The prevalence of metabolic syndrome among Ghanaian migrants and their homeland counterparts: the Research on Obesity and type 2 Diabetes among African Migrants (RODAM) study

Background

Metabolic syndrome (MetSyn) is an important risk factor for cardiovascular diseases and type 2 diabetes. It is unknown whether the MetSyn prevalence differs within a homogenous population residing in different settings in Africa and Europe. We therefore assessed the prevalence of MetSyn among Ghanaians living in rural- and urban-Ghana and Ghanaian migrants living in Europe.

Methods

We used data from the cross-sectional multi-centre RODAM study that was conducted among Ghanaian adults aged 25–70 years residing in rural- and urban-Ghana and in London, Amsterdam and Berlin (n = 5659). MetSyn was defined according to the 2009 harmonized definition. Geographical locations were compared using age-standardized prevalence rates, and prevalence ratios (PRs), adjusted for age, education, physical activity, and smoking and stratified for sex.

Results

In men, the age-standardized prevalence of MetSyn was 8.3% in rural Ghana and showed a positive gradient through urban Ghana (23.6%, adjusted PR = 1.85, 95% confidence interval 1.17–2.92) to Europe, with the highest prevalence in Amsterdam (31.4%; PR = 4.45, 2.94–6.75). In women, there was a rural-to-urban gradient in age-standardized MetSyn prevalence (rural Ghana 25%, urban Ghana 34.4%, PR = 1.38, 1.13–1.68), but small differences in MetSyn prevalence between urban-Ghanaian and European-Ghanaian women (Amsterdam 38.4%; London 38.2%).

Conclusion

MetSyn is highly prevalent in Ghana as well as in Ghanaian migrants in Europe. To assist prevention efforts, further research is needed to understand the mechanisms driving the geographical differences in MetSyn prevalence between migrant and non-migrant Ghanaians.

Hypertension prevalence, awareness, treatment, and control in Surinamese living in Suriname and The Netherlands: the HELISUR and HELIUS studies

We studied hypertension prevalence, awareness, treatment, and control among persons living in a middle-income country compared with those of similar ethnicity living in a high-income country. Data from the cross-sectional HELISUR and HELIUS studies were used among 1000 Surinamese and 6971 Surinamese migrants living in The Netherlands (18-70 years), respectively. Groups were formed based on country and self-defined ethnicity, and stratified by sex. Age-adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated for hypertension prevalence, awareness, treatment, and control. Subsequently, we focused on hypertension prevalence and adjusted for risk factors for hypertension: BMI and waist circumference (model 2), educational level, physical activity, and smoking (model 3). After adjustment for age, no significant differences in hypertension prevalence, awareness, treatment, and control between countries were seen in men. However, women in Suriname were more often hypertensive with lower levels of awareness and control than those in The Netherlands (African: OR 1.54 [95% CI 1.19, 2.00]; South-Asian: 1.90 [1.35, 2.67]; awareness: 0.62 [0.43, 0.88] in African women; control: 0.48 [0.28, 0.84] in South-Asian women). Higher hypertension prevalence was explained by differences in BMI and waist circumference in African women (adjusted OR 1.26 [0.96, 1.65]) and by education, physical activity, and smoking in South-Asian women (adjusted OR 1.29 [0.87, 1.89]). Particularly, women in Suriname bear a relatively high hypertension burden with lower levels of awareness and control. As the higher hypertension prevalence was mainly explained by lifestyle-related risk factors, health promotion interventions may reduce the hypertension burden in Suriname.

Developing a literature-based systems map of determinants of dietary intake in low-income groups

Background

Inequalities in obesity and related non-communicable diseases pertain in part to less healthy dietary intake in disadvantaged groups. Examining determinants of intake as a complex adaptive system - i.e. interconnected determinants exerting non-linear influence on outcomes - honours the complexity of dietary choices, behaviours and intake, and could inform policies. This study used literature to map the complex system underlying dietary intake in low-income groups, to identify system structure and goals perpetuating poorer dietary outcomes.

Methods

A systematic umbrella literature review examined determinants of dietary outcomes in children, adolescents and adults. Inclusion criteria were: • Low-income sample; analysis by income (Non-)systematic review of quantitative/qualitative, observational/intervention studiesHigher/upper-middle-income countriesExposures: individual, sociocultural, physical, political determinants/correlates; effect modifiers

Excluded outcomes were: breastfeeding, alcohol and neophobia.

Using causal loop diagramming, extracted data on determinants, associations and interpretation were embedded in a systems map of mechanisms driving dietary intake. System structure (e.g. sub-systems) and goals (e.g. feedback loops) were analysed.

Results

A systems map of hypothesised mechanisms driving dietary intake in low-income groups was developed from 43 reviews and expert consensus. The system comprised sub-systems: 1) accessibility, 2) household resources, 3) financial constraints, 4) health/biology, 5) knowledge, attitudes and beliefs, 6) sociocultural influences. Identified sub-system goals could undermine healthy intake opportunities, e.g. energy-dense food choices for cost-efficiency, heightened exposure to energy-dense foods determining preferences.

