Diabetes and Hypertension in India: A Nationally Representative Study of 1.3 Million Adults

Health disparity at the intersection of religion and caste: Evidence from India

Objective

The provisions and recognition of Schedule Castes (SCs), the constitutional term for the Dalits in India, have been exclusively extended to Hindus, Buddhists, and Sikhs (HBS). Omission of Dalit Muslims and Christians (MC) from the SC category stripped them of the affirmative action benefits tied with the SC status. This study aimed to explore how such differential treatment might play a role in differential health outcomes in Dalit women in India.

Methods

Drawing data on 177,346 Dalit women, aged 20 to 49 years, from two successive nationally representative surveys, we assessed the differential likelihood of hypertension and diabetes, between MC- and HBS- Dalit women. Accounting for birth cohort-, survey wave-, and state of residence- fixed effects, along with socioeconomic conditions and cardiometabolic risk factors, we obtained adjusted odds of having hypertension and diabetes in MC women. To check the validity of our results, we conducted similar analyses using data on 170,889 Scheduled Tribe (ST) women, another marginalized group, whose ST-status recognition were not tied to religion.

Results

We found that Dalit MC women were 1.13 (95% CI: 1.03-1.25) and 1.19 (95% CI: 1.05-1.36) times more likely to have hypertension and diabetes, respectively, compared to Dalit HBS women. Conversely, no statistically significant differential likelihood of these conditions was observed between MC and HBS women in the ST sample.

Conclusion

Our investigation thus, indicated a potential link at the crossroads of religion and caste that may contribute to the health disparities among marginalized women in India.

The Association Between Depressive Symptoms, Access to Diabetes Care, and Glycemic Control in Five Middle-Income Countries

OBJECTIVE

The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health systems differ and may impact this relationship. In this study, we investigate access to diabetes care for individuals with and without depressive symptoms in MICs.

RESEARCH DESIGN AND METHODS

We analyzed pooled data from nationally representative household surveys across Brazil, Chile, China, Indonesia, and Mexico. Validated survey tools Center for Epidemiologic Studies Depression Scale Revised, Composite International Diagnostic Interview, Short Form, and Patient Health Questionnaire identified participants with depressive symptoms. Diabetes, defined per World Health Organization Package of Essential Noncommunicable Disease Interventions guidelines, included self-reported medication use and biochemical data. The primary focus was on tracking diabetes care progression through the stages of diagnosis, treatment, and glycemic control. Descriptive and multivariable logistic regression analyses, accounting for gender, age, education, and BMI, examined diabetes prevalence and care continuum progression.

RESULTS

The pooled sample included 18,301 individuals aged 50 years and above; 3,309 (18.1%) had diabetes, and 3,934 (21.5%) exhibited depressive symptoms. Diabetes prevalence was insignificantly higher among those with depressive symptoms (28.9%) compared with those without (23.8%, P = 0.071). Co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (odds ratio [OR] 1.398, P < 0.001) and treatment (OR 1.344, P < 0.001), but not with higher odds of glycemic control (OR 0.913, P = 0.377).

CONCLUSIONS

In MICs, individuals aged 50 years and older with diabetes and depression showed heightened diabetes identification and treatment probabilities, unlike patterns seen in HICs. This underscores the unique interplay of these conditions in different income settings.

Correlates of diabetes mellitus and hypertension in India: Change as evidenced from NFHS- 4 and 5 during 2015-2021

Both diabetes mellitus (DM) and hypertension (HTN) have been on the rise in recent decades all over the world more remarkably in developing countries like India. We intend to measure the prevalence of DM and HTN in the Indian population and to compare the trends and various correlates of these diseases in NFHS (National Family Health Survey)-4 and 5. Data of NFHS-4 and 5 were accessed from dhs program website. All statistical analyses were done in SAS (version 9.4). Mixed effects survey logistic regression models were used for estimating odds ratio (OR).p-values <0.05 were considered significant .1,637,762 individual case entries were evaluated. Both the diseases showed an increasing trend as per the advancing age in both sexes. The highest prevalence of DM is seen in the age group of 45-49 years (7.8%) in females and > 50 years (11.9%) in males as per NFHS-5. Similarly, the highest prevalence of HTN was seen in the age group of45-49 years (31.2%) in females and > 50 years (41.4%) in males as per NFHS-5. The OR (95% CI) of prevalence of DM, HTN and both the diseases in age group >50 years was 14.46 (13.14-15.7), 16.65 (15.78-17.6), 79.5 (64.76-97.73) respectively when compared to reference age group15-19 years. Highest odds for having both DM, HTN concurrently was in age >50 years with aOR(95% CI) 65.32 (52.26-72.63) in NFHS 4 and 35.57 (97.47-45.53) in NFHS 5.Rise in prevalence of DM, HTN and concurrent presence is noted with an apparent increase in cases.

Prevalence, Outcomes, and Predictors of Prolonged Corrected QT Interval in Hydroxychloroquine-Naïve Hospitalized COVID-19 Patients

The studies regarding prevalence, outcomes, and predictors of prolonged corrected QT (QTc) among COVID-19 patients not on QTc-prolonging medication are not available in the literature. In this retrospective cohort study, the QTc of 295 hospital-admitted COVID-19 patients was analyzed and its association with in-hospital mortality was determined. The QTc was prolonged in 14.6% (43/295) of the study population. Prolonged QTc was seen in patients with older age (P = 0.018), coronary artery disease (P = 0.001), congestive heart failure (P = 0.042), elevated N-terminal-pro-B-type natriuretic peptide (NT-ProBNP) (P < 0.0001), and on remdesivir (P = 0.046). No episode of torsades de pointes arrhythmia or any arrhythmic death was observed among patients with prolonged QTc. The mortality was significantly high in patients with prolonged QTc (P = 0.003). The multivariate logistic regression analysis showed coronary artery disease (odds ratio (OR): 4.153, 95% CI 1.37-14.86; P = 0.013), and NT-ProBNP (ng/L) (OR: 1.000, 95% CI 1.000-1.000; P = 0.007) as predictors of prolonged QTc. The prolonged QTc was associated with the worst in-hospital survival (p by log-rank 0.001). A significant independent association was observed between prolonged QTc and in-hospital mortality in multivariate cox-regression analysis (adjusted hazard ratio: 3.861; (95% CI 1.719-6.523), P < 0.0001). QTc was found to be a marker of underlying comorbidities among COVID-19 patients. Prolonged QTc in hospitalized COVID-19 patients was independently associated with in-hospital mortality.

Cardiac troponin in hospitalized COVID-19 patients: Incidence, predictors, and outcomes

BACKGROUND

The incidence, predictors, and association of cardiac troponin with mortality in hospitalized COVID-19 were not adequately studied in the past and were also not reported from an Indian hospital.

METHODS

In this retrospective cohort study, the cardiac troponin of 240 hospitalized COVID-19 patients was measured. The incidence, predictors, and association of elevated cardiac troponin with in-hospital mortality were determined among hospitalized COVID-19 patients.

RESULTS

The cardiac troponin was elevated in 12.9% (31/240) of the patients. The troponin was elevated in the patients in the older age group (64 years vs. 55 years, p = .002), severe COVID-19 illness (SpO2 < 90%) (93.5% vs. 60.8%, p < .001), low arterial oxygen saturation (SpO2) (80% vs. 88%, p = .001), and low PaO2/FiO2 ratio (p < .0001). The patients with elevated cardiac troponin had elevated total leukocyte counts (TLC) (p = .001), liver enzyme (p = .025), serum creatinine (p = .011), N-terminal-Pro Brain natriuretic peptide (p < .0001), and d-dimer (p < .0001). The majority of the patients with elevated cardiac troponin were admitted to the intensive care unit (90.3% vs. 51.2%; p < .0001), were on a ventilator (61.3% vs. 21.5%; p < .0001), and had higher mortality (64.5% vs. 19.6%; p < .0001). The Kaplan-Meir survival analysis showed that the patients with elevated troponin had worse survival (p log-rank<.0001). Age, NT-ProBNP, d-dimer, and ventilator were the predictors of elevated troponin in multivariate logistic regression analysis. The Cox-regression analysis showed a significant association between elevated cardiac troponin and in-hospital mortality (adjusted hazard ratio 2.13; 95% confidence interval [CI] 1.145-3.97; p = .017). Two-thirds (65%) of patients with elevated cardiac troponin died during their hospital stay.

CONCLUSIONS

COVID-19 patients with elevated cardiac troponin had severe COVID illness, were more commonly admitted to an intensive care unit, were on a ventilator, and had high in-hospital mortality.

