|Year : 2015 | Volume
| Issue : 1 | Page : 39-45
Blood pressure indices, life-style factors and anthropometric correlates of casual blood glucose in a rural Nigerian community
Augustine N Odili1, Emmanuel O Abatta2
1 Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Abuja, Nigeria; Department of Cardiovascular Diseases, Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, University of Leuven, Leuven, Belgium
2 Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
|Date of Web Publication||7-Jan-2015|
Augustine N Odili
Department of Internal Medicine, College of Health Sciences, University of University of Abuja, Main Campus, Off Airport Road, PMB 117, Garki, Abuja, Nigeria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Disordered blood glucose metabolism is associated with poor cardiovascular disease outcomes. Relationship between casual blood glucose (CBG) and blood pressure indices among rural dwellers in Nigeria has been less studied.
Methods: We measured CBG, anthropometry, systolic blood pressure (SBP) and diastolic blood pressure (DBP) pulse pressure (PP) and mean arterial pressure (MAP) and life-style cardiovascular risk factors.
Results: The mean (standard deviation) of CBG was 6.2 (1.9) and values were similar in men and women. Age, SBP, DBP PP, MAP, body mass index (BMI) and waist circumference were positively correlated with CBG; r = 0.23, 0.30, 0.24, 0.28, 0.28, 0.24 and 0.22 respectively. In a multivariate analysis, only PP and BMI predicted CBG. A 5 mmHg increase in PP or a 2 kg/m 2 increase in BMI increased CBG by 0.15 or 0.18 mmol respectively. PP and BMI in combination explained 13% of the variation in CBG (P < 0.001).
Conclusion: PP and BMI are associated with CBG among rural dwellers in South-East Nigeria.
| Abstract in French|| |
Contexte: Trouble le métabolisme du glucose sanguin est associé avec pauvres cardiovasculairesmaladierésultats. Relation entre la glycémie occasionnels (CBG) et des indices de tension artérielle chez les habitants des zones rurales au Nigéria a été moins étudiée.
Méthodes: Nous avons mesuré la CBG, anthropométrie, systolique artérielle (SBP) et diastolique artérielle pression différentielle (DBP) (PP) et signifie artériel pression (carte) et facteurs de risque cardiovasculaire de style de vie.
Résultats: La moyenne (écart-type) de la CBG a 6.2 (1,9) et les valeurs étaient similaires chez les hommes et les femmes. Âge, SBP, DBP PP, carte, indice de masse corporelle (IMC) de et tour de taille étaient corrélés avec CBG ; r = 0,23, 0,30, 0,24, 0,28, 0,28, 0,24 et 0,22 respectivement. Dans une analyse multivariée, seulement le PP et le BMI prédit CBG. Une augmentation de 5 mmHg en PP ou une augmentation de 2 de 2 kg/m IMC augmenté respectivement de CBG 0,15 ou 0,18 mmol. PP et BMI en combinaison a expliqué 13 % de la variation de la CBG (P < 0,001).
Conclusion: PP et IMC sont associées à la CBG parmi les habitants des zones rurales au Nigéria du sud-est.
Mots-clés : Cardiovascular risk, casual artérielle impulsion de glucose, nigérians, ruraux
Keywords: Cardiovascular risk, casual blood glucose, Nigerians, pulse pressure, rural dwellers
|How to cite this article:|
Odili AN, Abatta EO. Blood pressure indices, life-style factors and anthropometric correlates of casual blood glucose in a rural Nigerian community. Ann Afr Med 2015;14:39-45
|How to cite this URL:|
Odili AN, Abatta EO. Blood pressure indices, life-style factors and anthropometric correlates of casual blood glucose in a rural Nigerian community. Ann Afr Med [serial online] 2015 [cited 2021 Jan 19];14:39-45. Available from: https://www.annalsafrmed.org/text.asp?2015/14/1/39/148735
| Introduction|| |
Nigeria and indeed many countries of sub-Saharan Africa faces an emerging epidemic of non-communicable diseases of which cardiovascular diseases (CVDs) are major contributors. It is currently estimated that 80% of global deaths due to non-communicable diseases occur in low and middle income countries and deaths due to CVDs account for 30% of this number.  Most of these deaths and disabilities occur in people at the most productive stage of their life resulting to a huge negative economic impact on society.
