BRITISH BIOMEDICAL BULLETIN

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1 Journal Home Page BRITISH BIOMEDICAL BULLETIN Original Prevalence and Correlates of Hypertension & Diabetes among 18 Years Urban Population in India Meshram II* 1, Vishnu Vardhana Rao M 2, Sudershan Rao V. 3, Laxmaiah A. 1 and Polasa K. 3 1 Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad , India 2 Division of Biostatistics, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad , India 3 Division of food & drug toxicology, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad , India A R T I C L E I N F O A B S T R A C T Received 24 Mar Received in revised form 26 Mar Accepted 03 Apr Keywords: Diabetes, Hypertension, Dyslipidemia, Overweight/obesity, Socioeconomic groups. Corresponding author: Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad , India. address: indrapal.m@rediffmail.com Background: With epidemiological, demographic, lifestyle and nutrition transition, non-communicable diseases are increasing in India. The present study was carried out to assess prevalence of cardio-metabolic risk factors and correlates of hypertension and diabetes among urban population. Materials & Method: A community-based cross-sectional study was carried out in urban India, using multistage stratified random sampling Information on household s socio-demographic particulars such as age, sex, education, occupation, income, etc was collected. Anthropometrics measurements such as height (cm), weight (kg), waist and hip circumference (cm), along with measurements of blood pressure, fasting blood sugar and lipid profile was carried out. Association was tested by using chi-square and logistic regression analysis was done. Results: The study showed that the prevalence of abdominal obesity, hypertension, diabetes and hyper triglyceridemia was 39%, 22%, 11.5% and 26% respectively among the urban population and was significantly higher among men as compared to women, although overweight/obesity was higher among women (48% Vs 29%). The prevalence was higher among high and middle income groups. The risk of hypertension and diabetes was significantly higher among men, middle aged & elderly (>59 years) and among overweight/obese. The risk of diabetes was significantly (p<0.01) lower among high and middle income groups as compared to slum dwellers. Conclusions: The prevalence of overweight/obesity and abdominal obesity was higher among high & middle income as compared to other socioeconomic groups. The risk of hypertension and diabetes was observed to be significantly associated with age, gender & overweight/obesity and also socioeconomic status. The information, education and communication (IEC) activities needs to be strengthened for control of these diseases.

2 2015 British Biomedical Bulletin. All rights reserved Introduction With Epidemiological, lifestyle and nutrition transition, non-communicable diseases such as hypertension, diabetes, cardiovascular diseases (CVDs) etc. are increasing in developing countries including India. Cardiovascular diseases caused about 9.1 million deaths in developing countries and 1.5 million deaths in India in the year It is estimated that by 2020, CVDs will be the largest cause of disability and appr. 2.6 million death among Indians 2,3. Hypertension is important modifiable risk factors for cardiovascular disease and is the third major killer disease accounting for one in every eight deaths worldwide 4. The World Health Organization (WHO) has estimated that globally about 62% of cerebrovascular diseases and 49% of ischemic heart diseases are attributable to suboptimal blood pressure (systolic > 115 mmhg), with little variation by sex 4. Hypertension is directly responsible for 57% deaths due to stroke and 24% deaths from coronary heart disease (CHD) in India. As per Indian council of Medical research (ICMR) study, prevalence of hypertension was 16-24% among urban adults in different states in India 5, while Midha et al reported 20-36% prevalence of hypertension 6. Diabetes mellitus (DM) is another important non-communicable disease. Globally, it is estimated that 382 million people are suffering from diabetes with a prevalence of 8.3%. North America and the Caribbean had the higher prevalence (11%), followed by the Middle East and North Africa (9.2%), Western Pacific regions (8.6%) 7. Diabetes mellitus occurs throughout the world, but is more common (especially type 2) in the more developed countries. However, it is predicted that the greatest increase will be in Asia and Africa by ICMR in 2009 reported 5-14% prevalence of diabetes in urban Indian population in different states 5. This increase in prevalence of chronic non-communicable diseases in developing countries follows the trend of urbanization and lifestyle changes, most importantly a "Western-style" diet i.e. environmental (i.e., dietary) effect. Overweight/obesity is important risk factor for chronic non-communicable diseases including type-2 diabetes, cardiovascular disease, hypertension and stroke, and certain forms of cancer 9 and is an emerging problem in Asian countries including India. Globally, there are more than 1 billion overweight adults, at least 300 million of them obese. The present study was carried out by National Institute of Nutrition (NIN), Hyderabad to assess consumption of processed and non-processed food along with the prevalence of overweight/obesity, hypertension and diabetes among urban population in 10 States of India during The information related to overweight/obesity, hypertension and diabetes among urban population 18 years is presented in this communication. Materials and Methods The study was approved by the Scientific Advisory Committee, and Institutional Ethical Review Board, National Institute of Nutrition (NIN), Hyderabad (IEC No. 05/2009). Written informed consent was obtained from each subjects involved in the study. Sampling design and frame It was a community-based, crosssectional study, carried out by adopting multistage stratified random sampling method.

