Commentary: Poverty and cardiovascular disease in India: do we need more evidence for action?

Socio-economic distribution of modifiable risk factors for cardiovascular diseases: An analysis of the national longitudinal ageing study in India

The association of socioeconomic status (SES) with modifiable risk factors for cardiovascular diseases (CVDs) is unclear in developing nations. We studied SES variations in major risk factors and their percentage distribution for adults aged 45 years or above in India. Using individual records of 59,672 individuals aged 45 years or above from the Longitudinal Ageing Study in India Wave 1 (cross-sectional study design), 2017-18, we chart age-and-sex-adjusted prevalence of clinical risk factors such as measured high blood pressure, hypertension, overweight, obesity, central adiposity and self-reported high blood glucose; and lifestyle risk factors such as excessive use of alcohol, current use of smoking and smokeless tobacco and physical inactivity across SES variables of education, quintiles of mean per capita expenditure and social caste. Multivariable analysis was used to explore the SES gradient of risk factors. The sample used in the study is predominantly rural (69.9%), illiterate (50.7%), has more females (54.2%), and belongs to other backward classes (45.6%). Prevalence of high blood pressure, overweight, obesity, central adiposity, high blood glucose, and physical inactivity increased; and excessive alcohol consumption and current use of smoking/smokeless tobacco decreased with income, education, and social caste. However, no significant income gradient was noted for lifestyle risk factors except the use of smokeless tobacco. The income gradient was largest for central adiposity (waist-circumference) with a difference of 23.4 percentage points as it increased from 38.7% among the poorest to 62.1% among the richest. The major burden of CVDs risk factors among older adults aged 45+ years falls among high SES.

Clinical profile and 90 day outcomes of 10 851 heart failure patients across India: National Heart Failure Registry

AIMS

Limited data on the uptake of guideline-directed medical therapies (GDMTs) and the mortality of acute decompensated HF (ADHF) patients are available from India. The National Heart Failure Registry (NHFR) aimed to assess clinical presentation, practice patterns, and the mortality of ADHF patients in India.

METHODS AND RESULTS

The NHFR is a facility-based, multi-centre clinical registry of consecutive ADHF patients with prospective follow-up. Fifty three tertiary care hospitals in 21 states in India participated in the NHFR. All consecutive ADHF patients who satisfied the European Society of Cardiology criteria were enrolled in the registry. All-cause mortality at 90 days was the main outcome measure. In total, 10 851 consecutive patients were recruited (mean age: 59.9 years, 31% women). Ischaemic heart disease was the predominant aetiology for HF (72%), followed by dilated cardiomyopathy (18%). Isolated right HF was noted in 62 (0.6%) participants. In eligible HF patients, 47.5% received GDMT. The 90 day mortality was 14.2% (14.9% and 13.9% in women and men, respectively) with a re-admission rate of 8.4%. An inverse relationship between educational class based on years of education and 90 day mortality (high mortality in the lowest educational class) was observed in the study population. Patients with HF with reduced ejection fraction and HF with mildly reduced ejection fraction who did not receive GDMT experienced higher mortality (log-rank P < 0.001) than those who received GDMT. Baseline educational class, body mass index, New York Heart Association functional class, ejection fraction, dependent oedema, serum creatinine, QRS > 120 ms, atrial fibrillation, mitral regurgitation, haemoglobin levels, serum sodium, and GDMT independently predicted 90 day mortality.

CONCLUSION

One of seven ADHF patients in the NHFR died during the first 90 days of follow-up. One of two patients received GDMT. Adherence to GDMT improved survival in HF patients with reduced and mildly reduced ejection fractions. Our findings call for innovative quality improvement initiatives to improve the uptake of GDMT among HF patients in India.

Prevalence and Risk Factors of High Blood Pressure among Adults in Banyuwangi Coastal Communities, Indonesia

Background

Hypertension is a disease that still a problem in the world. Hypertension is a risk factor for heart disease and stroke mortality. Economic development and an emphasis on coastal tourism may have an impact on public health conditions, such as hypertension. This study aimed to determine risk factors related to hypertension among adults in coastal communities in Indonesia.