Conclusions

The literature-based systems map articulates the systemic basis of poorer dietary outcomes in low-income groups. Understanding system structure and goals will inform equitable policy.

Key messages

Dietary intake in low-income groups is driven by a complex system of mechanisms which may perpetuate poorer dietary outcomes. Existing literature was synthesised as a systems map; identification of structures and goals of the system can inform health equity policies.

Social norms and obesity prevalence: From cohort to system dynamics models

Group-level obesity can be seen as an emergent property of a complex system, consisting of feedback loops between individual body weight perception, individual weight-related behaviour and group-level social norms (a product of group-level 'normal' body mass index (BMI) and sociocultural 'ideal' BMI). As overweight becomes normal, the norm might be counteracting health awareness in shaping individual weight-related behaviour. System dynamics modelling facilitates understanding and simulating this system's emergent behaviour. We constructed six system dynamics models (SDMs) based on an expert-informed causal loop diagram and data from six sociocultural groups (Dutch, Moroccan and South-Asian Surinamese men and women). The SDMs served to explore the effect of three scenarios on group-level BMI: 'what if' weight-related behaviour were driven by (1) health awareness, (2) norms or (3) a combination of the two. Median BMI decreased approximately 50% and 30% less in scenarios 2 and 3, respectively, than in 1. In men, the drop in BMI was approximately two times larger in scenario 1 versus 3, whereas in women, the drop was approximately equal in these scenarios. This study indicates that the overweight norm in men holds group-level BMI close to overweight despite health awareness. Since norms are counteracting health awareness less strongly in women, other drivers of obesity must be more relevant.

The Multifaceted Pathways Linking Populism to Ethnic Minority Health Comment on "A Scoping Review of Populist Radical Right Parties’ Influence on Welfare Policy and its Implications for Population Health in Europe"

Based on a scoping review of empirical studies accompanied by interviews with experts, Rinaldi and Bekker studied the impact of populist radical right (PRR) parties on access to welfare provisions – the latter standing proxy for population health and for health inequalities in particular. We argue that populism can impact on migrant and ethnic minority health in multiple ways, in addition to the welfare mechanism specified in that review. These include institutionalised discrimination affecting individuals’ positions in the social hierarchy, experiences of discrimination in interpersonal relationships, and a weakened legitimacy of health policies. Interdisciplinary teams that include public health scholars and political scientists should take up the challenge of understanding migrant and ethnic minority health from a systems perspective.

Growth patterns from birth to overweight at age 5-6 years of children with various backgrounds in socioeconomic status and country of origin: the ABCD study

INTRODUCTION

Children from minority groups are at increased risk of overweight. This study compared BMI growth patterns from birth onwards of boys and girls with overweight at 5-6 years, according to socioeconomic status (SES) and country of origin, in order to gain more insight into the critical periods of growth to overweight.

METHODS

A total of 3714 singletons of the multi-ethnic ABCD study were included. Within children with overweight at age 5-6 years (N = 487, prevalence boys: 11.6%, girls: 14.6%), BMI growth patterns from birth onwards (12.8 serial measurements; SD = 3.1) were compared between children from European (69.4%) and non-European mothers (30.6%), and between children from low (20.8%), mid (37.0%) or high SES (42.2%), based on maternal educational level.

RESULTS

BMI growth to overweight did not differ between children of European or non-European mothers, but it did differ according to maternal SES. Children with overweight in the low and mid SES group had a lower BMI in the first 2 years of life, an earlier adiposity rebound and increased in BMI more rapidly after age 2, resulting in a higher BMI at age 7 years compared to children with overweight in the high SES group [∆BMI (kg/m2 ) between high and low SES: boys 1.43(95%CI:0.16;3.01) and girls 1.91(0.55;3.27)].

CONCLUSION

Children with overweight from low SES have an early adiposity rebound and accelerated growth to a higher BMI at age 5-6 years compared to children with overweight from the high SES group. These results imply that timing of critical periods for overweight development is earlier in children with a low socioeconomic background as compared to other children.

A System Dynamics and Participatory Action Research Approach to Promote Healthy Living and a Healthy Weight among 10-14-Year-Old Adolescents in Amsterdam: The LIKE Programme

This paper describes the design of the LIKE programme, which aims to tackle the complex problem of childhood overweight and obesity in 10–14-year-old adolescents using a systems dynamics and participatory approach. The LIKE programme focuses on the transition period from 10-years-old to teenager and was implemented in collaboration with the Amsterdam Healthy Weight Programme (AHWP) in Amsterdam-East, the Netherlands. The aim is to develop, implement and evaluate an integrated action programme at the levels of family, school, neighbourhood, health care and city. Following the principles of Participatory Action Research (PAR), we worked with our population and societal stakeholders as co-creators. Applying a system lens, we first obtained a dynamic picture of the pre-existing systems that shape adolescents’ behaviour relating to diet, physical activity, sleep and screen use. The subsequent action programme development was dynamic and adaptive, including quick actions focusing on system elements (quick evaluating, adapting and possibly catalysing further action) and more long-term actions focusing on system goals and/or paradigm change. The programme is supported by a developmental systems evaluation and the Intervention Level Framework, supplemented with routinely collected data on weight status and health behaviour change over a period of five years. In the coming years, we will report how this approach has worked to provide a robust understanding of the programme’s effectiveness within a complex dynamic system. In the meantime, we hope our study design serves as a source of inspiration for other public health intervention studies in complex systems.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Associations Between Child Maltreatment, Autonomic Regulation, and Adverse Cardiovascular Outcome in an Urban Population: The HELIUS Study

