Prevalence of diagnosed and undiagnosed diabetes and hypertension in India--results from the Screening India's Twin Epidemic (SITE) study

Unmasking the silent epidemic: a comprehensive systematic review and meta-analysis of undiagnosed diabetes in Ethiopian adults

Background

Undiagnosed diabetes mellitus poses a significant global public health concern, exerting a substantial impact on the well-being of individuals, their families, and societies at large. Those individuals with undiagnosed diabetes miss opportunities to maintain quality of life and prevent diabetes-related complications. Even if there are ample primary studies on undiagnosed diabetes in Ethiopia, the results reveal conflicting results. Therefore, a comprehensive national picture of undiagnosed diabetes is essential for designing effective strategies at the national level.

Methods

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for prevalence studies (PROSPERO ID: CRD42021266676). PubMed, Web of Science and the World Health Organization's Hinari portal were searched using a strategy developed in collaboration with Liberians. The inclusion criteria comprised studies reporting undiagnosed diabetes in Ethiopia. Two independent reviewers conducted a quality assessment using a 10-item appraisal tool. Meta-analysis and meta-regression were performed using a random-effects model.

Result

Twenty-five studies with 22,193 participants met the inclusion criteria. The pooled prevalence of undiagnosed diabetes among the Ethiopian adult population was 5.68% (95% CI: 4.53 - 6.83, I2 = 75.4). Factors significantly associated with undiagnosed diabetes include age, waist circumference, overweight, family history of diabetes, and a history of hypertension.

Conclusion

Our systematic review found a noteworthy prevalence of undiagnosed diabetes in Ethiopia. The majority of factors linked with undiagnosed diabetes in this review were modifiable. This underscores the importance of targeted factors and public health interventions to improve early detection and reduce the burden of undiagnosed diabetes and its complications in Ethiopia.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42021266676.

The worldwide trend in diabetes awareness, treatment, and control from 1985 to 2022: a systematic review and meta-analysis of 233 population-representative studies

Background

With the rapid increase in the prevalence of DM, studies on the awareness, treatment, and control of this condition are essential. Therefore, this study aimed to review the literature and pool the awareness, treatment, and control of diabetes at the global, regional, and national levels.

Methods

In this systematic review and meta-analysis, several databases, including MEDLINE/PubMed, Institute of Scientific Information (ISI), Scopus, and Google Scholar, were searched using appropriate keywords up to June 2022. Observational studies investigating the awareness, treatment, and control of glucose levels among diabetic individuals were included. Awareness, treatment, and control were defined as the proportion of participants who were aware of their diabetes condition, treated pharmacologically, and achieved adequate glucose control, respectively. Two investigators independently conducted the study selection, data extraction, and quality assessment. Heterogeneity among studies was calculated using Chi-square, and a random-effect meta-analysis was used to pool the rates.

Results

A total of 233 studies published between 1985 and 2022 met the inclusion criteria. The included studies had a combined population of 12,537,968. The pooled awareness of DM was 60% (95%CI: 56-63) and ranged from 41% (25-57) in low-income countries to 68% (64-72) in high-income countries, with no significant trend observed over the assessed periods at the global level. The pooled treatment of DM globally was 45% (42-48) and varied from 37% (31-43) in lower-middle-income countries to 53% (47-59) in high-income countries, showing variation over the examined time period. Before 2000, the proportion of adequate DM control was 16% (12-20), which significantly improved and reached 22% (19-25) after 2010. The pooled awareness, treatment, and control of DM were higher in females, high-income countries, and urban areas compared to males, upper and lower-middle-income countries, and rural areas, respectively. The older adults population had higher awareness and treatment rates than the adult population, but their DM control did not differ significantly.

Conclusion

Despite the high level of awareness and treatment among the diabetic population, treatment success (control) is considerably low, particularly in low-income countries and rural areas. It is crucial to improve awareness, treatment, and control by strengthening the primary care system in all countries.

Primary health care in practice: usual source of care and health system performance across 14 countries

Primary health care (PHC) is central to attainment of the Sustainable Development Goals, yet comparable cross-country data on key aspects of primary care have not been widely available. This study analysed data from the People's Voice Survey, which was conducted in 2022 and 2023 in 14 countries. We documented usual source of care across countries and examined associations of usual source of care with core PHC services, quality ratings, and health system confidence. We found that 75% of respondents had a usual source of care, and that 40% of respondents accessed usual care in the public sector at primary level. 44% rated their usual source of care as very good or excellent. Access to PHC-linked screenings and treatments varied widely within and across countries. Having any usual source of care was associated with higher take-up of preventive services, greater access to treatment including mental health services, and greater health system endorsement. Strengthening links between health system users and primary care providers could improve take-up of preventive care and increase user satisfaction with health system performance.

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.

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 hypertension and determinants of treatment-seeking behaviour among adolescents and young adults in India: an analysis of NFHS-4

BACKGROUND

Previous evidences have reported that almost three-fourth of young hypertensives are not seeking care for their condition leading to severe complications. This study was conducted to assess the determinants of treatment-seeking behaviour among the young hypertensives in India.

METHODS

The National Family Health Survey-4 data were analysed. Sampling weights and clustering was accounted using svyset command. Screening, awareness, prevalence and control status were reported with 95% confidence interval (CI). Poisson regression was done to identify the determinants of treatment-seeking behaviour.

RESULTS

In total, 13.8% of younger adults had hypertension, 51.1% were aware of their status and 19.5% sought treatment. Participants in 15-19 years (adjusted Prevalence Ratio (aPR) = 0.70) and 20-29 years (aPR = 0.63), male gender (aPR = 0.84), Muslim religion (aPR = 1.14), urban region (aPR = 0.87), secondary (aPR = 0.88) and higher education (aPR = 0.86), residing in Northern (aPR = 0.79), Central (aPR = 0.76), Southern region (aPR = 0.65), preferring home treatment, medical shop or any other care (aPR = 0.63) were significant determinants of treatment-seeking behaviour.

CONCLUSION

More than 1 in 10 younger adults in India have hypertension and only half of them were aware of their status and one-fifth sought treatment. Adolescents, males, Hindus, urban population, higher education and residing in Northern, Central and Southern region had poor treatment-seeking behaviour.

Risk factors for cardiovascular disease in a healthy young population: Family matters

Background

India faces an epidemic of cardiovascular disease (CVD). This study sought the effect of family history of CVD and/or its risk factors (CVD-risk) on the presence of risk factors for CVD, in a healthy young college population.

Methods

Blood pressure (BP), heart rate (HR), anthropometric variables, fasting blood sugar and lipid fractions were measured in two hundred healthy individuals (163 men and 37 women), aged 17-22 years. Data were analysed to elicit effect of CVD-risk on measured parameters.