Methods

This was a cross-sectional study of 123 respondents between the age of 18–59 years old selected by cluster sampling. This study was conducted among coastal communities in Banyuwangi District, East Java, Indonesia. Data was analyzed using multivariate logistic regression.

Results

Our study showed that the prevalence of systolic and diastolic hypertension among residents of coastal communities were as high as 33.33% and 31.71%, respectively. Increasing age was associated with systolic and diastolic hypertension (OR_systolic=1.11; 95% CI=1.03–1.19, p=0.01 and OR_diastolic=1.07; 95% CI=1.01–1.15, p=0.03) after controlling other variables. Respondents with the poorest and richer socio-economic status had higher odds of having systolic and diastolic hypertension compared to respondents with the richest socio-economic status (OR_{systolic-poorest} =12.78; 95% CI=1.61–101.54, p=0.02; OR_{systolic-richer}=10.74; 95% CI =1.55–74.37, p=0.02 and OR_{diastolic-poorest}=10.36; 95% CI= 1.40–76.74, p=0.02;OR_{diastolic-richer}=6.45; 95% CI=1.01–41.43, p=0.05) after controlling other variables.

Conclusion

Being of older age and of the lower in socioeconomic status are significantly associated with increasing risk for systolic and diastolic hypertension in these coastal communities. More studies need to be done in these and other coastal village to help design appropriate health promotion and counseling strategies for coastal community.

Improving access to medicines for non-communicable diseases in rural primary care: results from a quasi-randomized cluster trial in a district in South India

BACKGROUND

A large proportion of non-communicable diseases (NCDs) are treatable within primary health care (PHC) settings in a cost-effective manner. However, the utilization of PHCs for NCD care is comparatively low in India. The Access-to-Medicines (ATM) study examined whether (and how) interventions aimed at health service optimization alone or combined with community platform strengthening improve access to medicines at the primary health care level within the context of a local health system.

METHOD

A quasi-randomized cluster trial was used to assess the effectiveness of the intervention (18 months) implemented across 39 rural PHCs (clusters) of three sub-districts of Tumkur in southern India. The intervention was allocated randomly in a 1:1:1 sequence across PHCs and consisted of three arms: Arm A with a package of interventions aimed at health service delivery optimization; B for strengthening community platforms in addition to A; and the control arm. Group allocation was not blinded to providers and those who assessed outcomes. A household survey was used to understand health-seeking behaviour, access and out-of-pocket expenditure (OOP) on key anti-diabetic and anti-hypertension medicines among patients; facility surveys were used to assess the availability of medicines at PHCs. Primary outcomes of the study are the mean number of days of availability of antidiabetic and antihypertensive medicines at PHCs, the mean number of patients obtaining medicines from PHC and OOP expenses.

RESULT

The difference-in-difference estimate shows a statistically insignificant increase of 31.5 and 11.9 in mean days for diabetes and hypertension medicines availability respectively in the study arm A PHCs beyond the increase in the control arm. We further found that there was a statistically insignificant increase of 2.2 and 3.8 percentage points in the mean proportion of patients obtaining medicines from PHC in arm A and arm B respectively, beyond the increase in the control arm.

CONCLUSION

There were improvements in NCD medicine availability across PHCs, the number of patients accessing PHCs and reduction in OOP expenditure among patients, across the study arms as compared to the control arm; however, these differences were not statistically significant.

TRIAL REGISTRATION

Trial registration number CTRI/2015/03/005640 . This trial was registered on 17/03/2015 in the Clinical Trial Registry of India (CTRI) after PHCs were enrolled in the study (retrospectively registered). The CTRI is the nodal agency of the Indian Council of Medical Research for registration of all clinical, experimental, field intervention and observation studies.

Distribution of risk factors of hypertension patients in different age groups in Tianjin

Background

To analyze the risk factors for hypertension in different age groups of urban and rural residents in Tianjin.

