Translating evidence into policy for cardiovascular disease control in India

Regional and socio-demographic variation in laboratory-based predictions of 10-year cardiovascular disease risk among adults in north and south India

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in India. There is no laboratory-based CVD risk data among Indians from different regions and backgrounds. This study estimated laboratory-based 10-year CVD risk across different population sub-groups.

METHODS

Data from UDAY derived from cross-sectional surveys of rural and urban populations of northern (Haryana) and southern (Andhra Pradesh) India were analysed. World Health Organization/International Society of Hypertension laboratory-based equations calculated 10-year CVD risk among participants without CVD history. Wilcoxon rank sum test analyzed average CVD risk across subgroups. Chi-square test compared population proportions in different CVD risk categories. Regression analysis assessed the association between CVD risk and participant characteristics.

RESULTS

The mean (SD) age of the participants (n = 8448) was 53.2 (9.2) years. Males in Haryana had increased CVD risk compared to those in Andhra Pradesh (p < 0.01). In both states, female gender was shown to have a protective effect on CVD risk (p < 0.01). Age correlated with increased risk (p < 0.01). Education level did not affect CVD risk however employment status may have. Hypertension, diabetes, hyperlipidemia, smoking, and insufficient exercise were associated with increased CVD risk (p < 0.01). Residence (urban versus rural) and wealth index did not largely affect CVD risk.

CONCLUSION

Minor differences exist in the distribution of laboratory-based CVD risk across Indian population cohorts. CVD risk was similar in urban wealthy participants and rural poor and working-class communities in northern and southern India. Public health efforts need to target all major segments of the Indian population to curb the CVD epidemic.

Prevalence and associated factors of cardiovascular diseases among men and women aged 45 years and above: Analysis of the longitudinal ageing study in India, 2017-2019

OBJECTIVE

Epidemiological studies on the prevalence and associated factors of cardiovascular diseases (CVDs) representative of all states of India among middle-aged and elderly are not much reported. The present study estimates the prevalence and associated factors of cardiovascular diseases across Indian states among men and women aged ≥45 years.

METHODS

We used data from the Longitudinal Ageing Study in India wave 1 (2017-2019), which included a final analytical sample size of 56,935 adults and their spouses aged 45 years and above. We estimated CVDs prevalence for sociodemographic and behavioural variables, and multivariable logistic regression was used to assess the association between behavioural factors and CVDs in both men and women.

RESULTS

The prevalence of CVDs was 5.2% among adults ≥45 years (women: 4.6%; men: 5.9%), hypertension was 46.7% (women:48.9%; men:44%). Men and women have a similar prevalence of diabetes (11.9%) and cholesterol (2.3%). Prevalence of physical inactivity was 30.3% (women:27%; men:34.1%). Hypertension (adjusted odds ratio; aOR women:2.60, 95% CI: 2.08-3.25, men:1.88, 95% CI 1.54-2.29), hypercholesterolemia (aOR women:1.70; 95% CI 1.07-2.69, men 3.55; 95% CI 2.66-4.74), diabetes (aOR women:2.53; 95% CI 1.83-3.51, men:1.77 95% CI 1.44-2.17), obesity, physical inactivity, and smoking in men were significantly associated with CVDs.

CONCLUSION

The prevalence of CVDs and lifestyle risk factors among middle-aged and elderly poses severe concerns regarding noncommunicable disease (NCD) healthcare services provided in a lower-middle-income country like India. The key to preventing CVDs is controlling hypertension, diabetes, hypercholesterolemia, and increasing physical activity among adults aged ≥45 years.

Are Primary Health Centers Prepared for Noncommunicable Disease Management? A Facility-Based Mapping of Gaps in Coastal Karnataka, India

BACKGROUND

India is in the middle of epidemiological and demographic transitions, with an estimated 63% of the deaths attributed to noncommunicable diseases (NCDs). Primary health centers (PHCs) can deliver a package of services to prevent and control NCDs.

OBJECTIVE

The aim of this sudy is to assess the status of health promotion activities and availability of resources for screening and the treatment of NCDs in PHCs of Dakshina Kannada district, Karnataka.

