Tropical Medicine and International Health

volume 2 no 11 pp 1039–1048 november 1997

Nationwide prevalence study of hypertension and related

non-communicable diseases in The Gambia
Marianne A. B. van der Sande1, Robin Bailey1,2, Hannah Faal3,Winston A. S. Banya1, Paul Dolin4, Ousman A.
Nyan1, Sana M. Ceesay1, Gijs E. L.Walraven1, Gordon J. Johnson4 and Keith P.W. J. McAdam1
1
Medical Research Council Laboratories, Fajara, The Gambia
2
Department of Clinical Sciences, London School of Hygiene and Tropical Medicine, London, UK
3
National Eye Care Programme, The Gambia
4
International Centre for Eye Health, Institute of Ophthalmology, University of London, UK

Summary The prevalence of hypertension, diabetes and obesity in The Gambia was assessed in a 1%
population sample of 6048 adults over 15 years of age. 572 (9.5%) subjects were hypertensive
according to WHO criteria (a diastolic blood pressure (DBP) of 95 mmHg or above and/or a
systolic blood pressure (SBP) of 160 mmHg or above); 325 (5.4%) had a DBP of 95 mmHg or
above, and 39 (2.3%) a DBP of 105 mmHg or above; 428 (7.1%) had a SBP of 160 mmHg or above.
By less conservative criteria (a DBP of 90 mmHg or above and/or SBP of 140 mmHg or above),
24.2% of subjects were hypertensive. The prevalence of hypertension was similar in the major
ethnic groups and in urban and rural communities. Age and obesity were risk factors for
hypertension; female sex was an additional risk factor for diastolic hypertension. Several
communities had a prevalence of diastolic hypertension double the national rate, and significant
community clustering of diastolic hypertension (P , 0.01) was confirmed by Monte Carlo
methods. Genetic and/or localized environmental factors (such as diet or Schistosoma
haematobium infection), may be involved. 140 (2.3%) subjects were obese. Obesity was associated
with female sex, increasing age, urban environment, non-manual work and diastolic hypertension.
Only 14 (0.3%) subjects were found to be diabetic. Hypertension appears to be very prevalent in
The Gambia, with a substantial population at risk of developing target organ damage. Further
studies to delineate this risk and appropriate interventions to reduce it are needed.

keywords hypertension, obesity, diabetes, clustering, The Gambia.

correspondence Dr Marianne van der Sande, Medical Research Council Laboratories, Fajara,
PO Box 273, Banjul, The Gambia

mortality. They affect mainly adults, who are usually

Introduction
Studies on human disease in developing countries have
concentrated on infectious diseases, which have received
emphasis in research and in health policy, with the result
that reductions in childhood mortality rates have been
achieved in many areas. In parallel, non-communicable
diseases (NCDs) are an emerging problem in the
developing world (World Bank 1993). NCDs tend to be
chronic and may lead to serious morbidity and
economically and socially responsible for the care of
both children and elderly people, so their impact has
repercussions for all age groups. It has been argued that
NCDs will become increasingly important causes of
morbidity and mortality in those parts of sub-Saharan
Africa where life expectancy is increasing, and where
increased stress and changes in diet and smoking habits
are occurring as a result of urbanization (Feachem et al.
1991; Mosley et al. 1993).

