CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 AFRICA 239 These findings are in agreement with a study conducted in northeast China that reported a high prevalence of high TG levels in women and a high prevalence of low HDL-C levels in men.44 Our study further showed that women had a high prevalence of overweight, obesity and abdominal obesity (high WC) compared to men (p < 0.05). This is consistent with a study conducted among participants from an urban Tanzanian population that reported a higher prevalence of obesity and abdominal obesity in women than in men.45 In this study, men with MA were found to have a significantly higher prevalence of a high HOMA compared to those without MA (p = 0.01), while women with MA were also found to have a higher prevalence of a high HOMA compared to those without MA (p = 0.00). Men with MA were found to have a lower prevalence of overweight and a higher prevalence of obesity compared to men without MA (p < 0.05). Women were found to have a higher prevalence of hypertension, high SBP and DBP compared to women without MA (p < 0.05). These results are in agreement with studies that reported that cardiovascular risk factors such as insulin resistance, obesity and hypertension were associated with MA.46-48 The prevalence of MA in this population was found to be 35.7%, which is similar to the prevalence of MA (39.7%) reported among diabetic patients attending the diabetes clinic at the Johannesburg Academic Hospital.49 In Nigeria, a study conducted at the cardiology out-patient clinic at the Ahmadu Bello University Teaching Hospital reported MA prevalence of 41.0% among patients with hypertension.50 On the other hand, the prevalence of MA in the current study was found to be lower than the 58.3% prevalence reported from a sub-analysis of a survey of 26 countries worldwide.51 In Botswana, the prevalence of MA has been estimated at 44.6%.52 The results of our study show that men with both high hs-CRP and high TG values were more likely to have MA compared to men with normal hs-CRP and TG levels. To the best of our knowledge this is the first study to report such an association between MA and serum TG and hs-CRP. The reason for this association is not known as only hs-CRP and TG were collectively associated with MA. The interaction could explain the association of MA with chronic kidney disease (CKD) and CVDs.28, 53 CRP has been reported to be increased in patients with CKD compared to controls.54 Serum TG levels have been acknowledged by the American Medical Association as important risk factors for CVD and death.55,56 Furthermore, low-grade inflammation was found to be associated with the risk of developing CVD,29 and CRP has been established as an important predictor of cardiovascular events in CKD patients.57 Studies have reported that patients with both MA and high hs-CRP levels had low HDL-C levels.58,59 Although not similar to the present study, these studies further reported an association between MA, serum lipids and inflammatory markers. This could mean that in the current population, men with high CRP and TG levels are likely to have MA. MAmay be responsible for dyslipidaemia via the up-regulation of 3-hydroxy-3-methylglutaryl CoA reductase60 and an acquired deficiency of lecithin-cholesterol acyltransferase. CRP was found to promote the production of pro-inflammatory cytokines, thus leading to mesangial cell proliferation, matrix overproduction and increased vascular permeability, causing MA.61 This association could also be explained by the association of endothelial dysfunction with MA, dyslipidaemia and low-grade inflammation.25,26 Endothelial dysfunction precedes the development of MA62,63 and has been found to be associated with inflammation and dyslipidaemia.25-27 Endothelial dysfunction has been reported as a risk factor for CVDs.64 MA is a marker of endothelial dysfunction.65 MA, dyslipidaemia and low-grade inflammation are cardiovascular risk factors.3,4,66 Therefore endothelial dysfunction might be associated with, or even a possible explanation of, the relationship between MA, dyslipidaemia and low-grade inflammation. This study further showed that women with and without MA had similar levels of IL-6 and hs-CRP, while men with MA had lower hs-CRP levels compared to their counterparts without MA, but similar levels of IL-6. Studies have reported similar levels of inflammatory markers such as CRP21 and IL-667 and this is in agreement with the results of our study in the total population, where the levels were similar in those with and without MA. However, men with MA showed lower hs-CRP levels than those without MA. The reason for the low hs-CRP in men with MA is not known but could be due to the method of diagnosis of MA used in the present study, where we used only one urine sample, as opposed to three urine samples over a three-month period. The hypothesis that MA is associated independently with low-grade inflammation was not supported in this study. In the present study, the levels of serum lipids such as TC, TG, HDL-C and LDL-C were found to be similar in participants with and without MA. The results of the study are in agreement with results of other studies, which found levels of TC, TG and LDL-C were similar in patients with and without MA.3,68 However, the difference was in the levels of HDL-C, which were increased in the hypertensive patients with MA in the above two studies, but in the present study, the levels were similar between those with and without MA. The comparable lipid levels also do not support the hypothesis that MA was independently associated with serum lipids in this population. No significant association was found between MA and TG in participants in the total study population, among men and among women. The results are in agreement with other studies, which also found no association between MA and TG.69,70 In this population, MA was not independently associated with serum lipids and this can be attributed to physical activity, which was reported to be high in this population,71,72 and the diet that this population is thought to consume. An unhealthy lifestyle together with physical inactivity may increase the risk of MA.7375 In a study conducted at the Dikgale HDSS site, the average physical activity was 11 615 steps per day (with a standard deviation of 5 139), showing that this population has a high level of physical activity.76 The study has shed light on the relationship among MA, serum lipids and inflammatory markers with confounders controlled in a rural black population. The results of the study will contribute to the discovery of markers that could possibly be used to determine which patients to screen for MA, since the screening procedure is long. Limitations The findings from this study should be considered in view of some limitations. Similar to other studies using a cross-sectional
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