Incidence of hypertension and its risk factors in rural Kerala, India: a community-based cohort study

Prevalence and risk factors associated with undiagnosed hypertension among adults aged 15-49 years in India: insights from the National Family Health Survey (NFHS-5)

OBJECTIVES

To estimate the prevalence and identify the factors associated with undiagnosed hypertension in India.

STUDY DESIGN

A secondary data analysis using the National Family Health Survey (NFHS-5) covering the period 2019-2021.

METHODS

Information on hypertension among individuals aged 15-49 years was extracted from the survey dataset. We estimated the prevalence of undiagnosed hypertension using physical measurements along with self-reported data from the survey. A log-binomial model with survey-adjusted Poisson regression was used to estimate the prevalence ratio between undiagnosed and diagnosed hypertension. Multinomial logistic regression analysis examined the factors associated with diagnosed hypertension (vs healthy) and undiagnosed hypertension (vs healthy). All the analyses were survey-weight adjusted and stratified by gender.

RESULTS

The survey-adjusted prevalence of undiagnosed hypertension was 8.75% (8.62%-8.87%) and was higher among males [13.56% (13.03%-14.12%)] than in females [8.14% (8.03%-8.25%)]. The proportion of individuals with undiagnosed hypertension among total hypertension was 44.99% (44.44%-45.55%) and was higher in males [65.94% (64.25%-67.60%)] than in females [42.18% (41.66%-42.71%)].

CONCLUSIONS

Our findings revealed that age, higher body mass index, no access to health care, and having no comorbidities were risk factors for undiagnosed hypertension. One in twelve people had undiagnosed hypertension, and of those with hypertension, one in two were undiagnosed, with males being disproportionately affected. Targeted public health interventions are crucial to improve hypertension screening, particularly among middle-aged and obese individuals without comorbidities.

Strengthening research capacity of early-mid career researchers: Implementation and evaluation of the Excellence in Non-COmmunicable disease REsearch (ENCORE) program

High-quality training and networking are pivotal for enhancing the research capacity of early- to mid-career researchers in the prevention and control of non-communicable diseases. Beyond building research skills, these professionals gain valuable insights from interdisciplinary mentorship, networking opportunities, and exposure to diverse cultures and health systems. Despite the significance of such initiatives, their implementation remains underexplored. Here, we describe the implementation and evaluation of the Excellence in Non-COommunicable disease REsearch (ENCORE) program, a collaborative initiative between Australia and India that was launched in 2016 and spanned a duration of 3 years. Led by a consortium that included the University of Melbourne and leading Indian research and medical institutions, ENCORE involved 15 faculty members and 20 early-mid career researchers. The program comprised various elements, including face-to-face forums, masterclasses, webinars, a health-technology conference, and roundtable events. ENCORE successfully trained the early-career researchers, resulting in over 30 peer-reviewed articles, 36 conference presentations, and the submission of seven grant applications, three of which received funding. Beyond individual achievements, ENCORE fostered robust research collaboration between Australian and Indian institutions, showcasing its broader impact on strengthening research capacities across borders.

Clustering of health behaviors and their associations with cardiometabolic risk factors among adults at high risk for type 2 diabetes in India: A latent class analysis

BACKGROUND

We aimed to identify clusters of health behaviors and study their associations with cardiometabolic risk factors in adults at high risk for type 2 diabetes in India.

METHODS

Baseline data from the Kerala Diabetes Prevention Program (n = 1000; age 30-60 years) were used for this study. Information on physical activity (PA), sedentary behavior, fruit and vegetable intake, sleep, and alcohol and tobacco use was collected using questionnaires. Blood pressure, waist circumference, 2-h plasma glucose, high-density lipoprotein and low-density lipoprotein cholesterol, and triglycerides were measured using standardized protocols. Latent class analysis was used to identify clusters of health behaviors, and multilevel mixed-effects linear regression was employed to examine their associations with cardiometabolic risk factors.

RESULTS

Two classes were identified, with 87.4% of participants in class 1 and 12.6% in class 2. Participants in both classes had a high probability of not engaging in leisure-time PA (0.80 for class 1; 0.73 for class 2) and consuming <5 servings of fruit and vegetables per day (0.70 for class 1; 0.63 for class 2). However, participants in class 1 had a lower probability of sitting for >=3 h per day (0.26 vs 0.42), tobacco use (0.10 vs 0.75), and alcohol use (0.08 vs 1.00) compared to those in class 2. Class 1 had a significantly lower mean systolic blood pressure (β = -3.70 mm Hg, 95% confidence interval [CI] -7.05, -0.36), diastolic blood pressure (β = -2.45 mm Hg, 95% CI -4.74, -0.16), and triglycerides (β = -0.81 mg/dL, 95% CI -0.75, -0.89).

CONCLUSION

Implementing intervention strategies, tailored to cluster-specific health behaviors, is required for the effective prevention of cardiometabolic disorders among high-risk adults for type 2 diabetes.

A longitudinal study of incident hypertension and its determinants in Indian adults aged 45 years and older: evidence from nationally representative WHO-SAGE study (2007-2015)

Objectives

Hypertension (HT) is a leading cause of mortality and morbidity in developing countries. This study aimed to estimate the incidence of HT among adults aged 45 years and older in India and its associated risk factors.

Methods

This study used longitudinal data from the Indian sample of the first and second waves of the World Health Organization Study on Global Ageing and Adult Health (WHO-SAGE). A bivariate analysis using Pearson's chi-square test was done to examine the associations of individual, lifestyle, and household characteristics with HT status reported in Wave 2. Incident HT changes were analyzed by adjusting for various covariates in the generalized estimating equation (logit link function) with an exchangeable correlation matrix and robust standard errors.

Results

The study found that during the 8-year period from 2007 to 2015, the incidence of HT in individuals aged 45 years and over was 20.8%. Pre-hypertensive individuals had an overall incidence rate of 31.1 per 1,000 [95% confidence interval (CI): 26.20-35.9] and a 2.24 times higher odds ratio: 2.24 (95% CI: 1.65-3.03) of developing incident HT compared to those who were normotensive. Adults aged 45 years and older, overweight/obese individuals, and women were more at risk of incident HT.

Conclusion

One in five individuals had developed HT over 8 years, with a greater risk of incident HT among women than men. Pre-hypertensive individuals were at a greater risk of developing incident HT compared to normotensive individuals. The study recommends comprehensive and effective management of pre-HT to tackle the burden of HT.

Development of a Modified Global Physical Activity Questionnaire and Its Construct Validity among Adults in Kerala, India

There is a need for a modified Global Physical Activity Questionnaire (GPAQ) to estimate physical activity levels more accurately in populations. We aimed to develop a modified GPAQ and examine its construct validity among adults in Kerala, India. We incorporated locality-specific, metabolic equivalent task (MET)-based activities into the original GPAQ and administered this modified GPAQ among randomly selected 451 individuals (age ≥ 20 years) residing in the Trivandrum district of Kerala. Construct validity of the modified GPAQ was assessed using generalized linear models by examining the association of total moderate-to-vigorous physical activity (MVPA) MET-minutes per week with clinical measures. The mean age of participants was 45.4 (SD: 14.1) years, and 52.6% were female. Increasing total MVPA MET-minutes per week was associated with decreasing weight (β = -0.011 kg, 95% CI: -0.020, -0.002), waist circumference (β = -0.013 cm, 95% CI: -0.023, -0.004), and systolic blood pressure (β = -0.009 mmHg, 95% CI: -0.015, -0.002), independent of age, sex, education, occupation, current smoking, current alcohol use, and fruit and vegetable intake. The validity coefficients and associations between total MVPA MET-minutes per week and theoretical constructs of physical activity agreed with those predicted, providing evidence of construct validity for the modified GPAQ.

