TRENDS IN NON-COMMUNICABLE DISEASES IN NIGERIA
* By: Prof. G.C Onyemelukwe (MON); Professor of Medicine and Immunology, Ahmadu
Bello University, Zaria. Former Chairman Expert Committee on Non-Communicable
Diseases, Federal Ministry of Health, Nigeria.
GLOBAL CONCERN AND RESPONSES
In the 1950s – 1960s, hypertension was said to be rare in Africans, but in recent decades
hypertension has become prevalent and as high as 20% of adult Nigerians.(1,2) It has taken the
nations of the world decades to come to recognize the impact of Non-Communicable Diseases
(NCDs) on global health. The United Nations General Assembly in May 2010 passed a
resolution (A/RES/64/265) on non-communicable diseases, recognizing the enormous suffering,
premature death and serious threat to global development as well as the negative socio-economic
impact caused by NCDs(3) – diabetes, stroke, hypertension, cardiovascular diseases, cancers,
asthma, chronic lung diseases, oral health disorders, injuries and violence, and sickle cell disease
and has alerted that deaths from NCDs will increase by 25% in 2015 if unchecked.
NCDS AND MILLENNIUM DEVELOPMENT GOALS
The World Economic Forum has reported NCDs as leading macroeconomic risk at global
level(4). There is evidence that NCDs are undermining the attainment of Millennium
Development Goals (MDGs) as the rising prevalence of high blood pressure, diabetes and other
risk factors among women of child bearing age in developing countries have direct consequences
on maternal health complications, pregnancy outcomes and child survival(5). Consequently, the
63rd World Health Assembly urged member states, international development partners and
WHO, in a resolution on health related millennium development goals to recognize the growing
burden of NCDs(6). The G1 millennium development goal of eradication of poverty and hunger
is unachieved in Nigeria, where underweight children below 5 years is up to 42% as shown by
1
National Demographic and Health Surveys. The G3 goal of empowering and educating women
which will impact on behaviour and dietary changes that underpin NCDs, is yet to be remarkably
addressed in Nigeria.
A grand challenge, noted in Bill and Melinda Gates Foundation’s Grand Challenges in
Global Health Initiative is “a specific critical barrier that if removed would help to solve an
important health problem”. About 20 grand challenges with regards to NCDs, are grouped under
six goals – raise public awareness; enhance economic, legal and environmental policies; modify
risk factors; engage business and community; mitigate health
urbanization; reorientate health
impacts of poverty and
system,(8) . The expected change that necessarily includes
behaviour change largely hinges on individual choices which aggregate to people and
community choices.
With regards to research, the Global Alliance for Chronic Disease (GACD)(9) was
launched in Seattle and initially operated by six national funding agencies from USA, Canada,
Australia, United Kingdom, China and India. South Africa later joined in 2010, but Nigeria is yet
to join. GACD initial priorities in 2009 were hypertension/stroke; reduction of tobacco use, and
reduction of indoor pollution from cooking. World Health Organization (WHO) estimates 2%
annual reduction of NCDs over the next 10years if its plan of action on NCDs is vigorously
pursued(10).
WHO has also developed a Global Strategy on Diet, Physical Activity and Health, as well
as passed a new resolution on “Marketing of foods and nonalcoholic beverages to children”.
WHO is guiding a global strategy to reduce the harmful use of alcohol and has created the NonCommunicable Diseases Network(11), NCDNet. An estimated annual death of 36 million per year
including 9 million dying before the age of 60 occurs in developing countries and especially in
2
those with economies in transition, and amongst the poorest and vulnerable; while twice as many
women die (per 100 adults) in Africa from NCDs(12,13).
DETERMINANTS
The magnitude of NCDs is rapidly increasing because of population aging (longer life
span demographic transition – initially described by Warren Thompson), unplanned
urbanization; trade globalization and marketing. Old age is associated with poor dental state,
increased insulin resistance, increasing blood pressure. Epidemiological transition from
previously predominant infectious disease pattern to NCDs occurring in developing countries is
another factor and a complex interplay of infectious diseases and NCDs exists with many of the
NCDs now linked to or caused by infectious causes(14).
Risk Factors
A risk factor is defined as an attribute, characteristic or exposure of an individual which
increases the likelihood of developing a disease or injury. Risk factors are either non-modifiable
such as genetic endowment, race, age and sex or are modifiable by behavioural or other
interventions such as changing diet, use of exercise and reduction of tobacco and alcohol use.
The level of exposure of people to risk factors of unhealthy diets, physical inactivity,
undue stress and pressure, tobacco use and harmful use of alcohol and drugs, has become higher
in developing countries than in high-income countries where comprehensive interventions at
prompting healthier behaviour, affordable and accessible health care services for early detection,
effective treatment and prevention of complications, are in place(15). The increased consumption
of unhealthy foods which include added salt, refined foods high in fat and simple sugars and low
in plant fibre compounded leading to increased prevalence of overweight in middle-to-lowincome countries is referred to as nutrition transition which is a type of malnutrition ensuing
3
from dietary shifts to foods rich in added sugar, saturated fat and sodium for foods rich in
vitamins, fibre, minerals and micronutrients such as fruits, vegetables and whole grains.
Developing countries struggling with hunger are consequently dealing with problems associated
with obesity both in childhood and adults. In many households, obesity and under nutrition coexist. When overweight was determined by body mass index (BMI) in Nigerian Hausa-Fulani
diabetics, it was found to be prevalent in 35% compared to 22% in controls. However, when it
was determined as central obesity (abdominal obesity) it was prevalent in 95% of same diabetics
and 0% in controls(16)
Furthermore, malnutrition and stress in pregnancy with low birth weight prevalent in
developing countries including Nigeria (14% low birth weight as reported in National
Demographic and Health Survey (NDHS), 2003) leads to intrauterine fetal programming(17),
which is further exaggerated during later rapid childhood growth(8) and leads to noncommunicable diseases in adults. Surveillance of risk factors(15) is necessary in all nations and
surveillance systems are still lacking in Nigeria.
Infection as determinants
Reference has been made to a comprehensive review describing the role of infections in
NCDs(14) and in Nigeria many infections cause or determine the emerging of patterns of noncommunicable diseases. Few examples include:
Group A beta haemolytic streptococci and Rheumatic heart diseases(18), Hepatitis B,C,D
viruses and hepatocellular carcinoma confirmed in Nigerians by studies of Fakunle(19) and
Ndububa(20) and Olubuyide and coworkers(21); Helicobacter pylori and peptic ulcer disease and
gastric carcinoma(22); Coxsackie virus and mycocarditis/cardiomyopathy(23); Human papilloma
virus types 16, 18 and 11and cervical cancer
(24, 25)
4
; HIV and malignancies including Kaposi
sarcoma
(26)
; Schistosomiasis and bladder cancer(27); Endomyocardial fibrosis associated with
parasitic infections in the studies of Andy and colleagues
(28)
; and Chlamydia linked to
atherosclerosis, stroke, hypertension, asthma and other diseases(14).
The classic research of Greenwood and co-workers(29) in Nigeria showed that malaria
parasite Plasmodium knowelsi suppressed or aborted the spontaneously developing autoimmune
disease in mice as well as adjuvant arthritis. The low prevalence of autoimmune mediated noncommunicable diseases in Nigeria and sub-Saharan Africa
(like type I diabetes mellitus,
autoimmune thyroid diseases, rheumatoid arthritis which are not as common as in Caucasians)
may be as a result of modulating effect of malaria. Furthermore, malaria may have served as a
selective factor for the sickle cell gene and glucose-6-phosphate dehydrogenese deficiency gene
as these confer survival advantages(30).
Determinant - Hazardous Environment
Another driving factor is environmental pollution by heavy metals - arsenic, cadmium,
mercury, iron, lead, zinc, radioactive elements
(31,32)
reported in Delta region, Lagos and other
states in Nigeria. The use of leaded petrol in Nigeria, petrochemical activities and the mining
activities in Kaduna, Plateau and other northern states where radioactive elements are also
exposed are sources of pollution.
The finding of lead and other metals in blood of Nigerians as well as fish(32) may contribute
to the development of Alhzemier’s disease, cancers, neurotoxicity, cardiovascular and other
diseases. High lead levels as found in Nigerians(33) (2-3 folds of levels in other countries: 10 –
58µg/dl) may cause depression of circulating 1,25:
dihydrovitamin D, so that rickets and
osteomalacia and other metabolic bone diseases evolve while anemia, neuropsychiatric
manifestations, immunosupression, hypertension, low sperm counts are other hidden deleterious
5
effects. Iron content in domestic water was shown to be high in Rivers State (range 0.0014 to
80mg/l as against recommended levels of 0.3mg/litre)(34) due to sediments brought down by
Niger and Benue rivers to riverine areas.
Drug abuse/use
X
Tobacco use/smoking
X
X
Salt excess
X
X
X
X
X
X
X
Unhealthy diets
X
Obesity
X
X
X
X
X
X
X
Abnormal lipids
X
X
X
Psychological stress
Low socio-economic status
Unsafe sex
X
X
X
X
X
X
X
X
X
Family history/heredity
X
Gender
= Increase risk of disease
Pulmonary Disease.
