Original Article Persistent High Prevalence of Cardiovascular Risk Factors in the Urban Middle Class in India: Jaipur Heart Watch-5

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1 JAPI march 2012 VOL Original Article Persistent High Prevalence of Cardiovascular Risk Factors in the Urban Middle Class in India: Jaipur Heart Watch-5 Rajeev Gupta 1, KK Sharma 1, Arvind Gupta 2, Aachu Agrawal 3, Indu Mohan 1, VP Gupta 1, RS Khedar 1, Soneil Guptha 4 Abstract Background and objective: Urban subjects have high burden of cardiovascular risk factors, therefore, to evaluate risk factors in middle socioeconomic subjects and to study secular trends we performed an epidemiological study. Methods: The study was performed at urban middle class locations defined according to municipal records in years Stratified random sampling using house-to-house survey was performed. Details of medical history, anthropometry and clinical examination were recorded and biochemical tests performed for estimation of fasting glucose and lipids. Current definitions were used for risk factor classification. Descriptive statistics are provided. Trends were calculated using ANOVA or Mantel Haenszel chi-square. Univariate and multivariate logistic regression was performed to assess risk factor determinants. To determine secular trends we compared risk factors with previous cross-sectional studies performed in same locations in years and in subjects years age. Results: We evaluated 739 subjects (men 451, women 288, response 67%). Age-adjusted prevalence (%) of risk factors in men and women respectively was smoking 95 (21.1) and 12 (4.2), low physical activity 316 (69.6) and 147 (52.3), high fat intake >20 gm/day 278 (73.4) and 171 (68.7), low fruits and vegetables intake <3 helpings/day 249 (70.3) and 165 (76.4), overweight/obesity 205 (46.2) and 142 (50.7), high waist size 58 (12.9) and 76 (26.6), high waist:hip 143 (31.9) and 154 (53.9), hypertension 177 (39.5) and 71 (24.6), high total cholesterol >200 mg/ dl 148 (33.0) and 93 (32.7), low HDL cholesterol <40/50 mg/dl 113 (25.1) and 157 (55.3), diabetes 62 (15.5) and 25 (10.8) and metabolic syndrome 109 (25.1) and 61 (22.0). Age-associated increase was observed in body mass index, waist size, waist ratio:hip, systolic blood pressure and fasting and total cholesterol, non-hdl cholesterol and triglycerides in women (p trend <0.01). Age related increase was also observed in prevalence of obesity, truncal obesity, hypertension, diabetes and metabolic syndrome (p trend <0.01). On univariate analysis significant determinants of risk factors were low educational and socioeconomic status for smoking, high fat diet for obesity and hypertension, low fruits and vegetables intake for metabolic syndrome, and low physical activity or obesity but on age-and sex-adjusted multivariate analysis only association was high fat diet with obesity and hypertension (logistic regression analysis p<0.05). Compared to studies performed at similar locations in years and there was increasing trend in prevalence of high non-hdl cholesterol and hypertriglyceridemia (p trend <0.05) while other risk factors did not change significantly. Conclusions: There is a high prevalence of multiple cardiovascular risk factors in Indian middle class individuals. Secular trends demonstrate a persistent high prevalence and increasing non-hdl cholesterol and triglycerides over 8-year period. Introduction India is undergoing a rapid demographic and epidemiological transition. 1 This has led to increasing life expectancy and change in disease burden. 2 From infection-related morbidity and mortality in the country in last century the disease burden has shifted to predominantly non-communicable diseases. 3 Mortality data from the report of Registrar General of India show that 55% of deaths are due to non-communicable diseases and this proportion is >60% in middle-aged individuals years and >70% among these subjects living in urban locations. 4 Four major diseases leading to this mortality burden are cardiovascular diseases (coronary heart disease, stroke), chronic obstructive lung diseases, cancer and injuries. 