|Year : 2020 | Volume
| Issue : 4 | Page : 348-356
Hypercholesterolaemia among urban residents in Lagos State: The knowledge, attitudes, prevalence and risk factors
Rosemary Oyindamola Babafemi1, Oluwakemi Ololade Odukoya1, Kolawole John Sodeinde2, Olayinka Olufunmi Ayankogbe1, Oluseyi Adegoke3
1 Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Lagos State, Nigeria
2 Department of Community Medicine, Babcock University, Ilisan, Ogun State, Nigeria
3 Internal Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Lagos State, Nigeria
|Date of Submission||24-Jul-2020|
|Date of Decision||31-Jul-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||04-Nov-2020|
Dr. Oluwakemi Ololade Odukoya
Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Lagos State
Source of Support: None, Conflict of Interest: None
Background: Hypercholesterolaemia, a modifiable risk factor for cardiovascular disease (CVD), is particularly increasing in urban areas of underdeveloped nations. This research assessed the knowledge of, attitude towards, prevalence of and risk factors for hypercholesterolaemia in an urban local government area of Lagos State. Methods: This descriptive cross-sectional research was conducted among 229 adult residents who were selected through a multistage sampling method. Data were collected with a structured interviewer-administered questionnaire. Anthropometric measures were assessed using standard tools while the lipid profile was assessed by finger pricks using a CardioChek® professional analyser. Participants with knowledge scores of at least 50% were considered as having good knowledge and scores below 50% were considered as poor knowledge. Data analysis was done using SPSS version 20.0. P < 0.05 was taken as statistically significant. Results: The mean age of the respondents was 38.9 ± 4.6 years. More than a third 89 (38.9%) of the respondents had high blood total cholesterol, 39 (17.0%) had high low-density lipoprotein and 8 (3.4%) had high triglycerides. Overall, 110 (48.0%) of the participants had good knowledge of hypercholesterolaemia and 131 (57.2%) of them had positive attitudes towards hypercholesterolaemia as a risk factor of CVD. Being a female (odds ratio [OR] = 2.16; 95 confidence interval [CI] = 1.19–3.91) and consumption of baked food (OR = 1.94; 95% CI = 1.054–3.57) were significant predictors of high cholesterol among respondents. Conclusion: Cholesterol levels were high in this sample of urban Nigerians. Overall, 110 (48.0%) of the respondents had a good level of knowledge while 131 (57.2%) had positive attitudes. Being a female and consuming baked food were significant predictors of high cholesterol among the respondents. This calls for gender-specific interventions for women and health education on dietary modification.
Keywords: Cardiovascular disease, hypercholesterolaemia, knowledge, Lagos State, prevalence
|How to cite this article:|
Babafemi RO, Odukoya OO, Sodeinde KJ, Ayankogbe OO, Adegoke O. Hypercholesterolaemia among urban residents in Lagos State: The knowledge, attitudes, prevalence and risk factors. Niger Postgrad Med J 2020;27:348-56
|How to cite this URL:|
Babafemi RO, Odukoya OO, Sodeinde KJ, Ayankogbe OO, Adegoke O. Hypercholesterolaemia among urban residents in Lagos State: The knowledge, attitudes, prevalence and risk factors. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 24];27:348-56. Available from: https://www.npmj.org/text.asp?2020/27/4/348/299906
| Introduction|| |
Worldwide, many disabilities and premature mortalities are caused by cardiovascular disease (CVD). Over 80% cases of CVD all over the world occur in third world countries. Hypercholesterolaemia has been described as the cause of one-third of ischaemic heart disease globally. In general, increased levels of cholesterol are assessed to be responsible for 2.6 million mortalities (4.5% of total) and 30 million disability-adjusted life years (DALYS) or 2.0% of total DALYS. High level of cholesterol is an important contributor to disease prevalence both in developing and developed climes and a major risk factor of CVD.
CVDs occur due to several risk factors. Hypercholesterolaemia, which is high blood cholesterol levels, is a main modifiable metabolic risk factor for atherosclerotic CVD., Hypercholesterolaemia follows disorders in fat metabolism which leads to alterations in lipid concentrations in the blood and typically includes elevated low-density lipoprotein (LDL) cholesterol. It may be primary or more frequently occur due to interaction of genes, food and other factors such as sedentary lifestyle or smoking.
