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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 22
| Issue : 1 | Page : 8-12 |
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Prevalence of metabolic syndrome in HIV-infected and Non-HIV infected Nigerian children in Jos
Abok Ibrahim Ishaya, Ige Olukemi
Department of Paediatric, Jos University Teaching Hospital, University of Jos, Lamingo, Plateau State, Nigeria
| Date of Submission | 16-May-2019 |
| Date of Decision | 25-Sep-2019 |
| Date of Acceptance | 14-Dec-2019 |
| Date of Web Publication | 20-May-2020 |
Correspondence Address:
Abok Ibrahim Ishaya
Department of Pediatrics, University of Jos, Plateau State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jomt.jomt_17_19
Background: Both Human Immune-deficiency Virus (HIV) and anti-retroviral (ARV) are associated with metabolic disorder. This study compared the prevalence of metabolic syndrome (MetS) among HIV and non-HIV infected children. Methods: This was a comparative cross-sectional study of 142 HIV infected and 142 HIV non-infected children. Socio-demographic and clinical data were collected. Blood pressure, height, weight abdominal circumference were assessed using standard procedure. Fasting blood samples were collected for blood glucose and blood lipid profile. Result: The mean age at diagnosis of HIV infection was 4.9 years and 140 children were on ARVs. Cumulatively, 23.9% of the non-HIV infected children compared to 16.2% of HIV children (P = 0.11) had one component of MetS. Abdominal obesity was prevalent in 3.5% of non-HIV compared to 0% of HIV infected children; high blood pressure (HBP) was present in 8.5% of non-HIV compared to 0.7% of HIV-infected children (P < 0.001). HIV-infected children had higher prevalence of hyper-triglyceridemia compared to non-HIV (9.3% compared 3.5% respectively; P = 0.05). Cumulatively the clustering of two components of MetS was prevalent in 2.8% each of HIV-infected and non-HIV-infected children. Atherogenic lipids (low high density lipo-protein and high triglyceride) was diagnosed in 2.8% versus 0.7% of HIV infected and non-infected respectively (P = 0.18). MetS was diagnosed in 0.7% of non-HIV infected children and none of the HIV infected children. Conclusion: While both HIV and non-HIV-infected children had a high prevalence of one component of the MetS, MetS is however uncommon in our study population.
Keywords: Children, dysglycemia, dyslipidemia, high blood pressure, HIV, metabolic syndrome
How to cite this article:
Ishaya AI, Olukemi I. Prevalence of metabolic syndrome in HIV-infected and Non-HIV infected Nigerian children in Jos. J Med Trop 2020;22:8-12 |
| Introduction | |  |
Antiretroviral (ARV) therapy has modified the natural course of HIV infection, allowing children to live a near normal and longer life.[1] It is well established that both ARV especially protease inhibitors and HIV infection caused either one or more of the following modifiable cardio-metabolic risk factors: dyslipidemia, dysglycemia, hypertension and lipodystrophy.[2] The clustering of these factors is termed metabolic syndrome (MetS), previously termed syndrome X by Reaven et al.[3] in 1988. Various working groups now consider the presence of any three findings of abdominal obesity, hypertension (HBP), hyperglycemia or insulin resistance, hypertriglyceridemia and decreased high-density lipoprotein cholesterol (HDL-C) as MetS.[4],[5] MetS doubles the risk of developing cardiovascular disease (CVD) and increases by six-fold the risk of type 2 diabetes. It also triples the risk of cardiovascular related mortality from coronary heart disease.[6],[7],[8] Previous studies have shown that the prevalence of MetS among HIV-infected adult patients ranges from 17.0% to 45.4%.[9] A prevalence of 28% and 25% for adult patients on ARV and ARV naïve individual was found in South East Nigeria.[10]
In Pediatric population dyslipidemia, dysglycemia have been documented even in our environment[11] but limited information is available on MetS amongst Nigerian children with and without HIV. This information is needed for a better clinical care that will reduce the cardio-metabolic burden later in life considering the medical, economic and psychosocial burden of both non-communicable disease and HIV infection.