X
X
X = Do not increase risk of disease, COPD = Chronic Obstructive
6
violence
X
Osteoporosis/Nutrition
Oral health
Sickle cell disease
X
X
X
Blindness
Asthma/COPD
Physical Inactivity
Alcohol Excess
Heart disease
Mental illness
Coronary artery disease
Cancer
Stroke
Diabetes mellitus
Hypertension
Table 1: Conventional Risk factors for NCD
X
ENVIRONMENT
1. PHYSICO-CHEMICAL-MICROBIAL ENVIRONMENT
2. PSYCHOSOCIAL ENVIRONMENT
3. INTRAUTERINE ENVIRONMENT
GENES
HIGH STRESS
LACK OF EXERCISE
HIGH FAT
SMOKING
HIGH SALT
HIGH RISK
BEHAVIOUR
ALCOHOL
UNSAFE SEX
FETAL UNDER NUTRITION
DRUG ABUSE
CHILDHOOD UNDER NUTRITION
WELLNESS
DISEASE
DISABILITY
ORGAN FAILURE
Fig. 1: Interaction of genes, environment and risk factors
7
Genetic Determinants
Genetic predisposition and environmental and lifestyles interact in determining the
expression of NCDS (fig I). The HLA genes of chromosomes 6 play important roles in the
outcome of immunological interactions with infectious causative agents that lead to some noncommunicable disease like type I diabetes mellitus. Famuyiwa and coworkers(35) showed that the
pattern of HLA antigens in Nigerian diabetics differs from Caucasians. Properdin factor B
allotypes in Nigerians also differs from Caucasians and Australians(36).
About 150 candidate genes have been identified for hypertension(37) including SNPs related
to genes for atrial natriuretic peptide A and B types, which are associated with vessel relaxation,
salt loss and inflammatory responses in salt sensitive hypertension.
Important genetic research findings in Nigerian women with breast cancer show
susceptibility to four polymorphic variants of CYP1A1 and BRCA1(38,39) conferring increased
risk and poor prognosis, related to insulin – like growth factors IGFBP2(40) and IGFBP5while
cell surface marker HER – 2(41) and reduced oestrogen and progesterone receptors are reduced in
Nigerians.
Genetic research with regard to Alzheimer’s(42) disease showed that apolipoprotein
E
haplotype is different between Yoruba and African Americans.
Quaak and others(43) showed that genetic variants in dopaminergic
systems, opoid
receptors, the buproprion-metabolising enzymes CYPZB6 and nicotine-metabolising enzyme
CYZA6 play important roles in habit formation and predicting smoking cessation responses to
nicotine replacement therapy and bupropion treatment.
Longer Leukocyte Telomere length (LTL), is associated with longer life span. This
complex genetic trait, is longer in women than men, is shortened by environmental factors
8
(smoking, obesity, psychological stress, low socio-economic status), diseases like hypertension,
insulin resistance, atherosclerosis, myocardial infarction, stroke and dementia(44) but lengthened
by exercise(45).
Determinant – Cocacolonisation
Globalization of soft drinks culture (cocacolonisation) has been articulated by Zimmet(46) and
linked with chronic diseases following excessive, persistent consumption of sugary drinks
(dietary fructose) which lead to obesity and also adversely affect lipids, platelet adhesiveness,
insulin levels(47). Fructose feeding induces diabetes in laboratory animals(49). The platelets of
native West Africans have been found to easily disaggregate unlike in Europeans when
aggregators like adrenalin, ristocetin, collagen are applied and rapid fibrinolysis also occurs in
Nigerians(49).
Table 2: Sugar contents of soft drinks marketed in Nigeria
Sugar (g/100ml)
Soft drinks Glucose
Sucrose
Fructose
Cocacola
0.22
1.31
0.67
Fanta
0.42
1.20
0.70
Sprite
0.20
0.68
0.60
Pepsicola
0.17
0.81
0.58
Mirinda
0.22
0.95
0.54
Maltina
0.22
1.13
0.50
Total
2.2
2.32
1.48
1.56
1.71
1.85
These protective advantages, which may account for low frequency of coronary artery
diseases in Nigerians and other West Africans, are being eroded with westernized lifestyle, and
urbanization by excessive soft drinks culture and by the presence of diabetes(50). Nigerian soft
drinks have been shown to be high in sucrose and fructose(50) which are much higher than the
brands in South Africa(52). Burkitt in 1973 and 1982(53 ), described and postulated the emergence
of diabetes, cardiovascular diseases and colorectal cancer and other malignancies with the
westernization of African diets.
9
Determinant – Breast feeding and artificial milk feeding
Retrospective surveys confirm that type 1 under five childhood diabetes is rare in Nigeria(54)
compared to Caucasians (Rivers State, 1991 – 1996, of 5739 admissions, prevalence of 1.2/1000
compared to 0.95 per 1000 in Sudan, and 10 fold in Europe). Cow milk used for early human
baby feeding in Denmark and Finland, contains bovine serum albumin which cross-reacts with
P69 antigen of pancreatic beta cells causing autoimmune damage(57). Exclusive breastfeeding
policy in Nigeria should be maintained as a preventive measure.
Cyanide content of Cassava Versus Bitter Leaf (Veronica Amygaline)
Two Nigerian varieties of cassava - sweet, eaten raw in northern states with low cyanide
content and the bitter variety in southern states which is toxic with high cyanide content.
Processed cassava may have little amount of cyanide which can be detoxified to thiocyanate by
sulphur containing amino acids mainly found in grains(56) . chronic low level exposure to cyanide
causes goitre and tropical ataxic neuropathy which was attributed to cyanide in cassava diets and
such patients also have increased prevalence of impaired glucose tolerance(56). Odeigah(57)
demonstrated that feeding albino rats with unprocessed Nigerian cassava for 36 weeks resulted in
acute blood glucose increase and glucose intolerance. Akah and Okafor(68) using bitter leaf
(Veronia Amygdaline) water extracts showed noticeable reduction in blood sugar levels in both
normal and alloxan diabetic rats. Traditional diets with bitter leaf utilized with the bitters may
have conferred some protective advantage to traditional Africans.
Brief Comment on Nigerian Responses
The Federal Government has so far appointed the Expert Committee on NCDs (1981 –
2000) chaired by Prof. O O Akinkugbe and (2001 – 2007) chaired by Prof. G.C Onyemelukwe to
formulate goals and policy for prevention, institutional manpower development and to undertake
10
national survey researches to determine prevalence of NCDs and their risk factors. Guidelines for
management of diabetes mellitus, asthma, cancers, hypertension have been created. Nigeria in
2003/2004 signed the WHO Framework Convention on Tobacco Control, and a comprehensive
antitobacco bill (2008) was passed by the National Assembly in 2011. Health promotion policy
document with strong NCD components was produced in 2004/2005. Nigeria committed herself
as an active member of Mega Country Health Promotion Network with other mega countries (a
mega country has population of more than 100 million) – Bangladesh, Brazil, China, India,
Indonesia, Japan, Mexico, Pakistan, Russian Federation, USA) - who make up two third of
world’s population and 60% of persons at risk of NCDs. Institutional strengthening to deal with
organ damage by NCDs has improved but are still inadequate as revealed by many uncared for
and those who go outside overseas for expert care. Cancer registries have been expanded and a
proclamation to set up National Cancer Centre in Abuja was made in 2010.
Hepatitis B vaccine has been included in expanded immunization programme of children
to combat chronic liver disease and hepatoma, but human papilloma virus vaccination is yet to be
instituted. Cervical, prostate and breast cancer screening centres are being set up across the
country especially in tertiary and private institutions. National transplantation law has been
included in the National Health bill (2011). National Health Insurance Scheme provides for
financial cost of NCDs but incompletely.
Road traffic accidents are being addressed by Federal Road Safety Commission and
Lagos State Assembly in 2006/7 passed Helmet law for motorcyclists as an example to be
emulated across other states. The NCD policy draft is yet to be completed while national surveys
on NCDs (1997)(59), (2003) (60), surveys for Blindness, Mental Health(61), Youth Tobacco(62) use
have been undertaken.
11
The example of Lagos State government (2007 – 2011) in instituting mass screening for
NCDs as well as Kanu Nwankwo Foundation for heart valve and other cardiac surgeries are
landmarks that need to be emulated and expanded by other state governments and private
philanthropists.
HYPERTENSION
Hypertension has grown over the last fifty years as a public health challenge in Nigeria,
with surveys revealing deficiencies in awareness, treatment and control of hypertension and clear
urban over rural prevalence in the studies of Oviasu; Akinkubge, Kadari, Ike, Soyanwo and
others. Hypertension contributes greatly to cardiac and renal diseases and failures as well as
strokes in Nigeria.
Table 3: Urban prevalence and burden of Hypertension in Nigeria.
Urban
Rural
Overall
Male
1990/2
14.6%
9.8%
11.2%
11.1%
National Survey Expert Committee
NCD (1997) reports (>15 years age)
1998 – 2003
18.4%
10.8%
(Hospital Based – Enugu) Ike (2009)
2003 National Survey Expert Systolic
Systolic
Committee NCD, Lagos S.W zone
28.9%
13.7%
22.5%
Diastolic
40.5%
20.5%
2007 University of Ibadan, Jaja
Ekore, Ajayi, Arije (2009) (Case
finding)
Diastolic
29.7%
30.6%
42.7%
Female
11.2%
Criteria
Systolic > 160
Diastolic > 95
7.6%
Systolic > 140
Diastolic > 90
Systolic > 140
Diastolic > 90
57.3%
Systolic > 140
Diastolic > 90
DIABETES MELLITUS IN NIGERIA
Deaths and disabilities have continued to increase in Nigeria with tangible and intangible
economic costs to families and the nation due to diabetic gangrene, diabetic renal disease,
diabetic eye complications, ketoacidosis and infections.
12
S/No
1
2
3
4
3
4
5
Table 4: Trend in Diabetes Prevalence in Nigeria
Year of study
Prevalence %
Another as
1960’s/70
0.56%
Adadevoh
1971
0.43%
Osuntokun
1988
1.7%
Ohwovoriole et al
1988
1.4%
Erasmus, Ebomoyi Fakaye
1996
1.6%
Bakari, Onyemelukwe et al
1997
2.73%
National Expert Committee
2003
3.0%
National Expert committee
Site
Ibadan (Hospital based)
Ibadan (Hospital based)
Urban (Lagos)
Rural (Kwara)
Semi-urban (Kaduna)
National
Lagos
Childhood diabetes – Type I diabetes in children is uncommon in Nigeria unlike in Caucasians.
