Nigerian Journal of Cardiology

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 16  |  Issue : 1  |  Page : 83--91

Obesity, hypertension, and dyslipidemia among human immunodeficiency virus patients in Abeokuta Ogun State, Nigeria


Mayowa Aridegbe1, Ikeola Adeoye1, Ayodipupo Oguntade2,  
1 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan; Department of Medicine, University College Hospital, Ibadan, Nigeria

Correspondence Address:
Dr. Ikeola Adeoye
Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan
Nigeria

Abstract

Context: The coexistence of human immunodeficiency virus (HIV) with non communicable disease risk factors is an emerging public health problem in sub-Saharan Africa. Aims: We investigated the prevalence and risk factors of obesity, hypertension, and dyslipidemia among HIV-positive patients in Abeokuta. Settings and Design: This was a cross-sectional study done using 206 persons living with HIV in three hospitals at Abeokuta, South Western Nigeria. Subjects and Methods: The WHO stepwise interviewer-administered questionnaire was used for data collection. Specific clinical information on HIV treatment status and traditional cardiovascular risk factors were assessed. Data were analyzed using descriptive statistics, Chi-square, and multivariate logistic regression at P < 0.05. Results: The prevalence of overweight/obesity was 34.0% (95% confidence interval [CI]: 27.5–40.5); 20.9% (95% CI: 15.3–26.4) for hypertension; and 40.2% (95% CI: 33.5–47.0) for dyslipidemia. Risk factors for obesity were sedentary time (odds ratio [OR] 1.2; 95% CI: 1.0–1.3), hypertension (OR 3.0; 95% CI: 1.1–6.0), and increasing duration of HIV (OR for 2–5 years = 2.0; 95% CI: 1.0–4.1 and OR for >5 years = 3.0; 95% CI: 1.0–6.3). Age >40 years (OR 7.9; CI: 2.7–23) and CD4 level ≥ 350/μl (OR 3.9; 95% CI: 1.0–14.6) were risk factors for hypertension while female sex protected against hypertension (OR 0.2; 95% CI: 0.1–0.6). None of the measured covariates predicted dyslipidemia. Conclusion: Obesity, hypertension, and dyslipidemia are common in HIV patients in Nigeria. HIV patients would benefit from cardiovascular diseases screening programs just like the general adult population if the gains of HIV care are not to be reversed.



How to cite this article:
Aridegbe M, Adeoye I, Oguntade A. Obesity, hypertension, and dyslipidemia among human immunodeficiency virus patients in Abeokuta Ogun State, Nigeria.Nig J Cardiol 2019;16:83-91


How to cite this URL:
Aridegbe M, Adeoye I, Oguntade A. Obesity, hypertension, and dyslipidemia among human immunodeficiency virus patients in Abeokuta Ogun State, Nigeria. Nig J Cardiol [serial online] 2019 [cited 2019 Dec 13 ];16:83-91
Available from: http://www.nigjcardiol.org/text.asp?2019/16/1/83/269643


Full Text



 Introduction



Noncommunicable diseases (NCDs) have emerged as a global public health concern, with cardiovascular diseases being the lead cause of mortality (48% of NCD deaths) and about 30% of deaths worldwide.[1],[2],[3] The major drivers of the global NCD epidemic are four major behavioral risk factors (unhealthy diet, physical inactivity, cigarette smoking, and alcohol consumption) which lead to four metabolic risk factors (obesity, hypertension, hyperglycemia, and dyslipidemia). Currently, low- and middle-income countries are undergoing epidemiologic transition due to changes in their lifestyle, urbanization, and an increasing aging population. These countries including Nigeria now bear double burdens of communicable and NCDs. Importantly, in the past few decades, sub-Saharan Africa has had the highest burden of human immunodeficiency virus (HIV)/AIDS, and now accounts for 66% of all HIV infections.[4] Nigeria contributes 9% of the global HIV prevalence with 3.2 million people contracting HIV infection at the end of 2016, thus making Nigeria have the second largest HIV epidemic in the world.[5]

