Temporal changes of cardiovascular risk factors in a town in Gujarat

S Peter; M Mashhadi; DJ Ajith; H Wesley

doi:10.4103/2347-6486.240042

ORIGINAL ARTICLE

Year : 2016 | Volume : 4 | Issue : 1 | Page : 31-38

Temporal changes of cardiovascular risk factors in a town in Gujarat

S Peter¹, M Mashhadi¹, DJ Ajith¹, H Wesley²
¹ Senior Research Scientist, GMC Cardiothoracic and Vascular Research Society, Mission road, Nadiad 387002, Gujarat, India
² Research Officer, GMC Cardiothoracic and Vascular Research Society, Mission road, Nadiad 387002, Gujarat, India

Date of Web Publication

29-Aug-2018

Correspondence Address:
H Wesley
Research Officer, GMC Cardiothoracic and Vascular Research Society, Mission road, Nadiad 387002, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-6486.240042

Abstract

Background: Modernization has also led to change in trivial health parameters which on aggregation culminate in transition of demography and epidemiology of disease pattern. Non-communicable diseases (NCDs) such as cardiovascular diseases (CVDs) have increased. 20 year trend comparison of CVD risk factors is depicted in this study.
Methods: Two cross-sectional studies were conducted about 20 years apart. The former survey was conducted during 1991-94 and the latter during 2011-2013 period. Details on self-reported diabetes, daily physical activity and tobacco use were collected using a questionnaire. Blood pressure was measured using a sphygmomanometer in the baseline survey and Omron HEM 7111(1) automatic blood pressure monitor in the latter survey. Serum total cholesterol level was measured using a random blood sample. The trends of CVD risk factors were compared using percentages.
Results: About 1882 and 2371 individuals were included in the former and latter study. Self-reported diabetes increased from 6% t0 19%. Tobacco use decreased from 52% to 20%. Sedentary physical activity decreased from 53% to 49%. Hypertension increased from 7% to 40%. Serum cholesterol above 255 mg/dl increased from 2% to 8%.
Conclusion: Though the two studies were different in their blood pressure measurement instrument, sampling technique, population characteristics, and the fact that few risk factors were self-reported which could involve reporting bias; this crude comparison of CVD risk factors can be an eye opener to the medical fraternity.

Keywords: Cardiovascular risk factors, tobacco use, physical activity, hypertension, diabetes

How to cite this article:
Peter S, Mashhadi M, Ajith D J, Wesley H. Temporal changes of cardiovascular risk factors in a town in Gujarat. J Integr Health Sci 2016;4:31-8

How to cite this URL:
Peter S, Mashhadi M, Ajith D J, Wesley H. Temporal changes of cardiovascular risk factors in a town in Gujarat. J Integr Health Sci [serial online] 2016 [cited 2023 Jun 9];4:31-8. Available from: https://www.jihs.in/text.asp?2016/4/1/31/240042

Introduction

Through the years man has modified his environment for ease of existence. Mechanized and automated devices have become a part of life. Mechanization has intruded man’s daily routines from equipment for household chores to livelihood procurement. While mechanization has increased productivity, it has caused the downfall of physical effort. Modernization has also led to change in trivial health parameters which on aggregation culminate in transition of demography and epidemiology of disease pattern.

Birth and death rate alterations over the years is termed as demographic transition. Countries move through stages of transition from rapid growth through stagnant rates to low growth. Developing countries have a demographic profile of high birth rates and low death rates, keeping the population stagnant. Health care system has also undergone modernization in its own pace from newer investigations, equipment and techniques which provide standard care and speedy recovery. Strategies acquired from Western world in controlling the maternal, neonatal, infant and other avertable deaths, has its effects on the demographic profile of the population.^[1] Since 1990, life expectancy has increased worldwide by an average of 6 years.^[2] As a result of this transition, non-communicable diseases (NCDs) have increased. NCDs depict greater predisposition on the developing countries owing to their inability to tackle the double burden of diseases i.e., infective and non-communicable type.^[3] NCDs kill about 38 million people per year with 17.5 million contributed by cardiovascular disease (CVDs).^[4] A Global Burden of Disease study in 2010 estimated 29.6% of all deaths worldwide are caused by CVDs, claiming a huge share among all diseases.^[5] According to government records the out- of-pocket health care expenditure for heart disease was Rs.11,000 per person or 120% of the average annual per capita expenditure of the households they belong to. High health care expenditure coupled with poorly built system have failed to regulate the incidence of these CVDs. However, research has proved cessation of probable risk factors would give a promising yield in terms of disease burden.

