Social class and coronary disease in rural population of north India. The Indian Social Class and Heart Survey

Socioeconomic status and education level are associated with dyslipidemia in adults not taking lipid-lowering medication: a population-based study

BACKGROUND

Socio-economic disparities account for changes in the lipid profile in developing countries. We aimed to investigate the association between blood lipids and socio-economic and educational strata in adults not taking lipid-lowering medications.

METHODS

A cross-sectional, population-based study enrolled 1614 individuals not taking lipid-lowering medications. Sociodemographic characteristics, monthly income, education level and the number of consumer goods available at home were obtained and individuals were classified into five socio-economic categories. Blood lipids were obtained in fasting participants.

RESULTS

In men, the higher the socio-economic or educational stratum, the higher the total cholesterol, low-density lipoprotein cholesterol (LDL-c) and triglyceride (TG) levels and the lower the high-density lipoprotein cholesterol (HDL-c), after controlling for age, body mass index, hypertension, smoking habit and physical activity. In women, the higher socio-economic strata were associated with elevated total cholesterol and HDL-c, while lower total cholesterol, LDL-c and TG levels were found in those with higher education levels. Also, individuals in the upper socio-economic strata had higher levels of total cholesterol and LDL-c, showing more than two times higher odds of having multiple alterations in blood lipids (men: OR 2.99 [95% CI 1.23 to 5.07]; women: OR 2.31 [95% CI 1.09 to 5.83]).

CONCLUSIONS

Dyslipidemia is highly prevalent in developing countries. Individuals in the highest socio-economic category are the ones at higher risk for dyslipidemia. This phenomenon calls for strategies to stimulate healthy diet habits and a physically active lifestyle to minimize health problems.

Socioeconomic Status and Its Relation to Hypertension in Rural Nepal

INTRODUCTION

Hypertension and its association with socioeconomic positions are well established. However, the gradient of these relationships and the mediating role of lifestyle factors among rural population in low- and middle-income countries such as Nepal are not fully understood. We sought to assess the association between socioeconomic factors (education, income, and employment status) and hypertension. Also, we assessed whether the effect of education and income level on hypertension was mediated by lifestyle factors.

METHODS

This cross-sectional study was conducted among 260 participants aged ≥18 years attending a rural health center in Dolakha, Nepal. Self-reported data on demographic, socioeconomic, and lifestyle factors were collected, and blood pressure, weight, and height were measured for all study participants. Those with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or administrating high blood pressure-lowering medicines were regarded as hypertensives. Poisson regression models were used to estimate the prevalence ratios and corresponding 95% confidence intervals to assess the association between socioeconomic factors and hypertension. We explored mediation, using the medeff command in Stata for causal mediation analysis of nonlinear models.

RESULTS

Of the 50 hypertensive participants, sixty percent were aware of their status. The age-standardized prevalence of hypertension was two times higher for those with higher education or high-income category. Compared to low-income and unemployed groups, the prevalence ratio of hypertension was 1.33 and 2.26 times more for those belonging to the high-income and employed groups, respectively. No evidence of mediation by lifestyle factors was observed between socioeconomic status and hypertension.

CONCLUSIONS

Socioeconomic positions were positively associated with hypertension prevalence in rural Nepal. Further studies using longitudinal settings are necessary to validate our findings especially in low- and middle-income countries such as Nepal.

A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries

Background

Non-communicable diseases (NCDs) are the leading cause of death globally. Eighty-two percent of premature NCD deaths occur within low- and lower middle-income countries (LLMICs). Research to date, largely drawn from high-income countries, suggests that disadvantaged and marginalized groups have a higher NCD burden, but there has been a dearth of research studying this relationship within LLMICs. The purpose of this systematic review is to map the literature on evidence from LLMICs on the socio-economic status (SES) gradient of four particular NCDs: cardiovascular disease, cancer, diabetes, and chronic respiratory diseases.

Methods

We conducted a comprehensive literature search for primary research published between 1 January 1990 and 27 April 2015 using six bibliographic databases and web resources. We included studies that reported SES and morbidity or mortality from cardiovascular disease, cancer, diabetes and chronic respiratory diseases within LLMICs.