Although HIV/AIDS has remained a public health challenge, significant progress has been made in turning a disease once regarded as a “death sentence” to a chronic and manageable illness. Particularly, antiretroviral therapy (ART) has resulted in a sustained suppression of HIV replication, prevention of opportunistic infections, improved survival, and quality of life of HIV patients.[6] However, the prolonged use of these drugs is associated with side effects which increase the risk of hypertension, obesity, and dyslipidemia. This is possibly related to the chronic inflammation that characterize HIV infection and perhaps more importantly, the metabolic adverse effects of highly active ART (HAART) which may promote endothelial dysfunction and altered lipid metabolism especially by protease inhibitors (PIs) and insulin resistance.[7] The chronic inflammation in HIV-infected patients with reactive oxygen species generation, cytokine burden, and the metabolic dysfunction associated with ART leads to a prothrombotic state, progression of atherosclerosis, and vascular dysfunction.[8] Furthermore, while HIV treatment naïve patients may have lower body mass index (BMI) due to wasting from tuberculosis (TB), those on long-term HAART have higher BMI following immune reconstitution and metabolic effects of antiretroviral (ARV) drugs.[8],[9] In addition, risky lifestyle choices that increase NCD risk has been reported among people living with HIV/AIDS (PLWHA) in Asian countries.[10],[11],[12]

The emerging coexistence of NCDs with HIV requires urgent public health attention as this duo has the potential of reversing the gains from past efforts on HIV/AIDS, particularly from mortality and morbidity of cardiovascular diseases. Studies on cardiovascular risk factors among HIV patients have largely been done in Caucasian populations; the few studies in sub-Saharan Africa and more recently in Nigeria have reported conflicting results while some other reports found no significant increased risk of hypertension or obesity among HIV patients compared to healthy populations.[13],[14] Others discovered the inconsistent association between ART treatment status and hypertension or dyslipidemia and some researchers have suggested that the prevalence of hypertension and obesity may be more related to the classical risk factors of cardiovascular disease and epidemiological transition with the acquisition of unhealthy lifestyle even in HIV populations.[9],[13],[14],[15] However, the effects of HIV virus or its treatment may be more important in those with established classical cardiovascular risk factors.

We therefore determined the prevalence and risk factors of obesity, hypertension, and dyslipidemia among HIV patients in Ogun state, Southwest Nigeria. We also explored the contributory role of duration of HIV infection, ART status, and CD4 count to these risk factors.

 Subjects and Methods



Study area and setting

This study was conducted in Abeokuta, the capital city of Ogun State, Southwest Nigeria. HIV prevalence in Abeokuta is 5%, and like many capital cities, the inhabitants are prone to high-risk sexual behaviors such as sexual promiscuity, chain-smoking, and heavy alcohol consumption. In addition, the drivers of NCDs in the city include various fast food outlets, clubs, and relaxation centers. The study was carried out in three hospitals (Federal Medical Centre, Abeokuta; Sacred Heart Personal Hospital, Lantoro; State Hospital, Ijaye) which work in collaboration with the Institute of Human Virology in Nigeria, Abeokuta Centre to provide care for PLWHA.

Study design, sampling technique, and sample size

A cross-sectional study was conducted among 206 HIV-positive patients at the three selected facilities. Study participants were proportionally distributed among the three centers and all HIV-positive diagnosed patients who met the eligibility criteria of being 18 years and above, nonpregnant, and who came to the clinic fasting; were purposively recruited for the study until the sample size was reached. Exclusion criteria were those patients with kidney disease, those on appetite suppressants and those who were too sick to participate in the study. The sample size was calculated using the sample size determination for single proportions based on a precision of 5%, a Z statistics for the level of confidence of 95%, and 17% prevalence (P) of cardiovascular disease risk factors among HIV-infected Nigerians receiving HAART in Northern Nigeria.[16] The minimum sample size was 181 and was adjusted to 206 to account for nonresponse rate of 20%.

Data collection

Data were collected using a modified WHO Stepwise protocol which consists of three steps.[17]

Step 1: Information on general, sociodemographic and behavioral lifestyleStep 2: Physical, anthropometric, and blood pressure (BP) measurementStep 3: Information on biochemical measurement.

Sociodemographic variables and specific clinical information on the duration of HIV status, HIV treatment status, ARVs, length of time on ARVs, HIV risk factors, adherence to ARVs, CD4 count, and history of TB were assessed. All physical measurement data (weight, height, waist circumference, and BP) were measured using the WHO STEP protocol.[17] Weight was measured using a weighing scale placed on a flat hard surface; patients were instructed to remove any heavy clothing (such as coats and shoes) and stand still on the weighing scale with hands. The weighing scales were calibrated daily according to the manufacturer's instructions. The height was measured with the aid of a stadiometer, while the participants were facing directly ahead. The waist circumference was measured using a tape measure. The midaxillary line midway between the last rib and the superior iliac crest was used as the reference point and measured to the nearest 0.1 cm. Hip circumference was measured at the point of maximum circumference over the buttocks.[18],[19],[20]

BP was measured while patients were in a sitting position, using an Omron® HEM 907XL automatic BP device. The average of the two last readings was estimated and used in the analysis. In addition, 5 ml of venous blood was drawn for assessment of the serum lipids after an overnight fast of at least 8 h. Fasting lipid was done using Randox kit®.

