Social determinants of cardiovascular disease outcomes in Indians

Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

Associations between social determinants and the presence of chronic diseases: data from the osteoarthritis Initiative

Background

Some studies investigated the relationship between musculoskeletal conditions and chronic diseases. However, no study examined the association between social determinants and chronic diseases among people at high risk for knee osteoarthritis. Thus, the current study was aimed to address this gap.

Methods

A secondary data analysis was conducted on a total of 3280 men and women aged 45 to 79 who were recruited in the Osteoarthritis Initiative.

Results

Multivariable logistic regression analyses show that age ≥ 65 years was associated with 1.98, 1.96, and 1.46 times odds of the presence of diabetes, heart attack, and multi-morbidity, respectively than age ≤ 64 years. Men were associated with 1.39, 1.41, 1.76, and 2.24 times odds of the presence of arthritis, cancer, diabetes, and heart attack, respectively than women. African American/Asian/ non-Caucasian was associated with 2.71, 2.56, and 1.93 times odds of the presence of arthritis, diabetes, and heart attack, respectively than Caucasian. Primary school/less education was associated with twice or more times the odds of arthritis and chronic obstructive pulmonary disease (COPD) than ≥high school education. Unemployment was associated with 1.41-, 1.73-, 1.58-, and 1.70-time odds of the presence of arthritis, cancer, COPD, and heart attack, respectively, then employed. Unmarried/widowed/separated was associated with 1.41, 1.75, 2.77, 2.76, 1.86, and 3.34 times odds of the presence of arthritis, asthma, cancer, COPD, diabetes, and heart attack, respectively than married. Annual income < 50,000 was associated with 1.33-, 1.44-, and 1.38-time odds of the presence of arthritis, diabetes, and multi-morbidity, respectively, then annual income ≥50,000. Overweight/obese was associated with 2.28 times the odds of the presence of diabetes than healthy weight. Current/former smoker was associated with 1.57, 2.47, 2.53, 1.63, and 1.24 times odds of the presence of arthritis, cancer, COPD, heart attack, and multi-morbidity, respectively than a nonsmoker. Consuming alcohol was associated with 1.32-, 1.65-, 1.50-, and 1.24-time odds of the presence of arthritis, COPD, diabetes, and multi-morbidity, respectively, then nonalcoholic.

Conclusions

Social determinants are associated with the presence of chronic diseases. Some of the social determinants are modifiable or treatable. Thus, these findings can inform public health strategies in the United States.

Chronic Disease, the Built Environment, and Unequal Health Risks in the 500 Largest U.S. Cities

Health is increasingly subject to the complex interplay between the built environment, population composition, and the structured inequity in access to health-related resources across communities. The primary objective of this paper was to examine cardiometabolic disease (diabetes, cardiovascular diseases, stroke) markers and their prevalence across relatively small geographic units in the 500 largest cities in the United States. Using data from the American Community Survey and the 500 Cities Project, the current study examined cardiometabolic diseases across 27,000+ census tracts in the 500 largest cities in the United States. Earlier works clearly show cardiometabolic diseases are not randomly distributed across the geography of the U.S., but rather concentrated primarily in Southern and Eastern regions of the U.S. Our results confirm that chronic disease is correlated with social and built environment factors. Specifically, racial concentration (%, Black), age concentration (% 65+), housing stock age, median home value, structural inequality (Gini index), and weight status (% overweight/obese) were consistent correlates (p < 0.01) of cardiometabolic diseases in the sample of census tracts. The paper examines policy-related features of the built and social environment and how they might play a role in shaping the health and well-being of America’s metropolises.

Incremental Prognostic Value of Anemia in Acute Coronary Syndrome from A Rural Hospital in India

Background:

Anemia is highly prevalent in low- and middle-income countries, where prevalence of acute coronary syndrome (ACS) is also rising. Evidence indicates that baseline anemia status can prognosticate ACS. However, the Global Registry of Acute Coronary Events (GRACE) score that is popularly used all over the world does not include information on anemia.