Therefore, this study determined the prevalence of the individual components of MetS and MetS in HIV-infected and non-HIV-infected children.
| Methods | | |
Study site and population
This study uses secondary data generated from a study on the cardiovascular risk factor of HIV infected children receiving care at the JUTH/APIN HIV clinic which has a population of about 1000 children of which 200 are aged 6–18 years.[11] This clinic serves HIV-infected and HIV-exposed children living in and around Jos, Plateau state. Non-HIV infected children were enrolled from two schools in Jos to serve as controls.
Inclusion criteria
HIV-positive children aged 6–18 years were enrolled as cases and HIV-negative children, 6–18 years were enrolled into the control group following primary caregiver givers consent/assent
Exclusion criteria
Exclusion criteria included children <6 years of age and those with known chronic medical illness beside HIV.
Study design
Comparative cross-sectional design.
Sample size
One hundred and forty-two children per group were enrolled. This sample is enough to give a power of over 90%, at an alpha of 5% and to detect an effect of 0.5.
Sampling technique
One hundred and forty-two HIV-positive children were selected consecutively in the Paediatric JUTH/APIN clinic. An equal number of, presumably healthy, HIV-negative age- and sex-matched controls from primary/secondary schools were recruited for the study.
Training of research assistants
Research assistants, which included two pediatric resident doctors, were trained by the researcher, where the schedule of the research was explained.
Ethical issues
Ethical clearance was obtained from the Jos University Teaching Hospital (JUTH) ethical Committee before the study commenced. Written informed consent was also sought for and obtained from the parents/caregivers of each child.
Data collection
An interviewer administered questionnaire was used to obtain information on socio-demographic variables and clinical variables. Weight, height, blood pressure and waist circumference were measured using standard method and procedure. Further data obtained on the HIV-positive participants included CD4 cell count, viral load, ARV and both clinical and immunological stages of disease as defined by World Health Organization (WHO).
Laboratory analysis
Serum lipid profile that included total cholesterol, HDL-cholesterol (HDL-c), LDL-cholesterol (LDL-c) and triglycerides (TG) and glucose were analyzed from a fasting blood sample. The enzymatic colorimetric assay and hexokinase G6PDH/UV methods were used to assay lipid and glucose, respectively. The equipment used for the analysis was the Roche-Cobas 311 manufactured in 2002.
Blood samples were taken from the all subjects for serum lipid, FBS, the control group were also assessed for HIV using the rapid diagnostic test after pre-test counselling.
Outcome parameters:
Metabolic syndrome was defined using the components of the Pediatrics IDF criteria.[12] However, because children less than 13 years were included, cut off for waist circumference and blood pressure were defined using age and sex appropriate percentiles. Therefore, abdominal obesity (abdominal circumference >90th percentile for age and sex) plus any two of the following: BP > 90th percentile for age and height, FBS> 100mg/dl, HDL C < 40mg/dl and Triglyceride >150mg/dl).
Data management
Data obtained were analyzed using Epi Info 7 statistical software (CDC, Atlanta). Summaries of socio-demographic characteristic were presented using mean, standard deviation and range where appropriate. Categorical variables were presented as proportion.
Comparison of HIV and non-HIV groups were performed using chi square and a P value of <0.05 considered significant.
| Results | | |
Socio-demographic characteristics
We studied 284 children comprising of 142 HIV-infected and 142 non-HIV-infected children. The mean age of the study subjects was 11± 3 years. One hundred and fifteen children were less than ten years of age. Females constitute 51.4% (146) of the study subjects. Children who belong to families stratified as upper class accounted for 33.0% (93) of the study population, while 80 children belong to the middle socioeconomic status. The comparison of age, age group, gender and SES by HIV status are presented in [Table 1]. | Table 1: Demographic and single component of MetS stratified by HIV status
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The HIV-positive participants had a mean age at diagnosis of 4.9 years (95% CI 4.2–5.6) and all HIV-positive children were likely to have been infected perinatal as their biological mothers were HIV positive.