INTRODUCTION

A mounting body of literature emphasizes the potential negative effects of adverse childhood experiences (ACEs) on both mental and physical health throughout life, including an increased risk for developing cardiovascular disease (CVD). Since CVD is one of the leading causes of mortality and morbidity worldwide, it is of great importance to advance our understanding of the effects of on CVD. This holds both for the actual incidence and for intermediate biological pathways that may convey CVD risk, such as imbalance in autonomic nervous system regulation, resulting in a chronically heightened sympathetic activity and lowered reactivity. In a large urban, multi-ethnic population-based cohort study we investigated whether there is an association between child maltreatment, CVD incidence and autonomic regulation.

METHODS

Within the Health in an Urban Setting (HELIUS) study, a large, multi-ethnic population cohort study including n = 22,165 Amsterdam residents, we used logistic regression analyses to investigate the association between the number of self-reported types of child maltreatment (range 0-4), and self-reported adverse cardiovascular outcome (aCVO). Self-reported child maltreatment included emotional neglect, emotional abuse, physical abuse, and sexual abuse. Furthermore, in a subsample (n = 10,260), mean age 44.3, we investigated associations between child maltreatment, autonomic regulation, and aCVO using linear regression analyses. Both baroreflex sensitivity (BRS) and heart rate variability (HRV) were assessed as non-invasive indices of autonomic regulation.

RESULTS

The number of endorsed child maltreatment types was significantly associated with a higher aCVO risk. The association remained significant after adjustment for demographic, socioeconomic, health-behavioral, and psychological covariates (p = 0.011, odds ratio: 1.078, confidence interval: 1.018-1.142). The cumulative exposure to child maltreatment was negatively associated with BRS and HRV, but the association was no longer significant after correction for socioeconomic and demographic covariates.

CONCLUSION

In a large, multi-ethnic urban-population cohort study we observed a positive association between number of endorsed child maltreatment types and self-reported aCVO but not autonomic regulation, over and above the effect of relevant demographic, health, and psychological factors. Future studies should examine the potential role of the dynamics of autonomic dysregulation as potential underlying biological pathways in the association between ACEs and CVD, as this could eventually facilitate the development of preventive and therapeutic strategies for CVD.

Acculturation and Food Intake Among Ghanaian Migrants in Europe: Findings From the RODAM Study

OBJECTIVE

This study examined the role of migration and acculturation in the diet of Ghanaian migrants in Europe by (1) comparing food intake of Ghanaian migrants in Europe with that of Ghanaians living in Ghana and (2) assessing the association between acculturation and food intake.

DESIGN

Data from the cross-sectional multicenter study Research on Obesity and Diabetes among African Migrants were used. Food intake was assessed using a Ghana-specific food propensity questionnaire (134 items and 14 food groups); foods were grouped based on a model of dietary change proposed by Koctürk-Runefors.

SETTING

Ghana, London, Amsterdam, and Berlin.

PARTICIPANTS

A total of 4,534 Ghanaian adults living in Ghana and Europe, with complete dietary data. Of these, 1,773 Ghanaian migrants had complete acculturation data.

MAIN OUTCOME MEASURE

Food intake (the weighted intake frequency per week of food categories).

ANALYSIS

Linear regression.

RESULTS

Food intake differed between Ghanaians living in Ghana and Europe. Among Ghanaian migrants in Europe, there were inconsistent and small associations between acculturation and food intake, except for ethnic identity, which was consistently associated with intake only of traditional staples.

CONCLUSIONS AND IMPLICATIONS

Findings indicate that migration is associated with dietary changes that cannot be fully explained by ethnic, cultural, and social acculturation. The study provides limited support to the differential changes in diet suggested by the Koctürk-Runefors' model of dietary change.

Differential associations between psychosocial stress and obesity among Ghanaians in Europe and in Ghana: findings from the RODAM study

PURPOSE

Psychosocial stress is associated with obesity in some populations, but it is unclear whether the association is related to migration. This study explored associations between psychosocial stress and obesity among Ghanaian migrants in Europe and non-migrant Ghanaians in Ghana.

METHODS

Cross-sectional data from the RODAM study were used, including 5898 Ghanaians residing in Germany, the UK, the Netherlands, rural Ghana, and urban Ghana. Perceived discrimination, negative life events and stress at work or at home were examined in relation to body mass index (BMI) and waist circumference (WC). Linear regression analyses were performed separately for migrants and non-migrants stratified by sex.