Disorders of glucose metabolism including undiagnosed Type 2 diabetes mellitus are recognized risk factors for CVDs. This synergistic relationship is strongly supported by the evidence from a collaborative DECODE study , which analyzed both all-cause and cardiovascular mortality in 27,714 subjects who had baseline glucose estimation and were followed-up for at least 11 years. People with diabetes mellitus and impaired glucose tolerance identified by 2 h post-glucose load had increased mortality while high fasting plasma glucose alone was not predictive once 2 h post-glucose is taken into consideration. In addition, increasing level of hemoglobin A1c, a maker of glucose metabolism over a longer period of time is associated with increasing CVD risk in several observational and outcome studies. ,
Recent observational studies indicate that the burden of CVD is increasing in Nigeria. ,,, Most authors adduce this to increasing westernized lifestyle and urbanization as a rural to urban gradient exits as regards the cardiovascular risk factors. Less attention is therefore paid to the fact that despite the rural-urban difference in CVD burden, the prevalence of risk factors like obesity  is substantially high in the rural areas. Consequently, the synergistic relationship between disorders of glucose metabolism and CVDs are less studied in the rural areas. We therefore set out to evaluate the relationship between casual blood sugar and anthropometric characteristics and blood pressure indices in a group of rural dwellers in South-Eastern part of Nigeria.
| Methods|| |
Ihite Aforukwu is a small rural community located about 40 km from Owerri, the capital city of Imo State in South-Eastern Nigeria. Residents are either subsistence farmers or involved in small scale trading within the neighboring communities. Most of the residents have been living within the community since birth except for a few who retired to the village having worked in the cities.
Ihite Aforukwu sits in typical rainforest vegetation; precipitation and temperature ranges from 2 to 20 mm and 21-34°C respectively with the highest precipitation experienced between July and September.
Training of field workers
Under the framework of Nigerian Population Research on Environment Gene and Health a cardiovascular assessment was incorporated in a yearly health promotion campaign at Ihitteafoukwu in Ahiazu-Mbaise Local Government area of Imo state, Nigeria. Two months to the exercise, three registered nurses who were indigenes of the community were trained on blood pressure measurement according to the European Society of Hypertension (ESH)/European Society of Cardiology guidelines. Training also covered other aspects of the protocol including questionnaire administration, anthropometric examination and blood glucose estimation using Accu-Check glucometer.
The field work was carried out in December 2012. All adults aged 18 years and above living in the community were invited to participate in the 2 day health screening exercise. 122 adults who consented were included in this analysis. We used a structured investigator administered a questionnaire to inquire into the medical history, smoking habits, alcohol consumption and intake of medications The Health Research Ethical Committee of University of Abuja Teaching Hospital, gave ethical approval and the study complied with guidelines involving research with human subjects as outlined in the Helsinki declaration. 
Blood pressure measurement
Trained observers measured blood pressure with a standard mercury sphygmomanometer 3 times consecutively. The guidelines of the ESH/European Society of Cardiology  were applied. Standard cuffs had a 12-24 cm inflatable bladder, but, if upper arm circumference exceeded 31 cm, a larger cuff with 15-35 cm bladder was used. After at least 10 min rest, three consecutive blood pressure readings were obtained in the sitting position with an interval of 30-60 s between readings. The cuff was deflated at approximately 2 mmHg/s and systolic blood pressure (SBP) and phase V diastolic blood pressure (DBP) were recorded to the nearest 2 mmHg. Each subject's blood pressure was the mean of the 3 readings and pulse pressure (PP) determined as the difference between SBP and DBP; mean arterial pressure (MAP) as diastolic pressure +1/3 PP.
Blood glucose estimation
Irrespective of the time of last meal, capillary blood was obtained by pricking the index finger. Blood was allowed to drop freely on the test strip already inserted on an Accu-Check glucometer without squeezing the pricked finger. The reading was expressed in mmol/l as the casual blood sugar.
Anthropometry and lifestyle factors
With the shoes off and light clothing and no cap or head gear, height and weight were measured with a standard stadiometer; to the nearest 0.2 cm and 0.1 kg respectively. The waist circumference (WC) was measured with a non-expansible tape without clothing or light clothing in between the lower coastal margin and the iliac crest with the arm relax by the side.
