|Year : 2012 | Volume
| Issue : 4 | Page : 197-202
Dyslipidemia in Nigeria: Prevalence and pattern
OC Oguejiofor, CH Onwukwe, CU Odenigbo
Department of Internal Medicine, Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Anambra State, Nigeria
|Date of Web Publication||24-Oct-2012|
O C Oguejiofor
Department of Internal Medicine, NAUTH, Nnewi. PO Box 1125 Nnewi
| Abstract|| |
Background: Dyslipidemia is a major risk factor for cardiovascular disease. Data are scanty on the prevalence and pattern of dyslipidemia in Nigeria. However, some studies on the subject are now becoming available. This article reviews these studies on the prevalence and pattern of this important risk factor for cardiovascular disease in Nigeria.
Materials and Methods: Intensive internet search on studies done in different parts of Nigeria showing the prevalence and pattern of dyslipidemia in various focal groups that include apparently healthy individuals, the elderly, diabetics, hypertensives, and diabetic hypertensives was carried out .
Results: Dyslipidemia was highly prevalent in all the geopolitical zones of Nigeria with the consistent pattern being low HDL-Cholesterol and high LDL-C. Overall, the prevalence of dyslipidemia ranged from 60% among apparently healthy Nigerians to 89% among diabetic Nigerians.
Conclusion: Dyslipidemia is highly prevalent in Nigeria and health education to increase awareness of the need for and to actually screen for dyslipidemia will facilitate early detection and treatment.
| Abstract in French|| |
Contexte: Dyslipidémie est un facteur de risque majeur pour les maladies cardiovasculaires. Les données sont rares sur la prévalence et le patron de dyslipidémie au Nigeria. Cependant, certaines études sur le sujet deviennent maintenant disponibles. Cet article examine les ces études sur la prévalence et le patron de cet important facteur de risque pour les maladies cardiovasculaires au Nigeria.
Matériel et méthodes: Recherche intensive d'internet sur les études menées dans différentes régions du Nigeria montrant la prévalence et le patron de la dyslipidémie dans divers groupes focaux qui incluent des individus apparemment en bonne santés, les personnes âgées, diabétiques, hypertendus et diabétiques hypertendus a été effectuée.
Résultats: Dyslipidémie était très répandue dans toutes les zones géopolitiques du Nigeria avec le modèle compatible HDL-cholestérol bas et élevés de LDL-C. Dans l'ensemble, la prévalence de la dyslipidémie variait de 60% chez les Nigérians apparemment en bonne santés à 89% chez les diabétiques nigérians.
Conclusion: Dyslipidémie est très répandu au Nigéria et éducation à la santé afin d'accroître la prise de conscience de la nécessité et à réellement écran dyslipidémie facilitera la détection précoce et le traitement.
Mots clés: Dyslipidémie, Nigéria, prévalence
Keywords: Dyslipidemia, Nigeria, prevalence
|How to cite this article:|
Oguejiofor O C, Onwukwe C H, Odenigbo C U. Dyslipidemia in Nigeria: Prevalence and pattern. Ann Afr Med 2012;11:197-202
| Introduction|| |
Dyslipidemia is a state that arises as a result of abnormalities in the plasma lipids. These abnormalities could be quantitative, qualitative or both. Quantitatively, dyslipidemia is due to elevated plasma total cholesterol (TC), elevated low-density lipoprotein cholesterol (LDL-C), elevated triglycerides (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels, occurring singly or in combinations. Qualitatively, dyslipidemia implies changes in composition of LDL-C which includes small dense LDL-C, increased TG content or increased electronegativity of LDL-C.
A linear relationship probably exists between lipid levels and cardiovascular risk. Dyslipidemia contributes to the development of atherosclerosis. The atherogenic dyslipidaemic profile is characterized by elevated TG, low HDL-C and a preponderance of small, dense LDL-C particles. This profile is typically associated with the metabolic syndrome and type 2 diabetes mellitus. 
The TC, TG, and HDL-C can be assayed while LDL-C is usually calculated. LDL-C constitutes about 60-70% of total serum cholesterol. 
There are no rigid numeric definitions of dyslipidemia. 
Standardized definitions for dyslipidemia
National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) Definition  : The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults, which is one of the most current and most frequently referenced diagnostic criteria for dyslipidemia, defines dyslipidemia as follows:
It further classified the risk associated with various lipid levels as follows:
- Total cholesterol >5.17 mmol/l (>200 mg/dl)
- LDL-C >3.36 mmol/l (>130 mg/dl)
- HDL-C <1.03 mmol/l (<40 mg/dl) for males, <1.3 mmol/l (<50 mg/dl) for females
- Serum TG >1.7 mmmol/l (> 150 mg/dl).
