Dyslipidaemia among African adults
Authors: Fred Stephen Sarfo
Journal: The Lancet Global Health (2018)

Dyslipidaemia is a pathophysiological state characterised by abnormalities in the metabolism of lipoproteins routinely detected as derangements in circulating concentrations of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides.1Stone NJ Robinson JG Lichtenstein AH et al.2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.Circulation. 2014; 129: S1-45Crossref PubMed Scopus (3082) Google Scholar As an established cardiometabolic risk factor, dyslipidaemia is potently associated with atherosclerotic cardiovascular diseases (CVDs), including stroke, coronary artery disease, and peripheral vascular disease, and substantially contributes to global morbidity and mortality.2GBD 2016 DALYs and HALE CollaboratorsGlobal, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and health life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1260-1344Summary Full Text Full Text PDF PubMed Scopus (1305) Google Scholar, 3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (2924) Google Scholar Sub-Saharan Africa is undergoing an epidemiological transition with a rapid rise in premature mortality from CVDs due to undetected and uncontrolled vascular risk factors, principally hypertension, diabetes, and dyslipidaemia.4Sarfo FS Akassi J Awuah D et al.Trends in stroke admission and mortality rates from 1983 to 2013 in central Ghana.J Neurol Sci. 2015; 357: 240-245Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar Deleterious consequences of dyslipidaemia have remained largely neglected in sub-Saharan Africa. The study by Jean Jacques Noubiap and colleagues5Noubiap JJ Bigna JJ Nansseau JR et al.Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysis.Lancet Glob Health. 2018; 6: e998-1007Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar is therefore timely as it provides the first comprehensive estimates of dyslipidaemia prevalence among Africans by use of a systematic review and meta-analysis. The authors reviewed 181 studies involving 309 207 participants from the community and individuals at high risk of CVD, including patients with hypertension, diabetes, HIV, and HIV receiving antiretroviral therapy. In the general population, the pooled prevalence was 41·1% for low HDL cholesterol, 25·7% for elevated LDL cholesterol, 23·6% for elevated total cholesterol, and 16·5% for elevated triglyceride concentrations. As expected, dyslipidaemia prevalence was significantly higher in groups at high risk of CVD: prevalence of elevated total cholesterol concentrations was 38·0% in patients with hypertension, low HDL cholesterol concentrations was 53·7% in patients with HIV, and elevated triglyceride concentrations was 35·5% in patients with diabetes. Dyslipidaemia prevalence was higher among urban dwellers than rural dwellers, which is consistent with the notion that urbanisation and adoption of westernised lifestyles among Africans are underpinning factors of the surge in CVDs. The authors included studies from all major regions in Africa thus enhancing the generalisability of their findings. This study5Noubiap JJ Bigna JJ Nansseau JR et al.Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysis.Lancet Glob Health. 2018; 6: e998-1007Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar fills an important knowledge gap in the literature by providing an overarching purview of the prevalence of dyslipidaemia in sub-Saharan Africa. The contribution of dyslipidaemia to the high and rising burden of CVDs in sub-Saharan Africa has become apparent. The Stroke Investigative Research and Educational Network study, the largest study on stroke in Africa using a case-control design, estimated the population attributable risk of dyslipidaemia for stroke occurrence among 2118 case-control pairs to be 35·8% (95% CI 25·3–46·2). Dyslipidaemia had the second highest population attributable risk for stroke after hypertension among West Africans—notably, the population attributable risk of dyslipidaemia for stroke among Africans younger than 50 years was higher than the population attributable risk among older patients with stroke (48·2% vs 33·6%).6Owolabi M Sarfo FS Akinyemi R et al.Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study.Lancet Glob Health. 2018; 6: e436-e446Summary Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 7Sarfo FS Ovbiagele B Gebregziabher M et al.Stroke among young west Africans: evidence from the SIREN, large multisite case-control study.Stroke. 