Faculty Bibliography

Metabolic syndrome is associated with higher rates of cardiovascular morbidity and mortality. Although significant disparities in the risks of metabolic syndrome by occupation type and sex are well documented, the factors associated with metabolic syndrome in low- to middle-income countries remain unclear. These gaps in evidence identify the need for patterns of metabolic syndrome among hospital personnel of both sexes in Nigeria. A total of 256 hospital workers comprising 32.8% men were studied. The mean age of the participants was 42.03+/-9.4 years. Using International Diabetic Federation criteria, the prevalence of metabolic syndrome was 24.2%. Women were substantially and significantly more likely to be identified with metabolic syndrome compared with men (34.9% vs 2.4%, respectively; P=.0001). This study identified metabolic syndrome among health workers with over one third of women with metabolic syndrome compared with <10% of men. These results support the implementation of lifestyle modification programs for management of metabolic syndrome in the health care workplace.

OBJECTIVES: African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions. METHODS: Using a cluster randomized design; the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling. RESULTS: 2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60+/-0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167+/- 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 +/- 0.293, p=0.622; group x quadratic time coefficient= -0.017 +/- 0.026, p=0.525). Results were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately. CONCLUSION: Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

BACKGROUND: The current Ebola Virus Disease (EVD) epidemic has ravaged the social fabric of three West African countries and affected people worldwide. We report key themes from an agenda-setting, multi-disciplinary roundtable convened to examine experiences and implications for health systems in Ghana, a nation without cases but where risk for spread is high and the economic, social and political impact of the impending threat is already felt. DISCUSSION: Participants' personal stories and the broader debates to define fundamental issues and opportunities for preparedness focused on three inter-related themes. First, the dangers of the fear response itself were highlighted as a threat to the integrity and continuity of quality care. Second, healthcare workers' fears were compounded by a demonstrable lack of societal and personal protections for infection prevention and control in communities and healthcare facilities, as evidenced by an ongoing cholera epidemic affecting over 20,000 patients in the capital Accra alone since June 2014. Third, a lack of coherent messaging and direction from leadership seems to have limited coordination and reinforced a level of mistrust in the government's ability and commitment to mobilize an adequate response. Initial recommendations include urgent investment in the needed supplies and infrastructure for basic, routine infection control in communities and healthcare facilities, provision of assurances with securities for frontline healthcare workers, establishment of a multi-sector, "all-hazards" outbreak surveillance system, and engaging directly with key community groups to co-produce contextually relevant educational messages that will help decrease stigma, fear, and the demoralizing perception that the disease defies remedy or control. The EVD epidemic provides an unprecedented opportunity for West African countries not yet affected by EVD cases to make progress on tackling long-standing health systems weaknesses. This roundtable discussion emphasized the urgent need to strengthen capacity for infection control, occupational health and safety, and leadership coordination. Significant commitment is needed to raise standards of hygiene in communities and health facilities, build mechanisms for collaboration across sectors, and engage community stakeholders in creating the needed solutions. It would be both devastating and irresponsible to waste the opportunity.

OBJECTIVES: The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies. DESIGN: Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the 'explanatory model of disease' concept. RESULTS: Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of 'body-listening,' constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence. CONCLUSIONS: The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.

BACKGROUND: Angiotensin converting enzyme inhibitors (ACEi) are widely used in the treatment of patients with hypertension. However, their efficacy in hypertensive blacks when compared with other antihypertensive agents is not well established. METHODS: Cohort study of patients using data from a clinical data warehouse of 434,646 patients from New York City's Health and Hospitals Corporation (HHC) from January 2004 - December 2009. Patients were divided into the following comparison groups: ACEi vs. Calcium Channel Blocker (CCB); ACEi vs. thiazide diuretics and ACEi vs. beta-blockers. Primary outcome was a composite of death, myocardial infarction or stroke. Secondary outcomes include the individual components and heart failure. RESULTS: In the propensity score matched ACEi vs. CCB comparison cohort (4,506 blacks in each group), ACEi was associated with higher risk of primary outcome (HR=1.45; 95% CI 1.19, 1.77; P=0.0003), myocardial infarction (HR=3.40; 95% CI 1.25, 9.22; P=0.02), stroke (HR=1.82; 95% CI 1.29, 2.57; P=0.001) and heart failure (HR=1.77; 95% CI 1.30, 2.42; P=0.0003) when compared with CCB. For the ACEi vs. thiazide diuretics comparison (5,337 blacks in each group), ACEi was associated with higher risk of primary outcome (HR=1.65; 95% CI 1.33, 2.05; P<0.0001), death (HR=1.35; 95% CI 1.03, 1.76; P=0.03), myocardial infarction (HR=4.00; 95% CI 1.34, 11.96; P=0.01), stroke (HR=1.97; 95% CI 1.34, 2.92; P=0.001) and heart failure (HR=3.00; 95% CI 1.99, 4.54; P<0.0001). For the ACEi vs. beta-blocker comparison, the outcomes between the groups were not significantly different. CONCLUSIONS: In a real-world cohort of hypertensive blacks, ACEi was associated with higher risk of cardiovascular events when compared with CCB or thiazide diuretics.