Methods

A total of 33,997 people (35–75 years old) from 13 community health service centers and primary hospitals in Tianjin participated in this study. They were divided into the youth group (≤ 40 years old), middle-aged group (41–65 years old), and elderly group (> 65 years old). Then, a questionnaire survey was administered, followed by physical and blood biochemical examinations. The demographic characteristics and prevalence were recorded and counted. Subsequently, risk factors were analyzed using univariate and stepwise multivariate logistic regression analysis.

Results

In the youth, middle-aged, and elderly groups, the prevalence rate of hypertension was 18.65, 51.80, and 76.61%, respectively. Logistic regression analysis showed that obesity(OR: 3.263, 95% CI: 1.039–1.656), men (OR: 2.117, 95% CI: 1.691–2.651), diabetes (OR: 1.978, 95% CI: 1.398–2.799), high triglycerides(OR 1.968 95% CI: 1.590–2.434) and family history of stroke (OR: 1.936, 95% CI: 1.287–2.911) are the five factors in youth. In middle-aged group, the significantly associating factors were obesity (OR: 2.478, 95% CI: 2.330–2.636), diabetes (OR: 2.173, 95% CI: 1.398–2.799), family history of stroke (OR: 1.808, 95% CI: 1.619–2.020), maleness (OR: 1.507, 95% CI: 1.412–1.609),Hypertriglyceridemia (OR 1.490 95% CI: 1.409–1.577),family history of cardiovascular disease (OR: 1.484, 95% CI: 1.307–1.684),Hypercholesterolemia (OR 1.228 95% CI: 1.160–1.299). In the elderly group, obesity (OR: 2.104, 95% CI: 1.830–2.418), family history of strokes (OR: 1.688, 95% CI: 1.243–2.292), diabetes mellitus (OR: 1.544, 95% CI: 1.345–1.773), family history of cardiovascular disease (OR: 1.470, 95% CI: 1.061–2.036), hypertriglyceridemia (OR: 1.348, 95% CI: 1.192–1.524) increased the risk for hypertension. Waist circumference (WC) and waist-to-height ratio (WHtR) increased with age, and the value of these two measures for predicting hypertension was better than BMI in middle-aged group.

Conclusion

Obesity is the most important risk factor for hypertension in all age groups. Diabetes, family history of strokes and high triglyceride were also significant risk factors for all age groups. There was a gender difference between the young and middle-aged groups, with men more likely to hypertension. Waist circumference (WC) and waist-to-height ratio (WHtR) were better predictors of hypertension than BMI in middle-aged group.

Ideal cardiovascular health in urban Jamaica: prevalence estimates and relationship to community property value, household assets and educational attainment: a cross-sectional study

OBJECTIVE

Ideal cardiovascular health (ICH) is associated with greater longevity and reduced morbidity, but no research on ICH has been conducted in Jamaica. We aimed to estimate the prevalence of ICH in urban Jamaica and to evaluate associations between ICH and community, household, and individual socioeconomic status (SES).

DESIGN

Cross-sectional study.

SETTING

Urban communities in Jamaica.

PARTICIPANTS

360 men and 665 women who were urban residents aged ≥20 years from a national survey, the Jamaica Health and Lifestyle Survey 2016-2017.

EXPOSURES

Community SES, using median land values (MLV); household SES, using number of household assets; and individual SES, using education level.

PRIMARY OUTCOME

The main outcome variable was ICH, defined as having five or more of seven ICH characteristics (ICH-5): current non-smoking, healthy diet, moderate physical activity, normal body mass index, normal blood pressure, normal glucose and normal cholesterol. Prevalence was estimated using weighted survey design and logistic regression models were used to evaluate associations.