At present, sub-Saharan Africa nations are undergoing a fast epidemiological transition with increasing urbanisation, westernisation and a changing lifestyle associated with unhealthy diets often rich in cholesterol., These have caused a rise in new cases of CVD, particularly in urban areas. Further, the bulk of people with the disease are often asymptomatic and present with complications making treatment more difficult and costly. Prevention, therefore, remains a cost-effective approach, against the backdrop of scarce health resources and weak health systems prevalent in many low-and middle-income countries including Nigeria.
Knowledge of hypercholesterolaemia and its associated health risks may be significant contributors to the effective management of the disease, as it may influence the early adoption of healthy low-fat diets and other pharmacologic and non-pharmacologic preventive measures. In a similar vein, a patient's attitude has been shown to be an important factor in determining their adherence to dyslipidaemic medications. Although CVD risk factors are widespread among the Nigerian adult populace, community-based data on the knowledge, attitudes and prevalence of cholesterol are sparse.
This research assessed the prevalence, knowledge of and attitude towards high blood cholesterol and its risk factors among urban residents of Lagos State, Southwest Nigeria. It is hoped that our findings will inform the design and execution of intervention programs to address hypercholesterolaemia among urban residents.
| Methods|| |
Study area, study design and population and sample size estimation
This descriptive cross-sectional study was conducted among urban residents in Lagos State, Nigeria. The state is comprised of 20 local government areas (LGAs) among which 12 are urban LGAs. Lagos State has a land mass of 3577 km2 with a population of 9,113,605 among which 5, 295,476 were above 19 years according to the 2006 census. The projected population for the state in 2016 was 12,550,600. Oshodi-Isolo was purposively selected among the urban LGAs for the study. The LGA had a population of 629,061 according to the 2006 census and a projected population of 866,300 in 2016.
Participants were adult residents aged 18 years and older and had resided in the area for at least 6 months. A minimum sample size of 206 was estimated using the Cochran formulan = z2pq/d2, where n is the desired sample size, z is the normal standard deviation set at 1.96 (for 95% confidence level), P is the prevalence of the characteristic of the study, q is 1.0 − p and d is the desired degree of accuracy taking as 0.05. The prevalence (p) was taken as 16% being prevalence of elevated LDL cholesterol among people living people living in a semi-urban area of Ekiti State, Southwest Nigeria. A 10% non-response rate was projected and added to the sample, making the minimum sample size to 229. The LGA is administratively divided into two constituencies: Constituency 1 which is made up of 5 wards and Constituency 2 which is made up of 6 wards. A multistage sampling method was employed to select eligible participants. First, a simple random sampling method (balloting) was used to select three wards from each of the two constituencies making a total of six selected wards. Then, a simple random sampling method was used to select ten streets from each ward after enumerating the 264 streets in the six selected wards. In total, 60 streets were selected. All residential houses on each selected street were enumerated. Then, a systematic sampling method was used to select four houses on each street. The first house on each street was selected by simple balloting. A systematic sampling method was then used to select the next house, and this process was continued until the last number was reached. Then, a simple random method was used to select households in houses with more than one household. In a house with just one household, the household was automatically selected. Respondents in households who met the eligible selection criteria were selected by simple random sampling.
Data collection instruments and study measures
A pre-tested, structured questionnaire administered by trained interviewers was used to elicit data for this study. The questionnaire was adapted from the WHO STEPS instrument and from previous related studies., The questionnaire elicited information on demographic attributes such as sex, age and ethnicity; knowledge of hypercholesterolaemia and its health risk, attitudes towards hypercholesterolaemia as a risk factor for CVDs, risk factors for hypercholesterolaemia including behavioural risk factors such as dietary habits, tobacco and alcohol use; physical measurements such as anthropometric parameters and blood pressure and biochemical measurements such as blood lipids.
Blood pressure values (systolic and diastolic) were measured thrice using a digital blood pressure machine (Omron®, Australia), with the participant seated in a relaxed position. The first blood pressure measurement was discarded, recording the mean of the second and third measurements. Waist circumference (WC) measurement was taken halfway between the iliac crest and coastal margin. Weight and height were measured with a weighing scale and a wall-mounted stadiometer, respectively. These weight and height measurements were used in calculating the body mass index (BMI).