1039 © 1997 Blackwell Science Ltd

 Tropical Medicine and International Health
M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia
Cardiovascular diseases, particularly hypertension,
are recognized as important emerging NCDs in this
region (Akinkugbe 1990). Hypertension and its sequelae
were generally found to be rare in rural communities in
the subcontinent (Shaper et al. 1969; Pobee et al. 1977;
Poulter et al. 1984; Simmons et al. 1986; Swai 1993).
However, migration to an urban area is associated with
a rise in blood pressure (Poulter et al. 1990). Moreover,
studies in the USA and Europe have found that
individuals of black African descent have a higher
prevalence of hypertension and are at increased risk of
target-organ damage, especially cerebrovascular
accidents (CVA), compared to the general population
(Akinkugbe 1990; Walker 1994; Sharp et al. 1995).
Obesity and non-insulin-dependent diabetes
(NIDDM) are other NCDs which are rare in rural sub-
Saharan African populations, but appear increasingly
prevalent with urbanization. NIDDM is frequently
associated with obesity and hypertension; and it has
been suggested that peripheral insulin resistance plays a
role in all 3 conditions (Reaven 1988); however, the
universality of this association in African populations
has been questioned by observations that in urban
Kenya, NIDDM patients had lower body mass index
than control subjects (Obel 1988).
We report here new data on the prevalence of
hypertension, obesity and diabetes in The Gambia. This
study was conducted opportunistically as part of a
national survey of blindness and low vision based on a
1% sample of the adult population of The Gambia. The
central purpose of this survey was to evaluate the
National Eye Care Program, which was initiated after a
similar survey in 1986 (Faal et al. 1989).
(Senegal)
THE
GAMBIA
FARAFENNI
Atlantic
Ocean
M.R.C.
FAJARA
River
BANJUL
Ga
m
bi
a
N
(Senegal)
1040 © 1997 Blackwell Science Ltd
volume 2 no 11 pp 1039–1048 november 1997
Materials and methods
The Gambia is the smallest state of sub-Saharan Africa.
It is located on the West African coast, stretched along
both sides of the river Gambia and extending about
400 km inland (Figure 1). During the 1993 census, the
population was just over 1.03 million, growing at an
annual rate of 4.2%. 44% of the population is below 15
years of age. Population density is high (97/km2). Life
expectancy for males is 54 years, for females 56 years;
infant mortality is estimated at 85/1000 live births.
Literacy is low, especially among females (15%). The
predominant religion is Islam. The most numerous
ethnic groups are the Mandinka (40%), Fula (19%),
Wollof (15%) and (Jola 11%).
A sample of 6000 adults over 15 years of age,
representing 1% of the population, was drawn from 73
communities, using multistage stratified cluster sampling
based on the 1993 national census enumeration areas.
An extensive information campaign using newspapers,
radio, television, and visits preceded the survey.
Enumeration of the sample was carried out by Gambia
Government Central Statistics Office staff.
Hypertension, diabetes and obesity and risk factors
pertaining to them were assessed by trained field
workers using simple measurements and a
questionnaire. Age, sex, area of residence, ethnic group,
pregnancy status and occupation of subjects were
recorded. Residence of participants was coded as either
rural or urban according to accepted local definitions
(Ministry of Finance and Economic Affairs 1995).
Occupations were coded as manual when they mainly
involved unskilled labour, as trades for occupations
AFRICA
Figure 1 Map of Africa showing
50 km position of The Gambia. Location of
study communities marked by ‘X’.
1041
© 1997 Blackwell Science Ltd

M. A. B. van der Sande et al.

Tropical Medicine and International Health

Table 1 Main characteristics of the study population. Mean blood pressures, mean BMI and prevalence of glycosuria by sex, age group, location and occupation

Male subjects Female subjects

Hypertension and related diseases in The Gambia

Attribute Total (%) DBP1 SBP1 BMI2 Glycosuria3 Total (%) DBP1 SBP1 BMI2 Glycosuria3
Mean(SD) Mean (SD) Mean (SD) (%) Mean (SD) Mean (SD) Mean (SD) (%)

Total sample 2706 76.1 (12.2) 129.6 (20.5) 20.1 (2.9) 19 (0.6%) 3342 75.3 (12.3) 124.3 ( 22.0) 21.3 (3.9) 17 (0.5%)
Age 4

16–25 972 (35.9%) 72.3 126.0 19.3 1 (0.1%) 1265 (37.9%) 71.4 119.1 20.7 30 (2%)
26–35 611 (22.6%) 75.6 127.4 20.2 3 (0.5%) 877 (26.3%) 74.6 119.2 21.6 0
36–45 449 (16.6%) 76.7 127.1 20.8 6 (1.4%) 564 (16.9%) 77.8 125.2 22.1 6 (1.1%)
46–55 309 (11.4%) 80.5 133.6 20.8 4 (1.4%) 285 (8.5%) 80.7 135.7 21.8 5 (1.8%)
56–65 205 (7.6%) 81.4 139.0 21.3 2 (1.0%) 201 (6.0%) 83.4 143.7 21.4 2 (1.1%)
66–75 110 (4.1%) 83.2 145.8 20.3 3 (2.9%) 93 (2.8%) 83.2 148.3 21.1 0
76 + 49 (1.8%) 83.5 151.1 19.7 0 51 (1.5%) 86.1 155.3 20.6 1 (2.5%)
Location5
urban 1196 (44.3%) 76.0 128.8 20.2 10 (0.9%) 1326 (39.8%) 75.3 123.4 22.0 7 (0.5%)
rural 1505 (55.7%) 76.1 130.2 20.0 9 (0.6%) 1326 (39.8%) 75.3 123.4 22.0 7 (0.5%)