Of the 142 HIV-infected children, 140 were on ARV drugs. About 104 (72.6%) of the 140 children on ARV drugs were on first-line drug therapy with a combination of two NRTIs and one non-nucleoside reverse transcriptase inhibitor (NNRTI), while 36 (25.7%) participants were on second-line drugs − two NRTIs and one PI, lopinavir/ ritonavir (LPV/r).
Metabolic syndrome components
Of the 284 children studied, the total single component of MetS was present in 56 (20.1%) children. Comparatively, the total single component of Met was present in 23(16.2%) of 142 HIV-infected children compared to 34 (23.9%) non-HIV-infected children. The breakdown is as follows: dysglycemia (impaired fasting glycaemia) was reported in (2) 0.7%, abdominal obesity in 5 (1.7%), hypertension in 13(4.6%) and high triglyceride in 18 (6.3%) while low high-density lipoprotein was reported in 19 (6.7%). Dysglycemia was equally distributed between HIV and non-HIV infected participants. All subjects with abdominal obesity were non-HIV-infected. Details of the other components of MetS are as seen on [Table 1].
Paired components of Mets were prevalent in 2.8% of the children studied. The non-HIV group had a 0.7% prevalence of atherogenic lipids (combination of low HDL and high triglyceride), 0.7% prevalence of abdominal obesity and hypertension and 0.35% prevalence of abdominal obesity and high triglyceride. The only paired component of MetS in HIV-infected children was clustering of atherogenic lipid in 2.8%. The HIV population accounted for 80% of the study population with elevated atherogenic lipids, while obesity paired with either HBP or increase TG was found exclusively in non-HIV infected children.
Metabolic syndrome was present in one child (0.7%) who was HIV negative.
| Discussion | | |
We found no evidence to suggest the clustering of cardio-metabolic risk factors, fulfilling the criteria of metabolic syndrome among children infected and being treated for HIV infection at the APIN/JUTH pediatric infectious disease unit. Rather 2.8% of HIV infected children had clustering of atherogenic lipid. The proportion of HIV infected children with either or any of the single component of Hyperglycemia, hypertension, obesity, increase TG and low HDL was 16.2% with high TG accounting for 9.2% of these. Among the non-HIV infected children MetS was diagnosed in 0.7% of children, clusters of two components were found in 2.8% of the study subjects with obesity and hypertension accounting for 1.4%. The proportion of non-HIV infected children with either or any of the single component of hyperglycemia, HBP, obesity increase TG and low HDL was diagnosed in 23.9% with HBP and low HDL accounting for 16.2% of these. No statistically significant difference in cumulative prevalence of a single or paired component of MetS was found between HIV and Non-HIV infected children.
In Nigerian there are no studies on prevalence of MetS in the general pediatric population. However, the prevalence amongst South African adolescent in Cape Town was reported as 5.9% by reported by Sekokotla et al.[12] in 2016. A systematic review mostly of European studies found a median prevalence of 3.3% (range, 0–19.2%).[13] Putting this in perspective in relationship to our current study, the prevalence of 0.7% was found amongst the non-HIV group which is comparable to the general pediatric population. This finding in our study is extremely lower than the above reference studies. Several reasons may account for these variabilities but most importantly, the prevalence of Mets in the general population is influenced proportionately by the prevalence of childhood obesity. Sekektola et al.[13] in South Africa reported that about one third of the adolescent (13–18 years) in their study had obesity. The prevalence of obesity in this current study assessed by wrist circumference, among the comparative group who are not HIV infected is slightly below three percent which is about ten times lower than that reported by Sekektola et al.[13] in South Africa. This may partly explain the lower prevalence of MetS because obesity is central and frequently associated with hypertension and dyslipidemia.