We collected fresh capillary whole blood by finger prick for the measurement of blood cholesterol levels. Lipid profile was then measured using CardioChek® professional analyser following the manufacturer's instructions. All participants fasted overnight for 8 h or more before the fasting blood samples were collected. Those who did not fast up to the given timeline were categorised to be tested using a random blood sample according to the American Diabetes Association.
Measurements of the particular exposures to risk factors were defined thus:
Dietary patterns: Dietary patterns of respondents were assessed by asking questions about how often they consumed various foods such as fruits vegetables, meat and poultry products which have different saturated fat contents.
Smoking: Smoking of any quantity of cigarettes/tobacco within the last 30 days.
Excessive alcohol: Consumption of 5 or more bottles while drinking on a typical day.
Low (inadequate) physical activity: Physical activity of fewer than 3 days a week for at least 150 min., Physical activities above this level is considered as adequate.
Hypertension was classified as a systolic blood pressure reading of 140 mmHg and above and/or diastolic blood pressure of 90 mmHg and above. Assessment of obesity was done using BMI and WC. BMI of <18.5 kg/m2 was categorised as underweight, 18.5–24.9 kg/m2 (normal weight), 25.0–29.9 kg/m2 (overweight) and above 30 kg/m2 (obese). WC of over 94 cm in males and over 80 cm in females was also considered obese based on the threshold for sub-Saharan ethnicity by the Joint Scientific Statement on Harmonizing the Metabolic Syndrome.
Classification of the lipid profile parameters (total cholesterol [TC], LDL cholesterol, triglyceride [TG] and high-density lipoprotein [HDL]) cholesterol followed the International Diabetes Federation criteria: boundary values of ≥200 mg/dl for total cholesterol signifies hypercholesterolaemia, ≥150 mg/dl (hypertriglyceridaemia), >130 mg/dl (high LDL), ≤40 mg/dl (low HDL among men) and ≤50 mg/dl (low HDL among women).
Knowledge of high cholesterol: Eleven questions were assessing the participants' knowledge of hypercholesterolaemia, each with three mutually exclusive options of 'yes', 'no' or 'I don't know' and scored. Participants who responded correctly were awarded a score of '1' while all other responses were scored '0'. The total score was converted to percentages with the cut-off score set at 50%. Participants with scores of at least 50% were considered as having good knowledge while participants with scores below 50% were considered as having poor knowledge.
Attitudes towards high cholesterol: There were 8 questions assessing participants' attitudes towards hypercholesterolaemia on a 3-point Likert scale – The scoring was done as follows: For every positive statement, 'Agree' = 3, 'Indifferent' = 2 and 'Disagree' = 1. These scores were reversed for negative statements, that is, 'Disagree' = 3, 'Indifferent' = 2 and 'Disagree' = 1. Respondents who had a score of 3 in 4 or more of the 8 questions were graded as having an overall positive attitude while those who had a score of 3 in < 4 of the 8 questions were graded as having an overall negative attitude.
The data were analysed using the Statistical Package for the Social Sciences Version 20. 0 (IBM SPSS Inc., Chicago, IL). and presented as means and standard deviations for continuous variables and percentages for categorical variables. Chi-square test was used to assess the relationship between high cholesterol levels and other variables such as knowledge, attitude, physical activities and alcohol intake. Respondents were classified into two groups, those having high levels of cholesterol (≥200 mg/dl) or normal (<200 mg/dl). Independent factors such as tobacco smoking, alcohol consumption, physical inactivity, obesity, blood pressure and family history were converted into dichotomous variables using the cut-off points based on the measures stated above. Independent variables significant during bivariate analyses were inputted into a regression model to determine the predictors of high cholesterol. P < 0.05 was taken as statistically significant.
Ethical approval for the study was obtained from the Health Research and Ethics Committee (HREC) of the Lagos University Teaching Hospital (ADM/DCST/HREC/APP/2412). The approval was given on 19 July 2018. Both written and verbal informed consent was gotten from all the participants. Data collection was from 21 July to 26 August 2018.
| Results|| |
[Table 1] shows that the mean age of respondents was 38.9 ± 4.6 years. There were more females 127 (55.5%) than males 102 (44.5%). A little over half 120 (52.4%) of the respondents had up to tertiary education while only a few 3 (1.3%) had no formal education. The majority 186 (81.2%) of the respondents were employed with the highest proportion 80 (34.9%) being in private establishments. Less than half 100 (43.7%) were earning a monthly income of < N50,000. A quarter 56 (24.5%) of the respondents had parents or close relatives with heart conditions, however, only two respondents (0.9%) had parents or close relatives with high cholesterol.