Objectives:

Our objective was to investigate if anemia at admission, along with the GRACE score, improves the prediction of adverse outcomes within 6 months in rural Indian patients of ACS.

Methods:

We enrolled 200 ACS patients at the Acharya Vinoba Bhave Rural Hospital—a rural, tertiary care hospital in central India. Patients were followed for 6 months for death and major adverse cardiac event (MACE). Improvement in the prediction of adverse events by including anemia in addition to the GRACE score was quantified using area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and the net reclassification index (NRI).

Results:

There were 31 deaths due to MACE and an additional 28 non-fatal MACE events during follow-up. Baseline hemoglobin was strongly and independently associated with both outcomes even after adjusting for a multivariable propensity score. For the outcome of death and death/MACE there was a moderate improvement in the AUC of 1% and 6%, respectively. However, for these outcomes the IDI for baseline hemoglobin was 6% (p = 0.03) and 12% (p << 0.0001), respectively, while the NRI was 0.50 (p = 0.01) and 0.78 (p << 0.0001), respectively.

Conclusions:

Inclusion of baseline anemia in addition to the GRACE score improves prognostication of ACS patients.

Association between socioeconomic position and cardiovascular disease risk factors in rural north India: The Solan Surveillance Study

Background

Although most Indians live in rural settings, data on cardiovascular disease risk factors in these groups are limited. We describe the association between socioeconomic position and cardiovascular disease risk factors in a large rural population in north India.

Methods

We performed representative, community-based sampling from 2013 to 2014 of Solan district in Himachal Pradesh. We used education, occupation, household income, and household assets as indicators of socioeconomic position. We used tobacco use, alcohol use, low physical activity, obesity, hypertension, and diabetes as risk factors for cardiovascular disease. We performed hierarchical multivariable logistic regression, adjusting for age, sex and clustering of the health sub-centers, to evaluate the cross-sectional association of socioeconomic position indicators and cardiovascular disease risk factors.

Results

Among 38,457 participants, mean (SD) age was 42.7 (15.9) years, and 57% were women. The odds of tobacco use was lowest in participants with graduate school and above education (adjusted OR 0.11, 95% CI 0.09, 0.13), household income >15,000 INR (adjusted OR 0.35, 95% CI 0.29, 0.43), and highest quartile of assets (adjusted OR 0.28, 95% CI 0.24, 0.34) compared with other groups but not occupation (skilled worker adjusted OR 0.93, 95% CI 0.74, 1.16). Alcohol use was lower among individuals in the higher quartile of income (adjusted OR 0.75, 95% CI 0.64, 0.88) and assets (adjusted OR 0.70, 95% CI 0.59, 0.82). The odds of obesity was highest in participants with graduate school and above education (adjusted OR 2.33, 95% CI 1.85, 2.94), household income > 15,000 Indian rupees (adjusted OR 1.89, 95% CI 1.63, 2.19), and highest quartile of household assets (adjusted OR 2.87, 95% CI 2.39, 3.45). The odds of prevalent hypertension and diabetes were also generally higher among individuals with higher socioeconomic position.

Conclusions

Individuals with lower socioeconomic position in Himachal Pradesh were more likely to have abnormal behavioral risk factors, and individuals with higher socioeconomic position were more likely to have abnormal clinical risk factors.

A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India: The Tamil Nadu-ST-Segment Elevation Myocardial Infarction Program

Importance

Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.

Objective

To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.

Design, Setting, and Participants

This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.

Exposures

Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology.

Main Outcomes and Measures

Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.

Results

A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).

Conclusions and Relevance

A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Socioeconomic Gradients and Distribution of Diabetes, Hypertension, and Obesity in India

IMPORTANCE

Cardiovascular disease and risk factors represent a major and increasing burden of death and disability in India, although socioeconomic aspects have been debated in recent years.