Results

All but one subject, had family history of a CVD-risk. Men with family history of coronary heart disease had higher diastolic BP (79.24 ± 7.7 vs 75.99 ± 7.49 mmHg, p = 0.007) and triglycerides (118.66 ± 57.98 vs 85.82 ± 50.89 mg/dL, p < 0.0001) compared with those without similar family history. Men with family history of hypertension (HTN) had higher diastolic BP (78.75 ± 7.15 vs 75.84 ± 8.37 mmHg, p = 0.019) and low-density lipoprotein (86.24 ± 25.38 vs 78.21 ± 17.93 mg/dL, p = 0.019), as well as lower high-density lipoprotein (50.27 ± 8.4 vs 53.96 ± 10.38 mg/dL, p = 0.019). Women with family history of diabetes mellitus had lower high-density lipoproteins (49.89 ± 8.05 vs 59.53 ± 11.44, p = 0.006). Family history of dyslipidaemia was associated with significantly higher triglycerides (146.14 ± 46.19 vs 98.44 ± 56.19 mg/dL, p = 0.002) in men and in subjects across sex. HDL was contrarily higher, in women with family history of cerebrovascular accident/HTN and men with family history of coronary heart disease/HTN. The proportion of pre-HTN, overweight/obese, impaired fasting glucose and borderline high triglycerides was 88.3%, 36.8%, 11% and 38.7% in men and 64.9%, 37.8%, 18.9% and 48.7% in female subjects.

Conclusion

Young adults with a family history of CVD-risk already have an incomplete/atypical CVD risk profile.

BMI mediates the association of family medical history with self-reported hypertension and diabetes among older adults: Evidence from baseline wave of the longitudinal aging study in India

Background

This study explored the association between family history of hypertension and diabetes with their diagnosis among older Indian adults. The study further examined the role of body mass index (BMI) as a potential mediator in these associations.

Methods

Data from the Longitudinal Ageing Study in India (LASI, 2017-18), wave-1 were used. The sample for the study included 31,464 older adults aged 60 years and above. Descriptive statistics and bivariate analysis has been conducted to assess the prevalence of self-reported hypertension and diabetes. Further, multivariable logistic regression models were used to test the research hypotheses of this study. The Karlson-Holm-Breen (KHB) mediation analysis was conducted to recover the direct and indirect effects of BMI in the association of family medical history and diagnosis of hypertension and diabetes.

Results

A proportion of 32.70% of older adults were diagnosed with hypertension and 14.23% of older adults were diagnosed with diabetes. A proportion of 19.48% and 14.69% of older adults had a family history of hypertension and diabetes, respectively. Also, 16.57% and 5.53% of older adults were overweight and obese, respectively in the current study. Older adults who had family history of hypertension had higher odds of being diagnosed with hypertension [aOR: 2.23, CI: 2.07-2.39] than those who had no such family history. This association was mediated by BMI (percent mediated: 6.31%). Similarly, older adults who had family history of diabetes had higher odds of being diagnosed with diabetes [aOR: 2.63, CI: 2.41-2.88] than those who had no such family history. This association was mediated by BMI (percent effect mediated: 6.66%).

Conclusion

The study highlights the relevance of using family medical history data along with information on BMI as potential source for the control and management of hypertension and diabetes among older population.

Prevalence, Awareness, Treatment, and Control of Hypertension in Young Adults (20-39 Years) in Kerala, South India

Objective

We sought to study the prevalence of hypertension and the levels of awareness, treatment and control of hypertension in the young adults in Kerala, India compared to older adults.

Methods

We identified 1,221 young adults (men 36.7%) in the age group 20-39 years from the 5,150 participants of the Cardiological Society of India Kerala Coronary artery disease (CAD) and its Risk factors Prevalence (CSI Kerala CRP) Study. We determined prevalence and levels of awareness, treatment and control of hypertension among them compared to older adults.

Results

We found that among the young adults, 11.2% had hypertension and 33.3% had prehypertension. Hypertension was nearly three times more prevalent among men than women (20.5 vs. 7.5% p < 0.001) while in older adults there was no difference between men and women in its prevalence. Male sex (OR 3.36, 95% CI 2.15-5.25 p-value <0.001), urban residence (OR 2.21, 95% CI 1.52-3.22 p-value <0.001), abdominal obesity (OR 1.74, 95% CI 1.06-2.87 p-value 0.028) and hypercholesterolemia (OR 1.64 95% CI 1.12-2.40 p-value 0.011) were significant factors favoring hypertension in the young adults. Awareness and treatment of hypertension were significantly poor among younger adults compared to older adults. In young adults, awareness, treatment and control of hypertension were significantly lower among men compared to women (23.9 vs. 51.7% p-value 0.001, 12.0 vs. 25.9% p-value 0.045, and 18.5 vs. 37.9% p-value 0.012, respectively). Participants who had checked blood pressure at least once during the previous year had significantly better awareness and treatment (58.7 vs. 24.0% and 41.3 vs. 19.2%, respectively).

Conclusions

We found that one eighth of young subjects had hypertension with three times higher prevalence of hypertension among men compared to women. Awareness, treatment and control of hypertension were less among young adults and worse in young men compared to young women. Identifying hypertension and measures to control it are important and should be specifically targeted to young men.

Uncontrolled Blood Pressure and Associated Factors Among Persons With Diabetes: A Community Based Study From Kerala, India

The coexistence of raised blood pressure (BP) in people with type 2 diabetes mellitus (T2DM) is a major contributor to the development and progression of both macrovascular and microvascular complications. The aim of our study was to determine the prevalence of uncontrolled BP and its associated factors in persons with T2DM in a district in Kerala.

Effect of internal migration on diabetes and metabolic abnormalities in India - The ICMR-INDIAB study

AIMS

To assess the effect of migration (rural-to-urban and vice versa) on prevalence of diabetes and metabolic disorders in Asian Indians participating in the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study.

MATERIALS AND METHODS

The ICMR-INDIAB study is a national study on diabetes and associated cardiometabolic disorders in individuals aged ≥20 years from 28 states and 2 union territories of India. Individuals who moved to a different place from their place of birth and had resided in the new location for at least one year were considered as migrants. Anthropometric measurements, blood pressure estimation and a capillary oral glucose tolerance test were performed.

RESULTS

Of the 113,043 participants, 66.4% were non-migrant rural dwellers, 19.4% non-migrant urban dwellers, 8.4% rural-urban migrants, 3.8% multiple migrants and 2.0% urban-rural migrants. Weighted prevalence of diabetes was highest in rural-urban migrants followed by urban dwellers, urban-rural migrants and rural dwellers [14.7%, 13.2%, 12.7% and 7.7% respectively (p < 0.001)]. Rural-urban migrants had highest prevalence of abdominal obesity (50.5%) compared to the other three groups. The risk for diabetes was 1.9 times higher in rural-urban migrants than among rural dwellers. Five risk factors [hypertension, abdominal and generalized obesity, physical inactivity and low fruit and vegetable intake] together explained 69.8% (partial population attributable risk) of diabetes among rural-urban migrants and 66.4% among non-migrant urban dwellers.