A six year period (1991 - 1998) in Rivers State showed a hospital prevalence of 1.2/1000(54)
CANCERS
The prevalent types of cancers have been collated in 13 cancer registries located in
teaching hospitals in Ibadan, Jos, Lagos, Zaria Ile-Ife, Enugu, Ilorin, Maiduguri, Benin, Kano,
Nnewi, Calabar and Sokoto over the years(27,63,64,65,66). The relative frequency (%) of common
cancers in 4 cancer registries are shown in the table below:
Table 5: Cancer Frequencies(%) in Four Registries in Nigeria
Site
Ibadan
Kano
Calabar
(2001-2005)
(1995-2004)
(2004-2006)
Breast
25.2
11.4
29.6
Cervix
19.5
9.7
8.2
Prostate
8.5
8.3
34.7
Non-Hodgkin’s
1.4
3.8
1.4
Lymphoma
Liver
2.6
1.6
2.2
Colorectal
3.5
6.4
2
Male (number)
4214
1001
255
Female (number)
2185
989
570
Kaposi Sarcoma has begun to increase as a result of increasing
Lagos
(2002-2007)
39.1
18.4
3.3
5.3
Average
%
26.3
13.9
13.7
3.0
6.5
3.9
3.6
446
1369
3.5 – 4.5% national
prevalence of HIV in Nigeria. Over the years, breast and cervical cancers have been the
common cancers in all these four registries as it has been reported by GLOBOCAN as world
trend. Currently, prostate cancer increasing in prevalence is the commonest killing disease in
aging men in Nigeria(67).
13
Childhood Cancers: Data from various parts of Nigeria show five commonest childhood
cancers are non-Hodgkin’s lymphoma (mainly Burkitt’s lymphoma),
retinoblastoma,
nephroblastoma, sarcomas and leukemia. Earlier Ibadan studies showed remarkable percentage
of brain tumours and leukemia, with Burkitt’s lymphoma commoner in southern states of
Nigeria than northern savannah areas. While retinoblastoma and nephroblastoma are commoner
under 5 years of age, lymphomas and sarcomas occur in older children (male to female ratio
1.4:1to 1.6:1, except for retinoblastoma with equal sex prevalence(27,68,69).
CORONARY HEART DISEASE/ISCHAEMIC HEART DISEASE
The World Health Organization projects that the number of deaths from ischaemic heart
disease in the African region will double by 2030. The incidence of myocardial infarction in
Nigerians(70,71) is low despite presence of predisposing disease like diabetes(72) and hypertension
being only about 6% of all cardiovascular diseases in black Africans. Although, the trend is
towards increase especially in Ibadan, Lagos(73) and urban centres(74), such increases have been
attributed to urbanization, westernized diet, diabetes, reduced level of physical activity, obesity,
hyperlipidemia, hypertension.
In the north of Nigeria, first case was reported in 1997(75) and in a ten year review (1985
– 1995) Danbauchi(74) reported 10 cases of ischaemic heart disease, with seven presenting as
myocardial infarction (4 were non-Nigerians). Compared to Europeans, Nigerians have relative
thombocytopenia, spontaneous fibrinolysis, rapid platelet disaggregation after ADP – induced
platelet aggregation, reduced or absent ristocetin induced platelet aggregation in Nigerian
platelet – rich plasma, probably due to a plasma component interacting with Von Willebrand
factor (VWF); high factor VIII coagulant activity, factor VIII related antigen(49).
14
CARDIOVASCULAR DISEASE – SPECIAL FEATURES IN NIGERIA
Over the last fifty years most cardiac diseases in Nigeria have been as a result of
hypertension and rheumatic heart disease and cardiomyopathy..
Paripartum Cardiac Failure (PPCF)
Among the Hausa and Fulani in northern states of Sokoto, Kaduna, Bauchi, Katsina
women after delivery by tradition ingest heavy loads of sodium (Kanwa(135) – 30g per day
3mol/g, rock salt) to “promote breast milk” and also heat their bodies by lying on hot clay with
fire beneath, splashing themselves with hot water twice daily – for 42 days(76). A follow up
study of 227 women from 1969 to 1993 – 1995 documented sodium hypervolemia, oedema,
high cardiac output and hypertension in the acute phase(77,78). The cultural practices are being
changed but persist in many areas. In Sokoto, incidence rate of PPCF was 1 per 100 deliveries,
accounting for 60% of admissions for heart failure in 2003 – 2005 of both primiparous and
multiparous women.(76)
Rheumatic Fever(RF) and Rheumatic Heart Diseases(RHD)
Over the last fifty years, RF and RHD have remain a burden in all parts of Nigeria,
located in the area of highest prevalence of rheumatic heart disease of 6 – 7 cases per 1000
children, aged 5 – 14 years
(79)
. WHO has alerted nations about the prevailing and unchecked
permanent vulvular damage that follow repeated streptococcal sore throat infections with group
A streptococci carrying virulence factors. Epitopes in the cell wall, cell membrane and the
A,B,C repeat regions of streptococcal M protein, on the basis of molecular mimicry, cross-react
immunologically
with
heart
myosin,
tropomyosin,
keratin,
laminin,
vimentin,
N-
acetylglucosamine.(80) Classical clinical features of acute rheumatic fever (ARF) may be masked
while valvular heart damage continues.
15
Nigerian Heart Foundation could spearhead and coordinate the opening of ARF registry
all over the country; monitor and document children with sore throat to prevent repeat attacks
with antibiotic treatments and follow up ARF or rheumatic heart disease development thus
taking every sore throat in Nigeria serious. The need to set up a system of primary, secondary
and tertiary prevention is urgent(81). Ogunbi reported in 1978, the epidemiology of rheumatic
fever and rheumatic heart disease in Lagos(83). Jaiyesimi and Antia(143) reported from Ibadan that
pharyngitis was associated with measles infection in the patients with mean age of 8.8years.
Between 1999 and 2002(84) a Zaria study showed that the patients with rheumatic heart disease
were in the age range of 5 -52 years with mitral incompetence and aortic incompetence
prevailing.
Pre-eclampsia, Eclampsia and Hypertension
The estimated prevalence of pre-eclampsia is 6 -10% of pregnancies in Nigeria worse in
Northern states and areas without antenatal care across. About 30% mortality of pregnant
women has been reported in Kano studies due to eclampsia. Pre-eclampsia is the leading cause
of maternal mortality in pregnant
women in developing countries(85). Ekwempu(86) had
suggested that infections were trigger factors. The exact mechanisms are yet undefined but
tumour necrosis factor (TNF) was markedly raised in pre-eclampsia/eclampsia when compared
to normal pregnant women and non-pregnant women and the reverse was found with interleukin
– 10 (IL -10) (in a Zaria study unpublished, 2008). TNF may be responsible for maternal and
fetal deaths in these diseases/subsequently, the development of hypertension in post partum
survivors occurs and has been described as sixteen (32.7%) of 49 females with hypertension
suffered from pre-eclampsia in previous pregnancies(87).
16
STROKE
The importance of hypertension in stroke causation has been growing with the years.
Over 66% of stroke patients were found to be hypertensive in Lagos by Danesi(88) and 79% by
Bwala in Maiduguri(89). Community based prevalence of 58 to 400 per 100,000 population was
reported in 1987 by Osuntokun and co-workers(58).
Recent community based studies in 2007 and 2008(90) in Lagos revealed prevalence of
114 per 100,000 per year and crude incidence rate of 25.1 per 100,000 per year. Over 80% of
Nigerian stroke cases in this study were below 45 years of age. Crude incidence rate varied
between 6.1/100,000 per year in the age group of 25 – 34 years; 20.1/100,000 per year in age
group 35-44 years and 39.9 per 100,000 per year in age group 65 – 74 years showing the
increasing vulnerability with advancing age.
The types of stroke in Nigeria consist of ischemic stroke 70 – 80% (atherothrombotic
infarction 14 – 40%; cardioembolic 15 - 30%) and lacuna infarction. Haemorrhagic strokes
constitute 20 – 30% of stroke made of intracerebral haemorrhage (10 – 20%) and subarachnoid
haemorrhage 5 – 15%(90). Sickle cell diseases causes strokes and acute cerebral syndrome in
Nigerian children with deficiencies of antithrombin III and other anti-thrombotic factors(91)
which blood transfusion reverse.
ASTHMA
National survey and the epidemiology of asthma have not been fully undertaken in
Nigeria. However, allergic asthma due to house dust mite (Dermatophagoides pteronnysinus
and Dermatophagoides farinae predominate in forest and savannah regions of Nigeria(92). Other
allergens – egg yolk, egg white, okro, frying oil, pepper, etc airborne fungi during harmathan
and pollens have been reported in various parts of Nigeria by Sofowora(93), Soyinka(94) (South
17
West) Haddock and Onwuka(95). Exercise induced asthma occurs as well as parasite associated
asthma especially in children who harbour parasites with lung migratory larval stages like
Hookworm, Strongyloides, filaria and others. In the annually repeated climatic harmattan haze
over the North of Nigeria that shifts to the southern states, genera of fungi found include
Fusarium, Alternaria, Penicillum and others(96) with various respiratory diseases manifestations.
Global Initiative for Asthma (GINA) guidelines of 1995, (revised 2006)
(97)
provide the
instrument to address the lack of exact statistics of asthma prevalence and burden in Nigeria as
well as the use of the International Study of Asthma and Allergies in Childhood (ISAA),
Asthma Insights and Reality (AIR) surveys instruments(98).
OSTEOPOROSIS
Osteoporosis especially of the vertebra (lumbo-sacral) with associated osteophytes and
nerve roots compression is being reported in diabetic patients, in obesity and in women who have
had multiple pregnancies. This silent development requires a national survey to document its true
burden.