Trends in hypertension prevalence, awareness, treatment, and control: an 8-year follow-up study from rural North India

Hypertension is a major contributor to global CVD burden. LMICs including India is challenged with rising hypertension prevalence, yet limited studies are available on temporal change and incidence among community-cohorts. This study aimed to describe trends in hypertension prevalence, awareness, treatment, and control over 8 years among a rural community-cohort from Haryana, India. The study also lends towards an analysis of incidence. Adults ≥ 30 years (N = 1542) recruited during baseline cross-sectional study between 2011 and 2014 were followed up after a median 8.1 years. At endline, demographic/lifestyle characteristics and blood pressure were re-examined. Overall median SBP significantly increased from 120 mmHg at baseline to 125.5 mmHg at endline (p < 0.001), while hypertension prevalence increased from 34.4% (95% CI 32.0-36.9) to 40.4% (95% CI 37.5-43.4) (p = 0.002). Age-standardized hypertension incidence was 30.2% (95% CI 26.7-35.2) over 8 years. Among hypertensive group, awareness, treatment, and control increased from 9.6, 8.8 and 5.0% to 31.8, 27.3 and 9.6% (p < 0.05), respectively. Increasing trend in SBP and hypertension prevalence was observed as the cohort ages. This increase is supported by the high incidence of hypertension. Nevertheless, our study highlights positive trends in hypertension care cascade but poor control, suggesting that this trend may not be adequately impactful to reduce hypertension burden.

Systematic literature review and meta-analysis of cardiovascular risk factor management in selected Asian countries

Aim: There is a need to understand the management status of hypertension, dyslipidemia/hypercholesterolemia, and diabetes mellitus in the Asia-Pacific region (APAC). Methods: We conducted a systematic literature review and meta-analysis to summarize the awareness, treatment, and/or control rates of these risk factors in adults across 11 APAC countries/regions. Results: We included 138 studies. Individuals with dyslipidemia had the lowest pooled rates compared with those with other risk factors. Levels of awareness with diabetes mellitus, hypertension, and hypercholesterolemia were comparable. Individuals with hypercholesterolemia had a statistically lower pooled treatment rate but a higher pooled control rate than those with hypertension. Conclusion: The management of hypertension, dyslipidemia, and diabetes mellitus was suboptimal in these 11 countries/regions.

Effectiveness of a School-Based Educational Intervention to Improve Hypertension Control Among Schoolteachers: A Cluster-Randomized Controlled Trial

Background The control of hypertension is low in low- and middle-income countries like India. We evaluated the effects of a nurse-facilitated educational intervention in improving the control rate of hypertension among school teachers in India. Methods and Results This was a cluster-randomized controlled trial involving 92 schools in Kerala, which were randomly assigned equally into a usual care group and an intervention group. Participants were 402 school teachers (mean age, 47 years; men, 29%) identified with hypertension. Participants in both study groups received a leaflet containing details of a healthy lifestyle and the importance of regular intake of antihypertensive medication. In addition, the intervention participants received a nurse-facilitated educational intervention on hypertension control for 3 months. The primary outcome was hypertension control. Key secondary outcomes included systolic blood pressure, diastolic blood pressure, and the proportion of participants taking antihypertensive medications. For the primary outcome, we used mixed-effects logistic regression models. Two months after a 3-month educational intervention, a greater proportion of intervention participants (49.0%) achieved hypertension control than the usual care participants (38.2%), with an odds ratio of 1.89 (95% CI, 1.06-3.35), after adjusting for baseline hypertension control. The odds of taking antihypertensive medications were 1.6 times higher in the intervention group compared with the usual care group (odds ratio, 1.62; 95% CI, 1.08-2.45). The reduction in mean systolic blood pressure was significantly greater in the intervention group by 4.2 mm Hg (95% CI, -7.2 to -1.1) than in the usual care group. Conclusions A nurse-facilitated educational intervention was effective in improving the control and treatment rates of hypertension as well as reducing systolic blood pressure among schoolteachers with hypertension. Registration URL: https://www.ctri.nic.in; Unique Identifier: CTRI/2018/01/011402.

Factors Associated With Hypertension Awareness, Treatment, and Control Among Adults in Kerala, India

Background: Hypertension, the most significant risk factor for cardiovascular disease, is an increasing contributor to global health burden, particularly in low- and middle-income countries (LMICs) such as India. While the rates of hypertension awareness, treatment, and control in India have been reported in several studies, the factors associated with these rates are less well-understood. Existing studies are predominantly cross-sectional, and the factors examined are limited. Understanding the predictors associated with these rates, using more rigorous study designs, is crucial for the development of strategies to improve hypertension management.

Aims: To examine a range of factors associated with hypertension awareness, treatment, and control using both cross-sectional and longitudinal analyses.

Methods: Data was derived from a population-based sample of 1,710 participants from Kerala, aged 30–60 years. We examined a comprehensive range of factors, including demographic, behavioral factors, anthropometric, clinical measures, psychosocial factors and healthcare utilization. Multilevel mixed effects logistic regression was used for both cross-sectional and longitudinal analyses (repeated measures for all variables across 2 years) to determine the factors associated with awareness, treatment, and control of hypertension.

Results: A total of 467 (27.3%) participants had hypertension at baseline. Among those, the rates of awareness, treatment, and control of hypertension were 54.4, 25.5, and 36.4%, respectively. Being male (OR 0.27, 95% CI 0.14–0.53) and consumption of alcohol (OR 0.49, 95% CI 0.31–0.80) were significant predictors of poorly controlled hypertension (longitudinal analysis). Depression (OR 2.04, 95% CI 1.15–3.61) and fair-to-poor self-perceived health status (OR 1.87, 95% CI 1.15–3.04) were associated with increased hypertension awareness, whereas anxiety (OR 1.97, 95% CI 1.04–3.71) was associated with increased hypertension treatment (cross-sectional analysis). Seeking outpatient service in the past 4 weeks was associated with higher awareness (OR 1.09, 95% CI 1.27–2.87), treatment (OR 1.73, 95% CI 1.20–2.50) and control (OR 1.96, 95% CI 1.37–2.80) (longitudinal analysis).

Conclusion: Our findings suggest the importance of considering psychosocial factors and better engagement with health services in hypertension management, as well as giving more attention to body fat control and largely male-related behaviors such as alcohol consumption, taking into account of some Indian specific attributes.

Incident hypertension in urban slums of central India: a prospective cohort study

Background

Numerous studies have highlighted the burden of hypertension by estimating its prevalence. However, information regarding quantum and characteristics of persons whose blood pressure converts to hypertension range from their previous state of prehypertension or normal blood pressure is crucial for any public health programme. We aimed to estimate incidence rate of hypertension and to identify risk factors for the same, so that it is useful for programme implementation.

Methods

We established a cohort of adults residing in urban slums of Bhopal, who were registered in a baseline cardiovascular risk assessment survey, which was performed between November 2017 and March 2018. Blood pressure assessment was done at least three times at baseline for diagnosis of hypertension, which was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on two occasions. Participants who did not have a diagnosis of hypertension were followed up during April–June 2019.