MATERIALS AND METHODS

A cross-sectional facility-based assessment of all the 65 functioning PHCs (2016-2017) was conducted for the status of health promotion activities, and availability of resources using a checklist evolved from the World Health Organization Package of Essential NCD Interventions framework and Indian Public Health Standards.

RESULTS

Forty-eight (74%) PHCs had displayed materials on the intake of healthy foods and avoiding junk food. Warning signs of cancer were displayed at 43 (66%) PHCs. The availability of drugs for the management of hypertension (Atenolol and Amlodepine) and diabetes mellitus (Metformin) were seen in all the PHCs. Insulin was available in 64 (98%) PHCs. Sorbitrate and Nifedefine were found in 11 (17%) and 7 (11%) PHCs. More than a quarter of the PHCs were not having the medical officer and other health-care professionals to manage NCDs.

CONCLUSIONS

Preparedness of the PHCs in the health promotion domain was good. The availability of human resources, laboratory support and emergency drugs for the management of NCDs needs improvement.

Challenges in management and prevention of ischemic heart disease in low socioeconomic status people in LLMICs

BACKGROUND

Cardiovascular diseases, principally ischemic heart disease (IHD), are the most important cause of death and disability in the majority of low- and lower-middle-income countries (LLMICs). In these countries, IHD mortality rates are significantly greater in individuals of a low socioeconomic status (SES).

MAIN TEXT

Three important focus areas for decreasing IHD mortality among those of low SES in LLMICs are (1) acute coronary care; (2) cardiac rehabilitation and secondary prevention; and (3) primary prevention. Greater mortality in low SES patients with acute coronary syndrome is due to lack of awareness of symptoms in patients and primary care physicians, delay in reaching healthcare facilities, non-availability of thrombolysis and coronary revascularization, and the non-affordability of expensive medicines (statins, dual anti-platelets, renin-angiotensin system blockers). Facilities for rapid diagnosis and accessible and affordable long-term care at secondary and tertiary care hospitals for IHD care are needed. A strong focus on the social determinants of health (low education, poverty, working and living conditions), greater healthcare financing, and efficient primary care is required. The quality of primary prevention needs to be improved with initiatives to eliminate tobacco and trans-fats and to reduce the consumption of alcohol, refined carbohydrates, and salt along with the promotion of healthy foods and physical activity. Efficient primary care with a focus on management of blood pressure, lipids and diabetes is needed. Task sharing with community health workers, electronic decision support systems, and use of fixed-dose combinations of blood pressure-lowering drugs and statins can substantially reduce risk factors and potentially lead to large reductions in IHD. Finally, training of physicians, nurses, and health workers in IHD prevention should be strengthened.

CONCLUSION

The management and prevention of IHD in individuals with a low SES in LLMICs are poor. Greater availability, access, and affordability for acute coronary syndrome management and secondary prevention are important. Primary prevention should focus on tackling the social determinants of health as well as policy and individual interventions for risk factor control, supported by task sharing and use of technology.

Improving the capacity of nurses for non-communicable disease service delivery in India: how do they fare in comparison to doctors?

India has witnessed a major shift in morbidity to non-communicable diseases (NCDs) in the last few decades. The service delivery for these long-term conditions has been physician-centred up till now. There is a recent move towards shared care, and nurses are being engaged in the delivery of NCD care. This study was performed in the context of a composite training initiative involving nurses and doctors. Our aim was to compare the performance of nurses with doctors to determine which skills need to be emphasised in future educational programmes. Baseline and end-training knowledge assessments were available from training records. In 2014, of a total of 387 participants from one state in India, 153 were followed up to assess long-term retention of knowledge in various NCD training domains. We found that despite a lower baseline, nurses had a similar attrition in knowledge after training compared to doctors. Results of our study emphasised that nurses can be trained for the primary care needs of NCDs and that both nurses and doctors have retraining needs.