FACTUAL INSIGHTS INTO SURVEYS
I. National survey by Expert Committee on NCDS with Chairman as Prof O. O.
Akinkugbe reported (1997)(59).
Hypertension (> 160/90) was found in 11.2% (or 4.3 million adult Nigerians, (66% with mild
hypertension; 20% with moderate hypertension, 14% with severe hypertension, 12.5% borderline
hypertension. Urban centres had more than rural). Sickle cell trait (AS) was found in 23.04%,
while 0.5% of adults had sickle cell disease (SS). Total cholesterol was low generally (mean
122.4 ± 42.0 mg per dl) with urban men and women having higher levels than rural dwellers.
Diabetes mellitus was found in 2.2% nationally and 2.1% in males and 2.3% in females. Highest
diabetes prevalence was in Lagos 4.7%, lowest in Plateau (0.6%). Urban communities had
higher diabetes prevalence (3.3%) than rural communities (2.6%).
18
Family history, advancing
age, increasing body mass index, positive alcohol history, and sedentary lifestyle were
contributory risk factors. 80% of diabetic persons were not aware of their condition.
II.
National survey by Expert Committee 2003, South West Zone – Lagos (South West
Zone) with Prof. G. C. Onyemelukwe as Chairman(60).
1082 subjects in urban and rural areas in Lagos state were surveyed.
Overweight was 36.3% (female 44.7%, male 26.7%). Hypertension BP>140/90 overall
systolic (>140) 22.5%; diastolic 29.7%, Urban systolic (28.9%), rural systolic (13.7%), urban
diastolic 40.5%, rural diastolic 20.5%. Genotypes obtained were AA (70.4%); AS (24.1%); AC
(4.7%); SC (0.4%); SS (0.4%). Blood lipids – triglycerides > 120mg/dl in 12.6% of subjects.
Blood sugar > 126mg/dl in 2.3% > 110mg/dl in 2.8% and 110-126mg/dl in (0.5%). Traffic safety
– never used seat belts ( front seats) 65%; never used seat belts (back seat) 86.6%). Females
health–never performed pap smear (97.2%), never performed self breast examination regularly
(71.3%). Male health - never performed screening for prostate cancer (98.1%)
With regards to risk factors, the following information were obtained;
Smoking currently (9.6%); started smoking at 20 years of age 47.4%; consumed alcohol
ever (32.7%); Physical activity with recreation five times per week 41.1%; Fruits, not eating at
all (13.7%): not eating fresh vegetables at all (32.7%) and using extra salt with food (10%)
III. NATIONAL SURVEY OF BLINDNESS IN NIGERIA (2005 – 2007)(99)
This survey was conducted on 13, 599 persons 40 years and above nationally, national
extrapolations have revealed 1,130,000 persons, aged more than 40years are currently blind,
(North West zone had 28.6%): 2,700,000 adults have moderate visual impairment. 400,000 are
severely visually impaired. This survey gave a total of 4.25 million adults visually impaired or
blind. No urban/rural differences was found. Cataract accounted for 45.3% of visual impairment,
and 43% of blindness. Glaucoma occurred in 16.7%; corneal scarring in 7.9%; hypertension
stage 2 occurred in 10.9%. hypertension stage 3 occurred in 3.9% while diabetes mellitus
occurred in 7.1%.
19
IV.
NATIONAL SURVEY ON MENTAL HEALTH WELL BEING (NSMHW) (2002
– 2003)(61)
NSMHW was conducted on 6752 respondents in six zones of Nigeria in subjects, aged
18years and above. The prevalence of any International Classification of Diseases (ICD-10) in
prior 12 are 7.3% (6.6% in males and 8.0% in females). Anxiety disorders were most prevalent
(males 4.1%, females 7.0%). Specific phobias were commonest anxiety disorders (3.2% males,
5.1% females). Substance abuse disorder, mainly alcohol occurred in 1.4% males. Life-time
prevalence of mental disorder was 14.2% i.e. 1 in every 5 adult Nigerians had experienced an
impairing level of the mental health condition. Life-time prevalence of non-affective psychosis
was 2.1% with visual hallucinations experienced by 1.2%. Sleeping difficulties lasting at least
two weeks in the month occurred in 12% of respondents (13.5% females, 10.1% males). Suicidal
thought occurred in 3% of the sample, females had more suicidal ideation. Only about 12% of
persons with ICD -10 mental disorders had received treatment in previous 12 months to the
surrey. Prevalence of life time substance use occurred in significant percentages in low, average
and high income respondents and Protestants, Catholics and Muslims, and other religious groups.
Nigeria suicidal rate is lower than other countries 0.70 per 100,000 per year, compared to
Uganda 7.0, Zambia 12.8, England 10, Hungary 40, Greece 2.8, Geneva 22.75.(100) . It is
necessary to note that depresses may manifest with bizarre symptoms of crawling sensations,
muscle twitches, internal heat in the so called internal heat syndrome(101) which may pose
difficulties for clinicians to diagnoses.
V ROAD TRAFFIC ACCIDENTS – WHO GUIDED POPULATION BASED SURVEY
Road traffic accidents have continued to increase since 60s in Nigeria. Nigerian Health
Nutrition and Population country status report 2005 stated that as at 2001, Nigeria ranked second
20
on the weighted scale of countries with very high road traffic accidents in Africa according to
WHO. As recorded by the Federal Road Safety Commission (FRSC) (102), 98,404 traffic crashes
occurred from 2000-2006 with 47, 092 deaths. In 2003, 4514 road traffic accidents occurred in
Lagos State alone. A survey of South West Zone (Lagos, Ogun, Oyo, Osun States) showed that
human, vehicular, and poor environmental factors contributed to 79.4% of road traffic cases in
the area. Over the last 30 years, there had been a five fold increase in traffic related deaths in
Nigeria with fatality per accident rate 20 times higher than in developed countries(103).
Prevalence of road traffic accidents are lower among drivers who do not take alcohol, kolanuts,
central nervous stimulants and those who undertake regular maintenance of vehicles and regular
eye examination.
Table 6: Percentage of sample respondents with RTI in last 12 months by Social and
Demographic Characteristics
ANY INJURY
Had injury
Had RT injury
TOTAL
N I Number
%
N2 Number
%
Number
Over all
Sex
349
Male
218
Female
131
Below 5
23
Age group
5 – 17
95
18 – 19
91
(104)
From Labinjo et al, 2009 .
11.3
13.8
8.6
5.3
8.8
14.2
127
89
38
0
34
39
4.1
5.6
2.5
0
3.1
6.1
3100
1579
1521
431
1085
643
A technical report on survey to assess burden of Road Traffic injuries was funded by
WHO and conducted by Labinjo and others(104) using WHO guidelines for conducting
community survey on injuries and violence. 3100 respondents were sampled in 80 households
each in seven states with high social, commercial and political activities (Kaduna, Borno,
Plateau, Abuja, Lagos, Anambra, Rivers). Percentage of sampled residents that suffered road
21
traffic injuries was 41% with male to female ratio of 2.2 to 1, with 18 – 29 age group most
implicated.
Rivers State had highest (29.9%), Abuja had 20.5%, Lagos 12.6%, and Kaduna 6.3%. 18
– 29 age group followed by 5 – 17 age groups and 30 – 44 had most injuries. By type of crash,
motor vehicle crash was 29.9%, motorcycle crash was 54.3%, tricycle crash was 1.6%,
pedestrian 11.8%, bicycle 2.4%. Slight injury occurred in 55.9%, serious injury 38.8%,
permanent disability in 3.9%, death at crash 0.8%, death at hospital 1.6%.
VI SURVEY OF VIOLENCE: POLICE-COMMUNITY VIOLENCE
Related to physical causes of morbidity and mortality due to road traffic accidents are the
deaths and injuries that occur in Nigeria because of ethnic and police and law enforcement
clashes with communities. A national survey to determine the root cause of police community
violence was undertaken by Center for Law(105) Enforcement (CLEEN) and National Human
Rights Commission. Violence conceived as homicide, summary executions, injuries and brutality
were documented. Other sources of violence include, ethnic, religious and political violence
which have been prevalent for decades through political riots of Western Nigeria (1961 - 66) and
Tiv riots (1961 – 64), Northern Region (1966 – 1967), Civil war (1967 – 71), Maitasene and
multiple religious riots (1980 - 2010), Boko-Haram riots and Riverine violencve by MEND.
VII GENDER BASED VIOLENCE
Gender based violence (GBV) which is almost synonymous with Violence against
women(106) (VAW) according to United Nations Development of International and Social Affairs
is endemic in Nigeria (with patriarchal society) manifesting as physical abuse (beating and
genital mutilation), sexual violence (rape), verbal and emotional abuse. In a 1999 study of 9686
randomly selected single female (aged 10 – 24) hawkers in motor parks, 60% experienced sexual
22
harassment, 7.4% were raped. In Ibadan study(107), of the 350 female apprentices 22.9% were
sexually harassed, 27.7% experienced attempted rape and 5.7% were raped. Sexual harassment
in primary, secondary and tertiary institution has risen over the years in Nigeria. Commercial sex
is forced on women trafficked out of Nigeria. Between March 1999 and April 2002, 1126(108)
women trafficked out of Nigeria were deported from various countries. Agencies like the
National Agency for Prohibition of Trafficking in Persons (WAPTIP), Women Rights
Advancement and Protection Alternative (WRAPA) and Women Trafficking and Child Labour
Eradication Foundation (WOTCLEF) have been formed in Nigeria to combat these issues.
Female Genital Cutting/Mutilation (FGC/FGM), from the National Demographic Health Survey
of 2003(109), showed that the practice was 19% prevalent with the Yorubas accounting for 61% of
cases, Igbos 45%, Fulanis 0.6% and Hausas 0.4%.