Assessment of Medication Adherence Among Patients With Hypertension and Diabetes Mellitus in a Tertiary Healthcare Center: A Descriptive Study

Introduction Effective management of diabetes and hypertension requires a comprehensive approach, including dietary adjustments, physical activity, routine screening for complications, and adherence to medication. Proper adherence to pharmacotherapy is essential for maintaining glycemic control and managing blood pressure. Non-adherence can result in increased complications, higher healthcare costs, and greater morbidity and mortality. This study aimed to evaluate the sociodemographic profile and medication adherence among adults with diabetes and hypertension, focusing on those undergoing treatment. The objective was to determine the extent of adherence and identify factors that influence adherence among patients with type 2 diabetes mellitus (T2DM) and hypertension. Methods A community-based study was conducted on patients with T2DM and/or hypertension in both rural and urban areas of Bhopal, specifically those attending JK Hospital, Bhopal, Madhya Pradesh, India. Participants were selected using a simple random sampling method. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8), a validated tool for measuring patient adherence behavior. Results The study included 300 participants, of whom 68% (n=204) were male and 32% (n=96) were female. The average age of the participants was 57.52±10.3 years. Among the 300 patients, 9% (n=27) had high adherence to medication, 24.7% (n=74) had moderate adherence, and 66.3% (n=199) had low adherence. Conclusions Effective strategies must include targeted patient education on medication costs, side effects, and the long-term benefits of adherence. Integrating technological aids like smartphone apps may enhance adherence. Patients who adhere closely to their regimens are more likely to achieve better control over blood pressure and glycated hemoglobin (HbA1c) levels, underscoring the critical importance of adherence in managing chronic conditions effectively.

Recent studies on hypertension prevalence and control in India 2023

Hypertension is the most important chronic disease risk factor in India. Recent epidemiological studies have reported that hypertension is increasing in India with a more rapid increase in rural and young populations. Fifth National Family Health Survey (NFHS-5) and Indian Council of Medical Research-INDIAB surveys have reported that there are substantial geographic variations in hypertension prevalence with greater prevalence in more developed states and districts of the country. There is a high prevalence of young-age hypertension, especially in the less developed states. The incidence of adverse events from hypertension-related cardiovascular disease is significantly greater in India than in more developed countries. A low level of hypertension awareness, treatment, and control, especially in rural and underserved urban populations is an important finding. In this narrative review, we highlight recent nationwide studies and unique features of hypertension in India and suggest strategies for better hypertension management and control.

A Bayesian network for estimating hypertension risk due to occupational aluminum exposure

Background

The correlation between metals and hypertension, such as sodium, zinc, potassium, and magnesium, has been confirmed, while the relationship between aluminum and hypertension is not very clear. This study aimed to evaluate the correlation between plasma aluminum and hypertension in electrolytic aluminum workers by the Bayesian networks (BN).

Methods

In 2019, 476 male workers in an aluminum factory were investigated. The plasma aluminum concentration of workers was measured by inductively coupled plasma mass spectrometry. The influencing factors on the prevalence of hypertension were analyzed by the BN.

Results

The prevalence of hypertension was 23.9% in 476 male workers. The risk of hypertension from plasma aluminum in the Q2, Q3, and Q4 groups was 5.20 (1.90-14.25), 6.92 (2.51-19.08), and 7.33 (2.69-20.01), respectively, compared with that in the Q1 group. The risk of hypertension from the duration of exposure to aluminum of >10 years was 2.23 (1.09-4.57), compared without aluminum exposure. Area under the curve was 0.80 of plasma aluminum and the duration of exposure to aluminum was based on covariates, indicating that aluminum exposure had important predictive value in the prevalence of hypertension in the occupational population. The results of the study using the BN model showed that if the plasma aluminum of all participants was higher than Q4 (≥47.86 µg/L) and the participants were drinking, smoking, diabetes, central obesity, dyslipidemia, and aged >50 years, the proportion of hypertension was 71.2%.

Conclusions

The prevalence of hypertension increased significantly with the increase of plasma aluminum level.

Pestilent relationship between smoking and hypertension or pulse pressure among males over 15 years in India: NFHS-5 Survey

OBJECTIVE

The Global Adult Tobacco Survey conducted in India has divulged that 28.6% of the populace aged 15 years and above partakes in tobacco consumption in various modalities. Despite the availability of numerous studies on the correlation between smoking and hypertension, the nexus between tobacco smoking and hypertension remains enigmatic. Smoking has predominantly been linked to blood pressure, with scant investigations exploring the plausible association that may subsist between smoking and pulse pressure.

METHODOLOGY

This study is based on secondary data analysis from the fifth National Family Health Survey (NFHS-5). 17 Field Agencies gathered information from 636,699 households, 724,115 women, and 101,839 men. The data related to only men was included and analysed in this present study.

RESULTS

Male participants had a mean age of 32.2+1.2 years, an average waist circumference of 80.4+12.2 cm, and mean systolic and diastolic blood pressure of 123.4+13.8 mmHg and 80.5+10.2 mmHg. Daily smokers had a slightly higher likelihood of hypertension compared to non-smokers (OR = 1.2, p <0.001). Male quitters had significantly lower odds of hypertension (OR = 0.9, p <0.001). Quitters had reduced odds of narrow pulse pressure but increased odds of wide pulse pressure (OR = 0.81 and 1.14, respectively).

CONCLUSION

The study found that regular smoking was associated with hypertension, while factors such as age, obesity, urban dwelling, wealth, and tribal residence were linked to increased blood pressure. Male quitters had a lower likelihood of hypertension, and middle-aged men and those with central obesity showed distinct associations with deranged pulse pressure.

A Retrospective Analysis of Clinicopathological Features in 117 Isolated Maxillary Sinus Pathologies in a Tertiary Care Hospital

Diagnosis of maxillary sinus pathologies is challenging. Herewith we describe the clinicopathological features in isolated maxillary sinus lesions in tertiary care hospital in Goa, India. The retrospective study included patients treated between 2017 and 2022, of all age groups and gender, who underwent either a biopsy or surgery, providing a histopathological diagnosis. Of the 117 pathologies, 88 (75.2%) were non-neoplastic. The overall frequency of pathologies were polyp in 40.2%, fungal lesions (18.8%), malignancy (13.7%), chronic rhinosinusitis (11.9%) and inverted papilloma (10.3%). There were 71 men (60.7%) and 46 women (39.3%). There were 10 patients (8.5%) below 20 years of age, of which 8 patients (80%) had non-neoplastic pathology. Common comorbidities were diabetes and hypertension, while symptoms were nasal blockage (75.2%), nasal discharge (47%) and ocular redness (16.2%). Each pathology was evaluated for demography, side of lesion, comorbidity, and symptoms. Most isolated maxillary sinus pathologies were benign lesions. However, a strong clinical suspicion and histopathological confirmation is needed for all lesions in all age groups due to a risk of malignancy.

Prevalence of type 2 diabetes among tribal population of india: a multi-centric cross-sectional study

BACKGROUND

The perception among healthcare workers is that the Indian tribal (indigenous) population are less affected by diabetes. This paper reports the prevalence of type 2 diabetes and its associated factors among tribal populations from six districts across India.

METHODOLOGY

Random blood glucose (RBG) and fasting blood glucose (FBG) were measured for 8486 and 3131 adults, respectively, with a glucose meter. FBG ≥ 126 mg/dL (7.0 mmol/L) and RBG ≥ 200 mg/dL (11.1 mmol/L) were used to diagnose diabetes. In addition, blood pressure, anthropometric (height, weight, waist and hip circumferences), socio-demographic (age, gender, education, type of tribe and type of village) and behavioural data (tobacco smoking, non-smoking tobacco use and alcohol consumption) were collected.

RESULTS

The overall prevalence of type 2 diabetes, based on RBG, was 4.77% (95% CI: 4.33-5.25). The prevalence of type 2 diabetes and prediabetes, based on FBG, was 6.80% (95% CI: 5.95-7.74) and 8.69% (7.72-9.73), respectively. The prevalence of type 2 diabetes was significantly associated with age (p<0.001), smokeless tobacco use (p < 0.05), hypertension (p < 0.001) and obesity (p < 0.01).

CONCLUSION

The prevalence of type 2 diabetes among the Indian tribal population reported in this study is less than the national average of 7.3% for the general population. Hypertension and obesity were the major risk factors. Due to changing behavioural patterns, including dietary behaviour, there is likely to be an increase in the prevalence of hypertension and obesity, which further leads to increased prevalence of type 2 diabetes. Hence, appropriate interventions are to be initiated by the primary healthcare system.

District-Wise Heterogeneity in Blood Pressure Measurements, Prehypertension, Raised Blood Pressure, and Their Determinants Among Indians: National Family Health Survey-5

Objective: The objective of the study was to determine the prevalence and determinants of ever-measured blood pressure, prehypertension, and raised blood pressure at national, state and district levels in India. Methods: We analysed data from the National Family Health Survey (NFHS-5), on 743,067 adults aged 18-54 years. The sample consisted of 87.6% females and 12.4% males. We estimated prevalence rates and determined adjusted odds ratios for various dependent variables related to blood pressure. Geographical variations were visualized on the map of India, and multivariate logistic regression was employed at state and district levels, with significance set at p < 0.05. Results: The prevalence of ever-measured blood pressure varied widely, from 30.3% to 98.5% across districts, with southern and northern regions showing higher rates. Prehypertension affected 33.7% of the population, with varying prevalence across districts. Raised blood pressure was there in 15.9%, with notably higher rates in southern region (16.8%). Determinants included age, gender, education, wealth, lifestyle, obesity, and blood glucose levels. Conclusion: These findings demonstrate the subnational variations in blood pressure, can guide evidence-based interventions at the state and district level, towards reducing the burden of raised blood pressure and enhancing overall population health.

Preparedness of diabetic patients for receiving telemedical health care: A cross-sectional study

Introduction

This study evaluates feasibility of telemedicine to deliver diabetic care among different regions of the country.