Low quality cardiovascular care is important coronary risk factor in India

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Hypertension: The most important non communicable disease risk factor in India

Non-communicable diseases are important causes of mortality and morbidity in India. Data from the Registrar General of India, World Health Organization and Global Burden of Disease (GBD) Study have reported that cardiovascular diseases (CVD) are the most important causes of death and disability. Age-adjusted mortality from these conditions has increased by 31% in last 25 years. Case-control studies have reported that hypertension is most important risk factor for CVD in India. GBD Study has estimated that hypertension led to 1.6 million deaths and 33.9 million disability-adjusted life years in 2015 and is most important cause of disease burden in India. Intensive public health effort is required to increase its awareness, treatment and control. UN Sustainable Development Goals highlight the importance of high rates of hypertension control for achieving target of 1/3 reduction in non-communicable disease mortality by 2030. It is estimated that better hypertension control can prevent 400-500,000 premature deaths in India.

Socio-Economic Inequality of Chronic Non-Communicable Diseases in Bangladesh

Introduction

Chronic non-communicable diseases (NCDs) are a major public health challenge, and undermine social and economic development in much of the developing world, including Bangladesh. Epidemiologic evidence on the socioeconomic status (SES)-related pattern of NCDs remains limited in Bangladesh. This study assessed the relationship between three chronic NCDs and SES among the Bangladeshi population, paying particular attention to the differences between urban and rural areas.

Materials and Method

Data from the 2011 Bangladesh Demographic and Health Survey were used for this study. Using a concentration index (CI), we measured relative inequality across pre-diabetes, diabetes, pre-hypertension, hypertension, and BMI (underweight, normal weight, and overweight/obese) in urban and rural areas in Bangladesh. A CI and its associated curve can be used to identify whether socioeconomic inequality exists for a given health variable. In addition, we estimated the health achievement index, integrating mean coverage and the distribution of coverage by rural and urban populations.

Results

Socioeconomic inequalities were observed across diseases and risk factors. Using CI, significant inequalities observed for pre-hypertension (CI = 0.09, p = 0.001), hypertension (CI = 0.10, p = 0.001), pre-diabetes (CI = -0.01, p = 0.005), diabetes (CI = 0.19, p<0.001), and overweight/obesity (CI = 0.45, p<0.001). In contrast to the high prevalence of the chronic health conditions among the urban richest, a significant difference in CI was observed for pre-hypertension (CI = -0.20, p = 0.001), hypertension (CI = -0.20, p = 0.005), pre-diabetes (CI = -0.15, p = 0.005), diabetes (CI = -0.26, p = 0.004) and overweight/obesity (CI = 0.25, p = 0.004) were observed more among the low wealth quintiles of rural population. In the same vein, the poorest rural households had more co-morbidities compared to the richest rural households (p = 0.003), and prevalence of co-morbidities was much higher for the richest urban households compared to the poorest urban households. On the other hand in rural the “disachievement” of health indicators is more noticeable than the urban ones.

Conclusion

The findings indicate the high burden of selected NCDs among the low wealth quintile populations in rural areas and wealthy populations in urban areas. Particular attentions may be necessary to address the problem of NCDs among these groups.

Knowledge and Awareness of Familial Hypercholesterolaemia among Registered Medical Practitioners in Tamil Nadu: Are They Suboptimal?

INTRODUCTION

Familial Hypercholesterolaemia (FH) is the most common monogenic disorder causing premature Coronary Artery Disease (CAD). However, the majority of people with FH are undiagnosed and under treated.

AIM

To determine awareness, knowledge and practices of registered medical practitioners regarding FH in India.

MATERIALS AND METHODS

Physicians from a southern state of India (Tamil Nadu) who see the general cases were requested to complete a structured online survey questionnaire based on the outcomes on screening, diagnostic and service aspects of FH.

RESULTS

A total of 133 physicians were surveyed, 27.9% perceived themselves to have above average familiarity with FH and 71.4% correctly described FH. 41.4% of physicians were unaware and unsure whether they had FH patients under their care. The awareness of specific aspects of FH were as follows: heritability 35.3%, prevalence 31.6%, typical lipid profile 34.6%, CVD relating to FH13.5%, genetic testing 33.1%, cascade screening 41.4%, preventive, management and referral services for FH 12.8%, 49.6% of them thought that the age for screening young people for FH should be 13 to 18 years. 84.2% selected GP's as the most effective health care provider for the early detection and care of FH as being useful. 69.2% selected interpretive commenting on lipid profile to highlight patients at risk of FH. 91.7% and 19.5% of physicians identified statins as monotherapy and statin with ezetimibe as combination therapy for FH, respectively.