3 Sample size calculation For hypertension Earlier studies have reported 20-36% prevalence of hypertension among urban adults of 18 years 6. Assuming the minimum level of prevalence of hypertension among urban adults (20%), with 95% confidence interval, 5% absolute precision, design effect of 1.5, the sample size required was 369~370 adults in each gender for each socio-economic group (i.e. 740 x 5=3700). Diabetes mellitus Fasting blood sugar level was estimated on alternate individual i.e subjects. Lipid profile estimation Serum lipid level was estimated on sub sample of subjects. Selection of States and cities Two states were selected randomly from each region in India and state capital was selected for study. Study was carried out in five socio-economic strata viz., High Income Group (HIG), Middle Income Group (MIG), Low Income Group (LIG), Slum dwellers and Industrial Labours (IL). (See figure 4.) Selection of HHs In order to get the required sample of 3700 subjects, considering 2.5 adults in each HHs, a total of 1500 HHs were covered. From each socio-economic group, 30 households were selected randomly. Thus a total of 150 HHs were covered from each city and thus 1500 HHs from 10 cities. Data collection The data was collected by a 5 teams consisting of Nutritionist, Research Assistant and Laboratory technician, recruited from local areas and were trained in survey methodology at National Institute of Nutrition, Hyderabad. The data was collected from the selected HHs on sociodemographic and economic particulars such as age, sex, community, education, income and occupation etc. of individuals. Anthropometric measurements were carried out using standard equipments and procedure. 10 Weight (nearest of 0.1kg) was measured with SECA weighing scale, and height (nearest of 0.1cm) with anthropometer rod. Waist and hip circumference was measured on all the adults covered for anthropometry using fibre reinforced non-elastic tape. 11 Waist circumference was measured at a point midway between lower rib margin and iliac crest. Three measurements of blood pressure (BP) at 5 minute interval in sitting position using OMRON digital BP Apparatus (HEM model) were taken on all the individual 18 years of age and average of three readings was used. Fasting blood glucose levels were estimated in a sub-sample by using one touch glucometers (Accu-Chek Active) and lipid levels were estimated using Cholestech LDX equipment. Data analysis The data was scrutinized, cleaned and entered into the computers at the National Institute of Nutrition, Hyderabad. The data was analyzed using SPSS version Mean ±SD, Proportion test, bivariate and multiple regression analysis was carried out to know the important risk factors associated with hypertension and diabetes. Individual with systolic blood pressure (SBP) 140 mmhg and/or diastolic blood pressure (DBP) 90 mmhg and/or currently on treatment for hypertension were categorized as hypertensive 12. Fasting blood sugar level of <110 mg/dl was considered as normal, mg/dl as impaired fasting glucose and 126 mg/dl as diabetes 13,14. Body mass index