Besides obesity, HIV infection and its treatment also constitute risk for MetS such that over one tenth to half (11.4% to 45.4%) of HIV infected adults have been reported with MetS depending on the setting and diagnostic criteria used.[14] Pediatric HIV-based prevalence of MetS is not common, but in Spain Espiau et al.[15] reported a 1.9% and 5.9% prevalence of MetS using the IDF and modified NCEP ATP III criteria respectively.[15] However, findings from this current study differ significantly from the above as none of the HIV-infected children fulfilled the criteria of IDF MetS or had a clustering of any three components of MetS. The scope of this current study is limited and may not proffer reason(s) for the above finding but the difference may have arisen from pharmaco-genetic variability to ARV, immunologic variability to HIV, variability in nutrition and physical activities. The low rate of obesity (0%) in the HIV non-infected group compared to non-HIV subpopulation (3.5%) may offer some insight to why MetS is completely absent among the HIV group. This assertion is further supported by the findings reported by ESpiau et al.[15] that showed a higher mean BMI Z score in HIV sub-population with MetS compared to those without MetS. This finding is consistent with the pathogenic role of obesity especially visceral in MetS. Interestingly based on the above cited report by Espiau et al.,[15] lipo-hypertrophy was documented in all children with MetS which was not assess in this study.The presence and clustering of two components of MetS, although similar in proportion in both the HIV infected and non-infected subgroups of children differ in composition, with the clustering tending more towards atherogenic lipid (low HDL and high TG) in the HIV group. The above process may have been driven by chronic inflammation or ARVs. This observation has clinical and public health relevance because atherogenic lipid get deposited in the sub-endothelial layer of blood vessels resulting in atheroma and eventually a cardiovascular event.
However, the larger proportion of children about twenty percent with at least one component of Mets may suggest that overtime, this can evolve into metabolic syndrome in adulthood. In Ogbomoso, Oyo state of Nigeria, Ayodele et al.[16] using the IDF criteria reported that almost one fifth of HIV infected adults have MetS. Although only few adults acquire HIV during childhood, it is right to assume that the burden of MetS in adults with HIV may increase significantly in the near future considering the proportion of children who are HIV infected that individual with just one component.
The strengthen of this study is that it answers a research question that is vital to the care of children with HIV and non-HIV children sampled from schools and a well-structured HIV clinic that is well experience in care of pediatrics HIV in Jos Nigeria using a robust design which compares the HIV infected and non-infected children. It is one of the first studies to our knowledge that tries to assess the burden of MetS in general population and in children with HIV. Thirdly, studies in pediatrics usually focuses on adolescent but we included children less than 10 years.
However, this study is limited by the following: the use of abdominal obesity as a criteria, which might not be very sensitive amongst HIV-infected children because they are likely to be asthenic especially in our environment were malnutrition, poverty is still a problem especially in HIV group which has a higher proportion of low socio economic status. At the center of the pathogenesis of metabolic syndrome is lipodystrophy which could be atrophy or hypertrophy either has metabolic consequences but this was not assessed in the subjects. This study unlike some study assayed Fasting sugar which is easier and cheaper but less sensitive in assessing insulin resistances when compared to oral glucose tolerance test (OGTT) or serum insulin assay.
| Conclusion and recommendation | | |
While both HIV and non-HIV infected children had a high prevalence of one component of the MetS, it is however uncommon in our study population. There seems to be no difference in the prevalence of the metabolic syndrome and cumulative frequency of a single or a paired component of metabolic syndrome between the general pediatric population and HIV infected children enrolled in this study. Nonetheless hypertension is commoner in the non-HIV infected children while atherogenic lipid was more prevalent in HIV-infected children. In developing countries, Pediatric HIV patients are likely to be non-obese, it may therefore be necessary to redefine the criteria for diagnosis of MetS in this population.
Financial support and sponsorship
The study was funded by the Medical Education Partnership in Nigeria (MEPIN), Jos, Plateau State, Nigeria.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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