CONCLUSIONS

Rural-to-urban migration is associated with increased risk of developing diabetes and other cardiometabolic abnormalities. Adoption of healthier lifestyle patterns among migrants could help prevent/delay onset of these abnormalities in this population.

Health capacity building for middle-aged Laotian women with a risk of metabolic syndrome through a non-communicable disease prevention program

The aims of the researchers were to develop an NCD prevention program including training for professionals who implement such programs, and to evaluate its effects on diabetes mellitus knowledge, hypertension knowledge, self-efficacy, and self-care in community-dwelling, middle-aged Laotian women. The study design was a randomized controlled trial. The study sample was composed of Laotian women aged 40 to 59 years living in Vientiane, Laos who fulfilled more than one diagnostic criterion for metabolic syndrome. This study provides a guide for low- and middle-income countries to develop future health capacity building programs for NCD prevention in middle-aged women.

Understanding the disproportionate effects of COVID-19 on nurses from ethnic minority backgrounds

People from ethnic minority backgrounds in the UK have been disproportionately affected by coronavirus disease 2019 (COVID-19), with higher death rates and suboptimal health outcomes compared with those from white ethnic backgrounds. This trend is reflected in healthcare staff from ethnic minority backgrounds, including nurses, who are disproportionately affected by COVID-19 and have higher death rates from the disease. The theory of intersectionality contends that social categorisations such as gender, race and class can contribute to discrimination and result in disadvantages. In this article, the authors outline several intersecting factors that could be contributing to the disproportionate effects of COVID-19 among nurses from ethnic minority backgrounds, as well as making recommendations for further research in this area.

Prevalence and trends of the diabetes epidemic in urban and rural India: A pooled systematic review and meta-analysis of 1.7 million adults

PURPOSE

India has experienced a recent sharp increase in diabetes/pre-diabetes. We conducted a systematic-review and meta-analyses to describe the most recent prevalence and trends of pre-diabetes/diabetes in urban and rural India.

METHODS

MethodsA literature search was conducted in PubMed and Scopus databases for population-based studies describing prevalence of diabetes/pre-diabetes in urban/rural populations. Trends were analysed in rural and urban settings overall, genderwise and statewise.

RESULTS

The study reports data from 1,778,706 adults in India (69-studies), from surveys conducted from 1972-2017. Prevalence of diabetes increased in both rural and urban India from 2.4% and 3.3% in 1972 to 15.0% and 19.0% respectively in year 2015-2019. This was independently observed in both genders. Similar increasing prevalence was observed for pre-diabetes, overall and in both genders. In the latest decade (2010-2019) rural and urban prevalence was highest in states of Goa (17.4%) and Tamil Nadu (24.0%) respectively. Statewise analysis observed a wide disparity in prevalence between the North and the South of India.

CONCLUSION

Pooled estimates show a relatively high burden of diabetes and pre-diabetes in rural and urban India, with narrowed urban-rural gap. Hence, it is important to plan urgent primary and secondary prevention strategies to minimize further increase in areas with high prevalence.

Risk Factors and Comorbidities in Young Indian Patients with Hypertension: REAL YOUNG (Hypertension) Study

Purpose

To analyze the risk factors and comorbidities among the young Indian adults with hypertension.

Patients and Methods

This was a retrospective, multicentric real-world study which included patients diagnosed with and receiving treatment for hypertension. Data were collected from the medical records of clinics/hospitals across 623 study sites in India. Patients of either sex and aged 18–45 years were included. Demographic details (age, sex, anthropometric measurement), medical and family history, sedentary lifestyle, smoking status and alcohol consumption data were extracted. Descriptive and comparative analysis (Mann–Whitney U and chi-squared test) was done.

Results

Out of 15,006 young patients diagnosed with hypertension (men=63.6%), 65.7% belonged to the age group of >35–45 years. The median body mass index was 27.0 kg/m². Patients diagnosed with only hypertension were 29.1% while other predominant comorbidities with hypertension were diabetes mellitus (42.4%) and dyslipidemia (7.8%). Hypertension with diabetes mellitus were prevalent in the age group of >35–45 years (43.8%). More than half of the patients with hypertension (n=7656) had a sedentary lifestyle. Overall, 35.6%, 47.3%, and 56.7% of the patients were alcoholic, smokers (present and former), and had a family history of hypertension, respectively.

Conclusion

The results showed that among the young population, hypertension was common in the age group of >35–45 years and diabetes mellitus and dyslipidemia were common comorbidities. Family history, sedentary lifestyle, smoking, alcohol consumption, and body mass index may also contribute to hypertension.

Tailoring Body Mass Index for Prediction of Obesity in Young Adults: A Multi-Centric Study on MBBS Students of Southeast India

INTRODUCTION

Body mass index (BMI) has been used for a long period as a surrogative measure for obesity. But BMI does not differentiate between fat and nonfat tissue (blood, bone, and muscle) due to which it is not considered accurate anymore. But since BMI is easier to estimate and used widely for assessment of obesity, it is better if it is re-standardized according to the body fat percentage (BFP) of a specific population, community, and their ethnicity.

OBJECTIVE

To estimate and propose the BMI cut-off values in young Indian population especially MBBS students taking BFP as a standard.

DESIGN

This is a cross-sectional study. Anthropometric data (age, gender, height, weight, waist circumference, and hip circumference) were collected from the participants after taking consent. BMI was calculated using Quetelet's Rule. BFP was estimated using Omron Body fat Monitor (HBF 385). It measures the BFP by the bioelectrical impedance (BI) method. Data were analyzed with appropriate statistical tests and receiver operating curve (ROC) curves were drawn to find the cut-off values of BMI to determine obesity.

SETTING

The present study is a multi-centric study conducted in four medical colleges (two in each state; Odisha and Andhra Pradesh, India).

PARTICIPANTS

Apparently healthy MBBS students aged 18-24 years were included in this study. Students having any chronic or acute illnesses were excluded from the study. Out of 904 students contacted from four medical colleges, 863 (430 males and 433 females) consented and participated.