4 (BMI) was calculated as weight (kg)/[ht. (mt) 2 ]. Individuals with BMI of <18.5 were classified as chronic energy deficiency (CED), BMI between as normal and BMI as overweight and 27.5 as obese 15. Individuals with waist circumference of 90 cm for men and 80 cm for women were considered cut off points for defining an abdominal obesity as per Asian cut off. Individuals with waist to hip ratio (WHR) of 0.90 for men and 0.80 for women were considered as cut off points for central obesity 16. Dyslipidemia National Cholesterol Education Programme guidelines were used for definitions of dyslipidemia 17. Hypercholesterolemia Serum cholesterol levels 200 mg/dl ( 5.2 mmol/liter). Hypertriglyceridemia Serum triglyceride levels 150 mg/dl ( 1.7 mmol/liter). High-Density lipoprotein cholesterol High-density lipoprotein cholesterol levels <40 mg/dl (<1.04 mmol/liter) for men and <50 mg/dl (<1.3 mmol/liter) for women. Results Coverage A total of 4295 individuals (Men: 2150; Women: 2147), with mean age: 38.9 ±15 years were covered. Blood pressure measurement was available for 3462, with mean systolic BP: ± 16.9 mmhg; and mean diastolic: 80.5 ±15.1mmHg. Fasting blood sugar was available for 1840 individuals with mean blood sugar ±40.1mg/dL. Mean waist circumference was 81.1± 12.2 and mean hip circumference was 91.6±10. Lipid profile such as serum triglycerides, HDL cholesterol and cholesterol were available for 570, 319, and 323 subjects (Table 1). Prevalence of cardio-metabolic risk factorsby gender The overall prevalence of overweight/obesity, abdominal and central obesity was 52%, 39% and 70% respectively, while that of hypertension, and diabetes was 22%, and 11% respectively. The prevalence of hypercholesterolemia, Low HDL and hyper-triglyceridemia was 14%, 87% and 26% respectively. The prevalence of overweight/obesity, abdominal and central obesity and dyslipidemia was significantly higher among women as compared to men, while that of hypertension and diabetes was higher among men (Fig. 1 & Fig. 2). Prevalence of cardio-metabolic risk factors by socio-economic groups The prevalence of overweight/ obesity and abdominal obesity was higher among HIG (63.2% & 46.4% respectively) and MIG (57.3% & 43.3% respectively) and lowest among Slum dwellers (38% & 29.3% respectively). Similarly, the prevalence of hypertension was significantly (p<0.01) higher among HIG and MIG group (25% each) and lower among slum dwellers (17.7%). The prevalence of diabetes was significantly (p<0.01) higher among slum dwellers (12.7%) and industrial labours (11.7%) and lower among LIG (10.2%). The prevalence of dyslipidemia i.e. hypercholesterolemia and triglyceridemia was higher among HIG (20% & 39%) and MIG (17% & 26%), as compared to LIG (16% & 21%) (Fig. 3, Table 2).