OBJECTIVE

To conduct a comprehensive equity analysis of the socioeconomic gradients and distribution of diabetes, hypertension, and obesity in India using the latest national data set.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of data originating from the fourth Indian National Family Health Survey collected from January 20, 2015, to December 4, 2016. The study population was based on a nationally representative cross-sectional sample of women aged 15 to 49 years and men aged 15 to 54 years in India, with a response rate of 97% and 92% among eligible women and men, respectively. Biomarker sampling of survey respondents captured height, weight, blood pressure, and random blood glucose levels. Markers of socioeconomic status (SES) were household wealth, education, and social caste. Descriptive analyses and logistic regression models that account for multistage survey design and sampling weights were estimated.

MAIN OUTCOMES AND MEASURES

Diabetes, hypertension, and obesity assessed by predetermined thresholds based on biomarker sampling or current medication were the primary outcomes.

RESULTS

The survey covered 757 958 individuals (weighted prevalence of 51.2% female). The overall prevalence of diabetes, hypertension, and obesity in the sample was 2.9%, 14.4% and 9.7%, respectively. Positive socioeconomic gradients were observed by household wealth, education, and social caste, and in a majority of states. The magnitude of the SES gradient was strongest for obesity (adjusted odds ratio for highest SES quintile vs lowest, 8.76; 95% CI, 7.70-9.95), followed by diabetes (adjusted odds ratio, 2.31; 95% CI, 1.88-2.85) and hypertension (adjusted odds ratio, 1.58; 95% CI, 1.45-1.72) (P < .001 for all associations). Analyses of the socioeconomic distribution indicated that between 70% and 90% of the population burden of diabetes, hypertension, and obesity was among the higher SES groups, and this figure was similar across states.

CONCLUSIONS AND RELEVANCE

Cardiovascular risk factors have an uneven distribution in India. Prevention and treatment strategies should reflect the distribution of the risk factor burden.

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.

Prevalence and Social Determinants of Type 2 Diabetes in a Coastal Area of Kerala, India

Introduction

Varying prevalence rates of type 2 diabetes have been observed in different parts of the southern state of Kerala, India which is in an advanced stage of epidemiologic transition. Social patterning is evident in diabetes and therefore it was decided to undertake a study on estimating the prevalence of diabetes and associated social determinants.

Methodology

The adopted local self administration unit of the Medical College which is also the field practice area with a population of 25,096 was taken for the study. All the households in the area were visited and the details regarding self reported diabetes was collected after obtaining informed consent and analysis done by multivariate logistic regression.

Result

The prevalence of self reported diabetes in this coastal area was found to be low at 7.4%. Type 2 diabetes was also found to occur significantly earlier among the respondents belonging to the below poverty line. Age above 40 years (OR 2 95% CI 1.5-2.7, p=.000), marital status (OR 1.9 95% CI 1.1-2.1, p=.006) presence of comorbidities (OR 635 95% CI 389-969, p=.000), more than 8 years of schooling (OR 0.64 95% CI 0.46-0.86, p=.004), living conditions as represented by presence of household source of drinking water(OR 1.4 95% CI 1.01-1.5) were found to be independent predictors. Though there was increasing trend of diabetes among the forward caste line families after backward logistic regression this disappeared leaving behind the proxy of socioeconomic status, household source of drinking water.

Conclusion

Though, the state of Kerala is in an advanced stage of epidemiologic transition, coastal areas are still in the earlier phases of transition with low prevalence of type 2 diabetes mellitus. Higher education and better living conditions are important social determinants of diabetes though further studies are necessary to delineate the impact of economic status and education.

Study of Erythrocyte Indices, Erythrocyte Morphometric Indicators, and Oxygen-Binding Properties of Hemoglobin Hematoporphyrin Patients with Cardiovascular Diseases

The current study investigates the functional state of erythrocytes and indices of the oxygen-binding capacity of hemoglobin in blood samples from healthy donors and from patients with coronary artery disease and myocardial infarction before and after treatment. It has been established that, in cardiovascular diseases, erythrocyte morphology and hemoglobin oxygen-transporting disorders are observed. Standard therapy does not result in the restoration of the structure and properties of erythrocytes. The authors believe that it is necessary for future therapeutic treatment to include preparations other than cardiovascular agents to enhance the capacity of hemoglobin to transport oxygen to the tissues.