RESULTS

Some 863 MBBS students have participated in this study. After adjusting for age, BMI was found to be higher in males. BMI was found to be 29.33 for males and in females it was 29.06. BFP was higher in females (34.23) as compared to males (20.77). Waist hip ratio was found to be higher in females (0.92) than in males (0.84). Whereas, fat free mass (FFM) and fat free mass index (FFMI) are higher in males, i.e., 56.24 and 18.48 respectively. Most appropriate cut-off value for obesity on ROC curve was found to be 22.09 (sensitivity 84.5%, specificity 83.46%) in males and that of females was 23.73 (sensitivity 85.26, specificity 81.23). Whereas, the conventional cut-off of 25 for males had sensitivity of only 46% and that of females was 70.5%. For total population BMI cut-off value was found to be 22.2 with 81% sensitivity and 74% specificity.  Conclusion: We propose the cut-off value for overweight/obesity in males to be 22.09 kg/m² and for females to be 23.73 kg/m² in young adult Indian population. These values were found to have more sensitivity and specificity than current BMI cut-off value.

The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India

Background

Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.

Methods

The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program’s electronic database.

Discussion

I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.

Trial registration

The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

Undiagnosed Hypertension and Associated Factors Among Adults in Hawela Tula Sub-City, Hawassa, Southern Ethiopia: A Community-Based Cross-Sectional Study

Background

Hypertension (HTN) is a major public health problem and often it is unnoticed. Undiagnosed HTN may lead to a high burden of cardiovascular diseases and complications such as stroke and heart attack. In this study, we aimed to assess the prevalence and associated factors of undiagnosed HTN.

Methods

From February to June 2019, a community-based cross-sectional study was conducted on 383 randomly selected adults in Hawela Tulla Sub-city, Hawassa, southern Ethiopia. Data were collected by pretested questionnaires, and physical measurements of weight, height and blood pressure were collected through standardized procedures adapted from WHO STEPS survey tools. Data entry and analysis were carried out using SPSS version 23 statistical software. Descriptive analysis and logistic regression models were used to describe the results. Logistic regression analysis results were declared statistically significant if the P-value was below 0.05 and the 95% CI did not cross the null value.

Results

The prevalence of undiagnosed HTN among the respondents was 12.3%. Only 152 (39.7%) of the study population knew the symptoms of HTN. Males (adjusted odds ratio [AOR] =2.5, 95% CI: 1.2, 5.2; P=0.016), people with a family history of HTN (AOR=2.7, 95% CI: 1.0, 7.0; P= 0.044), people who chewed khat (AOR=4.6, 95% CI: 2.0, 10.2; P<0.001), overweight or obese individuals (AOR=3.5, 95% CI: 1.7, 7.3; P=0.001) and people with diabetes mellitus (AOR=3.2, 95% CI: 1.1, 9.3; P=0.036) had a higher risk of undiagnosed HTN than their counterparts.

Conclusion

Identification of people with the risk factors of undiagnosed HTN and delivering health education to reduce the risky behaviors could reduce the burden and consequences of HTN. Integrating interventions at the community level may be important.

Effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension: Pretest-posttest study

AIM

To investigate the effect of nurse-led home-based biofeedback intervention on the blood pressure levels among patients with hypertension.

BACKGROUND

Nurse-led interventions are emerging as cost-effective as well as clinically proven in chronic illness management. Hypertension, a leading long-term cardiovascular condition, has autonomic dysregulation and increased sympathetic tone as its pathophysiological background. Complementary interventions evidenced to interplay hypertension pathophysiology.

DESIGN

A pretest-posttest design.

MATERIALS AND METHODS

Uncomplicated primary hypertension outpatients were randomly assigned as study group (n = 173) and control group (n = 173) at a tertiary care hospital. Sociodemographic, clinical, and outcome variables [the baseline blood pressure and galvanic skin response (GSR)] were collected. Study group patients were given four teaching sessions of abdominal breathing-assisted relaxation facilitated by GSR biofeedback. Daily home practice was encouraged and monitored to measure the effects on blood pressure and GSR at the end of the 1st, 2nd, and 3rd month of intervention.

RESULTS

The study group participants showed significant decrease in mean (SD) systolic [140.77 (8.31) to 136.93 (7.96), F = 469.08] and diastolic blood pressure [88.24 (5.42) to 85.77 (4.66), F = 208.21]. In contrast, control group participants had a mild increase in the mean systolic (F = 6.02) and diastolic blood pressure (F = 4.70) values from pretest to posttests. GSR showed a significant increase from 559.63 (226.33) to 615.03 (232.24), (F = 80.21) from pretest to posttest III.

CONCLUSIONS

Use of home-based biofeedback-centered behavioral interventions enabled BP reduction among hypertensive patients. Further studies should use biochemical markers of sympathetic nervous system activity to endorse this home-based chronic illness intervention.

Gender differences in the risk factors for high and very high blood glucose levels: A study of Kerala

BACKGROUND AND AIMS

Worldwide, lifestyle is a significant risk factor for diabetes. Lifestyle changes can lead to differences in the extent of risk of diabetes among women and men. Kerala, a state with one of the best health indicators in India, has a high prevalence of diabetes. This study aimed at comparing the variations in the risk factors for HBG and VHBG among adult women and men in Kerala.

METHODS

Data from the fourth round of the National Family Health Survey (2015-16) used to examine the differences in the risk factors for HBG and VHBG in men and women aged 15-49 years. We used bivariate, multivariate and Population Attributable Risk (PAR) techniques for analysing the data.

RESULTS

Bivariate results have shown the pattern of HBG and VHBG prevalence in women and men was same among all the age groups; however, men show a higher HBG and VHBG than women in all the age groups. Prevalence of HBG and VHBG was higher in women with a primary education, who were poor and not working as compared to their male counterparts. PARs results show that the prevalence of VHBG was higher among obese men and women as compared to normal men and underweight women. Prevalence of HBG was higher among men as compared to women due to alcohol use and weekly consumption of non-vegetarian food.

CONCLUSIONS

The study suggests that there is an urgent need for targeted intervention programs to address the problem of HBG and VHBG in both men and women in Kerala to control blood glucose levels.

Control of hypertension among teachers in schools in Kerala (CHATS-K), India

Objective

We investigated the prevalence, awareness, treatment, control of hypertension and the factors associated with hypertension prevalence and control among school teachers in Kerala, India.

Methods

We surveyed 2216 school teachers in Thiruvananthapuram district of Kerala as part of the control of hypertension among teachers in schools in Kerala (CHATS-K), India. We used World Health Organization STEPS tools for non-communicable diseases risk factor surveillance. Blood pressure, weight and height were measured using standard protocols. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, or self-reported current antihypertensive medication. Controlled hypertension was defined as SBP<140 and DBP<90 mmHg. Separate multivariate analysis was done for finding the associated factors with prevalence and control of hypertension.

Results

Age adjusted hypertension prevalence was 14.6%. Men, those with self-reported diabetes, having family history of hypertension and overweight were more likely to have higher prevalence of hypertension compared to their counterparts. Among hypertensives 62% were aware, 49% on treatment and 34% achieved adequate control. Hypertension control was significantly higher among women, diabetics and overweight individuals compared to their counterparts.