The European Atherosclerosis Society : This society defined dyslipidemia as the presence of any of the following:
- LDL-C: mg/dl (mmol/l)
<100 (<2.58) Optimal
100-129 (2.58-3.33) Above optimal
130-159 (3.36-4.11) Borderline high
160-189 (4.13-4.88) High
≥190 (>4.91) Very high
- TC: mg/dl (mmol/l)
<200 (<5.17) Desirable
200-239 (5.17-6.18) Borderline high
≥240 (>6.20) High
- HDL-C: mg/dl (mmol/l)
<40 (<1.03) Low
>60 (>1.55) High
- TG: mg/dl (mmol/l)
<150 (<3.87) Normal
150-199 (3.87-5.13) Borderline high
200-499 (5.17-12.87) High
>500 (12.90) Very high.
World Health Organization (WHO)  : The WHO defined dyslipidemia as the presence of any of the following:
TC >202 mg/dl (>5.2 mmol/l)
- HDL-C <35 mg/dl (<0.9 mmol/l)
- LDL-C >135 mg/dl (>3.5 mmol/l)
- TG >68 mg/dl (>1.75 mmol/l)
Atherogenic index AI (TC ÷ HDL-C) > 5.8.
Impact of dyslipidemia
- TG 150-400 mg/dl (1.7-4.5 mmol/l)
- TC >200 mg/dl (>5.2 mmol/l)
- LDL-C >135 mg/dl (>3.5 mmol/l)
- HDL-C <35 mg/dl (<0.9 mmol/l in men) or <40 mg/dl (<1.0 mmol/l in women)
- AI >5.
Dyslipidemia is a common disorder but most patients are not diagnosed and therefore not treated.  The burden of the condition is very high in terms of morbidity, mortality, and medical costs. Dyslipidemia is the second most prevalent cardiovascular risk factor.  Hypertriglyceridemia when associated with high LDL-C significantly increases the risk of coronary heart disease (CHD).  WHO estimates in 2002  showed that dyslipidemia accounted for 18% of ischemic heart disease, 56% of stroke, and more than 4 million deaths per year globally. Dyslipidemia together with CHD are leading causes of death for both men and women of all races and ethnicities in the United States of America.  Epidemiologic data show a continuous graded relationship between the total plasma cholesterol concentration and coronary risk, especially for younger men below the age of 40 years.  The age-standardized and sex-standardized mortality ratios in patients with hypercholesterolemia are 4-5 times higher than those in the general population.  A decline in plasma TC has significant impact on the morbidity and mortality rate from heart diseases, especially in patients at higher risk.  Longitudinal studies have demonstrated that reducing plasma TC by 1% decreases CHD mortality by 2-3%. 
Meta-analysis of 38 primary and secondary prevention trials also demonstrated that for every 10% reduction in plasma TC, CHD mortality is reduced by 15% and total mortality risk by 11%.  Incidence of dyslipidemia is highest in patients with premature coronary artery disease (defined as coronary artery disease occurring before 55-60 years of age in men and before 65 years of age in women). In this group of individuals, prevalence of dyslipidemia is as high as 75-85%, compared to approximately 40-48% in age-matched controls without CAD. 
In Nigeria, few studies have been done to describe the prevalence, pattern, and distribution of dyslipidemia in various parts of the country. This review article seeks to describe the prevalence and pattern of dyslipidemia based on available studies done in the different geopolitical zones of Nigeria.
| Materials and Methods|| |
An intensive internet search was carried out and print versions of studies on the prevalence and pattern of dyslipidemia in different parts of the country were obtained. The findings from both old and recent works were reviewed in order to determine the previous and current perspectives of dyslipidemia in Nigeria. Emphasis was placed on the prevalence and pattern in some groups of special interest including apparently healthy Nigerians, the elderly, diabetic subjects, hypertensive subjects, and diabetic hypertensive subjects.
| Results|| |
Earlier studies from Nigeria reported that dyslipidemia was rare amongst Nigerians. Onyemelukwe and Stafford in 1981 suggested that protective cholesterol (HDL-C) was significantly higher in tropical Africa,  while Kesterloot et al. in Benin, South South Nigeria in 1989 showed that blacks had a low prevalence of dyslipidemia. 
This review of 13s recent studies showed that dyslipidemia is highly prevalent in Nigeria. All the studies except two defined their subjects using the ATP III criteria. The two other studies used the WHO criteria and the European Atherosclerosis Society criteria respectively.
Apparently healthy Nigerian adults
- Odenigbo and Oguejiofor  in 2008 evaluated the prevalence of dyslipidemia in apparently healthy professionals in Asaba, South South Nigeria, using the ATP III criteria. They found a very high prevalence of dyslipidemia (60.0%) with low HDL-C being the commonest pattern of dyslipidemia (60%). Other patterns of dyslipidemia reported were high LDL-C (51%), TC (23%) and TG (5%) levels.