5 Three major risk factors smoking, improper diet and physical inactivity are important causes for these conditions. 6 Epidemiological transition in high and middle income countries has resulted in decreasing risk factors in general population, mainly in the upper and middle socioeconomic status (SES) subjects. 7 This has led to declining incidence and age-adjusted mortality from cardiovascular diseases in these 1 Departments of Medicine and Clinical Research, Fortis Escorts Hospital, Jaipur ; 2 Jaipur Research Centre, Jaipur ; 3 Department of Home Science, University of Rajasthan, Jaipur ; and 4 Jaipur Heart Watch Foundation, Jaipur countries The Indian middle class is a prototype of subjects living in middle-income countries and it has been hypothesised that these individuals shall have the earliest indication of decline in cardiovascular risk factors due to improving social, economic, material and psychosocial conditions. 1 Studies on population prevalence of cardiovascular risk factors in these populations have been few and have reported high prevalence of risk factors in such communities globally including India Limited number of studies have been performed to study trends in cardiovascular risk factors in India 14,15 and none reported trends in multiple risk factors. To evaluate the cardiovascular risk factors in urban middle-class subjects in India we performed epidemiological studies in Jaipur, Rajasthan. The present study also compares risk factors with previous studies 16,17 performed among similar group of subjects to evaluate risk factor trends. Methods An epidemiological study was performed in Jaipur, northwestern India to evaluate multiple cardiovascular risk factors in an urban middle-class population. The study was approved by institutional ethics committees and supported financially by organizations listed below. Middle SES locations were defined according to the Jaipur municipal council classification. 18 These are based on the cost of land, type of housing, public facilities (proper roads, water supply, electricity supply and gas),

2 12 JAPI march 2012 VOL. 60 Table 1 : Demographic and lifestyle variables in the study subjects Age (mean years) Age groups Educational status 0-10 yr years >15 years Social status Upper middle Middle Lower middle Regular physical activity High Moderate Low Fat intake >20 g/day Desirable <20 g day Regular fruits and vegetables intake Low <3 helpings/day Desirable >3 helpings/day Smoking Other tobacco use Men (n=451) 67 (14.9) 58 (12.9) 100 (22.2) 101 (22.4) 76 (16.9) 49 (10.9) 60 (13.4) 182 (40.7) 205 (45.9) 65 (14.7) 53 (12.0) 323 (73.2) 8 (1.8) 130 (28.6) 316 (69.6) 101 (26.6) 278 (73.4) 105 (29.7) 249 (70.3) 95 (21.1) 36 (8.0) Women (n=288) 21 (7.3) 49 (17.0) 74 (25.7) 63 (21.9) 58 (20.1) 23 (8.0) 89 (31.4) 123 (43.5) 71 (25.1) 105 (37.4) 29 (10.3) 147 (52.3) 4 (1.4) 38 (13.0) 250 (85.7) 78 (31.3) 171 (68.7) 51 (23.6) 165 (76.4) 12 (4.2) 3 (1.04) Total (n=739) 88 (11.9) 107 (14.5) 174 (23.5) 164 (22.2) 134 (18.1) 72 (9.7) 149 (20.4) 305 (41.8) 276 (37.8) 170 (23.5) 82 (11.4) 470 (65.1) 12 (1.6) 168 (22.5) 566 (75.9) 179 (28.5) 449 (71.5) 156 (27.4) 414 (72.6) 107 (14.5) 39 (5.3) Numbers in parentheses are percent. educational and medical facilities and municipal taxes. The study was performed in three middle SES municipal wards in Jaipur with a population of thousand adults per ward and included a total population of about 60,000 adults according to government voters lists. Randomly selected 1100 subjects (600 men, 500 women) were targeted similar to previous urban Jaipur Heart Watch (JHW) studies. 16,17 Data collection: Methodological details have been previously reported. 19 A detailed proforma was utilized for data collection. Briefly, we collected information regarding demographic data, educational status, self-perceived socioeconomic status, history of major illnesses such as coronary heart disease, hypertension, diabetes or high cholesterol levels, and smoking or tobacco intake. Physical activity was assessed according to self reported activity into mild, moderate and severe using a validated WHO questionnaire. Dietary history was focused on fat intake and fruit and vegetable intake which were evaluated according to the WHO recommendations. 