Conclusions

A higher level of hypertension control among school teachers in this study indicates an attainable level of hypertension control in the general population of the state. Teachers, with their highly regarded place in the social construct of the country and the state, could thus be used as role models for hypertension control for the general population in the state.

Obesity and its Link to Undiagnosed Diabetes Mellitus and Hypertension in Rural Parts of Western India

BACKGROUND

Obesity and overweight are becoming major health concerns worldwide. Hence, we studied the association between overweight and obesity with new-onset diabetes and hypertension in a selected rural population.

METHODOLOGY

Community health workers made house-to-house visits, inviting adults >20 years of age who were at a higher risk of diabetes, from a predefined rural area of Maharashtra, to visit a mobile diabetes clinic operating in a hub and spoke manner. Sociodemographic data and anthropometric measurements were recorded. BMI and waist circumference was classified according to the WHO recommended cutoffs for Asians. Subjects with capillary blood fasting glucose of ≥126 mg/dL or random glucose of ≥200 mg/dL by glucometer were diagnosed as diabetes and blood pressure of ≥140/90 mmHg by sphygmomanometer were diagnosed as hypertension. Subjects with a known history of diabetes mellitus and hypertension were excluded.

RESULTS

Out of 29,324 total population, 16.5% of subjects were overweight and 26.4% were obese. Mean ± SD of BMI of the participants was 22.9 ± 4.1 kg/m² in males and 22.4 ± 4.2 kg/m² in females. Around 35% of males and 30.5% of females had a high waist circumference of ≥90 cm and ≥80 cm, respectively, 20.5% of subjects had newly diagnosed hypertension, and 11.4% of subjects had newly diagnosed diabetes mellitus. The occurrence of newly diagnosed hypertension and diabetes showed an increasing trend with increasing BMI.

CONCLUSION

Our community-based screening suggested a high prevalence of overweight and obesity in rural India. There was a high prevalence of newly diagnosed hypertension and diabetes in this population.

Prevalence of Type 2 Diabetes and Prediabetes in the Gwalior-Chambal Region of Central India

AIM

This study evaluated the prevalence of prediabetes and type 2 diabetes mellitus in the Gwalior-Chambal region of India.

METHODS

A cross-sectional house-to-house survey was conducted on a population of 7608 subjects, aged between 20 and 79 years for fasting blood glucose level in finger-prick blood. Participants were stratified based on blood glucose levels, gender, age, family history, etc. to assess their impact.

RESULT

The prevalence of type 2 diabetes and prediabetes in the Gwalior-Chambal region was found to be 11.4% and 5.7%, respectively. The prevalence of diabetes was significantly higher in the urban population (12.7%) while that of prediabetes was higher in the rural population (7.9%). Male subjects recorded a higher prevalence of prediabetes (8.2%, OR 1.54 in rural; 5.1%, OR 1.26 in urban) as well as diabetes (rural 9.2%, OR 3.15; urban 16.5%, OR 1.57). Both prediabetes and diabetes were recorded as being higher in those subjects leading a sedentary lifestyle and in the aged population. The prevalence of hyperglycemia was much higher in those with a family history of type 2 diabetes (30.6% in rural, 21.5% in urban). Almost half of the diabetics in the rural population were diagnosed for the first time. The multivariate regression analysis identified male gender, increasing age of 30 years and above, and positive family history as significant risk factors for diabetes whereas age of 40 to 79 and less physical activity were significant risk factors for prediabetes.

CONCLUSION

Family history of diabetes, and sedentary lifestyle appeared as key factors promoting prediabetes and diabetes in the Gwalior-Chambal region. A lack of awareness appeared as one of the major causes of the high prevalence in the rural region.

The Prevalence of Overweight, Obesity, Hypertension, and Diabetes in India: Analysis of the 2015-2016 National Family Health Survey

Overweight, obesity, hypertension, and diabetes increase the risk of non-communicable diseases and all-cause mortality worldwide. Previous studies have not determined the prevalence of these conditions/diseases throughout India. Therefore, this study was aimed to address this limitation. Data on these conditions/diseases among men and women aged ≥ 18 years were obtained from the fourth National Family Health Survey conducted throughout India between January 2015 and December 2016. The prevalence and prevalence rate per 100,000 population were calculated at the national level and by age group, sex, and type of residence for each state and union territory. The national prevalence of overweight, obesity, hypertension, and diabetes were 14.6%, 3.4%, 5.2%, and 7.1%, respectively. The highest prevalence of these conditions/diseases at the national level was seen among those aged 35–49 years (54 years for men), especially women living in urban areas. In India, 1 out of every 7, 29, 19, and 14 individuals at the national level had overweight, obesity, hypertension, and diabetes, respectively—between 2015 and 2016. These results are important for the healthcare system and government policies in the future. Moreover, targeted efforts are required to establish public health strategies for the prevention, management, and treatment of these conditions/diseases throughout India.

Undiagnosed hypertension and diabetes among the elderly in Amirkola, North of Iran

Background:

As populations of elderly grow, the prevalence of type 2 diabetes and hypertension increases. These diseases can be asymptomatic for a long time and cause irreversible damages to organs. Therefore the aim of this study was to evaluate the prevalence of undiagnosed hypertension and diabetes among the elderly in Amirkola.

Methods:

This is a descriptive/analytical cross-sectional study and a part of the first phase of a cohort study on the health status of the elderly in Amirkola (a city in the North of Iran) which has been conducted on all people aged 60 and over since 2011. The demographic information was collected using a questionnaire, the hypertension was diagnosed by measuring blood pressure in lying down- position and the diabetes was diagnosed by measuring fasting blood glucose level.

Results:

This study was conducted on 1568 elderly participants including 703 (44.8%) females and 865 (55.2%) males. The overall prevalence of diabetes was 30.6% of which, 23.3% was diagnosed and 7.4% was undiagnosed. Nearly one-fourth (24.1%) of the participants with diabetes were unaware of their disease. Thirty-one percent of the people with undiagnosed diabetes also had undiagnosed hypertension. The overall prevalence of hypertension in this study was 62.8%, including 41.2% diagnosed and 21.5% undiagnosed hypertension.

Conclusion:

Regarding the results of this study and the high prevalence of undiagnosed diabetes and hypertension in elderly, improving the individual’s general awareness and screening in older adults for timely management are necessary.

Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey

Objective

Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults.

Methods

A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India.

Results

Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18–19, 20–44, 45–54, 55–64, 65–74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively.

Conclusion

There is a high prevalence of hypertension, with almost one in every three Indian adult affected.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.