VII DEMENTIA AND ALZHEIMER’S DISEASE SURVEY
The Indianapolis – Ibadan dementia project(110), comprised a community study with base
line survey (1992-1993) followed with prospective two years study (1994 – 1995) and prolonged
to five years study (1997-1998) of 2459 community dwelling Ibadan residents and 1214
community dwelling African Americans in Indianapolis, USA. The prevalence rates of dementia
in Nigerians and African-Americans were 2.29% and 8.24% respectively(111). The prevalence
rates of Alzheimer’s disease in Nigerians and African-Americans were 2.29% and 8.24 %
respectively. Old age (>65 years of age), female gender and family history were significant risk
factors while living with others appeared to be protective. The possession of apolipoprotein E
epsilon 4 allele was contributory and predisposing
for African-Americans. Because of the
rising prevalence of hypertension and diabetes, the need to extend the study of Alzheimer’s
disease to other parts of Nigeria is urgent.
23
VIII. ALCOHOL AND SUBSTANCE ABUSE - WHO Rapid Assessment and Response
(RAR)
This project used the snowball sampling technique to recruit 1142 (145 or 13% were exinjectors and 912 or 87% non-injecting drug users) street drug users(112) from eight state capitals
- Lagos, Kano, Port Harcourt, Ibadan, Benin, Calabar, Maiduguri, Kaduna,) in 2000, 2003, 2005.
The study convincingly proved the existence of injection drug users in Nigeria using heroin,
cocaine, speedball and pentazocine. Drug trafficking has grown in Nigeria over the last twenty
years as data of seizure trends of cannabis, cocaine, heroin and other drugs by National Drug and
Law Enforcement Agency (NDLEA)
(113)
showed the increasing trend and links to the central
role of Nigerian syndicates. The drug nexus in African utilizes seaports, airports, overland routes
and interior transport corridors.
Table 7: NDLEA data on trends of illicit drug seizures
Year
Cannabis (kg)
Cocaine (kg)
Heroin (kg)
Others (kg)
1999
170.60
110.60
861.25
2000
272,260.02
53.42
56.60
234.28
2003
535,593.75
134.74
87.58
937.41
2005
125,989.00
395.91
70.42
88.72
CRIMINAL BEHAVIOURAL DETERRENCE – ROAD ACCIDENTS AND OTHER
VIOLENCE
Road safety improvements which are required in Nigeria and which have been demonstrated
in Australia (since 1980s) USA and Canada etc is based on deterrence doctrine(90) after classical
Deterrence Theory of 18th century utilitarian philosophers (Bentham and Beccaria) that the
deterrence process of human behavior in a variety of criminal acts (robbery, violent crimes,
shoplifting, drug abuse, road traffic offences which include drink driving, over speeding, use of
24
drugs, stimulants/substances, reckless driving etc) are decreased with, perceived severity of legal
sanctions/punishments, certainty of apprehension, and swift administration of punishments(114).
Specific deterrence when effective, refers to one’s reluctance to commit further offending
behavior for fear of incurring additional punishment. This concept along with social/communal
control(115) are useful tools to examine and to implement in order curb violence, traffic offences
and violence, community- police violence and other crimes in Nigeria. The deployment of speed
detection cameras, alcohol breath tests, blood drug tests, vehicle sanctions and the police and law
enforcement agencies understanding the dimensions of violence are important components of
deterrence requiring additional and adequate funding(116).
IX. TOBACCO – GLOBAL YOUTH TOBACCO SURVEY (GYTS)
Lopez et al(117) had described the WHO adopted conceptual four stages of tobacco
epidemic in which prevalence of smoking in men, women and young persons as well as
prevalence of tobacco associated diseases and deaths are quantified. Nigerian is located between
stage I (prevalence of less than 20%, females (<10%) to stage II (increasing prevalence,
increases in women smoking, shifting to smoking initiation in younger ages.
In 1990 – 1992 national NCDs survey about 4.14 million Nigerians above 15
years(59)smoked. In 2003, Lagos survey(60) 14.1% ever smoked. In WHO report on Global
Tobacco epidemic in 2008(118), Nigeria smoking prevalences were 17.1% in male, and 0.9% in
adult females respectively. World Bank report also showed that cigarette consumption in Africa
increased by 38.4% between 1995 and 2000. WHO MPOWER report has also indicated passive
smoking prevalences of 34.8% in Nigeria, 21.9% in Ghana and 79.6% in Lebanon.
Smoking habits usually begins at youth age. The GYTS reveals the use of tobacco use in
boys and girls aged 13 – 15 years. Cross Rivers State study (2000 and 2008) showed over all
25
current tobacco smoking (7.0% and 4.1% respectively). The situation among boys and girls
shows 7.7% and 3.3% in 2000 respectively and 6.8% and 1.2% in 2008 respectively as
preventive measures had started in Cross River States through promulgated edict banning
cigarette advertisement. Recent national GYTS(62) of 4389 youths in schools from Abuja, Kano,
Ibadan, Lagos and Cross River states, conducted in 2008/2009 showed that over 8.9% of youths
smoked nationally with highest rate in Kano (6.2%; overall boys 11.4% girls 5.5%) with Lagos
rates of 2.6% overall (boys 2.8%; girls 1.8%). Tobacco smoke has been associated with the
metabolic syndrome in adolescents(119).
X. ORAL HEALTH IN NIGERIA- Surveys
Periodontal disease, dental carries, malocclusion, dental fluorosis (in northern states) are
common(120,121). Access to oral health is poor in rural area prompting the need for the
introduction of alternative oral health delivery methods like the New Zealand dental nurse
scheme or the WHO assisted community oral Health model of Thailand. The Inter-country Oral
Health Centres (ICOH) in Jos and Idikan – Ibadan are tasked with expanding community oral
health care in conjunction with Dental Association of Nigeria .
Table 7:Prevalence of Periodontal Diseases in Nigeria
Age (years)
1
2.
3.
15 – 19
15 – 19
McGregor and Sheiham 10 – 19
1974
20 – 29
Adegbembo et al 1999
15
25 – 39
Enweonwu 1966
Area in Nigeria
Prevalence (%)
North
West
West
West
Nation wide
Nation wide
15
40
33%
58%
39%
57%
Using Oral Health Index (OHI) and Community Periodontal Index (CPI), smokers in
Nigeria(122) have poor oral hygiene. Also using gingival index to assess severity of gingival soft
tissues inflammation (on a scale of 1 – 3 ) Odai and coworkers between 2008 – 2009(122) showed
26
that only 0.9% of 340 primary and post primary children in Benin had no gingivitis, while severe
gingivitis occurred in 56.47%. The surveys of periodontal diseases in Nigeria have shown(121)
high prevalences over the years as in the table below.
Dental fluorosis, another important public problem occurs in Northern Nigeria as a result
of high fluoride in drinking water exceeding threshold limit of 0.004 – 0.007mg/kg body weight
during period of tooth mineralization.
Dental caries has shown increasing prevalence of 4-30 % in surveys from 1968 to 2003.
The mean number of decayed, missing and filled teeth (DMFT) recorded in most
epidemiological studies in Nigeria has been below 4 in children and young adults as exposure to
cariogenic westernized diet along with oral mutant streptococci colonization is prevalent(101).
Table 8:Prevalence of caries in urban and rural Nigerians
Age (yrs)
Urban %
Rural %
Mean DMFT
Urban
Rural
Sheiham (1966)
< 34
33
3
-
<1
Henshaw and Adenubi (1975)
Akpata and Johnson (1979)
Adegbembo et al (1995)
10 – 40+
1 – 21
12
15
58
42
37
49
32
2–8
1.2
0.8
1.5
0–2
Akpata et al (2003)
Southern Nigeria
Northern Nigeria
15
15
24
36
3
13
**
1.1
1.0
2.6
XI. NUTRITION SURVEY IN NIGERIA
The documentation of the geographical distribution and manifestations of undernutrition
and overnutrition of macronutrients and micronutrients in Nigeria have been provided in
national nutrition surveys conducted with supports and collaborations of USAID, UNICEF,
USDA, PEPFAR, UNFPA and World Bank from 2001 to 2008(122). Low birth weight, which
27
may lead to non-communicable diseases later in life because of fetal programming(17) has
remained. The Child Stunting and wasting which also have similar impact in leading to noncommunicable diseases later, as well as overweight and obesity in children and women are
prominent features in these reports. Zinc, Iodine, vitamin A, Iron deficiencies have remained
common over the years. The National Health Demographic Survey and International Institute of
Tropical Agriculture. Ibadan study(124) have documented these since 1990 to 2008.
In 2008 National Demographic and Health Survey for example, 41% of children under
five are stunted, indicating chronic malnutrition, commoner in rural areas (45%) than urban
areas (31%) with zonal ranges from 22% in South East zone to 53% in North West zone. Some
findings from National Demographic and Health Surveys are shown in the tables below.
Table 9:Nutrition Status of Under Five Children In Nigeria
Low birth weight
Stunting
Wasting
2003
14%
42%
11%
NDHS
2008
41%
14%
NDHS
The prevalence of childhood (6 – 9years) obesity is 3.2% to 5.2%
Table 10: Women Nutritional Status (15 – 49 Years)
NORMAL
THIN
OVERWEIGHT
*BMI
(18.5-24.9)
(<18.5)
(25 – 29.9)
2008 NDHS
66%
12%
16%
2001–2003
68.5%
11.6%
14.2%
*BMI – Body Mass Index
Overweight
9%
OBESE
>30
6%
5.7%
The Roles of Measles and Aflatoxins
It is important to recognize the importance of measles in precipitating malnutrition as
described by Dossetter(126) and West(127) by causing protein losing enteropathy and malabsorption
as well as vitamin A deficiency especially in northern states and other areas where inadequate
vaccination coverage for measles occurred. The role of aflatoxins and other mycotoxins
28
contaminating Nigerian foods in precipitating malnutrition with cancrum oris in under fives as
described by Enweonwu(128) should be noted as many Nigerians have significant blood level of
aflatoxins(129).