Few risk factors play a cumulative role in incidence of NCDs. Tobacco use and sedentary lifestyle are among the four common risk factors causing four NCDs such as cardiovascular diseases, cancers, respiratory disease and diabetes.^[6] People with one or more factors such as diabetes, hypertension and elevated serum cholesterol level are considered to be at high cardiovascular risk.^[7] The present paper aims at analyzing the trend of cardiovascular risk factors such as tobacco use, sedentary lifestyle, elevated cholesterol level, diabetes, and hypertension in a town in Gujarat between two decades 1991-94 and 2011-13.

Methodology

Two cross-sectional studies were conducted about 20 years apart. The former survey was conducted during 1991-94 and the latter during 2011-2013 period. The studies were conducted in a town in Gujarat named Nadiad which is also the district headquarters of Kheda district. Both the studies were conducted among individuals above the age of 18 years. The previous survey was done using convenient sampling while the latter used random selection of streets followed by convenient sampling. Data collection and blood collection was carried out at the door step of the participants after obtaining their consent for voluntary participation. Data was collected using a simple questionnaire which included the demographic details, self- reported diabetes, daily physical activity and tobacco use. Blood pressure measurement was done using a sphygmomanometer in the baseline survey and calibrated Omron HEM 7111 automatic blood pressure monitor in the latter survey. Random blood sample was drawn to analyze serum total cholesterol level. The data was entered into prefabricated data entry formats and analyzed using Epi Info 7. The demographic data of both the surveys were represented as frequency tables and compared. The gender wise age distribution of the samples was done in order to compare the background characteristics of both the samples. Presence of few cardiovascular risk factors such as tobacco use, physical activity and previous history of diabetes were categorized and compared between both the years. Blood pressure was categorized based on JNC8 guidelines for each of the survey to be compared.^[8] Blood samples were processed at the laboratory adjoining the hospital. Serum cholesterol level cut off was fixed at 200mg/dl for trend comparison. For analysis purpose, use of tobacco in any form was considered under same category of tobacco use. Both the studies were approved by the ethics committee of the organization.

Results

The number of participants included in the 1991-94 survey were 1882 and those in the 2011-2013 survey were 2371. For the comparison, the background characteristics of participants of the two surveys are given in [Table 1].

Table 1: Background character variation through two decades

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The survey conducted in 1991-1994 involved more males (64.4%), while the 2011-2013 one involved more female population (53.9%). The 1991-1994 survey had included a higher proportion at younger age groups as compared to that of the 2011-2013 survey.

Among the participants of the 1991-1994 survey, nearly 54% of the males belonged to the age group 45-50 years. In the 2011-2013 survey, about 78% of the males were above 50 years of age. Most of the female participants of the 1991-1994 survey belonged to 45-50 years age group. In the 2011-2013 survey involved 73% of women above the age of 50 years. [Figure 1] depicts the distribution of age across the gender of the participants of the two surveys.

Figure 1: Gender and age group distribution between 1991-1994 and 2011-2013

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[Figure 2] displays the variation in cardiovascular risk factors such as tobacco use, physical activity, hypertension, diabetes (self - reported) and serum cholesterol trend through the decades. The use of tobacco which was 52% in 1991-94 survey had dripped comparing to 19.6% in 2011-13 survey. The sedentary category of physical activity has increased from 53.3% in 1991-94 to 62.8% in 2011-13. However, the heavy category of physical activity has fattened from 14.8% to 22.0%. The prevalence of hypertension has seen a phenomenal increase from around 7% to nearly 40%. On comparing the cholesterol levels between the years, the <220mg/dl category has slimmed to cause an increase in >255mg/dl category.

