Metabolic syndrome following hypertensive disorders of pregnancy and among HIV infected adults: understanding cardiovascular disease risk

In this dissertation we discuss the findings of two studies that describe the burden of the Metabolic syndrome (MetS) in Kenya, a low resource setting with increasing incidence and prevalence of cardiovascular disease (CVD) and other non-communicable diseases (NCD.). In these two complementary studies, we evaluate the risk of MetS in two different study populations, HIV-infected adults and HIV-uninfected postpartum women. In the first study, we use recently collected cross-sectional data to examine the link between HIV and NCD specifically CVD by estimating the prevalence of MetS in HIV infected adults and evaluating the association between use of antiretroviral therapy (ART) and MetS. We found that the prevalence of MetS did not differ between ART experienced and ART naïve groups (16.9% versus 15.2%). However, ART experienced patients had higher prevalence of elevated fasting blood sugars and lower prevalence of low high-density lipoprotein (HDL)-cholesterol. The prevalence of the other components of the MetS; abnormal waist circumference, elevated blood pressure and hypertriglyceridemia were comparable between the two groups. Older age, female sex and high body mass index were independently associated with diagnosis of MetS. The second and main study, is a six-month postpartum prospective cohort nested within a longer 3-year cohort of postpartum women. In this study, the exposed group comprised women with two specific hypertensive disorders in pregnancy (HDP), gestational hypertension and preeclampsia, while the unexposed group were normotensive. In this section of the dissertation we evaluated: 1) the prevalence of MetS between women with and without history of HDP, 2) the sociodemographic and clinical correlates of MetS, and 3) the association between the inflammatory markers, specifically high-sensitivity C-reactive protein (hsCRP) and MetS, overall and stratified by exposure to HDP. All the analyses were conducted at 6 months postpartum. Compared to women without HDP, the risk of MetS was 3 times greater among women with HDP. Also, the risk of 3 of the 5 components of MetS (fasting plasma glucose, triglycerides, and blood pressure) was elevated 3 or more times among those with compared to those without HDP. MetS was independently associated with HDP, higher body mass index, and below secondary level of education. The mean hsCRP level and proportions of high relative CVD risk hsCRP (>3mg/L) levels were higher in women with MetS compared to those without MetS and were significantly different when women with HDP were compared with those without HDP. From this dissertation, composed of two studies conducted in a low resource setting of sub-Saharan Africa, we come to two conclusions. First, we find evidence of similar risk of MetS comparing ART experienced and ART naïve adults, suggesting that traditional CVD risk factors rather than HIV may have a larger contribution to the CVD risk in this population. Secondly, increased risk of MetS among women with HDP versus those without HDP provides evidence that HDP is associated with increased risk of CVD. Also, women with MetS and those with HDP in particular were more likely to have elevated hsCRP levels supporting the role of chronic inflammation and evaluation of inflammatory biomarkers following HDP to estimate the risk of MetS and therefore CVD risk. The elevation of specific components of MetS namely triglycerides, fasting blood glucose, and blood pressure and increased levels of inflammatory marker, hsCRP are important in understanding future research priority areas. Interventions to reduce CVD risk among women after HDP may need to modify these specific risk factors, use inflammatory markers to triage risk and could include dietary changes, exercise, and use of lipid and blood pressure lowering medications, especially statins because they can also reduce inflammation.