PREFACE
This report is as a result of the World health organization (WHO) funding and was the first step towards updating Non-Communicable diseases (NCD) survey of 1997 at the six geopolitical regions of Nigeria viz South-West, South-East, South-South, North-Central, North-East and North-West Zones. A rural and an urban community in such geographical regions were chosen, enumeration and household selections undertaken prior to surveys. The membership of the expert committee on NCD appointed by the Federal Minister of Health Dr Tim Menakaya is shown on page iii and the committee drew on the work of earlier committee headed by Professor OO Akinkugbe(CON), in which Professor GC Onyemelukwe and Dr COAkintoye were members.
The WHO stepwise questionnaire, modified with Nigerian inputs by the expert committee under the direction and leadership of the chairman expert committee NCD, was utilized. The questionnaire is attached (pg 74-102) and was devised to be utilized in other geopolitical regions with provisions of infrastructural and financial support.
The NCD expert committee is grateful to the Federal Government of Nigeria and Federal Ministry of Health for the opportunity and responsibility conferred on it. The exceptional work of Professor A Osibogun and the secretary of the expert committee Dr AO Akinsete are acknowledged.
This report was submitted to Professor Eyitayo Lambo in 2005/06 with copies in the Federal Ministry of health.
Professor GC Onyemelukwe (MON)
Chairman Expert Committee on NCD
NCD EXPERT COMMITTEE
Professor G. C. Onyemelukwe, (MON) CHAIRMAN
Dr. Musa Borodo VICE CHAIRMAN
Dr. A. O. O. Akinsete SECRETARY
Professor Akin Osibogun MEMBER
Professor Wura Shokunbi “
Professor N. E. N. Obianyo “
Professor F. A. Durosinmi-Etti “
Dr. C. O. Akitoye “
Dr. J. N. Ajuluchukwu “
Dr. Cyril Chukwu “
Dr. H. T. O. Ladapo “
Dr. Mike Ekpo “
Dr. I. S. Danfillo “
Rep. National Eye Centre, Kaduna “
Rep. WHO “
Rep. UNICEF “
KEY SURVEY PERSONNEL/CONTRIBUTORS
*Professor G. C. Onyemelukwe, MON; Dept of Medicine, ABUTH, Zaria: Chairman,
Survey/Surveillance Subcommittee of National Expert
Committee in NCD
*Professor Akin Osibogun: Community Health Dept. LUTH, Lagos: Vice
Chairman, Survey/Surveillance Subcommittee of
National Expert Committee on NCD & Survey
Coordinator
*Dr. A. O. O. Akinsete; NCD Programme, Federal Ministry of Health: Member,
Survey/Surveillance Subcommittee of National Expert
Committee on NCD & Facilitator
*Dr. I. Ekanem; Dept. of Pathology, Unical Teaching Hospital,
Calabar: Facilitator
*Dr. K. K. Akinroye; Vice President, Nigerian Heart Foundation: Facilitator
*Dr. K. A. Odeyemi; Dept. of Community Health, LUTH, Lagos: Facilitator
& Survey Team Leader
*Dr. Onyechere; Nigerian Heart Foundation, Lagos: Supervisor
TABLE OF CONTENTS
Page
1.Prefaceii
2.NCD Expert Committeeiii
3.Survey Personneliv
4.Table of contentsv
5.Highlights of findingsvi-vii
6.Executive summaryviii-xv
7.Chapter 1: Introduction1
8.Chapter 2: Methodology2
9.Chapter 3: Sociodemographic Findings3-7
10.Chapter 4:Question-Based Assessment8
-Tobacco Use9
-Alcohol Use21
-Nutrition/Diet24
-Physical Activity33
-History of NCD39
-Traffic Safety43
-Violence44
-Female Reproductive Health45
-Male Reproductive Health53
11.Chapter 5:Physical Measurements56
-Obesity and Underweight57
-Hypertension59
12.Chapter 6:Biochemical and Haematological Measurents64
-Blood Lipids64
-Fasting Blood Sugar64
-Genotype65
13.Chapter 7:General Discussion66-70
14.References71
15.Appendix72-102
16.