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.

Age and Socioeconomic Gradients of Health of Indian Adults: An Assessment of Self-Reported and Biological Measures of Health

This paper describes overall socioeconomic gradients and the age patterns of socioeconomic gradients of health of Indian adults for multiple health indicators encompassing the multiple aspects of health. Cross-sectional data on 11,230 Indians aged 18 years and older from the WHO-SAGE India Wave 1, 2007 were analyzed. Multivariate logit models were estimated to examine effects of socioeconomic status (education and household wealth) and age on four health domains: self-rated health, self-reported functioning, chronic diseases, and biological health measures. Results show that socioeconomic status (SES) was negatively associated with prevalence of each health measure but with considerable heterogeneity across age groups. Results for hypertension and COPD were inconclusive. SES effects are significant while adjusting for background characteristics and health risk factors. The age patterns of SES gradient of health depict divergence with age, however, no conclusive age pattern emerged for biological markers. Overall, results in this paper dispelled the conclusion of negative SES-health association found in some previous Indian studies and reinforced the hypothesis of positive association of SES with health for Indian adults. Higher prevalence of negative health outcomes and SES disparities of health outcomes among older age-groups highlight need for inclusive and focused health care interventions for older adults across socioeconomic spectrum.

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

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

Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study

BACKGROUND

Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear.

METHODS

We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category.

RESULTS

Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m(2); waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups.

CONCLUSIONS

SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.

Prevalence of Hypertension in Boloor Diabetes Study (BDS-II) and its Risk Factors

INTRODUCTION

Hypertension is a major public health problem in India and worldwide. Since hypertension is often asymptomatic, it commonly remains undetected, leading to serious complications if untreated. Hypertension is one of the leading causes of end stage renal disease. It doubles the risk of developing coronary artery disease, increases the risk of congestive heart failure by four folds and that of cerebrovascular disease and stroke by seven folds. Hypertension is directly responsible for 57% of all stroke deaths and 42% of coronary heart disease deaths in India.

AIM

To identify prevalence and risk factors for hypertension in a semi urban population of Mangalore, who participated in Boloor Diabetes Study (BDS-II).

MATERIALS AND METHODS

This cross-sectional study was conducted on 551 subjects aged ≥ 20 years who were randomly selected. Hypertension was diagnosed and classified according to Joint National Committee 7 (JNC) criteria. Blood pressure was measured by a doctor using calibrated sphygmomanometer. Anthropometric measurements, lipid and glucose estimations were done for all subjects. Statistical analysis was done using Chi-square test and student's t-test (unpaired). Multivariate logistic regression analysis was done using hypertension as dependent variable and the various risk factors as independent variables.

RESULTS

Overall prevalence of hypertension in the community was 41% (227/551) (40.9% in men, 41.3% in women). Prehypertension was found in 40% (223/551) (45.4% in men, 38.1% in women), and only 18.3% (101/551) had normal blood pressure. Stage I hypertension was seen in 29.7% (164/551) (28.9% in men, 30.1% in women). Stage II hypertension was seen in 11.4% (63/551) (12% in men, 11% in women). Age, obesity, diabetes, serum cholesterol and serum triglycerides were strongly associated with hypertension. Only 46% (254/551) of the hypertensive subjects were aware that they were hypertensive.

CONCLUSION

Prevalence of hypertension was high in this population. Nearly 54% were unaware of their hypertensive status. Prevalence increased with age, obesity, diabetic status and dyslipidemia. Nearly half of subjects were prehypertensives. This study highlights the need for regular screening coupled with educational programmes to detect, improve awareness and optimally treat hypertension in the community to reduce cardiovascular and renal complications.