Results

Of the 5673 participants assessed at baseline, 4185 did not have hypertension of which 3199 (76.4%) were followed up after a median on 1.25 years (IQR 1.08–1.60) and a total of 170 (5.31%) individuals were detected with incident hypertension. Overall incidence rate of hypertension was 4.1 (95% CI 3.54 to 4.75) per 100 person-years of follow-up. On multivariate analysis, age (relative risk/RR 1.98; 95% CI 1.19 to 3.3, for age >60 years), being in first and second wealth tertile (T-1 RR 1.85; 95% CI 1.17 to 2.91) and being illiterate (RR 1.94; 95% CI 1.31 to 2.86) were significant predictors of incident hypertension. Individuals who had prehypertension at baseline also had a significantly increased risk of developing hypertension (RR 2.72; 95% CI 1.83 to 4.03).

Conclusions

We found that incidence of hypertension in urban slums of central India is higher with increasing age and in men. Illiteracy, lower Wealth Index and prehypertension are other determinants. We also demonstrate feasibility of establishing a cohort within the public health delivery system, driven by efforts of community health workers.

Effects of a lifestyle intervention on cardiovascular risk among high-risk individuals for diabetes in a low- and middle-income setting: Secondary analysis of the Kerala Diabetes Prevention Program

We aimed to examine whether a lifestyle intervention was effective in reducing cardiovascular disease (CVD) risk in individuals at high-risk of developing diabetes in a low- and middle-income setting. The Kerala Diabetes Prevention Program was evaluated by a cluster-randomized controlled trial (2013-2016) of 1007 individuals (aged 30-60 years) at high-risk for diabetes (Indian Diabetes Risk Score ≥ 60 and without diabetes) in Kerala state, India. Sixty polling areas in Kerala were randomized to intervention or control groups by an independent statistician using a computer-generated randomization sequence. Participants from 30 intervention communities received a 12-month structured peer-support lifestyle intervention program involving 15 group sessions and linked community activities, aimed at supporting and maintaining lifestyle change. The primary outcome for this analysis was the predicted 10-year CVD risk at two years, assessed using the Framingham Risk Score. The mean age at baseline was 46.0 (SD: 7.5) years, and 47.2% were women. Baseline 10-year CVD risk was similar between study groups. The follow-up rate at two years was 95.7%. The absolute risk reduction in predicted 10-year CVD risk between study groups was 0.69% (95% CI: 0.09% to 1.29%, p=0.024) at one year and 0.69% (95% CI: 0.10% to 1.29%, p=0.023) at two years. The favorable change in CVD risk with the intervention condition was mainly due to the reduction in tobacco use (change index: -0.25, 95% CI: -0.42 to -0.09). Our findings suggest that a community-based peer-support lifestyle intervention could reduce CVD risk in individuals at high-risk of developing diabetes in India. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.

Incidence of hypertension among Asian Indians: 10 year follow up of the Chennai Urban Rural Epidemiology Study (CURES-153)

AIMS

There are very few studies on incidence of hypertension from developing countries. We report on the incidence of hypertension and its risk factors in Chennai city in southern India.

METHODS

Participants were 1691 individuals from the Chennai Urban Rural Epidemiology Study (CURES) cohorts who did not have hypertension (normotensive n = 878, prehypertension n = 813) at baseline and who were followed for a median of 9.0 years. During the follow-up, 41 with missing blood pressure values were excluded, leaving 1650 individuals for the present analysis. Incidence rates of hypertension and predictors of progression to prehypertension and/or hypertension were estimated using Cox proportional hazards model.

RESULTS

During the follow-up period, 426 out of 1650 individuals developed hypertension, giving an overall incidence of hypertension of 28.7(95%CI 26.1-31.5) per 1000 person-years. Individuals with dysglycemia at baseline had higher incident rates of hypertension. Collectively, four modifiable risk factors [pre-hypertension, dysglycemia, central obesity and physical inactivity] accounted for 87.2% of the population attributable risk of incident hypertension.

CONCLUSIONS

Higher body weight, BMI, age and dysglycemia were associated with an increased risk of incident hypertension. Prehypertension, dysglycemia, central obesity and physical inactivity accounted for 87% of incident hypertension.

Cost-effectiveness of a lifestyle intervention in high-risk individuals for diabetes in a low- and middle-income setting: Trial-based analysis of the Kerala Diabetes Prevention Program

BACKGROUND

Data on the cost-effectiveness of lifestyle-based diabetes prevention programs are mostly from high-income countries, which cannot be extrapolated to low- and middle-income countries. We performed a trial-based cost-effectiveness analysis of a lifestyle intervention targeted at preventing diabetes in India.

METHODS

The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial of 1007 individuals conducted in 60 polling areas (electoral divisions) in Kerala state. Participants (30-60 years) were those with a high diabetes risk score and without diabetes on an oral glucose tolerance test. The intervention group received a 12-month peer-support lifestyle intervention involving 15 group sessions delivered in community settings by trained lay peer leaders. There were also linked community activities to sustain behavior change. The control group received a booklet on lifestyle change. Costs were estimated from the health system and societal perspectives, with 2018 as the reference year. Effectiveness was measured in terms of the number of diabetes cases prevented and quality-adjusted life years (QALYs). Three times India's gross domestic product per capita (US$6108) was used as the cost-effectiveness threshold. The analyses were conducted with a 2-year time horizon. Costs and effects were discounted at 3% per annum. One-way and multi-way sensitivity analyses were performed.

RESULTS

Baseline characteristics were similar in the two study groups. Over 2 years, the intervention resulted in an incremental health system cost of US$2.0 (intervention group: US$303.6; control group: US$301.6), incremental societal cost of US$6.2 (intervention group: US$367.8; control group: US$361.5), absolute risk reduction of 2.1%, and incremental QALYs of 0.04 per person. From a health system perspective, the cost per diabetes case prevented was US$95.2, and the cost per QALY gained was US$50.0. From a societal perspective, the corresponding figures were US$295.1 and US$155.0. For the number of diabetes cases prevented, the probability for the intervention to be cost-effective was 84.0% and 83.1% from the health system and societal perspectives, respectively. The corresponding figures for QALY gained were 99.1% and 97.8%. The results were robust to discounting and sensitivity analyses.

CONCLUSIONS

A community-based peer-support lifestyle intervention was cost-effective in individuals at high risk of developing diabetes in India over 2 years.

TRIAL REGISTRATION

The trial was registered with Australia and New Zealand Clinical Trials Registry ( ACTRN12611000262909 ). Registered 10 March 2011.

The Incidence and Awareness of Hypertension, among Adults in Ahvaz: A 5-Year Cohort Study in Southwestern Iran

BACKGROUND

According to the World Health Organization in 2009, hypertension is responsible for 13% of all deaths. Hypertension can increase the risk of stroke, coronary artery disease, dementia, heart disorder, kidney, and other chronic diseases. In this study, the prevalence and incidence of hypertension and knowledge and awareness of it among adults in Ahvaz are investigated.

METHODS

This cohort study was carried out on 688 participants in a study on the prevalence of metabolic syndrome investigated in adults in the city of Ahvaz in 2009. In 2014, participants were again recruited. Based on the standard method and disease history, blood pressure, height, and weight were measured, and a demographic information questionnaire was completed through interviews.

RESULTS

In this study, 688 individuals over 20 years of age participated with an average age of 42.7 ± 13.3 years, 300 men (43.6%), and 388 women (56.4%). Hypertension incidence was 65/1000 person-years which included 67.7 and 57.8/1000 person-years in men and women, respectively. The awareness of patients about hypertension was 51.2% in phase 2 (hypertension new cases).

CONCLUSIONS

In this study conducted in Ahvaz, the incidence rate of hypertension was 65/1000 person-years, higher in men than women. Hypertension awareness was 50.5%, 45.1% in men, and 55.1% in women.