volume 2 no 11 pp 1039–1048 november 1997

Occupation6
manual 1184 (44.1%) 76.1 130.5 20.1 8 (0.7%) 2540 (76.5%) 75.0 123.7 21.1 9 ( 0.4%)
trades 622 (23.2%) 76.1 128.9 20.2 6 (1.0%) 257 (7.7%) 76.8 124.0 23.0 1 (0.4%)
non-manual 381 (14.2%) 79.1 130.0 21.2 4 (1.1%) 176 (5.3%) 77.8 124.2 23.7 3 (1.7%)
others7 459 (18.6%) 73.6 128.1 19.3 1 (0.2%) 346 (10.4%) 75.2 129.2 20.3 4 (1.2%)

1
Blood pressure readings available for 2700 male and 3321 female subjects. 2Height and weight available for 2695 male and 3392 female subjects. 3Dipstick results available for
2632 male and 3266 female subjects. 4Age available for 2705 male and 3336 female subjects. 5Location available for 2701 male and 3333 female subjects. 6Occupation available
for 2686 male and 3319 female subjects. 7Others: heterogenous group of students, handicapped people, old/retired people.
 Tropical Medicine and International Health volume 2 no 11 pp 1039–1048 november 1997

M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia

mainly involving skilled manual labour; or as non-
manual. A heterogeneous group of others included the
unemployed, students, handicapped and retired subjects.
Blood pressure (BP) was measured to within 1 mm Hg
with electronic Omron 705CP monitors. All persons
with a diastolic blood pressure (DBP) above 90 mm Hg
were asked to return for a second measurement; where
two measurements were available, the lowest reading
was used for analysis. Following WHO criteria,
hypertension (HT) was defined as a systolic BP (SBP)
160 mm Hg and/or a DBP 95 mm Hg. Diastolic
hypertension (DHT) was defined as a DBP of 95 mm Hg
or more; and systolic hypertension (SHT) as an SBP of
160 mm Hg or above. Subjects with a DBP of 105 mm
Hg or above on both occasions were regarded as having
severe diastolic hypertension (severe DHT).
Subjects were screened for glycosuria using the Diabur-
Test 5000 dipstick test. In consenting glycosuric subjects,
a fasting blood glucose measurement was made using the
Haemocue B-glucose analyser, either on the same day as
the urine determination (the first half of the survey took
place during Ramadan when most adult subjects were
fasting) or on the next convenient day. Following WHO
criteria, diabetes was diagnosed in those with with a
fasting blood glucose of 6.7 mMol/l or above.
Weight was measured with calibrated Seca 770
electronic weighing scales. Height was measured using
standardized statometers, except in the initial phase of
the study, where measurements were made with locally
obtained equipment. Obesity was defined as a body
mass index (BMI: weight/height2) greater than or equal
to 30 kg/m2.
Preliminary analysis was performed in Epi Info 6.0.
Multiple logistic regression analyses in which HT,
DHT, SHT, obesity and glycosuria were primary
outcomes and age, sex, pregnancy, ethnicity, area of
residence and occupation explanatory variables, were
performed in EGRET software. DHT appeared to be
aggregated in certain communities; however,
conventional tests of inhomogeneity could not be
applied because of small cell sizes. Analysis of
clustering by settlement was thus performed using
Monte Carlo simulation methods (Bailey et al. 1989),
stratified to take differences in age/sex distribution

Table 2 Odds ratios, with their 95% confidence intervals, for hypertension and obesity by multiple logistic regression, adjusted for
all variables shown. ORs significantly different to 1 are denoted by bold type