5 Association of obesity, hypertension, and diabetes with socio-demographic variables The prevalence of overweight/ obesity, and abdominal obesity was significantly (p<0.01) higher among middle aged and elderly, among women, among literate and those engaged in service and business. The prevalence was observed to be significantly (p<0.01) higher among elderly as compared to younger subjects. The prevalence of hypertension and diabetes was significantly (p<0.01) higher among elderly, among men, among those engaged in service and business (Table 3). Logistic regression analysis for hypertension and diabetes Multiple logistic regression analysis showed that the risk of hypertension was 1.6 times higher among men (CI= ) as compared to women and 7 times (OR 7.3, CI= ) higher among elderly as compared to years subjects (Table 4). Overweight/obesity (BMI 23) had 2.4 times (2.35, CI= ), abdominal obesity had 1.4 times (CI= ), while central obesity had 1.5 times higher risk of hypertension (CI= ). Similarly, the risk of diabetes was 1.8 times higher among men (CI= ) as compared to women and 12 times (OR 12.2, ) higher among elderly as compared to years subjects. The risk of diabetes was significantly lower among HIG (OR: 0.43, ) and MIG (OR: 0.50, ) as compared to slum dwellers. Abdominal obesity had 2.4 times (CI= ) higher risk of diabetes as compared to normal subjects (Table 4). Discussions This is the first study carried out by NIN from 10 major cities of India in different socioeconomic groups. The study revealed that the prevalence of obesity (abdominal and central) as well as hypertension was higher among subjects from HIG and MIG as compared to slum dwellers. Also the prevalence of hypertension, diabetes and dyslipidemia was higher among men, although prevalence of obesity was higher among women. The study also showed that the risk of hypertension was higher among middle aged and elderly, among men and among obese, while the risk of diabetes was higher among elderly, among men and with abdominal obesity. Study carried out by ICMR in 7 different states in India showed that the prevalence of overweight and obesity in urban areas ranged from 11.5% in Mizoram to 30-32% in Andhra Pradesh, Tamil Nadu and Kerala. 5 Sen et al reported 33% and 50% prevalence of overweight/obesity among men & women respectively in urban areas of Jalpaiguri, West Bengal. 18. Mungrephy and Kapoor reported 27% prevalence of overweight and obesity among Tangkhul Naga women from North Eastern state 19. ICMR task force study carried out in 7 states observed 16% prevalence of hypertension in Andhra Pradesh, 18% in Maharashtra, 19% in Mizoram & Kerala, 20% in Tamil Nadu, 23% in Uttarakhand and 24% Madhya Pradesh 5. Gupta et al reported the highest prevalence of hypertension (48.2%) in a recent multi-centric study, conducted in the urban population of India 20. Prabhakaran et al in their study among urban population of Nellore, Andhra Pradesh reported 29.3% prevalence of hypertension 21. Chakraborty et al. observed lower prevalence of hypertension (17.6%) among years slum dwellers in Bengalee slum population 22. A study by ICMR conducted in 3 states and 1 union territory (UT) in urban and rural areas, showed that the prevalence

6 of diabetes in adults 20 years was 10.4% in Tamil Nadu, 8.4% in Maharashtra, 5.3% in Jharkhand and 13.6% in Chandigarh 23. Gupta et al reported that the prevalence of diabetes varies from 5.4% in a northern state to a high of % in Chennai, South India, and % in Jaipur, Central India 24. Higher risk of hypertension and diabetes among men, although overweight/ obesity is more among women, is mostly due to greater exposure of other risk factors such as environmental and behavioural risk factors among men. This is attributed to high prevalence of overweight/obesity among HIG and MIG due to sedentary lifestyle, consumption of fatty food and less of physical activity. High prevalence of diabetes among industrial workers and slum dwellers, despite of low prevalence of overweight/ obesity and low fat intake may be attributed to other behavioural risk factors such as smoking and alcohol consumption. Joshi et al in their study among urban population reported 19% hypercholesterolemia, 37% hypertriglyceridemia, 73% low HDL-C, and 16% high LDL-C in India 25. Similar findings are also reported by others 26. A study among Asian Indian immigrants in the United States (n = 1038), reported a prevalence of hypercholesterolemia of 43.5%, hypertriglyceridemia of 42.3%, low HDL-C of 26.4% and high LDL-C of 41.4% 27. It is concluded that the prevalence of overweight/obesity and abdominal obesity was higher among HIG & MIG as compared to other socioeconomic groups. The risk of hypertension was higher among men, among overweight/obese and with abdominal & central obesity, while diabetes was higher among elderly, men, among slum dwellers and with abdominal obesity. There is a urgent need to initiate programmes focussing on lifestyle, and dietary modification to control increasing burden on non-communicable diseases. Limitation We have not assessed the family history of hypertension and diabetes mellitus. Also use of tobacco in any form and alcohol consumption was not assessed. Industrial labour and slum dwellers were not covered in North eastern region as it may not be available. Contribution All the authors were involved in study design, concept and methods. Author 1 prepare manuscript, author 2 carried out statistical analyses, All other critically reviewed the article before final submission. Acknowledgement The authors are grateful to Shri P.I. Suvrathan, Chairperson and Shri VN Gaur, CEO, the Food Safety and Standards Authority of India, Ministry of Health and Family Welfare, Government of India, for commissioning and financial support. We are also thankful to Dr. VM Katoch, Director General and Secretary, Department of Health Research, Ministry of Health and Family Welfare, Government of India, for his support and encouragement. We are also thankful to our Ex-Director, Dr Sesikeran, for his valuable support and guidance during the survey. We are thankful to all Regional Coordinators, Project and Technical, Administrative, Secretarial, Supportive staff of FDTRC and Division of Community Studies, National Institute of Nutrition, ICMR, Hyderabad. We are also thankful to the entire field staff involved in data collection and also the participants involved in this study.

