotid arterial intima-media thickness, the relative risk for nonfatal myocardial infarction or coronary death was 2.2 (95% CI, 1.4 to 3.6) and the relative risk for any coronary event was 3.1 (CI, 2.1 to 4.5) (P < 0.001). Absolute intima-media thickness was also related to risk for clinical coronary events (P < 0.02). Absolute thickness and progression in thickness predicted risk for coronary events beyond that predicted by coronary arterial measures of atherosclerosis and lipid measurements (P < 0.001). Noninvasive B-mode ultrasonographic measurement of progression of intima-media thickness in the distal common carotid artery is a useful surrogate end point for clinical coronary events.

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Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach.

Elvin Geng, David R Bangsberg, Nicolas Musinguzi … (2010)

Losses to follow-up after initiation of antiretroviral therapy (ART) are common in Africa and are a considerable obstacle to understanding the effectiveness of nascent treatment programs. We sought to characterize, through a sampling-based approach, reasons for and outcomes of patients who become lost to follow-up. Cohort study. We searched for and interviewed a representative sample of lost patients or close informants in the community to determine reasons for and outcomes among lost patients. Three thousand six hundred twenty-eight HIV-infected adults initiated ART between January 1, 2004 and September 30, 2007 in Mbarara, Uganda. Eight hundred twenty-nine became lost to follow-up (cumulative incidence at 1, 2, and 3 years of 16%, 30%, and 39%). We sought a representative sample of 128 lost patients in the community and ascertained vital status in 111 (87%). Top reasons for loss included lack of transportation or money and work/child care responsibilities. Among the 111 lost patients who had their vital status ascertained through tracking, 32 deaths occurred (cumulative 1-year incidence 36%); mortality was highest shortly after the last clinic visit. Lower pre-ART CD4 T-cell count, older age, low blood pressure, and a central nervous system syndrome at the last clinic visit predicted deaths. Of patients directly interviewed, 83% were in care at another clinic and 71% were still using ART. Sociostructural factors are the primary reasons for loss to follow-up. Outcomes among the lost are heterogeneous: both deaths and transfers to other clinics were common. Tracking a sample of lost patients is an efficient means for programs to understand site-specific reasons for and outcomes among patients lost to follow-up.

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Author and article information

Journal

Journal ID (nlm-ta): J Glob Health

Journal ID (iso-abbrev): J Glob Health

Journal ID (publisher-id): JGH

Title: Journal of Global Health

Publisher: International Society of Global Health

ISSN (Print): 2047-2978

ISSN (Electronic): 2047-2986

Publication date (Print, pub): June 2020

Publication date (Electronic, pub): 17 March 2020

Volume: 10

Issue: 1

Electronic Location Identifier: 010407

Affiliations

[1 ]Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA

[2 ]Harvard Medical School, Boston, Massachusetts, USA

[3 ]Massachusetts General Hospital, Boston, Massachusetts, USA

[4 ]Brigham and Women’s Hospital, Boston, Massachusetts, USA

[5 ]Mbarara University of Science and Technology, Mbarara, Uganda

[6 ]Epicentre Research Base, Mbarara, Uganda

Author notes

Correspondence to: Isabelle T. Yang  Geisel School of Medicine 66 College Street Mailbox 128 Remsen Building Hanover, New Hampshire 03755 USA  Isabelle.T.Yang.MED@ 123456dartmouth.edu

Article

Publisher ID: jogh-10-010407

DOI: 10.7189/jogh.10.010407

PMC ID: 7101029

SO-VID: 2fab2b3e-0eb3-4978-b1c7-286a8572ad98

License:

This work is licensed under a Creative Commons Attribution 4.0 International License.

To fast or not to fast: Lipid measurement and cardiovascular disease risk estimation in rural sub-Saharan Africa

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Most cited references 40

Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987-1993.

The role of carotid arterial intima-media thickness in predicting clinical coronary events.

Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach.

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