RESULTS

The prevalence of overall ICH (seven characteristics) was 0.51%, while the prevalence of ICH-5 was 22.9% (male 24.5%, female 21.5%, p=0.447). In sex-specific multivariable models adjusted for age, education, and household assets, men in the lower tertiles of community MLV had lower odds of ICH-5 compared with men in the upper tertile (lowest tertile: OR 0.33, 95% CI 0.12 to 0.91, p=0.032; middle tertile: OR 0.46, 95% CI 0.20 to 1.04, p=0.062). Women from communities in the lower and middle tertiles of MLV also had lower odds of ICH-5, but the association was not statistically significant. Educational attainment was inversely associated with ICH-5 among men and positively associated among women.

CONCLUSION

Living in poorer communities was associated with lower odds of ICH-5 among men in Jamaica. The association between education level and ICH-5 differed in men and women.

Assessing cardiovascular disease risk factor screening inequalities in India using Lot Quality Assurance Sampling

Background

Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS).

Methods

LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined.

Results

A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level.

Conclusion

CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05914-y.

Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis

BACKGROUND

Cardiovascular diseases and their risk factors-particularly hypertension, dyslipidaemia, and diabetes-have become an increasing concern for middle-income countries. Using newly available, nationally representative data, we assessed how cardiovascular risk factors are distributed across subpopulations within South Africa and identified which cardiovascular treatments should be prioritised.

METHODS

We created a demographically representative simulated population for South Africa and used data from 17 743 respondents aged 15 years or older of the 2012 South African National Health and Nutrition Examination Survey (SANHANES) to assign information on cardiovascular risk factors to each member of the simulated population. We created a microsimulation model to estimate the health and economic implications of two globally recognised treatment recommendations: WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. The primary outcome was total disability-adjusted life-years (DALYs) averted through treatment of all cardiovascular disease or microvascular type 2 diabetes complications per 1000 population. We compared outcomes at the aspirational level of achieving access to treatment among 70% of the population.

FINDINGS

Based on the SANHANES data, South Africans had a high prevalence of hypertension (24·8%), dyslipidaemia (17·5%), and diabetes (15·3%). Prevalence was disproportionately high and treatment low among male, black, and poor populations. Our simulated population experienced a burden of 40·0 DALYs (95% CI 29·5-52·0) per 1000 population per year from cardiovascular disease or type 2 diabetes complications at current treatment levels, which lowered to 32·9 DALYs (24·4-44·7) under WHO PEN implementation and to 32·5 (24·4-44·8) under SA PC 101 implementation. Under both guidelines, there were increases in blood pressure treatment (4·2 percentage points under WHO PEN vs 12·6 percentage points under SA PC 101), lipid treatment (16·0 vs 14·9), and glucose control medications (1·2 vs 0·6). The incremental cost-effectiveness of implementing SA PC 101 over current treatment would be a saving of US$24 902 (95% CI 14 666-62 579) per DALY averted compared with a saving of $17 587 (1840-42 589) under WHO PEN guidelines.

INTERPRETATION

Cardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment.

FUNDING

Stanford University.

Self-reported hypertension in Northern China: a cross-sectional study of a risk prediction model and age trends

BACKGROUND

Hypertension is a major risk factor for the global burden of disease, particularly in countries that are not economically developed. This study aimed to evaluate risk factors associated with self-reported hypertension among residents of Inner Mongolia using a cross-sectional study and to explore trends in the rate of self-reported hypertension.

METHODS

Multi-stage stratified cluster sampling was used to survey 13,554 participants aged more than 15 years residing in Inner Mongolia for the 2013 Fifth Health Service Survey. Hypertension was self-reported based on a past diagnosis of hypertension and current use of antihypertensive medication. Adjusted odds risks (ORs) of self-reported hypertension were derived for each independent risk factor including basic socio-demographic and clinical factors using multivariable logistic regression. An optimized risk score model was used to assess the risk and determine the predictive power of risk factors on self-reported hypertension among Inner Mongolia residents.