NCD LAGOS SURVEY 2003
HIGHLIGHTS OF FINDINGS
NCD RISK FACTOR / Prevalence (%)SMOKING
Currently smoke / 9.6%
Heavy smokers (>10 sticks per day) / 16.3%
Started smoking at age 20-29 (Majority) / 47.4%
ALCOHOL
Ever consumed alcohol / 32.7%
Consumed alcohol in past 1 year / 77.7%
Consumed at least 1 drink 1-3 days a month (Majority) / 36.6%
Consume 1-3 drinks daily / 77.8%
Heavy drinkers (≥4 drinks per day) / 22.2%
DIET
Did not eat fresh fruits at all / 13.7%
Consume at least 5 servings of fresh fruits on daily basis / 4.1%
Did not eat fresh vegetables at all / 32.7%
Consume sweet soft drinks every day / 16.3%
Consume sweet soft drinks 1-3 days a week (Majority) / 44.5%
Consume sweet or chocolate every day / 10.9%
Always use extra salt with already prepared food / 10%
PHYSICAL ACTIVITY
Moderate activity(recreational) at least 5 times per week / 41.1%
TRAFFIC SAFETY
Never use seat belts (front seat) / 65%
Never use seat belts (back seat) / 86.6%
FEMALE HEALTH
Initiated sexual intercourse <15yrs of age / 3.7%
Initiated sexual intercourse at 15-19yrs (Majority) / 47.6%
First marriage at age 20-24yrs / 49.8%
Never performed pap smear / 97.2%
Did not perform pap smear last 3yrs / 99%
Do not perform breast examination regularly / 71.3%
Perform breast examination at least once a month / 57.9%
Perform breast examination less than once a year / 15.7%
MALE HEALTH
Sexual intercourse at age <15yrs / 11%
Sexual intercourse at 15-19yrs (Majority) / 44.9%
First marriage at 25-29yrs / 37.2%
Never performed screening test for prostrate cancer / 98.1%
MEASUREMENTS / Prevalence (%)
BMI
Waist circumference≥87cm / 24.3%
Overweight (BMI =25-29.9 kg/m2) / 36.3%
Female overweight / 44.7%
Male overweight / 26.7%
HYPERTENSION
Systolic BP ≥140mmHg / 22.5%
Systolic BP≥160mmHg / 7.4%
Diastolic BP≥90mmHg / 29.7%
Urban residents (systolic BP ≥140mmHg) / 28.9%
Rural residents (systolic BP ≥140mmHg) / 13.7%
Urban residents (diastolic BP≥90mmHg) / 40.5%
Rural residents (diastolic BP≥90mmHg) / 20.5%
BLOOD LIPIDS
Blood TG>120mg/dl / 12.6%
BLOOD SUGAR
FBS>126mg/dl / 2.3%
FBS>110mg/dl / 2.8%
FBS =110-126mg/dl / 0.5%
GENOTYPE
AA / 70.4%
AS / 24.1%
AC / 4.7%
SC / 0.4%
SS / 0.4%
EXECUTIVE SUMMARY
The results of this survey have highlighted important findings about the current state of Non-Communicable diseases in Lagos State of Nigeria, which will prove useful in planning, implementation and evaluation of control programmes.
Demographic Data:
A slight majority of the respondents (55.5%) had lived predominantlyin the urbanareas which imply that they are at higher risk of Non –Communicable diseases due to the higher prevalence of risk factors such as tobacco consumption in urban areas. (FIG.1)
A Slight majority of the respondents were females, which even though is different from the demographic profile in Nigeria as shown in surveys (where there is slightly higher male proportion), is not significant (FIG. 2). The predominant ethnic group is Yoruba and this does not come as a surprise because Yoruba is the most common ethnic group in South West Nigeria, within which zone Lagos State lies.
Majority of the respondents (66.4%) had an annual household income of less than N50, 000 while the mean was N60, 264. This implies that majority of the population were of lower socio-economic class as further evidenced by the fact that more than two thirds (2/3), live in single room accommodation. Such Nigerians cannot afford the expensive and life-long treatment of NCD on a user-fees basis alone. It also emphasizes the importance of primary prevention of Non-Communicable diseases. (FIG. 3)
More than half of the respondents had at least a primary education, which is consonant with the literacy rate in Nigeria (1). It also means that a combination of communication strategies will be useful in information, education and Communication on Non- Communicable diseases. (FIG. 4)
The Mean number of years of residence in an urban area of 23.7yrs may be sufficient enough for the effects of risk factors to impact on prevalence on Non-Communicable diseases.
Smoking:
Almost one - tenth (9.6%), of the respondents currently smoke daily with majority of respondents smoking for less than 10yrs. This figure is slightly higher than the 8.9% recorded in the National survey in 1990 (2) though is lower than 20.6% recorded in South Africa (3) and some European Countries (4). Tobacco use is acknowledged to be a powerful Risk Factor of major NCD such as Cancer, Stroke, Coronary heart disease among others (5). It is important therefore, that primary prevention of NCD focus on effective control of tobacco use.
Majority of respondents who currently smoke started in adolescence and young adulthood, emphasizing the need for Smoking Cessation interventions that target people within these age groups (FIGS. 5-8).