- Agboola-Abu and Onabolu  reported high prevalence of dyslipidemia among individuals of upper social class attending Igbinedion Hospital and Medical Research Centre, Okada in South South Nigeria. Most of the subjects (60.4%) had hypercholesterolemia while 22.6% had elevated TG.
- Osuji et al.  in 2010 studied prevalence of overweight/obesity and dyslipidemia amongst a group of women attending "August" meeting at Naze, Owerri, South East Nigeria and found very high (60.5%) prevalence of dyslipidemia. Low HDL-C was the commonest dyslipidemia pattern (37.6%). Other patterns were high TG (34.1%) and TC (31.4%) levels.
- Sani et al.  in 2010 from Katsina, North West Nigeria, cross-sectionally studied modifiable cardiovascular risk factors among apparently healthy adult Nigerians. They found high prevalence of dyslipidemia with low HDL-C being the commonest dyslipidemia (59.3%). Other dyslipidemia patterns were high TC (28.3%), LDL-C (25.7%) and TG (15.0%) levels.
- Odenigbo and Oguejiofor  in 2010 studied the prevalence of dyslipidemia in elderly subjects in Asaba, Delta State, South South Nigeria. This cross-sectional study involved 176 subjects recruited sequentially from attendees to the quarterly medical lectures of the Ebreme foundation, a nongovernmental organization (NGO). Dyslipidemia was highly prevalent (69.9%) with elevated LDL-C being the commonest and low HDL-C being the least common dyslipidemias. Elevated LDL-C was found in 60.9% of males and 62.1 % of females, elevated TC in 44.5% of males and 51.5% of females, high TG in 12% of males and 16.4% of females, and low HDL-C in 10.9% of males and 1.5% of females.
- Jisieike-Onuigbo, Unuigbe, Oguejiofor et al. in 2010 evaluated the prevalence of dyslipidemia among adult diabetic subjects with overt diabetic nephropathy in Anambra State, South East Nigeria using the WHO criteria. They reported very high prevalence of dyslipidemia with hypertriglyceridemia being the commonest dyslipidemia (66.7%). Other dyslipidemias were elevated TC (62.5%), reduced HDL-C (58.3%), and elevated LDL-C (45.8%).
- Ogbera, Fasanmade, Chinenye et al.  in 2009 "characterized lipid parameters in Diabetes Mellitus in Nigeria." This collaborative report from three tertiary centers in Nigeria-Lagos State University Teaching Hospital (LASUTH), Lagos University Teaching Hospital (LUTH),and University of Port Harcourt Teaching Hospital (UPTH) revealed extremely high prevalent rates of dyslipidemia (89.0%) with elevated LDL-C (74.0%) and low HDL-C (53.0%) being the commonest dyslipidemia. Other patterns were high TC (42%) and TG (13%) levels.
- Okafor, Fasanmade, and Oke  in 2008 studied the pattern of dyslipidemia among Nigerians with type 2 diabetes mellitus presenting to LUTH, Lagos, South West Nigeria, using ATP III criteria. Prevalence of dyslipidemia was extremely very high (89.1%) with low HDL-C being the commonest dyslipidemia (88%) and high TG levels the least (25.0%). Other patterns were elevated LDL-C (58.9%) and TC (55.2%) levels with combined dyslipidemia (64.5%).
- Idogun, Unuigbe et al.  in 2007 from Benin, South South Nigeria assessed serum lipids in Nigerians with type 2 diabetes mellitus complications using ATP III criteria. Prevalence of dyslipidemia was between 25% and 69% with combined dyslipidemia (high TC and TG levels) being common. Dyslipidemia was highest in patients with diabetic nephropathy.
- Agaba et al.  from North Central Nigeria also reported high prevalence rate of dyslipidemia in type 2 diabetes mellitus subjects with the commonest patterns being high TC (43.5%) and TG (34.8%) levels.
- Akintunde et al.  in 2010 studied dyslipidemia among newly diagnosed hypertensives (pattern and clinical correlates) in Osogbo, South West Nigeria. Dyslipidemia was highly prevalent overall (58.9%)-Isolated dyslipidemia (41.1%) and combined dyslipidemia (17.8%). Low HDL-C was the commonest dyslipidemia (47.9%). Other patterns were high LDL-C (23.3%), TG (15.3%) and TC (8.6%) levels.
- Ojji et al. in 2009  from Abuja, North Central Nigeria studied prevalence of dyslipidemia in normoglycemic subjects with newly diagnosed hypertension using ATP III criteria. Dyslipidemia was prevalent with low HDL-C being the commonest dyslipidemia (45.8%). Other dyslipidemias were high LDL-C (17%), TC (11.1%), and TG (7.6%) levels.