Results

Fifty-seven studies from 17 LLMICs met our inclusion criteria. Fourteen of the 18 papers that reported significant associations between cancer and SES suggested that low SES groups had the highest cancer risk. Eleven of 15 papers reporting significant relationships between CVD and SES suggested that low SES groups have higher risk. In contrast, seven of 12 papers reporting significant findings related to diabetes found that higher SES groups had higher diabetes risk. We identified just three studies on the relationship between chronic respiratory diseases and SES; none of them reported significant findings.

Conclusions

Only 17 of the 84 LLMICs were represented, highlighting the need for more research on NCDs within these countries. The majority of studies were medium to high quality cross-sectional studies. When we restricted our analyses to high quality studies only, for both cancer and cardiovascular disease more than half of studies found a significantly higher risk for those of lower SES. The opposite was true for diabetes, whilst there was a paucity of high quality research on chronic respiratory disease. Development programmes must consider health alongside other aims and NCD prevention interventions must target all members of the population.

Systematic review registration number

Prospero: CRD42015020169.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

BACKGROUND

Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs.

METHODS

We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604.

FINDINGS

After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings.

INTERPRETATION

Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4-reducing premature non-communicable disease mortality by a third by 2030-should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases.

FUNDING

WHO.

Can We Afford Better Health? A Study of the Health Differentials in China

Using survey data collected in eight provinces of China, this study examines the relationship between income disparities and adult physical health outcomes. It also explores the mechanisms underlying these income differentials in health. Our results show that the association between income and health can be explained largely by income differences in other areas. In the Chinese social context, we find that living conditions, access to health care services and community development are important mediating factors. These findings generally agree with earlier explanations on socioeconomic differentials in health. We also find that the factors that are most important in explaining income differentials in health vary by rural/urban residence. However, the results show that these factors are unable to fully explain income differentials in reported illness and disability. Moreover, we do not find consistent effects of lifestyle and health-related behaviors, such as drinking and smoking, on the link between income and health.

Cardiovascular Risk Factors in Iranian Adults according to Educational Levels: Isfahan Healthy Heart Program

There is abundant evidence that the socioeconomic status (SES) is inversely associated with CVD risk factors. The objective of this study is to describe the distribution of CVD risk factors according to educational level in Iranian adults. A cross-sectional survey was performed on subjects over the age of 19 in three cities. Demographic data, as well as information on educational level and smoking habits was obtained and then height, weight and blood pressure measurement and blood sampling were arranged. Data was analyzed by the Mantel-Haenszel, Kendalls T correlation and multivariate analysis test. Of 9587 subjects, 48% were men and 52% were women, with mean ages of 39.0±15.3 and 38.8±14.5 years, respectively. All CVD risk factors showed an inverse relationship with educational level in all subjects, except for smoking and low HDL-C in women. High TC and LDL-C and low HDL-C were inversely related to educational level (P<0.05); however, this relationship was not significant with Mantel-Haenszel test in men. The association between CVD risk factors and educational level in women was stronger than in men. The differences found between CVD risk factors with educational level are important and should be considered in programs designed to increase level of education in order to lower CVD risk factors. Asia Pac J Public Health 2005: 17(1): 9-14.

Social distribution of diabetes, hypertension and related risk factors in Barbados: a cross-sectional study

OBJECTIVE

To describe the distribution of diabetes, hypertension and related behavioural and biological risk factors in adults in Barbados by gender, education and occupation.

DESIGN

Multistage probability sampling was used to select a representative sample of the adult population (≥ 25 years). Participants were interviewed using standard questionnaires, underwent anthropometric and blood pressure measurements, and provided fasting blood for glucose and cholesterol measurements. Standard WHO definitions were used. Data were weighted for sampling and non-response, and were age and sex standardised to the 2010 Barbados population. Weighted prevalence estimates were calculated, and prevalence ratios were calculated for behavioural and biological risk factors by demographic and socioeconomic group.

RESULTS

Study response rate was 55.0%, with 764 women, 470 men. Prevalence of obesity was 33.8% (95% CI 30.7% to 37.1%); hypertension 40.6% (95% CI 36.5% to 44.9%); and diabetes 18.7% (95% CI 16.2% to 21.4%). Compared with women, men were less likely to be obese (prevalence ratio 0.5; 95% CI 0.4 to 0.7), or physically inactive (0.5; 0.4 to 0.6), but more likely to smoke tobacco (4.1; 2.5 to 6.7) and consume large amounts of alcohol in a single episode (4.6; 2.7 to 7.6). Both diabetes (0.83; 0.65 to 1.05) and hypertension (0.89; 0.79 to 1.02) were lower in men, but not significantly so. In women, higher educational level was related to higher fruit and vegetable intake, more physical activity, less diabetes and less hypercholesterolaemia (p 0.01-0.04). In men, higher education was related only to less smoking (p 0.04). Differences by occupation were limited to smoking in men and hypercholesterolaemia in women.