7 References 1. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. World Health Organ 2000, Tech Rep Ser. 894:i-xii, Goenka S, Prabhakaran D, Ajay VS, Reddy KS. Preventing cardiovascular disease in India-translating evidence to action. Current Science. 2009; 97: Reddy KS, Prabhakaran D, Chaturvedi V, Jeemon P, Thankappan KR, Ramakrishnan L et al. Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations. Bull World Health Organ. 2006; 84: World Health Organization. World Health Report. Reducing Risks, Promoting Healthy Life. World Health Organ, Geneva, Switzerland, Chapter 4, p-12. Available from: /en/whr02_ch4.pdf. Last accessed April 24, National Institute of Medical Statistics, Indian Council of Medical Research (ICMR). IDSP Non-Communicable Disease Risk Factors Survey, Phase-I States of India, National Institute of Medical Statistics and Division of Non- Communicable Diseases, Indian Council of Medical Research, New Delhi, India, Midha T, Bhola N, Kumari R, Rao YK, Pandey U. Prevalence of hypertension in India: A meta-analysis. World J Meta-Anal. 2013; 26: International Diabetes Federation Diabetes Atlas Sixth edition, Wild S, Roglic G, Green A, Sicree R, King H. "Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030". Diabetes Care. 2004; 27 (5): Rodgers A, Lawes C, MacMahon S. Reducing the global burden of blood pressure- related cardiovascular disease. J Hypertens Suppl. 2000; 18:S Jelliffee DB, Jelliffee EP. Community nutritional assessment. Oxford, Oxford University Press, World Health Organization. Measuring obesity: classification and description of anthropometric data. Copenhagen: WHO (Nutr UD, EUR/ICP/NUT 125). 12. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003; 289: World Health Organization; International Diabetes Federation. Geneva: World Health Organization; Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation, Indian Council of Medical Research (ICMR) - WHO Guidelines for measurement of Type 2 diabetes, ICMR, WHO Expert Consultation. Appropriate body - mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004; 363: World Health Organization, International Association for the Study of Obesity, International Obesity Task Force. The Asia- Pacific Perspective: Redefining obesity and its treatment. Sydney: Health Communications, National Institute of Health; National Heart, Lung and Blood Institute; Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults (Adult Treatment Panel III) Final Report. Publication No September Sen J, Mondal N, Dutta S. Factors affecting overweight and obesity among urban adults: a cross-sectional study. Epidem Bioststat Public Health. 2013; 10: Mungreiphy NK, Kapoor S. Socioeconomic changes as covariates of overweight and obesity among Tangkhul Naga tribal women of Manipur, north-east India. J Biosoc Sci : Gupta R, Pandey RM, Misra A, Agrawal A, Misra P, Dey S, et al. High prevalence and low awareness, treatment and control of