RESULTS

During study period, self-reported hypertension prevalence was 19.0% (2571/13,554). In multivariable analyses, both female and minority groups were estimated to be associated with increased risk of self-reported hypertension, adjusted ORs (95% CI) were 1.22 (1.08, 1.37) and 1.66 (1.29, 2.13) for other minority compared with Han, increased risk of self-reported hypertension prevalence was associated with age, marital status, drinking, BMI, and comorbidity. In the analyses calculated risk score by regression coefficients, old age (≥71) had a score of 12, which was highest among all examined factors. The predicted probability of self-reported hypertension was positively associated with risk score. Of 13,421 participants with complete data, 284 had a risk score greater than 20, which corresponded to a high estimated probability of self-reported hypertension (≥67%).

CONCLUSIONS

Self-reported hypertension was largely related to multiple clinical and socio-demographic factors. An optimized risk score model can effectively predict self-reported hypertension. Understanding these factors and assessing the risk score model can help to identify the high-risk groups, especially in areas with multi-ethnic populations.

Prevalence of noncommunicable disease risk factors among the Kani tribe in Thiruvananthapuram district, Kerala

Background & objective

Noncommunicable Disease (NCD) risk factors are on the rise and often linked to the adoption of modern lifestyles. This study explores NCD risk factors in a rapidly modernising indigenous population in Kerala, the Kani tribe.

Methods

A representative sample of 298 adults of the Kani tribe in Thiruvananthapuram district was studied using the WHO stepwise framework for surveillance of NCD risk factors. Descriptive, bivariate and multivariable analysis were done using the R statistical package.

Results

Prevalence of hypertension (48.3%), use of tobacco (81.5%) and alcohol consumption (36.2%) were found to be higher in the Kani tribe compared to the general population in Kerala. Abdominal obesity (22.1%) is found to be higher in Kani tribes compared to other tribal groups in India. The physical inactivity level (9.7%) was similar to urban Kerala and higher than many other tribes in India. Hypertension was scientifically associated (p < 0.05) with higher age, male sex, low education levels, and tobacco intake among them. On multivariable analysis, age and alcohol consumption were found to be the prominent risk factors for hypertension and high education level was found to be a protective factor.

Conclusion

The major modifiable NCD risk factors were found to be higher among the people of the Kani tribe compared to the general population in Kerala. Physical inactivity level was comparable to urban Kerala, and obesity rates were higher than many other tribal communities in India. The findings warrants targeted action in these vulnerable communities for effective control of the noncommunicable epidemic.

Socioeconomic patterning of chronic conditions and behavioral risk factors in rural South Asia: a multi-site cross-sectional study

OBJECTIVES

Our aim was to examine relationships between markers of socioeconomic status and chronic disease risks in rural South Asia to understand the etiology of chronic diseases in the region and identify high-risk populations.

METHODS

We examined data from 2271 adults in Chennai, Goa and Matlab sites of the Chronic Disease Risk Factor study in South Asia. We report age-sex adjusted odds ratios for risk factors (tobacco, alcohol, fruit-vegetable use and physical activity) and common chronic conditions (hypertension, diabetes, overweight, depression, impaired lung and vision) by education, occupation and wealth.

RESULTS

Respondents with greater wealth and in non-manual professions were more likely to be overweight [OR = 2.48 (95% CI 1.8,3.38)] and have diabetes [OR = 1.88 (95% CI 1.02,3.5)]. Wealth and education were associated with higher fruit and vegetable [OR = 1.89 (95% CI 1.48,2.4)] consumption but lower physical activity [OR = 0.52 (95% CI 0.39,0.69)]. Non-manual workers reported lower tobacco and alcohol use, while wealthier respondents reported better vision and lung function.

CONCLUSIONS

Ongoing monitoring of inequalities in chronic disease risks is needed for planning and evaluating interventions to address the growing burden of chronic conditions.

Prevalence and incidence of hypertension: Results from a representative cohort of over 16,000 adults in three cities of South Asia

BACKGROUND

Despite high projected burden, hypertension incidence data are lacking in South Asian population. We measured hypertension prevalence and incidence in the Center for cArdio-metabolic Risk Reduction in South Asia (CARRS) adult cohort.