Hypertension Obesity
——————————————————————————————————
Diastolic (DHT) Systolic(SHT) HT
————————————————
DBP95 DBP $ 105 SBP $ 160 BP $ 160/95 BMI $ 30

Sex vs. male

Female: non pregnant 1.47 (1.14–1.88) 1.10 (0.76–1.59) 1.04 (0.83–1.29) 1.22 (1.00–1.48) 5.33 (3.28–8.66)
Female pregnant 0.73 (0.26–2.04) 0.34 (0.05–2.56) 0.54 (0.20–1.49) 0.66 (0.30–1.43) 1.62 (0.37–7.17)
Age group vs. 25 years
26–35 3.10 (1.93–4.99) 3.24 (1.56–6.76) 1.13 (0.74–1.73) 1.64 (1.18–2.29) 1.52 (0.88–2.63)
36–45 4.57 (2.83–7.38) 3.76 (1.76–8.01) 2.74 (1.87–4.02) 2.87 (2.06–3.98) 2.77 (1.63–4.72)
46–55 9.76 (6.10–15.7) 9.15 (4.43–18.9) 5.87 (4.04–8.53) 5.75 (4.13–7.99) 1.99 (1.02–3.89)
56 17.1 (11.1–26.3) 16.5 (8.51–31.8) 13.9 (10.1–19.2) 13.5 (10.1–17.9) 2.56 (1.36–4.98)
Urban vs. rural 1.02 (0.76–1.35) 1.05 (0.68–1.61) 0.8 (0.65–1.10) 0.86 (0.68–1.09) 2.86 (1.89–4.35)
Occupation vs. unskilled manual
Trades 0.92 (0.61–1.38) 0.53 (0.26–1.06) 1.07 (0.75–1.53) 1.07 (0.79–1.46) 1.53 (0.91–2.55)
Non-manual 1.19 (0.77–1.82) 1.03 (0.56–1.91) 1.03 (0.69–1.55) 1.08 (0.76–1.54) 2.36 (1.38–4.04)
Others 1.09 (0.73–1.64) 0.97 (0.53–1.76) 1.38 (0.99–1.94) 1.30 (0.95–1.77) 0.33 (0.13–0.79)
BP > 160/95 na na na na 2.17 (1.36–3.49)
BMI > 30 1.98 (1.13–3.47) 4.69 (2.48–8.86) 1.85 (1.06–3.24) 2.32 (1.46–3.71) na
Glycosuria 1.99 (0.79–5.00) 1.98 (0.57–6.91) 2.08 (0.89–4.84) 1.51 (0.65–3.50) 4.54 (1.47–14.1)

Adjustment was also made for ethnic group, which in itself was not a significant variable.

1042 © 1997 Blackwell Science Ltd

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M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia

350

300

250
Frequency

200 Figure 2 Distribution of x2 statistics

from 1000 simulations in which cases of
150 diastolic hypertension were allocated to
the 73 communities at random
100 according to the national age/sex
specific prevalence rates. The x2 statistic
50 derived from the distribution of
diastolic hypertension actually observed
0 in the 73 communities falls between
30–40 40–50 50–60 60–70 70–80 80–90 90–100 100–110 110–120
that of the 991st and 992nd of 1000
Value of simulated χ2 simulation values, suggesting P , 0.01.

between study communities into account. Briefly, we
compared the x2 statistic calculated from the observed
distribution of cases to communities, with those
calculated from each of 1000 simulations applying
national age- and sex- specific prevalence rates in each
community.
The study was approved by the Gambia
Government/MRC Ethical Committee. All subjects
with either severe DHT or diabetes were referred to
local health centres for further assessment and
treatment.
Results
Study population
94.9% of the enumerated population were enrolled in
the survey. In all, 6048 subjects over 15 years of age were
studied in 73 communities nationwide. Principal
characteristics of the study population are shown in
Table 1.
Hypertension
Blood pressure (BP) measurements were recorded for
6021 individuals (99.6%). Of 764 participants with a first
reading above 90 mm Hg, 605 (79.2%) returned for a
repeat measurement. For the other 159 subjects, as for all
others, the single available reading was used in analysis.
Mean SBP and DBP for men and for women by age, area
of residence, and occupation are given in Table 1.
Figures 3 and 4 show the distribution of DBP and SBP in
10 mm Hg bands. 572 (9.5%) subjects were hypertensive.
428 (7.1%) subjects had SHT (160 mm Hg), 325 (5.4%)
DHT (95 mm Hg), of which 139 (2.3%) had severe DHT
(105 mm Hg), and 181 (3.0%) both DHT and SHT.
Mean blood pressure increased with age for both males