8 hypertension in Asian Indian women. J Hum Hypertens. 2012; 26: Prabakaran J, Vijayalakshmi N, Ananthaiah Chetty N. Risk Factors of Non- Communicable Diseases in an Urban Locality of Andhra Pradesh. Nat J Res Com Med. 2013; 2: Chakraborty R, Bose K, Kozieł S. Waist circumference in determining obesity and hypertension among years old Bengalee Hindu male slum dwellers in Eastern India. Ann Hum Biol. 2011; 38: Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. Diabetologia. 2011; 54: Gupta R, Mishra A. Type 2 diabetes in India: regional disparities. Br J Diabetes Vasc Dis. 2007; 7: Joshi SR, Anjana RM, Deepa M, Pradeepa R, Bhansali A, et al. Prevalence of Dyslipidemia in Urban and Rural India: The ICMR INDIAB Study. PLoS ONE. 2014; 9(5): e Sharma U, Kishore J, Garg A, Anand T, Chakraborty M, et al. Dyslipidemia and associated risk factors in a resettlement colony of Delhi. J Clin Lipidol. 2013; 7: Misra R, Patel T, Kotha P, Raji A, Ganda O, et al. Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: results from a national study. J Diabetes Complications. 2010; 24: Table 1. Mean± standard deviation (SD) of anthropometric & blood pressure measurements, fasting blood sugar and lipid profile Particulars N Mean (SD) Height (9.3) Weight (12.9) BMI (4.5) Waist circumference (18.5) Hip circumference (21.9) BP -Systolic (16.9) BP-Diastolic (15.1) Fasting blood sugar (40.1) Lipid profile Ser. cholesterol (34.4) Ser. Triglycerides (69.2) Ser. HDL (15.3) Ser. VLDL (55.0) BMI-body mass index, BP-blood pressure, HDL-high density lipoproteins, VLDLvery low density lipoproteins.

9 Table 2. Prevalence (%) of overweight/obesity, abdominal and central obesity in urban population in different SES groups-gender wise SES groups HIG MIG LIG IL Slum dwellers Pooled P value Gender Overweight/obesity (BMI 23) n Men Women Pooled Gender Abdominal obesity n Men Women Pooled Central obesity n Men Women Pooled Hypertension n Men Women Pooled Diabetes n Men Women Pooled n Ser cholesterol (mg/dl) < Ser Triglycerides (mg/dl) < Ser HDL (mg/dl) 40/ <40/< HIG-high income group, MIG- middle income group, LIG-low income group, IL-industrial labour, SES-socioeconomic status.

10 Table 3. Association of cardio-metabolic risk factor with socio-demographic variables among urban population Age groups n BMI 23 WC 90/80 WHR 0.9/0.8 HTN DM >= Pooled P value Gender Men Women P value Education Illiterate th class th & above P value NS NS 0.08 Occupation Labour Housewife Service+ others P value NS SES-socioeconomic groups HIG-high income group, MIG- middle income group, LIG-low income group, IL-industrial labour.

11 Table 4. Logistic regression analysis between hypertension & diabetes among study population with socio-demographic factors, BMI and obesity Particulars HTN Diabetes OR 95% CI OR 95% CI Gender Men 1.65*** *** Women Age groups (yrs) *** *** *** *** SES HIG *** MIG ** LIG * Ind Lab Slum CED BMI Normal 1.66* Overweight 2.43*** WC Normal Obese 1.35* *** WHR Normal 1.0 Obese 1.46** BMI-body mass index, WC-waist circumference, WHR-waist hip ratio, CED-chronic energy deficiency, OR: odds ratio, CI: confidence interval, Variables included: Age groups, gender, education, occupation, regions, social group, BMI, WC, WHR, *p<0.05, **P<0.01, ***p<0.001.

12 Figure 1. Prevalence (%) of cardio-metabolic risk factors among urban population-gender wise

13 Figure 2. Prevalence (%) of dyslilidemia among urban population-gender wise

14 Figure 3. Prevalence (%) of cardio-metabolic risk factors among different socio-economic groups in urban population Figure 4. Selected regions, States and cities