RESEARCH ARTICLE. Abbasi et al., IJAVMS, Vol. 6, Issue 5, 2012: DOI: /ijavms.24458

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1 RESEARCH ARTICLE Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458 Prevalence and Awareness of Cardiovascular Disease Risk Factors in the Government Servants of Muzaffarabad, the Capital of Azad Kashmir Muhammad Saleem Khan Abbasi, Wajid Aziz, Nazneen Habib 3, Huda Saleem 4, Atif Abbasi 5 Abbas Institute of Medical Sciences (AIMS) Muzaffarabad, (AK) Pakistan,3; Departments of Computer Sciences and Information Technology, 3 Sociology and Rural Development, and 5 Statistics City Campus AJK University Muzaffarabad (AK) Pakistan, 3; 4 Rawalpindi Medical College Pakistan. Corresponding Author s kh_wajid@yahoo.com Abstract Coronary artery disease (CAD) is leading cause of mortality in the developing countries. This study was to determine the prevalence and awareness of risk factors for CAD in apparently healthy Government servants employed in the Azad Jammu and Kashmir (AJK) Secretariat Muzaffarabad. A cross-sectional community based survey was conducted involving 55 Government servants. The prevalence of CAD risk factors was assessed on the basis of questionnaire and medical examination. The self-reported risk factors, blood pressure and anthropometric data were recorded. Blood samples were obtained for laboratory investigation of blood sugar and cholesterol. Chi square test was used to find the association of different risk factors with hypertension. The odds ratios were calculated by applying multivariate logistic regression. Physical inactivity (53.98%) was the most dominant risk factor in the study group. The prevalence of hypertension on questionnaire was 6.3% and on medical examination was.94%; 3.6% were overweight or obese; 33.% were smoking and 49.9% have exposure to cigarette; 3.68% of urban and 49.8% rural population employees had no CAD risk factors; 3.58% urban and 7.79% of rural population had more than two CAD risk factors. The most prevalent risk factors of CAD in our study population were physical inactivity, high cholesterol, obesity, hypertension, smoking and its exposure. Most of the government servants in AJK were aware of the major CAD risk factors. CAD was more prevalent in the employees of the urban community. Keywords: Azad Kashmir, Coronary Artery Diseases, Hypertension, Risk Factors Introduction Coronary Artery Disease (CAD) is the single most important disease worldwide in terms of mortality, morbidity and financial loss. Cardiovascular disease accounted for 6.7 million deaths all over the world in the year. South Asians have one of the highest rates of CAD deaths in the world 3-9. CAD is the leading cause of mortality in the developing countries with rapid rise expected towards. The concept of risk factors and their association to CAD has been investigated in numerous epidemiological studies in the United States and Europe -3. The most prevalent risk factors included cigarette smoking, hypertension, blood lipid levels, diabetes, abdominal obesity, diet low in low fruit and vegetable utilization, alcohol and psychosocial index 4,5. The identification and determination of overall risk provide a means for decreasing CAD risks by reducing modifiable risk factors and better treatment decisions 6. Recent community studies from various populations in Pakistan showed a very high prevalence of physical inactivity, hypertension, obesity, sedentary life style and diabetes 7-9. The people in Azad Kashmir have limited medical facilities and resources. The mortality due to the cardiovascular disease is on the rise in our community. Yet little is known about CAD and CAD risk factors in our population. According to our knowledge, no study so far has been made to identify the CAD risk factor in Azad Kashmir. The objective of the present study was to estimate