CONCLUSION

The study identified substantial deficit in the awareness and knowledge of FH among primary care physicians in Tamil Nadu. Extensive and continuous medical education programs are required to close the gap in coronary prevention.

Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India

Background

Government of India has launched National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to address high prevalence of non-communicable diseases (NCDs) in India. Cardiovascular diseases (CVDs) constitute a significant portion of NCD burden. While this program is yet to be launched in all districts of Madhya Pradesh state of India, we performed this study to understand facility-level gaps that need to be addressed to improve CVD services in primary care provided by the public sector.

Methods

This is a cross-sectional questionnaire based study. A standardized questionnaire was self-administered to 85 medical officers from as many primary care facilities from 24 districts of the state. These medical officers were working in two types of primary care facilities – primary health center (PHC) and community health centers (CHC). Facilities were assessed for 36 items in 5 domains (human-resource, equipment, drug supplies, point-of-care tests and laboratory services) with a focus on management of hypertension and diabetes mellitus in primary-care. Each item was to be answered as either present or absent at the facility where medical officer was working. We compared availability of an item across two levels of primary care facilities. All statistical analysis were done using Microsoft Excel.

Results

Availability of facilities was least in laboratory services, and human resource domains followed by drugs, and better in equipment and point-of-care supply domains. Across these domains, availability of items in CHCs was (37.1, 49.0, 56.1, 67.9 and 80.9 % respectively) and in PHCs (11.8, 18.2, 44.2, 55.1, and 55.3 % respectively).

Discussion

Current facility assessment study shows critical gaps in key items required for management of NCDs at primary care level. Human resource and laboratory services need to be strengthened the most, followed by sustained availability of all required drug classes, equipment and related supplies, and upgrading point-of-care testing. There are larger gaps in PHCs, which are level 1 facilities, as compared to CHCs, which are level 2 facilities in primary-care.

Conclusions

Increasing burden of NCDs like hypertension and diabetes mellitus necessitates public health response through health systems. Therefore health system preparedness in form of trained human resources, functional laboratories and well stocked pharmacies are essential in primary care facilities.

Smokeless tobacco and cardiovascular disease in low and middle income countries

Smoking is an important cardiovascular risk factor, however, use of smokeless tobacco has not been well studied. Smokeless tobacco use is high in countries of South and Southeast Asia, Africa and Northern Europe. Meta-analyses of prospective studies of smokeless tobacco users in Europe reported a relative risk for fatal coronary heart disease of 1.13 (confidence intervals 1.06-1.21) and fatal stroke of 1.40 (1.28-1.54) while in Asian countries it was 1.26 (1.12-1.40). Case-control studies reported significantly greater risk for acute coronary events in smokeless tobacco users (odds ratio 2.23, 1.41-3.52), which was lower than smokers (2.89, 2.11-3.96), and subjects who both chewed and smoked, had the greatest risk (4.09, 2.98-5.61). There is a greater prevalence of hypertension and metabolic syndrome in users of smokeless tobacco. Smokeless tobacco use leads to accelerated atherothrombosis similar to smoking. There is an urgent need for public health and clinical interventions to reduce smokeless tobacco addiction.

The need for multicentre cardiovascular clinical trials in Asia

Historically, the USA and European countries have been the dominant figures in medical research. However, in the past 10 years, Asia has emerged as a new 'hot spot' for clinical research owing to the tremendous potential generated by steady economic growth, remarkable advances in research and development capacity, and an expanding population. However, investigators involved with the set-up and conduct of multicentre trials in such a vast and heterogeneous continent face huge challenges-bridging the fundamental differences between the Asian countries, such as languages, resources, regulatory procedural timelines, and the general understanding of clinical research. In this Perspectives article, we explain why Asia should be established as a hub for large multicentre trials, discuss the challenges involved, and highlight the importance of a strong collaborative infrastructure for multiple investigational sites in this culturally diverse continent.