Materials and Methods

Medical interns affiliated with Rotaract Club of Medicrew (RCM) organized a Free Diabetes Screening Camp called "Diab-at-ease" at multiple sites across the country. Of all beneficiaries of the camp >18 years of age, patients previously diagnosed with diabetes and undiagnosed patients with a random blood sugar level of more than 200 mg/dL were interviewed regarding their knowledge, attitude, and practice regarding diabetes care and preparedness and vigilance to receiving care through telemedicine. Random blood sugar, height, weight, and waist circumference were also documented.

Results

About 51.1% (N = 223) of female patients aged 57.57 ± 13.84 years (>18 years) with body mass index (BMI) =26.11 ± 4.63 were the beneficiaries of the health camps. About 75.3% (n = 168) of them were on oral hypoglycemic agents (OHAs), 15.7% (n = 35) were on insulin preparations, and 59.6% (n = 156) and 88.5% (n = 31) of which were highly compliant with treatment, respectively. About 35% (n = 78) and 43.9% (n = 98) of them were unaware of their frequency of hypoglycemic and hyperglycemic episodes, respectively. About 64.6% (n = 144) of the patients were equipped for receiving teleconsultation. Glucometer was only possessed by 51.6% (115) of which only 46.95% (n = 54) can operate it independently. Only 80 patients (35.9%) were aware of the correct value of blood glucose levels.

Conclusion

While a majority of the population is compliant with treatment and aware about diabetes self-care, they lack adequate knowledge and resource equipment for the same leading to very limited utilization.

Prevalence and associated factors of undiagnosed hypertension among women aged 15-49 years in India: an analysis of National Family Health Survey-4 data

Hypertension is a major risk factor for cardiovascular diseases globally. Fortunately, there is a vast armamentarium of effective therapeutic options at our disposal so undiagnosed hypertension represents a missed opportunity. In a previous analysis [1] of the NFHS-4 dataset for the prevalence and risk factors for undiagnosed hypertension and its associated risk factors among Indian women aged 15-49 years, we had overestimated prevalence by inclusion of self-reported cases. We have since retracted when this anomaly was highlighted [2]. We have now re-analyzed the same database and here present these data. The current analysis shows that the overall prevalence of undiagnosed hypertension was 8.05% among women aged 15-49 years in India. In rural areas, it was 7.89% compared with 8.38% for urban areas. Factors associated with undiagnosed hypertension in rural and urban areas were age, BMI, wealth quintiles, educational level, religion, caste and geographical zones. Nearly half the women aged 15-49 years in India with hypertension are unaware and this has implications for personal and reproductive health.

An assessment of treatment compliance using the Morisky scale-8 tool in adult hypertensive patients of Eastern India

Background

Adequate management of hypertension is crucial for decreasing the likelihood of cardiovascular ailments and associated complications. Nonetheless, in the Indian context, maintaining compliance with prescribed hypertensive therapies presents a notable hurdle, impeding the attainment of favorable health outcomes. Thus, this study was conducted with the aim to evaluate the prevalence of treatment adherence and explore the diverse factors that impact adherence patterns among individuals diagnosed with hypertension.

Material and Methods

A community-based cross-sectional questionnaire-based study was carried out among the diagnosed hypertensive patients from 12 purposefully selected villages of Khagaul block, Patna. A total of 262 participants were recruited in the study by using non-probability sampling. The 8-item Morisky Medication Adherence Scale (MMAS-8) was used for measuring adherence. The Statistical Package for the Social Sciences (SPSS) for Windows version 21.0 (SPSS Inc; Chicago, IL, USA) was used for statistical analysis of data.

Result

As per MMAS scores, 10 (3.8%) had high, 133 (50.8%) moderate, and 119 (45.4%) poor adherence. However, good adherence was reported among geriatric patients [1.65 (1.01-2.7)], those with a history of absence of comorbidities [2.15 (1.21-3.85)], more than 5 years' duration of hypertension [3.2 (1.89-5.41)], once-a-day drug intake [2.8 (1.61-4.87)], and having controlled blood pressure [5.2 (3.08-8.96)]. Controlled blood pressure (AOR = 0.048, 0.023-0.098), perception of high benefit of treatment [0.497 (0.255-0.97)], and absence of comorbidity [0.016 (0.168-0.832)] were identified as predictors of good treatment adherence.

Conclusion

Overall medication adherence in the current study was 54.6%. Achieving treatment adherence frequently demands proactive patient engagement, highlighting their active role in disease management. Also, involving the patient's caregivers can offer an additional tactic to tackle non-adherence stemming from forgetfulness of the patient.

Predictors for Concurrent Diabetes in Tuberculosis Patients. Perspectives from Two Mining Districts of Eastern Tribal State Jharkhand, in India

Background

Tuberculosis and diabetes both diseases are present in large numbers in the country and we are major contributors to both globally. With the objective to understand the various traits of patients having both tuberculosis and diabetes and to ascertain various possible predictors for such occurrence based on the public health database we carried out this study. We seek answers to questions like they have any effects? Are they having any additive role to play?

Methods

One-year data from the NIKSHAY portal of both districts were analyzed to look for possible associations and other variable traits. Data were analyzed using standard methods to express data in frequency and percentage. Chi-square test was used to establish association, while step-wise approach was used to calculate univariate and multivariate logistic regression analysis for knowing various predictors. P-value of <0.05 was considered statistically significant.

Results

Concurrent diabetes in tuberculosis patients was close to 294 (6%) in the 4933 individuals. In total, 65.2% of the study population were male. Diagnosis of tuberculosis was made most of the time by chest X-ray (49.4%) followed by Microscopy ZN staining and cartridge-based nucleic acid amplification test (CBNAAT). Death was more among diabetics (4.4%) as compared to nondiabetics (3.5%).

Conclusion

Diabetes is increasing in tuberculosis patients; improvement in data quality is needed. More research is required to reveal various other reasons that make tuberculosis patients more prone to develop diabetes.

Predictors of Control Status of Hypertension in India: A Systematic Review and Meta-analysis

Predictors of hypertension (HTN) control status have not been well understood in India. This information is crucial for policymakers and program managers to devise newer HTN control strategies and implement relevant policies and programs. Therefore, we undertook this meta-analysis to estimate the effect of various factors on the control status of HTN in India. We systematically searched PubMed and Embase for observational studies and community-based trials published between April 2013 and March 2021 conducted among people (≥ 15 years) with hypertension in India. Quality of studies was assessed using Newcastle Ottawa (NO) scale. Meta-analysis was performed using random effects model. We reported the effect of various factors on the prevalence of controlled HTN using pooled odds ratio (OR) with 95% confidence interval (CI). Of the 842 studies screened, we analyzed nine studies that included 2,441 individuals. Based on the NO scale, majority (90%) of studies had a low risk of bias. The odds of having controlled HTN were significantly higher among women (OR 1.78, 95% CI 1.62-1.95), those aged > 45 years (OR 1.69, 95% CI 1.44-1.97), and those residing in urban parts of India (OR 1.74; 95% CI 1.48-2.03). These measures varied considerably across different regions of the country. Very few studies reported data on the relationship between behavioural risk factors of non-communicable diseases (NCDs) and HTN control status. We did not find any statistically significant differences between behavioural risk factors of NCDs and HTN control status. To improve HTN control in India, the ongoing/newer HTN control programs need to target men, those aged 15-45, and rural residents. Future studies on HTN control determinants should report disaggregated data and use standardized definitions for behavioral risk factors to enhance reliability and comprehensiveness of findings on the determinants of HTN control in future reviews.

Protocol of systematic reviews on implementation research on cardiovascular diseases, diabetes mellitus and mental ailments in India

Introduction

The burden of non-communicable diseases (NCDs) is a major public health concern across the world. Various initiatives have tried to address these with varying degrees of success.

Objective

The objective is to assess and collate existing evidence in implementation research done in India on three broad domains of NCDs namely, cardiovascular diseases (CVD), diabetes mellitus (DM), and mental health (MH) in India.

Materials and methods

Three systematic review protocols have been drafted to explore and collate extant evidence of implementation research on cardiovascular diseases, diabetes mellitus, and mental health in India, in accordance with the PRISMA-P statement. Academic databases including PubMed, Embase and Science Direct will be searched. Search strategies will be formulated in iterative processes and in accordance with the formats that are specific to the databases that will be searched. In addition, grey literature and non-academic databases will also be explored. Data extracted from the selected studies will be analysed and a narrative summary of the selected articles, using the SWiM (Synthesis without meta-analysis) guidelines will be produced.

Intended Outcomes

The outputs of these systematic reviews could help in a better understanding of implementation research gaps and also how to address them. Apart from giving insights into how healthcare initiatives for CVDs, diabetes and mental health could be implemented in a better way, the study could also advocate the need to build and consolidate capacity for implementation research in the country.