20 Physical examination was performed to assess height, weight, waist and hip size and blood pressure (BP) using previously reported methodology. 20 Body mass index (BMI) was calculated as weight (kg) divided by squared height (m). Waist-to-hip ratio (WHR) was calculated. Fasting glucose was determined at a central laboratory using glucose peroxidase method and external quality control. Quality control measures were also followed for estimation of total cholesterol, high density lipoprotein (HDL) cholesterol and triglycerides while low density lipoprotein (LDL) cholesterol was estimated using the Friedewald formula. Internal and external quality control was maintained in all the studies to ensure uniformity of methodology. The surveys were conducted from end of years 2008 to Diagnostic criteria: All present and past smokers have been included in smoker category. Users of other forms of tobacco have been categorised separately. The diagnostic criteria for tobacco use as well as other coronary risk factors have been advised by Table 2 : Age-adjusted prevalence of metabolic cardiovascular risk factors Overweight/ BMI >25.0 BMI >30.0 Waist >100 cm men, >90 cm women WHR >0.95 men, >0.85 women Men (n=451) Women (n=288) Total (n=739) 205 (46.2) 37 (8.3) 58 (12.9) 143 (31.9) 142 (50.7) 39 (13.9) 76 (26.6) 154 (53.9) 348 (48.1) 75 (10.4) 134 (18.1) 289 (39.3) 177 (39.5) 71 (24.6) 252 (34.4) High total cholesterol >200 mg/dl >240 mg/dl High LDL cholesterol >130 mg/dl >100 mg/dl Low HDL cholesterol <40 mg/dl/ <50 mg/dl High triglycerides >150 mg/dl (known or fasting glucose >126 mg/dl) Metabolic syndrome (ATP-3) 148 (33.0) 31 (6.9) 95 (21.1) 256 (57.1) 93 (32.7) 13 (4.4) 62 (21.9) 157 (55.3) 241 (32.8) 46 (6.2) 158 (21.5) 415 (56.6) 113 (25.1) 124 (43.7) 232 (31.7) 169 (37.6) 66 (23.1) 240 (32.8) 62 (15.5) 25 (10.8) 85 (13.4) 109 (25.1) 61 (22.0) 172 (24.2) Numbers in parentheses are percent. BMI body mass index; WHR waist-hip ratio; LDL low density lipoprotein; HDL high density lipoprotein; ATP adult treatment panel of US national cholesterol education program.. the WHO and reported earlier. 20 Educational status was classified according to number of years of formal education into three categories <10 years, years and >15 years. Physical activity was determined using work-time, commute-time or leisure time activities. Persons engaged in > 30 minutes of continuous activity >5 times per week were classified as moderately active and >60 minutes as highly active. Dietary fat intake was approximately determined and classified into low or high depending upon >20 g of visible fat intake daily. Green vegetables and fruit intake of > 3 servings was considered adequate. was diagnosed when systolic BP was >140 mm Hg and/or diastolic BP >90 mm Hg or a person was a known hypertensive. 21 was defined as BMI >25 kg/m was diagnosed when waist size was >100 cm in men and >90 cm in women and also when WHR was >0.95 in males and >0.85 in females according to the US National Cholesterol Education Program (NCEP) guidelines. 23 Dyslipidaemia was defined by the presence of high total cholesterol (>200 mg/dl), high LDL cholesterol (>100 mg/dl), high non-hdl cholesterol >130 mg/dl, low HDL cholesterol (<40 mg/dl in men and <50 mg/dl in women) or high triglycerides (>150 mg/dl) according to NCEP guidelines. 23 was diagnosed on the basis of either history of known diabetes or fasting glucose >126 mg/dl. Statistical analyses: The continuous variables are reported as mean+1 SD and ordinal variables in percent. Age-stratified values of various numeric variables are reported and age-adjustment performed within the statistical package (SPSS version 16.0, SPSS Inc., Chicago, USA) using analysis of covariance (ANCOVA). Trends in numerical risk factors were calculated using ANOVA for trend. Prevalence rates are reported in percent. Age-stratified prevalence rates and distribution of various risk factors have been reported for decadal intervals from 20 years to 70+ years. Age-adjustment of various prevalence rates was performed by direct method using the standard Jaipur population as reported earlier. 19 Significance of trends in prevalence rates