2018; 49: 1116-1122Crossref PubMed Scopus (73) Google Scholar The study investigators showed a substantial difference between dyslipidaemia prevalence among stroke cases and stroke-free controls (78% vs 61%). Noubiap and colleagues could not provide data on the proportion of participants with combined abnormalities in lipid subfractions that constitute dyslipidaemia because this information was absent in most studies analysed. Different cutoffs for lipid subfractions were used in different studies that also affected their estimates, particularly for total cholesterol concentrations.5Noubiap JJ Bigna JJ Nansseau JR et al.Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysis.Lancet Glob Health. 2018; 6: e998-1007Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar Given that dyslipidaemia is defined as a composite disorder encompassing abnormalities in total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride concentrations, further studies would be required to provide this information. The key message from the study by Noubiap and colleagues is that the burden of dyslipidaemia among continental Africans is substantial and comparable with estimates from other regions of the world. The authors draw attention to the high prevalence of dyslipidaemia among patients with HIV: this observation has important clinical and policy implications. More than 70% of the 37 million individuals with HIV globally reside in sub-Saharan Africa and the emergent threat of dyslipidaemia in this population might further encourage governments to support provision of life-long lipid-lowering therapy to avert the occurrence of adverse cardiovascular events in this group at high risk of CVD. Health-care systems would need to be strengthened to ensure availability, access, and affordability of evidence-based medicines, notably statins for the control of dyslipidaemia in sub-Saharan Africa. To improve access and affordability of statin therapy across the continent, public–private partnerships between governments and pharmaceutical companies would be crucial over the coming decades. Interventions such as differential pricing, whereby pharmaceutical companies price their products according to socioeconomic status, has been piloted in Ghana.8Mobula LM Sarfo S Arthur L et al.A multicenter prospective cohort study to evaluate the effect of differential pricing and health systems strengthening on access to medicines and management of hypertension and diabetes in Ghana: a study protocol.Gates Open Res. 2018; 2: 6Crossref PubMed Google Scholar Furthermore, because of clustering of cardiometabolic risk factors such as hypertension and dyslipidaemia, efficacy and cost-effectiveness of cardiovascular polypills with generic or innovator-branded antihypertensive and lipid modifier therapies should be tested in low-income and middle-income countries in sub-Saharan Africa.9Sarfo FS Ovbiagele B Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART): a pilot trial concept for improving stroke outcomes in sub-Saharan Africa.J Neurol Sci. 2017; 377: 167-173Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar The wider scientific community would play a crucial role in providing more evidence on the biological and environmental determinants of a complex phenotype such as dyslipidaemia in a continent with extensive genetic and ethnic diversity. Therefore, the H3Africa Cardiovascular working group, a consortia of research teams working to address CVD within sub-Saharan Africa, is well positioned to provide data to fill in the knowledge gaps related to dyslipidaemia and other CVDs in Africa.10Peprah E Wiley K Troyer J et al.Building a platform to enable NCD research to address population health in Africa: CVD Working Group discussion at the Sixth H3Africa Consortium Meeting in Zambia.Glob Heart. 2016; 11: 165-170Crossref PubMed Scopus (11) Google Scholar I declare no competing interests. Prevalence of dyslipidaemia among adults in Africa: a systematic review and meta-analysisThe prevalence of dyslipidaemia is high in the general adult population in Africa. Ongoing efforts to reduce cardiovascular diseases in Africa should integrate effective detection and treatment of dyslipidaemia. Full-Text PDF Open AccessGetting to the heart of non-communicable diseasesAs we mourn the loss of our treasured author, reviewer, and International Advisory Board member Bongani Mayosi, whose contribution to the field of cardiology on the African continent was virtually unparalleled, we recall that cardiovascular diseases (CVDs) are the leading cause of death and disability globally. If their sheer burden is remarkable—they cause one in three deaths worldwide—so is the fact that some of their main risk factors—smoking, an unhealthy diet, lack of physical activity, and excessive alcohol consumption—are largely avoidable. Full-Text PDF Open Access