Bean and Nut Intake Were Protective Factors for Comorbid Hypertension and Hyperuricemia in Chinese Adults: Results from China Nutrition and Health Surveillance (2015-2017)

This study aimed to describe the prevalence of comorbid hypertension and hyperuricemia (HH) and detected the dietary factors for HH in Chinese adults aged 18 to 64 years. All of the data were collected from the China Nutrition and Health Surveillance 2015-2017, with a stratified, multistage, random sampling method on a national scale. A total of 52,627 adult participants aged 18~64 years from the CNHS 2015-2017 were included in this study. HH was identified as SUA level cut-offs for males and females of 420 μmol/L and 360 μmol/L, respectively, with mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥ 90 mmHg and/or received antihypertensive treatment within two weeks. The differences in HH prevalence between or among the subgroups were compared by the Rao-Scott chi-square test. The correlations between HH and covariates or metabolic factors were detected by a weighted two-level multivariate survey logistic regression. The total weighted sufficient intake ratios of beans and nuts, vegetables, and red meat were 59.1%, 46.6%, and 64.8%, respectively. The weighted prevalence of HH in the total participants was 4.7% (95% CI: 4.3-5.0%). The positive effects of bean and nut on HH were observed. The participants who had sufficient bean and nut intake showed lower risk for HH (for the total participants: OR = 0.734, 95% CI = 0.611-0.881). The prevalence of HH might have been a public health problem, and bean and nut intake might be a protective factor for HH in the Chinese population.

Comorbidity Profiling in Rural and Urban Population of West Bengal, India: Report From a Community-Based Primary Healthcare System

Introduction The burden of non-communicable diseases (NCDs) is fast changing across the world, especially in the context of rapid urbanization, adoption of Western lifestyles, and an aging multi-morbid population. Over the last three decades, India has undergone a significant demographic and socioeconomic transition. For effective targeting of health system resources and services, it is essential to understand how the prevalence of NCDs varies among population groups across India. We set out to understand the distribution of NCDs and co-morbidities in urban and rural West Bengal. Methods As part of a service improvement project, data was collected from four urban and four rural community-based clinics across West Bengal, India. The reason for visiting the healthcare center was recorded as the primary diagnosis and co-morbidities were recorded per the Elixhauser comorbidity scoring criteria. Associations between all the demographic variables and NCDs were studied using the Poisson regression model and multivariate analysis. Demographic profile, co-morbidities, and Elixhauser comorbidity index were expressed as frequency (%), mean (standard deviation, SD), or median (interquartile range, IQR) as appropriate. Results We obtained data from 1244 patients of which 886 (71%) were from urban areas and 358 (29%) were from rural areas. Patients were mostly female (61%) and had a mean (SD) age of 53 (11) years. There was a positive correlation between living in an urban residence and age, body mass index (BMI), hypertension, cardiovascular disease (CVD), and respiratory disease. There was a positive correlation between CVD and age, male sex, living in an urban residence, and hypertension but did not correlate positively with diabetes. BMI positively correlated with living in an urban residence, hypertension, diabetes, and musculoskeletal disorders. We observed a significantly higher prevalence of musculoskeletal (p=0.002) and psychological diseases (p<0.001) in the rural population, while the prevalence of hypertension (p<0.001) and respiratory diseases among the participants living in urban areas was higher (p<0.001). There was no statistically significant difference in the prevalence of diabetes between urban and rural areas (p=0.38). In the multivariable analyses, we observed that increased age, being overweight, and living in urban areas were associated with hypertension (prevalence ratio (PR): 1.40, 1.30, and 1.30, respectively; all p-values <0.05). An interaction between sex and living area was associated with a lower prevalence of musculoskeletal diseases (PR: 0.34; 95%CI: 0.18-0.66), i.e., musculoskeletal diseases were less prevalent in males living in urban areas (p=0.002). Conclusion There is a rise in multimorbidity with changing demographic patterns and a narrowing of the urban-rural gap in disease distribution. More investment is required in risk factor prevention, screening, and treatment, with greater accessibility of healthcare resources for those in rural areas. Further work needs to be done to study the trends and distribution of NCDs in West Bengal to inform healthcare policy.

Improving the availability of antihypertensive drugs in the India Hypertension Control Initiative, India, 2019-2020

BACKGROUND

Antihypertensive drug supply is sometimes inadequate in public sector health facilities in India. One of the core strategies of the India Hypertension Control Initiative (IHCI) is to improve the availability of antihypertensive drugs in primary and secondary care facilities. We quantified the availability of antihypertensive drugs in 2019-20 and described the practices in supply chain management in 22 districts across four states of India.

METHODS

Twenty-two districts from 4 states (Punjab, Madhya Pradesh, Telangana, and Maharashtra) were studied. We described the practices and challenges in supply chain management. We collected data on drug procurement from 2018 to 2020 and drug availability from April 2019 to March 2020. Quantity procured, the proportion of facilities with stockout at the end of each quarter, and availability of drugs in patient days were tabulated.

RESULTS

All states selected drug- and dose-specific protocols with Amlodipine as the initial drug and shifted to morbidity-based forecasting. The total number of antihypertensive tablets procured for the 22 districts increased from 16 million in 2017-2018 to 160 million in 2019-2020. The proportion of facilities with Amlodipine stock-out was below 5% during the study period. Amlodipine stock was available for at least 60 patient days from the third quarter of 2019 onward in all districts.

CONCLUSIONS

This study demonstrates that including best practices can gradually strengthen the procurement and supply chain for antihypertensives in a low-resource setting. As the program was rapidly growing, there were still gaps in the procurement and distribution system which needed to be addressed to ensure the adequacy of drugs. We recommend that best practices, including choosing a single protocol, basing supply on projected patient load rather than an increment from historical levels, and using simple stock management tools, be replicated in other districts in India to increase and sustain coverage of hypertension treatment.

Prevalence and risk factors associated with undiagnosed diabetes in India: Insights from NFHS-5 national survey

Background

Undiagnosed diabetes is a significant public health concern in India, considering the accumulative burden of diabetes and its long-term complications. We have estimated the prevalence and factors associated with undiagnosed diabetes in India.

Methods

We used data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) to estimate undiagnosed diabetes prevalence aged under 50 (15-49) years. A log-binomial model with survey-adjusted Poisson regression was used to estimate the prevalence risk ratio (PR) between undiagnosed diabetes and various factors. Multinomial logistic regression analysis was performed to examine the factors associated with diagnosed diabetes (vs. healthy) and undiagnosed diabetes (vs. healthy). All the analyses were survey-weighted and stratified by gender and reported with 95% confidence intervals.

Results

The prevalence of diabetes for individuals aged 15-49 years was found to be 4.90% (4.80 to 5.00%) from the NFHS-5. Among them, the proportion of individuals with undiagnosed diabetes was 24.82% (24.07 to 25.59%), with higher among males (28.82% (26.45 to 31.30%)) than females (24.22% (23.44 to 25.01%)). The overall prevalence of undiagnosed diabetes was 1.22% (1.18 to 1.26%), with a higher prevalence among males (1.60% (1.46 to 1.76%)) than females (1.17% (1.13 to 1.21%)). Individuals who are middle-aged (45-49), have a higher body mass index (BMI), and are in a lower wealth index group, or live in the southern regions of India are at a higher risk of being undiagnosed for diabetes.

Conclusion

One in every four having diabetes is undiagnosed. The study highlights the need for public health interventions to improve diabetes screening and access to health care, particularly among middle-aged individuals, and those with higher BMI, as well as addressing lifestyle and dietary factors. The findings also reveal disparities in diabetes burden among population subgroups in India, underscoring the need for targeted efforts.

Prevalence of depression among clients with diabetes and hypertension in selected hospital at Mangaluru, India

BACKGROUND

Non-communicable diseases are lifestyle diseases that are increasing throughout the world. They are responsible for 71% of death worldwide, among which 16 million people die prematurely or before reaching the age of 70 years. Among the non-communicable diseases, diabetes and hypertension are the most common. The study aimed to find the prevalence of depression among diabetes and hypertensive clients.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted among 370 subjects diagnosed with diabetes mellitus, hypertension, and both in Justice K.S Hegde Charitable Hospital at Mangaluru. A purposive sampling technique was adopted to select the subjects. Patient health questionnaire-9 (PHQ-9) was used to find the depressive symptoms among the client. The statistical analysis was conducted using SPSS version 20 (Armonk, NY: IBM Corp.); descriptive (frequency and percentage) and inferential (one-way analysis of variance (ANOVA)) statistics were used to interpret the data.

RESULTS

Out of 370 subjects, 41% had no depression, and most 59% had mild to severe levels of depression. Among clients diagnosed with diabetes mellitus (n = 139), the majority (63%) had mild to severe depression. Similarly, of subjects diagnosed with hypertension, 51% had no depression, and 49% had mild to severe depression. In addition, among subjects diagnosed with both diabetes mellitus and hypertension (n = 99), 67% had mild to severe depression.

CONCLUSIONS

The study shows that many diabetes and hypertensive patients attending the outpatient departments of the hospital experience depression. So, it is crucial to identify the depressive symptoms early and take appropriate measures to prevent complications.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial

BACKGROUND

Structured lifestyle change education reduces the burden of cardiometabolic diseases such as diabetes. Delivery of these programs at worksites could overcome barriers to program adoption and improve program sustainability and reach; however, tailoring to the worksite setting is essential.

METHODS

The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at 11 large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, and peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system.

RESULTS

Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add a wider variety of exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees.

CONCLUSION

This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02813668. Registered June 27, 2016.