Framework for a National STEMI Program: consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of "systems of care" for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, "state-of-the-art" information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.

Geographic epidemiology of cardiometabolic risk factors in middle class urban residents in India: cross-sectional study

Objective

To determine epidemiology of cardiovascular risk factors according to geographic distribution and macrolevel social development index among urban middle class subjects in India.

Methods

We performed cross-sectional surveys in 11 cities in India during years 2005–2009. 6198 subjects aged 20–75 years (men 3426, women 2772, response 62%) were evaluated for cardiovascular risk factors. Cities were grouped according to geographic distribution into northern (3 cities, n = 1321), western (2 cities, n = 1814), southern (3 cities, n = 1237) and eastern (3 cities, n = 1826). They were also grouped according to human social development index into low (3 cities, n = 1794), middle (5 cities, n = 2634) and high (3 cities, n = 1825). Standard definitions were used to determine risk factors. Differences in risk factors were evaluated using χ² test. Trends were examined by least squares regression.

Findings

Age–adjusted prevalence (95% confidence intervals) of various risk factors was: low physical activity 42.1% (40.9–43.3), high dietary fat 49.9% (47.8–52.0), low fruit/vegetables 26.9% (25.8–28.0), smoking 10.1% (9.1–11.1), smokeless tobacco use 9.8% (9.1–10.5), overweight 42.9% (41.7–44.1), obesity 11.6% (10.8–12.4), high waist circumference 45.5% (44.3–46.7), high waist–hip ratio 75.7% (74.7–76.8), hypertension 31.6% (30.4–32.8), hypercholesterolemia 25.0% (23.9–26.9), low HDL cholesterol 42.5% (41.3–43.7), hypertriglyceridemia 36.9% (35.7–38.1), diabetes 15.7% (14.8–16.6), and metabolic syndrome 35.7% (34.5–36.9). Compared with national average, prevalence of most risk factors was not significantly different in various geographic regions, however, cities in eastern region had significantly lower prevalence of overweight, hypertension, hypercholesterolemia, diabetes and metabolic syndrome compared with other regions (P < 0.05 for various comparisons). It was also observed that cities with low human social development index had lowest prevalence of these risk factors in both sexes (P < 0.05).

Conclusions

Urban middle–class men and women in eastern region of India have significantly lower cardiometabolic risk factors compared to northern, western and southern regions. Low human social development index cities have lower risk factor prevalence.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Relationship between risk factors and in-hospital mortality due to myocardial infarction by educational level: a national prospective study in Iran

Introduction

Since no hospital-based, nationwide study has been yet conducted on the association between risk factors and in-hospital mortality due to myocardial infarction (MI) by educational level in Iran, the present study was conducted to investigate relationship between risk factors and in-hospital mortality due to MI by educational level.

Methods

In this nationwide hospital-based, prospective analysis, follow-up duration was from definite diagnosis of MI to death. The cohort of the patients was defined in view of the date at diagnosis, hospitalization and the date at discharge (recovery or in-hospital death due to MI). 20750 patients hospitalized for newly diagnosed MI between April, 2012 and March, 2013 comprised sample size. Totally, 2511 deaths due to MI were obtained. The data on education level (four-level) were collected based on years of schooling. To determine in-hospital mortality rate and the associated factors with mortality, seven statistical models were developed using Cox proportional hazards models.

Results

Of the studied patients, 9611 (6.1%) had no education. in-hospital mortality rate was 8.36 (95% CI: 7.81-8.9) in women and 6.12 (95% CI: 5.83-6.43) in men per 100 person-years. This rate was 5.56 in under 65-year-old patients and 8.37 in over 65-year-old patients. This rate in the patients with no, primary, high school, and academic education was respectively 8.11, 6.11, 4.85 and 5.81 per 100 person-years. Being woman, chest pain prior to arriving in hospital, lack of thrombolytic therapy, right bundle branch block, ventricular tachycardia, smoking and ST-segment elevation myocardial infarction were significantly associated with increased hazard ratio (HR) of death. The adjusted HR of mortality was 1.27 (95% CI: 1.06-1.52), 0.93 (95% CI: 0.77-1.13), 0.72 (95% CI: 0.57-0.91) and 0.82 (95% CI: 0.66-1.01) in the patients with respectively illiterate, primary, secondary and high school education compared to academic education.