Incidence of Prehypertension and Hypertension in Rural India, 2012-2018: A Sex-Stratified Population-Based Prospective Cohort Study

BACKGROUND

India is home to the largest number of hypertensive individuals, and factors responsible for the incidence of hypertension are poorly understood. This study examines predictors of transition to different stages of hypertension-incidence of hypertension, incidence of prehypertension, and incidence of prehypertension to hypertension.

METHODS

Population-based survey data from the Birbhum Population Project, located in West Bengal, India were used. A cohort of 8,977 individuals (male: 3,934, female: 5,043), participated in the 2012-13 survey, and were followed up for resurvey in 2017-18. The Seventh Report of the Joint National Committee (JNC 7) guidelines were followed to define hypertension. Bivariate and multivariate Poisson regression analyses were conducted to attain the study objective.

RESULTS

The incidence of hypertension, prehypertension among males (7.9% and 45.3%, respectively) is higher than that among females (5.9% and 32.7%, respectively). However, the incidence of prehypertension to hypertension is lower among males (23.6%) than among females (33.6%). Among both sexes, with age, the incidence of hypertension, and incidence of prehypertension to hypertension appeared to increase, whereas incidence of prehypertension among females increased with age. Findings indicate a diverse gradient of socioeconomic, behavioral, and anthropometric characteristics influencing the incidence of different stages of hypertension.

CONCLUSIONS

With a focus on females and the richest individuals, this study proposes that an appropriate intervention be designed in keeping with the socioeconomic, behavioral gradient of incidence of different stages of hypertension. The role of anthropometric indicators in hypertension is proposed to be further studied for better population-based screening.

Participant recruitment into a community-based diabetes prevention trial in India: Learnings from the Kerala Diabetes Prevention Program

Background

Data on participant recruitment into diabetes prevention trials are limited in low- and middle-income countries (LMICs). We aimed to provide a detailed analysis of participant recruitment into a community-based diabetes prevention trial in India.

Methods

The Kerala Diabetes Prevention Program was conducted in 60 polling areas (electoral divisions) of the Neyyatinkara taluk (subdistrict) in Trivandrum district, Kerala state. Individuals (age 30–60 years) were screened with the Indian Diabetes Risk Score (IDRS) at their homes followed by an oral glucose tolerance test (OGTT) at community-based clinics. Individuals at high-risk of developing diabetes (IDRS score ≥60 and without diabetes on the OGTT) were recruited.

Results

A total of 1007 participants (47.2% women) were recruited over nine months. Pilot testing, personal contact and telephone reminders from community volunteers, and gender matching of staff were effective recruitment strategies. The major recruitment challenges were: (1) during home visits, one-third of potential participants could not be contacted, as they were away for work; and (2) men participated less frequently in the OGTT screening than women (75.2% vs. 84.2%). For non-participation, lack of time (42.0%) was most commonly cited followed by ‘I am already feeling healthy’ (30.0%), personal reasons (24.0%) and ‘no benefit to me or my family’ (4.0%). An average of 17 h were spent to recruit one participant with a cost of US$23. The initial stage of screening and recruitment demanded higher time and costs.

Conclusions

This study provides valuable information for future researchers planning to implement community-based diabetes prevention trials in India or other LMICs.

Trial registration

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909.

Knowledge of risk factors for hypertension in a rural Indian population

Objective

To study knowledge of risk factors and consequences of hypertension in a rural population in South India.

Methods

This is a community-based study conducted among adults of a rural population in the Rishi Valley, India. Residents of randomised rural villages were invited to participate in a study of hypertension. We obtained measures of blood pressure, height, weight, waist and hip circumferences and questionnaire-based information on knowledge about hypertension, sociodemographic characteristics and health behaviours. Multivariable logistic regression analyses were conducted to determine the factors associated with knowledge of risk factors for hypertension (knowledge of ≥2 risk factors).

Results

The study comprised 641 adults; 132 aware and 218 unaware of their hypertension, and 291 with normal blood pressure. Only 31% of participants knew that hypertension adversely affects an individual's health and 7% knew the benefits of treating hypertension. Almost a third (30%) of those aware of their hypertensive status, and 48% overall, did not know any of the risk factors for hypertension. Being aware of one's hypertensive status (OR 2.51, 95% CI 1.44 to 4.39), being treated for hypertension, male sex, younger age, having some schooling, abdominal obesity and physical inactivity were associated with better knowledge of risk factors for hypertension.

Conclusion

Knowledge of risk factors and consequences of hypertension in this disadvantaged population was poor. There was better knowledge of risk factors in some, but not all, people who were aware of having hypertension. Screening and targeted educational programmes are warranted in this population to improve health behaviours and reduce the consequences of hypertension.

A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program

BACKGROUND

The major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score.

METHODS AND FINDINGS

The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30-60 years) were those with an Indian Diabetes Risk Score (IDRS) ≥60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66-1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: -1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (≥5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate.

CONCLUSIONS

A low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.

Body mass index, abdominal adiposity, weight gain and risk of developing hypertension: a systematic review and dose-response meta-analysis of more than 2.3 million participants

OBJECTIVE

This study aimed to test the association between anthropometric measures and risk of developing hypertension.

METHODS

We did a systematic search using PubMed and Scopus, from inception up to January 2017. Prospective cohort studies reporting the risk estimates of hypertension for three or more quantitative categories of indices of general and abdominal adiposity were included. Summary relative risks were calculated using random-effects models.

RESULTS

Fifty-seven prospective cohort studies were included. Summary relative risks were 1.49 (95% confidence interval [CI]: 1.41, 1.58; I²  = 97.4%, n = 50) for a five-unit increment in body mass index, 1.27 (95%CI: 1.15, 1.39; I²  = 95.0%, n = 14) for a 10-cm increment in waist circumference, 1.16 (95%CI: 1.09, 1.23; I²  = 77.8%, n = 5) for weight gain equal to a one-unit increment in BMI, and 1.37 (95%CI: 1.24, 1.51; I²  = 76.4%, n = 8) and 1.74 (95%CI: 1.35, 2.13; I²  = 58.9%, n = 4) for a 0.1-unit increment in waist-to-hip ratio and waist-to-height ratio, respectively. The risk of hypertension increased continuously with increasing all anthropometric measures, and also along with weight gain.

CONCLUSION

Being as lean as possible within the normal body mass index range may be the best suggestion in relation to primary prevention of hypertension.

Prevalence of metabolic syndrome and its risk factors in Kerala, South India: Analysis of a community based cross-sectional study

BACKGROUND

Coronary Artery Disease (CAD) is a leading cause of death and disability in Kerala, India. Metabolic syndrome (MS) is a constellation of established risk factors for CAD. We aimed to estimate the prevalence of MS and evaluate the association between MS and CAD using a community-based sample population.

METHODS

A cross-sectional community based survey was conducted in urban and rural areas of Kerala in 2011. We included 5063 individuals for analysis. Age standardized prevalence of MS, associated diagnoses (hypertension, diabetes and hypercholesterolemia) and other potential risk factors were assessed for men and women in both urban and rural locations. Univariate and multivariate logistic regression models were developed to identify participant characteristics that are associated with MS.

RESULTS

After standardization for age and adjustment for sex and urban-rural distribution, the prevalence of metabolic syndrome in Kerala was 24%, 29% and 33% for the NCEP ATP III, IDF and AHA/NHLBI Harmonization definitions, respectively. The mean (SD) age of the participants was 51 (14) years, and 60% were women. Women had a higher prevalence of MS than men (28% versus 20% for ATP III, p<0.001). Similarly, participants living in urban areas had higher prevalence of MS than their rural counterparts (26% versus 22%, p<0.001). Elevated body mass index, older age, and female sex were associated with MS in an adjusted multivariate model. The propensity for definite CAD was 1.7 times higher in individuals with MS defined based on ATP III criteria compared to those without MS (Adjusted OR = 1.69; 95% CI: 1.3-2.2, p<0.001).