RESULTS

Perceived discrimination was not associated with BMI and WC in both migrants and non-migrants. However, negative life events were positively associated with BMI (β = 0.78, 95% CI 0.34-1.22) and WC (β = 1.96, 95% CI 0.79-3.12) among male Ghanaian migrants. Similarly, stress at work or at home was positively associated with BMI (β = 0.28, 95% CI 0.00-0.56) and WC (β = 0.84, 95% CI 0.05-1.63) among male Ghanaian migrants. Among non-migrant Ghanaians, in contrast, stress at work or at home was inversely associated with BMI and WC in both males (β = - 0.66, 95% CI - 1.03 to - 0.28; β = - 1.71 95% CI - 2.69 to - 0.73, respectively) and females (β = - 0.81, 95% CI - 1.20 to - 0.42; β = - 1.46, 95% CI - 2.30 to - 0.61, respectively).

CONCLUSIONS

Negative life events and stress at work or at home are associated with increased body weight among male Ghanaians in European settings, whereas stress at work or at home is associated with reduced body weight among Ghanaians in Ghana. More work is needed to understand the underlying factors driving these differential associations to assist prevention efforts.

Higher prevalence of peripheral arterial disease in Ghana compared to Ghanaian migrants in Europe: The RODAM study

BACKGROUND

Evidence suggests that the burden of peripheral artery disease (PAD) is rising more rapidly than other forms of cardiovascular diseases in sub-Saharan Africa, but the extent to which they differ between rural and urban settings in Africa and upon migration to Europe is unknown. We assessed the burden of PAD among Ghanaians living in rural- and urban-Ghana and Ghanaian migrants living in three European countries.

METHODS

Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes among African Migrants (RODAM) study were done. Data from 5516 participants living in Europe (1487 Amsterdam, 546 Berlin, 1047 London) and Ghana [1419 urban and 1017 rural] aged 25-70years were included. PAD was defined as ankle brachial index≤0.90. Comparisons among sites were made using logistic regression analysis.

RESULTS

The age-standardized prevalence of PAD was higher in Ghanaians living in rural [7.52%, 95% CI = 5.87-9.51] and urban [8.93%, 7.44-10.64] Ghana than for their compatriots living in Europe [5.70%, 4.35-7.35 for London; 3.94%, 2.96-5.14 for Amsterdam; and 0.44%, 0.05-1.58 for Berlin]. The differences persisted even after adjustment for age, sex, education and the conventional cardiovascular risk factors [adjusted odds ratio = 3.16, 95% CI = 2.16-4.61, p < .001 for rural-Ghana; and 2.93, 1.87-4.58, p < .00 for urban-Ghana, compared with Ghanaian migrants in Europe].

CONCLUSIONS

Our study shows that Ghanaians living in Ghana have higher prevalence of PAD than their migrant compatriots. Further work is needed to identify potential factors driving the high prevalence of PAD among non-migrant Ghanaians to assist interventions aimed at reducing PAD burden.

Differential item functioning analysis of the CUDIT and relations with alcohol and tobacco use among men across five ethnic groups: The HELIUS study

Cannabis use has been rising despite recognition of the negative consequences associated with heavy use. The severity of these consequences has been shown to differ across racial/ethnic groups, even when controlling for consumption levels. The present study conducted an item response theory (IRT) analysis of the Cannabis Use Disorders Identification Test (CUDIT) to better understand the patterns of problematic cannabis use and their relation with other substance use across ethnic groups in the Healthy Life in an Urban Setting (HELIUS) study. CUDIT responses from 1,960 cannabis-using African Surinamese, South-Asian Surinamese, Dutch, Moroccan, and Turkish ethnic origin participants were used to test for differential item functioning (DIF) within an IRT framework. After restricting the sample to men because of low frequency of use among women, several instances of uniform DIF were identified. Multiple-group IRT analysis yielded a harmonized cannabis use phenotype that was used to estimate ethnic group differences in problematic cannabis use and its relation to alcohol and tobacco co-use. These analyses suggested that cannabis users from certain ethnic minority groups experienced higher rates of problematic use than the majority group despite lower rates of cannabis use. Further, cannabis and tobacco use were positively related across groups, whereas only ethnic minority groups showed a positive relation between cannabis and alcohol use. These results demonstrate the importance of accounting for DIF when examining group differences in problematic cannabis use, and support prior evidence suggesting that certain ethnic minority groups may be more likely to experience problematic cannabis use and alcohol co-use relative to the majority group. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Chronic kidney disease burden among African migrants in three European countries and in urban and rural Ghana: the RODAM cross-sectional study

Background

Chronic kidney disease (CKD) is a major burden among sub-Saharan African (SSA) populations. However, differences in CKD prevalence between rural and urban settings in Africa, and upon migration to Europe are unknown. We therefore assessed the differences in CKD prevalence among homogenous SSA population (Ghanaians) residing in rural and urban Ghana and in three European cities, and whether conventional risk factors of CKD explained the observed differences. Furthermore, we assessed whether the prevalence of CKD varied among individuals with hypertension and diabetes compared with individuals without these conditions.