Majority of respondents who currently smoke had smoked less than 5 sticks of cigarette a day with 16.3% smoking 10-20 sticks a day. The prevalence of Heavy smoking (greater than 10 sticks per day) of 16.3% is much higher than the 2.1% recorded in the National survey in 1990 (2). The differences may be due to the fact that in 1990, the survey was National where this findings report only findings in Lagos state. . It may also be due to differences in definition of heavy smoking. The risk of NCDS from smoking is dose dependent varying with number smoked per day and the duration of smoking.
Among respondents who were not smoking at the time of the survey, 14.6% had smoked in the past with majority for less than 10years. These respondents are at a higher risk than those who had never smoked, although their risk is lower than that of current smokers.
The main reason for respondents initiating smoking was the influence of peer pressure even though 17% mentioned advertisement, justifying the importance of banning advertisements as strategy for control of Non communicable diseases.
Slightly more than half of the respondents were aware of government warnings that smoking is harmful to health, which necessitates the intensification of awareness programmes on Tobacco Control. However, among those who currently smoke, only 39.4% are motivated to stop due to the warnings, which imply that smoking cessation programmes that rely entirely on communication of dangers of smoking will not be optimally effective.
More than one quarter of current smokers, however, wish to stop smoking, which implies that there are needs for programmes to support smokers who wish to quit.
More than three-quarters (3/4) of the respondents believe that smoking is dangerous to health and also support the banning of advertisements on smoking.
Other forms of tobacco use, such as nasal or chewing tobacco were practiced by less than half of the respondents, meaning that tobacco control efforts should focus on curbing smoking, particularly cigarettes.
Slightly less than one-third of respondents are exposed to smoke in public places, which implies that they are also at risk of non-communicable diseases from passive smoking even though their risk is lower than that of current smokers.
Alcohol:
Almost one third (1/3) of the respondents had consumed alcohol in the past, with 77.6% of these having consumed alcohol in the previous 12months before the survey. This finding is comparable to findings in 1990 National survey where 70% of respondents did not drink alcohol. Alcohol Consumption, especially in excess, is a strong risk factor of Non-Communicable diseases such as cancers, hypertension, and coronary heart disease among others (5). Majority of respondents in the survey consumed alcohol 1-3 days a week on the average, with most (77.8%) consuming 1-3 drinks per day.
The proportion of heavy drinkers (drinking 4 or more drinks per day) was 22.2% of the drinkers. This is higher than the 14% recorded in the 1990 survey (2). The differences may be due to varying definitions of “heavy drinking” in the two surveys; the definition of “heavy drinking” was arbitrary in the 1990 survey. The risk of NCDs increases with alcohol consumption with heavy drinkers at higher risk. In order to prevent cancers alcohol consumption should not exceed 2 units per day (6) (FIGS. 9 & 10).
Diet:
Majority of the respondents eat fresh fruits, doing soon about 1-3 days in a typical week, while 13.7% did not eat fresh fruits at all. Most of those who eat fruits consume about 1-3 servings per day (on days that fruits are consumed). Fresh fruits are rich in vitamins, which are useful in prevention of some NCDS. This survey showed that the recommendation for the consumption of 5 servings of fruits at least 5 times a week has not been achieved by majority of respondents. Daily intake of fresh fruits of 400g per day is recommended to reduce the risk of coronary heart disease, stroke and high blood pressure (5) (FIG. 11).
Slightly less than one third of respondents do not consume fresh vegetables in a typical week, while only 6.3% do not consume cooked vegetables. It would appear therefore, that most respondents, who eat vegetables, prefer to eat them cooked. In both instances, majority consume vegetables 1-3 times a week. Vegetables are rich in fibre and antioxidants, which are essential in the prevention of NCDs such as cancers. It is important to note that majority of respondents do not meet up with the 5 – A – DAY recommendation; i.e., consuming 5 servings of vegetables, 5 days a week (5). Less than one-third (1/3) of respondents consume cooked vegetables on a daily basis. There is thus an urgent need to promote the consumption of fruits and vegetables on a daily basis to reduce the risk of Non –Communicable diseases.
On the average, the most commonly consumed sources of carbohydrate were rice and cassava, while the most common source of protein was fish and meat. Regular consumption of fish is protective against coronary heart disease (5). Eggs, which increase risk of coronary heart disease, were consumed on the average about 3 times a week, while chicken was the least consumed, which may be due to its high cost.
Most of the respondents (89%) usually prepare their food at home, implying that they can decide to use healthy ingredients in food preparation. Majority of respondents use cholesterol-rich vegetable oil for cooking at home, a finding similar to those of other surveys (7). Vegetable oils that are rich in cholesterol increase the risk of non communicable diseases such as coronary heart disease.