CONCLUSIONS

One of four to one of three adult individuals in Kerala have MS based on different criteria. Higher propensity for CAD in individuals with MS in Kerala calls for urgent steps to prevent and control the burden of metabolic conditions.

Alarmingly high prevalence of hypertension and pre-hypertension in North India-results from a large cross-sectional STEPS survey

OBJECTIVES

The study was primarily aimed at estimating the prevalence of hypertension and pre-hypertension and the risk factors of hypertension in the North Indian state of Punjab. It also aimed at assessing the magnitude of undiagnosed cases of hypertension in the community and ascertaining the blood pressure control status of those on treatment.

METHODS

A non-communicable disease risk factor survey (based on WHO-STEPS approach) was done in the state of Punjab, India in a multistage stratified sample of 5127 individuals. The study subjects were administered the WHO STEPS-questionnaire and also underwent anthropometric and blood pressure measurements.

RESULTS

Overall prevalence of HTN among the study participants was found out to be 40.1% (95% CI: 38.8-41.5%) whereas prevalence of pre-hypertension, isolated diastolic and isolated systolic hypertension were 40.8% (39.5-42.2%), 9.2% (8.4-10.0%) and 6.5% (5.9-7.2%) respectively. Age group (45-69 years), male gender, social group, marital status, alcohol use, obesity and salt intake (> = 5 gms/day) were the risk factors significantly associated with HTN. Among all persons with HTN, only 30.1% were known case of HTN or on treatment, among whom nearly 61% had controlled blood pressure. Patients with uncontrolled BP were more frequently male, obese patients, with sedentary lifestyle and patients with diabetes.

CONCLUSIONS

The study reported alarmingly high prevalence of hypertension, especially of undiagnosed or untreated cases amongst the adult population, a significant proportion of whom have uncontrolled blood pressure levels. This indicates the need for systematic screening and awareness program to identify the undiagnosed cases in the community and offer early treatment and regular follow up.

Incidence of essential hypertension in young adult males followed for over two decades

BACKGROUND

The data about the incidence of hypertension in India is scarce and is lacking about hypertension in young adult patients. We studied the incidence of hypertension in a cohort of young adult male military personnel followed for a long duration.

METHODS

The data for this retrospective, observational study was derived from the electronic medical records (EMR) of the male service personnel enrolled between 1990 and 2015. All subjects were recruited before 18 years of age in good health without any disease. Hypertension in young adults was defined as the onset of the disease prior to 45 years of age. We calculated the incidence rates as per person years using appropriate statistical methods.

RESULTS

Our study population includes 51,217 participants (median age 33 years, range 17-54) with a mean follow up of 12.5 years, giving a total observation period of 613,925 person-years (py). During the study period, 360 patients developed hypertension, giving an incidence rate of 58.6 per 100,000 py (95% CI 52.8-64.9). The mean age at the time of diagnosis was 33.5±5.7years (range 20-45) with 5.6±3.9years (range 0.3-21yr) of follow up after the diagnosis. Only 16 patients (4.4%) had associated cardiovascular complications attributable to hypertension.

CONCLUSION

Our cohort had low incidence rates of hypertension when compared with other studies from abroad. Active military service may offer protection from the hypertension and associated complications.

The incidence of hypertension and its risk factors in the German adult population: results from the German National Health Interview and Examination Survey 1998 and the German Health Interview and Examination Survey for Adults 2008-2011

OBJECTIVE

To analyze incident hypertension and its risk factors based on 11.9 years follow-up of a recent National Examination Survey cohort in Germany.

METHODS

Out of 7124 participants of the German National Health Interview and Examination Survey 1998 (GNHIES98), 640 had died at follow-up 2008-2011 and 3045 were reexamined as part of the German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1). Baseline and follow-up included standardized blood pressure (BP) measurements. Hypertension was defined as BP of at least 140/90 mmHg or intake of antihypertensive medication in participants with known hypertension.

RESULTS

Out of 2231 GNHIES98-DEGS1 participants aged 18-79 years without hypertension in 1998, 26.2% developed hypertension within a mean of 11.9 (range 10.0-14.1) years (men 29.0%, women 23.4%). In univariate analysis, hypertension incidence was positively associated with age, BMI, initial BP levels, pulse pressure, and alcohol consumption. Comorbidities such as diabetes and hyperlipidemia increased the chance to develop hypertension. In the multivariate model, initial SBP and DBP levels had the strongest influence on the development of future hypertension (7% increase in men and 5% in women per mmHg SBP). The percentage of aware, treated, and controlled hypertensive patients were 75.8, 62.1, and 50.3% in men and 83.8, 73.3, and 59.0% in women.

CONCLUSION

The high 11.9-year incidence in all age groups points to the lifelong potential for prevention of hypertension.

Seven-year longitudinal change in risk factors for non-communicable diseases in rural Kerala, India: The WHO STEPS approach

Nearly three-quarters of global deaths from non-communicable diseases (NCDs) occur in low- and middle-income countries such as India. However, there are few data available on longitudinal change in risk factors for NCDs in India. We conducted a cohort study among 495 individuals (aged 15 to 64 years at baseline) in rural Kerala state, India, from 2003 to 2010. For the present analysis, data from 410 adults (aged 20 to 64 years at baseline) who participated at both baseline and follow-up studies were analyzed. We used the World Health Organization STEPwise approach to risk factor surveillance for data collection. Age-adjusted change in risk factors for NCDs was assessed using the mixed-effects linear regression for continuous variables and the generalized estimating equation for categorical variables. The mean age of participants at baseline was 41.6 years, and 53.9% were women. The mean follow-up period was 7.1 years. There were significant increases in weight (mean change +5.0 kg, 95% confidence interval [CI] 4.2 to 5.8), body mass index (mean change +1.8 kg/m2, 95% CI 1.5 to 2.1), waist circumference (mean change +3.9 cm, 95% CI 3.0 to 4.8), waist-to-height ratio (mean change +0.022, 95% CI 0.016 to 0.027), current smokeless tobacco use (men: odds ratio [OR] 1.6, 95% CI 1.1 to 2.2), alcohol use (men: OR 2.6, 95% CI 1.9 to 3.5; women: OR 4.8, 95% CI 1.8 to 12.6), physical inactivity (OR 2.0, 95% CI 1.3 to 3.0), obesity (OR 2.2, 95% CI 1.7 to 2.8), and central obesity (OR 1.9, 95% CI 1.5 to 2.3). Over a seven-year period, several NCD risk factors have increased in the study cohort. This calls for implementation of lifestyle intervention programs in rural Kerala.

Enhancing an International Perspective in Public Health Teaching through Formalized University Partnerships

Teaching in the field of public health needs to employ a global perspective to account for the fact that public health problems and solutions have global determinants and implications as well. International university partnerships can promote such a perspective through the strengthening of cooperation, exchange, and communication between academic institutions across national boundaries. As an example for such an academic network in the field of public health, we introduce the International Public Health Partnership-a collaboration between a university in Germany and universities in India, Turkey, and Nigeria. Formed in 2005, it facilitated the exchange of information, fostered discussion about the transferability of public health concepts, contributed to the structural development of the universities involved, and promoted an intercultural dialog through a combination of local and distance learning activities. Although well accepted by students and staff, different obstacles were encountered; these included limited external funding, scarce own financial, time and personnel resources, and diverging regulations and structures of degree programs at the partnership sites. In the present article, we share several lessons that we learned during our joint collaboration and provide recommendations for other universities that are involved in partnerships with institutions of higher education or are interested to initiate such collaborations.