Investigator administered questionnaire was used to collect information on alcohol consumption, past and present cigarette smoking perceived stress as modified from the Cohen et al. perceived stress scale  and physical activity as modified from the International Physical Activity Questionnaire. 
SAS software (SAS institute, Cary, NC, USA), version 9.3 was used for database management and statistical analysis. The central tendency and spread of the data were reported as mean and standard deviation (SD). Normality of continuously distributed variables was evaluated by the Kolmogorov-Smirnov.  Skewness and Kurtosis were computed as the third and fourth moments about the mean. We used Student's t-tests to evaluate differences between paired and unpaired samples. We used a Pearson correlation to determine correlation between blood pressure indices; life-style factors and casual blood glucose (CBG). A stepwise multiple linear regression was used to analyze the relationship in a model that included CBG as dependent variable and all the other factors studied as independent variable. A stepwise approach was used and the P value for any variable to remain in the model was set at 0.15. For a variable to be significantly associated with casual blood pressure, a P value of change in R2 must be 0.05 or less.
| Results|| |
Characteristics of participants
The 122 participants included 67 (54.9%) women; their age averaged 54.7 and ranged between 19 and 80 years. 23 (18.9%) had greater than 6 years of formal education and 90 (73.8) reported experiencing moderate to severe level of stress. Both cigarette smoking and alcohol consumption were significantly higher among men when compared with women. 66 (54.1%) and 10 (8.2%) of all participants had hypertension and diabetes mellitus respectively; with no significant gender difference. The men were significantly older (59.8 vs. 50.5 years) and had higher body mass index (BMI) (25.9 vs. 27.8 kg/m 2 ) than women; P < 0.001 and 0.05 respectively. The mean (SD) SBP, DBP, PP and MAPs were 133.2 (26.8), 78.8 (12.9), 54.4 (17.4) and 96.9 (16.8) mmHg respectively and all the blood pressure indices showed a trend toward higher values in men than women. The mean (SD) of CBG was 6.2 (1.9) and there was no significant gender difference. Other characteristics are as shown in [Table 1].
Correlates of CBG
As it has shown in [Table 2], CBG has a positive correlation with age, BMI, WC and systolic, diastolic, PP and MAP. The Pearson correlation coefficients, r (P value) were 0.23 (0.02); 0.24 (0.02); 0.22 (0.03); 0.30 (0.002); 0.24 (0.01); 0.28 (0.004) and 0.28 (0.004) respectively. None of the life-style factors correlated with CBG [Table 2].
In the multivariate analysis, only PP (β = 0.030, P < 0.001) and BMI (β =0.088, P < 0.05) were found to be significantly associated with CBG. Increasing PP by 5 mmHg or BMI by 2 kg/m 2 was associated with a 0.15 and 0.18 mmol/l increase in CBG respectively. PP and BMI together explained 13% of the variation in CBG; 9% of which is attributed to PP alone [Table 3].
The relationship between PP and CBG appear to be J shaped with the rise in PP becoming steep and apparent at the blood glucose level of about 6.0; in both younger (<50 years) and older (>50 years) participants [Figure 1] and [Figure 2]. The rise in PP with increasing BMI showed a continuous relationship in all participants [Figure 3]. This relationship was maintained when subjects were separated into younger (<50 years) and older(>50 years) age groups [Figure 4]. The rise in casual blood sugar [Figure 5] is continuous across all ranges of BMI classes (overweight; 26 30 kg/m 2 through to obese; >30 kg/m 2 ).
|Figure 1: Mean pulse pressure against mean casual blood glucose in quintiles for 122 participants|
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|Figure 2: Mean pulse pressure against mean casual blood glucose in quintiles of participants aged <50 years (dots) and ≥50 years (square)|
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|Figure 3: Mean pulse pressure in participants with mean body mass index in three categories; <25 kg/m (normal) 25-30 kg/m2 (overweight) and >30 kg/m2 (obese)|
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|Figure 4: Mean pulse pressure with mean body mass index in three categories; <25 kg/m2 (normal) 25-30 kg/m2 (overweight) and >30 kg/m2 (obese) in participants <50 years (dots) and ≥50 years (square)|
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|Figure 5: Casual blood glucose with mean body mass index in three categories; <25 kg/m2 (normal) 25-30 kg/m (overweight) and >30 kg/m2 (obese) in participants <50 years (dots) and ≥50 years (square)|
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| Discussion|| |
In our present study, CBG was significantly associated with PP and BMI. Both variables explained about 13% of the variation in CBG. The association of PP or BMI was independent of the other confounding variables such as age, sex, alcohol consumption, educational qualification and psychosocial stress.