Methods

For this analysis, data from Research on Obesity & Diabetes among African Migrants (RODAM), a multi-centre cross-sectional study, were used. The study included a random sample of 5607 adult Ghanaians living in Europe (1465 Amsterdam, 577 Berlin, 1041 London) and Ghana (1445 urban and 1079 rural) aged 25-70 years. CKD status was defined according to severity of kidney disease using the combination of glomerular filtration rate (G1-G5) and albuminuria (A1-A3) levels as defined by the 2012 Kidney Disease: Improving Global Outcomes severity classification. Comparisons among sites were made using logistic regression analysis.

Results

CKD prevalence was lower in Ghanaians living in Europe (10.1%) compared with their compatriots living in Ghana (13.3%) even after adjustment for age, sex and conventional risk factors of CKD [adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.56-0.88, P = 0.002]. CKD prevalence was markedly lower among Ghanaian migrants with hypertension (adjusted OR = 0.54, 0.44-0.76, P = 0.001) and diabetes (adjusted OR = 0.37, 0.22-0.62, P = 0.001) compared with non-migrant Ghanaians with hypertension and diabetes. No significant differences in CKD prevalence was observed among non-migrant Ghanaians and migrant Ghanaians with no hypertension and diabetes. Among Ghanaian residents in Europe, the odds of CKD were lower in Amsterdam than in Berlin, while among Ghanaian residents in Ghana, the odds of CKD were lower in rural Ghana (adjusted OR = 0.68, 95% CI 0.53-0.88, P = 0.004) than in urban Ghana, but these difference were explained by conventional risk factors.

Conclusion

Our study shows important differences in CKD prevalence among Ghanaians living in Europe compared with those living in Ghana, independent of conventional risk factors, with marked differences among those with hypertension and diabetes. Further research is needed to identify factors that might explain the observed difference across sites to implement interventions to reduce the high burden of CKD, especially in rural and urban Ghana.

Illness representations and coping practices for self-managing hypertension among sub-Saharan Africans: A comparative study among Ghanaian migrants and non-migrant Ghanaians

OBJECTIVE

Hypertension (HTN) control is a major obstacle among sub-Saharan African populations partly due to poor self-management. We explored and compared how persons' social and physical context shapes their illness representations regarding HTN and the coping strategies they develop and adapt to mitigate challenges in self-managing HTN.

METHODS

A cross sectional multisite qualitative study using semi-structured interviews among 55 Ghanaians with HTN living in The Netherlands and urban and rural Ghana. A thematic approach was used in data analysis.

RESULTS

Family HTN history, personal experiences with HTN and outcomes of using biomedical and traditional treatments shaped participants' illness representations and coping strategies. Migrants and urban non-migrants modified medication schedules and integrated taking medication into daily routine activities to cope with experienced side effects of taking antihypertensive medication while rural non-migrants used traditional remedies and medicines to mitigate experienced medication side effects and/or in search for a cure for HTN.

CONCLUSION

Contextual factors within participants' social and physical environments shape their illness representations and coping strategies for HTN though interactive phrases.

PRACTICE IMPLICATIONS

Health professionals should harness the relationships within peoples' social and physical environments, encourage implementation of family-wide behavioural changes and involve family and communities in HTN treatment to enhance patients' self-management of HTN.

Is social support associated with hypertension control among Ghanaian migrants in Europe and non-migrants in Ghana? The RODAM study

Hypertension (HTN) control is crucial in preventing HTN-related complications such as stroke and coronary heart disease. Yet, HTN control remains suboptimal particularly among sub-Saharan African (SSA) populations partly due to poor self-management. Self-management of HTN is influenced by social support, but the evidence on the role of social support on HTN control particularly among SSA populations is limited. This study assessed the association between multiple proxies for social support and HTN control among Ghanaians resident in Ghana and Europe. The Research on Obesity and Diabetes among African Migrants (RODAM) study participants with HTN and who self-reported HTN (n = 1327) were included in this analysis. Logistic regression was used to assess the association between proxies of social support and HTN control (SBP < 140 mmHg and DBP < 90 mmHg) with adjustments for age and socioeconomic status (SES). Among Ghanaian males in both Europe and Ghana, cohabiting with more than two persons was associated with increased odds of having HTN controlled. Male hypertensive patients cohabiting with ≥ 5 persons had the highest odds of having HTN controlled after adjustment for age and SES (OR 0.30; 95% CI 0.16-0.57; 0.60; 0.34-1.04, respectively). This association was not observed among females. Relationship status, frequency of religious activity attendance and satisfaction with social support did not show any significant association with HTN control. Our study shows that cohabitation is significantly associated with HTN control but in males only. The other proxies for social support appeared not to be associated with HTN control. Involving persons living with Ghanaian men with HTN in the treatment process may help to improve adherence to HTN treatment. Further research is needed to explore in-depth, how these social support proxies could contribute to improved HTN control among SSA populations.