Blood pressure control in diabetes-the Indian perspective

A tremendous increase in the coexistence of diabetes and hypertension has been observed recently in India. Apart from lifestyle and genetic factors, socioeconomic status, age, gender, occupation and lack of awareness are also contributing to the tremendous increases in the prevalence of both the diseases. Hypertension has been long recognised as one of the major risk factors for chronic disease burden, morbidity and mortality in India, attributable to 10.8% of all deaths in the country. Even though microvascular complications are frequently linked to hyperglycaemia, studies have also proven the critical involvement of hypertension in the development of these co-morbidities. The co-occurrence of hypertension in diabetic patients considerably escalates the risks of coronary heart disease, stroke, nephropathy and retinopathy. The annual expenditure for diabetes for the Indian population was estimated to be 1541.4 billion INR ($31.9 billion) in 2010. The expense of diabetes care further escalates in the presence of complications or co-morbidities. Generally, a diabetic patient with hypertension spent an average of 1.4 times extra than a diabetic patient without hypertension. Even though diabetes and hypertension are considered as important risk factors for cardiovascular and chronic kidney diseases, the awareness about the prevention, treatment and control of these diseases remains alarmingly low in the developing countries like India. The healthcare system in India should focus on better hypertension screening and control, especially in diabetic patients, to minimise the burden of the dual epidemic.

The Burden of Undiagnosed Diabetes Mellitus in Adult African Population: A Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of diabetes is rapidly increasing in Africa. Type two diabetes may remain undetected for many years, leading to severe complications and healthcare costs. This underlines the importance of understanding the magnitude of undiagnosed diabetes in different populations of Africa. This study is intended to summarize and pool the results of community-based studies to provide a continental level estimate of the undiagnosed diabetes mellitus.

METHODS

We searched MEDLINE/PubMed, HINARI, Cochrane Library, and Google Scholar for community-based studies on diabetes mellitus in Africa. Descriptive information for the original studies was presented in a table, and the quantitative results were presented in forest plots. The Cochran's Q test and I 2 test statistic were used to test heterogeneity across studies. The pooled prevalence of undiagnosed diabetes and subgroup analyses within urban and rural population and diagnostic methods were computed by a random effects model from 2011 to 2017.

RESULTS

One hundred fifty-seven articles were identified through electronic searching using keywords. Of these, seventeen studies, with a total population of 20,350, met the inclusion criteria. A random effects meta-analysis showed that the pooled prevalence of undiagnosed diabetes mellitus in African population was 5.37% (95% CI: 4.57, 6.81). The pooled prevalence from subgroup analyses indicated that undiagnosed diabetes mellitus in the urban population (8.68%, 95% CI: 5.33, 12.03) is twice higher than that in the rural population (3.93%, 95% CI: 2.91, 4.95). The prevalence of UDM by OGTT (8.84%, 95% CI: 1.95, 15.73) was higher than that by the FPG diagnostic method (4.54%, 95% CI: 3.59, 5.49).

CONCLUSION

This study found high proportions of undiagnosed diabetes mellitus in different communities of the African countries. Policy makers must consider diagnostic strategies to improve screening for the undiagnosed diabetes mellitus cases for effective care, which can bring about a substantial reduction in diabetes-related complications and mortality. This review is registered with PROSPERO registration number CRD42018092637.

Prevalence and real-world assessment of central aortic blood pressure in adult patients with essential hypertension uncontrolled on single anti-hypertensive agents

OBJECTIVE

To assess the prevalence of high central aortic pressure (CAP) in Indian patients with uncontrolled essential hypertension while on anti-hypertensive monotherapy. Also, to determine correlation between brachial blood pressure (BBP) and CAP, and ascertain if it is impacted by anti-hypertensive drug class and patients' age.

METHODS

In this real-world, observational, prospective study, patients (30-70 years) with uncontrolled BBP (systolic BP [SBP] ≥140 mmHg or diastolic BP [DBP] ≥90 mmHg) were enrolled. Treatment was adjusted at Visit 1 (baseline), based on BBP and at treating physicians' discretion. Primary endpoint was proportion of patients with uncontrolled central aortic SBP (>125 mmHg) at baseline. Secondary endpoints were comparison of BBP and CAP across drugs classes and age groups at baseline and Visit 2 (End-of-study, ∼8 weeks post-baseline), and proportion of patients with uncontrolled central SBP at end-of-study.

RESULTS

Of 2030 patients screened, 1949 patients reported at baseline and 1740 patients completed end-of-study visit. Central SBP was >125 mmHg for 84.3% patients at baseline, and 48% patients at end-of-study. Interestingly, at end-of-study, 6.6% patients still had uncontrolled brachial SBP and controlled central SBP, while 13.6% patients had uncontrolled central SBP and controlled brachial SBP. At both visits, brachial SBP and central SBP showed positive correlation across most drug classes and age groups. At baseline, ACE inhibitors showed better efficacy than other drug classes. At end-of-study, BP control was better with fixed-dose combinations, though free-drug combinations were more frequently prescribed.

CONCLUSION

Measurement of CAP along with BBP can be vital in management of hypertension.

CTRI REGISTRATION NUMBER

CTRI/2015/10/006302.

Emerging trends in hypertension epidemiology in India

Hypertension is the most important risk factor for chronic disease burden in India. Studies from various parts of India have reported high prevalence of hypertension. These studies have also reported that hypertension is increasing and there is low awareness and control. Two recent studies have been conducted with uniform tools and nationwide sampling to determine the true prevalence of hypertension in the country. Fourth National Family Health Survey evaluated hypertension in a large population based sample (n = 799,228) and reported hypertension in 13.8% men vs. 8.8% women (overall 11.3%) aged 15-49 and 15-54 respectively. More representative data (age > 18 years, n = 1,320,555) in Fourth District Level Household Survey reported hypertension in 25.3% with greater prevalence in men (27.4%) than women (20.0%). This translates into 207 million persons (men 112 million, women 95 million) with hypertension in India. Prevalence would be much higher using 2017 American guidelines. Global Burden of Diseases study reported that hypertension led to 1.63 million deaths in India in 2016 as compared to 0.78 million in 1990 (+108%). The disease burden (DALYs) attributable to hypertension increased from 21 million in 1990 to 39 million in 2016 (+89%). Social determinants of hypertension are important and Indian states with greater urbanization, human development and social development have more hypertension. There is poor association of hypertension prevalence with healthcare availability although there is positive association with healthcare access and quality. The health system in India should focus on better hypertension screening and control to reduce cardiovascular morbidity and mortality.

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.

Prevalence and determinants of comorbid diabetes and hypertension: Evidence from non communicable disease risk factor STEPS survey, India

PROBLEM STATEMENT

Comorbidity of non-communicable diseases carries a significant risk of cardiovascular events and mortality. With the rising burden of diabetes, hypertension and other risk factors, and ageing population in India, this is likely to pose a major threat to the health system. It is therefore essential to understand this high risk group. This article reports prevalence of comorbid diabetes and hypertension and its associated risk factors in the North Indian state of Punjab.