METHODS

The CARRS Study recruited representative samples of Chennai, Delhi, and Karachi in 2010/11, and socio-demographic and risk factor data were obtained using a standard common protocol. Blood pressure (BP) was measured in the sitting position using electronic sphygmomanometer both at baseline and two year follow-up. Hypertension and control were defined by JNC 7 criteria.

RESULTS

In total, 16,287 participants were recruited (response rate=94.3%) and two year follow-up was completed in 12,504 (follow-up rate=79.2%). Hypertension was present in 30.1% men (95% CI: 28.7-31.5) and 26.8% women (25.7-27.9) at baseline. BP was controlled in 1 in 7 subjects with hypertension. At two years, among non-hypertensive adults, average systolic BP increased 2.6mm Hg (95% CI: 2.1-3.1), diastolic BP 0.7mm Hg (95% CI: 0.4-1.0), and 1 in 6 developed hypertension (82.6 per 1000 person years, 95% CI: 80.8-84.4). Risk for developing hypertension was associated with age, low socio-economic status, current alcohol use, overweight, pre-hypertension, and dysglycemia. Risk of incident hypertension was highest (RR=2.95, 95% CI: 2.53-3.45) in individuals with pre-hypertension compared to normal BP. Collectively, 4 modifiable risk factors (pre-hypertension, overweight, dysglycemia, and alcohol use) accounted for 78% of the population attributable risk of incident hypertension.

CONCLUSION

High prevalence and poor control of hypertension, along with high incidence, in South Asian adult population call for urgent preventive measures.

Cardiovascular Diseases in India: Current Epidemiology and Future Directions

Cardiovascular diseases (CVDs) have now become the leading cause of mortality in India. A quarter of all mortality is attributable to CVD. Ischemic heart disease and stroke are the predominant causes and are responsible for >80% of CVD deaths. The Global Burden of Disease study estimate of age-standardized CVD death rate of 272 per 100 000 population in India is higher than the global average of 235 per 100 000 population. Some aspects of the CVD epidemic in India are particular causes of concern, including its accelerated buildup, the early age of disease onset in the population, and the high case fatality rate. In India, the epidemiological transition from predominantly infectious disease conditions to noncommunicable diseases has occurred over a rather brief period of time. Premature mortality in terms of years of life lost because of CVD in India increased by 59%, from 23.2 million (1990) to 37 million (2010). Despite wide heterogeneity in the prevalence of cardiovascular risk factors across different regions, CVD has emerged as the leading cause of death in all parts of India, including poorer states and rural areas. The progression of the epidemic is characterized by the reversal of socioeconomic gradients; tobacco use and low fruit and vegetable intake have become more prevalent among those from lower socioeconomic backgrounds. In addition, individuals from lower socioeconomic backgrounds frequently do not receive optimal therapy, leading to poorer outcomes. Countering the epidemic requires the development of strategies such as the formulation and effective implementation of evidence-based policy, reinforcement of health systems, and emphasis on prevention, early detection, and treatment with the use of both conventional and innovative techniques. Several ongoing community-based studies are testing these strategies.

Disparities in Prevalence of Cardiometablic Risk Factors in Rural, Urban-Poor, and Urban-Middle Class Women in India

OBJECTIVE

Urbanization is an important determinant of cardiovascular disease (CVD) risk. To determine location-based differences in CVD risk factors in India we performed studies among women in rural, urban-poor and urban middle-class locations.

METHODS

Population-based cross-sectional studies in rural, urban-poor, and urban-middle class women (35-70 y) were performed at multiple sites. We evaluated 6853 women (rural 2616, 5 sites; urban-poor 2008, 4 sites; urban middle-class 2229, 11 sites) for socioeconomic, lifestyle, anthropometric and biochemical risk factors. Descriptive statistics are reported.