Evaluation of 'Normal' Cognitive Functions and Correlation With MRI Volumetry: Towards a Definition of Vascular Cognitive Impairment

Introduction It is important to establish criteria to define vascular cognitive impairment (VCI) in India as VCI is an image-based diagnosis and magnetic resonance imaging (MRI) changes resulting from age with prevalent vascular risk factors may confound MRI interpretation. The objective of this study was to establish normative community data for MRI volumetry including white matter hyperintensity volume (WMHV), correlated with age-stratified cognitive scores and vascular risk factors (VRFs), in adults aged 40 years and above.  Methods We screened 2651 individuals without known neurological morbidity, living in Mumbai and nearby rural areas, using validated Marathi translations of Kolkata Cognitive Battery (KCB) and geriatric depression score (GDS). We stratified 1961 persons with GDS ≤9 by age and cognitive score, and randomly selected 10% from each subgroup for MRI brain volumetry. Crude volumes were standardized to reflect percentage of intracranial volume.  Results MRI volumetry studies were done in 199 individuals (F/M = 90/109; 73 with body mass index (BMI) ≥25; 44 hypertensives; 29 diabetics; mean cognitive score 76.3). Both grey and white matter volumes decreased with increasing age. WMHV increased with age and hypertension. Grey matter volume (GMV) decreased with increasing WMHV. Positive predictors of cognition included standardized hippocampal volume (HCV), urban living, education, and BMI, while WMHV and age were negative predictors. Urban dwellers had higher cognitive scores than rural, and, paradoxically, smaller HCV.  Conclusion In this study of MRI volumetry correlated with age, cognitive scores and VRFs, increasing age and WMHV predicted lower cognitive scores, whereas urban living and hippocampal volume predicted higher scores. Age and WMHV also correlated with decreasing GMV. Further study is warranted into sociodemographic and biological factors that mutually influence cognition and brain volumes, including nutritional and endocrine factors, especially at lower cognitive score bands. In this study, at the lower KCB score bins, the lack of laboratory data pertaining to nutritional and endocrine deficiencies is a drawback that reflects the logistical limitations of screening large populations at the community level. Our volumetric data which is age and cognition stratified, and takes into account the vascular risk factors associated, nevertheless constitutes important baseline data for the Indian population. Our findings could possibly contribute to the formulation of baseline criteria for defining VCI in India and could help in early diagnosis and control of cognitive decline and its key risk factors.

Hypertension care cascade in an urban resettlement colony and slum in Delhi, India: a cross-sectional survey

BACKGROUND

Hypertension care cascade in resource-limited settings is compromised with a majority of patients with hypertension remaining undiagnosed, untreated, non-adherent, and poorly controlled at every stage. However, there is paucity of information on care and management of hypertensive patients in community-based settings of low-income urban neighbourhoods in India.

METHODS

This was a community-based cross-sectional study conducted in an urban resettlement colony and slum area in the Northeast District of Delhi. The adult population was screened for hypertension using standardized methods, and adherence to medications was assessed using the Morisky Green Levine scale. Binary logistic regression analysis was conducted to ascertain the sociodemographic predictors of the outcome (presence of hypertension, adherence to antihypertensive medication, blood pressure control). A p-value < 0.05 was considered statistically significant.

RESULTS

We included 8850 adult participants including 5295 females and 3555 males in this study. Nearly 29% of the participants were hypertensive, of which 61.77% were newly diagnosed cases. Furthermore, nearly 81% of the previously diagnosed cases had been initiated on antihypertensive medication, of which 57.54% were adherent to their medications while 36.12% attained controlled blood pressure levels. The odds of having hypertension were significantly higher among males (AOR = 1.87, 95% CI: 1.63 to 2.15), age ≥ 60 years (AOR = 9.15, 95% CI: 7.82 to 10.70), high waist circumference (AOR = 2.24, 95% CI: 1.86 to 2.70) and Body Mass Index of ≥ 25.00 (AOR = 2.55, 95% CI: 2.00 to 3.26). Furthermore, on adjusted analysis, patients of hypertension having diabetes (DM) comorbidity had significantly higher odds of being adherent to anti-hypertensive medications (AOR = 1.81, 95% CI: 1.31 to 2.51) compared to those without DM comorbidity, while tobacco users had significantly lower odds of being adherent to antihypertensive medication (AOR = 0.50, 95% CI: 0.31 to 0.82).

CONCLUSIONS

Hypertension care cascade in urban slum-resettlement colony setting revealed a high burden of undiagnosed hypertension, low rates of medication adherence, and poor blood pressure control. Strengthening community screening and primary care continuum of care is necessary to improve the hypertension care cascade from early diagnosis to effective management with optimal health outcomes to reduce patient complications and increase longevity.

Hypertension Diagnosis, Treatment, and Control in India

Importance

Hypertension is a major cause of morbidity and mortality worldwide. Previous efforts to characterize gaps in the hypertension care continuum-including diagnosis, treatment, and control-in India did not assess district-level variation. Local data are critical for planning, implementation, and monitoring efforts to curb the burden of hypertension.

Objective

To examine the hypertension care continuum in India among individuals aged 18 to 98 years.

Design, Setting, and Participants

The nationally representative Fifth National Family Health Survey study was conducted in 2 phases from June 17, 2019, to March 21, 2020, and from November 21, 2020, to April 30, 2021, among 1 895 297 individuals in 28 states, 8 union territories, and 707 districts of India.

Exposures

District and state of residence, urban classification, age (18-39, 40-64, and ≥65 years), sex, and household wealth quintile.

Main Outcomes and Measures

Hypertension was defined as a self-reported diagnosis or a newly measured blood pressure of 140/90 mm Hg or more. The proportion of individuals diagnosed (self-reported), the proportion of individuals treated among those diagnosed (self-reported medication use), and the proportion of individuals with blood pressure control among those treated (blood pressure <140/90 mm Hg [aged 18-79 years] or <150/90 mm Hg [aged ≥80 years]) were calculated based on national guidelines. Age-standardized estimates of treatment and control were also provided among the total with hypertension. To assess differences in the care continuum between or within states (ie, between districts), the variance was partitioned using generalized linear mixed models.

Results

Of the 1 691 036 adult respondents (52.6% women; mean [SD] age, 41.6 [16.5] years), 28.1% (95% CI, 27.9%-28.3%) had hypertension, of whom 36.9% (95% CI, 36.4%-37.3%) received a diagnosis. Among those who received a diagnosis, 44.7% (95% CI, 44.1%-45.3%) reported taking medication (corresponding to 17.7% [95% CI, 17.5%-17.9%] of the total with hypertension). Among those treated, 52.5% (95% CI, 51.7%-53.4%) had blood pressure control (corresponding to 8.5% [95% CI, 8.3%-8.6%] of the total with hypertension). There were substantial variations across districts in blood pressure diagnosis (range, 6.3%-77.5%), treatment (range, 8.7%-97.1%), and control (range, 2.7%-76.6%). Large proportions of the variation in hypertension diagnosis (94.7%), treatment (93.6%), and control (97.3%) were within states, not just between states.

Conclusions and Relevance

In this cross-sectional survey study of Indian adults, more than 1 in 4 people had hypertension, and of these, only 1 in 3 received a diagnosis, less than 1 in 5 were treated, and only 1 in 12 had blood pressure control. National mean values hide considerable state-level and district-level variation in the care continuum, suggesting the need for targeted, decentralized solutions to improve the hypertension care continuum in India.

The Indian registry on current patient profiles & treatment trends in hypertension (RECORD): One year interim analysis

Background & objectives

In India, hypertension constitutes a significant health burden. This observational, non-interventional, prospective study was conducted in five centres across India to evaluate the current clinical practices for the management of hypertension.

Methods

Participants were enrolled if they were newly diagnosed with essential hypertension or had pre-existing hypertension and were on the same therapeutic plan for the previous three months. At baseline, three months, six months, and one year, information on the patient and their treatment regimen was documented, and their quality of life (QoL) was evaluated.

Results

A total of 2000 individuals were enrolled in this study, with a mean age of 54.45 yr. Of these, 55.7 per cent (n=1114) were males, and 957 (47.85%) were newly diagnosed with hypertension, while 1043 (52.15%) had pre-existing hypertension. Stage 2 hypertension (systolic blood pressure (BP) >140 or diastolic BP ≥90 mmHg) accounted for more than 70 per cent of the participants (70.76% of pre-existing and 76.29% of newly diagnosed); the average duration of pre-existing hypertension was 68.72 months. Diabetes (31.6%) and dyslipidaemia (15.8%) were the most common comorbidities. In 43.3 per cent of the participants, monotherapy was used, and in 56.7 per cent (70.55% fixed-dose combination), combination therapy was used. Telmisartan (31.6%), amlodipine (35.2%), and a combination of the two (27.1%) were the most commonly prescribed treatment regimens. At three months, six months, and one year, treatment modifications were observed in 1.4, 1.05, and 0.23 per cent of the participants receiving monotherapy and 2.74, 4.78 and 0.35 per cent receiving combination therapy, respectively. In both groups, the proportion of individuals with controlled hypertension (≤140/90 mmHg) increased by more than 30 per cent after a year. At one year, physical and emotional role functioning, social functioning, and health improved considerably.

Interpretation & conclusions

Combination therapy for hypertension is increasingly preferred at the time of initial diagnosis. The efficacy, safety, and tolerance of the recommended medications were reflected by improvements in the QoL and the minimal changes in the therapeutic strategy required.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial

Background

Delivery of proven structured lifestyle change education for reducing the burden of cardiometabolic diseases such as diabetes at worksites could overcome barriers to program adoption and improve sustainability and reach of these programs; however, tailoring to the worksite setting is essential.

Methods

The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at eleven large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system.

Results

Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees.