3 JAPI march 2012 VOL Table 3: Age specific mean values of various risk factors and trends in men and women Age groups P value (ANOVA trend) Men (n=451) Height 171.5± ± ± ± ± ±8.4 <0.001 Body mass index 23.2± ± ± ± ± ± Waist 84.7± ± ± ± ± ± Waist:hip ratio 0.88± ± ± ± ± ±0.08 <0.001 Systolic BP 128.3± ± ± ± ± ±17.6 <0.001 Cholesterol 172.6± ± ± ± ± ± LDL cholesterol 101.5± ± ± ± ± ± Non-HDL cholesterol 127.5± ± ± ± ± ± HDL cholesterol 45.1± ± ± ± ± ± Triglycerides 129.8± ± ± ± ± ± Glucose fasting 83.3± ± ± ± ± ±37.7 <0.001 Women (n=288) Height 155.9± ± ± ± ± ± Body mass index 24.3± ± ± ± ± ± Waist 78.1± ± ± ± ± ± Waist:hip ratio 0.84± ± ± ± ± ± Systolic BP 117.4± ± ± ± ± ±18.6 <0.001 Cholesterol 165.4± ± ± ± ± ±36.2 <0.001 LDL cholesterol 94.4± ± ± ± ± ± Non-HDL cholesterol 114.1± ± ± ± ± ±33.9 <0.001 HDL cholesterol 51.4± ± ± ± ± ±16.1 <0.001 Triglycerides 98.5± ± ± ± ± ± Glucose fasting 80.7± ± ± ± ± ± LDL low density lipoprotein; HDL high density lipoprotein. was determined using ANOVA for continuous variables and Mantel-Haenszel X 2 for trends for ordinal variables. P less than 0.05 were considered significant. Results We evaluated 739 subjects of targeted 1100 (response 67%), 451 men and 288 women. The demographic characteristics are shown in Table 1. majority of subjects belonged to age-groups years. Level of illiteracy was medium to high and most of the subjects belonged to middle and low-middle socioeconomic status. There was a low prevalence of smoking or tobacco use and high prevalence of physical inactivity (men 69.6%, women 85.7%). Intake of fats was high (>20 g visible fat/day in 278 (73.4%) men and 171 (68.7%) women; while that of fruits and green vegetables low (<3 helpings/day in 249 (70.3%) men and 165 (76.4%) women. Age-adjusted prevalence (%) of metabolic risk factors in men and women is shown in Table 2. Prevalence of risk factors in men and women respectively was obesity in 205 (46.2) and 142 (50.7), high waist size in 58 (12.9) and 76 (26.6), high WHR in 143 (31.9) and 154 (53.9), hypertension in 177 (39.5) and 71 (24.6), high total cholesterol in 148 (33.0) and 93 (32.7), high LDL cholesterol >100 mg/dl in 256 (57.1) and 157 (55.3), low HDL cholesterol in 113 (25.1) and 157 (55.3), diabetes in 62 (15.5) and 25 (10.8) and metabolic syndrome according to NCEP guidelines 23 in 109 (25.1) and 61 (22.0). Prevalence of truncal obesity (high waist size and WHR) and low HDL cholesterol was more in women and hypertension and diabetes more in men (p<0.05). Age-specific levels of various risk factors are shown in Tables 3 and 4. In men there is age-associated escalation in mean values of BMI, waist size, WHR, systolic BP, HDL cholesterol and fasting glucose; among women increase is observed in systolic BP, total cholesterol, LDL cholesterol, non-hdl cholesterol and fasting glucose (ANOVA test, p trend <0.01). Age associated increase is also observed in men for prevalence of obesity, truncal obesity, hypertension and diabetes and in women for hypertension, hypercholesterolemia, diabetes and metabolic syndrome (Mantel-Haenszel X 2 test, p trend <0.05). Lifestyle determinants of risk factors were evaluated and odds ratios (OR) with 95% confidence intervals (CI) calculated using univariate and multivariate logistic regression. On univariate analysis significant determinants of risk factors were low educational and socioeconomic status for smoking, high fat diet for obesity and hypertension, low fruits and vegetables intake for metabolic syndrome, and low physical activity or obesity. On age-and sex-adjusted multivariate analysis (Figure 1) only association was high fat diet with obesity and hypertension (logistic regression analysis p<0.05). We compared age- and