RESULTS

Mean levels of body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, fasting glucose and cholesterol in rural, urban-poor and urban-middle class women showed significantly increasing trends (ANOVAtrend, p <0.001). Age-adjusted prevalence of diabetes and risk factors among rural, urban-poor and urban-middle class women, respectively was, diabetes (2.2, 9.3, 17.7%), overweight BMI ≥25 kg/m2 (22.5, 45.6, 57.4%), waist >80 cm (28.3, 63.4, 61.9%), waist >90 cm (8.4, 31.4, 38.2%), waist hip ratio (WHR) >0.8 (60.4, 90.7, 88.5), WHR>0.9 (13.0, 44.3, 56.1%), hypertension (31.6, 48.2, 59.0%) and hypercholesterolemia (13.5, 27.7, 37.4%) (Mantel Haenszel X2 ptrend <0.01). Inverse trend was observed for tobacco use (41.6, 19.6, 9.4%). There was significant association of hypertension, hypercholesterolemia and diabetes with overweight and obesity (adjusted R2 0.89-0.99).

CONCLUSIONS

There are significant location based differences in cardiometabolic risk factors in India. The urban-middle class women have the highest risk compared to urban-poor and rural.

Social epidemiology of excess weight and central adiposity in older Indians: analysis of Study on global AGEing and adult health (SAGE)

OBJECTIVES

We aimed to estimate the prevalence of overweight and obesity, represented by extra body weight and abdominal circumference, among older Indians; and to characterise the social pattern of obesity and measure the magnitude of hypertension attributable to it.

SETTING

A nationally representative sample of older Indians was selected from 6 Indian states, including Rajasthan, Uttar Pradesh, West Bengal, Assam, Maharashtra and Karnataka, as a part of the multicountry Study on global AGEing and adult health (SAGE).

PARTICIPANTS

Indians aged 50 years or more (n=7273) were included in the first wave of the SAGE (2010), which we used in our study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures included excess weight (EW), defined by body mass index (BMI) >25 kg/m(2), and central adiposity (CA), defined by waist circumference >90 cm for men and >80 cm for women. The secondary outcome included hypertension, defined by systolic blood pressure >139 or diastolic blood pressure >79 mm Hg, or by those receiving antihypertensive medications.

RESULTS

14% of older Indians possessed EW, whereas 35% possessed CA; 50.9% of the wealthier third and 27.7% of the poorer two-thirds have CA; the proportions being 69.1% and 46.2%, respectively, in older women. Mostly wealth (adjusted OR for CA: 4.36 (3.23 to 5.95) and EW: 4.39 (3.49 to 5.53)), but also urban residence, privileged caste, higher education, white-collared occupation and female gender, were important determinants. One of 17 older Indians overall and 1 of 18 in the poorer 70% suffered from CA-driven hypertension, independent of BMI.

CONCLUSIONS

The problem of CA and its allied diseases is already substantial and expected to rise across all socioeconomic strata of older Indians, though currently, CA affects the privileged more than the underprivileged, in later life. Population-based promotion of appropriate lifestyles, with special emphasis on women, is required to counteract prosperity-driven obesity before it becomes too entrenched and expensive to uproot.

The rising burden of chronic conditions among urban poor: a three-year follow-up survey in Bengaluru, India

Background

Chronic conditions are on rise globally and in India. Prevailing intra-urban inequities in access to healthcare services compounds the problems faced by urban poor. This paper reports the trends in self-reported prevalence of chronic conditions and health-seeking pattern among residents of a poor urban neighborhood in south India.

Methods

A cross sectional survey of 1099 households (5340 individuals) was conducted using a structured questionnaire. The prevalence and health-seeking pattern for chronic conditions in general and for hypertension and diabetes in particular were assessed and compared with a survey conducted in the same community three years ago. The predictors of prevalence and health-seeking pattern were analyzed through a multivariable logistic regression analysis.