2 the prevalence and awareness of CAD risk factors in Governments servants belonging to secretariat group in Azad Kashmir and to determine which risk factors are more prevalent. Methods A cross sectional community based survey of 8-6 years old 55 Govt. servants of secretariat group in Muzaffarabad city was conducted to assess the prevalence of CAD risk factors. A questionnaire was developed with the continuous input from a cardiologist, a medical specialist from Abbas Institute of Medical Sciences (AIMS), a community medicine specialist (Theodore Fliedner Academy) and faculty member from Computer Sciences Department. The questionnaire included questions about level of education, profession, state of health behavior and socio economic circumstances. Three staff nurses from AIMS, were selected for data collection. Before data collection and interviewing, the staff nurses were properly trained and there was a counter check of the recoded data by a cardiologist and a medical specialist. Prevalence of risk factors among the study cohort was assessed on the basis of data collected from questionnaire completed by each participant and his/her medical examination. Height, weight and waste measurements were taken using standard procedures. Weight was measured using a portable scale that was rapidly calibrated against a balance beam scale. BMI was subsequently calculated. Blood pressure was measured using a mercury monometer. An average of two readings 5 min apart was recorded. Blood samples were obtained from each individual for random blood sugar and cholesterol & analyzed by enzymatic methodology. The data was analyzed using SPSS version 4. Descriptive Statistics was done using mean ± SD for continuous variables and frequencies with percentages for categorical variables. To find the association of different risk factors with hypertension the Chi-Square test was applied and to find out the most significant risk factors of hypertension. The odds ratios were calculated by applying multivariate logistic regression. Furthermore, 95% confidence interval was calculated using the following relation: ^ ^ P±.96 P( P) n Prior to the data collection consent was taken from the participants and the competent authorities. Results The distribution of socio-demographic characteristics of the study population is shown in table.the majority of the Government servants in AJK Secretariat group are male Table : Socio-Demographic characteristics of the study population Variable Number Percentage Age Range Gender Male Female 3.5 Education Illiterate 4 8 Primary or less Secondary 3.3 Intermediate Graduate/Post Graduate Marital Status Single Married Divorced 4.8 Resident Urban Rural ^ (97.5%). The mean age of employees was 4.5± years. Of the 55 participants, 9% government servants were literate (6.4% graduate/post graduate, 3.9% intermediate 3.3% secondary and 8.4% primary/less). Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458

3 In table and table 3, the results of prevalence of CAD risk factors among the subjects on questionnaire and medical examination are presented respectively % of overall population did not participate in any kind of physical activity or exercise, 3. % were smokers and almost 5% have smoking exposure. The overall prevalence of hypertension on questionnaire was 6.3 % and on medical examination was.94%. The prevalence of diabetes was 4.66 and high cholesterol was 34.95%. The prevalence of multiple risk factors in the study population is shown by bar chart in the figure. 4.6% of overall population had no CAD risk factors, 33.6% has only one risk factor, % had two risk factors and 5.6 % had three risk factors. In table 4, the prevalence of multiple risk factors with age, gender, education and residence (rural/urban) is given. The prevalence of CAD risk factors was low in the employees of rural area. CAD risk factors were found in 3.68 % of urban and 49.8 % rural community employees. 3.58% urban and 7.79% of rural population government employees had more than two CAD risk factors. Table : Prevalence of cardiovascular risk factors among Study population on questionnaire Number of 95% CI (%) subjects (%) Variable Physical Activity Smoking Smoking Exposure Hypertension Diabetes Don t know 37 (46.) 78 (53.98) 7 (33.) 344 (66.8) 57 (49.9) 58 (5.) 84 (6.3) 43 (83.69) 4 (4.66) 388 (75.34) 3 (.) (4.7, 5.3) (49.68, 58.8) (9.4, 37.6) (6.8,7.78) (45.58, 54.) (45.78, 54.4) (3., 9.5) (8.5, 86.88) (.84, 6.48) (7.6, 79.6) Table 3: Prevalence of cardiovascular risk factors among study population on medical examination Variable High Random Sugar High Cholesterol Hypertension BMI Underweight rmal Overweight Obese Number of subjects (%) 3 (.5) 5 (97.48) 8 (34.95) 335 (65.5) 3 (.94) 4 (78.6) 34 (6.6) 33 (6.78) 38 (6.8) 38 (7.38) (., 3.96) (96.4, (3.83, 39.7) (6.93, 69.7) (8.37, 5.57) (74.49, 8.63) (4.46, 8.74) (56.57, 64.99) (.98, 3.6) (3.8,7.84) 95% CI (%) In table 5, the awareness of the government employees in AJK about the causes of cardiovascular disease are presented. Among the study cohort, 6.9% identified stress, 6% hypertension, 57.9% high cholesterol, 56.5% eating fatty foods, % obesity and 36.3% smoking as causes of heart disease. The awareness about sedentary life style and physical inactivity as CAD risk factors were.68% and 7.77% respectively. Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458