sex-adjusted prevalence rates of risk factors among middle age subjects (20-59 years) in the present study with similar individuals in Jaipur Heart Watch (JHW) studies performed at similar locations in years and (Figure 2). There is no significant change in prevalence of smoking, obesity, truncal obesity, hypertension and diabetes. Increasing trends are observed in prevalence of high non-hdl cholesterol and high triglycerides (Mantel Haenszel X 2 p trend >0.05). Discussion This study shows a high prevalence of multiple lifestyle and metabolic cardiovascular risk factors- physical inactivity, high fat intake, low fruits and vegetables intake, smoking, obesity, truncal obesity, hypertension, dyslipidemias and the metabolic syndrome in an urban Indian middle class population. Important determinants of risk factors are age, gender, low educational status, high fat diet and low physical activity. The study also shows increasing prevalence of lipid abnormalities (high cholesterol and high triglycerides) in the urban middle class over an eight year period and stable prevalence of obesity, truncal obesity, hypertension, and metabolic syndrome. A high prevalence of multiple cardiovascular risk factors in middle socioeconomic status subjects has been reported from

4 14 JAPI march 2012 VOL. 60 other parts of the world including Europe and north America. 24 High cardiovascular risk has also been observed among middle class subjects in middle income countries such as Mexico, 25 Latin American countries, 26 central and southern European countries, 27 and east Asian region. 28,29 However, secular trends shows that there are divergent trends in risk factors. 30 Unlike in our study, the prevalence of smoking is declining in these countries while prevalence of obesity, hypertension, hypercholesterolemia, diabetes and the metabolic syndrome are increasing. The Global Burden of Metabolic Risk Factors study reported 35-year trends in population level of BMI, BP and cholesterol levels in 190 countries worldwide Overall, an increase in mean BMI and decline in systolic BP and cholesterol levels were reported. In high income countries there was increase in BMI and decline in systolic BP and cholesterol while in low income countries, such as South Asian countries, there was increase in BMI and systolic BP and stable total cholesterol levels. In middle income countries the mean BMI increased while levels of systolic BP and cholesterol levels did not change. 34 This is similar to the present study results (Table 5) and shows that this middle-class data are comparable to other middle income countries. This study is also comparable to previous studies performed in middle class Indian populations. Chadha et al studied Gujarati middle class businessmen in Delhi and reported high prevalence of multiple cardiovascular risk factors. 35 Similar results were reported from studies conducted among middle SES individuals in multiple industrial sites and elsewhere in India Our results are also comparable to previous studies among middle Table 4: Age-specific prevalence of risk factors and trends Age groups P value (X trend) Men (n=451) Smoking 15 (22.7) 11 (19.7) 21 (21.0) 26 (26.2) 12 (15.8) 10 (20.4) Other tobacco use 9 (14.3) 4 (7.4) 7 (7.1) 10 (10.3) 4 (5.4) 2 (4.3) BMI 25 kg/m 2 20 (29.9) 28 (49.1) 54 (55.1) 64 (64.6) 44 (60.3) 23 (46.9) BMI > 30 kg/m 2 3 (4.5) 4 (7.0) 9(9.2) 17(17.2) 9(12.3) 3 (6.1) High Waist > 100 cm 3 (4.5) 9 (15.5) 12 (12.1) 26 (25.7) 21 (28.0) 5 (10.2) High WHR > (10.4) 24 (41.4) 33 (33.3) 54 (53.5) 48 (64.0) 22 (44.9) < (28.8) 16 (28.1) 42 (42.0) 54 (54.0) 50 (66.7) 30 (61.2) <0.001 Cholesterol 200 mg/dl 18 (26.9) 18(31.0) 41 (41.4) 37(37.0) 27 (35.5) 17 (34.7) LD cholesterol 130 mg/dl 10 (14.9) 14 (24.1) 25(25.3) 24 (24.0) 19(25.0) 13 (26.5) Non-HDL cholesterol 160 mg/dl 13 (19.4) 18 (31.0) 30 (30.0) 30(29.7) 20 (26.3) 16 (32.7) (0.296) HDL cholesterol < 40 mg/dl 17 (25.4) 18 (31.0) 29 (29.3) 14 (14.0) 17(22.4) 10 (20.4) Triglycerides 1 50 mg/dl 24 (35.8) 23 (39.7) 46(47.5) 32 (32.0) 25 (32.9) 16 (32.7) Total:HDL