Operational definitions

Hypertension was assumed if systolic BP was ≥140 mmHg and/or diastolic BP was ≥90 mmHg.[21] BMI was calculated as weight (kg) divided by the square of the height (m2) and categorized using the WHO classification. Patients were obese if the BMI was ≥30 kg/m2; overweight if the BMI is 25–29.9 kg/m2, and normal if the BMI is between 18.5 and 24.9 kg/m2 and underweight if <18.5 kg/m2.[18]

Waist–hip ratio

This is calculated as the ratio of waist to hip circumference. According to the WHO, abdominal obesity is defined as a waist–hip ratio of >0.9 for males and >0.85 for females.

Dyslipidemia is defined as total cholesterol >200 mg/dl and/or triglyceride >150 mg/dl, and/or HDL-Cholesterol <40 mg/dl in men and < 50 mg/dl in women, LDL >130 mg/dl.

Drug-naïve patients are those who did not report any current or previous use of ARV drugs.

Individuals who are ART-experienced are those who reported current and or previous use of ARV drugs. ART, ARVs, and HAART are used interchangeably here.

Data analysis and management

Data entry and cleaning were done using SPSS version 20.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp.). Data analysis was done using STATA version 12 (Stata Statistical Software, TX: StataCorp LP.). It was stratified by age and ART status. The dependent variables were overweight and obesity, hypertension, and dyslipidemia. The independent variables were age, gender, behavioral risk factors, and HIV-related characteristics. Categorical variables were described using frequency tables while continuous variables were presented as means and standard deviation. Characteristics of participants by demographic, lifestyle, clinical, and HIV-related characteristics in Abeokuta are presented in [Table 1]. The overall prevalence estimates and 95% confidence intervals (CIs) of the dependent factors by selected covariates are displayed in [Table 2]. Chi-square for trend was performed, and their P values presented. The logistic regression model was applied to measure the independent roles of different predictors and confounders to the prevalence of overweight or obesity, hypertension, and dyslipidemia in separate analyses. P < 0.05 was deemed statistically significant.{Table 1}{Table 2}

Ethical consideration

Ethical approval for the study was obtained from the Ethical Review Boards of Federal Medical Centre, Sacred Heart State Hospital, Abeokuta, Ogun State. Permission to conduct the study was obtained from the medical/research director of each hospital. Informed written consent was obtained from the individual respondents before the commencement of the research. The study protocol and conduct adhered to the principles laid down in the Declaration of Helsinki.

 Results



[Table 1] describes the demographic, lifestyle, clinical, and HIV-related characteristics of HIV-positive respondents in Abeokuta. The mean age was 43.3 ± 9.6 years with about 60% above 40-year-old and females were 82.5%. Alcohol consumption (4.9%) and current smoking (1.5%) of cigarettes were not common among the respondents. The average sedentary time was 4.6 ± 3.1 h. According to their BMI, 13.6% were obese, 20.4% were overweight, 61.2% were of normal weight, and 4.9% were underweight. Abdominal obesity was common among the respondents (61.6%). Hypertension was present in 20.9% while hypercholesterolemia was present in 40.2%. Regarding their HIV-related characteristics, 68.9% have being diagnosed with HIV for 2 years or more, 86.9% are HAARTs exposed, 90.5% had CD 4 levels more than 200/μl, and 11.8% had pulmonary TB comorbidity.

[Table 2] displays the prevalence and 95% CIs of obesity, hypertension, and dyslipidemia among the respondents. The overall prevalence of overweight or obesity was 34.0% (95% CI: 27.5–40.5), with an increased rate though not statistically significant among those who are ≤40 years, 38.1% 95% CI: 27.6–48.6), females, 36.5% (95% CI: 29.2–43.8) and those without PTB comorbidity (35.1%, 95% CI: 28.2–42.2). The prevalence of overweight or obesity was also significantly higher (P = 0.015) among those with high BP, 46.5% (95% CI: 31.3–61.7) than those without 30.7% (95% CI: 23.5–37.8). Being overweight or obese also significantly increased (P = 0.021) with duration of HIV diagnosis: less than 2 years – 21.9% (95% CI: 11.6–32.1), between 2 and 5 years – 38.0% (95% CI: 27.1–48.8), and more than 5 years – 41.3% (95% CI: 28.9–53.6). In addition, the prevalence of hypertension among HIV-positive patients was 20.9% (95% CI: 15.3–26.4) and the prevalence significantly increased (P < 0.001) with age; 29.5% (95% CI: 21.3–37.7) for those above 40 years compared with 8.3% (95% CI: 2.4–14.3) for respondents aged 40 years and below. The prevalence of hypertension also significantly increased (P = 0.043) in males, 33.3% (95% CI: 17.6–49.0) compared with females, 18.2% (95% CI: 12.4–24.1) and also significantly increased among those overweight/obese (P = 0.050) and those with high waist–hip ration (P = 0.015). Dyslipidemia was prevalent 40.2% (95% CI: 33.5–47.0) among the study participants. Although not statistically significant, it was common among those who consume alcohol 50.0% (95% CI: 17.1–82.9) and those with pulmonary TB comorbidity 45.8% (95% CI: 25.3–66.3).