4 Figure : Prevalence of multiple risk factors among the study population Table 4: Prevalence rate of Hypertension in the presence of different risk factors. Hypertension Risk Factors Range/Value Odd Ratio Chi Square p-value rmal High Age Education Dependents Physical Activity Life Style Eating Fatty Foods Smoking Family History BMI Diabetes ne Primary Secondary college University >5 rmal Luxurious yes yes Under Wight rmal Over Weight Obese The association of different risk factors with hypertension was checked by applying Chi Square test. The results in table 4 showed that only the factor age showed nonsignificant result that is the p-value is greater than level of significance (.5) While all the remaining variables that are education, dependents, physical activity, life style, eating fatty foods, smoking, family history, body mass index and diabetes showed the highly association with hypertension that is each have p-value less than level of significance.5 so these are strongly associated with hypertension. To find out the most significant risk factors of hypertension the multivariate logistic regression was used with hypertension considered as a binary response variable with different independent variables that are age education, number of dependents, smoking, physical inactivity, eating fatty food, family history, life style, Body mass index and diabetes were considered as independent variables. The odds ratios were calculated to check the prevalence rate of hypertension in the presence of different risk factors. The results showed that the value of odd ratio at different categories which Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458

5 indicate that the patients in the age group 3-4,4-5,and 5-6 years were.94,3.679 and 7.35 times more likely to have hypertension as compared to those who are in the reference age group 8-3 years The education of the respondent for different education levels, primary, secondary, college & university; with the value of odds ratio,.97,.894,.586.&.678 respectively shows although positive association but not significant as compared to those who are illiterate.. Similarly the respondent having 3-5 and > 5 number of dependents have.7 and.79 times more chances of having hypertension then the respondent having -3 dependents so number of dependents is also a significant factor for the prevalence of hypertension. Smoking is also associated with hypertension but not Significant. The findings revealed that individual person having no physical activity are.99 more likely to develop hypertension compare to those who exercise daily. It was also observed that the respondent eating fatty foods are.84 times more likely to have hypertension. Similarly the life style of the respondent also showed positive association with hypertension. Table 5: Prevalence of multiple risk factors with age, gender, education and residence Risk Factors Variables Total 3 4 Age Groups Gender Male Female Education Illiterate Primary or less Secondary Intermediate Graduate/Post Graduate Resident Urban Rural 57(6.96) 83(6.) 53(.3) 6(3.) 4(39.6)5(.) (4.3) 49(9.5) 48(9.3) 5(.) 38(7.4) 83(6.) 6(4.5) (4.) 54(.5) 69(3.4) 9(5.6) 7(33.4) (.) (.) 3(6.) 46(8.9) 4(7.8) 44(8.5) 9(7.7) 8(5.9) 3(.5) 3(6) 33(6.4) 6(5%) 98(9.) 5(.) 5(.) 8 (.6) (3.9) 4(4.7) 46(8.9) 68(3.) 35(6.8) (.) 7(.4) (.) (.9) 7(5.) (.4) 3(.6) 6(.) 6(.) 6(.) 8(.6) 9(3.7) (.9) () () () (.) (.) () () () () (.) () (.) () Table 6: Awareness about CAD risk Factors Category N(%) 95% CI(%) Hypertension 39 (6%) High cholesterol 94 (57.9%) Stress 34 (6.9%) Smoking 87 (36.3%) Physical Inactivity 43 (7.77%) Family history 3 (58.45%) Obesity 6 (43.88%) Eating fatty food 9 (56.5%) Eating too much 34 (45.44%) Life style 55 (.68%) Diabetes 8 (35.34%) (7.9) 75(34) 66(3.) 8(5.9) 5(97.5) 3(.5) 4(8.) 95(8.4) (3.3) 3(3.9) 36(4.6) 6(5.9) 53(49.9) The respondents with family history have.6 times more likely to be affected with hypertension than those having not family history. It can be observed that body mass index of the subjects showed a significant association with hypertension for different categories of BMI such as normal, Over-weight & obsese. The odds ratio showed that the chances of hypertension 6.3, 7.744, & 9.4 more for normal weight, overweight and obese respectively as compared to reference category (under-weight subjects). Similarly the prevalence of hypertension was.644 times more in diabetic as compared non diabetic subjects. Discussion Research evidences have shown causal associational of risk factors with coronary artery disease. Cholesterol, hypertension, diabetes mellitus and smoking have high and consistent association with CAD 4. A decrease in mortality due to the cardiovascular disease has been observed globally as the result of acute and consequent secondary preventions. Coronary artery disease is achieving epidemic level in Pakistan and other developing countries 7 & 8. In Azad Kashmir Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458