CONCLUSIONS

In this developing country population, sex appears to be a much stronger determinant of behavioural risk factors, as well as obesity and its related risks, than education or occupation. These findings have implications for meeting the commitments made in the 2011 Rio Political Declaration, to eliminate health inequities.

National prevalence of coronary heart disease and its relationship with human development index: A systematic review

BACKGROUND

Coronary heart disease has become a major health concern over the past several decades. Several reviews have assessed the effects of socioeconomic status on the coronary heart disease epidemic in communities and countries, but only a few reviews have been performed at a global level. This study was to explore the relationship between the prevalence of coronary heart disease and socioeconomic development worldwide using the Human Development Index.

DESIGN

Systematic review.

METHODS

The data in this study were collected from the MEDLINE database. Cross-sectional studies reporting the prevalence of coronary heart disease until November 2014 were collected. The Human Development Index was sourced from the United Nations Development Programme Database and was used to measure the socioeconomic achievements of countries. Each country was classified as a developing or developed country based on its level of development according to the Human Development Index value.

RESULTS

Based on the data analysis on the global level, coronary heart disease prevalence had no association with the national Human Development Index (rho = 0.07). However, there was a positive association between coronary heart disease prevalence and the national Human Development Index in developing countries, although a negative association existed in developed countries (rho = 0.47 and -0.34, respectively). In addition, the past decades have witnessed a growing coronary heart disease epidemic in developing countries, with reverse trends observed in developed countries (P = 0.021 and 0.002, respectively).

CONCLUSIONS

With the development of socioeconomic status, as measured by the Human Development Index, the prevalence of coronary heart disease is growing in developing countries, while declining in developed countries. Future research needs to pay more attention to the reasonable allocation of medical resources and control of coronary heart disease risk factors.

Distribution of lipid parameters according to different socio-economic indicators- the EPIC-Norfolk prospective population study

Background

Data on the relationship between plasma levels of cholesterol and triglycerides and social class have been inconsistent. Most previous studies have used one classification of social class.

Methods

This was a cross-sectional population based study with data on occupational social class, educational level obtained using a detailed health and lifestyle questionnaire. A total of 10,147 men and 12,304 women aged 45–80 years living in Norfolk, United Kingdom, were recruited using general practice age-sex registers as part of the European Prospective Investigation into Cancer (EPIC-Norfolk). Plasma levels of cholesterol and triglycerides were measured in baseline samples. Social class was classified according to three classifications: occupation, educational level, and area deprivation score according to Townsend deprivation index. Differences in lipid levels by socio-economic status indices were quantified by analysis of variance (ANOVA) and multiple linear regression after adjusting for body mass index and alcohol consumption.

Results

Total cholesterol levels were associated with occupational level among men, and with educational level among women. Triglyceride levels were associated with educational level and occupational level among women, but the latter association was lost after adjustment for age and body mass index. HDL-cholesterol levels were associated with both educational level and educational level among men and women. The relationships with educational level were substantially attenuated by adjustment for age, body mass index and alcohol use, whereas the association with educational class was retained upon adjustment. LDL-cholesterol levels were not associated with social class indices among men, but a positive association was observed with educational class among women. This association was not affected by adjustment for age, body mass index and alcohol use.

Conclusions

The findings of this study suggest that there are sex differences in the association between socio-economic status and serum lipid levels. The variations in lipid profile with socio-economic status may be largely attributed to potentially modifiable factors such as obesity, physical activity and dietary intake.

Association between socioeconomic status and self-reported diabetes in India: a cross-sectional multilevel analysis

OBJECTIVES

To quantify the association between socioeconomic status (SES) and type 2 diabetes in India.

DESIGN

Nationally representative cross-sectional household survey.

SETTING

Urban and rural areas across 29 states in India.

PARTICIPANTS

168 135 survey respondents aged 18-49 years (women) and 18-54 years (men).

PRIMARY OUTCOME MEASURE

Self-reported diabetes status.