Population-based intervention for cardiovascular diseases related knowledge and behaviours in Asian Indian women

BACKGROUND & OBJECTIVES

There is poor knowledge and behaviors regarding chronic diseases related nutritional and lifestyle factors among women in low income countries. To evaluate efficacy of a multilevel population-based intervention in improving knowledge and practices for related factors we performed a study in India.

METHODS

Population based study among women 35-70 years was performed in four urban and five rural locations. Stratified sampling was performed and we enrolled 4624 (rural 2616, urban 2008) of eligible 8000 women (58%). Demographic details, medical history, diet, physical activity and anthropometry were recorded and blood hemoglobin, glucose and total cholesterol determined. Knowledge and behaviors regarding diet in chronic diseases were inquired in a randomly selected 100 women at each site (n = 900). A systematic multilevel population based intervention (using posters, handouts, street plays, public lectures, group lectures and focused group discussions) was administered over 6 months at each site. The questionnaire was re-administered at the end in random 100 women (n = 900) and differences determined. Descriptive statistics are reported. Comparison of parameters before and after intervention was assessed using Mann Whitney test.

RESULTS

Prevalence (%) of chronic disease related lifestyles and risk factors in rural/urban women, respectively, was illiteracy in 63.6/29.4, smoking/tobacco use 39.3/18.9, high fat intake 93.6/93.4, high salt intake 18.2/12.6, low physical activity 59.5/70.2, overweight/obesity 22.5/45.6, truncal obesity 13.0/44.3, hypertension 31.6/48.2, hypercholesterolemia 13.5/27.7, and diabetes in 4.3/15.1 percent. Composite chronic diseases knowledge at baseline vs after intervention increased significantly in overall (32.0 vs 62.0), rural (29.0 vs 63.5) and urban (39.5 vs 60.5) groups (p < 0.001). Significant increase in knowledge regarding diet in hypertension, diabetes, heart disease and anemia as well as importance of dietary proteins, fats, fibres and fruits was observed (p < 0.001). There was insignificant change in most of the practices regarding intake of low fat, high protein, high fibre diet except sieving the flour which declined significantly (80.1 vs 53.6, p < 0.001).

CONCLUSIONS

A short-term multilevel population-wide intervention among women in rural and urban locations in India increased chronic disease knowledge but failed to influence practices.

Association of educational, occupational and socioeconomic status with cardiovascular risk factors in Asian Indians: a cross-sectional study

BACKGROUND

To determine correlation of multiple parameters of socioeconomic status with cardiovascular risk factors in India.

METHODS

The study was performed at eleven cities using cluster sampling. Subjects (n = 6198, men 3426, women 2772) were evaluated for socioeconomic, demographic, biophysical and biochemical factors. They were classified into low, medium and high socioeconomic groups based on educational level (<10, 10-15 and >15 yr formal education), occupational class and socioeconomic scale. Risk factor differences were evaluated using multivariate logistic regression.

RESULTS

Age-adjusted prevalence (%) of risk factors in men and women was overweight or obesity in 41.1 and 45.2, obesity 8.3 and 15.8, high waist circumference 35.7 and 57.5, high waist-hip ratio 69.0 and 83.8, hypertension 32.5 and 30.4, hypercholesterolemia 24.8 and 25.3, low HDL cholesterol 34.1 and 35.1, high triglycerides 41.2 and 31.5, diabetes 16.7 and 14.4 and metabolic syndrome in 32.2 and 40.4 percent. Lifestyle factors were smoking 12.0 and 0.5, other tobacco use 12.7 and 6.3, high fat intake 51.2 and 48.2, low fruits/vegetables intake 25.3 and 28.9, and physical inactivity in 38.8 and 46.1%. Prevalence of > = 3 risk factors was significantly greater in low (28.0%) vs. middle (23.9%) or high (22.1%) educational groups (p<0.01). In low vs. high educational groups there was greater prevalence of high waist-hip ratio (odds ratio 2.18, confidence interval 1.65-2.71), low HDL cholesterol (1.51, 1.27-1.80), hypertriglyceridemia (1.16, 0.99-1.37), smoking/tobacco use (3.27, 2.66-4.01), and low physical activity (1.15, 0.97-1.37); and lower prevalence of high fat diet (0.47, 0.38-0.57),overweight/obesity (0.68, 0.58-0.80) and hypercholesterolemia (0.79, 0.66-0.94). Similar associations were observed with occupational and socioeconomic status.

