South African Medical Journal (SAMJ)
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Weight management over the reproductive years for adult women living with obesity
No full textRECOMMENDATIONS
These recommendations pertain to the management of weight over the reproductive years for adult women living with obesity (i.e. body mass index ≥30 kg/m2) with a singleton pregnancy, who are ≥18 years of age and do not have pre-existing diabetes or gestational diabetes.
General advice. We recommend that healthcare providers (HCPs) should discuss weight management targets specific to the reproductive years with adult women living with obesity: pre-conception weight loss (Level 3, Grade C); gestational weight gain of 5 - 9 kg over the entire pregnancy (Level 4, Grade D); and postpartum weight loss of – at minimum – gestational weight gain (Level 3, Grade C), to reduce the risk of adverse outcomes in the current or a future pregnancy.
Combined behaviour change interventions. HCPs should offer behaviour change interventions, including both nutrition and physical activity, to adult women living with obesity who are considering a pregnancy (Level 3, Grade C), who are pregnant (Level 2a, Grade B) and who are postpartum (Level 1a, Grade A),[16] in order to achieve weight targets.
Nutrition counselling alone. We recommend that HCPs encourage and support pregnant women with obesity to consume foods consistent with a healthy dietary pattern in order to meet their target gestational weight gain (Level 3, Grade C).
Physical activity counselling alone. We recommend that HCPs encourage and support pregnant women with obesity who do not have contraindications to exercise during pregnancy to engage in at least 150 minutes per week of moderate-intensity physical activity to assist in the management of gestational weight gain (Level 3, Grade C).
Pharmacotherapy. HCPs should not prescribe metformin for managing gestational weight gain in women with obesity (Level 1b, Grade A). We suggest no weight management medications during pregnancy or breastfeeding (Level 4, Grade D).
Breastfeeding. We recommend that women with obesity be offered additional breastfeeding support owing to decreased rates of initiation and continuation (Level 3, Grade C)
Pharmacotherapy for obesity management
No full textRECOMMENDATIONS
1. Pharmacotherapy for obesity management can be used for individuals with a BMI ≥30 kg/m2, or ≥27 kg/m2 with adiposity-related complications, in conjunction with medical nutrition therapy, physical activity and psychological interventions (semaglutide 2.4 mg weekly [Level 1a, Grade A] liraglutide 3.0 mg daily [Level 2a, grade B], naltrexone/bupropion 16 mg/180 mg twice a day [BID] [Level 2a, Grade B], orlistat 120 mg three times a day [TID] [Level 2a, Grade B]).
2. Pharmacotherapy may be used to maintain weight loss and to prevent weight regain (liraglutide 3.0 mg daily [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]).
3. Pharmacotherapy for obesity management in conjunction with health behaviour changes for people living with prediabetes and overweight or obesity (BMI ≥27 kg/m2) can be used to delay or prevent T2DM (liraglutide 3.0 mg daily [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]).
4. Obesity pharmacotherapy can be used in conjunction with health behaviour changes in people living with T2DM and a BMI ≥27 kg/m2, for weight loss and improvement in glycaemic control (semaglutide 2.4 mg weekly [Level 1a, Grade A], liraglutide 3.0 mg daily [Level 1b, Grade A], naltrexone/bupropion 16 mg/180 mg BID [Level 2a, Grade B], orlistat 120 mg TID [Level 2a, Grade B]).
5. Pharmacotherapy can be considered in conjunction with health behaviour changes in treating people with obstructive sleep apnoea and a BMI ≥30 kg/m2, for weight loss and associated improvement in the apnoea-hypopnoea index (liraglutide 3.0 mg daily [Level 2a, Grade B]).
6. Pharmacotherapy can be considered in conjunction with health behaviour changes in treating people living with metabolic dysfunction- associated steatohepatitis (MASH) and overweight or obesity, for weight loss and improvement of MASH parameters (liraglutide 1.8 mg daily [Level 3; Grade C], semaglutide 2.4 mg [Level 4 Grade D]).
7. Metformin and psychological treatment (such as cognitive behavioural therapy) should be considered for prevention of weight gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain (Level 1a, Grade A).
8. For people living with overweight or obesity who require pharmacotherapy for other health conditions, we suggest choosing medications that are not associated with weight gain (Level 4, Grade D, Consensus).