RESULTS

Markers of SES were social caste, household wealth and education. The overall prevalence of self-reported diabetes was 1.5%; this increased to 1.9% and 2.5% for those with the highest levels of education and household wealth, respectively. In multilevel logistic regression models (adjusted for age, gender, religion, marital status and place of residence), education (OR 1.87 for higher education vs no education) and household wealth (OR 4.04 for richest quintile vs poorest) were positively related to self-reported diabetes (p<0.0001). In a fully adjusted model including all socioeconomic variables and body mass index, household wealth emerged as positive and statistically significant with an OR for self-reported diabetes of 2.58 (95% credible interval (CrI): 1.99 to 3.40) for the richest quintile of household wealth versus the poorest. Nationally in India, a one-quintile increase in household wealth was associated with an OR of 1.31 (95% CrI 1.20 to 1.42) for self-reported diabetes. This association was consistent across states with the relationship found to be positive in 97% of states (28 of 29) and statistically significant in 69% (20 of 29 states).

CONCLUSIONS

The authors found that the highest SES groups in India appear to be at greatest risk for type 2 diabetes. This raises important policy implications for addressing the disease burdens among the poor versus those among the non-poor in the context of India, where >40% of the population is living in poverty.

Socioeconomic status and coronary heart disease

BACKGROUND

Iran has undergone a remarkable demographic transition over the last three decades. Socioeconomic status (SES) indicators including education, income, and occupation are associated with coronary heart disease (CHD) risk factors, morbidity, and mortality. The aim of the present study was to describe demographic and socioeconomic characteristics, their association to the diseases, and to explore the predictive risk of CHD in Tabriz, the fourth largest city in Iran and the capital of East Azerbaijan Province.

METHODS

This cross-sectional descriptive study was carried out to explore and analyze the current SES status of CHD patients. The study was conducted in Tabriz and all patients (n=189) refereed to the Central Referral Hospital for cardiac patients (Shahid Madani Hospi-tal) from 2009 to 2010 were considered. A researcher structured questionnaire with 15 ques-tions was used to collect data. Descriptive statistics were used to describe the basic SES fea-tures of the CHD patients and data analysis was done using SPSS ver. 16.

RESULTS

Less educated participants were more susceptible to CHD. Regarding to occupa-tional status, housewives and retired men were in higher risk of CHD than the rest of the peo-ple.  Studied patients also reported to be mostly from urban areas that were living in apart-ment complexes.

CONCLUSION

In line with some international research evidence the study results suggested that people from lower/middle social classes were in greater CHD risk than higher social classes.  This epidemic might be halted through the promotion of healthier lifestyles and the support of environmental and policy changes.

Effect of crude extract of Bombyx mori coccoons in hyperlipidemia and atherosclerosis

The silkworm is the larva or caterpillar of the domesticated silkmoth, Bombyx mori and being a primary producer of silk is an economically important insect. These days the silk is emerging as a resource for solving a broad range of biological problems. The silk (Abresham) is popularly known as Abresham muqriz (muqriz means cut) in Unani medicine. Its cocoons are extensively used as an ingredient of various Unani formulations like Khameer-E- Abresham Sada, Khameere Abresham Hakeem Arshad Wala, Khameere Abresham Ood Mastagi Wala etc. and are used to treat many cardiac and nervous disorders. The hypolipidemic activity of this drug, along with Nepata Hindostana (Badranjboya) and Terminalia Arjuna (Arjan) has been documented. But action of extract of Bombyx mori cocoons as a single drug is not documented. That's why; it was decided to study its effect on hyperlipidemia and atherosclerosis. The Male New Zealand White rabbits all of 1.5kgs were selected for the study. After stabilization period (2 weeks) the rabbits were divided into 3 groups (Group I - Control, Group II Lesion Control and Group III treated with extract of Bombyx mori silk cocoon). Hyperlipidemia and atherosclerosis were induced with 1% cholesterol diet. After induction of hyperlipidemia and atherosclerosis for twelve weeks, Group III rabbits were treated with Bombyx mori for 6 weeks (45 days). A significant decrease in hyperlipidemia was seen within 4 weeks of treatment. Histopathologically, the atherosclerotic plaques showed reduction in size. The third group showed a significant increase in the body weight and also an increase in the HDL cholesterol levels. The study concludes that extract of Bombyx mori cocoons has a significant effect on hypercholesterolemia and atherosclerosis probably because of its antioxidant and hypolipidemic effect.