The nutritional status of Nigerian children is poor, showing little improvement since 1990
when the stunting (chronic malnutrition) was 42%. The proportion of children aged 6 – 35
months who were chronically malnourished increased from 44% in 1990, to 50% in 1999
(NDHS).
CONCLUSION
All the non-communicable diseases clearly have shown on the trend of increase in the last
fifty years in Nigeria. The future direction should be on urgent and comprehensive intersectoral
collaboration involving Federal, state, local governments, communities, professional
associations, women societies and labour organizations with sustained programmes that
emphasize amongst other issues, surveillance –for risk factors using WHO step wise approach;
health education that results in attitudinal and behavioural changes, and engagement in healthy
lifestyles; promotion of tobacco smoking cessation; promotion of healthy diets; and the use of
Nigerian foodstuffs to create food pyramids and the teaching of the populace cooking methods
that maximize nutritional value.
The promotion of physical activity – both at home, school, workplaces and at leisure and the
promotion of healthy attitudes and health seeking behavior are important.
The roles of communication by media, churches and mosques need to be emphasized both
for exercising, health promotion talks and screening. The health care system must be expanded
and strengthened at the levels of primary, secondary and tertiary health care. National Health
Insurance Scheme should be restructured to fund chronic non-communicable disease.
29
The Monitoring and eliminating environment pollution and enforcing the legal backing for
tobacco control, reduction of use of alcohol including local brews, elimination of drug abuse and
the setting up of addiction treatment centres.
The checking of violence and the maintenance of road safety should be based on deterrence,
social re-education, and good governance as well as the committing adequate funds for training
of staff. There is need to disseminate and use of available guidelines and policies, some of which
are listed below.
List of Guidelines available that need to be disseminated
i. Hypertension guidelines – developed with Hypertension Society of Nigeria under leadership
of Prof A. Isah
ii. Diabetes guidelines – developed with Diabetes Association of Nigeria (2010).
iii. Asthma guidelines – developed under leadership of Dr. Chukwu and ASMARCAP (Asthma
–family handbook)
iv. Sickle Cell- guidelines – Sickle cell foundation under leadership of Prof. A. Akinyanju
v. Non-communicable disease Handbook for Primary Health care – 1996 series III under the
chairmanship of Prof. Akinyanju.
vi. Non-Communicable diseases Handbook for health professionals series II under the
chairmanship of Prof. O Akinkugbe.
vii. Guidelines for Smoking Cessation in Africa and Middle East – Smoking cessation in the
Africa and Middle East. A multidisciplinary consensus on intervention strategies for health
care providers. Ahmed Ali, Tarek Safwat, Onyemelukwe GC, Otaibi M.A, Amin A.A,
Nawas Y.N, Aouina H., Afif H., Bolliger C.
viii. Food – based dietary- Dietary guidelines by Nutrition division of Federal Ministry of Health
with WHO
ix. Guidelines on health promotion – Health promotion policies, Federal Ministry of Health.
x. Guidelines for school exercises. Ministry of Education
xi. Guidelines for good agricultural practices and elimination of environmental pollution .
Ministries of Environment/Agriculture.
xii. Guidelines for elimination of pollutants – Ministry of Environment
The Expert Committee on Non-communicable diseases has developed and publisized the civic
duties of Nigerians with regards to NCDs as below;
30
Table 11: Ten Command Civic Duties of all Nigerians
S/N
DUTIES
BENEFITS
1.
Exercise daily (including walks)
Prevention of hypertension, diabetes, obesity, mental ill health,
cancers etc.
2.
Know blood pressure from age 30 and above (annually/six monthly
Detect hypertension early (blood pressure increases with age)
3.
Know blood sugar from age 40 years
Detect diabetes mellitus (blood sugar increases with age)
4.
Know sickle cell genotype of all family
For counseling of family
5.
Monthly breast self examination by females from age 17
To detect lumps and early breast cancer
6.
Know presence of hepatitis B surface antigen in blood of family
members
Prevent liver cancer and other diseases
7.
Know prostate specific antigen (PSA) blood level (men 50 years)
To detect prostate cancer
8.
Women screen cervical smear (PAP Smear) every 2 – 3 years
To prevent, detect early cervical cancer.
9.
Know blood cholesterol by obese or overweight people from age 40 Prevent coronary heart disease
years
10.
Know body mass index (BMI) weight in kg)
Height X height (mtrs)
To watch nutritional excess or deficiency
Issued by NCD Expert Committee on Non-Communicable Diseases
Note: BMI > 30kg/mtr2 is Obesity
BMI > 25kg/mtr2 is overweight
BMI < 18.5kg/mtr2 shows under-nutrition
31
REFERENCES
1. Akinkugbe O.O, Ojo A. Arterial pressures in rural and urban population in Nigeria.BMJ
1969, 2:222-224
2. Akinkugbe O.O, Epidemiology of hypertension and stroke in Africa. Monogr Citation
1976: 29: 28-42.
3. United Nations General Assembly, Resolution 64/265. Prevention and control of
noncommunicable diseases; 2010.
4. World Economic Forum Global Risks 2010. A global risks network report: 2010.
<http://www.weforum.org/pdf/globalrisks 2010-pdf>
5. World Bank Organization Equity, social determinants and public health programmes
WHO 2011.
6. World Health Organization Resolution WHA63.15 monitoring of the achievement of the
health related millennium development goals WHO 2010.
7. Grand challenges in Global Health from www.grandchallenges,org
8. Daar AS, Singer PA, Persad DL, Pramming SK Mathews DR, Beaaglehole R et al.
Grand challenges in chronic non-communicable diseases. Nature 2007; 450: 494-6
9. Global Alliance for chronic diseases www.ga-cd.org.
10. WHO
plan
of
Action
on
non
–communicable
diseases
from:
http://whqlibdoc.who.int/publications/2009/9789241597418-eng.pdf
11. NCD
Net,
the
Non-communicable
Diseases
Network
from:
http://www.who.int/ncdnet/about/en/
12. World Health Organization Global burden of disease 2004-update. &
www.who.int/healthinfo/global-burden-disease/2004-report-update.
13. World Health Organization discussion in paper: noncommunicable diseases, poverty and
the development agenda (July 2009) Ecosoc high-level segment; 2009.
<http://www.who.int/nmh/publications/discussionon-paper-ncdenpdf>
14. Ogoina D, Onyemelukwe G.C: the role of infections in the emergence of noncommunicable diseases (NCDs): compelling need for novel strategies developing world.
J. Infect. Public Hlth 2009, 2, 14-29
15. Surveillanca of non-communicable diseases risks factors. WHO Publication, retrieved
Jan, 2009. Available at www.who.int/mediacentre/factsheet/fs273/
16. Bakari AG, Onyemelukwe GC Indices of obesity among type 2 diabetic Hausa-Fulani
Nigerians Int. J. Diabetes Metab 2005; 13: 28-29.
17. Yajnik CS, Desmukh W. Maternal nutrition, intrauterine programming and consequential
risks in the offspring. Rev. Endocr Metab Disord. 2008; 9 (3) 203-11.
18. Omokhodion S1. Management of patients with Rheumatic fever and Rheumatic Heart
Disease in Nigeria-need for national system of primary, secondary and tertiary
prevention. S.Afr Med J. 2006: 96 (3pt2) 237-9.
32
19. Fakunle YM, Ajdukiewic AB, Greenwood B, Edington GB. Primary Liver cell
carcinoma (PLCC) in the Northern Guinea Savannah of Nigeria. Trans Roy Soc. Trop
Med Hyg. 1977 71(4) 451 -452.
20. Ndububa DA, Yakicier CM, Ojo OS, Adeodu OO, Rotimi O, Ogunbiyi O
et al. P53 codon 249 mutation in hepatocellular carcinoma from Nigeria Afr. J. Med.
Med Sci 2001 30(1-2) 125-7.
21. Olubuyide I. Aliyu B, Olaleye OA, Ola S.O. Olawuyi, F. Malabu MH Odemuyiwa SO,
Oaibi ON, Cook GC. Hepatitis B and C Virus and Hepatocellular Carcinoma – Trans.
Roy. Soc. Top. Med. Hyg.1997, 91(1) 36-41.
22. Oluwasola AO, Ogunbiyi JO, Helicobacter Pylori-associated gastritis and gastric cancer
in Nigeria. India J. Gastroenterol 2003: 22(6) 212-214.
23. Falase AO Infections and dilated cardiomyopathy in Nigeria. Heart Vessels Suppl. 1985,
1:40-44.
24. Thomas JO, Herrore R. Omiogbodun AA, Ojemakinde K, Ajayi IO, Fawole A, Oladepo
O,Smith JS, Arslan A. Munoz A, Snijders P, Merjer CJ, Franceshi S. Prevalence of
papilloma virus infection in women in Ibadan, Nigeria: a population base study. Br. J.
Cancer 2004: 90(3) : 638-645.
25. Banjo AAF, Anorlu RI, Daramola AO, Anunobi CC, Akinde OR, Abdulkareem FB.
Prevalence and distribution of high risk human papilloma virus (HPV) types in invasive
cervical cancer in two states of south Western Nigeria.paper presented at the world
Cancer Congress, Geneva. Aug.2008. [Pos-c 186].
26. Ocheni, S, Aken’ova YA, Association between HIV/AIDS and malignancies in a
Nigerian tertiary institution. West Afr. J. Med. 2004 23(2): 151-5
27. Mohammed AZ, Edin ST, Ochicha O, Gwarzo AK, Samaila O. Cancer in Nigeria 10 year
analysis of Kano Cancer Registry. Nig. J. Med 2008; 17(3) 280-284.
28. Andy JJ, Ogunowa PO, Akpan HA, Helminth associated hypereosinophilia and tropical
endomyocardial fibrosis (EMF) in Nigeria. Acta Tropica 1998, 69; 199-207.