cholesterol (23.9) 23 (39.7) 36 (36.4) 28 (28.0) 17 (22.4) 11 (22.4) (0.0) 4(7.5) 23 (27.1) 24 (27.6) 25 (36.8) 16 (41.0) <0.001 Metabolic syndrome 14 (20.9) 14 (24.6) 29 (30.5) 24 (24.7) 22 (30.1) 13 (28.3) Women (288) Smoking 1 (4.8) 3 (6.1) 0 (0.0) 1 (1.6) 4 (7.2) 3 (13.0) Other tobacco use 0(0.0) 1 (2.0) 1 (1.4) 0(0.0) 1 (1.8) 0 (0.0) BMI > 25 kg/m 2 6 (30.0) 28 (57.1) 46 (62.2) 43 (71.7) 35 (62.5) 9 (40.9) BMI > 30 kg/m 2 2 (10.0) 6 (12.2) 16 (21.6) 11 (18.3) 7 (12.5) 3 (13.6) High Waist > 90 cm 3 (15.0) 12 (25.0) 28 (37.8) 24 (38.1) 20 (34.5) 7 (30.4) High WHR > (45.0) 28 (58.3) 43 (58.1) 38 (60.3) 31 (53.4) 14 (60.9) (4.8) 5 (10.4) 22 (29.7) 36 (57.1) 36 (62.1) 17 (73.9) <0.001 Cholesterol 200 mg/dl 3 (14.3) 16 (37.7) 26 (35.6) 31 (49.2) 28 (48.3) 11 (52.4) LDL cholesterol 130 mg/dl 3 (14.3) 9 (18.4) 15 (20.8) 20 (31.7) 23 (39.7) 9 (42.9) Non-HDL cholesterol 160 mg/dl 3 (14.3) 8 (16.3) 15 (20.3) 19 (30.2) 20 (34.5) 7 (33.3) HDL cholesterol < 50 mg/dl 10 (47.6) 26 (53.1) 31 (43.1) 20 (31.7) 18 (31.0) 4 (19.0) Triglycerides 150 mg/dl 3 (14.3) 10 (20.4) 24 (33.3) 23 (36.5) 17 (29.3) 5 (23.8) Total:HDL cholesterol (4.8) 7 (14.3) 4 (5.6) 9 (14.3) 7(12.1) 1 (4.8) (2.3) 9 (14.8) 12 (24.0) 15 (34.1) 7 (43.8) <0.001 Metabolic syndrome 3 (14.3) 9 (19.1) 19 (27.1) 17 (28.3 ) 21 (36.8) 6 (30.0) Numbers in parentheses are percent. BMI body mass index; WHR waist-hp ratio; LDL low density lipoprotein; HDL high density lipoprotein. class subjects in Jaipur. 16,17 Similar trend analyses have not been reported from India. Ahlawat et al 14 reported significant increase in prevalence of hypertension in Chandigarh over a thirty year period and Mohan et al reported increasing diabetes prevalence in Chennai. 15 Bansal et al 41 reported increasing cardiovascular risk factors in a self-selected sample of middle-level executives. However, multiple cardiovascular risk factors were not studied in the first two studies and population based sample was not studied in the third. Hence, the present study is unique and not comparable to these studies. The changing pattern of risk factors in the present study indicates rapidly advancing epidemiological transition 42 and stabilisation of risk factors in this population. Causes of these trends are not clear but improving awareness and better educational status may be important. 43 This study has multiple limitations and strengths. The study focuses only on middle-class individuals and this group is not representative of general Indian urban population. However, this group is the most dynamic and rapidly growing segment of Indian society. 1 Current estimates put this population to be almost 300 million or one third of the national population and a study among this group of high risk subjects is required. This group is also the fastest changing and the study was powered to capture an increase or decline in risk factors among this population. Lack of a significant increase in various cardiovascular risk factors in this group has shown that the risk factors may have stabilised and with further epidemiological transition we could likely observe a decline in risks as is observed in many developed countries. 7,8 Secondly, the sample size is

5 JAPI march 2012 VOL Low educational status High fat diet small and further gender-based sub-division has led to smaller number. On the other hand the sampling frame covered more than 60,000 adults living in the three municipal wards and is representative of this population. Thirdly, almost a third of the subjects contacted did not participate in the study. This is the bane of most of the epidemiological studies performed in India and other developing countries where response rates are low especially when blood based investigations are required. We tried to contact the persons who did not respond but were unable to convince them for participation and this remains an important limitation. However, similar response rates were observed in the earlier studies and the data in the three studies 16,17 reported here (Table 5) are therefore comparable. Fourthly, location based classification of socioeconomic status may not be the best way of classification of socioeconomic status but such studies have been reported from developed countries. 