Socioeconomic patterning in tobacco use in Argentina, 2005

INTRODUCTION

Globally, tobacco is the number one preventable cause of death, killing 1 in 10 adults. By 2030, 80% of all tobacco deaths will occur in developing countries. Social factors drive the adoption and cessation of smoking in high-income countries, but few studies have examined the socioeconomic patterning of smoking in developing countries.

METHODS

Using data from the 2005 National Survey of Risk Factors for Non-communicable Diseases in Argentina, we investigated gender-specific socioeconomic patterning of current, former, and never-smoking status; the intensity of smoking; and smokers' readiness for cessation using multinomial logistic and ordinary least squares regression. We also investigated heterogeneity in the patterning by age.

RESULTS

Higher socioeconomic position (SEP) was associated with less smoking for men in all age groups, although the results were most pronounced for men at younger ages (odds ratio [OR] of current vs. never smoking = 0.57, 95% CI 0.51-0.63 for higher vs. lower education at ages 18-24 years). For women, higher SEP was associated with more smoking in older age groups but less smoking in younger age groups (OR = 1.51, CI 1.41-1.62 and OR = 0.86, CI 0.78-0.96 for higher vs. lower education at ages 50-64 and 18-24 years, respectively). Higher SEP was also associated with higher odds of recently quitting compared to not considering quitting for men regardless of age group but for women only in younger age groups.

DISCUSSION

The higher burden of smoking among those of lower SEP, especially in younger age groups, is a troubling pattern that is certain to impact future disparities in chronic disease outcomes unless interventions are undertaken.

Global use of alcohol, drugs and tobacco

Humans have always used drugs, probably as part of their evolutionary and nutritional heritage. However, this previous biological adaptation is unlikely to be so in the modern world, in which 2 billion adults (48% of the adult population) are current users of alcohol, 1.1 billion adults (29% of the adult population) are current smokers of cigarettes and 185 million adults (4.5% of the adult population) are current users of illicit drugs. The use of drugs is determined largely by market forces, with increases in affordability and availability increasing use. People with socio-economic deprivation, however measured, are at increased risk of harmful drug use, as are those with a disadvantaged family environment, and those who live in a community with higher levels of substance use. Substance use is on the increase in low-income countries which, in the coming decades, will bear a disproportionate burden of substance-related disability and premature death.

Prevalence of ischemic heart disease among urban population of siliguri, west bengal

OBJECTIVES

To determine the prevalence of ischemic heart disease and the associated risk factors among the urban population of Siliguri.

MATERIALS AND METHODS

A cross-sectional survey of a random sample of the population aged >/=40 years old in the Municipal Corporation area of Siliguri. Study variables were age, sex, occupation, addiction, food habit, physical activity, body mass index, blood pressure, and electrocardiogram change.

RESULTS

Out of 250 individuals who took part in this study, 29 (11.6%) had ischemic heart disease (IHD) and 118 (47.2%) had hypertension. Males had a higher (13.5%) prevalence of IHD than females (9.4%). About 5% of the patients had asymptomatic IHD. IHD among the study population is significantly associated with hypertension and smoking.

Social patterning of chronic disease risk factors in a Latin American city

Most studies of socioeconomic status (SES) and chronic disease risk factors have been conducted in high-income countries, and most show inverse social gradients. Few studies examine these patterns in lower- or middle-income countries. Using cross-sectional data from a 2005 national risk factor survey in Argentina (a middle-income country), we investigated the associations of individual- and area-level SES with chronic disease risk factors (body mass index [BMI], hypertension, and diabetes) among residents of Buenos Aires. Associations of risk factors with income and education were estimated after adjusting for age, sex (except in sex-stratified models), and the other socioeconomic indicators. BMI and obesity were inversely associated with education and income for women, but not for men (e.g., mean differences in BMI for lowest versus highest education level were 1.55 kg/m2, 95%CI = 0.72-2.37 in women and 0.17 kg/m2, 95%CI = -0.72-1.06 in men). Low education and income were also associated with increased odds of hypertension diagnosis in all adults (adjusted odds ratio [AOR] = 1.48, 95%CI = 0.99-2.20 and AOR = 1.50, 95%CI = 0.99-2.26 for the lowest compared to the highest education and income categories, respectively). Lower education was strongly associated with increased odds of diabetes diagnosis (AOR = 4.12, 95%CI = 1.85-9.18 and AOR = 2.43, 95%CI = 1.14-5.20 for the lowest and middle education categories compared to highest, respectively). Area-level education also showed an inverse relationship with BMI and obesity; these results did not vary by sex as they did at the individual level. This cross-sectional study of a major urban area provides some insight into the global transition with a trend toward concentrations of risk factors in poorer populations.