6 medical resources are scare as compared to major cities of Pakistan. Prevention and awareness about CAD risk factors are hence clearly important issues. Our study has reported a high frequency of CAD risk factors in our community. The comparison of our study with that of urban population of Karachi 8 revealed almost similar patterns of CAD risk factor with miniscule differences. Hypertension, diabetes and physical inactivity were smaller in our population than urban population of Karachi. The difference in CAD risk among the two study groups could be due to the following reasons. Firstly, in our population the number of females was very small. Secondly, our study cohort includes both rural and urban population. Thirdly, dietary habits and life style of the two communities are quite different. Smoking exposure has been implicated as substantially higher risk factor for CAD in Indo- Pakistan male population 7. Smoking exposure (5%) was second most prevalent risk factor and 33.3% of study cohort was smokers. The majority of males in study population and sharing rooms by a number of employees in Government offices may be the reason of high prevalence smoking and its exposure. The rural population has comparatively smaller number of CAD risk factor than urban population. Walking habits, use of vegetables and natural food and simple life style of rural may be reason for this finding. The awareness about the causes of heart diseases in our study population was high compared to the urban population of Karachi. The reason for this finding could be higher education rate of Governments servants (73.6% secondary or above) and awareness due to mutual and public interaction. Conclusion In this study, a community health survey was conducted to assess the prevalence of CAD risk factors and number of risk factors in order to predict the future cardiovascular disease events in Government servant of our community. The most dominant risk factors were physical inactivity, high cholesterol, smoking and its exposure, obesity and hypertension. Smoking and its exposure to the government servant is high in the offices. The government needs to take strict action against those who smoke in offices. Our study has potential limitations. First, the number of females was very small and the prevalence of risk factors on gender basis could not be assessed. Second, majority of Government employees were educated and have awareness about causes of CAD, the general population may have little awareness about these causes that may result in higher prevalence of CAD risk in our community. References. Gazino JM. Global burden of cardiovascular disease. In Braunwald Eugene, Heart disease a text book of cardiovascular medicine USA 7 th edition, WB Saunders company. Philadelphia Pennsylvania, 5.. World Health Report. Shaping the Future. Geneva, World Health Organization, Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath V. Epidemiological study of coronary heart disease in urban population of Delhi. Indian J Med Res B,99; 9: Gupta M, Singh N, Verma S. South Asians and cardiovascular risk: what clinicians should know. Circulation, 6; 3:e Howard BV, Lee ET, Cowan LD, et al. Rising tide of cardiovascular disease in American Indians. The Strong Heart Study. Circulation 999; 99 (8): Joshi P, Islam S, Pais P et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA, 7; 97: Jafar TH, Qadri Z Chaturvedi. Coronary Artery disease epidemic in Pakistan: more cardiovascular electrocardiographic evidence of ischemia in women than in men. Heart, 8; 94: Kamath SK, Hussain EA, Amin D, et al. Cardiovascular disease risk factors in distinct ethnic groups: Indian and Pakistani compared with American premenopausal women. Am J Clin Nutr 999; 69 (4): Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. Int J Cardiol 993; 39: Abbasi et al., IJAVMS, Vol. 6, Issue 5, : DOI:.5455/ijavms.4458

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