40

30
%

20

10

0 Figure 3 Distribution of diastolic

< 50 51–60 61–70 71–80 81–90 91–100 101–110 > 110 blood pressure in bands of 10 mm Hg
Diastolic blood pressure (mm Hg) for male (j) and female (h) subjects.

1043 © 1997 Blackwell Science Ltd

 Tropical Medicine and International Health volume 2 no 11 pp 1039–1048 november 1997

M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia

25

20

15
%

10

0
< 90

91–100

101–110

111–120

121–130

131–140

141–150

151–160

161–170

171–180

181–190

> 190
Figure 4 Distribution of systolic blood
pressure in bands of 10 mm Hg for male
Systolic blood pressure (mm Hg) (j) and female (h) subjects.

and females. After adjustment for age and other factors weight (BMI 18–25), 485 (8.1%) were overweight (BMI
(self reported) pregnancy was not a significant variable. 25–30) and 140 (2.3%) were obese (BMI > 30). The
In a multivariate logistic regression analysis (Table 2), remaining 1107 (18.0%) subjects were underweight with
DHT was associated with age, female sex and obesity; a BMI < 18. The variation in mean BMI with age, sex,
SHT was associated with age and obesity. No ethnic or area of residence and occupation is shown in Table 1.
urban/rural prevalence differences were found. Mean BMI in bands of 2 units are shown in Fig. 5.
Several communities, both in the more urbanized coastal Mean BMI increased with age to age 45, tended to
area and in the more rural eastern part of the country, had remain constant till age 65, and declined thereafter. Mean
DHT or SHT rates twice the national average. The use of BMI was highest (26.1) in 46–55-year-old women in non-
Monte Carlo methods suggested that DHT, but not HT or manual occupations. In multivariate analysis (Table 2),
SHT, was significantly clustered by community (P , 0.01) obesity was significantly associated with being female,
after stratification for age and sex (Figure 2). increasing age, urban residence, non-manual occupation,
hypertension and glycosuria. Obesity also showed
significant community clustering, after adjustment for
Obesity
age and sex, but the identified clusters were all in urban
Measurements for BMI were recorded for 6024 communities, consistent with the increased risk due to
individuals (99.6%). 4292 (71.6%) subjects had a normal urban residence in the multivariate analysis.