Obesity and dyslipidemia among young general physicians in Iran

This study describes overweight, obesity and dyslipidemia in young general physicians aged 26-40 years in Rasht City, northern Iran. A random sample of 272 physicians (137 men and 135 women) was studied. Data on age, body weight, height and original weight were collected; and blood lipid levels were measured. The findings showed that the prevalence of overweight/obesity among men and women were 54.5% and 13.3% respectively. High serum LDL-c levels (54.5%) and low serum level of HDL-c (66.7%) was the main feature of dyslipidemia in the study men and women, respectively. These data showed that overweight and blood lipid abnormality is highly prevalent in this group of young physicians. The increasing prevalence of obesity in the Iranian medical professions is a cause for concern.

Is coronary heart disease rising in India? A systematic review based on ECG defined coronary heart disease

The aim of this study was to investigate whether coronary heart disease (CHD) is rising in India and assess the quality of the evidence. Thirty one studies were reviewed. The sample sizes of the studies varied from approximately 500 to 14,000, with response rates generally over 90%. Many did not fulfil basic requirements for epidemiological research and most studies were in or around Delhi. The three incidence studies used different diagnostic criteria; however, the incidence of myocardial infarction (MI) in urban India in the 14 years to 1991 remained similar at about 6/1000 in males and 2/1000 in females. Prevalence range was higher in urban than rural areas in men (35-90/1000 v 17-45/1000) and women (28-93/1000 v 13-43/1000). There was no clear rise in age specific rates in men over a 27 year period, whereas a rise was seen in women. In conclusion, using a relatively objective measure of CHD it was found that CHD is more common in urban than rural areas of India, but there was little evidence of a rise in CHD over time, especially in men.

Family income a strong predictor of coronary heart disease events but not of overall deaths among Turkish adults: a 12-year prospective study

OBJECTIVE

The objective of this study was to assess whether family income affected future deaths and coronary heart disease (CHD) events.

DESIGN

A prospective population-based survey (the Turkish Adult Risk Factor study) was used.

SETTING

The setting was numerous communities in all geographic regions of Turkey surveyed between 1990 and 2001/2002.

SUBJECTS

The subjects were a random sample of 2704 men and women 20 years of age or over at baseline examination.

METHOD

Monthly family incomes were categorized by the participants into four increasing brackets. Information on the mode of deaths was obtained from first-degree relatives and/or health personnel of the local heath office. The diagnosis of definite or suspected CHD among survivors was based on history, physical examination of the cardiovascular system, and Minnesota coding of resting ECGs. CHD event was defined as newly developed fatal or nonfatal myocardial infarction, new onset stable angina, and/or myocardial ischemia following the baseline survey. After exclusion of participants with CHD at onset, 250 deaths and 297 fatal and nonfatal CHD occurred among 2704 men and women (mean age 41.6+/-15) during a mean 10.0 years of follow-up.

MAIN RESULTS

All-cause deaths failed to be significantly associated with income brackets in logistic regression analysis when adjusted for age, sex, and three major risk factors. Systolic blood pressure and cigarette smoking were significant independent predictors of overall mortality. In regard to fatal and nonfatal CHD, even after adjusting for age, sex and three major risk factors, a significant excess was noted in the two lowest brackets as opposed to the high income bracket (relative risk 1.56 and 1.75, respectively, P<0.03).

CONCLUSIONS

Family income in the Turkish community was not predictive of overall mortality, but was strongly predictive of future CHD events independent of age, sex, and three major factors, posing a huge coronary risk on the individual and the society.