9. We do not suggest the use of prescription or over-the-counter medications other than those approved in SA for obesity management (Level 4, Grade D, Consensus)
Maternal near miss and maternal mortality and their determinants among pregnant women at a rural tertiary centre in the Eastern Cape Province, South Africa: A cross-sectional study
Get PDFBackground. Maternal near miss (MNM) is a significant entity in the assessment of the quality of obstetric care, particularly at institutional level. It renders possible the assessment of events surrounding a woman surviving what would otherwise have been a fatal outcome during childbirth or within 42 days post termination of pregnancy. The World Health Organization (WHO) introduced a tool that eases the identification of such cases and the interventions that were offered during their care. There have been several assessments of maternal deaths within South Africa (SA), but no audit of maternal near-miss cases has been carried out in rural Eastern Cape Province.
Objectives. To establish the period prevalence of MNM and mortality index, and to compare near-miss cases with maternal mortality and to identify their risk factors and causes.
Methods. A prospective cross-sectional study was carried out at Nelson Mandela Academic Hospital, a rural tertiary hospital in the Eastern Cape Province, over a 6-month period between January 2019 and June 2019. All cases that met the WHO criteria for MNM, together with maternal mortality cases, were identified and included in the study.
Results. There was a total of 1 706 live births, 228 maternal near-miss cases and 24 maternal death cases. The institutional severe maternal outcome ratio was 147/1 000 live births, with an overall mortality index of 9.5%. The MNM ratio (MNMR) was 133.6/1 000 live births, the maternal mortality ratio was 1 406.8/100 000 live births and the MNM/maternal mortality ratio (MNMR/MMR) was 9.5:1. The stillbirth rate was found to be 95.0/1 000 births. The leading causes of MNM were eclampsia (47.8%), abruptio placentae (19.7%) and postpartum haemorrhage (8.3%), and the leading causes of maternal death were eclampsia (29.2%), puerperal sepsis (25%) and postpartum haemorrhage (12.5%).
Conclusion. The MNMR and the MMR found in this study were comparable with other reports from sub-Saharan Africa, although these ratios were notably higher than in urban areas within SA. The conditions that resulted in the highest fatality rate were potentially preventable, namely eclampsia and puerperal sepsis. Many patients with life-threatening conditions were low-risk patients, and this emphasises the need for more vigilant surveillance of patients during the antenatal, intrapartum and postpartum periods
Building an artificial intelligence-enabled telehealth future for South Africa: The case for regulatory vision and sectoral strategy
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Response to ‘Re: Monitoring District Health System performance in South Africa: A proposed dashboard based on key pragmatic indicators’
Get PDFTrends in hypertension prevalence among adults aged ≥40 years in Agincourt, South Africa (2014 - 2022)
No full textBackground. Hypertension is a leading cause of cardiovascular disease. There are limited longitudinal data on temporal trends in hypertension prevalence in rural South Africa (SA).
Objectives. To analyse trends in hypertension prevalence and investigate its associated factors among adults aged ≥40 years in SA.
Methods. A retrospective observational secondary quantitative analysis of a sample from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) was conducted. Data for the HAALSI study were collected over three waves during 2014, 2018 and 2021 from the existing Agincourt Health and Socio-demographic Surveillance System (AHDSS) framework, with a total sample of 3 707 participants in the present study. Descriptive statistics were used to summarise sociodemographic data. A bivariate analysis and multivariable generalised estimating equation (GEE) model was applied to determine factors associated with hypertension prevalence, with significance set at p<0.05.
Results. The overall prevalence of hypertension declined from 58% (95% confidence interval (CI) 56.42 - 59.58) in wave 1 to 42% (95% CI 40.42 - 43.58) in wave 2, and further decreased to 30% (95% CI 28.58 - 31.42) in wave 3. Transitions between hypertensive and normotensive status were observed, with 1 018 individuals transitioning to normotensive from wave 1 to wave 2, and 1 167 individuals from wave 2 to wave 3. The GEE analysis identified significant predictors of hypertension. High body mass index (BMI) was associated with increased odds in wave 2 (adjusted odds ratio (aOR) 1.11; 95% CI 1.02 - 1.21; p=0.014). Frequent alcohol consumption increased the odds of hypertension in wave 3 (aOR 1.19; 95% CI 1.04 - 1.37; p=0.009). No formal education was associated with higher hypertension prevalence (aOR 1.07; 95% CI:1.00 - 1.14; p=0.0026). Younger age (40 - 49 years) was protective, with decreased odds of hypertension in wave 2 (aOR 0.64; 95% CI 0.48 - 0.84; p=0.014), as was employment (aOR 0.82; 95% CI 0.69 - 0.96; p=0.020) and fruit consumption in wave 3 (aOR 0.95; 95% CI 0.91 - 0.99; p=0.037).