Conclusion

This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings.

Trial Registration

Clinicaltrial.gov NCT02813668, registered June 27, 2016.

Evaluation of community-based care delivered by primary healthcare providers in management of hypertension in a rural area of West Bengal

Background

Lifestyle modifications and medication compliance are key strategies.

Objectives

To evaluate the effect of community-based care delivered by trained primary healthcare providers in management of hypertension.

Materials and Methods

A longitudinal study was conducted between two groups of newly diagnosed hypertensive patients to evaluate the impact of an educational intervention. Six blocks in a district were chosen with pairwise matching. All primary healthcare providers of one block in each pair were randomized to receive the intervention and the other was controlled. Next screening for risk factors, detection of hypertension, counseling, and follow-up care were provided. The patients within the control group received usual care as per clinician's discretion. A total of 227 patients in the "study" group and 230 patients in the "control" group were recruited from 12 subcenters selected randomly. Data analysis was done by χ2 test, t test, and GLM analysis using SPSS 16.

Results

Patients in the intervention blocks demonstrated a statistically significant mean reduction in SBP of 16.14 ± 0.82 and DBP by 11.65 ± 0.53 compared to 9.83 ± 1.02 and 7.68 ± 0.66, respectively, in the control blocks after adjusting for age, sex, and baseline blood pressure at one-year follow-up. Regarding lifestyle-related cardiovascular risk factors, statistically significant differences were found in favor of the intervention group.

Conclusion

The study supports and reinforces the utilization of trained primary healthcare providers under the NPCDCS program in screening and promoting blood pressure control by preventive services to hypertensive patients in the community.

National Estimates of the Adult Diabetes Care Continuum in India, 2019-2021

Importance

Diabetes is widespread and treatable, but little is known about the diabetes care continuum (diagnosis, treatment, and control) in India and how it varies at the national, state, and district levels.

Objective

To estimate the adult population levels of diabetes diagnosis, treatment, and control in India at national, state, and district levels and by sociodemographic characteristics.

Design, Setting, and Participants

In this cross-sectional, nationally representative survey study from 2019 to 2021, adults in India from 28 states, 8 union territories, and 707 districts were surveyed for India's Fifth National Family Health Survey (NFHS-5). The survey team collected data on blood glucose among all adults (18-98 years) who were living in the same household as eligible participants (pregnant or nonpregnant female individuals aged 15-49 years and male individuals aged 15-54 years). The overall sample consisted of 1 895 287 adults. The analytic sample was restricted to those who either self-reported having diabetes or who had a valid measurement of blood glucose.

Exposures

The exposures in this survey study were district and state residence; urban vs rural residence; age (18-39 years, 40-64 years, or ≥65 years); sex; and household wealth quintile.

Main Outcomes and Measures

Diabetes was defined by self-report or high capillary blood glucose (fasting: ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555]; nonfasting: ≥220 mg/dL). Among respondents who had previously been diagnosed with diabetes, the main outcome was the proportion treated based on self-reported medication use and the proportion controlled (fasting: blood glucose <126 mg/dL; nonfasting: ≤180 mg/dL). The findings were benchmarked against the World Health Organization (WHO) Global Diabetes Compact targets (80% diagnosis; 80% control among those diagnosed). The variance in indicators between and within states was partitioned using variance partition coefficients (VPCs).

Results

Among 1 651 176 adult respondents (mean [SD] age, 41.6 [16.4] years; 867 896 [52.6%] female) with blood glucose measures, the proportion of individuals with diabetes was 6.5% (95% CI, 6.4%-6.6%). Among adults with diabetes, 74.2% (95% CI, 73.3%-75.0%) were diagnosed. Among those diagnosed, 59.4% (95% CI, 58.1%-60.6%) reported taking medication, and 65.5% (95% CI, 64.5%-66.4%) achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Among those diagnosed in the 707 districts surveyed, 246 (34.8%) districts met the WHO diagnosis target, while 76 (10.7%) districts met the WHO control target. Most of the variability in diabetes diagnosis (VPC, 89.1%), treatment (VPC, 85.9%), and control (VPC, 95.6%) were within states, not between states.

Conclusions and Relevance

In this survey study, the diabetes care continuum in India is represented by considerable district-level variation, age-related disparities, and rural-urban differences. Surveillance at the district level can guide state health administrators to prioritize interventions and monitor achievement of global targets.

Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17)

BACKGROUND

Non-communicable disease (NCD) rates are rapidly increasing in India with wide regional variations. We aimed to quantify the prevalence of metabolic NCDs in India and analyse interstate and inter-regional variations.

METHODS

The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, a cross-sectional population-based survey, assessed a representative sample of individuals aged 20 years and older drawn from urban and rural areas of 31 states, union territories, and the National Capital Territory of India. We conducted the survey in multiple phases with a stratified multistage sampling design, using three-level stratification based on geography, population size, and socioeconomic status of each state. Diabetes and prediabetes were diagnosed using the WHO criteria, hypertension using the Eighth Joint National Committee guidelines, obesity (generalised and abdominal) using the WHO Asia Pacific guidelines, and dyslipidaemia using the National Cholesterol Education Program-Adult Treatment Panel III guidelines.

FINDINGS

A total of 113 043 individuals (79 506 from rural areas and 33 537 from urban areas) participated in the ICMR-INDIAB study between Oct 18, 2008 and Dec 17, 2020. The overall weighted prevalence of diabetes was 11·4% (95% CI 10·2-12·5; 10 151 of 107 119 individuals), prediabetes 15·3% (13·9-16·6; 15 496 of 107 119 individuals), hypertension 35·5% (33·8-37·3; 35 172 of 111 439 individuals), generalised obesity 28·6% (26·9-30·3; 29 861 of 110 368 individuals), abdominal obesity 39·5% (37·7-41·4; 40 121 of 108 665 individuals), and dyslipidaemia 81·2% (77·9-84·5; 14 895 of 18 492 of 25 647). All metabolic NCDs except prediabetes were more frequent in urban than rural areas. In many states with a lower human development index, the ratio of diabetes to prediabetes was less than 1.

INTERPRETATION

The prevalence of diabetes and other metabolic NCDs in India is considerably higher than previously estimated. While the diabetes epidemic is stabilising in the more developed states of the country, it is still increasing in most other states. Thus, there are serious implications for the nation, warranting urgent state-specific policies and interventions to arrest the rapidly rising epidemic of metabolic NCDs in India.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Comparison of the Prevalence of Type 2 Diabetes Mellitus in Asian Indians Living in the United States and India: Does Location Matter?

Introduction

Type 2 diabetes mellitus (T2DM) has affected many people worldwide. One population that is greatly affected by T2DM is the Asian Indian population. The relative effects of genetics and environment on the development of diabetes in adults are not completely understood.

Objectives

We conducted an analysis to determine if location, through the environment and different diets, affects T2DM inheritance in Asian Indians. We hypothesised that the prevalence of T2DM depended on location.

Materials and Methods

We analysed previously collected data on T2DM in the individual states of India and the U.S. and used this information to compare the prevalence of T2DM in Asian Indians living in these two countries.

Results

A total of 1,117,465,226 individuals were surveyed in India. Of these, 108,295,674 individuals had T2DM. Similarly, of the 1,704,846 individuals in the US, 298,107 had T2DM. The prevalence of T2DM was 17.49% in Asian Indians living in the US compared to 9.69% for Indians living in India (P < 0.00001). In individuals with similar genetic backgrounds, environmental factors significantly influence the development of T2DM.

Spatial Patterns in the Distribution of Hypertension among Men and Women in India and Its Relationship with Health Insurance Coverage

The present study explores district-level data associated with health insurance coverage (%) and the prevalence of hypertension (mildly, moderately, and severely elevated) observed across men and women as per NFHS 5. Coastal districts in the peninsular region of India and districts in parts of northeastern India have the highest prevalence of elevated blood pressure. Jammu and Kashmir, parts of Gujarat and parts of Rajasthan have a lower prevalence of elevated blood pressure. Intrastate heterogeneity in spatial patterns of elevated blood pressure is mainly seen in central India. The highest burden of elevated blood pressure is in the state of Kerala. Rajasthan is among the states with higher health insurance coverage and a lower prevalence of elevated blood pressure. There is a relatively low positive relationship between health insurance coverage and the prevalence of elevated blood pressure. Health insurance in India generally covers the cost of inpatient care to the exclusion of outpatient care. This might mean that health insurance has limited impact in improving the diagnosis of hypertension. Access to public health centers raises the probability of adults with hypertension receiving treatment with antihypertensives. Access to public health centers has been seen to be especially significant at the poorer end of the economic spectrum. The health and wellness center initiative under Ayushman Bharat will play a crucial role in hypertension control in India.

Prevalence of diabetes mellitus in Indian tribal population: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM), a significant public health problem across the nations, is among the top ten leading causes of death. More than 370 million indigenous people (referred to as tribal people in India) are spread across 90 countries. India has the largest tribal people of 104 million. Tribal populations are not exceptional to the threat of type 2 DM (T2DM) and other non-communicable diseases, and hence, public health programmes are addressing this problem. This paper reports the systematic review and meta-analysis of the literature on the prevalence of T2DM.