Prevalence of Hypertension and Associated Risk Factors among Rural Bapedi Women in Sekhukhune Area, Limpopo Province, South Africa

The study investigated the prevalence of hypertension and identified risk factors in the Bapedi women of Sekhukhune area. Fifty (50) women diagnosed with hypertension and receiving treatment from local clinics were recruited. Questionnaires and focus group discussions were used. Most participants were at the average age of 50.50 ± 7.93 years and weight of 81.17 ± 9.96 kg. Blood pressure measurements recorded were systolic blood pressure (SBP) 163 ± 22.41 mmHg and diastolic blood pressure (DBP) 91 ± 5.41 mmHg. An insignificant number of participants had smoking or drinking habits (0% and 2%, respectively). The largest group of women (46%) had primary level of education, 14% completed junior secondary education, 6% completed matric, and 2% had basic education. All women consumed cereal; a large number of women (50%) consumed oils and fats; 44% flesh meats; 30% fruits and vegetables; 26% tubers and roots; 22% organ meats; 10% fish, 10% eggs, and 8% milk. Results showed a high prevalence of hypertension in the Bapedi women in the Sekhukhune area. Changes in diet and lifestyle could significantly improve the health of most women in the area.

Sex differences in the risk profile of hypertension: a cross-sectional study

OBJECTIVE

To assess the socioeconomic and behavioural risk factors associated with hypertension among a sample male and female population in India.

SETTING

Cross-sectional survey data from a Health and Demographic Surveillance System (HDSS) of rural West Bengal, India was used.

PARTICIPANTS

27 589 adult individuals (13 994 males and 13 595 females), aged ≥18 years, were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hypertension was defined as mean systolic blood pressure (SBP) ≥140 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg, or if the subject was undergoing regular antihypertensive therapy. Prehypertension was defined as SBP 120-139 mm Hg and DBP 80-89 mm Hg. Individuals were categorised as non-normotensives, which includes both the prehypertensives and hypertensives. Generalised ordered logit model (GOLM) was deployed to fulfil the study objective.

RESULTS

Over 39% of the men and 25% of the women were prehypertensives. Almost 12.5% of the men and 11.3% of the women were diagnosed as hypertensives. Women were less likely to be non-normotensive compared to males. Odds ratios estimated from GOLM indicate that women were less likely to be hypertensive or prehypertensive, and age (OR 1.04, 95% CI 1.03 to 1.05; and OR 1.08, 95% CI 1.07 to 1.09 for males and females, respectively) and body mass index (OR 1.64, 95% CI 1.38 to 1.97 for males; and OR 1.32, 95% CI 1.08 to 1.60 for females) are associated with hypertension.

CONCLUSIONS

An elevated level of hypertension exists among a select group of the rural Indian population. Focusing on men, an intervention could be designed for lifestyle modification to curb the prevalence of hypertension.

Patterns and predictors of undiagnosed and uncontrolled hypertension: observations from a poor-resource setting

Early detection is the cornerstone of hypertension management; still majority remains undetected until complications arise, especially in poor-resource settings. Paucity of information regarding undiagnosed and uncontrolled hypertension in eastern India thus called for a detailed investigation involving a representative sample of adults in Malda, one of the poorest districts in the region. In a cross-sectional study, between October 2013 and July 2014, using multistage random sampling with probability-proportional-to-size, 18 028 consenting adults were interviewed. Diagnosed cases were defined as uncontrolled if they still had hypertensive level of blood pressure (according to JNC-VIII criteria) while those detected during this study were defined as undiagnosed. Descriptive and regression analyses were performed using SAS version 9.3.2. Among 18 028 participants, 4695 (26.04% (95% confidence intervals: 95% CI=25.40-26.68)) had hypertension, of which 3937 (83.86% (82.80-84.91)) were undiagnosed and 548 (72.30 (69.10-75.49)) had uncontrolled hypertension. Relatively older subjects (adjusted Odds ratio (aOR)_{41-60 years}=0.34 (95% CI=0.26-0.43) and aOR_{>60 years}=0.29 (0.21-0.38)), who were divorced/separated/widowed/widower (aOR=0.76 (0.61-0.95)), had higher education (aOR=0.61 (0.43-0.88)), better socio-economic status (SES) (aOR_Middle=0.77 (0.60-0.99) and aOR_Upper=0.64 (0.48-0.85)) and urban residence (aOR=0.44 (0.36-0.55)) were less likely while subjects who belonged to backward castes (aOR=1.37 (1.15-1.64)) were more likely to have undiagnosed hypertension. Odds of having uncontrolled hypertension were higher among participants aged >60 years (aOR=2.25 (1.27-3.99)). Burden of hypertension (diagnosed and undiagnosed) was high in Malda district of West Bengal. Significant predictors of undiagnosed hypertension were young age, backward caste, poor education and lower SES, while older subjects had poor control. Thus, appropriate surveillance targeting these at-risk groups might be effective in controlling hypertension in similar poor-resource settings.

A Risk Score to Predict Hypertension in Primary Care Settings in Rural India

We used the data of 297 participants (15-64 years old) from a cohort study (2003-2010) who were free from hypertension at baseline, to develop a risk score to predict hypertension by primary health care workers in rural India. Age ≥35 years, current smoking, prehypertension, and central obesity were significantly associated with incident hypertension. The optimal cutoff value of ≥3 had a sensitivity of 78.6%, specificity of 65.2%, positive predictive value of 41.1%, and negative predictive value of 90.8%. The area under the receiver operating characteristic curve of the risk score was 0.802 (95% confidence interval = 0.748-0.856). This simple and easy to administer risk score could be used to predict hypertension in primary care settings in rural India.

Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension

Background:

A region-specific (urban and rural parts of north, east, west, and south India) systematic review and meta-analysis of the prevalence, awareness, and control of hypertension among Indian patients have not been done before.

Methods:

Medline, Web of Science, and Scopus databases from 1950 to 30 April 2013 were searched for ‘prevalence, burden, awareness, and control of blood pressure (BP) or hypertension (≥140 SBP and or ≥90 DBP) among Indian adults’ (≥18 years). Of the total 3047 articles, 142 were included.

Results:

Overall prevalence for hypertension in India was 29.8% (95% confidence interval: 26.7–33.0). Significant differences in hypertension prevalence were noted between rural and urban parts [27.6% (23.2–32.0) and 33.8% (29.7–37.8); P = 0.05]. Regional estimates for the prevalence of hypertension were as follows: 14.5% (13.3–15.7), 31.7% (30.2–33.3), 18.1% (16.9–19.2), and 21.1% (20.1–22.0) for rural north, east, west, and south India; and 28.8% (26.9–30.8), 34.5% (32.6–36.5), 35.8% (35.2–36.5), and 31.8% (30.4–33.1) for urban north, east, west, and south India, respectively. Overall estimates for the prevalence of awareness, treatment, and control of BP were 25.3% (21.4–29.3), 25.1% (17.0–33.1), and 10.7% (6.5–15.0) for rural Indians; and 42.0% (35.2–48.9), 37.6% (24.0–51.2), and 20.2% (11.6–28.7) for urban Indians.

Conclusion:

About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for hypertension. One-tenth of rural and one-fifth of urban Indian hypertensive population have their BP under control.

Evaluation of effectiveness and cost-effectiveness of a clinical decision support system in managing hypertension in resource constrained primary health care settings: results from a cluster randomized trial

Background

Randomized control trials from the developed world report that clinical decision support systems (DSS) could provide an effective means to improve the management of hypertension (HTN). However, evidence from developing countries in this regard is rather limited, and there is a need to assess the impact of a clinical DSS on managing HTN in primary health care center (PHC) settings.