Conclusion

A disparity was noted in post-MI mortality incidence in different educational levels in Iran. HR of death was higher in illiterate patients than in the patients with academic education. Identifying disparities per educational level could contribute to detecting the individuals at high risk, health promotion and care improvement by relevant planning and interventions in clinics and communities.

"Every disease…man can get can start in this cab": focus groups to identify south Asian taxi drivers' knowledge, attitudes and beliefs about cardiovascular disease and its risks

South Asian (SA) taxi drivers potentially possess a double epidemiologic risk for cardiovascular disease (CVD) due to their ethnicity and occupation. This study investigates SA taxi drivers' knowledge, attitudes, beliefs about general health, CVD and approaches to reduce CVD risk. Five focus groups were conducted with 31 SA taxi drivers in the participants' primary language (Bengali, Hindi, Urdu or Punjabi). Audio-recordings of the sessions were transcribed, translated and entered into ATLAS.ti 6.2 for coding and analysis. SA drivers in an urban setting perceive themselves to be at high risk for CVD because of high work-related stress, physical inactivity, poor diet and poor health care access. Participants attributed their occupation to increasing risk for heart disease; none believed that being SA increased their risk. Interventions to lower CVD risk among SA taxi drivers should be multi-level and involve the individual drivers and the taxi industry.

Attitudes and beliefs regarding cardiovascular risk factors among Bangladeshi immigrants in the US

The US has increasingly growing Bangladeshi population, a South Asian sub-ethnic group with a high prevalence of cardiovascular disease (CVD). We conducted a qualitative study using individual in-depth interviews to explore attitudes towards and difficulties with modifying CVD related behaviors among a Bangladeshi cohort. We interviewed 55 patients before reaching data saturation. Bangladeshis discussed the meaning of health and heart disease in the context of how disease can potentially impact their ability to care for their family. Behavioral and psychological factors were discussed as the causes of CVD. Internal forces and external forces were brought up to explain difficulties addressing the causes of CVD. Bangladeshi individuals in our study were aware of CVD, but felt unable to address behavioral risk factors. They cite a combination of internal and external factors as barriers to lifestyle modification. Interventions to address these barriers must simultaneously addressing self-efficacy and work-life balance.

Age and sex pattern of cardiovascular mortality, hospitalisation and associated cost in India

CONTEXT

Though the cardiovascular diseases are the leading cause of mortality in India, little is known about the human and economic loss attributed to the disease. The aim of this paper is to account the age and sex pattern of mortality, hospitalisation and the cost of hospitalisation for cardiovascular diseases in India.

DATA AND METHODS

Data for the present study has been drawn from multiple sources; 52(nd) and 60(th) rounds of the National Sample Survey, Special Survey of Death, 2001-03 and the Sample Registration System 2004-2010. Under the changing demographics and constant assumptions of mortality, hospitalisation and cost of hospitalisation, we have estimated the deaths, hospitalisation and cost of hospitalisation for cardiovascular diseases in India during 2004 to 2021. Descriptive analyses and multivariate techniques were used to understand the socio-economic differentials in cost of hospitalisation for cardiovascular diseases in India.

FINDINGS

In India, the cardiovascular diseases accounted for an estimated 1.4 million deaths in 2004 and it is likely to be 2.1 million in 2021. An estimated 6.7 million people were hospitalised for cardiovascular diseases in 2004, and projected to be 10.9 million by 2021. Unlike mortality, majority of the hospitalisation due to cardiovascular diseases will be in the prime working age group (25-59). The estimated cost of hospitalisation for cardiovascular diseases was 94/- billion rupees in 2004 and expected to be 152/- billion rupees by 2021, at 2004 prices. The cost of hospitalisation for cardiovascular diseases was significantly high in private health centres, high fertility states and among high socio-economic groups.