[Table 2] shows that two-third of the respondents 153 (66.8%) knew about cholesterol. The most commonly known risk factors for hypercholesterolaemia were unhealthy diet and overweight which were identified by 127 (55.5%) and 125 (54.6%) of the respondents, respectively. Less than half of the respondents identified tobacco smoking and inactivity (101, 44.1% in each case) as risk factors for hypercholesterolaemia. The least known risk factor for hypercholesterolaemia was large WC (central obesity) which was recognised by less than one-third 69 (30.1%) of the respondents. Overall, 110 (48.0%) of the respondents had a good level of knowledge while 119 (52.0%) had poor knowledge.
|Table 2: Knowledge of hypercholesterolaemia as a risk factor of cardiovascular diseases (n=229)|
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[Table 3] shows respondents' attitudes towards hypercholesterolaemia as a risk factor for CVDs. The majority 200 (87.3%) disagreed that tobacco smoking is good for health. Less than half 103 (45.0) of the respondents agreed with the fact that physically active people are less likely to have raised blood cholesterol levels while 39 (17.0%) disagreed. The remaining 87 (38.0%) were indifferent to the statement. More than half 125 (54.6%) agreed that blood cholesterol levels could be controlled by eating healthy diets while a few 21 (9.2%) disagreed. In all, 131 (57.2%) of the respondents had positive attitudes while 98 (42.8%) had negative attitudes.
|Table 3: Attitudes towards hypercholesterolaemia as a risk factor for cardiovascular diseases|
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[Table 4] shows that there were statistically significant associations between consumption of meat (P = 0.003), salt (P = 0.009) and baked food (P = 0.012) with total cholesterol. There were however, no statistically significant associations between consumption of fried food (P = 0. 82), sugary drinks (P = 0.26), vegetables (P = 0.86), water (P = 0.48) and consumption of nuts (P = 0.83).
|Table 4: Dietary patterns of the participants and serum cholesterol levels|
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[Table 5] also shows associations that were statistically significant between total cholesterol levels and age (P = 0.039), gender (P = 0.003) and frequency of participation in sports and fitness activities (P = 0.02). Nevertheless, there were no statistically significant associations between educational status (P = 0.432), employment status (P = 0.817), overall physical activity (P = 0.790), current smoking status (P = 0.530), age of initiation of smoking (P = 0.08), the frequency of smoking (P = 0.72), current alcohol consumption status (P = 0.532), frequency of alcohol consumption (P = 0.3) and quantity of alcohol consumed (P = 0.63) with level of cholesterol. A higher proportion of respondents who were below 40 years old (n = 93, 67%) had more normal cholesterol than those who were at least 40 years old (n = 49, 53.8%). A higher proportion of males (n = 74, 72.5%) had more normal cholesterol as compared to females (n = 68, 53.5%).
[Table 6] shows that being a female (odds ratio [OR] = 2.16; 95 confidence interval [CI] = 1.19–3.91) and consumption of baked foods (OR = 1.94; 95% CI = 1.054–3.57) were significant predictors of high cholesterol among respondents.
Physical and biochemical measurements of the respondents
Over half of the respondents had normal systolic and diastolic blood pressure < 120 mmHg (54.1% and 59.4%, respectively). Less than one-fifth (17.0%) had systolic blood pressure of 120–139 mmHg (pre-hypertension) while over a quarter (26.6%) had diastolic blood pressure within this range. Less than one-third (28.8%) and over one-tenth (12.2%) had systolic and diastolic hypertension, respectively. Using BMI, half 116 (50.7%) of the respondents had normal weight, a quarter 58 (25.3%) of the respondents were overweight, while a little over one-fifth (21.0%) were obese. Only a few 7 (3.1%) had underweight. Just above one-third 79 (34.4%) and one-tenth (10.3%) of male respondents had normal and high waist/hip ratio, respectively, while two-fifth 92 (40.1%) and less than one-fifth 35 (15.2%) of the female respondents had normal and high waist/hip ratio respectively. Majority 158 (69.0%) of the respondents had normal WC while less than one-third 71 (31.0%) had high WC. Almost two-fifth 89 (38.9%) of had high blood cholesterol while 140 (61.1%) had normal blood cholesterol, 39 (17.0%) had raised LDL and a few 8 (3.4%) had high TGs. HDL was normal in three-quarter 173 (75.5%) of the respondents and low in 56 (24.5%) respondents [Figure 1].