METHODS

We conducted a systematic review and meta-analysis of the literature to understand the prevalence of T2DM among the tribal populations of India, following the guidelines of the PRISMA Statement for Reporting Systematic Reviews and Meta-Analysis. The gender-wise prevalence was recalculated by extracting the data wherever possible. Forest plots were depicted based on the prevalence, and other analyses were performed.

RESULTS

On initial searches from three databases, 5422 citations were identified, and ultimately 27 studies were included in the review. These studies were undertaken amongst different tribes in different parts of India. The pooled prevalence of T2DM among men, women and combined were 6.04% (95% confidence interval (CI): 5.55% to 6.57%), 6.48% (95% CI: 6.01% to 6.99%) and 4.94% (95% CI: 4.72% to 5.17%), respectively. Considerable heterogeneity was found among these studies.

CONCLUSION

This systematic review provides an overview of the prevalence of T2DM among the Indian tribal population. The pooled overall prevalence is slightly lower than the general population. This situation is worrisome as the epidemic of T2DM will affect the poor tribal communities, who can least afford to bear the health care costs. Hence, the public health care services must be strengthened in all tribal areas. This review further warrants establishing surveillance of T2DM in tribal areas.

The burgeoning cardiovascular disease epidemic in Indians - perspectives on contextual factors and potential solutions

Cardiovascular diseases (CVD) are the leading cause of death and disability in India. The CVD epidemic in Indians is characterized by a higher relative risk burden, an earlier age of onset, higher case fatality and higher premature deaths. For decades, researchers have been trying to understand the reason for this increased burden and propensity of CVD among Indians. It can partly be explained by population-level changes and the remaining by increased inherent biological risk. While increased biological risk can be attributed to phenotypic changes caused by early life influences, six major transitions can be considered largely responsible for the population-level changes in India-epidemiological, demographic, nutritional, environmental, social-cultural and economic. Although conventional risk factors explain substantial population attributable risk, the thresholds at which these risk factors operate are different among Indians compared with other populations. Therefore, alternate explanations for these ecological differences have been sought and multiple hypotheses have been proposed over the years. Prenatal factors that include maternal and paternal influences on the offspring, and postnatal factors, ranging from birth through childhood, adolescence and young adulthood, as well as inter-generational influences have been explored using the life course approach to chronic disease. In addition to this, recent research has illustrated the importance of the role of inherent biological differences in lipid metabolism, glucose metabolism, inflammatory states, genetic predispositions and epigenetic influences for the increased risk. A multifaceted and holistic approach to CVD prevention that takes into consideration population-level as well as biological risk factors would be needed to control the burgeoning CVD epidemic among Indians.

Association of multiple anthropometric indices with in 944,760 elderly Chinese people

OBJECTIVES

The aims of this study were to update the latest data on the prevalence of hypertension (HTN) in the elderly Chinese population and to assess relationships between new anthropometric indices and HTN.

METHODS

Data were obtained from the Basic Public Health Service (BPHS) survey for Jiangsu Province, China. A total of 944,760 people aged 65 years and older were included in this study. Blood pressure was measured by trained investigators. Body weight, body mass index (BMI), waist circumference (WC), waist-to-height ratio (WtHR), conicity index (COI), body roundness index (BRI), and a body shape index (ABSI) were included in the analysis as anthropometric indices. Logistic regression analysis and restricted cubic splines were used to evaluate the association of anthropometric indices with HTN.

RESULTS

The prevalence of HTN among elderly residents of Jiangsu Province was 64.7% (95% confidence interval, 64.6 to 64.8). After adjusting for multiple covariates, all anthropometric indices except ABSI showed significant non-linear positive dose-response associations with HTN across sex (pnonlinear<0.001). Among participants with BMI <28 kg/m2, abnormal weight, WC, WtHR, BRI, COI, and ABSI were positively associated with HTN.

CONCLUSIONS

The prevalence of HTN in the elderly in Jiangsu Province is gradually increasing. It is necessary to consider the combination of ABSI and COI with BMI for screening elderly individuals for HTN in follow-up prospective studies.

Examining chronic disease onset across varying age groups of Indian adults using competing risk analysis

In low-and-middle-income countries, people develop chronic diseases at a younger age, leading to health-and-economic loss. Estimates of the age of onset of chronic disease provide evidence for policy intervention, but in the Indian context, evidence is limited. The present study aims to explore the onset of seven chronic diseases across adults and the elderly, along with the prognostic factors of chronic disease onset. Using Wave 1 data of the Longitudinal Ageing Study in India (LASI), we estimated the statistical distributions, the median age at onset, and Loglogistic and Weibull accelerated failure time model to understand the onset of seven medically diagnosed self-reported chronic diseases across age groups. We also obtained the sub-distribution hazard ratio (SHR) from the Fine-Gray model to determine the risk of contracting selected chronic diseases in a competing risk setup. The seven chronic diseases- hypertension, diabetes, lung disease, heart disease/stroke, arthritis, neurological disease, and cancer- were developing early, especially in individuals aged 45-54 and 55-64. Arthritis risk was higher in rural areas, and physically active adults and elderly were 1.32 times (95% CI 1.12-1.56) more likely to develop heart disease/stroke. The emerging evidence of the early onset of neurological diseases in middle-aged adults (i.e., among the 45-54 age group) reminds us of the need to reinforce a balance between the physical and mental life of individuals. The early onset of chronic diseases in the independent and working-age category (45-54 years) can have many social and economic implications. For instance, it can create a greater healthcare burden when these individuals grow older with these diseases. Further, disease-specific interventions would be helpful in reducing future chronic disease burden.

Hidden educational inequalities in high blood pressure and high blood glucose levels in Kerala: evidence from the National Family Health Survey (2019-2021)

OBJECTIVE

This study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity.

DESIGN

The present findings are drawn from a large-scale, nationally representative cross-sectional study.

SETTINGS AND PARTICIPANTS

India's Demographic and Health Survey (conducted in 2019-2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Measured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs.

RESULTS

The largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII -45.4% (95% CI -47.3% to -43.4%); RCI -26.6% (95% CI -27.9% to -25.3%)), self-reported high BP (SII -34.5% (95% CI -36.3% to -32.7%); RCI -19.0% (95% CI -20.1% to -17.9%)). High BG levels were concentrated among those with lower educational attainment (SII -26.6% (95% CI -28.6% to -24.7%); RCI -15.7% (95% CI -16.9% to -14.5%)), represented by negative SII and RCI values.

CONCLUSIONS

The study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.

Pharmacist Interventions in Minimizing Drug Related Problems in Diabetes With Co-Existing Hypertension: A Five-Year Overview and Ground Report From India

Objective: The study aimed to investigate the pharmacist interventions in minimizing drug-related problems in diabetes with co-existing hypertension.

Methods: Prospective observational study.

Results: Overall, a total of 628 interventions were recommended for 1,914 patients during the 5-year period of study. Among all the interventions, the majority were suggested regarding “substituting the drug” (39%), change in frequency of administration (25%), and addition of drug (14%). Patient compliance status was found significant (p = 0.29 ± 0.07).

Conclusion: Clinical pharmacists have a crucial role in minimizing drug related problems. Particularly, there should be a greater emphasis on patient counselling and patient follow-up.

Sociodemographic and geographic inequalities in diagnosis and treatment of older adults' chronic conditions in India: a nationally representative population-based study

CONTEXT

Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India.

METHODS

We used 2017-18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models.

FINDINGS

About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large.

CONCLUSIONS

Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed.

A Strategic Research Framework for Defeating Diabetes in India: A 21st-Century Agenda

Indian people are at high risk for type 2 diabetes (T2DM) even at younger ages and lower body weights. Already 74 million people in India have the disease, and the proportion of those with T2DM is increasing across all strata of society. Unique aspects, related to lower insulin secretion or function, and higher hepatic fat deposition, accompanied by the rise in overweight (related to lifestyle changes) may all be responsible for this unrelenting epidemic of T2DM. Yet, research to understand the causes, pathophysiology, phenotypes, prevention, treatment, and healthcare delivery of T2DM in India seriously lags behind. There are major opportunities for scientific discovery and technological innovation, which if tapped can generate solutions for T2DM relevant to the country's context and make leading contributions to global science. We analyze the situation of T2DM in India, and present a four-pillar (etiology, precision medicine, implementation research, and health policy) strategic research framework to tackle the challenge. We offer key research questions for each pillar, and identify infrastructure needs. India offers a fertile environment for shifting the paradigm from imprecise late-stage diabetes treatment toward early-stage precision prevention and care. Investing in and leveraging academic and technological infrastructures, across the disciplines of science, engineering, and medicine, can accelerate progress toward a diabetes-free nation.

Population Preferences for Primary Care Models for Hypertension in Karnataka, India

Importance

Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences.

Objective

To quantify population preferences for attributes of public primary care services for hypertension.

Design, Setting, and Participants

This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey.

Main Outcomes and Measures

Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication.

Results

Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: β = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, β = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, β = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]).

Conclusions and Relevance

In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

Hypertension treatment capacity in India by increased workforce, greater task-sharing, and extended prescription period: a modelling study

Background

The worldwide control rate for hypertension is dismal. An inadequate number of physicians to treat patients with hypertension is one key obstacle. Innovative health system approaches such as delegation of basic tasks to non-physician health workers (task-sharing) might alleviate this problem. Massive scale up of population-wide hypertension management is especially important for low- and middle-income countries such as India.