Majority of respondents consume sweet soft drinks on the average, about 1-3 times a week, even though most rarely, or never consume sweetsor chocolates. Most of the respondents consume beverages everyday with majority drinking 1-2cups per day with majority using 1-2 cubes of sugar. The consumption of food or drinks rich in free sugars increases energy intake by reducing appetite control, thereby increasing the risk of Obesity and other NCDs. The consumption of free sugars should not be more than 10% of energy intake (5). In addition, to prevent dental caries for example, consumption of food or drinks containing free sugar should be limited to a maximum of 4 times per day (5). There is therefore a need for increased awareness of dangers of heavy consumption of free sugars in drinks and food.
Majority of respondents use full cream milk in preparation of tea. Full cream milk contains saturated fats and increases risk of NCDS such as coronary heart disease. In order to reduce the risk of non-communicable diseases, use of skimmed milk should be promoted.
More than two thirds (2/3), of respondents never add salt to already prepared food while only 10% always do so. This is lower than findings in some surveys (8) where up to 39% of respondents always add salt. High intake of salt, as evidenced by the need to always add salt to already prepared food is a risk factor for hypertension. Indeed it is recommended that the total salt intake should be less than 5g per day including those contained in food additives such as monosodium glutamate.
Almost all the respondents eat breakfast which is comparable to other surveys (8).The consumption of breakfast reduces the need for consumption of foods rich in free sugars which promote risk of obesity.
Less than one third (1/3) of respondents were advised to change their diet in the past year while majority had not changed their diet in the past year.
Physical Activity:
More than one third (1/3), of respondents undergo moderate physical activity for about 5 days a week and on the average, 6 hours a day. Physical inactivity is a risk factor for non communicable diseases such as Cardiovascular diseases, diabetes, Obesity, osteoporosis and some cancers (9,10). It is recommended that adults undergo at least 30 minutes of moderate activity at least 5 days a week. This calls for the promotion of increased physical activity among the general population. This could be during work, recreation or at home.
Most of the respondents believe that they are of normal weight and majority had not been advised to increase their level of physical activity (FIGS 12 & 13).
Females:
Among the female respondents, 16% had ever used hormonal contraceptives with about three quarters (3/4) using oral pills for about 3 years. More than half of those who had babies in past 5 years practicedexclusive breast-feeding for about 4-6months. Exclusive breastfeeding reduces the risk of childhood morbidity and mortality and may also reduce risk of obesity both in childhood and adult life. (FIG. 15)
Less than 5% initiated sexual intercourse before age 15, while majority did so between 15-19yrs. Early initiation of sexual intercourse (before 15yrs) increases the risk of cervical cancer (11).
Even though almost 15% of female respondents had experienced vaginal bleeding, only 2.8% had ever performed pap smears. There is therefore a need to promote and encourage women to present themselves for Pap smears in order to ensure early diagnosis and treatment of cancer of cervix. Less than one third of respondents perform breast self-examination regularly thereby increasing the risk of delayed diagnosis of breast cancer (FIGS 16-18).
Also, although majority of female respondents believe that condoms prevent sexualtransmitted diseases, most never use it during sexual intercourse. Almost an equal number are not concerned and very concerned about the harmful effects of non –use of condoms on their health (FIG20).
Males:
Among male respondents, less than 2% had ever performed screening test for cancer of the prostate and majority had no difficulty in passing urine. Slightly over half had never used condoms even though more than three-quarters believe that condoms prevent sexually transmitted diseases (FIGS 21-24).
Family History:
Less than five percent (5%) of the respondents had a family history of NCD, with about 3% reporting a history of sickle cell disease in the family. About 4.7% of respondents reported a family history of hypertension in the father, which is lower than the 11.8% reported in the 1990 National survey. (2) Family history is important in some NCDs such as cancer, hypertension and diabetes (FIG 25).
Health-Seeking Behaviour:
Slightly less than 10% of respondents had been told that they were hypertensive by health workers while about 2% had been told that they were diabetic. About half of the respondents had not visited a health worker /doctor in the past year which implies that the risk of delayed detection of non-communicable diseases such as hypertension and diabetes is high.
Slightly more than half (1/2) of the respondents select health centers or clinics as the first choice of health services, which implies that a significant proportion may not benefit from control programmes targeting health centers/clinics.
Road Traffic Accidents:
Majority of respondents admit that they neveruse seat beltsin the front seat. This may well be front seat passengers rather than drivers. Less than 5% say they have driven under the influence of alcohol. They are therefore at increased risk of road traffic accidents (FIG26-27).