Cross-sectional study of association between psychosocial stressors with chronic kidney disease among migrant and non-migrant Ghanaians living in Europe and Ghana: the RODAM study

OBJECTIVES

The association between psychosocial stressors (PS) and chronic kidney disease (CKD) among sub-Saharan African (SSA) populations is unknown. We examined the association between PS and CKD prevalence among rural and urban Ghanaians and Ghanaian migrants living in three European cities. We also assessed if the influence of PS on CKD is partially mediated by primary risk factors (hypertension and diabetes) of CKD.

DESIGN

A multi-centred cross sectional data from the Research on Obesity and Diabetes among African Migrants study.

SETTING

Rural and urban Ghana and three European cities (Amsterdam, Berlin and London).

PARTICIPANTS

A random sample of 5659 adults (Europe 3167, rural Ghana 1043 and urban Ghana 1449) aged 25-70 years.

EXPLANATORY MEASURES

PS defined by negative life events, perceived discrimination, perceived stress at work/home and depressive symptoms. Three CKD outcomes were considered using the 2012 Kidney Disease: Improving Global Outcomes severity of CKD classification. Comparisons between PS and CKD outcomes were made using logistic regression analyses across all sites.

RESULTS

We observed higher proportion of negative life events (68.7%) and perceived permanent stress (15.9%) among Ghanaians living in Ghana than Ghanaians living in Europe. Depressive symptoms (7.5%) and perceived discrimination (29.7%) were more common among Ghanaians living in Europe than Ghanaians living in Ghana. No significant association was observed between any of the PS constructs and CKD outcomes across sites except for positive association between stress at work/home and albuminuria (2.81, 95% CI 1.46 to 5.40) and CKD risk (2.78, 95% CI 1.43 to 5.43) among Ghanaians living in Berlin.

CONCLUSION

Our study found a positive association between stress at work/home and albuminuria and CKD risk. There was no convincing evidence of associations between the other PS constructs and the prevalence of CKD risk. Further studies are needed to identify potential factors driving the high prevalence of CKD among these populations.

Associations between healthcare consumption in country of origin and in country of residence by people with Turkish and Moroccan backgrounds living in the Netherlands: the HELIUS study

BACKGROUND

In Europe, a substantial percentage of the 22 million inhabitants with histories of migration from non-European countries utilize healthcare in their countries of origin. That could reflect avoidance of healthcare in the country of residence, but this has not been studied previously.

METHODS

We linked Dutch healthcare reimbursement data to the multi-ethnic population-based data from the HELIUS study conducted in Amsterdam. In multivariable logistic regression and negative binomial generalized estimating equation (GEE) analyses, we examined associations between healthcare use in country of origin and in country of residence by people with Turkish and with Moroccan backgrounds (N = 2920 and N = 3031, respectively) in the period 2010-15.

RESULTS

Participants with Turkish and Moroccan backgrounds who utilized healthcare one or multiple times in the country of origin (n = 1335 and n = 558, respectively) were found to be more likely, in comparison with non-users (n = 1585, n = 2473), to be frequent attenders of services by general practitioners, medical specialists and/or allied health professionals in the Netherlands [odds ratios between 1.21 (95% CI 0.91-1.60) and 3.15 (95% CI 2.38-4.16)]. GEE analyses showed similar results.

CONCLUSION

People with Turkish or Moroccan backgrounds living in the Netherlands who use healthcare in their countries of origin are more likely than non-users to be higher users of healthcare in the Netherlands. We thus found no indications for avoidance of healthcare in the country of residence.

Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials

AIMS/HYPOTHESIS

Individuals of South Asian origin have a high risk of type 2 diabetes and of dying from a diabetes-attributable cause. Lifestyle modification intervention trials to prevent type 2 diabetes in high-risk South Asian adults have suggested more modest effects than in European-origin populations. The strength of the evidence of individual studies is limited, however. We performed an individual participant data meta-analysis of available RCTs to assess the effectiveness of lifestyle modification in South Asian populations worldwide.

METHODS

We searched PubMed, EMBASE, Cochrane Library and Web of Science (to 24 September 2018) for RCTs on lifestyle modification interventions incorporating diet and/or physical activity in South Asian adults. Reviewers identified eligible studies and assessed the quality of the evidence. We obtained individual participant data on 1816 participants from all six eligible trials (four from Europe and two from India). We generated HR estimates for incident diabetes (primary outcome) and mean differences for fasting glucose, 2 h glucose, weight and waist circumference (secondary outcomes) using mixed-effect meta-analysis overall and by pre-specified subgroups. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence of the estimates. The study is registered with the International Prospective Register of Systematic Reviews ([PROSPERO] CRD42017078003).