Conclusion. The study found that the prevalence of hypertension in Agincourt decreased from 58 to 30% between waves 1 and 3. High BMI, high alcohol use frequency and no formal education were key predators of hypertension. The study highlights the need for targeted public health interventions, including regular hypertension screening, lifestyle modification and better management of associated factors. These efforts will be crucial in reducing hypertension-related morbidity and mortality in rural SA
A 5-year retrospective study to determine the spectrum of crescentic glomerulonephritis in three tertiary hospitals in Gauteng Province, South Africa
No full textBackground. Rapidly progressive glomerulonephritis is a clinical syndrome that results in rapid decline in kidney function over a period of weeks to months. Its histological hallmark is extensive crescent formation.
Objective. To determine the causes of crescentic glomerulonephritis (CGN) in the South African (SA) setting.
Methods. The number of kidney biopsies performed at three tertiary hospitals during the 5-year study period was determined. Demographic data and serological test results were recorded. The underlying disease process of each of the CGN cases was defined under the three immunopathological categories: anti-glomerular basement membrane disease; immune complex-mediated; and pauci-immune vasculitis.
Results. There were a total of 980 native kidney biopsies performed at the three tertiary hospitals, namely, Chris Hani Baragwanath Academic Hospital, Charlotte Maxeke Johannesburg Academic Hospital and Helen Joseph Hospital, in Gauteng Province, SA, between 1 January 2015 and 31 December 2019. There were 43 crescentic glomerulo nephritidies (4.4%). The patients’ ages ranged from 19 to 65 years, and 30 patients were female. The study comprised a majority of black patients (83.7%). Most CGN cases (39/43; 90.7%) were immune complex-mediated, and the remainder were anti-neutrophil cytoplasmic antibody mediated. The underlying cause of the 39 immune complex-mediated crescentic glomerulo nephritides was lupus nephritis in 32 (82%) cases, post-infectious glomerulonephritis (PIGN) in 2(5.1%), IgA nephropathy in 1 (2.6%) and 4 (10.2%) with an undetermined underlying cause.
Conclusions. This study revealed the predominant cause of CGN to be lupus nephritis in 82.1% of patients, followed by PIGN in 5.1%. The prevalence of CGN was 4.4%. This study emphasises the variation in aetiologies of CGN in sub-Saharan Africa
Metabolic and bariatric surgery: Surgical options and outcomes
No full textRECOMMENDATIONS
1. MBS is recommended for individuals with a BMI >35 kg/m2, regardless of the presence, absence or severity of comorbidities,* to:a) reduce long-term overall mortality (Level 2b, Grade B)b) induce significantly better long-term weight loss compared with medical management alone (Level 1a, Grade A)[4]c) induce control and remission of T2DM, in combination with best medical management, over best medical management alone (Level 2a, Grade B)d) significantly improve QoL (Level 3, Grade C)
e) induce long-term remission of most obesity-related diseases, including dyslipidaemia (Level 3, Grade C),[8] hypertension (Level 3, Grade C) and MASLD (Level 3, Grade C).
2.MBS should be considered for individuals with metabolic disease and a BMI of 30 - 34.9 kg/m2*.
3.We suggest that the choice of metabolic and bariatric procedure be decided according to the patient’s need, in collaboration with an experienced MDT (Level 4, Grade D, Consensus).
4.We suggest that adjustable gastric banding should not be offered owing to unacceptable complications and long-term failure (Level 4,Grade D).
5.We suggest that one-anastomosis gastric bypass should not be routinely offered owing to long-term complications in comparison with standard Roux-en-Y gastric bypass (Level 4, Grade D).
*Recommendation 1 (Level 5, Grade D) and Recommendation 2 (Level 2a, Grade B).