Figure 2: 20 years trends of cardiovascular risk factors in Nadiad, Gujarat

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The gender-wise trend distribution of these cardiovascular risk factors is given in [Table 2]. In males, the trend of self-reported diabetes between 1991-94 and 2011-13 survey has seen a four times upsurge from about 6% to 21.1%. The trend of serum cholesterol level in males, has increased in >255mg/dl category. Hypertension trend in 1991-94 and 2011-13 survey has seen a rise from 8% to 41%. In females, the self-reported diabetes has seen a threefold increase (6% to 16.7%, serum cholesterol level >255mg/dl has undergone fivefold expansion (2% to 9.1%), hypertension has suffered a little more that sevenfold rise (5% to 38.7%), tobacco use has dwindled four times (31% to 7.7%) and sedentary lifestyle has seen an increase from 43% to 71.2% [Figure 3].

Table 2: Gender-wise 20 years trends of cardiovascular risk factors in Nadiad, Gujarat

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Figure 3: Changes in cardiovascular risk factors over 20 years

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Discussion

Last century has experienced remarkable improvements in various fields in differing magnitude across different countries. Industrialization, urbanization, mechanization, economic development led to improvised water and sanitation facilities, enriched nutrition, and infrastructure development. All these advances are entangled with health transition too.^[9],[10]

According to a report by the Ministry of Statistic and Programme Implementation, Government of India the proportion of above 60 years was 5.5% in 1951and expected to double by 2021.^[11] Comparing the three census data namely, 1991, 2001 and 2011 some light was thrown on age distribution of Indian population. Above 60 years age group has doubled (56.5 to 103.2 million) while the 15-59 years group is steadily rising (464.8 to 729.9 million). Census 2011 reports the median age of Indian states to range between 19 and 31 years. Above 65 years population of India in 2000 was 45 million, expected to reach 76 million by 2020.^[12] A joint report of United Nations Population Fund (UNFPA) and Help Age International projected elderly population increase to 323 million by 2050 from 100 million at present.^[13] Dependency ratio in India according to World Bank has seen a fall from 70.6 to 54.4 per 100 population of 15-64 years between 1990 and 2010.^[14] The demographic transition by growth of the elderly population in India is evidence by these statistics. Eventhough smapling techniques was different in both the studies the changes in age and gender distribution is keeping in trend with the national scenario. No doubt these changes have a large effect on the economic growth due to the increase in dependency ratio, which encroaches into available resources in the form of health care and pension. Raised blood pressure accounts for 57 million disability adjusted life years (DALYS) which is 3.5% of total DALYS.^[15] High blood pressure ranks third as a risk factors for attributable burden of disease in South Asia.^[16] A meta-analysis in India between 1950 and 2013 reported 29.8% hypertension prevalence.^[17] Indian studies dated 1950s reported hypertension prevalence of 1.2-4%, while subsequent studies showed increasing prevalence of 5% in 1960s and 12-15% in 1990s.^[18]

Pooling of recent epidemiological studies in India reveal 25% and 10% hypertension prevalence in urban and rural India.^[18] Midha et al. (2013) reported higher hypertension prevalence in urban (40.8%) and rural areas (17.9%).^[19] Bansal et al. (2012) reported 32.3% hypertension prevalence in a village of Uttarakhand.^[20] The present study shows a similar increasing trend in blood pressure hand in hand with the previous evidences.

World Health Organization (WHO) has identified physical activity as fourth leading risk factor for global mortality accounting for 3.2 million deaths annually.^[21] Globally one in four adults are physically inactive.(21) Tobacco is a totally avoidable risk factor of CVD accounts for 6 million deaths a year.^[22] The cardiovascular risk that of a smoker halves within 5 years of quitting smoking and nullifies within 15 years.^[23] There are approximately 275 million tobacco users in India.^[24] A report of the Tobacco Control Foundation of India said that major portion of direct medical and indirect morbidity costs of tobacco use about Rs.3600 cores was on cardiovascular diseases.^[25] The present study shows a downward trend between the decades.