Methods

Using constrained optimization models, we estimated the hypertension treatment capacity and salary costs of staff involved in hypertension care within the public health system of India and simulated the potential effects of (1) an increased workforce, (2) greater task-sharing among health workers, and (3) extended average prescription periods that reduce treatment visit frequency (e.g., quarterly instead of monthly).

Findings

Currently, only an estimated 8% (95% uncertainty interval 7%-10%) of ∼245 million adults with hypertension can be treated by physician-led services in the Indian public health system (assuming the current number of health workers, no greater task-sharing, and monthly visits for prescriptions). Without task-sharing and with continued monthly visits for prescriptions, the least costly workforce expansion to treat 70% of adults with hypertension would require ∼1.6 (1.0-2.5) million additional staff (all non-physicians), with ∼INR 200 billion (≈USD 2.7 billion) in additional annual salary costs. Implementing task-sharing among health workers (without increasing the overall time on hypertension care) or allowing a 3-month prescription period was estimated to allow the current workforce to treat ∼25% of patients. Joint implementation of task-sharing and a longer prescription period could treat ∼70% of patients with hypertension in India.

Interpretation

The combination of greater task-sharing and extended prescription periods could substantially increase the hypertension treatment capacity in India without any expansion of the current workforce in the public health system. By contrast, workforce expansion alone would require considerable, additional human and financial resources.

Funding

Resolve to Save Lives, an initiative of Vital Strategies, was funded by grants from Bloomberg Philanthropies; the Bill and Melinda Gates Foundation; and Gates Philanthropy Partners (funded with support from the Chan Zuckerberg Foundation).

Hypertension Control Cascade and Regional Performance in India: A Repeated Cross-Sectional Analysis (2015-2021)

Background The weak control cascade of hypertension from the time of screening till the attainment of optimal blood pressure (BP) control is a public health challenge, particularly in resource-limited settings. The study objectives were to (1) estimate the change in the rate of prevalence of hypertension, the yield of newly diagnosed cases, initiation of treatment, and attainment of BP control in the age group 15 to 49 years; (2) ascertain the magnitude and predictors of undiagnosed hypertension, lack of initiation of treatment, and poor control of those on antihypertensive therapy; and (3) estimate the regional variation and state-level performance of the hypertension control cascade in India. Methodology We analyzed demographic and health surveillance (DHS) data from India's National Family Health Survey Fifth Series (NFHS-5), 2019-2021, and NFHS-4 (2015-2016). The NFHS-5 sample comprised 695,707 women and 93,267 men in the age group of 15 to 49 years. Multiple logistic regressions were performed to find the associated predictors, and respective adjusted odds ratios (aORs) were reported. Results The prevalence of hypertension (cumulative previously diagnosed and new cases) among individuals aged 15 to 49 years was 22.8% (22.6%, 23.1%; n = 172,532), out of which 52.06% were newly diagnosed cases. In contrast, in NFHS-4, the prevalence of hypertension among individuals aged 15 to 49 years was 20.4% (20.2%, 20.6%; n = 153,384), of which 41.65% were newly diagnosed cases. In NFHS-5, 40.7% (39.8% and 41.6%) of the previously diagnosed cases were on BP-lowering medications compared to 32.6% (31.8%, 33.6%) in NFHS-4. Furthermore, in NFHS-5, controlled BP was observed in 73.7% (72.7% and 74.7%) of the patients on BP-lowering medication compared to 80.8% (80.0%, 81.6%) in NFHS-4. Females compared to males (aOR = 0·72 and 0·007), residents of rural areas (aOR = 0·82 and 0·004), and those belonging to the socially disadvantaged groups were not initiated on treatment despite awareness of their hypertension status indicative of poor treatment-seeking behavior. Furthermore, increasing age (aOR = 0·49, P < 0·001), higher body mass index (aOR = 0·51, P < 0·001), and greater waist-to-hip ratio (aOR = 0·78, P = 0·047) were associated with uncontrolled hypertension in patients on antihypertensive drug therapy. Conclusions Hypertension control cascade in India is largely ineffectual although screening yield and initiation of antihypertensive treatment have improved in NFHS-5 compared to NFHS-4. Identification of high-risk groups for opportunistic screening, implementing community-based screening, strengthening primary care, and sensitizing associated practitioners are urgently warranted.

Socioeconomic inequality in awareness, treatment and control of diabetes among adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

Diabetes is a growing epidemic and a major threat to most of the households in India. Yet, there is little evidence on the extent of awareness, treatment, and control (ATC) among adults in the country. In this study, we estimate the prevalence and ATC of diabetes among adults across various sociodemographic groups and states of India. We used data on 2,078,315 individuals aged 15 years and over from the recent fifth round, the most recent one, of the National Family Health Survey (NFHS-5), 2019-2021, that was carried out across all the states of India. Diabetic individuals were identified as those who had random blood glucose above 140 mg/dL or were taking diabetes medication or has doctor-diagnosed diabetes. Diabetic individuals who reported diagnosis were labelled as aware, those who reported taking medication for controlling blood glucose levels were labelled as treated and those whose blood glucose levels were < 140 mg/dL were labelled as controlled. The estimates of prevalence of diabetes, and ATC were age-sex adjusted and disaggregated by household wealth quintile, education, age, sex, urban-rural residence, caste, religion, marital status, household size, and state. Concentration index was used to quantify socioeconomic inequalities and multivariable logistic regression was used to estimate the adjusted differences in those outcomes. We estimated diabetes prevalence to be 16.1% (15.9-16.1%). Among those with diabetes, 27.5% (27.1-27.9%) were aware, 21.5% (21.1-21.7%) were taking treatment and 7% (6.8-7.1%) had their diabetes under control. Across the states of India, the adjusted rates of awareness varied from 14.4% (12.1-16.8%) to 54.4% (40.3-68.4%), of treatment from 9.3% (7.5-11.1%) to 41.2% (39.9-42.6%), and of control from 2.7% (1.6-3.7%) to 11.9% (9.7-14.0%). The age-sex adjusted rates were lower (p < 0.001) among the poorer and less educated individuals as well as among males, residents of rural areas, and those from the socially backward groups Among individuals with diabetes, the richest fifth were respectively 12.4 percentage points (pp) (11.3-13.4; p < 0.001), 10.5 pp (9.7-11.4; p < 0.001), and 2.3 pp (1.6-3.0; p < 0.001) more likely to be aware, getting treated, and having diabetes under control, than the poorest fifth. The concentration indices of ATC were 0.089 (0.085-0.092), 0.083 (0.079-0.085) and 0.017 (0.015-0.018) respectively. Overall, the ATC of diabetes is low in India. It is especially low the poorer and the less educated individuals. Targeted interventions and management can reduce the diabetes burden in India.

Geospatial analysis of type 2 diabetes mellitus and hypertension in South Sulawesi, Indonesia

The spatial variation of type 2 diabetes mellitus (T2DM) and hypertension and their potential linkage were explored in South Sulawesi Province, Indonesia. The Global Moran's I and regression analysis were utilized to identify the characteristics involved. The methods were performed based on T2DM and hypertension data from 2017 and 2018 acquired from Social Health Insurance Administration in Indonesia. The spatial variation of T2DM and hypertension showed that the prevalence rate of T2DM and hypertension tends to occur randomly (p = 0.678, p = 0.711, respectively). By utilizing Generalized Poisson Regression Analysis, our study showed a significant relationship between T2DM and hypertension (p ≤ 0.001). This research could help policy makers to plan and support projects with the aim of overcoming the risk of T2DM and hypertension.

Association of greenness with COVID-19 deaths in India: An ecological study at district level

BACKGROUND

The world has witnessed a colossal death toll due to the novel coronavirus disease-2019 (COVID-19). A few environmental epidemiology studies have identified association of environmental factors (air pollution, greenness, temperature, etc.) with COVID-19 incidence and mortality, particularly in developed countries. India, being one of the most severely affected countries by the pandemic, still has a dearth of research exploring the linkages of environment and COVID-19 pandemic.

OBJECTIVES

We evaluate whether district-level greenness exposure is associated with a reduced risk of COVID-19 deaths in India.

METHODS

We used average normalized difference vegetation index (NDVI) from January to March 2019, derived by Oceansat-2 satellite, to represent district-level greenness exposure. COVID-19 death counts were obtained through May 1, 2021 (around the peak of the second wave) from an open portal: covid19india.org. We used hierarchical generalized negative binomial regressions to check the associations of greenness with COVID-19 death counts. Analyses were adjusted for air pollution (PM_2.5), temperature, rainfall, population density, proportion of older adults (50 years and above), sex ratio over age 50, proportions of rural population, household overcrowding, materially deprived households, health facilities, and secondary school education.

RESULTS

Our analyses found a significant association between greenness and reduced risk of COVID-19 deaths. Compared to the districts with the lowest NDVI (quintile 1), districts within quintiles 3, 4, and 5 have respectively, around 32% [MRR = 0.68 (95% CI: 0.51, 0.88)], 39% [MRR = 0.61 (95% CI: 0.46, 0.80)], and 47% [MRR = 0.53 (95% CI: 0.40, 0.71)] reduced risk of COVID-19 deaths. The association remains consistent for analyses restricted to districts with a rather good overall death registration (>80%).

CONCLUSION

Though cause-of-death statistics are limited, we confirm that exposure to greenness was associated with reduced district-level COVID-19 deaths in India. However, material deprivation and air pollution modify this association.