The odds ratios (OR) and 95% CIs of the factors associated with obesity, hypertension, and dyslipidemia among HIV-positive patients in Abeokuta is displayed in [Table 3]. The odds of overweight and obesity increased with sedentary times (adjusted OR [AOR]: 1.2, 95% CI 1.0–1.3), and increased duration of being with HIV: 2–5 years (AOR: 2.0, 95% CI 1.0–4.1) and over 5 years AOR: 3.0, 95% CI 1.0–6.3). There was also increased association of overweight and obesity with hypertension (AOR: 3.0, 95% CI 1.1–6.0). The determinants of hypertension were age, male gender, and high levels of CD4 count. The likelihood of hypertension was 8 times higher among respondents above 40 years (AOR: 7.9, 95% CI: 2.7–23.0) compared with those below 40 years.{Table 3}

 Discussion



HIV has evolved from being a terminal disease to a chronic but manageable illness particularly with the advent of ART which has led to better survival and quality of life among HIV-positive patients. Aside from the side effects of the ARV drugs, HIV patients are similarly prone to NCD risk factors such as the general population. Hence, in this study, we investigated the prevalence and risk factors of obesity, hypertension, and dyslipidemia among HIV-positive patients in Abeokuta, Nigeria, evidence that is scarcely available among the Nigerian HIV population. We found a high prevalence of obesity/overweight, hypertension, and hypercholesterolemia among adult HIV respondents which substantiates the high rate of cardiometabolic risk factors even among their population in Nigeria.

The prevalence of overweight and obesity were 20.4% and 13.6% respectively while only a negligible proportion (4.9%) was underweight. The prevalence of overweight/obese is lower compared with those reported among HIV-positive population within Africa, for example, Kenya (22.6% in HIV-positive women)[22] and South Africa (29.3% and 23.8% in HIV-positive women).[13] Particularly, we found that the prevalence of being overweight/obese significantly increased (P = 0.021) with the duration of HIV. Previously, HIV was regarded as a wasting disease because of substantial weight loss, TB comorbidity, general debility, and poor health.[23],[24],[25],[26] HIV patients on HAART treatment have been observed to gain weight and to have BMIs that are similar to that of the general population.[7] The reasons propounded for this include: the metabolic effects of ARVs, better nutritional, more social support for HIV patients, metabolic deregulation mediated by insulin resistance, and chronic inflammation.[22],[24] Even then, some researchers have still found a persistence of low BMI among HIV-positive persons.[9],[13],[25] In addition, we noted that while alcohol consumption, cigarette smoking, and intake of fruits and vegetables had no relationship with being overweight/obese, there was a significant association with being sedentary. As the odds of overweight/obese increased by 20% among our study population with increased sedentary time. Evidence has shown that low levels of physical activity are one of the most common NCD risk factors among the general population. This emphasizes the need to also promote physical activity among HIV just like the general population and the World Health Organization recommends 150 min of moderate intensity of physical activity per week. Expectedly, TB comorbidity reduced the likelihood of overweight/obesity by half. HIV/TB comorbidity occurred in 11.8% of our study population inspire of close to 90% of the respondents being on HAARTs, and a significant proportion of them (90.5%) had CD4 count >200/μl. This is a cause for concern for HIV treatment programs for early detection and treatment of HIV and TB in the community. Furthermore, we noted a significant association with hypertension, while this might be explained by a temporal sequence; it might also be mediated by the metabolic effect of elevated BP and chronic inflammation of HIV which tend to contribute to insulin resistance in HIV patients.