Lipids and coronary heart disease in Asia

In Western countries, it has been shown that coronary heart disease (CHD) is related to high serum total cholesterol (TC) levels. In less developed continents such as Asia and Africa, serum lipid levels are low and CHD incidence is much lower as compared with Western countries. With growing urbanization and industrialization in Asia, it has been shown that there is a concomitant rise in the level of serum TC and with it a rise in CHD. In all the Asian countries, serum TC levels are also higher in the urban compared with the rural population. Singapore, the only Asian country which is 100% urbanized since 1980, showed a rise of serum TC similar to that seen in the US and UK from the 1950s to the 1980s followed thereafter by a fall. This is reflected in the trend (rise followed by a fall) of CHD morbidity and mortality as well. In spite of a declining trend in serum TC level, CHD morbidity and mortality are still high in Singapore and comparable to the Western countries. The rest of the Asian countries show a different pattern from Singapore. In general, there is still a rising trend in serum TC level and in CHD mortality in most Asian countries. However, Japan is considered an exception in having a decreasing CHD mortality in spite of an increasing trend in serum TC. This may be attributed to a better control of other CHD risk factors such as hypertension and smoking. The rising trend in serum TC level remains a cause for concern, as this will emerge as a major problem for CHD morbidity and mortality in the future.

Socioeconomic status and the prevalence of coronary heart disease risk factors

South Asian countries have a high prevalence of coronary heart disease (CHD) in line with their economic development. India, in particular, has a high burden of CHD. Hence, the aim of the present study was to assess the prevalence of CHD risk factors in a semiurban population of Andhra Pradesh, India, in different socioeconomic status (SES) groups. Information was collected on socioeconomic status, physical activity, cigarette smoking, body mass, blood pressure (BP) and serum lipid profiles among a healthy sample of 440 men and 210 women with an age range of 20-70 years. Mean levels of serum cholesterol (SC), high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC) and skinfold ratio were found to be higher among women, whereas triglycerides (TG), systolic BP and diastolic BP were higher in men. No statistically significant differences in body mass index (BMI) or pulse rate were observed between the sexes. In men, a significant positive rank correlation (rho = P < 0.05) was observed between SES and SC, TG, systolic and diastolic BP, pulse rate and BMI, but in women, the same trend was found only with SC, TG, skinfold ratio and age. The prevalence (age standardized to the world population of Segi, 95% CI) of obesity was 14.37% (11.06-17.68), hypertension 13.13% (9.11-17.15), hypercholesterolemia 18.56% (13.88-23.24), hypertriglyceridemia 45.98% (36.47-55.49) and low HDLC 31.01% (24.25-37.77). In both sexes, the prevalence of hypercholesterolemia, hypertriglyceridemia and sedentary life style increased among higher SES groups (P < 0.05). Also, an increase in the level of social class was positively associated with mean levels of serum cholesterol and triglycerides in both men and women. The results demonstrate that higher SES groups have greater prevalence of CHD risk factors than lower SES groups. Preventive measures are required to reduce the risk factors among higher SES groups.

Social class, coronary risk factors and undernutrition, a double burden of diseases, in women during transition, in five Indian cities

OBJECTIVE

To find out the association between social class and coronary risk factors in women.

DESIGN AND SETTING

Cross-sectional surveys were conducted in six-twelve urban streets in each of five cities from various regions of India following a common study protocol and criteria of diagnosis.

SUBJECTS AND METHODS

We randomly selected 3257 women, aged 25-64 years inclusive, from the cities of Moradabad (n=902), Trivandrum (n=760) Calcutta (n=410), Nagpur (n=405) and Bombay (n=780). Evaluation was by questionnaires validated at Moradabad. All subjects, after pooling of data, were divided into social class 1 (n=985), social class 2 (n=790), social class 3 (n=674), social class 4 (n=602) and social class 5 (n=206), based on various attributes of socioeconomic status.

RESULTS

The prevalence of hypertension, diabetes mellitus, family history of coronary disease, obesity, central obesity and sedentary lifestyle were significantly associated with higher social classes and tobacco consumption was not associated with social class. Oral contraceptive intake and postmenopausal status were also more common among higher social classes, which may be due to more education and a longer lifespan among the higher social classes, respectively. Mean total cholesterol, high density lipoprotein cholesterol, systolic and diastolic blood pressure, mean body mass index and waist-hip ratio showed significant association with higher social classes. Mean age, body weight, body mass index, waist-hip ratio, systolic and diastolic blood pressure, total cholesterol and 2-h blood glucose were significantly positively correlated with social class, as assessed by Spearman's rank correlation. Higher social classes 1-3 were more common in Trivandrum and Bombay than in Moradabad. The prevalence of hypertension, diabetes mellitus and being overweight (body mass index >25 kg/m2) were also more common in Trivandrum and Bombay compared to Moradabad. Undernutrition was negatively associated with higher social classes and was more common in Moradabad and Nagpur than Trivandrum.