Introduction: Sleep duration has been inconsistently associated with elevated body mass index (BMI) in many populations. The Modeling the Epidemiologic Transition Study (METS), provides an excellent opportunity to assess these associations among populations of African origin at different levels of social and economic development. Methods: METS enrolled 500 young adults, 25-45 years, from each of 5 study sites: rural Ghana, urban South Africa, Seychelles, urban Jamaica and suburban U.S. Anthropometrics and self-reported sleep duration data were collected. Multivariate regression models were used to assess associations between habitual sleep duration and markers of obesity (BMI > 30 kg/m²) using aggregated data (using dummy site variables; n = 2,500), as well as with data from each site individually (n = 500 per analysis). Results: The mean (+/- SD) age was 34.7 (6.2) years. Among men, mean BMI ranged from 22.2 +/- 2.7 to 29.7 +/- 7.5 and among women it ranged from 25.5 +/- 5.2 and 34.1 +/- 8.8 in Ghana and the U.S., respectively. Percent body fat, fat mass, fat-free mass and waist and hip circumferences followed the same general pattern, lowest in Ghana and highest in the U.S. Mean sleep duration was shortest in the US (6.7 +/- 1.4 hours), intermediate in Seychelles (7.2 +/- 1.3), Jamaica (7.3 +/- 1.8), and Ghana (7.9 +/- 1.5) and longest in South Africa (10.3 +/- 1.7; p < 0.001), for both men and women. In multivariate regressions, adjusting for sex, age and site, sleep was significantly inversely associated with BMI, fat mass, fat-free mass, waist circumference and hip circumference (all p < 0.001). When site-specific regressions were conducted, results remained statistically significant across all sites only for fat-free mass (all sites p < 0.05). Conclusion: Sleep duration varied significantly between participants in South Africa and the other 4 METS study sites. In each and across all sites, fat-free mass was consistently more strongly associated with sleep duration than other indicators of obesity, warranting further investigation

Introduction: Resistant hypertension (RHTN) is an important condition affecting 3-29%) of the US population, albeit more common among blacks. We evaluated associations of RHTN with short sleep among blacks. Methods: Data came from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study characterizing metabolic syndrome (MetS) among blacks. Analysis was based on 883 patients (mean age: 62 +/- 14 years; female: 69.2%). MetS was defined according to criteria from the Adult Treatment Panel (ATP III). RHTN was defined as failure to achieve blood pressure goal (BP) of < 140/90 mm/Hg or < 130/80 mm/Hg among patients with diabetes or kidney disease when on maximal doses of a three-drug regimen. This also includes patients requiring more medications to achieve BP goal. Short sleep, derived from subjective reports, was defined as < 7 hours, referenced to healthy sleep (7-8 hours). OSA risk was assessed using the Apnea Risk Evaluation System (ARESTM); patients with a score > 6 were considered at high OSA risk, based on validated studies. Results: Most (90.4%) were overweight/obese; 61.4% had diabetes; 74.8%, dyslipidemia; 30.2%, heart disease; and 48% were at OSA risk. Overall, 92.6% had HTN, and 20.8% met criteria for RHTN. Analyses showed no significant difference in HTN prevalence comparing short (91.4%) and healthy sleepers (93.1%), but those with RHTN were more likely to be short sleepers (26.8% vs. 14.9%, p < 0.001). Based on logistic regression analysis, adjusting for effects of age, sex and medical comorbidities, patients with RHTN had increased odds of being short sleepers (OR = 1.90, 95% CI: 1.27-2.90, p = 0.002). Of interest, odds of being short sleepers among those at OSA risk were similar (OR = 1.92, 95% CI: 1.38-2.68, p< 0.001). Conclusion: Among blacks with metabolic syndrome, patients meeting criteria for RHTN showed a twofold greater likelihood of being short sleepers. Adjusted odds of short sleep were remarkably similar to those observed for patients at OSA risk