Methods and Results

We performed a cluster randomized trial to test the effectiveness and cost‐effectiveness of a clinical DSS among Indian adult hypertensive patients (between 35 and 64 years of age), wherein 16 PHC clusters from a district of Telangana state, India, were randomized to receive either a DSS or a chart‐based support (CBS) system. Each intervention arm had 8 PHC clusters, with a mean of 102 hypertensive patients per cluster (n=845 in DSS and 783 in CBS groups). Mean change in systolic blood pressure (SBP) from baseline to 12 months was the primary endpoint. The mean difference in SBP change from baseline between the DSS and CBS at the 12th month of follow‐up, adjusted for age, sex, height, waist, body mass index, alcohol consumption, vegetable intake, pickle intake, and baseline differences in blood pressure, was −6.59 mm Hg (95% confidence interval: −12.18 to −1.42; P=0.021). The cost‐effective ratio for CBS and DSS groups was $96.01 and $36.57 per mm of SBP reduction, respectively.

Conclusion

Clinical DSS are effective and cost‐effective in the management of HTN in resource‐constrained PHC settings.

Clinical Trial Registration

URL: http://www.ctri.nic.in. Unique identifier: CTRI/2012/03/002476.

The cumulative incidence of conventional risk factors of cardiovascular disease and their population attributable risk in an Iranian population: The Isfahan Cohort Study

Background:

Cardiovascular diseases (CVDs) are the leading cause of death in Iran. The present study evaluated the 7-year incidence of CVD risk factors among the participants of Isfahan cohort study (ICS).

Materials and Methods:

ICS was a longitudinal study on adults over 35 years of age from the urban and rural areas in three counties in central Iran. Data on clinical examination and blood measurements were collected in 2001. Subjects were followed and similar data were collected in 2007. Cumulative incidence was calculated through dividing new cases of each risk factor by the population free of that risk factor at baseline. Incidence proportion was determined for major CVD risk factors including hypertension (HTN), hypercholesterolemia (HC), hypertriglyceridemia (HTg), obesity, diabetes mellitus (DM), metabolic syndrome (MetS), and smoking.

Results:

A total number of 6323 adults free of CVDs were recruited. After 7 years of follow-up, 3283 individuals were re-evaluated in 2007. The participants’ age was 49.2 ± 10.3 years in 2001 (mean ± SD). The 7-year cumulative incidence of HTN, HC, HTg, overweight, obesity, DM, MetS, and smoking was 22.8%, 37.4%, 28.0%, 26.3%, 7.4%, 9.5%, 23.9%, and 5.9% in men and 22.2%, 55.4%, 33.5%, 35.0%, 18.8%, 11.3%, 36.1%, and 0.7% in women, respectively. Among those with overweight or obesity, 14.7% of men and 7.9% of women decreased their weight up to the normal level.

Conclusions:

The present study revealed a high incidence of CVD risk factors especially dyslipidemia, obesity, MetS and HTN. Therefore, the application of life-style modification interventions seems necessary.

Screening for hypertension among adults: community outreach in Cairo, Egypt

BACKGROUND

Studies have shown alarming levels of hypertension among adults in the Middle East. The aim of our study is to measure the prevalence rate of hypertension among adults in Cairo (Egypt), identify possible risk factors for the development of hypertension and assess the rates of undiagnosed and uncontrolled hypertension.

METHODS

Cluster sampling was utilized and the fieldwork was conducted by 12 teams; each team consisted of a house officer, community worker and senior epidemiologist. A formulated questionnaire that addresses risk factors for hypertension was filled by all participants. Also, weight and height measurements were done to calculate the body mass index. Blood pressure measurement was done by calibrated sphygmomanometers. Blood pressure measurement was done twice, and a mean recording was calculated. A case which recorded both systolic blood pressure of ≥140 and diastolic blood pressure of ≥90 was considered hypertensive.

RESULTS

The study included 774 adult residents of Al-Waily District (Western Zone of Cairo) in late 2011 and early 2012. The mean age of the study participants was 46.5 (SD 17.9) years. Female subjects constituted 67.1% of the studied sample. The prevalence rate of hypertension in our study was 16.5% (95% confidence interval (CI): 13.9-19.3). The rate of hypertension was higher among females and three times higher among obese compared with normal or overweight adults. The prevalence of undiagnosed hypertension was 11% (95% CI: 8.4-13.9), and uncontrolled hypertension was 30% (95% CI: 24.2-37).

CONCLUSIONS

Community outreach campaigns should be conducted regularly in the future for early detection of hypertension cases and proper health education about hypertension and its dangerous consequences.

Prevalence and Risk Factors of Hypertension among Male Occupational Bus Drivers in North Kerala, South India: A Cross-Sectional Study

Background. Hypertension is a leading cause of morbidity and mortality worldwide. We aimed to evaluate the prevalence of hypertension in a population of male bus drivers in North Kerala, India. Methods. The study population included male bus drivers of Corporation Bus stand Kozhikode, Kerala. Blood pressure, height, and weight of subjects were measured, and relevance was obtained using a structured questionnaire. Results. Age varied from 21 to 60 years (mean 36.5 ± 8.4). Among 179 bus drivers studied, 16.8% (30/179) had normal BP, 41.9% (75/179) had prehypertension, and 41.3% (74/179) had hypertension. Isolated systolic HTN was seen in 6.70% (12/179) individuals. Out of 74 hypertensives, 9 (12.1%) were aware of their hypertension, while 3 (4.0%) were medicated and only 1 (1.3%) had BP adequately controlled. Age > 35 years (P = 0.015), BMI ≥ 23 kg/m² (P = 0.007), supporting more than four family members (P = 0.011), and taking main meals from restaurants on most working days (P = 0.017) were independently associated with HTN in binary logistic regression. Conclusion. Prevalence of hypertension was high among bus drivers. Age > 35 years, elevated BMI, supporting a large family, and dietary habits associated with the job showed significant association with hypertension. Primary and secondary prevention strategies need to be emphasized in this occupational group.

Ethnic differences in the incidence of hypertension among rural Chinese adults: results from Liaoning Province

BACKGROUND

This study was conducted to examine the differences in the incidence of hypertension and associated risk factors between Mongolian and Han populations in northeast China.

METHODS

A population-based sample of 4753 Mongolian subjects and 20,247 Han subjects aged ≥ 35 years and free from hypertension at baseline were followed from 2004-2006 to 2010. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, or current use of antihypertensive medication.

RESULTS

During mean 4.3 years follow-up, a total of 8779 individuals developed hypertension. The age-adjusted incidence of hypertension for Mongolian subjects was 12.64 per 100 person-years, for Han subjects was 9.77 per 100 person-years (P<0.05). The incidence of hypertension was positively correlated with age, physical activity, drinking, body mass index (BMI), family of hypertension and prehypertension in the Han population. In the Mongolian population, hypertension was positively correlated with age, physical activity, education level, drinking, BMI, prehypertension and family history of hypertension. The rates of awareness, treatment and control of hypertension for newly developed cases among both Han and Mongolian populations were low. (36.5% vs. 42.3%, 13.1% vs. 18.2%, 0.7% vs. 1.3%, P<0.05, respectively).

CONCLUSIONS

The incidence rate of hypertension is higher in the Mongolian populations than that in the Han populations, and hypertension in both ethnic populations was associated with similar risk factors. Our results suggest that most newly-diagnosed cases of hypertension are not adequately treated. Improvements in hypertension prevention and control programs in rural China are urgently needed.

Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program

BACKGROUND

India currently has more than 60 million people with Type 2 Diabetes Mellitus (T2DM) and this is predicted to increase by nearly two-thirds by 2030. While management of those with T2DM is important, preventing or delaying the onset of the disease, especially in those individuals at 'high risk' of developing T2DM, is urgently needed, particularly in resource-constrained settings. This paper describes the protocol for a cluster randomised controlled trial of a peer-led lifestyle intervention program to prevent diabetes in Kerala, India.

METHODS/DESIGN

A total of 60 polling booths are randomised to the intervention arm or control arm in rural Kerala, India. Data collection is conducted in two steps. Step 1 (Home screening): Participants aged 30-60 years are administered a screening questionnaire. Those having no history of T2DM and other chronic illnesses with an Indian Diabetes Risk Score value of ≥60 are invited to attend a mobile clinic (Step 2). At the mobile clinic, participants complete questionnaires, undergo physical measurements, and provide blood samples for biochemical analysis. Participants identified with T2DM at Step 2 are excluded from further study participation. Participants in the control arm are provided with a health education booklet containing information on symptoms, complications, and risk factors of T2DM with the recommended levels for primary prevention. Participants in the intervention arm receive: (1) eleven peer-led small group sessions to motivate, guide and support in planning, initiation and maintenance of lifestyle changes; (2) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors, prevention and management; (3) a participant handbook containing information primarily on peer support and its role in assisting with lifestyle modification; (4) a participant workbook to guide self-monitoring of lifestyle behaviours, goal setting and goal review; (5) the health education booklet that is given to the control arm. Follow-up assessments are conducted at 12 and 24 months. The primary outcome is incidence of T2DM. Secondary outcomes include behavioural, psychosocial, clinical, and biochemical measures. An economic evaluation is planned.

DISCUSSION

Results from this trial will contribute to improved policy and practice regarding lifestyle intervention programs to prevent diabetes in India and other resource-constrained settings.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909.

Screening performance of diabetes risk scores among Asians and whites in rural Kerala, India

We compared the screening performance of risk scores for Asians and whites for diabetes, dysglycemia, and metabolic syndrome. Our subjects were 451 people aged 15 to 64 years who participated in a cohort study from May 2003 through September 2010 in a rural area of the Thiruvananthapuram district of Kerala, India. All outcome measures showed overlap in the range of area under the receiver operating characteristic curves of Asian and white diabetes risk scores (DRSs). Asian and white DRSs performed similarly in rural India.

Impact of a community based intervention program on awareness, treatment and control of hypertension in a rural Panchayat, Kerala, India

OBJECTIVE

Community based intervention to control hypertension is extremely limited in India. We conducted this study to find the effectiveness of a community based intervention program on the awareness, treatment and control of hypertension.

METHODS

A baseline survey was conducted among 4627 adults aged ≥30 years (men 44%) selected by cluster sampling. Information was collected using a structured interview schedule by trained local volunteers. They measured weight, height, waist circumference and blood pressure using standard protocol. The volunteers monitored blood pressure at least once a month and educated the people in neighborhood groups on the need for regular medication and reducing risk factors of hypertension for a period of six years. A post intervention survey was conducted among 2263 adults aged ≥30 years (men 49%). Stepwise logistic regression analysis was done to find the odds of change in awareness, treatment and control of hypertension.

RESULTS

The odds of awareness (OR 4.18, 95% CI 3.44-5.08), treatment (OR 3.44 CI 2.81-4.22) and control (OR 4.39 CI 3.36-5.73) of hypertension increased significantly in the post intervention survey compared to the baseline survey. Baseline hypertension prevalence of 34.9% (CI 33.8-36.1) was reduced to 31.0% (CI 29.1-32.9) in the post intervention survey based on age adjusted analysis.

CONCLUSION

Our community based intervention using trained community based volunteers could increase awareness, treatment and control of hypertension among adult hypertensives.

Incidence of tobacco use among adults (15-64 years) in rural Kerala

We analyzed data from a cohort study in rural Kerala, India, to study the incidence of current smoking and current smokeless tobacco use. At baseline, of 452 individuals aged 15 to 64 years, 385 were current nonsmokers and 402 were current nonusers of smokeless tobacco. Over a mean follow-up of 7.1 ± 0.2 years, 5.5% became current smokers and 9.0% became current smokeless tobacco users. Among men, 21.1% (95% confidence interval [CI] = 11.1-36.4) of younger individuals (15-24 years) became current smokers and 22.2% (CI = 10.6-40.8) of older individuals (55-64 years) became current smokeless tobacco users. No women smoked both at baseline and at follow-up, but 9.7% (CI = 3.4-24.9) of older women (55-64 years) became current smokeless tobacco users. These findings call for effective implementation of India's Cigarettes and Other Tobacco Products Act, 2003.

Achutha Menon Centre Diabetes Risk Score: a type 2 diabetes screening tool for primary health care providers in rural India

The authors aimed to develop a diabetes risk score for primary care providers in rural India. They used the baseline data of 451 participants (15-64 years) of a cohort study in a rural area of Kerala, India. The new risk score with age, family history of diabetes, and waist circumference identified 40.8% for confirmatory testing, had a sensitivity of 81.0%, specificity of 68.4%, positive predictive value of 37.0%, and negative predictive value of 94.0% for an optimal cutoff ≥4 with an area under the receiver operating characteristic curve of 0.812 (95% confidence interval = 0.765-0.860). The new risk score with 3 simple, easy-to-measure, less time-consuming, and less expensive variables could be suitable for use in primary care settings of rural India.

"Health divide" between indigenous and non-indigenous populations in Kerala, India: population based study

Background

The objective of this study is to investigate the magnitude and nature of health inequalities between indigenous (Scheduled Tribes) and non-indigenous populations, as well as between different indigenous groups, in a rural district of Kerala State, India.

Methods

A health survey was carried out in a rural community (N = 1660 men and women, 18–96 years). Age- and sex-standardised prevalence of underweight (BMI < 18.5 kg/m²), anaemia, goitre, suspected tuberculosis and hypertension was compared across forward castes, other backward classes and tribal populations. Multi-level weighted logistic regression models were used to estimate the predicted prevalence of morbidity for each age and social group. A Blinder-Oaxaca decomposition was used to further explore the health gap between tribes and non-tribes, and between subgroups of tribes.

Results

Social stratification remains a strong determinant of health in the progressive social policy environment of Kerala. The tribal groups are bearing a higher burden of underweight (46.1 vs. 24.3%), anaemia (9.9 vs. 3.5%) and goitre (8.5 vs. 3.6%) compared to non-tribes, but have similar levels of tuberculosis (21.4 vs. 20.4%) and hypertension (23.5 vs. 20.1%). Significant health inequalities also exist within tribal populations; the Paniya have higher levels of underweight (54.8 vs. 40.7%) and anaemia (17.2 vs. 5.7%) than other Scheduled Tribes. The social gradient in health is evident in each age group, with the exception of hypertension. The predicted prevalence of underweight is 31 and 13 percentage points higher for Paniya and other Scheduled Tribe members, respectively, compared to Forward Caste members 18–30 y (27.1%). Higher hypertension is only evident among Paniya adults 18–30 y (10 percentage points higher than Forward Caste adults of the same age group (5.4%)). The decomposition analysis shows that poverty and other determinants of health only explain 51% and 42% of the health gap between tribes and non-tribes for underweight and goitre, respectively.

Conclusions

Policies and programmes designed to benefit the Scheduled Tribes need to promote their well-being in general but also target the specific needs of the most vulnerable indigenous groups. There is a need to enhance the capacity of the disadvantaged to equally take advantage of health opportunities.