29. Greenwood BM, Herrick E, Voller A. Suppression of autoimmune disease in NZB and
(NZBx NZW) F1 Hybrid mice by infection. Nature 1970, 226; 266-267.
30. Sergeant GR, Sergeant AE, The epidemiology of sickle cell disorders a challenge for
Africa. Arch. Ibadan Med 2001(2) 45-52.
31. Adeniyi FAA, Anetor JJ Lead poisoning in two distant states of Nigeria. An indication
of the size of the problem. Afr. J. Med. Sci, 1999 28: 102-112.
32. Okoye COB. Lead and other metals in dired fish from Nigerian markets. Bull Environ
Control Toxicol 1999, 23: 825-832.
33. Anetor JI High blood levels of lead in general population causes and implications
Proceedings of National Conference on the Phase-out of leaded gasoline in Nigeria Nov.
15-16 2001 pg 27.
33
34. Famuyiwa OO, Nwabuebo IE, Abiye AA. Pattern of histocompatibility (HLA) antigen
distribution among Nigerians (West African black) diabetics Diabetes 1982 31(12) 11791122.
35. Ohia MJ. Delineation, assessment and effects of iron in the ground water resources of
Rivers state, Nigeria. Presented 1991.
Department of Geology Ahmadu Bello
University, Seminar.
36. Uko GP, Onyemelukwe GC. Dawkins RL Properdin factor B allo types in diabetic
Nigerians. A preliminary report on chromosome 6 markers. East Afr. Med. J 1990,
67(10) 726-31.
37. Bailey J, Halushka M. CWRU Genomics. Hypertension candidate genes from:
cmbi.bjmu.edu.cn/candidates.html.
38. Okobia M, Bonker C. Zmudis J-Kammerer C. Vogel V, Uche E, Anyanwu S, Ezoeme E,
Ferrel R, Kuller L. Cytochrome P450 AI genetic polymorphisms and breast cancer risk in
Nigeria woman. Breast Cancer Res Treat 2005, 94(3); 285-93.
39. Zhan B, Fackkenthal JD, Niu Q, Huo D, Sveen WE, Demarco T, Adebamowo CA
Ogundiran T. Olopede OI. Evidence for an ancient BRCAI mutation of breast cancer
patients of Yoruba ancestry. Fam. Cancer 2008.
40. Garner CP, Ding YC, John EM, Ingles SA Olopade OI, Huo D, Adebamowo C,
Ogundiran I, Neuhansen. Genetic variation in IGFBP2 and 1GFBP5 is associated with
breast cancer in populations of African descent. Hum Genet. 2008 123(3)-247-255.
41. Gukas ID, Jennings BA, Marndong BM, Igun Girling AC, Manasseh AN, Ugwu BT,
Leinster SS. Clinicopathological features and molecular markers of breast cancer in Jos,
Nigeria. West Afr. J. Med 2005, 24(3) 209-13.
42. Murrel JR, Price BM, Baiyewu O. Gureje O. Deeg M, Wendre A. et al. The fourth
apolipoproten E haplotype found in the Yoruba of Ibadan. Am. Genet B Neuropsychiatr
Genet, 2006; 141(4) 426-422.
43. Quaak M, Van Schayek CP, Knanpan AM Van Schooter FJ. Genetic variation as a
predictor of smoking cessation success. A promising preventive and intervention tool
for chronic respiratory diseases. Eur Resp J. 2009 33, 468-980.
44. Fitzpatrick AL, Kronmad RA, Gardner JP, Psaty BM, Jerry NS, Tracy RP, Walston J,
Kimura M, Aviv A. Leukocyte length and cardiovascular disease in the Cardiovascular
Health Study. Am. J. Epidemiol. 2007. 165(1); 14-21
45. LaRocca JT, Seals DR, Pierce GL. Leukocyte Telomere Length is preserved with aging
in Endurance exercise-trained Adults and related to Maximal Aerobic Capacity. Mech.
Ageing Dev. 2010 131(2) 165 – 167.
46. Zimmet P. Globalization, Coco-colonisation and chronic disease epidemic: can the
doomsday scenario be averted. J. Int. Med. 2007, 247 (3) 301 – 310.
47. Szanto S, Yudkin J. The effect of dietary sucrose on blood lipids, serum insulin, platelet
adhesiveness and body weight in human volunteers. Post Grad. Med. J. 1969: 602 – 607.
48. Cohen AM, Teitalbaum A, Roseman E: Diabetes induced by a high fructose diet.
Metabolism 1977, 26: 17 – 24.
34
49. Dupuy E, Fleming AF, Caen JP. Platelet function, factor VIII, fibrinogen and
fibrinolysis in Nigerians and Europeans in relation to atheroma thrombosis. J. Clin
Pathol 1978, 31; 1094 – 1101
50. Onyemelukwe GC, Bakari AG, Mba EC Platelet aggregation in diabetic Nigerians. Int.
J. Diabetes Metab. 2006 14:30 – 34.
51. Onyemelukwe GC, Bakari AG, Ogbadu G. Sugar and caloric contents of selected soft
drinks marketed in Nigeria. Int. J. Diabetes Metab. 2006.
52. Vanderhorst G, Wesso I, Burger AP et al Chemical analysis of soft drinks and pure
fruits – some clinical implications.S. Afr. Med. J. 1984; 66: 755 – 758.
53. Burkitt DP. Western diseases and their emergence related to diet. S. Afr. Med. J. 1982;
61(26) 1013 – 1015.
54. Anochie I, Nkanginieme KE, Childhood diabetes in Port Harcourt, Southern Nigeria.
Diabetes International 2002; 12(1) 626 – 629
55. Karjalainer J, Martin JM, Knip M et al. A bovine albumin peptide as a possible trigger
of insulin dependent diabetes mellitus N. Eng. J Med. 1992; 327: 302 – 307.
56. Osuntokun B.O, Adeniji A.O, Schoenberg B.S Neurological disorders in Nigerian
Africans: A community based study. Acta. Neurol. Scand. 1987: 73, 13 – 21.
57. Odeigah PG. The glycaemic effect of cassava in albino rat Int. Diabetes Digest 1993: 44
(3) 84 – 87.
58. Akah PA, Okafor CL. Blood sugar lowering effect of Veronica amygdaline (Bitter leaf)
seen in an experimental rabbits model. Phytotherapy Res. 1992; 6; 171 – 173.
59. Akinkugbe O.O. National Expert Committee on Non-communicable disease. Final
Report of National Survey. Federal Ministry of Health. 1997.
60. Onyemelukwe G.C. Report: National Survey of Non-Communicable diseases South
West zone 2003.
From: www.gconyelukwe.com
61. Gureje O, Uwakwe R, Udofia O.’Mental Disorders among adult Nigerians. A report
from the National Survey of Mental Health and Wellbeing 2002 – 2003.
62. Ekanem IA, Asuzu MC, Anunobi CC, Malams SA, Jibrin PG, Ekanem AD,
Onyemelukwe GC, Anibueze M. Prevalence of tobacco use among youths in five
centers in Nigeria; A global tobacco survey (GYTS) approach. J. Commun. Med and
Primary Hlth care 2010, 22(1/2) 62 – 67.
63. Edington G.M. Maclean CMV. A Cancer rate survey in Ibadan Western Nigeria, 1960 –
1963. Br. J. Cancer 1965, 19; 471 -481
64. Cederguist R, Attah EB. Zaria Cancer Registry, 1976 – 1978 in: Parkin PM Ed. Cancer
occurrence acne in Developing Countries (IARC Scientist Publication No 750) Lyon,
IARC pp 68 – 73.
65. Thomas JU, Aghadinuno PU. Nigeria: Ibadan Cancer Resgistry 1985 – 1992 in: Parkin
PM, Kramarova C, Draper G.J. et al (ed). International Incidence of Childhood Cancer.
Vol. II (IARC Scientific Publication No 141) Lyon IARC pp 43 -45.
66. Holcombe C, Babayo U. The pattern of malignant disease in North East Nigeria. Trop.
Geog. Med 1991 43(1-2) 189 – 192
67. Ekwere PD, Egbe SN. The changing pattern of prostate cancer in Nigerians: Current
status in the South Eastern States. J. Natl. Med. Assoc. 2002: 94(7) 619 – 627
35
68. Onwuasigwe CN, Aniebue PN, Adu AC. Spectrum of paediatric malignancies in Eastern
Nigeria (1989 – 1998). West Afr. J. Med 2002 21: 31 – 33.
69. Akang EEU. Childhood tumours in Ibadan (1973 – 1990). Pediatric; Pathol. Lab Med,
1996, 16; 791 – 800
70. Falase AU, Ladapo OO, Kanu EO, Relatively Low incidence of myocardial infarction in
Nigerians.Trop. Cardiol 2001, 27/u107:45-47.
71. Onyemelukwe GC, Mba E. Rarity of large vessel disease in African diabetes – a role of
antithrombin III. East Afr. Med. J. 1988; 65,(3) 620 - 625.
72. Danbauchi SS, Onyemelukwe GC. Ischaemic heart disease in Nigeria: Report of two
cases. Intern. Diabetes 2000, 10; 59 – 60.
73. Oke DA, Talabi HA. Myocardial infarction as seen in Lagos Universality Teaching
Hospital, Nigeria.
74. Danbauchi SS. Ischaemic heart disease and myocardial infarction, a short report. Cent.
Afr. J. Med. 1996 42; 209 – 217.
75. Adesanya CO, Nirodi N. Fatal coronary atherosclerotic heart disease in a Nigerian: case
report with necropsy findings. J. Trop. Med. Hyg. 1977; 80: 219 – 223.
76. Isezue S, Abubakar SA. Epidemiologic profile of peripartum cardiomyopathy in a tertiary
hospital. Ethnicity and Diseases 2003; 228 – 233.
77. Davidson NM, Parry EHO. Peripartum cardiac failure: Quart. J. Med. 1978; 188; 431 –
463.