About one in every five (20.9%) HIV patient in our study had hypertension. This is lower than the prevalence reported by Crum-Cianflone et al.[26] among HIV patients in the United States but similar to the prevalence of 20.1% found in the community survey conducted by Malaza et al.[13] in South Africa. More so, this falls within the range of the prevalence of hypertension reported for the Nigerian populace. For example, Akinlua et al. estimated in a systematic review estimated the prevalence of hypertension in Nigeria ranged between 2.1% and 47.2%.[27] This could suggest that HIV patients may be exposed to the same risk factors for hypertension as the general population.[28],[29] This has important implications considering that hypertension accounts for >80% of cardiovascular mortality globally. This increasing prevalence of hypertension in the HIV population requires clinical attention if the gains of HIV care are not to be reversed in Nigeria and other sub-Saharan African countries battling with the burden of communicable and NCDs. Similar to what is known in the general population,[18] we also found that an older age (<40 years), male gender, overweight/obese and abdominal obesity were significantly associated with hypertension. These determinants were also reported among HIV respondents in Kenya.

In addition, we found that a CD4 count of 350 or greater was significantly associated with almost a four times risk of having hypertension (OR = 3.9). This is held by Bloomfield et al.[22] stated that CD4 count <200/μl was associated with higher risk of hypertension in HIV patients even though this effect was attenuated when adjusted for age, BMI, and gender. The pathogenesis of this is not well established, but it is probably due to improved overall general health and nutritional status of HIV patients with immune reconstitution. Although we did not find exposure to HAARTs a predictor of hypertension Ekali et al.[24] found that the prevalence of hypertension significantly increased with the duration of HAART use while a recent systematic review and meta-analysis showed evidence of increased hypertension risk among HIV patients on HAART.[23] A high CD4 count being associated with hypertension was also reported by Bloomfield et al.[22] In all, it appears that the risk of hypertension among HIV patients is related to both classical risk factors and HIV status or HIV-related factors. Although the attributable effects of HIV on the vascular system may be smaller than the effects of other classical risk factors such as age, sex, and BMI. In fact, in this study, being older than 40 years was associated with an 8-fold increased risk of hypertension confirming that age is perhaps the most important risk factor for hypertension in HIV and the general population. Increasing age and the male gender have been corroborated by other HIV epidemiologists as being important determinants of hypertension in this population.[13],[22],[30]

Importantly, the high prevalence of dyslipidemia in this study (40.2%) was not significantly associated with any of the correlated risk factors including obesity, hypertension, HAART use, HIV duration, and CD4 count. This is not in tandem with the reports by other investigators.[16],[31],[32] This may be because our sample was not adequately powered to detect these associations None of the measured covariates predicted dyslipidemia among HIV patients. This is surprising given that studies have shown the lipid abnormalities on HIV patients are related to the virus itself, ARVs especially PIs, female gender, and HIV duration.[8],[9],[16],[31],[33] Furthermore, researches on dyslipidemia in HIV in Nigeria have been largely descriptive and only Ekali et al.[24] showed a strong association between hypercholesterolemia and HAART duration.

Our study determined the prevalence and predictors of obesity, hypertension, and dyslipidemia among a homogenous HIV population enrolled in HIV care in Abeokuta, Ogun State. We have shown that obesity, hypertension, and dyslipidemia are common in HIV patients notwithstanding in middle-aged in Nigeria. The determinants of obesity in this population were sedentary time, long duration of HIV infection and hypertension. On the other hand, the determinants of hypertension were older age, male gender, being overweight/obese and high CD4 count. None of the covariates predicted dyslipidemia among the respondents. Thus, it seems that obesity and hypertension in HIV patients may be more related to classical epidemiological risk factors in addition to their HIV status. Therefore, HIV patients would benefit from screening programs just like the general adult population for the early detection and treatment of cardiovascular diseases if the gains of HIV care are not to be reversed by the rising burden of cardiovascular diseases and epidemiological transition occurring in African populations.

In spite of the aforementioned, our study might be limited by our modest sample size which may not have been adequately powered to detect important HIV-specific associations. Furthermore, selection bias may have affected the study findings. The patients were purposively recruited from the HIV treatment centers and not from the community. The nonreport of data on specific ARVs especially PIs is an important limitation to generalizability of the finding of no association between ARVs and dyslipidemia. More so, the study is cross-sectional and cannot be used to prove causal association. These limitations may limit generalizability of the study findings to the general HIV population. Further research in this area is needed preferably prospective studies in Nigeria and other sub-Saharan African countries to confirm the causative roles of these covariates to obesity, hypertension and dyslipidemia incidence in African patients. The preventive cardiovascular health programs should be embedded in HIV care so that the burden of cardiovascular diseases in HIV patients can be reversed and the gains of HIV treatment consolidated.

Acknowledgment

We would like to acknowledge the assistance of the clinical staff at the study sites for their invaluable support during this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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