| Discussion|| |
Hypercholesterolaemia is chiefly responsible for the development and progression of atherosclerosis, and it is a significant risk factor for early coronary artery disease. Findings from this study showed that about two-fifth of the respondents had hypercholesterolaemia, and a quarter of the respondents had low HDL; 17.0% of the respondents had high LDL while a few (3.4%) had high TG levels. The lipid profile reported in our study was different from what was reported in a similar study in Asaba, Nigeria, where only 5.0% had hypercholesterolaemia and 51.0% had elevated LDL three times the values of LDL reported in our study. Low HDL was the most common lipid disorder reported in the study in Asaba occurring in three-fifth of the participants. The differences in the lipid pattern of respondents in our study and the study in Asaba may be a result of cultural diversity since the two study areas are from different geopolitical zones of Nigeria. Moreover, the participants in Asaba were older and they were all professionals unlike the participants in our study who were selected from the general population.
Gender-related differences have been reported in the pathophysiology, diagnosis and treatment of lipid disorders. Gender is strongly associated with the serum concentration of lipid fractions such as LDL, and men are known to have more risk as compared to women., This may be partly because oestrogen is protective among women reducing TC and LDL and increasing HDL. Contrary to this, our study reported higher cholesterol levels among women as compared to men. A study in Southeast Nigeria among rural dwellers and from a 7-year hospital database in India reported similar findings where lipid abnormalities were found more among women. Several reasons may be postulated for higher cholesterol levels among the women in our study. First, the female participants were older with a mean age of 40.1 ± 13.4 as compared to the male counterparts who had a mean age of 37.4 ± 13.0. This older age could have contributed to the higher cholesterol levels reported among the females in our study. Second, certain physiological stages like menopause are associated with lipid profiles characterised by higher serum concentrations of TC, LDL and TG, and several Nigerian studies have reported that women reached the age of menopause in their 40s., Furthermore, women who have had hysterectomy have also been shown to have increased risk of TC.
Increasing age is associated with higher atherogenic lipid levels like LDL., Several studies have described age as the most significant contributor of dyslipidaemia with positive correlations with TC, LDL and TG concentrations and negative correlations with HDL., Besides, older adults with dyslipidaemia also often have hypertension, diabetes and obesity, and this makes its management critical in the effort to reduce cardiovascular risk. According to the American Heart Association, adults should check their cholesterol levels every 4–6 years, beginning from age 20 when cholesterol level starts to rise. As with previous similar studies,, our study observed a direct relationship between age and TC. Total cholesterol was significantly higher among participants 40 years and above as against those below 40 years.
Knowledge and attitude towards high cholesterol levels and its risk factors are important for effective management of the condition. It has been documented that people change their eating habit with particular focus on reduction in dietary fat intake. However, our study revealed poor knowledge and attitude among the participants, and this may explain the high prevalence of hypercholesterolaemia reported in this study.
Studies have shown that the increasing consumption of diets of modern Western societies promotes raised cholesterol levels and weight gain., Our study found consumption of baked food to be a significant predictor of high cholesterol levels. We also observed that higher proportions of those who were overweight had abnormal cholesterol levels compared to those who were not overweight. This was, however, not statistically significant. We also did not record a relationship between income, education and smoking as documented in similar studies.,, Our study calls for educational interventions for women in the context of increased awareness and lifestyle modifications for risk factors for raised cholesterol levels. Dietary modifications should also be emphasised.
This study has some limitations. Cholesterol levels were collected as a one-time event and hourly or within-person variations were not accounted for. Second, because the study was cross-sectional in nature, assessment of temporal relationships between risk factors and cholesterol levels could not be established.
| Conclusion|| |
Hypercholesterolaemia was prevalent among these respondents. The most commonly known risk factors for hypercholesterolaemia were unhealthy diet and overweight. The knowledge of and attitude towards hypercholesterolaemia as a risk factor for CVDs were poor. High cholesterol levels were more common among women and those who were older. Being a female was the only significant predictor of high cholesterol among respondents. This study calls for the adoption of gender-specific interventions to raise awareness and promote lifestyle modifications and prevent raised cholesterol levels.
The protected time for the contribution of OO (Oluwakemi Odukoya) towards the research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under the Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]