11 A recent study in developing countries 44 has confirmed use of location based survey as indicator of socioeconomic status. Fifthly, there is some discordance in secular trends of risk factors. Such trends have also been reported from middle-income countries in Europe and indicate evolution of the population. 34 And finally, serial cross sectional studies are not the best approach to evaluate secular changes. Prospective cohort studies such as the Framingham study in USA and large studies in UK and Europe are excellent method but are very expensive. 45,9 Landmark studies such as the Seven Countries Study in Europe and Asia 27 and the international WHO-MONICA study 46 used design similar to ours and reported trends in risk factors. Strengths of the study include representativeness of Jaipur as measure of a typical urban conglomerate, Jaipur is at the median of Human Development Index in India, 38 and adequate sampling according to the WHO guidelines. 20 Secular trends to identify population based risk factors have not been performed before in India and this study is therefore unique. The study also focuses on urban middle class population which is usually a blind spot in cardiovascular risk factor epidemiology in India. In conclusion, this study shows a high prevalence of cardiovascular risk factors in the urban middle class subjects in India. Trends show that over an eight year period many risk factors such as smoking, hypertension and obesity have Low physical activity Low fruits and vegetables Fig. 1 : Multivariate age- and sex-adjusted odds ratios and 95% confidence intervals for association of lifestyle variables (low educational status <10 yr, low physical activity <30 minutes/day 5 days/week, high fat diet >20 g/day, and low fruits and vegetables <3 helpings/day) with various metabolic risk factors. Significant association is observed only for high fat diet with obesity and hypertension. metabolic syndrome. % prevalence in subjects years Smoking Truncal obesity JHW-3 JHW-4 JHW-5 stabilised while biochemical risk factors are increasing. These trends are similar to the 35-year international data reported from more than 190 countries recently. 34 Reasons for these trends need further in-depth studies. Meanwhile it is important to develop and implement public health policies to contain the epidemic of increasing cardiovascular risks and cardiovascular diseases in India. Acknowledgments This study was supported by financial grants from South Asian Society for Atherosclerosis and Thrombosis, Bangalore; Jaipur Heart Watch Foundation, Jaipur; and Research Unit at Fortis Escorts Hospital, Jaipur. References 1. Panagariya A. India: The Emerging Giant. New York. Oxford University Press Patel V, Chatterjee S, Chisholm D, Ebrahim S, Gururaj G, Mathers C, et al. Chronic diseases and injuries in India. Lancet 2011;377: Gupta R, Guptha S, Joshi R, Xavier D. Translating evidence into policy for cardiovascular disease control in India. Health Res Policy Plan 2011;9:8. 4. Office of Registrar General of India. Report on Causes of Deaths in India: New Delhi. Registrar General of India, Ministry of Home Affairs, Government of India World Health Organization. Diet, nutrition and chronic diseases. 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Explaining the decline in coronary High cholesterol High triglycerides Fig. 2: Age- and sex-adjusted prevalence of cardiovascular risk factors among middle socioeconomic status subjects aged years in the present Jaipur Heart Watch (JHW-5) study conducted in years as compared to previous studies in (JHW ) and (JHW-4 17 ) in Jaipur. Persistently high prevalence of multiple cardiovascular risk factors is observed. Significant increase is observed for high cholesterol and high triglycerides (Mantel Haenzel X2 for trend p<0.05) while other trends are insignificant.

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