Results

The overall self-reported prevalence of chronic conditions was 12 %, with hypertension (7 %) and diabetes (5.8 %) being the common conditions. The self-reported prevalence of chronic conditions increased by 3.8 percentage point over a period of three years (OR: 1.5). Older people, women and people living below the poverty line had greater odds of having chronic conditions across the two studies compared. Majority of patients (89.3 %) sought care from private health facilities indicating a decrease by 8.7 percentage points in use of government health facility compared to the earlier study (OR: 0.5). Patients seeking care from super specialty hospitals and those living below the poverty line were more likely to seek care from government health facilities.

Conclusion

There is need to strengthen health services with a preferential focus on government services to assure affordable care for chronic conditions to urban poor.

The need for multisectoral food chain approaches to reduce trans fat consumption in India

BACKGROUND

The World Health Organization (WHO) recommends virtually eliminating trans fat from the global food supply. Although several high-income countries have successfully reduced trans fat levels in foods, low- and middle-income countries such as India face additional challenges to its removal from the food supply. This study provides a systems analysis of the Indian food chain to assess intervention options for reducing trans fat intake in low-income consumers.

METHODS

Data were collected at the manufacturer, retailer and consumer levels. Qualitative interviews were conducted with vanaspati manufacturers (n = 13) and local food vendors (n = 44). Laboratory analyses (n = 39) of street foods/snacks sold by the vendors were also conducted. Trans fat and snack intakes were also examined in low-income consumers in two rural villages (n = 260) and an urban slum (n = 261).

RESULTS

Manufacturers of vanaspati described reducing trans fat levels as feasible but identified challenges in using healthier oils. The fat content of sampled oils from street vendors contained high levels of saturated fat (24.7-69.3 % of total fat) and trans fat (0.1-29.9 % of total fat). Households were consuming snacks high in trans fat as part of daily diets (31 % village and 84.3 % of slum households) and 4 % of rural and 13 % of urban households exceeded WHO recommendations for trans fat intakes.

CONCLUSIONS

A multisectoral food chain approach to reducing trans fat is needed in India and likely in other low- and middle-income countries worldwide. This will require investment in development of competitively priced bakery shortenings and economic incentives for manufacturing foods using healthier oils. Increased production of healthier oils will also be required alongside these investments, which will become increasingly important as more and more countries begin investing in palm oil production.

Educational status-related disparities in awareness, treatment and control of cardiovascular risk factors in India

OBJECTIVE

To determine association of socioeconomic status, defined by educational status (ES), with awareness, treatment and control of cardiovascular risk factors.

METHODS

We performed an epidemiological study at 11 cities in India using cluster sampling. 6198 subjects (3426 men, 2772 women, response 62%, age 48±10 years) were evaluated for sociodemographic, lifestyle, anthropometric and biochemical factors. ES was categorised according to years of schooling into low (≤10 years), medium (11-15 years) and high (>15 years). Risk factors were diagnosed according to current guidelines. Awareness, treatment and control status were determined for hypertension, diabetes and hypercholesterolaemia. For smoking/tobacco use, quit rate was determined. Descriptive statistics are reported.

RESULTS

Age-adjusted and sex-adjusted prevalence (%) of various risk factors in low, medium and high ES subjects was hypertension 31.8, 29.5 and 34.1, diabetes 14.5, 15.3 and 14.3, hypercholesterolaemia 24.0, 23.9 and 27.3, and smoking/tobacco use 24.3, 14.4 and 19.0. Significantly increasing trends with low, medium and high ES were observed for hypertension awareness (30.7, 37.8, 47.0), treatment (24.3, 29.2, 35.5) and control (7.8, 11.6, 15.5); diabetes awareness (47.2, 51.5, 56.4), treatment (38.3, 41.3, 46.0) and control (18.3, 15.3, 22.8); hypercholesterolaemia awareness (8.9, 22.4, 18.4), treatment (4.1, 6.2, 7.9) and control (2.8, 3.2, 6.9), as well as for smoking/tobacco quit rates (1.6, 2.8, 5.5) (χ(2) for trend, p<0.05).

CONCLUSIONS

Low ES subjects in India have lower awareness, treatment and control of hypertension, diabetes and hypercholesterolaemia and smoking quit rates.