35

30

25

20
%

15

10

0
14.1–16

16.1–18

18.1–20

20.1–22

22.1–24

24.1–26

26.1–28

28.1–30

30.1–32

> 32
< 14

Figure 5 Distribution of Body Mass

Index in bands of 2 units for male and
Body mass index (units) female subjects

1044 © 1997 Blackwell Science Ltd

 Tropical Medicine and International Health
M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia
Diabetes
Dipstick results were available for 5898 individuals
(97.5%). 36 subjects (0.6%) had glycosuria on dipstick
testing. The proportion of subjects with glycosuria by
age, sex, place of residence and occupation is shown in
Table 1. Diabetes was confirmed in 14 of the 29 subjects
who consented to fasting blood glucose samples.
Compared to the general population, diabetic subjects
tended to be older (mean age 53.7 vs. 34.6), with higher
mean blood pressures (161/91 vs. 127/76) and mean
BMI(23.2 vs. 20.8); subjects with glycosuria showed a
similar but less pronounced trend (mean age 45.7; mean
BP 146/84, mean BMI 21.4).
Discussion
Hypertension
The prevalence of hypertension appears to be substantial
among the Gambian adult population, in which 9.5% of
subjects are hypertensive according to WHO criteria. This
prevalence rate is compatible with similar studies in sub-
Saharan Africa. However, comparability between studies
is hampered by different denominators, different
sampling frames and different definitions (Akinkugbe
1990; Cooper & Rotimi 1994). A community-based study
among adults in different areas of Tanzania found
hypertension prevalences between 2.6% and 7.5%,
varying by region (Swai et al. 1993). A study among Bantu
populations in Zaire found 14.2% and 9.9% prevalence
rates in rural and urban areas, respectively (M’Buyamba-
Kabangu et al. 1987). Using less conservative criteria (a
DBP 89 mm Hg and/or SBP 139 mm Hg), Gilles et al.
(1994) found 12.5% prevalence in a Liberian study: using
this definition, 24.2% of subjects in our study would have
been classified as hypertensive.
A pragmatic definition of hypertension has been
proposed as ‘that level of blood pressure above which
treatment does more good than harm’ (Evans & Rose
1971). There is little data on what constitutes an
appropriate threshold in African populations, but
studies in the USA and Europe have found a higher
prevalence of hypertension and sequelae among people
of African origin (Akinkugbe 1990; Chaturvedi et al.
1993; Sharp et al. 1995). There may thus be a lower
threshold for target organ damage in African
populations, implying that antihypertensive therapy
should be initiated earlier (Chaturvedi et al. 1994).
1045 © 1997 Blackwell Science Ltd
volume 2 no 11 pp 1039–1048 november 1997
It is generally accepted that an individual diagnosis of
hypertension should only be made after repeated
measurements. In this population-based study, we used
a single measurement to screen for hypertension, and
performed second readings in those with a first diastolic
reading 90 mm Hg. To avoid problems of regression to
the mean resulting from physiological variation in blood
pressure, the lowest of the two readings was used in the
analysis. As only a single reading was available for 159
(20.8%) of the DHT subjects, we may have
overestimated the prevalence of hypertension; some of
these subjects could have been classified as normotensive
following remeasurement. We analysed diastolic and
systolic hypertension separately, as pathogenesis and
therapeutic possibilities differ. We have found
differences in risk factors between the different forms of
hypertension, supporting the idea that different
mechanisms may operate.
Hypertension has been found almost uniformly to
become more prevalent with increasing age, and to be
associated with obesity and urbanization (Kaufman &
Barkey 1993). We did not find an urban-rural difference
in hypertension prevalence, but what is considered
urban in The Gambia might well be considered rural in
other sub-Saharan countries with more urbanized
communities. The influence of urbanization may be
mediated by increased stress and by changes in diet, in
particular a higher salt intake when more processed
foods are consumed (Poulter et al. 1990; Elliott et al.
1996; Antonios & MacGregor 1996). These factors were
not assessed in the present study, but are possibly less
variable in The Gambia than elsewhere.
The observation that diastolic hypertension (DHT)
clusters in a variety of communities may indicate the
presence of other important determinants of
hypertension besides the known risk factors. Clusters of
DHT were identified in both urban and rural areas and
spread over the country, which may indicate that
localized environmental or genetic factors influence the
prevalence of DHT. A possible environmental factor is
schistosomiasis; a small study in The Gambia (Wilkins
1977) found a 2–4 times higher prevalence of DHT
among adults in communities where S. haematobium
was endemic. However, our study also found clusters in
areas where S. haematobium has never been endemic,
raising the possibility that genetic factors are also
involved. Heritability of hypertension is estimated at
25–30% (Ward 1990); and recently described
 Tropical Medicine and International Health
M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia
polymorphisms in the genes for Lp(a) lipoprotein and
the renin-angiotensin-aldosterone system (Berg 1996;
Corvol et al. 1996; Lifton 1996; Dwyer 1995) have been
associated with susceptibility to hypertension. The