A report on trend of diabetes in United States revealed 2.9% (7.21 million) in 1991 and 7.2% (22.3 million) in 2013.^[26] According to Chennai Urban Rural Epidemiological Study (CURES), diabetes prevalence showed a progressive rise of 72.3% in a span of 14 years from 8.3% in 1989 to 11.6% in 1995 to 13.5% in 2000 to 14.3% in 2004.^[27] Two studies conducted 5 years apart in 1989 and 2004 showed 41.5% rise from 8.2% to 11.6%.^[28] Similarly the present study observed a rise in prevalence of self-reported diabetes from 6% in 1991-9 4 survey to 19% in 2011-2013 survey. These changes in diabetes trends can be attributed to the rapid urbanization, fast food culture, sedentary lifestyle, genetic predisposition and socioeconomic transition happening in the South Asian countries.^[29],[30] Gupta et al. (2008) reported increasing trends of all cholesterol parameters in an urban Indian population.^[31] The present study also shows a similar trends in hypercholesterolemia. In five cross- sectional studies conducted between 19912-2010 in Jaipur, smoking and systolic BP decreased, but hypercholesterolemia and diabetes remained stable.^[32] However the present study showed decreasing trend for tobacco use and sedentary lifestyle with steep rise in self-reported diabetes and increasing trend in hypertension and hypercholesterolemia. [Figure 2] Gupta et al. (2003) concluded increase in coronary artery disease risk factors such as diabetes, total cholesterol, smoking and hypertension in two cross sectional studies several years apart.^[33]

Conclusion

Despite the two studies different in their blood pressure measurement instrument, sampling technique, population characteristics, few risk factors were self-reported which could involve reporting bias this crude comparison of CVD risk factors can be an eye opener to the medical fraternity. Tobacco use has decreased drastically, the linkage to the anti-tobacco legislations with strict implementation clubbed with public awareness on the ill effects is unknown. However, the other risk factors did not show such a decrease. A steep climb is observed in the hypertension trend. Diabetes and hypercholesterolemia show a steady increase in between the years. Sedentary lifestyle showed a gradual decrease. A higher proportion of older individuals were observed in the latter survey as compared to the former survey. Demographic transition, changes in health parameter and variations in the behavioral aspects of the individuals are obvious.