METHODS

A household NCD STEPS survey was done in Punjab, India in a multistage stratified sample of 5127 individuals. All the subjects were administered the WHO STEPS questionnaire, anthropometric and blood pressure measurements. Every alternate respondent in the sample (n=2499) were assayed for blood glucose and lipid parameters.

RESULTS

The prevalence of comorbid DM and HTN was 4.5% in the general adult population. DM, HTN and dyslipidemia co-existed in 1.8% of the population. Obesity and dyslipidemia are the most common comorbidities among persons with DM and HTN alone and comorbid DM and HTN. Factors strongly associated with comorbid DM and HTN include elderly age group, dyslipidemia, obesity and family history of DM.

CONCLUSIONS

The study reported high burden of comorbid diabetes and hypertension among the elderly, strongly associated with obesity and dyslipidemia. This emphasizes the role of nonpharmacological intervention such as weight reduction, physical activity, and dietary modification.

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India)

OBJECTIVE

India has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or "co morbidities" makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices.

METHOD

This cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire"Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)". Statistical analyses were done using STATA.

RESULTS

Overall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0-14] than females [0-6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85-6.62]and [OR = 2.46; CI 95%1.16-5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01-3.91] and obesity [OR = 3.96; 95%CI 1.01-15.76].

CONCLUSION

The results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

Aging and obesity are associated with undiagnosed hypertension in a cohort of males in the Central Province of Sri Lanka: a cross-sectional descriptive study

BACKGROUND

Lifestyle factors associated with hypertension (HT) in South Asian populations are relatively unknown. The objective of the current study was to investigate the prevalence rates of undiagnosed HT and factors associated with it in a cohort of males from the Central Province of Sri Lanka.

METHODS

The study group consisted of 2462 males (mean age 31 years, range: 16-72 years) who underwent a routine medical examination at the National Transport Medical Institute, Kandy, Sri Lanka. Participants with previously diagnosed heart disease, diabetes, hypertension or other chronic illnesses were excluded from this study. Dietary and other lifestyle factors were studied using validated self-administered questionnaires. Body Mass Index (BMI) cut-off values for Asians were used to categorize the subjects according to weight status. The association of individual dietary and lifestyle patterns with HT was assessed by fitting into binary logistic regression models.

RESULTS

The mean systolic (SBP) and diastolic blood pressures (DBP) of the individuals were 125.9 mmHg and 80.5 mmHg, respectively. The prevalence rate of undiagnosed HT was 31.7%. Both SBP and DBP showed significant positive correlations with age, weight, BMI and waist circumference. After adjusting for potential confounders, HT was associated with older age (p = 0.001) and increased weight status (p < 0.001) with trends of association for level of education (p = 0.058). Level of income, alcohol consumption, sleeping hours, smoking, physical activity level, ethnic difference, consumption of fruits, fish, meat, dairy, sweets or fried snacks were not significantly associated with HT. Obese males were 92.1% [odds ratio: 1.9 (1.4-2.7)] more likely to be hypertensive compared to normal weight males.

CONCLUSIONS

Undiagnosed HT is prevalent at an alarming rate among adult males in the Central Province of Sri Lanka. Its association with age and BMI (weight status) highlights the importance of routine screening for HT as well as interventions targeted at reducing obesity to curb the rise of this modifiable cardiovascular disease risk factor.

Framingham Risk Score and Estimated 10-Year Cardiovascular Disease Risk Reduction by a Short-Term Yoga-Based LifeStyle Intervention

OBJECTIVE

The aim of this study was to evaluate the efficacy of a short-term yoga-based lifestyle intervention program in lowering Framingham Risk Score (FRS) and estimated 10-year cardiovascular risk.

METHODS

This was a single-arm, pre-post interventional study including data from a historical cohort with low to moderate risk for cardiovascular disease (CVD). It was conducted in a tertiary-care hospital. Participants with low (0 or 1 CVD risk factors) to moderately high risk (10-year risk between 10% and 20% and two or more CVD risk factors) were included. Participants with previously diagnosed CVD, defined as a history of myocardial infarction, congestive heart failure, or cerebrovascular accident, were excluded from the analysis. However, those with controlled hypertension were included. Intervention included a pretested short-term yoga-based lifestyle intervention, which included asanas (physical postures), pranayama (breathing exercises), meditation, relaxation techniques, stress management, group support, nutrition awareness program, and individualized advice. The intervention was for 10 days, spread over 2 weeks. However, participants were encouraged to include it in their day-to-day life. Outcomes included changes in FRS, and estimated 10-year CVD risk from baseline to week 2. A gender-based subgroup analysis was also done, and correlation between changes in FRS and cardiovascular risk factors was evaluated.

RESULTS

Data for 554 subjects were screened, and 386 subjects (252 females) were included in the analysis. There was a significant reduction in FRS (p < 0.001) and estimated 10-year cardiovascular risk (p < 0.001) following the short-term yoga-based intervention. There was a strong positive correlation between reduction in FRS and serum total cholesterol (r = 0.60; p < 0.001). There was a moderate positive correlation between reduction in FRS and low-density lipoprotein cholesterol (r = 0.58; p < 0.001), and a weak but positive correlation between reduction in FRS and triglycerides (r = 0.26; p ≤ 0.001), serum very-low-density lipoprotein cholesterol (r = 0.29; p < 0.001), and systolic blood pressure (r = 0.20; p ≤ 0.001).

CONCLUSIONS

This yoga-based lifestyle intervention program significantly reduced the CVD risk, as shown by lowered FRS and estimated 10-year CVD risk. Further testing of this promising intervention is warranted in the long term.

Burden and Socio-Behavioral Correlates of Uncontrolled Abnormal Glucose Metabolism in an Urban Population of India

BACKGROUND

Progressive burden of diabetes mellitus is a major concern in India. Data on the predictors of poor glycemic control among diabetics are scanty. A population-based cross-sectional study nested in an urban cohort was thus conducted in West Bengal, India to determine the burden and correlates of total and uncontrolled abnormalities in glucose metabolism (AGM) in a representative population.

METHODS

From 9046 adult cohort-members, 269 randomly selected consenting subjects (non-response = 7.24%) were interviewed, examined [blood pressure (BP), anthropometry], tested for fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1C). Those having pre-diagnosed diabetes or FPG ≥126 or HbA1c≥6.5 were defined as diabetic. Among non-diabetics, subjects with FPG (mg/dl) = 100-125 or HbA1C(%) = 5.7-6.4 were defined as pre-diabetic. Pre-diagnosed cases with current FPG ≥126 were defined as uncontrolled AGM. Descriptive and regression analyses were conducted using SAS-9.3.2.