- Isezuo et al.  from Sokoto, North West Nigeria did a comparative analysis of lipid profiles among patients with type 2 diabetes mellitus, hypertension, and concurrent type 2 diabetes mellitus and hypertension, using the European Atherosclerosis Society criteria. Dyslipidemia was common with the most frequent pattern being elevated TG (31.1%) and TC (20.8%) levels. They reported that dyslipidemia did not differ significantly among the three groups and that concurrent diabetes mellitus and hypertension do not result in excess hyperlipidemia than when either condition occurs alone.
| Discussion|| |
Dyslipidemia is a global pandemic and a major risk factor for cardiovascular disease. The burden of the disease in terms of morbidity, mortality, and medical costs is immense. It is a leading cause of death for both men and women of all races and ethnicities in the United States of America  and WHO  holds it accountable for more than 4 million deaths annually, globally. Higher prevalence of dyslipidemia in Caucasians or developed nations compared to Blacks or developing nations is reported severally in literature. The American Heart Association  in 2006 estimated that a third of all Americans (over 100 million people) have TC levels>200 mg/dl (moderately high levels), while 34 million adult Americans have TC levels>240 mg/dl (high levels necessitating treatment). Goff et al. in their Multi Ethnic Study of Atherosclerosis (MESA) which focused on dyslipidemia prevalence, treatment, and control and which involved a multicenter cohort of 6814 persons, aged 45-84 years, free of clinical cardiovascular disease at baseline, recruited from six US communities, reported an overall dyslipidemia prevalence of 29.3%. Non-Hispanic whites (males 36.9%, females 24.4%) recorded higher prevalence compared to Blacks (males 31.2%, females 29.1%).
Dyslipidemia was previously thought to be rare in Black Africa, including Nigeria. Early reports suggested that blacks have lower prevalence of dyslipidemia possibly due to genetic, nutritional, and environmental factors.  Some believed that protective (HDL-C) cholesterol was significantly higher in Tropical Africa,  similar to reports showing that populations with increased intake of fish and marine mammals have high levels of HDL-C.
Our findings show that the current state of dyslipidemia in Nigeria clearly contradicts previous perceptions. Our review shows that dyslipidemia is no longer rare in Nigeria and that the gap in dyslipidemia prevalence compared to Caucasians is not only closing but that the high prevalence values obtained is comparable to Caucasian values. This transition cuts across all the focal groups evaluated. While many of the studies which were carried out in urban locations did not adduce reasons for this high prevalence value, some postulated that this may be closely linked to rapid urbanization and western diet with most urban cities saturated with fast food outlets and increasing sedentary lifestyle which contrasts with our previous highly active agrarian based lifestyle. Ironically, while it took Europe and North America centuries to experience gradual modification of lifestyle where diet based on high intake of carbohydrates replaced the traditional hunter gatherer diet rich in proteins,  similar transition is occurring in the developing world in decades only.
Among apparently healthy Nigerian adults, very high prevalence values were obtained - 60% (Odenigbo and Oguejiofor),  60.5% (Osuji et al.),  and 59.3% (Sani et al.).  The pattern of dyslipidemia was consistently low HDL-C and high LDL-C.
Dyslipidemia is believed to be very common in both diabetic and hypertensive subjects and our findings were consistent with this expectation. Idogun et al. reported a dyslipidemia prevalence of 25-69% in Nigerians with type 2 diabetes,mellitus complications, similar to the report from Akbar  (25-60%) among diabetic subjects in Saudi Arabia. Prevalence of dyslipidemia in Black Africans with type 2 diabetes mellitus appears indeed to be rising to very high levels. In Nigeria, the prevalence of dyslipidemia in this population was extremely high (89.0%: Ogbera et al. ; 89.1%: Okafor et al. ). In South Africa, Vezi et al. reported a comparatively very high prevalence rate of 90.3% in the same population.
Among hypertensive cohorts, the pattern of high prevalence of dyslipidemia persists in Black Africans. Akintunde et al. from Nigeria reported a prevalence of 58.9% compared to report from Congo (40.0%) by Lepira et al.
| Conclusion|| |
Dyslipidemia is highly prevalent in Nigeria and Black Africa at a rate currently comparable with Caucasian values. The pattern of dyslipidemia among the various groups studied was almost consistently low HDL-cholesterol and high LDL- cholesterol. Hence, we recommend periodic fasting lipid profile screening for adult Nigerians, especially apparently healthy Nigerians of the upper social class and Nigerians with other cardiovascular disease risk factors. This will enhance early detection and treatment and reduce the high burden of this underdiagnosed and undertreated disease.
| Acknowledgement|| |
Dr Oguejiofor O.C received an Honorarium from Astrazeneca Pharmaceuticals (PTY) Limited in connection with the development of this manuscript.
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