CONCLUSIONS

Low educational, occupational and socioeconomic status Asian Indians have greater prevalence of truncal obesity, low HDL cholesterol, hypertriglyceridemia, smoking or tobacco use and low physical activity and clustering of > = 3 major cardiovascular risk factors.

Regional variations in cardiovascular risk factors in India: India heart watch

Cardiovascular disease (CVD) is an important cause of mortality and morbidity in India. Mortality statistics and morbidity surveys indicate substantial regional variations in CVD prevalence and mortality rates. Data from the Registrar General of India reported greater age-adjusted cardiovascular mortality in southern and eastern states of the country. Coronary heart disease (CHD) mortality is greater in south India while stroke is more common in the eastern Indian states. CHD prevalence is higher in urban Indian populations while stroke mortality is similar in urban and rural regions. Case-control studies in India have identified that the common major risk factors account for more than 90% of incident myocardial infarctions and stroke. The case-control INTERHEART and INTERSTROKE studies reported that hypertension, lipid abnormalities, smoking, obesity, diabetes, sedentary lifestyle, low fruit and vegetable intake, and psychosocial stress are as important in India as in other populations of the world. Individual studies have reported that there are substantial regional variations in risk factors in India. At a macro-level these regional variations in risk factors explain some of the regional differences in CVD mortality. However, there is need to study the prevalence of multiple cardiovascular risk factors in different regions of India and to correlate them with variations in CVD mortality using a uniform protocol. There is also a need to determine the "causes of the causes" or fundamental determinants of these risk factors. The India Heart Watch study has been designed to study socioeconomic, anthropometric and biochemical risk factors in urban populations in different regions of the country in order to identify regional differences.

Migrating husbands and changing cardiovascular risk factors in the wife: a cross sectional study in Asian Indian women

OBJECTIVE

The authors studied the influence of migration of husband on cardiovascular risk factors in Asian Indian women.

METHODS

Population-based studies in women aged 35-70 years were performed in four urban and five rural locations. 4608 (rural 2604 and urban 2004) of the targeted 8000 (57%) were enrolled. Demographic details, lifestyle factors, anthropometry, fasting glucose and cholesterol were measured. Multivariate logistic and quadratic regression was performed to compare influence of migration and its duration on prevalence of risk factors.

RESULTS

Details of migration were available in 4573 women (rural 2267, rural-urban migrants 455, urban 1552 and urban-rural migrants 299). Majority were married, and illiteracy was high. Median (interquartile) duration of residence in urban locations among rural-urban migrants was 9 (4-18) years and in rural areas for urban-rural migrants 23 (18-30) years. In rural, rural-urban migrants, urban and urban-rural migrants, age-adjusted prevalence (%) of risk factors was tobacco use 41.9, 22.7, 18.8 and 38.1; sedentary lifestyle 69.7, 82.0, 79.9 and 74.6; high-fat diet 33.3, 54.2, 66.1 and 61.1; overweight 21.3, 42.7, 46.3 and 29.7; large waist 8.5, 38.5, 29.2 and 29.2; hypertension 30.4, 49.4, 47.7 and 38.4; hypercholesterolaemia 14.4, 31.3, 26.6 and 9.1 and diabetes 3.9, 15.8, 14.9 and 8.4, respectively (p<0.001). In rural-urban migrants, there was a significant correlation of duration of migration with waist size, waist-to-hip ratio and systolic blood pressure (quadratic regression, p<0.001). Association of risk factors with migration remained significant, though attenuated, after adjustment for socioeconomic, lifestyle and obesity variables (logistic regression, p<0.01).

CONCLUSIONS

Compared with rural women, rural-urban migrants and urban have significantly greater cardiometabolic risk factors. Prevalence is lower in urban-rural migrants. There is significant correlation of duration of migration with obesity and blood pressure. Differences are attenuated after adjusting for social and lifestyle variables.