References

1.	De Brouwere V, Tonglet R, Van Lerberghe W. Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?. Tropical medicine & international health. 1998 Oct 1;3(10):771-82.
2.	WHO \| Life expectancy [Internet]. [cited 2015 Apr 20]. Available from: http://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/
3.	Marshall SJ. Developing countries face double burden of disease. Bulletin of the World Health Organization. 2004 Jul;82(7):556.
4.	WHO \| Noncommunicable diseases [Internet]. [cited 2015 Mar 4]. Available from: http://www.who.int/mediacentre/factsheets/fs355/en/
5.	Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, AlMazroa MA. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2013 Jan 4;380(9859):2095-128.
6.	WHO \| Four noncommunicable diseases, four shared risk factors [Internet]. [cited 2014 Oct 17]. Available from: http://www.who.int/ncdnet/about/4diseases/en/
7.	WHO \| Cardiovascular diseases (CVDs) [Internet]. WHO. [cited 2015 Feb 19]. Available from: http://www.who.int/mediacentre/factsheets/fs317/en/
8.	James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama. 2014 Feb 5;311(5):507-20.
9.	Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Quarterly. 2005 Dec 1;83(4):731-57.
10.	Yusuf S, Reddy S, Ôunpuu S, Anand S. Global burden of cardiovascular diseases part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001 Nov 27;104(22):2746-53.
11.	Situation Analysis Of The Elderly in India. New Delhi: Central Statistics Office Ministry of Statistics & Programme Implementation Government of India; 2011 Jun.
12.	Bhat PM. Indian demographic scenario, 2025. Institute of Economic Growth; 2001 Jun.
13.	http://economictimes.indiatimes.com//articleshow/16625974.cms [Internet]. The Economic Times. [cited 2015 Apr 30]. Available from: http://economictimes.indiatimes.com//articleshow/16625974.cms
14.	India - Dependency Ratios - Total dependency ratio (0-14&65+ per 15-64) [Internet]. Knoema. [cited 2015 Apr 30]. Available from: http://knoema.com/atlas/India/topics/Demographics/Dependency-Ratios/Total-dependency-ratio-0-14and65-per-15-64
15.	WHO \| Raised blood pressure [Internet]. [cited 2015 Apr 28]. Available from: http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/
16.	Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, Anderson HR, Andrews KG, Aryee M. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2013 Jan 4;380(9859):2224-60.
17.	Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, Prabhakaran D. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. Journal of hypertension. 2014 Jun 1;32(6):1170-7.
18.	Gupta R. Trends in hypertension epidemiology in India. Journal of human hypertension. 2004 Feb 1;18(2):73-8.
19.	Midha T, Nath B, Kumari R, Rao YK, Pandey U. Prevalence of hypertension in India: A meta- analysis. World J Meta-Anal. 2013 Aug 26;1(2):83-9.
20.	Bansal SK, Goel D, Saxena V, Kandpal SD, Gray WK, Walker RW. The prevalence of hypertension and hypertension risk factors in a rural Indian community: A prospective door-todoor study. Journal of cardiovascular disease research. 2012 Jun 30;3(2):117-23.
21.	WHO \| Physical activity [Internet]. WHO. [cited 2015 Apr 30]. Available from: http://www.who.int/topics/physical_activity/en/
22.	Mendis S, Puska P, Norrving B, World Health Organization, World Heart Federation, World Stroke Organization, editors. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization; 2011. 155 p.
23.	U.S. Department of Health and Human Services. The Health Consequences of Smoking: what it means to you. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.;
24.	Experts predict 1.5 million smoking deaths in India by 2020 \| Waterloo News [Internet]. [cited 2015 Apr 20]. Available from: https://uwaterloo.ca/news/news/experts-predict-15-million-smoking-deaths-india-2020
25.	Tobacco Control Foundation of India [Internet]. [cited 2015 Apr 20]. Available from: http://www.tobaccoindia.org/Tobacco- Facts.html
26.	Long term trends in Diabates [Internet]. National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC).; 2014 Oct [cited 2015 May 1]. Available from: http://www.cdc.gov/diabetes/statistics
27.	Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, Datta M. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India—the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia. 2006 Jun 1;49(6):1175-8.
28.	Ramachandran A, Snehalatha C, Latha E, Vijay V, Viswanathan M. Rising prevalence of NIDDM in an urban population in India. Diabetologia. 1997 Jan 1;40(2):232-7.
29.	Ramachandran A, Snehalatha C, Shetty AS, Nanditha A. Trends in prevalence of diabetes in Asian countries. World J Diabetes. 2012 Jun 15;3(6):110-7.
30.	Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian journal of medical research. 2007 Mar 1;125(3):217-30.
31.	Gupta R, Guptha S, Agrawal A, Kaul V, Gaur K, Gupta VP. Secular trends in cholesterol lipoproteins and triglycerides and prevalence of dyslipidemias in an urban Indian population. Lipids in Health and Disease. 2008 Oct 24;7(1):1.
32.	Gupta R, Guptha S, Gupta VP, Agrawal A, Gaur K, Deedwania PC. Twenty-year trends in cardiovascular risk factors in India and influence of educational status. European journal of preventive cardiology. 2012 Dec 1;19(6):1258- 71.
33.	Gupta R, Gupta VP, Sarna M, Prakash H, Rastogi S, Gupta KD. Serial epidemiological surveys in an urban Indian population demonstrate increasing coronary risk factors among the lower socioeconomic strata. Journal- Association of Physicians of India. 2003 May 17;51:470-8.