observation that salt-sensitive hypertension is more
common in people of African descent (Rutledge 1994)
may also have a genetic basis. Further studies of the role
of environmental and genetic factors in the pathogenesis
of hypertension in this environment may guide the
choice of appropriate therapy.
Obesity
Obesity was associated with diastolic hypertension,
especially with severe diastolic hypertension, and with
female sex, increasing age, urban residence, non-manual
work and glycosuria. The precision of the height and
weight measurements may have been affected by the
change of equipment after the initial phase of the survey,
but this is unlikely to have introduced a bias by residence
or occupation in a particular direction. Although
hypertension is associated with obesity, and obesity with
urban residence, this does not lead to an overall
association between hypertension and urban residence.
The frequent coexistence of hypertension, obesity and
NIDDM which we and others have observed may be
mediated through a common genetic predisposition to
hypertension and to insulin resistance (Weidmann et al.
1995). It has been suggested that some populations are
especially susceptible to this syndrome and that lifestyle
changes may play important aetiological roles (Fujimoto
et al. 1995). Obesity is commonly associated with
hyperinsulinaemia, which may induce hypertension
through indirect mechanisms (Bonner 1994; Brands et al.
1995) and/or increase the subsequent risk of
cardiovascular disease (Hall et al. 1995). However,
whether hyperinsulinaemia has a truly causal role in the
association between obesity and hypertension is
unknown. Further studies are in progress to assess the
relationship between hyperinsulinaemia, obesity and
hypertension in The Gambia.
Diabetes
Our study found a considerably lower prevalence
(0.3%) of diabetes than reported in other studies from
sub-Saharan Africa (Tanzania 0.6–0.8%, Swai et al.
1993; King 1993). Although there was an increased
1046 © 1997 Blackwell Science Ltd
volume 2 no 11 pp 1039–1048 november 1997
prevalence in urban areas, this study was not powerful
enough to show a marked rural/urban difference. The
age of the identified patients, and the absence of clinical
symptoms reported suggest that these patients had non-
insulin-dependent diabetes mellitus. The prevalence of
hypertension among diabetics was higher than in the
general study population, a finding which has been
reported elsewhere (Hypertension in Diabetes Study
Group 1993; Mugusi et al. 1995). Although the numbers
were small, our results indicated that trends in
glycosuria prevalence reflected known risk factors for
DM (age, urban residence, hypertension, obesity) in
common with observations made elsewhere.
We did not take fasting blood sugar measurements
from all participants for reasons of compliance, expense
and logistics. The effect this strategy had on the results is
unknown; the sensitivity and specificity of dipstick
screening have not been determined in this environment;
but in our sample the positive predictive value is about
50%. Ongoing research is aimed at establishing a locally
appropriate ‘gold standard’ for diabetes diagnosis using
fasting blood glucose and/or glucose tolerance testing, and
formally assessing the sensitivity of dipstick screening.
Conclusions
Hypertension is a common finding among Gambian
adults. The size of the population at risk, and the paucity
of data on what constitutes an appropriate threshold for
intervention indicate a need for further studies to identify
those most at risk of target organ damage. The
observation of case clustering suggests that localized
environmental and genetic factors may influence the
development of hypertension. Further studies are needed
to unravel the dynamic interaction between obesity,
hypertension and diabetes, and to explore modifiable risk
factors for these conditions and development of long-
term complications, such as physical inactivity, smoking,
diet and salt intake.The choice between therapeutic
options and the formulation of appropriate control
strategies is likely to be helped by a better understanding
of the role of genetic susceptibility and environmental
triggers in hypertension, obesity and diabetes.
Acknowledgements
This study was carried out in collaboration with the
Gambia National Resurvey of Blindness and Low
 Tropical Medicine and International Health
M. A. B. van der Sande et al. Hypertension and related diseases in The Gambia
Vision, which was funded by Sight Savers International,
the British Council for the Prevention of Blindness, and
the WHO Programme for the Prevention of Blindness
and Deafness (WHO/PPBD). Additional funding for the
NCD component of the study was provided by the UK
Medical Research Council. SMC is sponsored by the
MRC Dunn Nutrition Unit, Cambridge, UK. We thank
the people of The Gambia who participated, the
Ministry of Health of The Gambia and the Director of
Health Services, The National Eye Care Program, the
staff and management of The National Resurvey of
Blindness and Low Vision, Abdoulai Jatta, Mariatou
Joof, Mufta Hydara, Musu Bojang, and the MRC
computer centre and transport section staff, who were
all essential to the study. We thank Jo Morris, Maarten
Schim van der Loeff, Melanie Newport, Paul McKeigue,
Tom Doherty and anonymous reviewers for their
valuable comments and suggestions.
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