CONCLUSION

The cardiovascular mortality and hospitalisation will be largely concentrated in the prime working age group and the cost of hospitalisation is expected to increase substantially in coming years. This calls for mobilising resources, increasing access to health insurance and devising strategies for the prevention, control and treatment of cardiovascular diseases in India.

Social and Economic Implications of Noncommunicable diseases in India

Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. In this paper, we review the social and economic impact of NCDs in India. We outline this impact at household, health system and the macroeconomic level. Cardiovascular diseases (CVDs) figure at the top among the leading ten causes of adult (25-69 years) deaths in India. The effects of NCDs are inequitable with evidence of reversal in social gradient of risk factors and greater financial implications for the poorer households in India. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and 25%, respectively, are driven to poverty. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease. These high numbers also pose significant challenge for the health system for providing treatment, care and support. The proportion of hospitalizations and outpatient consultations as a result of NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from 1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 5-10% of GDP, which is significant and slowing down GDP thus hampering development. While India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies, chronic diseases, and injuries, individual interventions for clinical care are unlikely to be affordable on a large scale. While it is clear that "treating our way out" of the NCDs may not be the efficient way, it has to be strongly supplemented with population-based services aimed at health promotion and action on social determinants of health along with individual services. Since health sector alone cannot deal with the "chronic emergency" of NCDs, a multi-sectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required.

Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India

BACKGROUND

Data on prevalence, pattern of tobacco use, proportion of population dependent on nicotine and their determinants are important for developing and implementing tobacco control strategies. The aim of the study was to estimate the prevalence and determinants of tobacco use and nicotine dependency.

METHODS

A cross-sectional survey among a representative sample of 18,018 individuals in the age group of >=14 years was conducted in the Union Territory of Andaman and Nicobar Islands during 2007-09. A structured questionnaire, a modified version of an instrument which was used successfully in several multi-country epidemiological studies of the World Health Organisation, was used to survey individual socio-demographic details, known co-morbid conditions, tobacco use and alcohol use. Fagerström Test for Nicotine Dependence (FTND) was used to estimate nicotine dependence.

RESULTS

The response rate of our survey was 97% (18,018/18,554). Females (n = 8,888) were significantly younger than males (34.3 + 14.6 Vs 36.2 + 15.4 years). The prevalence of current tobacco use in any form was 48.9% (95% CI: 48.2-49.6). Tobacco chewing alone was prevalent in 40.9% (95% CI: 40.1-41.6) of the population. While one tenth of males (9.7%, 95% CI: 9.1-10.4) were nicotine dependent, it was only 3% (95% CI: 2.7-3.4) in females. Three fourth of the tobacco users initiated use of tobacco before reaching 21 years of age. Age, current use of alcohol, poor educational status, marital status, social groups, and co-morbidities were the main determinants of tobacco use and nicotine dependence in the population.

CONCLUSION

The high prevalence of tobacco use especially the chewing form of tobacco in the Union Territory of Andaman and Nicobar Islands and the differences in prevalence and pattern of tobacco use and nicotine dependency observed across subgroups warrants implementation of culturally specific tobacco control activities in this population.

Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity

BACKGROUND

The South-East Asia region (SEAR) accounts for one-quarter of the world's population, 40% of the global poor and ∼30% of the global disease burden, with a disproportionately large share of tuberculosis (35%), injuries (30%), maternal (33%) and <5-year-old mortality (30%). In this article, we describe the disease burden and status of epidemiological research and capacity in the SEAR to understand, analyse and develop capacity in response to the diverse burdens of diseases in the region.