CONCLUSIONS

Higher social classes among Indian urban women have a higher prevalence of coronary risk factors, hypertension, diabetes mellitus, being overweight, central obesity, sedentary lifestyle, family history of coronary disease, oral contraceptive intake and postmenopausal status. Mean concentrations of total and high density lipoprotein cholesterol were also significantly associated with higher social classes.

Serum cholesterol and coronary artery disease in populations with low cholesterol levels: the Indian paradox

OBJECTIVE

To examine the relation between serum cholesterol and coronary artery disease prevalence below the range of cholesterol values generally observed in developed countries.

DESIGN AND SETTING

Cross-sectional survey of two randomly selected villages from Moradabad district and 20 randomly selected streets in the city of Moradabad.

SUBJECTS AND METHODS

3575 Indians, aged 25-64 years including 1769 rural (894 men, 875 women) and 1806 urban (904 men, 902 women) subjects. The survey methods were questionnaires, physical examination and electrocardiography.

RESULTS

The overall prevalences of coronary artery disease were 9.0% in urban and 3.3% in rural subjects and the prevalences were significantly (P<0.001) higher in men compared to women in both urban (11.0 vs. 6.9%) and rural subjects (3.9 vs. 2.6%). The average serum cholesterol concentrations were 4.91 mmol/l in urban and 4.22 mmol/l in rural subjects without any sex differences. The prevalences of coronary artery disease were significantly higher among subjects with low and high serum cholesterol concentration compared to subjects with very low cholesterol and showed a positive relation with serum cholesterol within the range of serum cholesterol level studied in both rural and urban in both sexes. Among subjects with low serum cholesterol, there was a higher prevalence of coronary risk factors, hypertension, diabetes, obesity and sedentary lifestyle. Serum cholesterol level showed a significant positive relation with low density lipoprotein cholesterol and triglycerides in all the four subgroups. Logistic regression analysis after pooling of data from both rural and urban, with adjustment of age showed that low serum cholesterol level (odds ratio: men 0.96, women 0.91) had a positive strong relation with coronary artery disease and there was no evidence of any threshold. Diabetes mellitus (men 0.73, women 0.74) and sedentary lifestyle (men 0.86, women 0.74) were significant risk factors of coronary disease in both sexes. Hypertension (men 0.82, women 0.64) and smoking (men 0.81, women 0.52) were weakly associated with coronary disease in men but not in women.

CONCLUSION

Serum cholesterol level was directly related to prevalence of coronary artery disease even in those with low cholesterol concentration (<5.18 mmol/l). It is possible that some Indian populations may benefit by increased physical activity and decline in serum cholesterol below the range of desired serum cholesterol in developed countries.

Social class and coronary artery disease in a urban population of North India in the Indian Lifestyle and Heart Study

OBJECTIVE

To determine the association of social class with prevalence of coronary risk factors and coronary artery disease (CAD).

DESIGN AND SETTING

Total community cross sectional survey of 20 randomly selected streets in the city of Moradabad.

SUBJECTS AND METHODS

1806 urban (904 men and 902 women) randomly selected subjects aged 25-64 years. The survey methods were physician and dietitian administered questionnaire, physical examination and electrocardiography. All subjects were divided into social classes 1-5 based on attributes of education, occupation, per capita income, housing condition and consumer durables and other family assets.

RESULTS

Social classes 1, 2 and 3 were mainly high and middle socioeconomic groups and 3 and 4 low income groups. The prevalence of CAD and coronary risk factors hypercholesterolemia, hypertension, diabetes mellitus and sedentary lifestyle were significantly higher among social classes 1, 2 and 3 in both sexes compared to lower social classes. Mean serum cholesterol, triglycerides, low density lipoprotein cholesterol and blood pressure were significantly associated with higher and middle social classes. Smoking was significantly associated with lower social classes. Multivariate logistic regression analysis after adjustment of age revealed that social class was positively associated with CAD (odds ratio: men 0.84, women 0.86), hypercholesterolemia (men 0.87, women 0.85), hypertension (men 0.91, women 0.89), diabetes mellitus (men 0.71, women 0.68) and sedentary lifestyle (men 0.68, women 0.66). Smoking was significantly associated with CAD in men.

CONCLUSION

Social class 1, 2 and 3 in an urban population of India have a higher prevalence of CAD and coronary risk factors hypercholesterolemia, hypertension, diabetes mellitus and sedentary lifestyle in both sexes.