78. Ford L, Abdullahi A, Anjorin FI, Danbauchi SS, Isa MC, Maude GH, Parry EHO. The
outcome of peripartum Cardiac failure in Zaria, Nigeria. Quart. J. Med. 1998; 91; 93 –
103.
79. Carapetis JR, Steer AC, Mul Holland EK. Global burden of group A streptococcal
diseases Lancet Inf. Dis. 2005, 5: 685 – 691.
80. Guilherme L, Kalil J., Cunningham M, Soyinka.Molecular mimicry in the autoimmune
pathogenesis of rheumatic heart disease. Autoimmunity 2006, 39: 31 – 37.
81. Omokhodion SI. Management of patients with rheumatic fever and rheumatic heart
disease in Nigeria – need for national system of primary, secondary and tertiary
prevention. S. Afr. Med. J. 2006; 96(3 pt 2) 237 -9.
82. Ogunbi O. An epidemiological study of rheumatic fever and rheumatic heart disease in
Lagos. J. Epidermiol. Comm. Health. 1998: 32: 68 – 71.
83. Jaiyesimi F, Antia AO.Childhod rheumatic heart disease. Trop. Geogr. Med. 1981 33(1)
8 – 13.
84. Danbauchi SS, Alhassaan MA, David SO, Wammande R, Oyati A. Spectrum of
Rheumatic heart disease in Zaria, Northern Nigeria. Annals of Afr. Med. 2004; 3(1) 17 –
21.
85. Roberts JM, Redman CW. Pre-eclampsia more than pregnancy induced hypertension.
Lancet, 1993; 504 – 508.
86. Ekwempu CC. Infection as a possible trigger factor in the genesis of eclampsia. Trop.
Doctor 1980, 10, 174 – 135.
87. Oyati AI, Danbauchi SS, Isa MS, Alhassan MA, Sani BG, Anyiam CA, Bosan IB, David
SO. Role of pre-eclamptic toxaemia or eclampsia in hypertensive women attending
cardiac clinic of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Ann. Afr.
Med 2008; 7: 133-7
36
88. Danesi MA, Oyenola YA, Onitiri CA.Risk factors associated with cerebrovascular
accidents in Nigerians – a case control study .East Afr. J. 19ed. 1983; 30; 190 – 195.
89. Bwala SA, Stroke in Sub-Saharan Nigerian Hospital – a retrospective study. Tropical
Doctor 1989 Jan, 11 – 14.
90. Danesi MA, Okudebajo N, Ojin F. Prevalence of Stroke in urban mixed income
community in Lagos, Nigeria. Neuroepidermiology. 2007; 204, 1 – 8
91. Onyemelukwe GC, Jibril HB. Antithrombin III deficiency in Nigerian children with
sickle cell disease. Possible role in the cerebral syndrome. Trop. Geogr. Med. 1992. 44;
37 – 41
92. Onyemelukwe GC, Shakib F, Saeed TK, Salloum ZA, Lavande RV, Obineche E. Rast
Specific IgE in Nigerian asthmatic patients. Ann. Allergy 1986 56(2); 167 – 170
93. Sofowora EO, Bronchial asthma in the tropics. A study of 250 Nigerian patients E. Afr.
Med. J. 1970, 47: 434 – 439
94. Soyinka F. The pattern of bronchial Asthma in the Equatorial forest zone of Nigeria. J.
Trop. Med. Hyg. 1977, 80(10). 204 -212.
95. Haddock DR, Onwuka SI. Skin test in Nigerian asthmatics for the Equatorial forest zone
in Benin, Nigeria. Trans. Roy. Soc. Trop. Med. Hyg. 1977, 71 32-34.
96. Lawande R, Onyemelukwe GC. Airborne fungi, during harmattan in Zaria. Ann. Allergy.
1984 58(11) 48 – 49.
97. Bateman EO, Hurd SS, Barness PJ. Bousquet J. Drazen JM, Fitzgerald M. et al. Global
strategy for asthma management and prevention GINA executive summary. Eur. Resp. J.
2008, 31: 143 – 78.
98. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1959;
The Asthma Insights and Reality in Europe (AIRE) study. Eur. Resp. J. 2000; 16: 802 –
203.
99.
The Nigeria National Blindness and Visual Impairment Survey 2005 – 2007. In
collaboration; International Centre for Eye Health UK, Institute of Ophthalmology
U.K; National Programme of Prevention of Blindness, Federal Ministry of Health
National Eye Centre, Kaduna; Sight savers International Kaduna, and Sight Savers
International U.K.
100. WHO World Mental Health Survey Initiative 2008. Nock et al: New Approaches to
Education of Deliberate Self-Harm. From www.wjh.harvard.edu/-nock/nock/ah/N--101. Onyemelukwe GC, Ahmed MH, Onyewotu I.I. Survey of depressive symptomatology
in rural and urban Nigerians and the internal heart syndrome. E. Afr. Med. J. 1987;
64(2) 140 – 149.
102. Federal Safety Commission Report (1994 – 2006).
103. Asogwa SE. Road Traffic Accidents in Nigeria; a review and Appraisal. Accid Anal.
Prev. 1992 24: 149 – 155.
104.
Labinjo M, Jullaird C, Kubishinye O.C. The burden of road traffic injuries in
Nigeria; results of a population based survey. Injury Prevention 2009 13(3) 157 –
162.
105. Alemika EE, Chukwuma IC Police – Community Violence in Nigeria 2000.
106. United Nations Development of International Economics and Social Affairs. The
World ’s Women: Trends and Statistics. 1970 – 1990 New York 1991.
37
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
Araoye O. Child labour and Sexual Exploitation in Nigeria. Working papers in
African Child studies of the Institute for African Child, Olio University, USA 2002
No 03; pg 12.
Agbu D. Corruption and Women Trafficking: The Nigerian Case: West Africa
Review, Lagos 2003.
National Population Commission (NPC; Nigeria) Nigeria Demographic and Health
Survey 2003.
Oguniyi A, Baiyewu O, Gureje O, Hall KS, Unverzagt F, Siu SF, Goa S, Farlow M,
Oluwole OS, Kom olafe O, Hendrie HC. Epidemiology of dementia in Nigeria:
results from the Indianapolis-Ibadan study. Eur. J. Neurol. 2000 7(5): 485 – 50.
Hendrie HC, Ogunniyi A, Hall KS, Baiyewu O, Unverzagt FW, Gureje O, Gao S,
Evans RM, Ogunseiyinde AO, Adeyinka AO, Musick B, Hui SC. Incidence of
dementia and Alzheimer’s disease in two communities; Yoruba residing in Ibadan,
Nigeria and African Americans residing in Indianapolis, Indiana. JAMA 2001 285(6),
735-47.
Degenhart L, Chiu WT, Sampson N, Kessler RC, Anthony JC et al. Toward a global
view of alcohol, tobacco, cannabis and cocaine use findings from the WHO world
Mental Health Survey. PLos Med. 2008 5(7). ei40:do10:1371/journet.pmed0050141.
National Drug Law Enforcement Agency 2006.
Andaenes J. Punishment and deterrence. Ann Arbor; The University of Michigan
Press. 1974. 91. Decker S, Wright R, Logie R. Perceptual deterrence among active
residential burglars; a research note Criminal. 1993; 31: 135 -7.
Meier RF, Johnson WT Deterrence as social control: the legal and extralegal
production of conformity. Am. Sociol. Rev. 1997; 42; 292 -304.
World Health Organization. Global Status Report on Road Safety: Time for action.
Geneva WHO, Department of Violence and Injury Prevention 2009.
Lopez AD, Collishaw NE, Piha T. A descriptive model of cigarette epidemic in
developed countries Tobacco Control 1994; 3, 242 – 247
WHO Report on the Global Tobacco Epidemic 2008
From: http://www.who.int/entity/tobacco/mpower-report-prevalence-data-2008pdf.
Weitzman M, Cook S, Auinger p, Florin TA, Daniels S, Nguyen M, Winickoff JP.
Tobacco smoke is associated with metabolic syndrome in adolescents. Circulation
2005, 112: 862 – 869.
Aderinokun GA. Review of a Community Oral Health Progamme in Nigeria after ten
years. Afr. J. Biomed. Res. 2000, 3, 123 – 128.
Akpata ES. Oral Health in Nigeria. Intern. Dental J. 2004; 54(6)5: 361 – 366.
Nwhator SO, Ayanbadejo P, Savage KW Jeboda SO. Oral Hygiene Status and
Periodontal treatment needs of Nigerian male smokers. TAF Prev. Med. Bull. 2010,
9(2) 107 – 112.
Nigerian Demographic and Health Surveys: National Population Commission 2003,
2005, 2008.
Maziya – Dixon B, Akinyele IO, Oguntona ED Nokoe S, Sanusi RA, Harris E.
Nigeria Food Consumption and Nutrition Survey (NFCNS 2001 – 2003).
International Institute of Tropical Agriculture (IITA) 2004, Ibadan, Nigeria.
38
125.
126.
127.
128.
Dossetter JFB, Whittle HC. Protein loosing enteropathy and malabsorption in acute
measles. BMJ 1975; 2; 592 – 3.
West CE. Vitamin A and measles. Nutrition Review 2000, 58 (2) 546 – 554.
Enweonwu C, Falker WA, idigbe EO, Afolabi LM, Ibrahim M, Onwujekwe D,
Savage O, Meeks MI. Pathogenesis of cancrum Oris (NOMA): Confounding
Interaction of malnutrition and infection. Amer. J. Trop. Med. Hyg. 1998: 60; 223 –
233.
Onyemelukwe GC, Ogbadu G. Salifu A. Aflatoxin levels in sera of healthy first time
blood donors – preliminary report. Trans Roy Soc. Trop. Med. Hyg. 1981, 76(6) 780
– 782.
39