METHODS

Data on morbidity, mortality, risk factors, social determinants, research capacity, health education, workforce and systems in the SEAR were obtained using global data on burden of disease, peer-reviewed journals, World Health Organization (WHO) technical and advisory reports, and where available, validated country reports and key informants from the region.

RESULTS

SEAR countries are afflicted with a triple burden of disease-infectious diseases, non-communicable diseases and injuries. Of the seven WHO regions, SEAR countries account for the highest proportion of global mortality (26%) and due to relatively younger ages at death, the second highest percentage of total years of life lost (30%). The SEAR exceeds the global average annual mortality rate for all three broad cause groupings-communicable, maternal, perinatal and nutritional conditions (334 vs 230 per 100 000); non-communicable diseases (676 vs 573 per 100 000); and injuries (101 vs 78 per 100 000). Poverty, education and other social determinants of health are strongly linked to inequities in health among SEAR countries and within socio-economic subgroups. India, Thailand and Bangladesh produce two-thirds of epidemiology publications in the region. Significant efforts to increase health workforce capacity, research and training have been undertaken in the region, yet considerable heterogeneity in resources and capacity remains.

CONCLUSIONS

Health systems, statistics and surveillance programmes must respond to the demographic, economic and epidemiological transitions that define the current disease burden and risk profile of SEAR populations. Inequities in health must be critically analysed, documented and addressed through multi-sectoral approaches. There is a critical need to improve public health intelligence by building epidemiological capacity in the region.

Early and current socio-economic position and cardiometabolic risk factors in the Indian Migration Study

Aims:

The aim of this study is to estimate the associations of early and current socio-economic position (SEP) on adult cardiometabolic risk factors in the Indian Migration Study (N = 7,067).

Methods and Results:

Linear mixed models were used to estimate associations between early and current SEP and cardiometabolic risk factors: systolic blood pressure (SBP), body fat and Homeostasis Model Assessment (HOMA) score. In males, high current SEP was associated with higher SBP. In both genders, high early and current SEP were associated with higher body fat, current SEP dominating the associations. High early SEP was associated with higher HOMA score in males only, and the effect size halved after adjustment for current SEP. High current SEP was associated with higher HOMA score more strongly in males than in females.

Conclusion:

Higher SEP, more importantly in adulthood than childhood, was associated with cardiometabolic risk factors in an Indian population. The relationship between SEP over the life course and urbanization should be considered in the Indian context when public health interventions to prevent cardiovascular disease are planned.

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.

Distribution of 10-year and lifetime predicted risk for cardiovascular disease in the Indian Sentinel Surveillance Study population (cross-sectional survey results)

INTRODUCTION

Cardiovascular disease (CVD) prevention guidelines recommend lifetime risk stratification for primary prevention of CVD, but no such risk stratification has been performed in India to date.

METHODS

The authors estimated short-term and lifetime predicted CVD risk among 10,054 disease-free, adult Indians in the 20-69-year age group who participated in a nationwide risk factor surveillance study. The study population was then stratified into high short-term (≥ 10% 10-year risk or diabetes), low short-term (<10%)/high lifetime and low short-term/low lifetime CVD risk groups.

RESULTS

The mean age (SD) of the study population (men=63%) was 40.8 ± 10.9 years. High short-term risk for coronary heart disease was prevalent in more than one-fifth of the population (23.5%, 95% CI 22.7 to 24.4). Nearly half of individuals with low short-term predicted risk (48.2%, 95% CI 47.1 to 49.3) had a high predicted lifetime risk for CVD. While the proportion of individuals with all optimal risk factors was 15.3% (95% CI 14.6% to 16.0%), it was 20.6% (95% CI 18.7% to 22.6%) and 8.8% (95% CI 7.7% to 10.5%) in the highest and lowest educational groups, respectively.

CONCLUSION

Approximately one in two men and three in four women in India had low short-term predicted risks for CVD in this national study, based on aggregate risk factor burden. However, two in three men and one in two women had high lifetime predicted risks for CVD, highlighting a key limitation of short-term risk stratification.