Both earlier ,, and more recent ,, studies indicated that prevalence of hypertension in diabetic individuals is about two fold that in the non-diabetic population. Population data from Nigeria evaluating the prevalence of hypertension in diabetes patients are lacking but a clinic based observational study  in Lagos, South West Nigeria indicated that 10% of patients visiting the medical out-patient department had concomitant hypertension and diabetes. Diabetes and hypertension acts synergistically to cause many CVDs. Hypertension causes a fourfold increase in cardiovascular risk in people with diabetes and presence of diabetes on the other hand doubles the CVD risk in hypertensive men and more than triples the risk in women. 
The pathophysiological mechanisms explaining the relationship between disorders of glucose metabolism and increasing blood pressure and other CVDs has been linked to insulin resistance and hyperinsulinemia in a wide range of experimental ,,,, and clinic studies. ,,,, Hyperinsulinemia has been associated with increased renal reabsorption of sodium,  sympathetic nervous system over activity, , increased activation of renin-angiotensin system,  endothelial dysfunction; , and small  and large ,, artery remodeling. Aortic, carotid and coronary blood vessels are all involved in the remodeling process. Aortic stiffening increases the pulse wave velocity and thus augments the second systolic peak, resulting in an elevation of SBP and an increase in PP.  In our present study, PP was independently associated with casual blood sugar and thus supports the notion that the dysglycemia is also an important CVD risk even among rural dwellers in Nigeria.
Abnormalities in the structure and function of adipose tissue have been identified as early events that prelude the development of insulin resistance and hyperinsulinemia hence obesity is the key driver in the cardiovascular continuum of disordered glucose metabolism. The mean BMI, 27 kg/m 2 obtained in this present study was higher than reported in cross-sectional population studies in rural communities in Western  and Northern  regions of the country. The reason for this discrepancy is not clear but the possibility of increasing urbanization of rural areas of the South-Eastern region of Nigeria as documented in the reports of the National Bureau of Statistics  offers a possible explanation. In the 2010 report of the harmonized standard of living in Nigeria, the South-East region has the highest number of people who are self-employed in non-agricultural activities. The implication is that involvement in agrarian activities, a hallmark of a rural residency may be dwindling in that region.
Our current results must be interpreted within the context of its potential limitations. First, our present report is based on relatively small sample size since it is an on-going project. This study however is meant to open up research interest into the study of cardio-metabolic diseases in rural areas of Nigeria which were presumed hitherto to be free of CVDs. Furthermore, we applied a validated protocol of blood pressure measurement and maintained a strict quality control program. 
We measured casual blood sugar as against the diagnostic gold standard of oral glucose tolerance test. Measurement of casual blood sugar is cheap and convenient and thus could easily be translated to everyday clinical practice in such resource poor setting. In addition, it has been reported that casual blood sugar measurement could identify undiscovered diabetic patients in a general Nigerian urban population. 
Our study raises some important public health issues. The common CVDs seen in the urban areas of Nigeria may equally be rising in the rural communities especially in the South-Eastern Nigeria. Primary prevention strategies being advocated for the urban communities should thus be extended to the rural ones. Prevention of CVD should include screening for disordered glucose metabolism. Glucometers for capillary blood glucose estimation are cheap and do not require high technical know-how to operate. We therefore advocate a paradigm shift in the cardiovascular primary prevention strategies in Nigeria to include blood glucose estimation as the cost of screening the entire population by measurement of CBG far outweighs the cost of managing cardiovascular complications of diabetes.
| Acknowledgments|| |
The authors gratefully acknowledge the support of Chioma Onuoha, Faith Nwachukwu, Ozioma Egbujor, Adaeze Ike, Ikechukwu Duru and Dimeke Onyebuchi in mobilizing the community.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]