RESULTS

Incident diabetes was observed in 12.6% of participants in the intervention groups and in 20.0% of participants in the control groups. The pooled HR for diabetes incidence was 0.65 (95% CI 0.51, 0.81; I² = 0%) in intervention compared with control groups. The absolute risk reduction was 7.4% (95% CI 4.0, 10.2), with no interactions for the pre-specified subgroups (sex, BMI, age, study duration and region where studies were performed). The quality of evidence was rated as moderate. Mean difference for lifestyle modification vs control groups for 2 h glucose was -0.34 mmol/l (95% CI -0.62, -0.07; I² = 50%); for weight -0.75 kg (95% CI -1.34, -0.17; I² = 71%) and for waist -1.16 cm (95% CI -2.16, -0.16; I² = 75%). No effect was found for fasting glucose. Findings were similar across subgroups, except for weight for European vs Indian studies (-1.10 kg vs -0.08 kg, p = 0.02 for interaction).

CONCLUSIONS/INTERPRETATION

Despite modest changes for adiposity, lifestyle modification interventions in high-risk South Asian populations resulted in a clinically important 35% relative reduction in diabetes incidence, consistent across subgroups. If implemented on a large scale, lifestyle modification interventions in high-risk South Asian populations in Europe would reduce the incidence of diabetes in these populations.

Early-life factors are associated with waist circumference and type 2 diabetes among Ghanaian adults: The RODAM Study

Early-life experiences may fuel the emergence of obesity and type 2 diabetes among African populations. We evaluated childhood socio-economic status (SES) and childhood nutritional status as risk factors for increased waist circumference and type 2 diabetes among Ghanaian adults. In the multi-center, cross-sectional Research on Obesity and Diabetes among African Migrants (RODAM) Study, we calculated associations (adjusted for demographics and lifestyle) of parental education and anthropometric markers of childhood nutrition [leg length, leg length-to-height ratio (LHR)] with waist circumference and type 2 diabetes, respectively. Among 5,575 participants (mean age: 46.2 years; 62% female), lower education of either parent (vs. higher) was consistently associated with higher waist circumference (∆: 1.6-3.4 cm). Lower father's education tended to increase the odds of type 2 diabetes by 50% in women (95% confidence interval (CI): 1.0, 2.4). Reduced leg length and LHR were associated with higher waist circumference. But only in men, leg length was inversely related to type 2 diabetes (OR per 1 standard deviation decrease: 1.1; 95% CI: 1.0, 1.3). In this study, markers of poor childhood SES and early-life nutritional status relate to abdominal obesity in men and women and to type 2 diabetes in men. Thus, prevention efforts should start in early childhood.

Cross-sectional study of association between socioeconomic indicators and chronic kidney disease in rural-urban Ghana: the RODAM study

OBJECTIVES

Studies from high-income countries suggest higher prevalence of chronic kidney disease (CKD) among individuals in low socioeconomic groups. However, some studies from low/middle-income countries show the reverse pattern among those in high socioeconomic groups. It is unknown which pattern applies to individuals living in rural and urban Ghana. We assessed the association between socioeconomic status (SES) indicators and CKD in rural and urban Ghana and to what extent the higher SES of people in urban areas of Ghana could account for differences in CKD between rural and urban populations.

SETTING

The study was conducted in Ghana (Ashanti region). We used baseline data from a multicentre Research on Obesity and Diabetes among African Migrants (RODAM) study.

PARTICIPANTS

The sample consisted of 2492 adults (Rural Ghana, 1043, Urban Ghana, 1449) aged 25-70 years living in Ghana.

EXPOSURE

Educational level, occupational level and wealth index.

OUTCOME

Three CKD outcomes were considered using the 2012 Kidney Disease: Improving Global Outcomes severity of CKD classification: albuminuria, reduced glomerular filtration rate and high to very high CKD risk based on the combination of these two.

RESULTS

All three SES indicators were not associated with CKD in both rural and urban Ghana after age and sex adjustment except for rural Ghana where high wealth index was significantly associated with higher odds of reduced estimated glomerular filtration rate (eGFR) (adjusted OR, 2.38; 95% CI 1.03 to 5.47). The higher rate of CKD observed in urban Ghana was not explained by the higher SES of that population.

CONCLUSION

SES indicators were not associated with prevalence of CKD except for wealth index and reduced eGFR in rural Ghana. Consequently, the higher SES of urban Ghana did not account for the increased rate of CKD among urban dwellers suggesting the need to identify other factors that may be driving this.

Neighbourhood characteristics and prevalence and severity of depression: pooled analysis of eight Dutch cohort studies

BACKGROUND

Studies on neighbourhood characteristics and depression show equivocal results.AimsThis large-scale pooled analysis examines whether urbanisation, socioeconomic, physical and social neighbourhood characteristics are associated with the prevalence and severity of depression.

METHOD

Cross-sectional design including data are from eight Dutch cohort studies (n = 32 487). Prevalence of depression, either DSM-IV diagnosis of depressive disorder or scoring for moderately severe depression on symptom scales, and continuous depression severity scores were analysed. Neighbourhood characteristics were linked using postal codes and included (a) urbanisation grade, (b) socioeconomic characteristics: socioeconomic status, home value, social security beneficiaries and non-Dutch ancestry, (c) physical characteristics: air pollution, traffic noise and availability of green space and water, and (d) social characteristics: social cohesion and safety. Multilevel regression analyses were adjusted for the individual's age, gender, educational level and income. Cohort-specific estimates were pooled using random-effects analysis.