RESULTS

Among participants, 28.62% [95% Confidence Interval (95%CI) = 23.19-34.06)] were overweight [body mass index(BMI) = (25-29.99)kg/meter2], 7.81% (4.58-11.03) were obese(BMI≥30kg/meter2), 20.82% (15.93-25.70) were current smokers, 12.64% (8.64-16.64) were current alcohol-drinkers and 46.32% of responders (39.16-53.47) had family history of diabetes. 17.84% (13.24-22.45) had stage-I [140≤average systolic BP (AvSBP in mm of mercury)<160 or 90≤average diastolic BP (AvDBP)<100] and 12.64% (8.64-16.64) had stage-II (AvSBP≥160 or AvDBP≥160) hypertension. Based on FPG and HbA1c, 10.41% (6.74-14.08) were diabetic and 27.88% (22.49-33.27) were pre-diabetic. Overall prevalence of diabetes was 15.61% (11.25-19.98). Among pre-diagnosed cases, 46.43% (26.74-66.12) had uncontrolled AGM. With one year increase in age [Odds Ratio(OR) = 1.05(1.03-1.07)], retired subjects [OR = 9.14(1.72-48.66)], overweight[OR = 2.78(1.37-5.64)], ex-drinkers [OR = 4.66(1.35-16.12)] and hypertensives [ORStage I = 3.75(1.42-9.94); ORStage II = 4.69(1.67-13.17)] had higher odds of diabetes. Relatively older subjects [OR = 1.06(1.02-1.10)], unemployed [OR = 19.68(18.64-20.78)], business-owners [OR = 25.53(24.91-16.18)], retired [OR = 46.53(45.38-47.72)], ex-smokers [OR = 4.75(1.09-20.78)], ex-drinkers [OR = 22.43(4.62-108.81)] and hypertensives [ORStage II = 13.17(1.29-134.03)] were more likely to have uncontrolled AGM.

CONCLUSIONS

Burden of uncontrolled AGM was high among participants. Efforts to curb the diabetes epidemic in urban India should include interventions targeting appropriate diabetic control among relatively older persons, unemployed, business-owners, retired, ex-smokers, ex-drinkers and hypertensives.

Vascular Disease in Young Indians (20-40 years): Role of Hypertension

Hypertension (HTN) being one of the important risk factors for cardiovascular disease (CVD) is a significant health concern, especially in India. With age, prevalence of HTN, especially systolic HTN increases. Special attention needs to be directed to HTN in young ages (20-40 years) due to lower awareness, need for early treatment and better control of HTN. HTN in the age group of 20-40 years needs critical reappraisal. Given the high prevalence of HTN in the general population in India, in this review we attempt to provide current evidence and expert opinion on epidemiology, aetiopathogenesis and treatment of HTN in young (20-40 years) Indians.

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.

Estimating the proportion of persons with diabetes developing diabetic retinopathy in India: A systematic review and meta-analysis

BACKGROUND

Available evidence from India shows that the control of diabetes is poor in majority of the population. This escalates the risk of complications. There is no systematic review to estimate the magnitude of diabetic retinopathy (DR) in India.

MATERIALS AND METHODS

A systematic literature search was carried out in Ovid Medline and EMBASE databases using Mesh and key search terms. Studies which reported the proportion of people with diabetes with DR in a representative community population were included. Two independent reviewers reviewed all the retrieved publications. Data were extracted using a predefined form. Review Manager software was used to perform meta-analysis to provide a pooled estimate. Studies included were assessed for methodological quality using selected items from the STROBE checklist.

RESULTS

Seven studies (1999-2014; n = 8315 persons with diabetes) were included in the review. In the meta-analysis, 14.9% (95% confidence interval [CI] 10.7-19.0%) of known diabetics aged ≥30 years and 18.1% (95% CI 14.8-21.4) among those aged ≥50 years had DR. Heterogeneity around this estimate ranged from I(2)= 79-87%. No linear trend was observed between age and the proportion with DR. The overall methodological quality of included studies was moderate.

CONCLUSIONS

Early detection of DR is currently not prioritized in public health policies for noncommunicable diseases and blindness programs. Methodological issues in studies suggest that the proportion of diabetics with DR is underestimated in the Indian population. Future research should emphasize more robust methodology for assessing diabetes and DR status.

Prevalence of and risk factors for hypertension among urban communities of North Sudan: Detecting a silent killer

Background:

Hypertension is a common global health problem in many countries including Sudan. The objective of this study was to determine the prevalence of and risk factors for high blood pressure (BP) in River Nile State (RNS), Sudan.

Materials and Methods:

A community-based, cross-sectional study was conducted by a house-to-house survey; all consented adults from the main four cities, Atbara, Shendi, Ed Damer, and Berber, were interviewed using standardized pretested questionnaire to record medical history, sociodemographic and lifestyle characteristics. BP was measured using the standardized technique. Body mass index, waist circumference, and blood glucose were also determined.

Results:

A total of 954 individuals were included in the study. The mean age was 39.5 ± 16.6 years and 54.3% were females. The prevalence of hypertension was 35.7% and the newly diagnosed cases were 22.4%. Increasing age, low educational level, diabetes mellitus, obesity, and central obesity were found to be risk factors for hypertension.

Conclusion:

Hypertension is diagnosed in more than one-third of the population living in urban communities of RNS and correlates well with features of the metabolic syndrome.

Age and Sex Specific Reference Intervals for Modifiable Risk Factors of Cardiovascular Diseases for Gujarati Asian Indians

Objective. We aimed to establish age and sex specific percentile reference data for cardiovascular risk factors such as lipids, sugar, blood pressure, and BMI in apparently healthy and disease-free Gujarati population. Methods. In this cross-sectional study, we enrolled 3265 apparently healthy and disease-free individuals of both genders residing in Gujarat state. Fasting samples of blood were used for biochemical estimations of lipids and sugar. The measurement of BMI and blood pressure was also done according to the standard guidelines. Age and gender specific 5th, 25th, 50th, 75th, 90th, and 95th percentiles were obtained. Results. The mean values of lipids, sugar, blood pressure, and BMI were significantly (p < 0.001) higher in males as compared to female population. Age-wise distribution trends showed increase in the risk factors from the 2nd decade until the 5th to 6th decade in most of the cases, where loss of premenopausal protection in females was also observed. Specific trends according to gender and age were observed in percentile values of various parameters. Conclusion. The outcome of current study will contribute significantly to proposing clinically important reference values of various lipids, sugar, blood pressure, and BMI that could be used to screen the asymptomatic Gujarati Indian population with a propensity of developing dyslipidemia, diabetes, blood pressure, and obesity.