RESULTS

The pooled analysis showed that higher urbanisation grade (odds ratio (OR) = 1.05, 95% CI 1.01-1.10), lower socioeconomic status (OR = 0.90, 95% CI 0.87-0.95), higher number of social security beneficiaries (OR = 1.12, 95% CI 1.06-1.19), higher percentage of non-Dutch residents (OR = 1.08, 95% CI 1.02-1.14), higher levels of air pollution (OR = 1.07, 95% CI 1.01-1.12), less green space (OR = 0.94, 95% CI 0.88-0.99) and less social safety (OR = 0.92, 95% CI 0.88-0.97) were associated with higher prevalence of depression. All four socioeconomic neighbourhood characteristics and social safety were also consistently associated with continuous depression severity scores.

CONCLUSIONS

This large-scale pooled analysis across eight Dutch cohort studies shows that urbanisation and various socioeconomic, physical and social neighbourhood characteristics are associated with depression, indicating that a wide range of environmental aspects may relate to poor mental health.Declaration of interestNone.

Dietary Patterns Are Associated with Predicted 10-Year Risk of Cardiovascular Disease Among Ghanaian Populations: the Research on Obesity and Diabetes in African Migrants (RODAM) Study

BACKGROUND

Sub-Saharan African populations are disproportionately affected by cardiovascular disease (CVD). Although diet is an important lifestyle factor associated with CVD, evidence on the relation between dietary patterns (DPs) and CVD risk among sub-Saharan African populations is limited.

OBJECTIVE

We assessed the associations of DPs with estimated 10-y atherosclerotic cardiovascular disease (ASCVD) risk in Ghanaian adults in Ghana and Europe.

METHODS

Three DPs ('mixed'; 'rice, pasta, meat, and fish'; and 'roots, tubers, and plantain') were derived by principal component analysis (PCA) based on intake frequencies obtained by a self-administered Food Propensity Questionnaire in the multi-center, cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study. The 10-y ASCVD risk was estimated using the Pooled Cohort Equations (PCE) for 2976 subjects, aged 40-70 y; a risk score ≥7.5% was defined as 'elevated' ASCVD risk. The associations of DPs with 10-y ASCVD risk were determined using Poisson regression with robust variance.

RESULTS

Stronger adherence to a 'mixed' DP was associated with a lower predicted 10-y ASCVD in urban and rural Ghana and a higher 10-y ASCVD in Europe. The observed associations were attenuated after adjustment for possible confounders with the exception of urban Ghana (prevalence ratio [PR] for Quintile 5 compared with 1: 0.70; 95% CI: 0.53, 0.93, P-trend = 0.013). The 'rice, pasta, meat, and fish' DP was inversely associated with 10-y ASCVD across all study sites, with the adjusted effect being significant only in urban Ghana. A 'roots, tubers, and plantain' DP was directly associated with increased 10-y ASCVD risk.

CONCLUSIONS

Adherence to 'mixed' and 'rice, pasta, meat, and fish' DPs appears to reduce predicted 10-y ASCVD risk in adults in urban Ghana. Further investigations are needed to understand the underlying contextual-level mechanisms that influence dietary habits and to support context-specific dietary recommendations for CVD prevention among sub-Saharan African populations.

Contribution of type 2 diabetes to all-cause mortality, cardiovascular disease incidence and cancer incidence in white Europeans and South Asians: findings from the UK Biobank population-based cohort study

OBJECTIVE

To investigate whether the health implications of having type 2 diabetes (T2D) were different in South Asian compared with white European participants.

RESEARCH DESIGN AND METHODS

Prospective data from UK Biobank were used, and 457 935 participants of white European and 7102 of South Asian background were included. Cox proportional regression was performed to investigate the association between T2D and health outcome by ethnicity.

RESULTS

Over a mean of 7.0 years (IQR 6.3-7.6) of follow-up, 12 974 participants had died, and 30 347 and 27 159 developed cardiovascular disease (CVD) and cancer, respectively. South Asians had a higher risk for CVD mortality (HR: 1.42, 95% CI 1.07 to 1.89) and incidence (HR: 1.78, 95% CI 1.63 to 1.94), but a decreased risk for cancer mortality (HR: 0.59, 95% CI 0.41 to 0.85) and incidence (HR: 0.80, 95% CI 0.70 to 0.92) compared with white Europeans. Compared with individuals without T2D, both white Europeans and South Asians with T2D had a higher risk for all-cause mortality (1.59 (1.48 to 1.71) vs 2.83 (1.76 to 4.53)), CVD mortality (2.04 (1.82 to 2.28) vs 4.40 (2.37 to 8.16)) and CVD incidence (1.37 (1.31 to 1.44) vs 1.60 (1.31 to 1.95)), respectively. However, the magnitude of the risk was higher for South Asians than white Europeans.

CONCLUSIONS

Although T2D was associated with a higher risk for all-cause mortality and CVD incidence and mortality, in both white Europeans and South Asians, the risk experienced by South Asians with T2D was higher than their white European counterparts.